**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation it was determined that the facility failed to to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 3 nursing units observed for environment and evidenced by the following: Upon initial tour of Unit 2 on 06/04/2025 at 10:24 AM, the surveyor observed a nurse's call bell wall unit depressed through the drywall with medical tape securing it to the wall. On 06/06/2025 at 11:11 AM, the surveyor observed the same nurse's call bell unit depressed through the drywall with medical tape securing it to the wall. During an interview with the surveyor on 06/06/2025 at 11:17 AM Certified Nursing Assistant (CNA#1) indicated that their responsibilities included daily check of the resident's room to make sure everything was in a safe working order. On 06/11/2025 at 10:32 AM, the surveyor requested that Licensed Practical Nurse Unit Manager (LPN/UM#1) to accompany them in room [ROOM NUMBER]. Both LPN/UM#1 and the surveyor received permission from the resident to enter their room. The surveyor pointed out the nurse's call bell wall unit. LPN/UM#1 acknowleged that she would think that it should not be that way. When asked if it's condition should have been reported, the LPN/UM#1 responded that the nurses and CNA's may not have noticed it. The surveyor requested that LPN/UM#1 activate the call bell system and then clear it. The surveyor observed as LPN/UM#1 approached the wall unit and place her finger inside the depressed area of the drywall in order to clear the call alarm. At this time, LPN/UM#1 stated that she would have expected that the wall unit would have been reported. On 06/11/2025 at 12:59 PM, during an interview with the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional Clinical Director of Nursing (RCDON), and Regional Administrator (RD), confirmed that there should not be broken items or items taped to resident walls. A review of the facility's Safe and Homelike Environment Policy, Implemented on 9/1/2024, identified under the Policy Explanation and Compliance Guidelines: [ .]Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. NJAC 8:39-4.1(a)11; 31.1(b)

**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 complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 34 residents reviewed, Resident #18 as evidenced by the following: Upon initial tour of the Unit 2 on 06/04/2025 at 9:52 AM, the surveyor observed an individual outside room [ROOM NUMBER] putting on personal protective equipment. The surveyor observed the individual's uniform displaying a hospice name and she identified herself as a hospice aide caring for Resident #18. On 06/06/2025 at 10:23 AM, the surveyor observed Resident #18 in resting in bed with family in room holding their hand. Resident #18 was admitted to the facility on [DATE] with diagnosis that included Multiple Sclerosis. A review of the Physician's Orders identified an order for Hospice Evaluation and Treatment on 2/3/2025. The surveyor reviewed the MDS assessments for Resident #18. A SCSA MDS was not completed for the change in status for Resident #18. SCSA MDS is a federally mandated process comprehensive assessment that is required when a resident enrolls in a hospice program and must be completed within 14 days after the determination date to ensure that the resident will be assessed. The comprehensive assessment must include a care plan meeting with the Interdisciplinary Team to provide the resident the best quality of care. During an interview with the surveyor on 06/06/2025 at 11:24 AM, the MDS Coordinator (MDSC) stated that a SCSA MDS was required with a resident change in status like hospice and should be completed in 14 days. When asked if a SCSA could be included in a quarterly assessment, the MDSC denied. The surveyor requested that the MDSC review the submitted MDS assessments for Resident #18. The MDSC responded that the hospice was captured in the Quarterly Assessment on 3/24/2025. The surveyor inquired if a significant change should have been completed for Resident #18 and the MDSC agreed. On 06/12/2025 at 10:09 AM, during an interview with the Director of Nursing (DON) , in the presence of the Licensed Nursing Home Administrator (LNHA) Regional Clinical Director of Nursing (RCDON), Regional Administrator (RD), acknowledged that SCSA MDS should have been submitted. A review of the facility's Conducting an Accurate Resident Assessment Policy, Reviewed/Revised on 3/1/2025, identified under the Policy: The purpose of this policy is to assure that all residents receive and accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. NJAC 8:39- 11.2(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. The deficient practice was identified for 1 of 23 residents (Resident #5) reviewed and was evidenced by the following: A review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS also indicated that the resident received nutritional, and hydration needs through the PEG tube (a feeding tube inserted through the abdominal wall into the stomach). A review of the resident's Order Summary Report (OSR), dated 4/4/2025, included the following physician's orders (PO) for the resident to have NPO (Nothing by mouth) diet, NPO texture, NPO consistency and enteral feed. A PO dated 4/4/25, reflected an order to flush the PEG tube with 185 ml (mililiters) before and after each bolus feed, four times a day with tap water. A review of the resident's Interdisciplinary Care Plan (ICP) indicated the following: A focus area dated 2/1/25, indicated an alteration in gastro-intestinal status (NPO), related to dysphagia (difficulty or inability to swallow). Interventions included: encourage the resident to avoid alcohol, smoking, coffee (even decaffeinated), fatty foods, chocolate, citrus juices, [NAME], tomato products, garlic, onions, and encourage a bland diet, however the resident was to have nothing by mouth. A focus area dated 2/3/25, indicated a swallowing problem related to a swallowing assessment result and that the resident was unable to elicit mouth opening for trials of food or liquid. The intervention included that all staff were to be informed of the resident's special dietary and safety needs, however the resident was to have nothing by mouth. A focus area dated 3/7/25, indicated Resident #5 had a potential for fluid deficit related to the feeding tube. The interventions included: educate the resident/family/caregivers on importance of fluid intake, encourage the resident to drink fluids of choice, and monitor and document intake and output as per facility policy, however the resident was to have nothing by mouth. A focus area dated 3/7/25 indicated that Resident #5 had a feeding tube to help meets needs due to the resident not being able to safely eat. The intervention reflected that Resident #5 was to receive 250 ml of free water fluid (FWF) every four hours. The ICP was not updated to reflect the physician's order that the resident was to receive 185cc of tap water prior to and after feeding. On 6/6/25 at 09:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who explained that the ICP was resident specific and should provide an accurate description of the resident's needs. The ADON stated that Resident #5 ICP had multiple inaccuracies. The ADON stated that the ICP should not indicate that the resident should be encouraged to drink fluids or eat a bland diet as the physician ordered that the resident maintain an NPO status. The surveyor asked the ADON if the resident was able to use the call bell to ask for assistance as written on the ICP. The ADON stated that she did not think that the resident could use a call bell, and it should not have been on the ICP. On 6/6/25 at 10:12 AM, the surveyor interviewed the Registered Dietician (RD), who reviewed Resident #5's ICP that indicated that the resident had a fluid volume deficit and should be encouraged to drink fluids. The RD stated that this would not be an appropriate care plan because the resident was NPO and was to not to receive anything by mouth. On 6/6/25 at 11:54 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1), who explained that Resident #5 required total care with all aspects of activities of daily living (ADL's). The CNA stated that that she was unsure if the resident could use the call bell and that she did not think that the resident could. The CNA could not immediately recall the resident's feeding status or that the resident was NPO. Another CNA (CNA #2), who was at the nurses' station during the interview, stated that Resident #5 could not use the call bell and received nothing by mouth. On 6/9/25 at 08:39 AM, the surveyor interviewed DOR, who stated that the Resident #5 did not have a specific evaluation for call bell usage and the Resident was not cognitively intact to use any type of call bell system. The DOR explained that staff anticipated the resident's needs and were required to check on the resident every couple of hours. The DOR verified that the resident could not use the call bell and that it should not be part of the resident's care plan. On 6/9/25 at 12:26 PM, the surveyor interviewed the MDS Coordinator (MDSC) who had been the MDSC since November and only had the responsibility to ensure that the ICP matched the resident's diagnoses. The MDSC explained that the unit manager, dietician, social worker, and activities director were responsible for updating, revising, and ensuring the accuracy of the ICP. On 6/10/25 at 10:54 AM, the surveyor interviewed the Regional Clinical Director (RCD) and Director of Nursing (DON) who stated that the purpose of a ICP was to outline a residents' healthcare needs and should be resident specific and person centered. The RCD and DON in the presence of the surveyor, reviewed the resident's ICP. Both verified the discrepancies stated above did not reflect the resident's current healthcare needs and were not appropriate for the resident's care. The facility policy Comprehensive Care Plans dated 9/1/2024, indicated that it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The facility policy Documentation in Medical Record dated 10/1/2024, indicated that each resident's medical record shall contain an accurate representation of the actual experiences of the rident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. NJAC 8:39-11.2 (1), (2), 12.1, 27.1 (a)

Based on observation, interview and record review it was determined that the facility failed to maintain the necessary respiratory care and services for 1 of 2 residents (Resident #74) reviewed. This deficient practice was evidenced by: A review of the admission Record (admission summary) indicated that Resident #74 was admitted to the facility with the diagnoses which included but was not limited to respiratory conditions due to other external agents, chronic respiratory failure with hypoxia (a condition that occurs when the body tissues do not get sufficient oxygen supply) and chronic obstructive pulmonary disease (COPD) (an ongoing lung condition caused by damage to the lungs). A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care dated 4/11/25, indicated that Resident #74 scored a 14 on the basic interview for mental status (BIMS) which indicated that the resident was cognitively intact. The MDS also indicated that the resident required supervision with activities of daily living (ADL's) and was on oxygen (O2). On 6/5/25 at 10:39 AM, the surveyor observed Resident #74 lying in bed, fully dressed and watching TV. The resident was observed utilizing oxygen by way of [via] nasal cannula (a tube that delivers oxygen into the nostrils). The resident was not in respiratory distress. The resident stated they had the diagnoses of chronic obstructive pulmonary disease (COPD). The surveyor did not observe that the resident was on humidification with the oxygen and there was no humidification on the oxygen concentrator (device that concentrates the oxygen from a gas supply). On 6/6/25 at 09:50 AM, the surveyor observed that the resident continued on oxygen and there was no humidification hooked to the concentrator. The surveyor reviewed the resident's electronic medical records (EMR) which revealed the following information: A review of the Order Summary Report (OSR) dated 12/13/24, contained an order to administer oxygen at 4 liters per minute continuously with humidification every shift for diagnoses of COPD. The Interdisciplinary Care Plan (ICP) dated 4/4/2024, reflected a focus that indicated Resident #74 was at risk for alteration in respiratory status and difficulty breathing related to a history of acute and chronic COPD. The ICP specified that Resident #74 was utilizing O2 via nasal cannula at 4 L/min continuous with humidification. On 6/6/25 at 10:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that Resident #74 was alert oriented and able to make needs known. The CNA stated that the resident was incontinent at times but only when having difficulty with breathing. She stated that the resident had COPD and was on O2 continuously. She stated that the O2 tubing was hooked straight into concentrator and that the resident's oxygen was not humidified. On 6/6/25 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she worked for the agency. She stated that Resident #74 requires one person to assist with care and ADLs. She stated that the resident was on O2 at 4 liters/min however humidification was not required. The LPN reviewed the physician orders in the presence of the surveyor and admitted that the physician ordered the O2 to be administered with humidification and that she would obtain it immediately. On 6/6/25 11:12 AM, the Assistant Director of Nursing (ADON) stated that if the resident's physician ordered the resident to receive humification with O2 administration, then the nurses were responsible to assure that humidification bottle was present on the O2 concentrator. On 6/6/25 at 12:06 PM, the surveyor observed the resident lying in bed with humidified O2 on at 4 liters per minute. The resident stated that the humidification bottle was just applied after surveyor inquiry. The resident added that they had not had the humidification for a while and that their nose would get dry at times and bleed. A review of the facility policy dated 9/1/24 and titled, Oxygen Administration indicated that oxygen therapy was administered under the orders of a physician and that the resident's care plan shall identify the interventions for oxygen therapy based on the resident's assessment and orders. The policy also indicated that the equipment needed for oxygen administration will depend on the type of delivery system ordered to include humidity bottle and tubing. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently document enteral tube feeding flush administration to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents (Residents #5), reviewed for enteral tube feeding and was evidenced by the following: Review of the admission Record (admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses that included but was not limited to; acute respiratory failure, aphasia (difficulty expressing self or difficulty in processing language), dysphasia (swallowing problems) and epilepsy (seizures). Review of the quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/23/25, indicated that Resident #5 had short and long-term memory deficits. The resident was severely impaired for decision making and required maximum assistance with activities of daily living (ADLs). The MDS also indicated that the resident received nutritional, and hydration needs through the peg tube (Percutaneous endoscopic gastrostomy (PEG) is a feeding tube inserted through the abdominal wall into the stomach). On 6/5/25 at 11:27 AM, the surveyor observed Resident #5 dressed and up in a reclining chair out by the nurse's station. The surveyor attempted to interview the resident however the resident could not verbalize. The surveyor was unable to interview the resident due to intellectual developmental disabilities. The surveyor reviewed the resident electronic medical records (EMR) which revealed the following information: A review of the Medication Review Report (MRR) contained a physician order (PO) dated 4/4/25, to flush the peg tube with 185cc (cubic centimeters) of tap water prior to and after feeding. This would equal 370 cc of water that should have been administered four times a day with each feeding. This would equal to 1480 ml (mililiters) of free water flushes a day. A review of the Registered Dietician note dated 5/21/2025 at 12:01PM, indicated that Resident #5 was to have free water flushes four times a day with tap water, 185 ml before and after each bolus feed to equal 1480 ml. A review of the Medication Administration Record (MAR) dated 4/4/25 at 8:00 PM to 4/30/25, reflected a physician's order to flush the peg tube with 185 cc of tap water prior to and after tube feeding. The nursing documentation on the MAR revealed that the facility had 105 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of physician ordered water flushes 76 out of 105 opportunities. A review of the MAR dated 5/1/25 to 5/31/25, reflected a physician's to flush the peg tube with 185cc of tap water prior to and after tube feeding. The nursing documentation on the MAR revealed that the facility had 124 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of water flushes 121 out of 124 opportunities. A review of the MAR dated 6/1/25 to 6/9/25 at 6:00 am, reflected a physician's order to flush the peg tube with 185cc of tap water prior to and after tube feeding. The nursing documentation on the MAR reflected that the facility had 33 opportunities to administer the correct peg tube water flushes, however the nurses documented the wrong amount of flushes 25 out of 33 opportunities. On 6/5/25 at 12:50, the surveyor observed the Licensed Practical Nurse (LPN) administer the peg tube feeding. The LPN applied a gown, gloves and mask and proceeded to bring an irrigation set filled to 200cc of water into the resident's room. The LPN attached the piston syringe to the residents peg tube. Prior to administration of the water flush, the surveyor asked the LPN what the calibration was on the piston syringe. The LPN stated that the piston syringe held 60 cc of fluid. The LPN then proceeded to fill the piston syringe with water two times to equal 120cc. She then flushed the peg tube prior to the administration of the formula. After the administration of the formula, the LPN then proceeded to flush the peg tube using the piston syringe. She filled the piston syringe with water two times to equal 120cc. The LPN was interviewed at this time and stated that she flushed the peg with a total of 185 cc of water prior to and after the feeding. The surveyor asked the LPN why she only filled the piston syringe with water two times that equaled 120cc and she admitted that she did not give 185cc of water prior to and after the residents feeding. The LPN reviewed the physician's order with the surveyor and confirmed that the order was to flush the peg tube with 185cc of water prior to and after the feeding. The LPN agreed and stated that she would have to clarify the order with the physician. On 6/06/25 at 9:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who reviewed Resident #5's physician's orders in the presence of the surveyor and stated that Resident #5 was to be administered 185ml of water before and after each feeding. The ADON agreed that according to the documentation on the MAR from April 2025 until surveyor inquiry in June 2025, the nurses were not consistently administering the correct peg tube flushes prior to and after the residents feeding. She stated that the nurses should be documenting that they administered 370 cc of water total flushes four times a day on the MAR, but instead were documenting 185 cc as well as different amounts as the total flush four times a day. She said that the nurses did not correctly document the total amount correctly on the MAR and stated they should have documented that they flushed the peg tube with 185cc prior to and after the feeding to equal 370 cc. She stated that when the surveyor observed the LPN perform the peg tube flushes the LPN should not have used the piston syringe to measure how much water flushes the resident was to receive and should have used a medication cup that had increment measurements of 5 cc. She stated that the LPN should have administered 185 cc of water prior to and after the resident's feeding as ordered by the physician. On 6/6/25 at 10:12 AM, the surveyor interviewed the Registered Dietician who stated that it was important to follow the physician's orders to assure proper fluid and hydration status for every resident, especially residents fed by a tube feed. She stated that tube fed residents were usually NPO and this is the only way they could obtain adequate amounts of fluid. The RD reviewed Resident #5's MAR in the presence of the surveyor and verified that when the nurses documented 185 cc on the MAR, that would indicate that the nurses only gave 185cc total flush at that time. She stated that since the physician's order indicated that 185cc was to be administered prior to and after the resident's feeding, the nurses should have documented a total of 370 cc of water each time the resident received a tube feeding. She stated that 370 cc of water four times a day would equal to 1,480cc a day of free fluid a day and that the dietician had documented this in the nutritional notes. She stated that by not administering the correct amount of water flushes, the resident could become dehydrated, but according to the resident's labs the resident had no indication that they were having issues pertaining to dehydration. Review of the Physician/Nurse Practitioner (NP) notes dated 6/10/2025 indicated that the resident's labs were reviewed, and that the resident was stable and in no acute distress. 06/10/25 09:37 AM, the surveyor interviewed the Regional Clinical Coordinator Registered Nurse (RCC/RN) and Director of Nursing (DON) who both verified that the nurses documented the wrong total amount of flushes that were provided to the resident prior to and after the feeding. She stated that the resident should have received 185 cc of tap water prior to and after feeding to equal 370cc of water with each feeding. A review of the facility policy dated 9/1/24 and titled, Appropriate Use of Feeding Tubes indicated that the facility would ensure that a resident maintains acceptable parameters of nutritional and hydration status. A review of the facility policy dated 9/1/24 and titled Medication Orders indicated that medications should be administered only upon the signed order of a person lawfully authorized to prescribe. Each medication order should be documented, and the order should be recorded in the physician's order and MAR. A review of the facility policy dated 10/1/2024 and titled, Documentation in the Medical Record indicated that each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a pciture of the resident's progress through complete, accurate, and timely documentation. NJAC 8:39-27.1(a)

NJ Complaint: #NJ186246 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 3 of 3 (Resident #77, 110, ) residents reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #77's quarterly Minimum Data Set (an assessment tool) dated 12/25/2024, revealed that Resident #77 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review Resident # 77's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to Diabetes Mellitus (the body's inability to use insulin properly, leading to high blood sugar levels). A review of Resident #77 physician's orders revealed the following orders but not limited to Insulin Regular Human Injection Solution 100 UNIT/Milliliter (a hormone produced in the pancreas that plays a crucial role in regulating blood sugar levels) Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call md if above 400 subcutaneously three times a day for diabetes and Basaglar solution (a long-acting insulin) inject 24units subcutaneously at bedtime. On 06/05/25 at 10:04 AM, during an interview with Surveyor #1, Resident #77 said that he/she had concerns with receiving medications late. A review of Resident #77's Medication Administration Audit Report for May 2025 and June 2025 revealed the Insulin Regular Human Injection Solution for diabetes was administered past the required time frame as follows: 05/02/2025 at 12:00 PM administered at 02:55 PM 05/03/2026 at 04:30 PM administered at 07:52 PM 05/04/2025 at 08:00 AM administered at 09:43 AM 05/04/2025 at 12:00 PM administered at 01:22 PM 05/06/2025 at 08:00 AM administered at 10:01 AM 05/08/2025 at 04:30 PM administered at 05:39 PM 05/11/2025 at 12:00 PM administered at 01:21 PM. 05/11/2025 at 04:30 PM administered at 06:54 PM 05/12/2025 at 08:00 AM administered at 01:15 PM 05/12/2025 at 12:00 PM administered at 01:09 PM 05/12/2025 at 04:30 PM administered at 08:48 PM 05/14/2025 at 12:00 PM administered at 01:28 PM 05/15/2025 at 12:00 PM administered at 01:15 PM 05/16/2025 at 12:00 PM administered at 01:20 PM 05/17/2025 at 12:00 PM administered at 01:45 PM 05/18/2025 at 08:00 AM administered at 10:37 AM 05/19/2025 at 12:00 PM administered at 02:37 PM 05/19/2025 at 04:30 PM administered at 06:13 PM 05/22/2025 at 08:00 AM administered at 01:04 PM 05/22/2025 at 12:00 PM administered at 01:05 PM 05/23/2025 at 08:00 AM administered at 11:24 AM 05/23/2025 at 12:00 PM administered at 02:45 PM 05/24/2025 at 04:30 PM administered at 11:55 PM 05/25/2025 at 08:00 AM administered at 11:12 AM 05/25/2025 at 04:30 PM administered at 05:57 PM 05/26/2025 at 08:00 AM administered at 09:09 AM 05/26/2025 at 12:00 PM administered at 01:22 PM 05/28/2025 at 04:30 PM administered at 05:46 PM 06/03/2025 at 08:00 AM administered at 09:56 AM 06/04/2025 at 04:30 PM administered at 05:36 PM 06/05/2025 at 04:30 PM administered at 05:41 PM A review of Resident #77's Medication Administration Audit Report for May 2025 and June 2025 revealed the Basaglar solution (a long-acting insulin) was administered past the required time frame as follows: 05/04/2025 at 09:00 PM administered at 10:52 PM 05/05/2025 at 09:00 PM administered on 10:16 PM 05/08/2025 at 09:00 PM administered at 10:11 PM 05/09/2025 at 09:00 PM administered at 10:18 PM 05/16/2025 at 09:00 PM administered on 05/17/2025 at 12:38 AM 05/17/2025 at 09:00 PM administered at 10:34 PM. 05/21/2025 at 09:00 PM administered at 10:12 PM 05/24/2025 at 09:00 PM administered at 11:56 PM 05/28/2025 at 09:00 PM administered at 10:51 PM 06/01/2025 at 09:00 PM administered at 10:36 PM 06/03/2025 at 09:00 PM administered at 11:29 PM 06/06/2025 at 09:00 PM administered at 10:46 PM 06/07/2025 at 09:00 PM administered at 11:05 PM During an interview with Surveyor #1 on 06/06/2025 at 10:55 AM, the Licensed Practical Nurse (LPN) #1 said that medication should be administered an hour before or an hour after the scheduled administration time. She further said that the nurse should document that a medication is administered right after the medication is given. During an interview with Surveyor #1 on 06/1020/25 at 10:02 AM, the Unit Manager of Unit 2 said that insulin should be administered according to the order. She further said that insulin should not be given late. During an interview with Surveyor #1 on 06/12/2025 at 10:14 AM, the Director of Nursing said she reviewed Resident #77's medication audit and acknowledged that this resident's insulin was administered late. A review the facility policy titled, Timely Administration of Insulin dated 9/1/2024 revealed that, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident to prevent adverse effects on a resident's condition. The policy further revealed, 1. All insulin will be administered in accordance with physician's orders. and lastly, 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. A review Resident # 110's diagnoses located in the Electronic Medical Record (EMR) include but are not limited to Type 2 Diabetes Mellitus (the body's inability to use insulin properly, leading to high blood sugar levels) and End Stage Renal Disease (a condition where the kidneys no longer function properly and cannot effectively filter waste and excess fluid from the blood). A review of Resident # 110's physician's orders located in the EMR revealed orders for Insulin Lispro Injection Solution to inject as per sliding scale: if 180 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units And call MD [Medical Doctor] for insulin dose subcutaneously before meals for DM [Diabetes Mellitus]. A review of the facility meal times that were provided during the Entrance Conference reflect the following times: Breakfast - 7:30 AM - 8:30 AM Lunch - 12:00 PM - 1:00 PM Dinner - 4:00 PM - 5:00 PM A review of the Medication Audit Report located in the EMR revealed the scheduled time of administration for the insulin and the actual administration times: Scheduled Date 5/1/2025 at 4:30 PM; Administration Time 8:52 PM Scheduled Date 5/2/2025 at 8:00 AM; Administration Time 9:22 AM Scheduled Date 5/2/2025 at 11:30 AM; Administration Time 2:02 PM Scheduled Date 5/6/2025 at 4:30 PM; Administration Time 5:48 PM Scheduled Date 5/10/2025 at 4:30 PM; Administration Time 6:17 AM on 5/11/2025 Scheduled Date 5/11/2025 at 8:00 AM; Administration Time 11:09 AM Scheduled Date 5/11/2025 at 11:30 AM; Administration Time 4:03 PM Scheduled Date 5/11/2025 at 4:30 PM; Administration Time 5:58 PM Scheduled Date 5/13/2025 at 4:30 PM; Administration Time 6:07 PM Scheduled Date 5/14/2025 at 8:00 AM; Administration Time 10:04 AM Scheduled Date 5/14/2025 at 11:30 AM; Administration Time 1:29 PM Scheduled Date 5/17/2025 at 4:30 PM; Administration Time 6:18 PM Scheduled Date 5/18/2025 at 4:30 PM; Administration Time 5:34 PM Scheduled Date 5/20/2025 at 4:30 PM; Administration Time 6:25 PM Scheduled Date 5/20/2025 at 9:00 PM; Administration Time 11:05 PM Scheduled Date 5/23/2025 at 8:00 AM; Administration Time 11:39 AM Scheduled Date 5/23/2025 at 11:30 AM; Administration Time 3:37 PM Scheduled Date 5/23/2025 at 4:30 PM; Administration Time 8:53 PM Scheduled Date 5/24/2025 at 6:00 PM; Administration Time 7:30 PM Scheduled Date 5/24/2025 at 9:00 PM; Administration Time 10:15 PM Scheduled Date 5/26/2025 at 11:30 AM; Administration Time 12:43 PM Scheduled Date 5/27/2025 at 9:00 PM; Administration Time 10:55 PM Scheduled Date 5/28/2025 at 4:30 PM; Administration Time 10:08 PM Scheduled Date 5/30/2025 at 11:30 AM; Administration Time 1:06 PM Scheduled Date 6/03/2025 at 11:30 AM; Administration Time 1:39 PM During an interview with the surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed that Resident # 110 does receive insulin. She denied that Resident # 110 had a history of refusing medications. The UM/LPN denied Resident # 110 had any hypoglycemic episodes. She said that it is important that he/she get insulin at the prescribed time to accommodate his/her meal times to prevent hypoglycemic episodes. A review the facility policy titled, Timely Administration of Insulin dated 9/1/2024 revealed that, It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident to prevent adverse effects on a resident's condition. The policy further revealed, 1. All insulin will be administered in accordance with physician's orders. and lastly, 4. Insulin administration will be coordinated with meal times and bedtime snacks unless otherwise specified in the physician order. 3. On approximately 6/10/2025 at 11:30 AM, the surveyor reviewed the medical record for Resident #28. A review of the [admission Record], an admission summary, revealed the resident had diagnoses which included, but were not limited to: Fracture of the right radial styloid process (fracture at the base of the thumb which is significant because of the its impact of the wrist function). A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Glargine Subcutaneous Solution 100u/mL (units/mililiter] to inject 15 unit subcutaneous in the morning (7:30 AM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/2/25 ordered for 7:30 AM and administered at 8:42 AM 5/6/25 ordered for 7:30 AM and administered at 9:30 AM 5/9/25 ordered for 7:30 AM and administered at 9:09 AM 5/10/25 ordered for 7:30 AM and administered at 9:13 AM 5/11/25 ordered for 7:30 AM and administered at 9:43 AM 5/12/25 ordered for 7:30 AM and administered at 8:59 AM 5/13/25 ordered for 7:30 AM and administered at 8:58 AM 5/14/25 ordered for 7:30 AM and administered at 9:19 AM 5/15/25 ordered for 7:30 AM and administered at 12:04 PM 5/18/25 ordered for 7:30 AM and administered at 8:44 AM 5/20/25 ordered for 7:30 AM and administered at 8:54 AM 5/22/25 ordered for 7:30 AM and administered at 8:32 AM 5/24/25 ordered for 7:30 AM and administered at 9:10 AM 5/25/25 ordered for 7:30 AM and administered at 9:50 AM 5/31/25 ordered for 7:30 AM and administered at 8:37 AM 6/2/25 ordered for 7:30 AM and administered at 8:40 AM 6/3/25 ordered for 7:30 AM and administered at 8:36 AM 6/8/25 ordered for 7:30 AM and administered at 8:50 AM A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Lispro Solution 100u/mL- Inject 15 unit subcutaneously before meals (7:30 AM; 11:30 AM; 4:30 PM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/2/25 ordered for 7:30 AM and administered at 8:42 AM 5/6/25 ordered for 7:30 AM and administered at 9:30 AM 5/9/25 ordered for 7:30 AM and administered at 9:09 AM 5/10/25 ordered for 7:30 AM and administered at 9:13 AM 5/10/25 ordered for 11:30 AM and administered at 12:37 PM 5/11/25 ordered for 7:30 AM and administered at 9:43 AM 5/11/25 ordered for 11:30 AM and administered at 3:33 PM 5/12/25 ordered for 7:30 AM and administered at 8:59 AM 5/13/25 ordered for 7:30 AM and administered at 8:58 AM 5/13/25 ordered for 11:30 AM and administered at 1:04 PM 5/13/25 ordered for 4:30 PM and administered at 5:56 PM 5/14/25 ordered for 7:30 AM and administered at 9:19 AM 5/14/25 ordered for 11:30 AM and administered at 1:18 PM 5/15/25 ordered for 7:30 AM and administered at 12:04 PM 5/16/25 ordered for 11:30 AM and administered at 2:22 PM 5/16/25 ordered for 4:30 PM and administered at 5:57 PM 5/18/25 ordered for 7:30 AM and administered at 8:44 AM 5/20/25 ordered for 11:30 AM and administered at 12:33 AM 5/20/25 ordered for 4:30 PM and administered at 8:39 PM 5/22/25 ordered for 7:30 AM and administered at 8:32 AM 5/22/25 ordered for 11:30 AM and administered at 1:01 PM 5/22/25 ordered for 4:30 PM and administered at 5:54 PM 5/23/25 ordered for 11:30 AM and administered at 1:37 PM 5/23/25 ordered for 4:30 PM and administered at 5:44 PM 5/24/25 ordered for 7:30 AM and administered at 9:10 AM 5/24/25 ordered for 11:30 AM and administered at 1:09 PM 5/25/25 ordered for 7:30 AM and administered at 9:50 AM 5/25/25 ordered for 11:30 AM and administered at 12:58 PM 5/28/25 ordered for 4:30 PM and administered at 5:49 PM 5/29/25 ordered for 11:30 AM and administered at 12:31 PM 5/29/25 ordered for 4:30 PM and administered at 5:54 PM 5/30/25 ordered for 4:30 PM and administered at 5:50 PM 5/31/25 ordered for 7:30 AM and administered at 8:37 AM 6/1/25 ordered for 11:30 AM and administered at 12:32 PM 6/1/25 ordered for 4:30 PM and administered at 5:48 PM 6/3/25 ordered for 7:30 AM and administered at 8:36 AM 6/4/25 ordered for 4:30 PM and administered at 5:46 PM 6/8/25 ordered for 7:30 AM and administered at 8:50 AM 6/8/25 ordered for 4:30 PM and administered at 5:47 PM A review of the medication audit report from 4/01/2025 -6/10/25 which reflected that order for Insulin Lispro Solution 100u/mL- Inject 30 unit subcutaneously at bedtime (9:00 PM), with an order date of 4/24/2025 and discontinue date of 5/29/2025, was administered late on the following dates and times: 5/6/25 ordered for 9:00 PM and administered at 10:17 PM 5/20/25 ordered for 9:00 PM and administered at 10:49 PM 5/22/25 ordered for 9:00 PM and administered at 11:04 PM 5/29/25 ordered for 9:00 PM and administered at 10:13 PM 5/30/25 ordered for 9:00 PM and administered at 12:46 PM 6/8/25 ordered for 9:00 PM and administered at 10:13 PM N.J.A.C. 8.39-29.2 (d)

Complaint #: NJ183557 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 04/24/2025 and 04/29/2025, it was determined that the facility failed to follow standards of clinical practice for Physician Orders (POs) for medication administration and follow the Care Plan (CP) interventions for a resident (Resident #5). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 6 residents reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. According to Resident #5's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (an impairment of gas exchange, resulting in dangerously high CO2 levels in the blood), Chronic Obstructive Pulmonary Disease (COPD) (a lung condition that causes airflow obstruction), and Hypertension (high blood pressure). According to the Minimum Data Set (MDS), an assessment tool dated 02/20/2025, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. According to Resident #5's CP with a date of 03/07/2025, under Focus revealed: Resident #5 requires oxygen therapy r/t (related to) end stage COPD, under Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. According to Resident #2's Order Summary Report (OSR) Active Orders as of 02/01/2025, the OSR revealed a physician order for the following medication: Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml (milligram/milliliter). Give 0.25 ml by mouth four times a day for air hunger. 0.25 ml=5mg at 04:00 A.M., 09:00 A.M, 01:00 P.M, 05:00 P.M with a start date of 8/10/23. Review of Resident #5's Electronic Medication Administration Record (eMAR) showed medication was not administered on the following date and time. Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml (milligram/milliliter). Give 0.25 ml by mouth four times a day for air hunger. 0.25 ml=5mg at 04:00 A.M. Review of Resident #5's Individual Patient Controlled Substance Administration Record (declining inventory used for narcotics) for Morphine, there was no evidence of administration on the date above. The Licensed Practical Nurse (LPN) who did not administer Resident #5's Morphine was unable to be reached for an interview during the survey. On 04/24/2025, at 01:53 P.M., during an interview with the surveyor, the Licensed Practical Nurse (LPN), stated medication should be administered within the ordered time frame and the order is verified. She further stated, if a resident refuses medications staff should document the refusal via eMAR and progress notes. She stated blank eMAR would indicate someone didn't sign and that means the medication was not given. On 04/274/2025, at 2:49 P.M., during an interview with the surveyor, the Director of Nursing (DON), We don't expect blanks on a MAR. Expectation is that my staff should do the five rights of med (medication) administration.The DON said if a medication is administered, it should be immediately documented by the administering nurse in the resident's eMAR. She further stated facility policy is to document all medications and there should be no blank spaces. When presented with Resident #5's eMAR for 02/2025, the DON confirmed the blank space for Morphine and that the medication was not given as ordered. Review of the facility policy titled Medication Administration with an implemented date of 09/01/2024 under Policy reveals: medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under Policy Explanation and Compliance Guidelines: #21. Sign MAR after administered. For those medications requiring vital signs, record vitals onto the MAR. NJAC 8:39- 11.2 (b)

Complaint #: NJ183557 Based on interview and review of facility documents on 5/22/25, it was determined that the facility failed to ensure a Registered Nurse (RN) worked for at least eight consecutive hours a day for 1 of 21 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Reports completed by the facility for the weeks of 02/09/25 through 02/15/25, 04/06/2025 through 04/12/2025, and 04/13/2025 through 04/119/25, revealed that the facility had no RN coverage for all shifts on 02/09/25 The surveyor reviewed the facility's policy titled Nursing Services and Sufficient Staff updated 03/05/25 which indicated, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. NJAC 8:39-25.2(h)

Complaint # NJ00181615, NJ00177959 Based on observations, interviews, and record review, as well as a review of pertinent facility documents on 12/23/24, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a medication [Sucralfate], an anti-ulcer medication, was administered to a resident (Resident #1) in a timely manner as ordered by a physician. Sucralfate was a medication to be administered before meals. This deficient practice was observed in 1 of 4 residents reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses including but not limited to: Urinary Tract Infection, Hypertension, Paraplegia, Autonomic Dysreflexia, Neuromuscular Dysfunction of Bladder, Personality Disorder, Colostomy Status, Gastro-Esophageal Reflux Disease without Esophagitis, and Mood Disorder. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 10/15/2024, indicated Resident #1's Brief Interview for Mental Status (BIMS) Score was 15 revealing the Resident's cognition was intact. The MDS further revealed in Section GG-Functional Abilities and Goals that Resident #1 required assistance in his/her completion of Activities of Daily Living (ADLs). A review of Resident #1's Order Summary Report (OSR) with Active Orders As of: 12/20/2024 revealed an order for the following: Sucralfate Oral Tablet 1 GM [gram] (Sucralfate) Give 1 tablet by mouth before meals and at bedtime for GERD [Gastro-esophageal reflux disease, a chronic disease that occurs when stomach acid flows back into the food pipe and irritates the lining] with an Order and Start Date of 09/15/2024. A review of Resident #1's electronic Medication Administration Record (eMAR) dated 11/1/2024-11/30/2024 indicated the abovementioned medication was scheduled and to be administered as follows: Sucralfate Oral Tablet 1 GM [gram] (Sucralfate) Give 1 tablet by mouth before meals and at bedtime for GERD at 0730 [7:30 in the morning], 1130 [11:30 in the morning], 1630 [4:30 in the afternoon], and at bedtime 2100 [9:00 in the evening]. A review of Resident #1's eMAR Resident Details (RD), under the Administration Details revealed that the above-mentioned medication was administered as follows: Sucralfate Oral Tablet 1 GM (Sucralfate) was scheduled to be administered at 0730 [morning], 1130 [morning], 1630 [4:40 afternoon], and at 2100 [9:00 evening], however, on the following days the medication was given late as follows: 11/5/2024 0730 - medication was administered at 08:45 [morning] 11/5/2024 1130 - medication was administered at 13:52 [1:52 in the afternoon] 11/5/2024 1630 - medication was administered at 17:26 [5:26 in the afternoon] 11/6/2024 0730 - medication was administered at 8:56 [morning] 11/6/2024 1130 - medication was administered at 12:50 [afternoon] 11/7/2024 0730 - medication was administered at 10:52 [morning] 11/8/2024 1630 - medication was administered at 19:46 [7:46 in the evening] 11/9/2024 0730 - medication was administered at 10:02 [morning] 11/9/2024 1630 - medication was administered at 17:47 [5:47 in the afternoon] 11/10/2024 0730 - medication was administered at 09:14 [morning] 11/11/2024 0730 - medication was administered at 10:18 [morning] 11/11/2024 1130 - medication was administered at 13:17 [1:17 in the afternoon] 11/12/2024 0730 - medication was administered at 08:58 [morning] 11/12/2024 1130 - medication was administered at 13:52 [1:52 in the afternoon] 11/12/2024 1630 - medication was administered at 17:43 [5:43 in the afternoon] 11/13/2024 0730 - medication was administered at 09:37 [morning] 11/13/2024 1130 - medication was administered at 14:00 [2:00 in the afternoon] 11/14/2024 0730 - medication was administered at 09:34 [morning] 11/14/2024 1630 - medication was administered at 18:57 [6:57 in the evening] 11/15/2024 1130 - medication was administered at 13:39 [1:39 in the afternoon] 11/16/2024 1630 - medication was administered at 19:52 [7:52 in the evening] 11/17/2024 0730 - medication was administered at 09:51 [morning] 11/18/2024 0730 - medication was administered at 09:30 [morning] 11/18/2024 1130 - medication was administered at 14:57 [2:57 in the afternoon] 11/19/2024 0730 - medication was administered at 09:38 [morning] 11/19/2024 1130 - medication was administered at 13:29 [1:29 in the afternoon] 11/21/2024 0730 - medication was administered at 10:01 [morning] 11/22/2024 0730 - medication was administered at 09:04 [morning] 11/22/2024 1130 - medication was administered at 13:45 [1:45 in the afternoon] 11/26/2024 0730 - medication was administered at 8:52 [morning] 11/26/2024 1130 - medication was administered at 13:23 [1:23 in the afternoon] 11/27/2024 0730 - medication was administered at 08:53 [morning] 11/27/2024 1130 - medication was administered at 14:29 [2:29 in the afternoon] 11/28/2024 0730 - medication was administered at 09:12 [morning] 11/28/2024 1130 - medication was administered at 14:06 [2:06 in the afternoon] 11/29/2024 0730 - medication was administered at 10:46 [morning] 11/30/2024 0730 - medication was administered at 09:04 [morning] 11/30/2024 1130 - medication was administered at 12:57 [afternoon] 11/30/2024 1630 - medication was administered at 17:58 [5:58 in the afternoon] A review of Resident #1's Progress Notes (PN) from 11/01/2024 to 11/30/2024 showed no documentations that the Resident's attending physician (AP) was notified that the medication was not administered according to the scheduled time on the aforementioned dates. The PN further indicated there was no evidence of harm to Resident #1 from the late administration of medications. In an interview of the Surveyor with Resident #1 in his/her room on 12/20/2024 at 1:49 p.m. [afternoon] regarding his/her medication, Resident #1 stated, they do not always come on time, my medication sucralfate was always late especially in the morning. It has been frequent the last month. In an interview of the Surveyor with Licensed Practical Nurse (LPN #1) on 12/20/24 at 12:28 p.m. [afternoon], LPN #1 stated that for every after medication administration, in the eMAR, the nurse clicked on the Check [sign], then clicked the Save [box] and it will turn green meaning the medication was administered and given to the resident. For every after administration of medication, I tried to make it [box] green right away. In an interview of the Surveyor with Registered Nurse (RN #1) Unit Manager, RN #1 stated that in the eMAR if the medication boxes are yellow that means the medications are due for that time. Once it is green, the nurse had already clicked the Save button which means the medication was administered. RN #1 also stated that if the medications were not administered according to the scheduled time or running late with medications or if the resident refuses, nurse would document that the medication was given late and would call the doctor to notify that the medication was not administered according to the scheduled time. NJAC 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for Resident # 257 who sustained a fracture of unknown origin of the left hip. Resident # 257 required an Open Reduction and Internal Fixation (ORIF) of the left hip on 09/25/23 . This deficient practice was identified for 1 of 1 Resident (Resident #257) reviewed for fracture of unknown origin and was evidenced by the following: Refer to 684G On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding reportable events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation and then provided the surveyor with a copy of a Reportable Event (a required document to be submitted to the Department of Health). Review of the documents attached to the Reportable Event (RE) included a titled, Investigational Summary and Conclusion, one page of a Care Plan, and copies of fax transmissions dated 09/29/23, to the Department of Health and Ombudsman's office. There were no witness statements or documented interviews provided. The surveyor asked if there was a root cause analysis completed regarding the fracture of unknown origin, and the DON stated, no, that is QAPI (Quality Assurance and Performance Improvement). The surveyor requested the complete investigation for Resident #257's fracture of unknown origin. A review of the RE dated 09/26/23 and Person Reporting: Director of Nursing (DON), revealed: Date of Event: 09/24/23 and Time of Event: 9:42 PM; Was This a Significant Event: Yes. The Type of Incident: Injury; Narrative- Resident was admitted on [DATE] [status post] fall at home. On admission resident c/o [complained of] pain to the left hip, with bruising to left thigh. On 09/22/23, resident continued to c/o [complain of] pain to left hip with PRN [as needed] pain medication given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked the nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted left turned inward. Resident denied pain at that time. MD ordered STAT [immediately] X-Ray. X-ray results showed subcapital fracture of left hip. Resident was sent out to ER [Emergency Room] and admitted with left hip fracture. Resident is alert to self with a BIMS [brief interview of mental status] of 6/15 (Severely impaired cognition), past medical history of malnutrition, hypertension, difficulty walking, history of falls, anemia, and syncope and collapse. The document titled Investigational Summary and Conclusion, revealed: Date of Incident: 09/24/23, Incident Type: Fracture,: Description of Event: Resident was admitted on [DATE], s/p [status post] fall at home. Upon admission resident c/o [complained of] pain to left hip with bruising noted to left thigh. On 09/22/23, resident continued to complain of pain to left hip with PRN [as needed] pain meds [medication] given. On 09/23/23, resident's [spouse] alerted staff that resident had a fall at home and asked nurse to look at patients left lower extremity. Noted purple discoloration to left lateral thigh. Further assessment done and noted leg turned inward. Resident denied pain at that time. MD [medical doctor] ordered Stat X-ray. X-ray results showed sub capital fracture of left hip. Resident was sent out to ER and admitted with left hip fracture. The Conclusion section of the document revealed: Resident was admitted status post falls at home. Upon admission residents left thigh noted with bruising. Hospital record reports that the resident had multiple falls at home and complained of pain to left leg. An X-ray of the left foot left ankle and left knee were obtained while in the hospital and were negative. A doppler was also done in the hospital of the left leg due to resident's pain, that was negative for DVT (blood clot in the leg). Resident also had a history of left pubic fracture. On 09/23/23, resident's [spouse] asked the staff to assess resident left leg as resident had a fall at home. Upon assessment bruising noted to left thigh as documented on admission, with slight inward rotation of left leg. An X-ray was done that resulted in a left sub-capital fracture of left hip. Resident did not have a fall in our facility and was confirmed by [spouse] and resident that the fall occurred prior to the hospital. Based on the facts gathered and after conducting a comprehensive investigation, facility has concluded that the fracture occurred as a result of the falls sustained at home. Resident continued to have pain to left leg during the hospital stay however an X-ray of the hip was not done. Investigational summary completed by: [DON's name]. There were no statements obtained from any staff that cared for the resident, the spouse, and no documented evidence regarding a fall that caused a fracture prior to admission included, and as documented in the RE. Review of the one page care plan attached to the Reportable Event revealed a Care Plan Focus for High risk for falls dated 09/24/23, Left hip fracture, no fall. On 02/02/24 at 11:00 AM, the surveyor reviewed the closed electronic medical record and paper record for Resident #257 which revealed the following: The admission Record (an admission summary) revealed the resident had diagnoses which included, but were not limited to; chronic kidney disease Stage- 4 [severe], syncope [fainting] and collapse, and history of falling. Review of the Nursing Comprehensive Assessment, dated 09/21/23 at 22:04 [10:04 PM] revealed the resident was admitted from the hospital and required extensive assistance with bed mobility and transfer. C. Skin integrity, Site: left thigh rear, bruising (Details and Comments section was left blank) Length, Width, Depth, Stage: left blank. L. Pain: 37. Pain Management: 1. Received scheduled pain medication regimen, No, 2. Received PRN pain medications or was offered and declined, Yes. 3. Received non-medication intervention for pain, No was checked off. 39. Staff Assessment, Should the Staff Assessment for Pain Be Conducted, No was checked off. Review of the September 2023 Physician Order Summary revealed the following orders: - an order dated 09/23/23 at 16:56 [4:56 PM] with an end date of 09/26/23 for an X-ray of left hip one time only for to rule out fracture for three days. - an order dated 09/22/23, Complete a Pain assessment every shift (0=No Pain/Asleep; 1-3= Mild Pain; 4-7 = Moderate Pain; 8-10= Severe pain) every shift. - Acetaminophen (pain medication) Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for pain 2 Tablets = 650 mg, Order Date-09/21/2023 1916 [7:16 PM]. - Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for mild pain 2 Tablets = 650 mg.do not exceed 3 grams per day from all sources. -Order Date-09/22/23 at 12:15. A review of the Medication Administration Record (MAR) and Progress Notes for September 2023 revealed the following: - A Nursing Documentation Progress Note, dated 09/21/23 at 21:21 [9:21 PM] and signed by a Licensed Practical Nurse (LPN) revealed Skin Check completed: No skin injury/wounds were noted. - There was no Acetaminophen documented as administered on 09/21/23. - A Health Status Progress Note, dated 09/22/23 at 12:19 AM, signed by an LPN, revealed, Minimal assist of 1 with ADL's and transfers, [Spouse] in for visit this AM. Denies Pain or discomfort at this time, No acute distress noted. This contradicted the Nursing admission assessment dated one day prior, on 09/21/23, which indicated the resident required extensive assistance with activities of daily living (ADLs). - Acetaminophen was administered on 09/22/23 at 9:33 AM for a Pain Level=4. There was no corresponding progress note regarding the Pain Level=4 and there was no additional Acetaminophen documented as administered on 09/22/23. - A Nursing Documentation Progress Note, dated 09/22/23 at 17:28 [5:28 PM], signed by an LPN revealed Pain Level=0, No Pain. Skin Check completed: No skin injury/wounds(s) were noted. - A Health Status Progress Note, dated 09/22/23 at 21:58 [9:58 PM], signed by a Registered Nurse (RN) revealed Family visit most of this shift. Mood is quiet. Responds appropriately to questions. Denies Needs. Completed care provided for bathing, grooming dressing by one staff. Extensive assistance provided with two staff for bed mobility, Extensive assistance provided by one staff for all surface to surface transfers. Denies Pain. - A Health Status Progress Note, dated 09/23/23 at 6:56 AM, signed by an RN revealed Mood is quiet and appropriate with good affects. Slept X [times] 8 hours. Denies Pain. - A Health Status Progress Note, dated 09/23/23 at 13:39 [1:39 PM], signed by an LPN revealed Alert and oriented. Clearly verbalizes needs. Denies any pain or discomfort . Heart rate and rhythm regular. Lung sounds clear in all lobes. Respirations even and unlabored . - A Health Status Progress Note, dated 09/23/23 at 16:50 [4:50 PM], singed by an LPN revealed [Patient] voicing [complaints of] pain [at Left Lower Extremity]. Observed [with] fading blue-green vertical ecchymosis (a bruise) at mid-anterior thigh, a circular purple area of burst vessels, and a circular compartmented area of non-pitting edema at the right upper thigh/groin area, [Left Lower Extremity] and foot area are externally rotated. Spouse is in room visiting at this time and stated that [patient] had fallen at home prior to going to hospital. [New Order] for X-ray of left hip. Positioned in bed for safety and comfort, call bell in reach and spouse at bedside assisting with dinner meal at this time. -A Health Status Progress Note, dated 09/23/23, completed by a RN at 19:02 [7:02 PM] . Mood appropriate with good affects. [Spouse] at bedside. [Spouse] alerted staff about [Resident's] fall at home and asked to look at patient left lower extremity. Noted purple discoloration lateral on thigh, proximal to hip, lower extremity rotate outward laterally and raised area proximal to left groin. Resident denies pain. Supervisor made aware. This was documented 2-hours after the LPN first documented that the spouse had alerted the LPN, who observed the external rotation of the LLE. Review of the Hospital Records revealed the following: - A physician note dated 09/19/23, revealed a urinary tract infection and altered mental status. - An Occupational Treatment Note dated 09/20/23 at 10:40 AM revealed: Patient did not complain of LLE [Left Lower Extremity] pain with movement today. Remains weak. Posterior lean, cognitive deficits and weakness continue to impact safe and independent transfers and ADLs. Continue to recommend rehab at discharge. - A physician note dated 09/20/23 at 11:14 AM which revealed the patient is awake and alert, denies pain. -Registered Nurse progress note dated 09/21/23 at 13:21 revealed: no complaints, denies any abdominal/pelvic pain and medically stable for discharge to sub-acute rehabilitation. On 02/02/24 at 11:34 AM, the surveyor interviewed the DON regarding the RE with the supporting documents that were provided to the surveyor and asked the DON if there was an additional investigation. The DON looked at the RE and stated this is the investigation. The surveyor asked the DON what the components of an investigation included, and the DON stated an incident report and that she had one but did not bring it with her. The surveyor requested for the DON to provide the incident report. On 02/02/24 at 11:39 AM, in the presence of the survey team, the DON stated and confirmed I don't have an incident report for him/her, he/she didn't have any incident, and the spouse told us the resident had a fall at home. The DON confirmed that there were no statements obtained. The surveyor asked what is typically completed regarding an investigation and the DON stated an incident report. On 02/02/24 at 11:43 AM, the [NAME] President of Clinical Operations (VPCO) joined the interview and the surveyor asked if reportable events were investigated and the VPCO stated yes. The DON and VPCO confirmed that there was no investigation, or an incident report completed regarding the fracture of unknown origin for Resident #257. The VPCO stated REs should be investigated. The Accidents and Incidents-Investigating and Reporting Policy, adopted 10/2018 revealed: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place, b. The nature of the injury/illness (e.g. bruise, fall, nausea, etc.), c. The circumstance surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs; j. The disposition of the injured (i.e. transferred to hospital, put to bed, sent home, returned to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 4. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. R.N. must complete physical assessment of resident of associated incident. On 02/02/24 at 1:14 PM, the surveyor informed the Licensed Nursing Home Administrator LNHA, DON, VPCO and Corporate Administrator of the above concerns. On 02/05/24 at 10:15AM, the DON provided the survey team with copies of hospital records including a copy of a left knee X-ray, dated 09/13/23 with findings of no fracture or dislocation. The facility did not provide any documentation including an investigation with any statements and confirmed that an incident report to determine the causal factor of the fracture of unknown origin was not completed. 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 revise a resident-centered on-going Care Plan (CP) for a resident who received oxygen therapy. This deficient practice was identified for 1 of 25 residents (Resident #47) reviewed for CP and was evidenced by the following: On 01/29/24 at 11:05 AM, the surveyor observed Resident #47 lying in bed. The resident was observed to be wearing a nasal cannula (nc) with oxygen tubing attached to an oxygen concentrator that was situated on the floor next to the bed. On 01/29/24 at 2:21 PM, the surveyor observed Resident #47 in his/her room lying in bed with a nc on, the oxygen tubing attached to an oxygen concentrator which was situated on the floor next to the bed. Resident #47 stated he/she was not aware of the amount of oxygen that he/she was receiving. A review of the admission Record revealed that Resident #47 had diagnoses which included but were not limited to; chronic respiratory failure with hypoxia (lack of oxygen), paraplegia (a type of paralysis), anemia, and Chronic Obstructive Pulmonary Disease (COPD). A review of the quarterly Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 12/27/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 15/15 which indicated the resident was cognitively intact. The MDS further indicated the resident received oxygen therapy while a resident at the facility. A review of the Order Summary Report included an order dated 08/30/22, for oxygen 2 LPM (liters per minute) via nc (nasal cannula) PRN (as needed) for SOB (shortness of breath) which was discontinued. An order dated 12/28/23, to apply oxygen per nasal cannula/mask at 2 lpm to keep oxygen sats (saturations- % of oxygen in the blood) equal to or above 92% every shift for SOB and as needed. A review of the resident-centered on-going CP failed to document a focus area, any goals, any interventions, or time frames regarding Resident #47's oxygen therapy. On 02/02/24 at 9:28 AM, the Director of Nursing (DON) stated in that the information in a resident's CP included anything that pertained to resident such as if the resident was on hemodialysis or had hypertension (elevated blood pressure). The DON stated that the nursing department would update their specific areas of a resident care plan. She stated that if there was a new order or diagnosis, the care plan should be updated within three days. The DON further stated that it was important to keep the CP updated and current because it is the patient centered care. On 02/02/24 at 9:51 AM, the Licensed Practical Nurse (LPN) Unit Manager (LPN/UM) stated oxygen should be included on a resident's care plan. She stated she was responsible to update the resident care plans on her unit. The LPN/UM and the surveyor reviewed Resident #47's Care Plan. The LPN/UM acknowledged oxygen should be on the care plan, but it was not documented. The LPN/UM further stated that it was important to have anything related to care on the care plan, so all staff would know how to care for a resident. A review of the facility provided, Staff Nurse job description, undated, included but was not limited to; develops a nursing care plan, individualizing the care, revises as necessary. Routinely assesses the needs of the resident and adjust the care plans as needed. Reviews care plan daily to ensure that appropriate care is being rendered. A review of the facility provided, Nurse Manager job description, undated, included but was not limited to; oversees or initiates care plans based on resident needs identified in the Resident Assessment Protocol and update care plans. A review of the facility provided, Director of Nursing job description, undated, included but was not limited to; assist an d participate in the developing for each resident the preliminary and comprehensive assessment and plan of care that identifies medical problems and/or needs of the resident and the goals to be accomplished for each problem and/or need identified participate in assessing reviewing and revising care plans as required. A review of the facility provided, Care Plans, Comprehensive Person-Centered policy updated 01/2023, included but was not limited to; Statement: Includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Interpretation and Implementation: 2. Interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. includes measurable objectives and timeframes; b. describes services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. incorporates identified problem areas; h. incorporates risk factors associated with identified problems; k. reflects treatment goals, timetables, and objectives in measurable outcomes; identify the professional services responsible for each element of care. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the conditions change. NJAC 8:39-11.2

Complaint #169841 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice by failing to: a.) follow a physician order for weights for 1 of 4 residents (Resident #95) reviewed for nutrition, and b.) administer physician prescribed medications and document physician notification for 1 of 4 closed records (Resident # 256) 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. a.) On 01/29/24 at 10:34 AM, during an interview with Surveyor #1 , Resident #95 was observed watching television in his/her room. The resident stated he/she had pancakes with bacon, milk, and coffee for breakfast. The surveyor observed an empty meal tray inside the room and on top of the nightstand. During an observation on 01/31/24 at 12:25 PM, the surveyor observed Resident #95 in the main dining area of Unit 3 and was sitting with peers having lunch. The lunch meal tray was observed to have beef goulash over noodles, mixed vegetables, and cake. The resident had consumed more than 50% of the meal at that time. A review of the medical record for Resident # 95 revealed that Resident #95 had a physician order dated 9/25/23 as follows: Weekly Weight, every day shift every Monday for monitoring document in weight binder. A review of the documented weights in the Electronic Medical Record (EMR) revealed the following weights: -9/26/2023 223.0 lbs (pounds) -10/10/2023 205.0 lbs -10/17/2023 102.2 lbs -10/25/2023 199.6 lbs -11/1/2023 200.0 lbs -12/1/2023 213 lbs - 12/5/23 210 lbs -1/2/2023 206.2 lbs The facility failed to follow the physician order written on 9/25/23 to obtain weekly weights for Resident #95. The facility documented 1 out of 4 weeks for the month of November 2023, 1 out of 4 weeks for the month of December 2023 and 1 out of 4 weeks in the month of January 2024. On 02/02/24 at 9:50 AM, surveyor interviewed the Registered Dietitian (RD). The RD stated that it was the responsibility of the Certified Nursing Assistant (CNA) and nurses to obtain the weights of the residents and log them into the weight binder. The RD stated after the weekly weights were documented in the weight binder by the nurses it was the RD's responsibility to transcribe them into the EMR. The RD also stated that the weekly weights needed to be logged in the EMR on Fridays every week, by the end of the day. The RD stated it was important to have the weights readily accessible in the EMR because they were used to monitor progress and make clinical judgements. The RD confirmed that the weekly weights should have been documented in the EMR for resident #95. During an interview with the surveyor on 02/02/24 at 10:13 AM, the Unit Manager Licensed Practical Nurse (UMLPN) for Unit 3 stated that resident had an order for weekly weights since 9/25/23. The UMLPN confirmed that the weekly weights were not documented in the EMR and they should have been. The UMLPN stated it is important to monitor for weekly weights to ensure the resident gets the proper nutrition. A review of the facility provided, Weight Assessment and Intervention policy interpretation and implementation updated 11/2023, included but was not limited to; #2. Weights will be recorded in the resident's electronic medical record, #8. It is the responsibility of the nursing to obtain and enter weights upon admission/readmission into the facility and also to obtain and enter daily weights as ordered by the MD (Medical Doctor). A review of the facility provided job description of the Dietitian, undated, included but was not limited to; Duties and Responsibilities: -Provides and maintains accurate documentation -Plans, implements, and reports on performance improvement activities and directs quality assurance audits -Ensures compliance with state and other regulatory agencies. b.) A review of the closed medical record for Resident #256 revealed diagnoses which included but were not limited to; acute myocardial infarction (tissue death of the heart muscle caused by a lack of oxygen), acute respiratory failure with hypoxia (lack of oxygen), hyperlipidemia (elevated fats in the blood), and pain. A review of the first assessment Minimum Data Set (MDS) an assessment tool used to facilitate resident care, dated 05/02/23, included but was not limited to; a Brief Interview for Mental Status of 15/15 which indicated the resident was cognitively intact. A review of the resident-centered on-going care plan included but was not limited to; focus area has constipation related to decreased mobility, pain with interventions that included to monitor medications for side effects. A focus area of altered cardiovascular status related to myocardial infarction. A review of the Order Summary Report included but was not limited to; a physician's telephone order dated 04/26/23, for Atorvastatin (medication to treat hyperlipidemia) 80 mg (milligrams) give one tablet by mouth one time a day. A physician's telephone order dated 04/26/23, Senna-S (sennosides-docusate sodium) (a medication to treat constipation) give two tablets by mouth at bedtime for constipation hold for LBM (loose bowel movements). A review of the Medication Administration Record (MAR) dated 4/1/23 through 4/30/23, included but was not limited to; the physician ordered Atorvastatin plotted for 1800 (6:00 PM) with an x for the date 4/26/23. The physician ordered Senna plotted for 2100 (9:00 PM) with an x for the date 4/26/23. The MAR had documentation that five other physician ordered medications were administered on the evening shift to Resident #256. The MAR contained chart codes which have a numeric value to explain why a medication was not administered. The MAR did not include the numeric value from the chart code for the Atorvastatin or the Senna only an x. The MAR did not reveal any circle or staff initial per facility policy to indicate the medication was either withheld, refused, or given at a time other than the scheduled time. A review of the Progress Notes (PN) included but were not limited to; documentation starting on 4/26/23. The PNs failed to include any documentation that the physician was notified that Resident #256 had not received his/her Atorvastatin or Senna. The PNs also failed to document any monitoring or response related to Resident #256s omission of the two medications. On 01/31/24 at 8:40 AM, Surveyor #2 interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The LPN/UM stated that if there was no documentation, the medication was not administered. The LPN/UM further stated that any medications not administered would be noted why and the physician would also be notified. On 02/05/24 at 10:10 AM, during an interview with the surveyors, the Director of Nursing (DON) was asked what the expectation was for the staff who administered medications. The DON stated the medication should be documented and that if it was not administered, the physician should be notified. A review of the facility provided, Staff Nurse job description, undated, included but was not limited to; Purpose: provide direct nursing care to residents under the medical direction of the residents; attending physicians Charting and Documentation duties: charts relevant, concise, and descriptive manner that reflects the care provided to the resident and the resident's response to care. Planning and Delivery of care: assures resident care delivery in accordance with facility policies and procedures. Is responsible for administering and documenting medications according to the physician's order. A review of the facility provided, Administering Medications policy, updated 1/2023, included but was not limited to; medications are administered in a safe and timely manner as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit. 17. For residents otherwise unavailable to receive medication, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 18. If a drug is withheld or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space for that drug and dose. A review of the facility provided, Documentation of Medication Administration policy, updated 1/2023, included but was not limited to; Interpretation and Implementation: 3. Documentation of medication includes as a minimum: f. reason(s) why a medication was withheld, not administered, or refused. A review of the facility provided, Charting and Documentation policy, updated 1/2023, included but was not limited to; Policy: all services provided 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition. 2. The following information is to be documented. b. medications administered. The facility failed to administer two medications to Resident #256. The facility failed to document the reasoning the medications were not administered or that staff contacted the physician regarding the medications for any physician orders if needed. NJAC 8:39-27.1, 29.3(5)

**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 follow physician orders for the oxygen settings at liters per minute (lpm). This deficient practice was identified for 2 of 2 residents (Resident #34 and #47) reviewed for oxygen and was evidenced by the following: a.) On 01/29/24 at 9:39 AM, the surveyor toured the Unit 2 and observed Resident #34 lying in bed awake and alert. The surveyor observed that Resident #34 had a nasal cannula (nc) on, and the tubing was attached to an oxygen concentrator which was situated on the floor next to the bed. The oxygen setting was 3.5 lpm. Resident #34 stated that staff had told him/her their oxygen level was low and he/she needed to use oxygen and he/she had never used oxygen before. Resident #34 stated the oxygen dries out my nose. A review of the admission Record revealed that Resident #34 had diagnoses which included but were not limited to; multiple sclerosis, Chronic Obstructive Pulmonary Disease (COPD) chronic respiratory failure with hypoxia (low oxygen levels), hemiplegia left side (unable to use the left side of the body), and difficulty in walking. A review of the Annual Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 11/17/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 14/15 which indicated Resident #34 was cognitively intact. Section GG revealed the resident was dependent on staff for toileting, shower/bathe, upper and lower body dressing; and the resident was not applicable to walk 10 feet or to sit to stand. Section O indicated the resident received oxygen therapy while a resident at the facility. A review of the Order Summary Report included but was not limited to; an order dated 09/11/23, O2 (oxygen) 2 L/min (liters per minute) via NC as needed for SOB (shortness of breath). A review of the resident-centered on-going care plan included but was not limited to; a focus area of ADL (Activities of Daily Living) self-care performance deficit related to activity intolerance. Interventions included resident requires staff assistance to turn and reposition, dress, hygiene, toileting, and to move between surfaces. A focus area of prescribed oxygen therapy, Related to Multiple Sclerosis. Interventions included monitor for signs and symptoms of respiratory distress. On 01/29/24 at 2:17 PM, the surveyor observed Resident #34's oxygen level at 3.5 lpm. This was not at the physician prescribed order of 2 lpm. On 01/29/24 at 2:27 PM, the direct care Licensed Practical Nurse (LPN) stated that Resident #34 had a physician order for oxygen at 2 lpm. The LPN stated that she checked the oxygen settings in the morning. The LPN and surveyor went into Resident #34's room. The LPN then acknowledged the oxygen was set at 3.5 lpm and stated it was too high. She further stated that oxygen at too high of a level can cause dryness and irritability to the resident. b.) On 01/29/24 at 11:05 AM, a surveyor observed Resident #47 lying in bed. The surveyor observed the resident was wearing a nc and the tubing was attached to an oxygen concentrator which was situated on the floor next to the bed. The surveyor observed that the oxygen was set to 5 lpm. On 01/29/24 at 2:21 PM, the surveyor observed Resident #47 in bed with the nc on, the tubing was attached to the oxygen concentrator which was situated on the floor next to the bed. The surveyor asked the resident if he/she knew what oxygen level he/she should be using. Resident #47 stated he/she believed it was ordered for 3 lpm. The surveyor observed the oxygen was set at 5 lpm. A review of the admission Record revealed that Resident #47 had diagnoses which included but were not limited to; Chronic Obstructive Pulmonary Disease (COPD), heart failure, chronic kidney disease, and anemia. A review of the quarterly MDS dated [DATE], included but was not limited to; a BIMS of 15/15 which indicated the resident was cognitively intact. Section O revealed that Resident #47 received oxygen therapy while a resident at the facility. A review of the Order Summary Report revealed an active order dated 12/28/23, apply oxygen per nasal cannula/mask at 2 liters/minute. A review of the Treatment Administration Record (TAR) dated 1/1/24 through 1/31/24, documented that on 01/29/24, the nurse on the day shift signed off that the oxygen at 2 lpm was administered. A review of the resident-centered on-going comprehensive care plan failed to document the resident's use of oxygen therapy, any focus area, goal, interventions, or time frames. On 01/29/24 at 2:35 PM, the direct care Registered Nurse (RN) stated that the night shift should check the oxygen settings for Resident #47 and stated, to be honest, I did not look at it [the oxygen setting] today. The RN and the surveyor went to the resident's room where the RN observed and acknowledged that Resident #47's oxygen was set to 5 lpm. The RN stated that oxygen set at that high of a level could blow his/her lungs out because he/she has a history of COPD. The RN was unable to adjust the oxygen level on the concentrator at that time, and the RN removed the concentrator and obtained and set up a new oxygen concentrator . On 01/29/24 at 2:39 PM, the LPN Unit Manager (LPN/UM) stated that the nurses should be checking the resident's oxygen settings every shift. She stated that if oxygen was set too high, a resident could become dependent on oxygen. She stated that Resident #34 had COPD and oxygen set too high can make the COPD worse. A review of the facility provided, Staff Nurse job description undated, included but was not limited to; execution of physician's orders periodic (at least daily) rounds to observe and evaluate the resident's physical and emotional status and to ensure continuing quality resident care. Is responsible for administering and documenting medications according to the physician order. A review of the facility provided, Oxygen Administration policy, updated 1/2023, included but was not limited to; Purpose: to provide guidelines for safe oxygen administration. Preparation: review the physician's orders . Steps: 7. Adjust the oxygen delivery device for the proper flow of oxygen. A review of the facility provided, Administering Medication policy, updated 1/2023, included but was not limited to; Purpose: medications are administered in a safe and timely manner and as prescribed. Policy: 4. administered in accordance with the prescriber's orders 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 ensure resident specific prescription medications were stored securely. This deficient practice was identified for 1 of 2 units (Unit 2) observed and was evidenced by the following: On 01/31/24 at 6:13 AM, the surveyor observed two nurses on Unit 2 working at their medication carts. One nurse was at the high end of the hall, and the second nurse was at the low end of the hall. Both nurses were observed actively working at their nursing carts. The surveyor walked down toward the low end of the hall, toward the middle of the unit and observed a third nursing medication cart. The third nursing medication cart was placed up against a wall across from the nursing desk. The surveyor observed six bingo cards (a pop out pill dispensing system) with resident names printed on them, with prescription medication inside the bingo cards, a container with a resident name printed on it that contained prescription eye drops, and a prescription inhaler system with a resident name on the label. The surveyor remained at the nursing desk and observed two housekeeping staff walking past the accessible, unsecured prescription medications. On 01/13/24 at 6:35 AM, one of the nurses who was identified as an agency Licensed Practical Nurse (LPN) approached the third medication cart with the unsecured prescription medications on top. At that time, the surveyor inquired why the medications were sitting on top of the medication cart. The LPN stated, logically they [the prescription medications] should be put away, but I did not sign for their delivery. The LPN opened the bottom drawer of the third medication cart and placed all the prescription medications that had been delivered inside the drawer and then locked the medication cart. On 01/31/24 at 6:37 AM, the second nurse who was identified as the facility Registered Nurse (RN) stated she had signed for the delivery of those medications but did not secure them because the LPN had the keys to the third medication cart. The RN stated that the medications should have been secured when they were delivered, and not left on top of the medication cart. On 01/31/24 at 8:38 AM, the Director of Nursing (DON) and the Unit 2 LPN Unit Manager (LPN/UM) were made aware of the prescription medications being unsecured and out of direct sight of the nurses for 22 minutes, and staff observed walking passed the medication on the unit. At that time, the DON stated the process was that medications would be delivered, and the nurses would be responsible to reconcile the medications against the delivery sheet from the pharmacy. She further stated that the medications would be given to the nurse who was responsible for that resident's medications in the medication cart. The DON stated that medications left unsecured on top of a medication cart was unacceptable because anyone could have taken them. On 01/31/24 at 9:14 AM, the 7:00 AM to 3:00 PM, RN on Unit 2 stated the process for prescription medication deliveries was that the nurse who accepted the delivery would reconcile the medications with the pharmacy delivery sheet. The medications would be delivered to their respective medication carts depending on the resident, and taken care of right away. Narcotics would require the signature of two nurses. The RN stated that prescription medication should never be left unattended because anyone, even residents, could take them. On 01/31/24 at 9:25 AM, the pharmacy consultant in the presence of the survey team, stated the nurses should have eyes on it [the delivered prescription medications] at all times. She further stated that all medications should be stored behind a lock, it is a law and that there could be residents who could swallow the unattended medications. The pharmacy consultant stated that medications were easy enough to pop out of the bingo cards. A review of the facility provided Packing Slip Proof of Delivery, dated 1/31/24, revealed that the agency LPN had signed for the pharmacy delivered medications at 5:28 AM. A review of the facility provided, Staff Nurse job description undated, included but was not limited to; performs all tasks in accordance with established policies and procedures. Ensures a safe environment. A review of the facility provided, Administering Medications policy updated 1/2023, included but was not limited to; 16. the medication cart is kept closed and locked when out of sight of the nurse. No medications are kept on top of the cart. The cart must be clearly visible must be inaccessible to residents or others passing by. A review of the facility provided, Storage of Medications policy, updated 1/2023, included but was not limited to; heading: store all drugs and biologicals in a safe, secure, and orderly manner. Interpretation and Implementation: 1 Stored in locked compartments Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage . in a clean, safe, and sanitary manner. 6. Compartments containing drugs and biologicals are locked when not in use. NJAC 8:39-27.1, 29.3(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to a.) properly don (put on) a Personal Protective Equipment (PPE) gown used to mitigate the spread of infection for Resident #306, 1 of 4 residents reviewed for Transmission Based Precautions (TBP) , b.) maintain appropriate infection control practices for 2 residents (Resident #106 and #306) with an indwelling urinary catheter, and c.) to perform appropriate hand hygiene during meal service on 1 of 3 units (Unit 3) for two meals. This deficient practice was evidenced by the following: a.) On 01/30/24 at 8:21 AM, Surveyor #1 observed a staff member outside of Resident #306's room. The surveyor observed signage posted at the door for enhanced barrier precautions which included but was not limited to; providers and staff must also: wear gloves and gown for the following high-contact resident care activities which included dressing and transferring. The surveyor observed a bin full of available PPE. At that time, a staff member approached Resident #306's room. The staff member was wearing a surgical mask and donned a PPE gown. The staff member failed to secure the PPE gown with the ties around her back. The staff member entered the room and explained to the resident she was there to help her get dressed and work with her. The staff member was in direct contact with the resident, the resident's bed, and kneeled down with the PPE gown freely flowing open and in direct contact with the resident and the resident's environment. At 01/30/24 at 8:28 AM, Resident #306's Licensed Practical Nurse (LPN) was in the hall outside of the resident's room. The LPN stated that the resident was on precautions because he/she had a nephrostomy (a tube into the kidney to facilitate removal of urine), a urinary tract infection, and sepsis. The LPN stated that to provide care, staff were to apply gloves and PPE. When asked about how to apply the PPE gown, the LPN replied to put the hole over the head, slide arms through, and tie it in the back in order to cover the entire body. She stated it needed to cover the staff completely in order to prevent infection on the staff and being transferred to other residents. The LPN knocked on the door, opened the door and was able to acknowledge that the staff member did not wear the PPE gown properly to prevent the spread of infection. The LPN and surveyor observed the staff member in direct contact with the resident and assisting the resident with dressing. The resident had his/her hands in the air and the Director of Therapy was actively assisting him/her putting on a top. On 01/30/24 at 8:34 AM, the staff member exited the room and was interviewed at that time. The staff member identified herself as the Director of Therapy. She stated the resident was on TBP because of an infection in the urine. She further stated that she was aware she had her PPE gown on incorrectly and that she just forgot. She stated that the importance of wearing the PPE was to ensure her whole body was covered to prevent infection. A review of the admission Record revealed that Resident #306 was recently admitted with diagnoses which included but were not limited to; urinary tract infection; sepsis due to Escherichia coli (E. coli a bacteria that can cause infection and can be spread easily), and anxiety. A review of the Order Summary Report revealed an order dated 1/28/24, Skilled PT [physical therapy] eval [evaluation] & tx [treatment] 4-6 x/wk [times a week] x 41 days or as tolerated for therapeutic exercise, therapeutic activities, neuromuscular re-education, gait training, bed mob [mobility]/transfer training, pt.[patient]/caregiver education, d/c [discharge] planning. A review of the resident-centered on-going care plan included but was not limited to; a focus area of ADL [activities of daily living] deficit related to impaired balance, limited mobility with interventions which included staff assistance which included bathing and dressing. A focus area requires enhanced barrier precautions related to (indwelling medical device, infection, or colonization with MDRO [multi drug resistant organism]. Interventions included but were not limited to; clear signage on the door indicating the type of precautions and required PPE. for Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. A review of the Physical Therapy Summary of Daily Skilled Services, dated 01/30/24, included but was not limited to; BLE [bilateral lower extremities] there [therapy] ex [exercise] for hip flex [flexion], 3 x 10 res [repetitions]. Dynamic standing balance. Gait training. Skilled interventions focused on transfer, training to increase functional task, performance, strengthening activities to increase functional performance . intermittent tactile cues/ intermittent physical assistance. Transfers sit to stand with minimum A [assistance]. On 01/30/24 at 9:22 AM, the LPN Infection Preventionist (LPN/IP) stated that the Director of Therapy had been educated in donning and doffing (removing) PPE. The LPN/IP stated that it was important to wear PPE correctly to protect the staff members clothes and prevent them from transmitting infection to other residents. A review of the facility provided In-Service, Droplet Precautions, Contact Precautions, EBP (Enhanced Barrier Precaution), hand hygiene and PPE Review, dated 12/26/23, included the Director of Therapy had attended and was educated. The education material included but was not limited to; clinical competency validation critical elements: Gowning 5. Pull gown on, making sure it completely covers clothing/torso. If it does not, use 2 gowns. [NAME] the first gown with opening to the front. Use the second gown over the first, with opening to the back. The facility included the competency that the Director of Therapy had demonstrated and passed, dated 12/26/23. A review of the facility provided, Enhanced Barrier Precautions Policy and Procedure, revised 7/22/22, included but was not limited to; Purpose: the implementation of EBP will reduce the transmission of resistant organism by employing targeted gown and glove use during high contact resident care activities. Policy: EBP will be implemented for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Nursing home residents with Indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. b.) On 01/29/24 at 10:25 AM, Surveyor #2 observed Resident #106 sitting in a wheelchair in the room with a urinary drainage leg bag attached to the resident's right leg. On 01/29/24 at 11:01 AM, Surveyor #2 returned to the room and found the resident was awake and alert and informed the surveyor he/she just returned from Physical Therapy (PT) and was tired. The surveyor asked for the resident's consent to check the bathroom. The surveyor then observed the Foley urinary catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The Foley urinary catheter drainage port was not capped. On 01/31/24 at 12:45 PM, Surveyor #2 entered the room and observed Resident #106 in bed. Surveyor #2 observed the Foley urinary catheter drainage bag inside a dignity bag rested in direct contact on the floor. The surveyor left the room and informed the LPN who was at the nurses station of the observation. The LPN went to the room, adjusted the bed and exited the room. On 01/31/24 at 1:15 PM, during an interview with the LPN, the LPN stated that the dignity bag should not be rested in direct contact on the floor to prevent infection. On 02/01/24 at 11:30 AM, Surveyor #2 observed the resident in bed. The urinary drainage dignity bag was noted in direct contact with the floor. The surveyor escorted the LPN to the room and she confirmed the surveyor's observations and repositioned the bed. A review of the admission Face Sheet (a summary assessment) reflected that Resident #106 was admitted to the facility with diagnoses which included but were not limited to; malignant neoplasm of bilateral ovaries, difficulty in walking and urinary retention. The admission Minimum Data Set (MDS) dated [DATE], reflected that Resident #106 had intact cognition. Resident #106 scored 15/15 on the Brief Interview for Mental Status (BIMS). The Comprehensive Care Plan dated 01/19/24, reflected that Resident #106 had an indwelling Foley urinary catheter related to urinary retention. The Order Summary Report dated 02/01/24, reflected an order to render indwelling Foley Catheter Care every shift and as needed. An interview with the LPN on 01/29/24 at 11:40 AM, revealed that the Certified Nursing Assistant (CNAs) were responsible to provide catheter care to the residents. The LPN stated, the CNAs would empty the drainage bag, and recorded and reported the urinary output to the nurse. The LPN added that during the day the CNAs would switch the Foley urinary catheter drainage bag to a leg bag to facilitate therapy. On 02/01/24 11:50 AM, Surveyor #2 interviewed the CNA regarding the storage of the Foley urinary catheter drainage bag. The CNA stated that the drainage bag should be capped to prevent infection. A review of the Progress Notes dated 01/16/24 timed 11:36 PM, revealed that the Foley urinary catheter tubing was noted with viscous white sediment. The physician was informed and ordered a urine analysis and culture and sensitivity to rule out a urinary tract infection. The urine specimen collected on 01/16/23 was positive for E.coli ( Escherichia coli) a bacteria which normally live in the intestines, and (Proteus Mirabilis) a gram-negative organism. Resident #106 was diagnosed with a Urinary Tract Infection (UTI). A review of the admission Face Sheet revealed that Resident #306 was admitted to the facility with diagnoses which included but were not limited to: Urinary Tract infection and sepsis due to to E.coli. The admission Care Plan dated 01/27/24, reflected that Resident #306 had a focus for Urinary Tract Infection related to E coli. The goal was the urinary tract infection will be resolved without complications. Interventions included: Encourage adequate fluid intake, monitor vital signs, obtain and monitor lab/diagnostic work as ordered . Resident #306 had also a focus for enhanced barrier precautions related to indwelling medical device: Nephrostomy tube. The goal was that Resident #306 will have no ill effects related to the enhanced barrier precautions. Interventions included: Clear signage must be posted on the door or wall outside of the resident room. Educate the resident /family and care giver on the importance of handwashing. The care plan did not provide the direct care staff directives regarding storage of the Foley catheter drainage bag to prevent infection. On 01/30/24 at 9:30 AM, Surveyor #2 observed Resident #306 sitting in the room with urinary collection leg bag attached to the right leg. The surveyor asked the resident if she could checked the bathroom. The resident agreed. The surveyor went to the bathroom and observed the Foley urinary catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The drainage port was not capped. On 01/31/24 at 9:40 AM, Surveyor #2 observed Resident #306 sitting in a wheelchair in the room with the urinary collection leg bag secured to the right leg. The surveyor went to the bathroom and observed the Foley catheter drainage bag stored in a plastic bag hung on the rail in the bathroom. The drainage port was not capped. The surveyor left the room and escorted the LPN to the bathroom. The LPN donned gloves and retrieved the Foley Catheter drainage bag from the plastic bag in the bathroom. The Foley catheter drainage bag was noted with cloudy residual urine, the bag dated 01/27, and the drainage port was not capped. The nurse stated that the bag should be rinsed and capped to prevent infection. On 01/31/24 at 9:52 AM, Surveyor #2 interviewed the CNA who cared for the resident. She acknowledged that she cared for Resident #306 that morning and disposed of the drainage bag in the receptacle bin. The surveyor went to the bathroom with the CNA and we both observed the Foley urinary catheter drainage bag stored in the plastic bag hung on the rail in the bathroom. When asked regarding catheter care, the CNA demonstrated to the surveyor how she switched the Foley urinary catheter drainage bag to the leg bag during care. She did not acknowledged that the drainage port needed to be disinfected before being connected. On 01/31/24 at 10:12 AM, Surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM) regarding Foley urinary catheter care. The LPN/UM revealed that the CNAs were to clean and observe the area around the catheter. The LPN/UM added that the residents would have the Foley urinary catheter drainage bag while in bed, but the leg urinary bag was being used during the day when the resident was up and in therapy. The Foley urinary catheter drainage bag was changed weekly and as needed. The CNAs were to wash their hands, explain the procedure to the resident, don gloves, cleanse the port with an alcohol swab and switch over to the leg urinary bag. The Foley urinary catheter drainage bag was to be rinsed of any residual urine, stored in a plastic bag in the bathroom with the drainage port capped. The LPN/UM stated that she was aware of the concerns, and she would consult with the Infection Preventionist (IP) and identify when the last in-service on Foley urinary catheter care was done. On 01/31/24 at 11:16 AM, the Director of Nursing (DON) provided an in-service sign-in sheet for the Foley urinary catheter policy and procedure dated 11/08/23. Both CNAs involved attended the in-service education. On 02/02/24, Surveyor #2 reviewed the facility's Policy/Procedure: Catheter Care, Urinary with a revision date of 08/2022 updated 1/2023, which included but was not limited to; Purpose The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control Use aseptic technique when handling or manipulating the drainage system Be sure the catheter tubing and drainage bag are kept off the floor. Cleaning drainage bags: Disconnect the drainage bag from the catheter; replace with a clean bag. Use a soft, plastic squirt bottle to rinse the used bag with tap water and drain. Cleanse the drainage bag with water' Drain the water, and allow the bag to air dry with the clam open. Use bleach that is not scented or concentrated. When using a water, use gloves, aprons, and goggles to protect from fumes and irritation caused by contact. After cleansing, air-dry the bag. After cleaning, cap drainage bag tubing between uses and disinfect the end of the tubing with alcohol before reconnecting it to the catheter. On 02/02/2024 at 1:14 PM, the survey team met with the administrative staff and informed them of the findings. On 02/05/24, the facility provided in-service education done on Foley urinary catheter care. No additional information was provided. Surveyor: Nocks, [NAME] L. c. On 01/31/24 from 7:31 AM to 7:49 AM, the surveyor observed the breakfast meal delivery on Unit 3. The meal trays were distributed from a meal cart and the surveyor observed two Certified Nurse Aides (CNA #1 and #2) distribute meals. CNA #1 was observed, wearing gloves in the hallway, then removed a meal tray from the meal cart. She then brought the meal tray to room [ROOM NUMBER], and proceeded to set the meal tray up for the resident, then without first removing her gloves and performing hand hygiene, she repeated the same observation in room [ROOM NUMBER], and #307 wearing the same gloves. The surveyeyor then interviewed CNA #1 regarding what should be done between the meal trays and setting up the residents. CNA #1 stated she knows she needed to use hand hygine (HH), howerver, there was no HH available in the hallway for the staff to use. The surveyor then interviewed the Unit Manager (UM) regarding the surveyor's observations. The UM stated that they should have had hand sanitizer on them and showed the surveyor a bottle that she had in her pocket, and stated hand sanitizer was also located behind the nurses station. On 01/31/24 at 12:09 PM, during the lunch meal service in the Unit 3, activities room, the surveyor observed six staff members deliver lunch trays to 13 residents without performing hand hygiene between residents. The surveyor did not observe any hand gel readily available to the staff in the activities room. The surveyor observed a CNA, using hand hold assistance, ambulated an unsampled resident and assisted the resident to a chair at a table. CNA#1 then went to the food cart and obtained the resident's lunch tray, placed it in front of the resident, removed the plate and juices from the tray and placed them on the table. CNA#1 returned the tray to the food cart. CNA#1 did not perform hand hygiene before proceeding to assist another resident. The surveyor observed CNA#2 assist an unsampled resident by adjusting his/her legs onto the wheelchair leg rests. CNA #2 then assisted another resident set up their juice on the table without performing hand hygiene between residents. On 01/31/24 at 12:17 PM, the surveyor interviewed an Activities Aide (AA) who stated that during lunch meal he would help pass out the lunch trays, make sure the diets are correct and that it was the correct lunch tray for the right resident. When asked if hand hygiene should be performed between residents, the AA stated I did not do it today because we were serving fast. I normally do but not today. On 01/31/24 at 12:21 PM, the surveyor interviewed CNA #1 who stated you're supposed to use hand hygiene between residents when serving trays but we don't have any. I know the rules but we don't have hand gel. The Handwashing/Hand Hygiene Policy, Adopted 11/2018 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 9. 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 practice for preventing healthcare-associated infections. NJAC NJAC 8:39-19.4 (a) (1)(5)

On 01/29/24 at 10:07 AM, Surveyor #2 was interviewing Resident #6 in his/her room. Resident #6 was lying in bed with the head of the bed elevated. Resident #6 had a supplement drink on the over bed table. The surveyor asked if he/she needed to use the call bell to request assistance with the supplement drink. Resident #6 stated, look behind me. Resident #6 next stated, I can't use the call bell because I haven't had one in a while. Resident #6 was unable to say how long his/her call bell was missing but stated that he/she relied on asking the roommate to call when needed. A review of the admission Record revealed Resident #6 had diagnoses which included but were not limited to; hypotension (low blood pressure), chronic kidney disease, dementia, congestive heart failure, and unsteadiness on feet. A review of the Annual Minimum Data Set (MDS) an assessment tool to facilitate resident care dated 12/23/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 10/15 which indicated Resident #6 had moderate cognitive impairment. Section GG - Functional Abilities and Goals revealed that Resident #6 was dependent on staff for toileting, shower/bathing, dressing, and personal hygiene. A review of the resident centered on-going care plan included but was not limited to; a focus area of ADL (Activities of Daily Living) self-care deficit related to limited mobility date imitated 6/22/18. Goals included ADL care needs will be anticipated and met. Interventions included dependent of 1 staff with showering; extensive assistance for bed mobility; extensive assist by 1 staff to dress; minimal assistance by 1 staff for oral care tasks; extensive assist by 1 staff for toileting; extensive assist by 1 staff to move between surfaces and as necessary; and encourage to use bell to call for assistance. On 01/29/24 at 10:09 AM, Surveyor #2 went to the Unit #2 nurse's desk and asked the Liscensed Practical Nurse Unit Manager (LPN/UM) to accompany the surveyor to Resident #6's room. The LPN/UM looked around the room and acknowledged there was no call bell available for Resident #6. The LPN/UM then stated it was important for all residents to have a call bell and that the call bell be within reach because the call bell was a resident's lifeline. At that time, Resident #6 stated to the LPN/UM and surveyor that he/she has had to rely on their roommate to call for help. On 02/02/24 at 9:47 AM, Surveyor #2 observed Resident #6 in bed. The surveyor did not observe a call bell. The surveyor asked Resident #6 if he/she had his/her call bell and the resident shook his/her head no. The surveyor looked for the call bell and observed it at the top of the bed above the residents pillow and was out of reach of the resident. On 02/02/24 at 9:49 AM, the second unit LPN/UM accompanied Surveyor #2 to the resident's room and acknowledged the call bell was not in reach of the resident. A review of the facility provided, Certified Nursing Assistant job description undated, included but was not limited to; answer resident calls promptly. Ensure a safe environment. A review of the facility provided, Staff Nurse job description undated, included but was not limited to; make (at least daily) rounds to evaluate and observe the resident's physical and emotional status and to ensure continuing quality of care. Answers call lights promptly. Ensures a safe environment. Ensures that resident who are unable to call for help are checked frequently. A review of the facility provided, Call Lights procedure updated 01/2023, included but was not limited to; Purpose: the light and/or sound system to alert staff to patient needs. Equipment: bedside call light with cord. Procedure: 6. Always position call light conveniently for use and within reach of the resident. 8. Check lights when providing care to ensure that cord length is appropriate, and that light is in working order. Report defective call lights promptly . NJAC 8:39-31.8 (9) Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure all residents had a call bell available and within reach to alert staff for assistance. This deficient practice was identified for 2 of 25 residents reviewed for call bells (Resident 100 and Resident #6) on 2 of 3 resident units (Unit #1 and #2) and was evidenced by the following: On 01/29/24 at 11:40 AM, while in the hallway on the Unit #1, Surveyor #1 heard a staff member calling on the nurse to assist with Resident #106. The surveyor followed the nurse and observed Resident #106 sitting on a low bed and had attempted to get out of the bed unassisted. The resident stated that he/she needed to go the bathroom. The surveyor did not observe a call bell located near the resident. On 01/29/24 at 12:11 PM, Surveyor #1 observed the resident in a recliner chair at the nurse's station. The surveyor attempted to interview the resident. The resident stated,I need to go to sleep and you should go to sleep. The surveyor returned to the room and observed the call bell was behind the dresser at the adjacent corner of the room. On 01/30/24 at 8:20 AM, Surveyor #1 observed Resident #100 in bed. The bed was in a low position with a floor mat on the right side of the bed. The call bell was noted in the same position, behind the dresser at the adjacent corner of the room. The call light was not accessible to the resident. On 01/30/24 at 9:00 AM, Surveyor #1 entered the room with the Licensed Practical Nurse (LPN). Surveyor #1 observed Resident #100 was awake in bed, and there was no call bell attached to the wall or within reach of the resident. The surveyor inquired to the LPN if she could show and activate the call bell for Resident #100. The nurse could not locate the call bell. The call bell was not attached to the bed. The nurse looked into the room and reached for the call light that was behind the dresser in the room. The nurse stated that the call light should be accessible and attached to the resident's blanket. On 01/30/24 at 9:12 AM, Surveyor #1 asked the Unit # 1 Licensed Practical Nurse /Unit Manager (LPN/UM) how the resident's care was communicated to the direct care staff. The LPN/UM revealed that in the morning the nurses would give report to the Certified Nursing Assistant (CNA). The surveyor then inquired regarding Resident #100's care. The LPN/UM stated that Resident #100 was confused at times, had poor safety awareness, and that all needs must be anticipated. The LPN/UM stated that Resident #100 can activate the call bell and the call bell should be within reach. On 01/30/24 at 11:19 AM, Surveyor #1 reviewed Resident #100's medical record. The admission Record revealed that Resident #100 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy, difficulty in walking and muscle weakness. The admission Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 01/15/24, reflected that Resident #100 had a moderately impaired cognition and scored 08/15 on the Brief Interview for Mental Status (BIMS). Review of Progress Notes dated 01/14/24 at 15:06 (3:06 PM), reflected that Resident #100 was alert with confusion and required substantial/maximum assistance of 2 persons for bed mobility. The comprehensive Care Plan dated 01/12/24 had a focus area for falls related to limited mobility. One of the goal was to place call light within reach at all times. Surveyor #1 observed Resident #100 in bed on 01/29/24 at 11:40 AM, 01/30/24 at 8:20 AM, and again at 9:00 AM. The call bell was not accessible to the resident.

Based on observation, interview, and document review it was determined that the facility failed to ensure meals were served at a palatable temperature for 6 of 6 residents who attended a resident council meeting, and on 2 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 01/30/24 at 11:04 AM, the surveyor conducted a resident council meeting with six residents. The surveyor inquired about the meals served and 6/6 residents interviewed stated the [hot food] was always served cold and especially the coffee. On 01/31/24 at 7:30 AM, surveyor #1 observed the meal truck enter Unit 3. The first meal tray was passed at 7:31 AM, and the last meal tray was passed at 7:49 AM. At that time, the surveyor removed the last meal tray and completed a test meal observation, in the presence of the Unit Manager Nurse, with the following recorded temperatures: Oatmeal: 136 degrees Farenheight (F) Sausage: *112 F 2 Pancakes: *120 F 4-ounce Orange Juice: *51 F 8-ounce Low Fat Milk: *56 F Coffee: *112 F On 01/31/24 at 8:40 AM, surveyor #2 observed the meal cart arrive on Unit 2 and the last tray was served at 8:50 AM. In the presence of a Certified Nurse Aide, surveyor #2 recorded the following food temperatures: Oatmeal: 148.5 F 2 Pancakes: *114.3 F Sausage: *111.7 F Coffee: 154 F 4- ounce Orange Juice: 42 F *Items did not meet Temperature Standards per the Test Tray form. On 01/31/24 at 8:00 AM, the surveyor entered the kitchen and observed the meal tray line was in progress. The RDFS was on the tray line and was serving the hot food items, with the FSD opposite of the RDFS preparing the trays. During the observation, the surveyor observed that pancakes were being served. The surveyor asked the RDFS what the hot food temperatures should be when the food reached the resident and he stated, no less than 145 degrees [Fahrenheit], and the temperatures were documented on the Test Tray form. On 01/31/24 at 8:06 AM, the surveyor reviewed the Test Tray form which revealed Temperature Standards Hot Entree: 130 F, Hot Beverage: 150 F, Juice: 50 F, Cold Beverage 45 F. On 02/01/24 at 12:32 PM, surveyor #1 interviewed the RDFS regarding the Temperature Standards on the Test Tray form. The RDFS confirmed to surveyor #1 that the Temperature Standards were the temperatures that the foods should be when the meals were served to the residents. The Test meal/Tray Audit Policy, dated 01/01/2024 revealed A test meal or tray audit will be conducted as deemed necessary to ensure proper temperatures and acceptable quality of all foods served. NJAC 8:39-17.4(a)2

Based on observation, interview, and document review it was determined that the facility failed to ensure a) the kitchen environment and equipment was maintained in a clean and sanitary manner, b) all food items were labeled with a use by date, and c) staff practiced appropriate hand hygiene during meal service to prevent the potential spread of food borne illness. The deficient practice was evidenced by the following: On 01/29/24 at 9:24 AM, the surveyor completed an initial tour of the kitchen with the Food Service Director (FSD) and the Regional Director of Food Service (RDFS) and observed the following: 1. The walk-in refrigerator unit identified as the cold cut box had debris and crumbs on the floor underneath the racks. The surveyor asked when the box was cleaned and the FSD stated, not as often as it should. The door gasket was visibly soiled and ripped. 2. The walk-in freezer unit had ice buildup by the door and the gasket was ripped. 3. The bread rack contained a package of rye bread that was dated with an expiration date of 01/22/24, and there was an unsealed package of hot dog rolls. The FSD discarded the items and stated, that's garbage. 4. A bag of rice and a bag of breadcrumbs were stored inside their bags, in a bin with crumbs on the bottom of the bin. 5. The wall by the affixed knife rack was soiled and two of the knives, identified as clean, were soiled. 6. Clean utensils, were hung directly next to the hand washing sink and the metal spoon and ladle had visible debris on them. On 01/31/24 at 8:00 AM, the surveyor entered the kitchen and observed the meal tray line was in progress. The RDFS was on the tray line and was serving the hot food items at that time, with the FSD opposite of the RDFS preparing the trays. During the observation, the surveyor observed that pancakes were being served and the surveyor asked the RDFS what the hot food temperatures should be when the food reached the resident. The RDFS stated , no less than 145 degrees [Fahrenheit]. The surveyor then continued to observe the ongoing tray preparation on the tray line. The RDFS was observed placing oatmeal by a ladle, utilizing his gloved hands, into a Styrofoam cup and then placed it on a plate. Then, without using a utensil, or first removing his gloves and performing hand hygiene, he proceeded to pick up two pancakes with his gloved hands, and then placed them on the resident meal plate. The surveyor observed that there was no serving utensils inside the pan of pancakes. The RDFS then touched a pink towel that was in front of the steam table with his gloved hands, and then turned around and opened the refrigeration unit that was behind him and used his gloved hand and removed an item. The RDFS, without first performing hand hygiene, continued to pick up two more pancakes with the same gloved hands. The RDFS then turned around and opened the hot box that was behind him, using the handle with the same gloved hands, and removed an omelet, closed the hot box, and then placed the omelet on a resident meal plate. Then, without performing hand hygiene, or removing the gloves, the RDFS picked up two more pancakes with his gloved hands and placed them on a resident meal plate. At 8:04 AM, the surveyor asked the RDFS if he should go back and forth and open and close doors and pick up pancakes with the same gloved hands, and he acknowledged he should not. The surveyor asked the FSD, who also observed the RDFS utilizing gloved hands to complete different tasks, then pick up food with the same gloved hands and plate the food. The FSD stated that food should not be touched with gloved hands. On 02/02/24 at 8:42 AM, in the presence of the survey team, the surveyor conducted an interview with the Regional Dietitian (RD). The surveyor informed the RD of the observations regarding the meal service that occurred on 01/31/24. The surveyor asked the RD if it was acceptable to touch foods directly with gloved hands, and then touch other non food items and continue to touch food with the same gloved hands. The RD stated no, that is not acceptable and the staff was trained to not do that. The Handwashing/Hand Hygiene Policy, Adopted 11/2018 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 9. 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 practice for preventing healthcare-associated infections. The Cleaning Policy, Updated 01/2023 revealed it is the responsibility of all staff to maintain sanitary standards in their areas and where needed per food service director. Fod Service Director: Execute daily sanitation audit to find deficient areas in kitchen and assign daily tasks to staff. Audit all staff tools from previous day. The Dining Service Inc., Dating Policy dated 01/01/2024 revealed Follow manufacturers expiration date on all un-opened products. All fresh and frozen foods must be dated with date it was received into the kitchen. NJAC 8:38-17.2(g)

Based on interview and document review it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility self-identified areas for improvement and followed the facility policy to ensure the Quality Assurance and Performance Improvement (QAPI) Program reviewed adverse events. This deficient practice occurred for 1 of 1 fractures of unknown origin and was evidenced by the following: Refer to 610G, 761E, 880E On 02/02/24 at 8:55 AM, the surveyor interviewed the LNHA, in the presence of the survey team, regarding what the process was to determine what became a QAPI. The LNHA stated I haven't done anything because I have only been here one month. The LNHA stated he had a meeting with his staff and the surveyor inquired as to what QAPIs were in place already. The LNHA stated that he started looking through the old LNHA's QAPI documents, but he did not get through all of it. The surveyor asked the LNHA how he established what is a high-risk concern and reviewed at QAPI, including adverse events like a reportable event (RE). The LNHA stated he was unaware if adverse events were tracked at the QAPI and that the Director of Nursing would know that information. When asked who was responsible for the QAPI process, the LNHA stated he took responsibility for the QAPI. The surveyor then asked if there was anything that would be considered high risk and he stated, Yes, I am sure that is why they would put it in QAPI. On 02/02/24 at 9:03 AM, the surveyor asked the LNHA to inform the surveyor regarding all the active QAPIs. The LNHA stated his current QAPIs included the following: 1. Housekeeping- mechanical lift pads were getting ripped off and torn. 2. Kitchen- cooks not logging temperature log right before they served the meals. 3. Therapy- orders. 4. Activities- related to picture consents. 5. Infection prevention- regarding water cups in rooms. 6. Material Data Set (MDS)- care plan reviews not signed off. 7. Business office- authorization forms and accounts resident accounts. 8. Nursing- Activity of Daily Living completion logs and completed documentation. On 02/02/24 at 9:10 AM, the LNHA stated he has not yet had a QAPI meeting. The surveyor inquired how the LNHA determine what is brought QAPI, and the LNHA stated maybe a grievance and we see if there are any issues with nursing. On 02/02/24 at 9:15 AM, the DON joined the interview with the LNHA. The surveyor asked the DON what her role was in QAPI process. The DON stated if we see any issues, and the LNHA stated with nursing we would use a root cause analysis and education. The surveyor asked the LNHA what a root cause analysis was and he stated, we do an investigation, in a sense. On 02/02/24 at 9:17 AM, the surveyor asked the DON if the current nursing QAPI plans included the folowing concerns that were identified during the survey: -Hand Hygiene, she responded- no. -Medication Receipt, she responded no. -Anything related to catheter use, she responded no. On 02/02/24 at 9:17 AM, the surveyor asked the DON if she brought any significant events/ or Reportable Events to QAPI and she stated, no. On 02/02/24 at 9:58 AM the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) regarding Reportable Events and the Quality Assurance and Performance Improvement process. The surveyor inquired about any recent significant events and the DON informed the surveyor about Resident #257 who sustained a fracture of unknown origin. The surveyor inquired further about what was completed regarding the incident, and the DON stated the resident fell at home and I just did an investigation and then provided the surveyor with a copy of a Reportable Event (a required document for a significant incident that must be submitted to the Department of Health). The surveyor asked the DON if she completed a root cause analysis regarding the fracture of unknown origin. The DON stated, no, that is QAPI, I just did an investigation, and stated the resident fell at home. The Qulaity Assurance and Perforamnce Improvement (QAPI) program-Feedback, Data and Monitoring policy revealed: The QAPI program is based on the collection information obtained from date, self-assessment and systems of feedback. Information is collected, evaluated and monitored by the QAPI committee.Policy Interpretation and Implementation: 1. Information obtained about the quality of care and services delivered to residents is evaluated and monitored by the QAPI committee in order to identify problems that are high risk, high volume or problem prone and to guide decisions regarding opportunities for improvement. 2. The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. The Quality Assurance and performance Improvement (QAPI) Program, Reviewed 5/2023 revealed: The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. The objectives of the QAPI Program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Authority, 3. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory requirements. Systematic Analysis and Systemi Action: Root Cause Analysis is used to fully understand systemic problems, causes of the problems, and implications for change. Teams are formed to identify the root cause and contributing factors of an issue employing the process of the Five Whys of root cause analysis. A thorough understanding of all possible causes or factors impacting the area of focus is critical to identify actions that maybe implemented or systemic changes that my be needed to employ for improvement. NJAC 8:39-27.1(a)

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ155753 Based on interviews, medical record review, and review of other pertinent facility documents on 5/8/2023 and 5/10/2023, it was determined that the facility failed to develop and implement an Incontinence Care Plan (CP) for a resident (Resident #18), dependent on staff for care. The facility also failed to follow its policy titled Care Plans, Comprehensive, Person-Centered. This deficient practice was identified for 1 of 19 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the admission Record (AR), Resident #18 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Kidney Failure, Unspecified Cerebral Infraction, Anemia, Heart Failure, and Hemiplegia and Hemiparesis. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/22/2022, Resident #18 had a Brief Interview of Mental Status (BIMS) score of 0/15, which indicated the resident was severely cognitively impaired. The MDS also showed Resident #18 was always incontinent of bowel and bladder and required two-person physical assistance for all ADLs and transfers. A review of Resident #18's CP initiated on 7/4/2021 did not reveal evidence of an incontinence CP being placed. During an interview on 5/10/2023 at 2:33 p.m., When asked by the Surveyor if Resident #18 should have had an incontinence CP in place, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated, Yes, there should have been a CP for Resident #18's incontinence. During an interview on 5/10/2023 at 2:49 p.m., the Director of Nursing (DON) stated, The purpose of the CP is to outline the different point of care for nursing staff, different goals they [the residents] might have. She stated that the incontinence CP should be initiated upon admission by Nursing in collaboration with Therapy. When presented with Resident #18's CP, the DON stated, I don't see a CP for incontinence; Yes, there should be an incontinence CP for every resident. A review of the facility's Care Plans, Comprehensive, Person-Centered revised 10/2022 under Policy: 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: Interpretation #8. The comprehensive, person-centered care plan will: b. describes the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being; #13. Assessments of the residents are ongoing, and care plans are revised as information about the residents and residents' condition change. #14. The interdisciplinary Team must review and update the care plan: a. when there is a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay. N.[NAME].C.: 8:39-11.2(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ163142 Based on interviews, medical record review, and review of other pertinent facility documents on 4/10/2023, 4/13/2023, and 4/19/2023, it was determined that the facility failed to revise the Care Plans after the Speech Therapist assessment for 5 of 19 residents (Resident #1, Resident, #2, #14, #15, and #17), with Physician's Orders for Chopped diets. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered, and the Speech Therapist Job Description. This deficient practice was evidenced by the following: Review of the Electronic Medical Records (EMRs) was as follows: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Multiple Sclerosis, Unspecified Heart Failure, Unspecified Hypothyroidism, and Paraplegia. According to the Minimum Data Set (MDS), an assessment tool dated 2/3/2023, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #1 needed total assistance with feeding and all Activities of Daily living (ADLs). Review of the Speech Therapy (ST) SLP Evaluation and Treatment Plan dated 4/6/2023 under Short-Term Goals revealed: Pt (patient) will consume a chopped diet texture with functional mastication and oral clearance in 95% of bites when fed by staff to minimize the need for further diet texture downgrade. Review of Resident #1's Order Summary Report (OSR) with a date range of 3/1/2023-3/31/2023 revealed a Physician's Order (PO's): Dietary-Diet Order Summary regular Chopped texture, Thickened Liquid Nectar consistency, extra gravy on the side, no straw with an order date of 4/7/2023. Review of Resident #1's Care Plan (CP) initiated on 5/11/2022 and revised on 4/2023 revealed under Focus: Nutrition: Resident is at risk for malnutrition. Under Goal included: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. [The] Resident will have weight stability . The CP also included under Interventions: Monitor intake PRN [as needed]. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN. Provide Diet as ordered. Provide with food/beverage preferences as available. Further review of Resident #1's CP showed no updates for the Chopped Diet order and the ST recommendation Chopped. 2. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Vascular Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction without residual deficits; and Type 2 Diabetes Mellitus with Hyperglycemia. According to the MDS, dated [DATE], Resident #2 had a BIMS score of 9/15, which indicated the Resident was moderately cognitively impaired. The MDS also showed Resident #2 needed supervision for transfers and was independent in eating with one person's physical assistance. Review of the Speech Therapy SLP Evaluation and Treatment Plan dated 11/1/2022 under Short-Term Goals revealed: Pt (patient) will consume a diet downgrade of chopped textures and ground meats employing compensatory swallowing strategies effectively 80% of the time with minimal cues. Review of Resident #2's Medication Review Report (MRR) with a date range of 3/1/2023-3/31/2023 revealed a PO's: Dietary-Diet Order Summary: CCD diet Chopped texture, Thin Liquids consistency, ground meats with an order date of 11/02/2022 and a start date of 11/02/2022. Review of Resident #2's CP initiated on 10/31/2022 and revised on 3/28/2923 revealed under Focus: Nutrition: Resident is overweight. Under Goal: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. [The] Resident will lose 1-2# wk [pounds per week] . The CP also included under Interventions: Monitor intake PRN. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN. Provide Diet as ordered. Provide with food/beverage preferences as available. Further review of Resident #2's CP showed no updates for the Chopped Diet order and the ST recommendation Chopped. 3. According to the AR, Resident #14 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Dysphagia Oral Phase, Orthostatic Hypertension, Acute Ischemic Heart Disease Unspecified and Edema. According to the MDS, dated [DATE], Resident #14 had a BIMS score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #14 was independent with feeding and needed minimal assistance with ADLs. Review of the Speech Therapy SLP Evaluation and Treatment Plan dated 4/18/2023 under Summary of Skills revealed: Physician's order received, chart reviewed, hx (history) noted, evaluation completed, and POT (Plan of Treatment) developed on this day and communicated with caregivers regarding recommendations. Pt to continue on a chopped diet texture. Review of Resident #14's OSR with a date range of 3/1/2023-3/31/2023 revealed a Physician's Order: Dietary-Diet Order Summary NAS [No Added Salt] CCD, Chopped texture; Thin liquid dated 7/6/2022. Review of Resident #14's CP initiated on 11/15/2023 under Focus: Nutrition: Resident requires more protein. Under Goal: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. The CP also included under Interventions: Monitor intake PRN. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN (as needed). Provide Diet as ordered. Provide with food/beverage preferences as available. Further review of Resident #14's CP showed no CP updates for the Chopped Diet order and the ST recommendation Chopped. 4. According to the AR, Resident #15 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Dysphagia, Oral Phase, History of Falls, Hypokalemia and Essential Hypertension. According to the MDS, dated [DATE], Resident #15 had a BIMS score of 7/15, which indicated the Resident was cognitively impaired. The MDS also showed Resident #15 was independent with feeding and needed total assistance with Activities of Daily living (ADL). Review of Resident #15's CP initiated on 12/13/2021 revealed under Focus: Nutrition: Diet texture has been altered due to dysphagia; Resident is at risk for malnutrition. Under Goal: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. [The] Resident will have weight stability . The CP also included under Interventions: Monitor intake PRN. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN (as needed). Provide Diet as ordered. Provide with food/beverage preferences as available. Further review of Resident #15's CP showed no CP updates for the Chopped Diet order and the ST recommendation Chopped. 5. According to the AR, Resident #17 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Dysphagia, Oral Phase, Muscle Weakness, Essential Primary Hypertension, and Alzheimer's Disease. According to the MDS, dated [DATE], Resident #17 had a BIMS score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #17 required setup with meals and total assistance with ADLs. Review of the Speech Therapy SLP Evaluation and Treatment Plan dated 3/30/2023 under Assessment Summary revealed: Assessment /Recommendations: Pt presents with oral stage dysphagia due to missing dentition needing a mechanically altered diet of chopped to facilitate ease of chewing. Recommend continuing current chopped Diet; no further Speech Therapy indicated. Review of Resident #17's MRR with a date range of 3/1/2023-3/31/2023 revealed a Physician's Order: Dietary-Diet Order Summary: CCD diet Chopped texture, Thin Liquids consistency, soft diet no coffee and tea for diet with an order date of 3/31/2023. Further review of Resident #17's CP showed no CP was initiated for the Chopped Diet order. Review of Resident #17's CP initiated on 3/31/2023 revealed under Focus: Nutrition: Diet texture has been altered due to difficulty chewing and dysphagia. Under Goal: Resident meal intake will be >50% (percent). [The] Resident will follow Diet as ordered. The Resident will not choke or aspirate. The CP also included under Interventions: Monitor intake PRN. Monitor Weights and Labs as avail [available]. Notify MD [physician] of any significant weight changes PRN (as needed). Provide Diet as ordered. Provide with food/beverage preferences as available. Further review of Resident #17's CP showed no CP updates for the Chopped Diet order and the ST recommendation Chopped. During an interview on 4/10/2023 at 11:23 a.m., the Dietitian stated that she is responsible for writing the CP. She stated that Speech Therapy downgraded Resident #2's Diet and was switched to a chopped texture and ground meat starting 10/28/2022. The Dietician further stated once a resident is screened, evaluated, and treated by the ST, the ST updates the CP with the ordered Diet for the Resident. During an interview on 4/19/2023 at 12:36 p.m., the Speech Therapist stated she put the diet order into point click care (PCC) after the results of her initial evaluation of the Resident. She continued to say that therapy has its own separate care plan, including the patient's focus, goal, and intervention to tolerate the least restrictive Diet. When asked by the Surveyor who writes the diet order on the CP, the Speech Therapist stated, The diet order is put on the CP by the Speech Therapist. She further stated the CP should include the diet texture and liquid consistency that the Resident is on. According to the Speech Therapist, Resident #2's CP should show Chopped Diet with ground meat and thin liquid. She explained, I would put this on in the therapy section on the CP. When presented with the CP for Resident #2, the Speech Therapist stated, I don't see my Speech CP on here, yes there should be one under the therapy section, and it should show the diet texture (chopped with ground meat) and fluid consistency (thin liquids) for [Resident #2]. During an interview on 4/19/2023 at 1:57 p.m., the Director of Nursing (DON) the purpose of the CP is patient-centered, regarding the patient's care. The DON stated nursing initiated the CP within 24-48 hours, and MDS has their time frame. The DON continued, If a resident comes in on a diet, the dietician updates the CP, and the dietician puts in their CP for the diet. It is usually a collaborative approach; the Dietician will include the diet texture the Resident is on. If there is an issue with the Diet on admission, the nurse will refer the Resident to speech to evaluate and treat the Resident if needed. When the Surveyor presented the CP to the DON and asked if the Diet was on the CP, the DON stated, No, there is no diet texture for Resident #2 on the CP; I will have to check the policy if speech puts the diet texture on the CP. Review of the facility policy titled Care Plan, Comprehensive Person-Centered, revised on 10/2019, under Policy, reveals: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical needs, psychosocial and functional needs are developed and implemented for each Resident. Under Policy Interpretation and Implementation #12. The comprehensive person-care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Review of the Speech Therapist Job Descriptions under Job Responsibilities revealed: 2. Document findings on the standardized evaluation format neatly, accurately, and adhering to all guidelines. 3. Provide a comprehensive treatment plan including long and short-term goals, frequency, duration and treatment modalities, therapeutic interventions, and clinical and technical guidelines. N.[NAME].C.: 8:39-11.2(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ155753, NJ163142 Based on interviews, medical record review, and review of other pertinent facility documents on 5/8/2023 and 5/10/2023, it was determined that the facility failed to follow professional standards of clinical practice by not administering medications and treatments as ordered by the Physician for 2 of 19 residents (Resident #2 and #18). The facility also failed to follow its policy titled Charting and Documentation. This deficient practice was evidenced by the following: A review of the Electronic Medical Records (EMRs) was as follows: 1. According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction without Residual Deficits; and Type 2 Diabetes Mellitus with Hyperglycemia. According to the Minimum Data Set (MDS), an assessment tool dated 2/4/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 9/15, which indicated the Resident had moderately impaired cognition. The MDS also showed Resident #2 needed supervision with transfers and was independent in eating with one-person physical assistance. A review of Resident #2's Medication Review Reports (MRRs) dated 03/01/2023 -03/31/2023 revealed the following Physician Orders (POs): Humalog KwikPen Solution Pen Injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial) Inject as per sliding scale subcutaneously before meals, order date 10/28/2022. Vital Signs every shift, order date 10/28/2022. A review of Resident #2's Medication Administration Record (MAR) dated 3/1/2023 through 3/31/2023 revealed the above-aforementioned POs were not documented on the following dates as being completed as follows: Humalog KwikPen Solution Pen Injector 100 UNIT/ML (Insulin Lispro (1 Unit Dial) Inject as per sliding scale subcutaneously before meals at 6:30 a.m. on 3/2/2023, 3/3/2023, 3/4/2023, 3/5/2023, 3/6/2023, 3/8/2023, 3/11/2023, 3/13/2023, 3/20/2023, and 3/28/2023 was blank. Vital Signs every shift on the day shift on 3/13/2023, 3/14/2023, and 3/16/2023 was blank. 2. According to the admission Record (AR), Resident #18 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Kidney Failure, Unspecified Cerebral Infraction, Anemia, Heart Failure, and Hemiplegia and Hemiparesis. A review of the MDS, dated [DATE], Resident #18 had a BIMS score of 0/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #18 was always incontinent of bowel and bladder and required two-person physical assistance for all ADLs and transfers. A review of Resident #18's Order Summary Report (OSR) dated 07/01/2021 -07/31/2021 revealed the following Physician Orders (POs): Apply skin prep to the left heel daily, dated 07/21/2021. Cleanse left lateral ankle with NSS (Normal Saline Solution). Apply Medihoney alginate to the opening. Cover with ABD (abdominal dressing) and Kling once daily every night shift, dated 07/14/2021. Cleanse left lateral foot with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift, dated 07/14/2021. Cleanse LLE (left Lateral extremity) with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift, dated 07/14/2021. Cleanse right ankle with NSS. Apply skin prep to surrounding skin daily on the day shift, dated 07/14/2021. Turn patient frequently and as tolerated each shift, dated 07/07/2021. Cleanse left trochanter (hip) with Dakin's 0.25% (half strength). Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 07/14/2021. Cleanse right Ischium with Dakin's 0.25% (half strength). Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 07/14/2021. Cleanse right trochanter (hip) with Dakin's 0.25% (half strength). Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 07/14/2021. Cleanse sacrum with Dakin's 0.25% (half strength). Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 07/14/2021. Fall Mat on both sides of the bed every shift for fall precautions. Order dated 07/07/2021. Heel protectors to BLL (bilateral lower extremities) every shift for heel protection to prevent DTI (deep tissue injury), dated 07/07/2021. Keep the bed in a low position when in bed every shift for fall precautions, dated 07/07/2021. O2 (oxygen) at 2L (liters) via NC (nasal cannula) every shift, dated 07/08/2021. A review of Resident #18's Treatment Administration Record (TAR) dated 07/1/2021 through 07/31/2021 revealed the aforementioned POs were not documented on the following dates as being completed as follows: Apply skin prep to left heel daily on 07/24/2021, was blank. Cleanse left lateral ankle with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift on 07/26/2021 was blank. Cleanse left lateral foot with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift on 07/26/2021 was blank. Cleanse LLE with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift on 07/26/2021 was blank. Cleanse right ankle with NSS. Apply skin prep to surrounding skin daily on the day shift on 07/24/2021, and 07/31/2021 was blank. Turn patient frequently and as tolerated each shift; on 07/24/2021 and 07/31/2021, on the day shift was blank. Cleanse left trochanter (hip) with Dakin's 0.25% (half strength). Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed on 07/24/2021 on the day shift was blank. Cleanse right Ischium with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed on the day shift on 07/24/2021 was blank. Cleanse right hip with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed on the day shift on 07/24/2021 and 07/31/2021 was blank. Cleanse sacrum with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed on the day shift on 07/24/2021 and 07/31/2021 was blank. Fall Mat on both sides of the bed every shift for fall precautions on 07/09/201 on the night shift and 07/31/2021 on the day shift was blank. Heel protectors to BLL every shift for heel protection to prevent DTI on 07/09/2021 on the night shift and 07/24/2021 on the day shift. 07/31/2021 was blank. Keep the bed in the low position when in bed every shift for fall precautions on the day shift on 07/09/2021 was blank. O2 (oxygen) at 2L via NC, every shift on the night shift, 07/09/2021 and 07/18/2021, was blank. A review of Resident #18's OSR dated 08/01/2021 - 08/31/2021 revealed the following POs: Apply skin prep to left heel daily on the day shift, dated 07/21/2021. Apply skin prep to the right knee daily on the day shift, dated 08/08/2021. Cleanse left lateral ankle with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift, dated 07/14/2021. Cleanse left lateral foot with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift, dated 07/14/2021. Cleanse LLE with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night, dated 07/14/2021. Cleanse right lateral ankle with NSS. Apply betadine, and cover with ABD and Kling once daily on the evening shift, dated 07/21/2021. Cleanse right ankle with NSS. Apply skin prep to surrounding skin daily on the day shift, dated 07/14/2021. Cleanse left ankle with NSS. Apply skin prep to surrounding skin daily on the day shift, dated 08/11/2021. Cleanse right knee with NSS. Apply Medihoney alginate. Cover with foam dressing once daily in the evening, dated 07/21/2021. Turn patient frequently and as tolerated each shift, dated 07/07/2021. Cleanse left hip with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/11/2021. Cleanse right Ischium with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/11/2021. Cleanse sacrum with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/11/2021. Apply skin prep to the left lateral foot every shift, dated 08/11/2021. Fall Mat on both sides of the bed every shift for fall precautions, dated 07/07/21021. Flush 30 ML (milliliter) of room temperature water prior to administration and after every shift, dated 08/03/2021. Heel protectors to BLE every shift to prevent DTI, dated 07/07/2021. Keep the bed in a low position when in bed every shift for fall precautions, dated 07/07/2021. A review of Resident #18's TAR dated 08/1/2021 through 08/31/2021 revealed the above-aforementioned POs were not documented on the following dates as being completed as follows: Apply skin prep to left heel daily on the day shift on 08/13/2021 was blank. Apply skin prep to the right knee daily on the day shift on 08/13/2021 was blank. Cleanse left lateral ankle with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night of 08/08/2021 was blank. Cleanse Left Lateral foot with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night of 08/08/2021 was blank. Cleanse LLE with NSS. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night of 08/08/2021 was blank. Cleanse right lateral ankle with NSS. Apply betadine, cover with ABD, and Kling once daily on the evening shift on 08/12/2021 was blank. Cleanse right ankle with NSS. Apply skin prep to surrounding skin daily on the day shift on 08/11/2021 was blank. Cleanse left ankle with NSS. Apply skin prep to surrounding skin daily on the day shift on 08/12/201 was blank. Cleanse right knee with NSS. Apply Medihoney alginate. Cover with foam dressing once daily in the evening of 08/12/2021 was blank. Turn patient frequently, and as tolerated, each shift on the day shift on 08/13/2021 was blank. Cleanse left hip with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and, as needed, on the evening shift on 08/12/2021 was blank. Cleanse right Ischium with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shift and as needed on the evening and night shift on 08/11/2021 was blank. Cleanse sacrum with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shift on the evening shift on 08/12/2021 was blank. Apply skin prep to the left lateral foot every shift on the evening shift on 08/12/201, and the day shift on 08/13/2021 was blank. Fall Mat on both sides of the bed, every shift for fall precautions on the night shift on 08/08/2021 and the day shift on 08/12/2021 was blank. Flush 30 ML (milliliter) of room temperature water prior to administration and after every shift on the night shift on 08/08/2021 was blank. Heel protectors to BLE every shift for heel protectors to prevent DTI on the night shift on 08/08/2021, and the evening shift on 08/12/2021 was blank. Keep the bed in a low position when in bed every shift for fall precautions on the night shift on 08/08/201 and the evening shift on 08/12/2021 was blank. A review of Resident #18's Order Summary Report (OSR) dated 09/01/2021 -09/30/2021 revealed the following Physician Orders (POs): Cleanse the right trochanter with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/24/2021. Cleanse sacrum with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/24/2021. Apply skin prep to the left lateral foot every shift, dated 08/24/201. Cleanse left trochanter with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/24/2021. Cleanse right Ischium with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/24/2021. Cleanse left and right buttocks along with tailbone with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts and as needed, dated 08/24/2021. Apply skin prep to the right knee daily, every shift, dated 08/24/2021. Contact precautions for ESBL (extended-spectrum beta-lactamase) of the right hip wound every shift. Order dated 08/24/2021. Flush 30 ML of room temperature water prior to administration and after every shift, dated 08/24/2021. Cleanse right malleolus with Dakin's 0.25%. Apply Medihoney alginate to the opening. Cover with ABD and Kling once daily on the night shift, dated 08/24/2021. A review of Resident #18's Treatment Administration Record (TAR) dated 09/1/2021 through 09/30/2021 revealed the above-aforementioned POs were not documented on the following dates as being completed as follows: Cleanse the right trochanter with Dakin's 0.25%. Pack with Dakin's-soaked gauze loosely. Cover with foam dressing twice daily every evening and night shift and as needed on the evening shift on 09/07/2021 was blank. Cleanse sacrum with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shift and as needed on the evening and night shift on 09//05/2021 and 09/07/2021 was blank. Apply skin prep to the left lateral foot every shift on the evening shift on 09/05/2021, and the evening and night shifts on 09/07/2021 was blank. Cleanse left trochanter with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts on 09/05/2021 and 09/7/2021 was blank. Cleanse right Ischium with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts every evening on 09/05/2021, and 09/07/2021 was blank. Cleanse left and right buttocks along with tailbone with Dakin's 0.25%. Pack with Dakin's soaked loosely. Cover with foam dressing twice daily on the evening and night shifts, on the evening shift on 09/05/2021, and on the evening and night shift on 09/07/2021 was blank. Apply skin prep to the right knee daily every shift on 09/05/2021 on the evening shift and 09/07/2021 on the evening and night shifts was blank. Contact precautions for ESBL of the right hip wound every evening and night shift on 09/07/2021 was blank. Flush 30 ml of room temperature water prior to administration and after every shift on 09/07/2021 on the evening and night shifts was blank. Cleanse right malleolus with Dakin's 0.25%. Apply Medihoney alginate to the opening. Cover with ABD and Kling on the night shift on 09/07/2021 was blank. During this survey, the Surveyor attempted to reach the Nurses involved with the blank spaces on the TAR, but they were not available for interviews. During an interview on 5/8/2023 at 2:15 p.m., when the Surveyor asked the Unit Manager/Licensed Practice Nurse (UM/LPN) in Unit 3 what the meaning of blank spaces on the MARs meant, she replied, The blank spaces mean the medication was not given, or the medications were not signed for [at the time given]. She continued to say the expectation is for the MARs to be documented right after the medication is given. During an interview on 5/8/2023 at 3:07 p.m., when the Surveyor asked the Director of Nursing (DON) what the meaning of blank spaces is, she replied, The blank spaces mean it [the medication] wasn't signed off on if a Blood Sugar (BS) is blank, I have to interview the nurse to know more. The DON continued, The expectation is the MAR is to be documented as soon as it's [the medication] done. During a telephone interview on 5/8/2023 at 4:06 p.m., when the Surveyor asked the LPN who cared for Resident #2 on the 11:00 p.m.-7:00 a.m. shift on 3/2/2023, 3/3/2023, 3/4/2023 and 3/5/2023, about the blank spaces on the MARs, he replied the blank spaces on the MAR mean the medication wasn't given or it [the medication] wasn't signed off . During an interview on 5/10/2021 at 2:27 p.m., the Registered Nurse (RN) informed the Surveyor that the Nurse is responsible for completing the treatment orders for the Resident. She stated, The treatment should be documented on the TAR when completed. When asked if there should be any blank spaces on the TAR, the RN said, No, there should be no blank spaces on the TAR. During a second interview on 5/10/2021 at 2:49 p.m., when the Surveyor asked the Director of Nursing (DON) what the meaning of blank spaces is, she replied, The blank spaces mean it [the treatment] wasn't done. The DON continued, The expectation is for the LPN to document on the TAR after completion of a treatment. A review of the policy titled Charting and Documentation with an updated date of 1/2022 revealed Under Policy Statement included: 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. The medical record should facilitate communication between the interdisciplinary team regarding the Resident's condition and response to care. Under Policy Interpretation and implementation, included: 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: .b. Medications administered; c. Treatments or services performed; .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the Resident tolerated the procedure/treatment; e. Whether the Resident refused the procedure/treatment; f. Notification of family, Physician, or other staff, if indicated; and g. The signature and title of the individual documenting. N.J.A.C.: 8.39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ155753, NJ163142 Based on observations, interviews, review of the medical record, and other pertinent facility documents on 5/8/2023 and 5/10/2023, it was determined that the facility failed to consistently document Activities of Daily Living care as being provided to residents (Resident #6, #11, #12, #18 and #19). The facility also failed to follow its Certified Nursing Assistant's job description and its policy titled Activities of Daily Living (ADLs) Supporting for 5 of 19 residents reviewed. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #6 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Schizoaffective Disorder, Bipolar Type, Unspecified Alzheimer's Disease, Anxiety Disorder, and Unspecified Glaucoma. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/17/2023, Resident #6 had short-term and long-term memory problems. The MDS also indicated the resident had severe cognitive impairment and required 1-person physical assistance with ADLs and transfer. A review of Resident #6's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for May 2023, showed blank spaces indicating the tasks were not completed as follows: Bladder Documentation on 5/3/2023 and 5/4/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023, and the 3:00 p.m. to 11:00 p.m. shift. Bowel Documentation on 5/3/2023, 5/4/2023, and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Fall Observation on 5/3/2023 and 5/4/2023 from 11:00 p.m. to 7:00 a.m. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Bathing on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Bed mobility on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Dressing on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Locomotion off Unit on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on Unit on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Personal Hygiene on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Toilet Use on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Transferring on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Walk-in Hall/Corridor on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Walk-in Room on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Behavior monitoring and interventions on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Oral care on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Skin Observation on 5/7/2023 from 3:00 p.m. to 11:00 p.m. Turn and Repositioned on 5/3/2023 and 5/4/2023 on the 11:00 to 7:00 a.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Assist of 1 for meals on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Meal Intake on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. Hs Snack on 5/7/2023 on the 3:00 p.m. to 11:00 p.m. shift. 2. According to AR, Resident #11 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Muscle Weakness, Essential Hypertension, Unspecified Anxiety Disorder, and Rheumatoid Arthritis. A review of the MDS dated [DATE], Resident #11 had a BIMS score of 3/15, which indicated the resident had severe cognitive impairment. The MDS also showed Resident #11 was dependent on staff for all ADLs. A review of Resident #11's v2, for May 2023, showed blank spaces indicating the tasks were not completed as follows: Personal Hygiene on 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. Toilet Use on 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. Bladder Documentation on 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. Bowel Documentation on 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Fall Observation on 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. Turn and Repositioned on 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. 3. According to the AR, Resident #12 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Unspecified Focal Traumatic Brain Injury with Loss of Consciousness, Essential hypertension, Unspecified Hypotension, and Unspecified Dementia. A review of MDS dated [DATE], Resident #12 had a BIMS score of 3/15, which indicated the resident had severe cognitive impairment. The MDS also showed Resident #12 was dependent on staff for ADLs. A review of Resident #12's v2, for May 2023, showed blank spaces indicating the tasks were not completed as follows: Dressing on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Locomotion on Unit on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Personal Hygiene on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Toilet Use on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 a.m. to 7:00 a.m. shift. Transferring on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Walk-in Hall/Corridor on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Walk-in Room on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Behavior Monitoring on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Bladder Documentation on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Bowel Documentation on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Fall Observation on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Oral care on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift, Skin Observation on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. On 5/6/2023 and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. Turn and Repositioned on 5/2/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/6/2023, on the 7:00 a.m. to 3:00 p.m. shift. Eating: able to feed self independently after set-up on 5/2/2023 and 5/8/2023 at 5:00 p.m. and on 5/6/2023 at 8:00 a.m. and 12:00 p.m. Bathing on 5/6/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/8/2023, on the 3:00 p.m. to 11:00 p.m. shift. Bed Mobility on 5/6/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/8/2023, on the 3:00 p.m. to 11:00 p.m. shift Meal intake on 5/6/2023 at 8:00 a.m. and 12:00 p.m. and 5/8/2023 at 5:00 p.m. 4. According to the AR, Resident #18 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Kidney Failure, Unspecified Cerebral Infraction, Anemia, Heart Failure, and Hemiplegia and Hemiparesis. A review of the MDS dated [DATE], Resident #18 had a BIMS score of 0/15, which indicated the resident had severely impaired cognition. The MDS also showed Resident #18 was totally dependent on staff with ADLs. A review of Resident #18's v2, for July 2021, showed blank spaces indicating the tasks were not completed as follows: Bathing on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/18/2021, 7/25/2021, and 7/27/2021 on the 3:00 p.m. to 11:00 p.m. shift. On 7/20/2021,7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Bed Mobility on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/18/2021,7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift, on 7/20/2021, 7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Dressing on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/18/2021,7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion off Unit on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on Unit on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. Personal Hygiene on 7/17/2021,7/18/202,7/21/2021,7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. Toilet Use on 7/17/2021, 7/18/202, 7/21/2021, 7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift, on 7/20/2021, 7/23/2021, and 7/29/2021, on the 11:00 p.m. to 7:00 a.m. shift. Transferring Total lift on 7/17/2021, 7/18/202, 7/21/2021, 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. Bladder Documentation on 7/17/2021, 7/18/2021, 7/21/2021, 7/28 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift, on 7/20/202, 7/23/2021, 7/28/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Bowel Documentation on 7/17/2021, 7/18/2021,7/21/2021, 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/18/2021, 7/25/2021, and 7/27/2021 on the 3:00 p.m. to 11:00 p.m. shift. On 7/20/2021, 7/21/2021, 7/23/2021,7/28/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Fall Observation on 7/17/2021, 7/18/2021, 7/21/2021, 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 7/20/2021, 7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Oral care on 7/17/2021, 7/18/2021, 7/21/2021, 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 7/25/2021 and 7/27/2021 on the 3:00 p.m. to 11:00 p.m. shift. Skin Observation on 7/17/2021, 7/18/2021, 7/21/2021, 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, n 7/18/2021,7/25/2021, and 7/27/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 7/20/2021, 7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Turned and Repositioned 7/17/2021, 7/18/2021, 7/21/2021, and 7/28/2021 through 7/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 7/18/2021, 7/25/2021, and 7/27/20221 on the 3:00 p.m. to 11:00 p.m. shift, on 7/20/2021, 7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Low Bed on 7/22/2021 and 7/23/2021, and 7/29/2021 on the 11:00 p.m. to 7:00 a.m. shift, 7/25/2021, and 7/27/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 7/28/2021 through 7/31/2021, on the 7:00 a.m. to 3:00 p.m. shift. A review of Resident #18's v2, for August 2021, showed blank spaces indicating the tasks were not completed as follows: Bathing on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Bed Mobility on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021 and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift Dressing on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Locomotion off Unit on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on Unit on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Personal Hygiene on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021and 8/31/2021, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Toilet Use on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021 and 8/30/2021, on 8/5/2021, 8/7/2021, 8/8/2021, 8/15/2021, 8/29/2021 and 8/31/2021 on the 11:00 p.m. to 7:00 a.m. shift. Air Mattress on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 8/5/2021, 8/7/2021, 8/14/2021, 8//29/2021, and 8/31/2021 on the 11:00 p.m. to 7:00 a.m. shift. Bladder Documentation on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift., on 8/5/2021, 8/7/2021, 8/14/2021, 8//29/2021, and 8/31/2021 on the 11:00 p.m. to 7:00 a.m. shift. Bowel Documentation on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 8/3/2021, 8/5/2021, 8//7/2021, 8/8/2021, 8/14/2021, 8/29/2021, and 8/31/2021, on the 11:00 p.m. to 7:00 a.m. shift. Fall Observation on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 8/3/2021, 8/5/2021, 8//7/2021, 8/8/2021, 8/14/2021, 8/29/2021, and 8/31/2021, on the 11:00 p.m. to 7:00 a.m. shift. Low Bed on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift, on 8/5/2021, 8/7/2021, 8/8/2021, 8/14/2021, and 8/29/2021 on the 11:00 p.m. to 7:00 a.m. shift. Oral Care on /1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Skin Observation on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. Turn and Repostioned on 8/1/2021, 8/2/2021, 8/4/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/13/2021, 8/15/2021, 8/17/2021 and 8/31/2021 on the 7:00 a.m. to 3:00 p.m. shift, on 8/3/2021, 8/5/2021, 8/6/2021, 8/8/2021, 8/9/2021, 8/15/2021, and 8/30/2021 on the 3:00 p.m. to 11:00 p.m. shift. A review of Resident #18's v2, for September 2021, showed blank spaces indicating the tasks were not completed as follows: Bathing on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Bed Mobility on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Dressing on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion off Unit on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on Unit on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Personal Hygiene on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Toilet Use on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Transferring Total Lift on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Air Mattress on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 9/4/2021, on the 11:00 to 7:00 a.m. shift. Bladder Documentation on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 9/4/2021, on the 11:00 to 7:00 a.m. shift. Bowel Documentation on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 9/4/2021, on the 11:00 to 7:00 a.m. shift. Fall Observation on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 9/4/2021, on the 11:00 to 7:00 a.m. shift. Low Bed on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. On 9/4/2021, on the 11:00 to 7:00 a.m. shift. Oral care on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. Skin Observation on 9/1/2021, 9/3/2021, 9/7/2021, and 9/8/2021 on the 7:00 a.m. to 3:00 p.m. shift. On 9/4/2021, on the 3:00 p.m. to 11:00 p.m. shift. 5. According to the AR, Resident #19 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Heart Failure, Unspecified Anxiety Disorder, and Bell's Palsy. A review of the MDS dated [DATE], Resident #19 had a BIMS score of 8/15, which indicated the resident had moderately impaired cognition. The MDS also showed Resident #19 was totally dependent on staff with ADLs. A review of Resident #19's v2, for May 2023, showed blank spaces indicating the tasks were not completed as follows: Bowel Documentation 5/3/2023, 5/4/2023, 5/6/2023, and 5/9/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Bladder Documentation on 5/3/2023, 5/4/2023, and 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023 and 5/8/2023 on the 3:00 p.m. to 11:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Fall Observation 5/3/2023, 5/4/2023, and 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Turn and Repositioned on 5/3/2023, 5/4/2023, and 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Toilet Use on 5/3/2023, 5/4/2023, and 5/6/2023 on the 11:00 p.m. to 7:00 a.m. shift. On 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Bathing on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Bed Mobility on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Dressing on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion off Unit on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on Unit on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Personal Hygiene on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Transferring on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Walk-in Hall/Corridor on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Walk-in Room on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Behavior Monitoring and Interventions on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Oral care on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Skin Observation on 5/7/2023 and 5/8/2023 on the 7:00 a.m. to 3:00 p.m. shift. On 5/7/2023, on the 3:00 p.m. to 11:00 p.m. shift. Eating: Feeds self after the tray is set up on 5/7/2023 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Meal Intake on 5/7/2023 at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Hs Snack on 5/7/2023 at 8:00 p.m. A review of the resident's EMRs for Resident #6, #11, #12, #18, and #19 showed no further evidence that the tasks mentioned above were completed. During an interview on 5/10/2023 at 12:44 p.m., the Certified Nursing Assistant (CNA) stated, If the ADLs sheet is blank [not initialed], then it [care] was not done [completed]. When presented with the printed copy of the ADLs sheets, the CNA stated, The blanks will indicate that the task was not completed. She further stated, There should be no blanks on the ADLs sheet; it [the task] should be documented at the end of each shift. During an interview on 5/10/2023 at 2:29 p.m., the Director of Nursing (DON) stated, The CNAs provide ADLs for the residents, and it is documented on the kiosk (an electronic medical device used to store patients' medical information) at the end of each shift. She further stated, There should be no blank spaces on the kiosk. When presented with the printed ADLs sheets from the kiosk, the DON stated, Looking at the ADL sheets with the blank spaces, that means the tasks were not completed. A review of the facility's policy last updated on 10/2021, titled Activities of Daily Living (ADLs), Supporting, under Policy Statement Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal oral Hygiene. Policy Interpretation and Implementation revealed: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. elimination (toileting); d. Dining (meals and snacks). A review of the updated facility's document titled Certified Nursing Assistant Job Description reveals under Purpose of Your Job Position: To provide each of your assigned residents with routine daily nursing care services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing the facility. Under Duties and Responsibilities, revealed: Perform all assigned tasks in accordance with our established policies and procedures and as instructed by your supervisors. NJAC 8:39-35.2 (a)(g)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ155753, NJ163142 Based on interviews, medical record review, and review of other pertinent facility documents on 5/8/2023 and 5/10/2023, it was determined that the facility failed to ensure that the Physician responsible for supervising the care of residents conducted face-to-face visits and write progress notes at least every 60 days for 8 of 19 residents (Resident #2, #3, #7, #10, #11, #15, #17, & #18). The facility also failed to follow its policy titled Physician Visits and the Medical Practice Agreement. This deficient practice was evidenced by the following: A review of the Electronic Medical Records (EMRs) was as follows: 1. According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction without Residual Deficits; and Type 2 Diabetes Mellitus with Hyperglycemia. A review of the Physician/NP (Nurse Practitioner)/PA (Physician's Assistant) Progress Notes (PPNs) revealed that from 1/19/2023 through 3/20/2023, the Nurse Practitioner (NP) documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #2's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 2. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Primary Generalized (Osteo) Arthritis, Encounter for Palliative Care, and Unspecified Anemia. A review of the PPNs revealed that from 1/19/2023 through 3/20/2023, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #3's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 3. According to the AR, Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Recurrent Major Depressive Disorder, Unspecified Protein-Calorie Malnutrition, and Other Asthma. A review of the PPNS revealed that from 9/15/2022 through 3/20/2023, the Physician did a face-to-face visit with the Resident only on 3/20/2023; the other visits were with the NP. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #7's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 4. According to the AR, Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Essential Primary Hypertension. A review of the PPNs revealed from 3/31/2023 through 4/3/2023; the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #10's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 5. According to the AR, Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Unspecified Chronic Obstructive Pulmonary Disease. A review of the PPNS revealed from 3/14/2023 through 4/10/2023, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #11's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 6. According to the AR, Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Focal Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, Subsequent Encounter, and Unilateral Inguinal Hernia, Without Obstruction or Gangrene, Not Specified as Recurrent. A review of the PPNS revealed that from 03/14/2023 through 4/10/2023, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #12's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 6. According to the AR, Resident #15 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4 Chronic Kidney Disease or Unspecified Chronic Kidney Disease and Adjustment Disorder with Depressed Mood. A review of the PPNS revealed that from 03/20/2023 through 4/25/2023, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #15's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 7. According to the AR, Resident #17 was admitted on [DATE] with diagnoses which included but were not limited to Fracture of Unspecified Part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, and Gastro-Esophageal Reflux Disease Without Esophagitis. A review of the PPNS revealed that from 3/31/2023 through 4/3/2023, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #17's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. 8. According to the AR, Resident #18 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Kidney Failure, Unspecified Cerebral Infraction, Anemia, Heart Failure, and Hemiplegia and Hemiparesis. A review of the PPNS revealed that from 7/12/2021 through 9/8/2021, the NP documented that she had seen the Resident and completed the visit. However, there was no documentation provided by the facility to the Surveyor at the time of the survey that Resident #18's primary Physician had conducted alternating face-to-face visits with the Resident while working in collaboration with the Nurse Practitioner's visits. During an interview on 5/10/2023 at 10:08 a.m., when the Surveyor asked the Administrator and the Director of Nursing (DON) should the Physician be doing regular visits, the Administrator stated, Yes, the doctors [physicians] should be making rounds to assess and [to] document on the residents according to our Policy. The Administrator continued, I would say the doctor did not follow our policy to come in and assess the resident[s] and document . At the time of the survey, the Surveyor attempted to contact the Physician, but they were unavailable for an interview. A review of the facility's policy titled Physician Visits with an updated date of 1/2022 revealed, The Attending Physician must make visits in accordance with applicable state and federal regulations. Under Policy Interpretation and Implementation included: 1. The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems cannot be handled readily by phone. 2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the Resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Medical Practice Agreement included the following: The purpose of this agreement is to achieve a high level of quality healthcare for each facility resident. This agreement defines the relationships among the attending physicians, the medical director, and the facility. Under provisions of care, I will visit my patients in the facility as required by regulation and consistent with good medical practice. N.J.A.C.: 8.39-27.1 (a)

C#: NJ155753, NJ163142 Based on observation, interview, and record review on 05/08/2023, it was determined that the facility failed to ensure that the Dietary Aides had specific competencies to meet the nutritional needs of the residents. This deficient practice was evidenced by the following: During an interview on 4/10/2023 at 4:10 p.m., the Dietary Director (DD) stated, Certified Nursing Assistants (CNAs) and Nurses continued to be in serviced if they get an incorrect tray, it should be sent back to the kitchen, and the kitchen staff would be educated on the proper diet texture, specific diets, as well as diabetic, heart healthy diets as to what they are and what not to provide to those residents. She further stated continuous education is being provided to all Dietary and nursing staff so that we are all on the same page about what the diet looks like. However she was unable to provide any evidence of staff being trained on Carbohydrates Control Diets (CCD) at the time of the survey. During an interview on 5/8/23 at 10:09 a.m., the Surveyor interviewed a Dietary Aide (DA #1) who worked in the kitchen on the prep line about therapeutic and CCD. The DA stated she calls out the tickets on the prep line, whether they are chopped, pureed, or ground, and whether any allergies or preferences are noted on the ticket. When asked by the Surveyor if she was educated or trained on CCD, the DA stated she didn't know what that was or what that meant. The DA stated she had in-servicing done on textured diets and allergies but not on CCD or therapeutic diets. During a second interview on 5/8/23 at 10:15 a.m., the Surveyor interviewed the DD, who described the type of textured diets they had in the facility. The DD stated the speech or nursing staff gave food service the diet slip in PCC, and then she would enter the diet slip in the tray line, and a specialized computer program would print out the dietary slips for the kitchen staff. The DD had the different textured diets posted on her office window but not specialized diets such as CCD, Renal, and No Salt (NAS). If the resident had a CCD diet, the Dietician would inform the DD, and the DD would know what to do. When the Surveyor asked the DD if the staff received in-services on CCD, she stated that in-service were done on the day of hire and, most recently, in April on allergies, textured, and specialized diets. The DD further stated that all DAs had in-service training for all specialized diets. However, she could not present the training for specialized diets at the time of the survey. During an interview on 5/8/23 at 10:25 a.m., the Surveyor interviewed a new DA (DA #2), who started at the facility one month prior. The DA stated she was responsible for the tray line and the food trucks. She looked at the resident's food ticket, and based on what it said, she would determine what was supposed to be put on their food tray. The Surveyor inquired about the DA's education when she started the facility. The DA stated she had no in-servicing done other than another kitchen employee showing her what to do. She said that when she worked on the tray line, she would know what was not supposed to be on the food tray by looking at the ticket. If it needed to be corrected, she would call the DD or the Lead [NAME] to be sure the resident was getting the right food. When asked by the Surveyor if she knew what a CCD diet was, the DA did not know what it was or what food should be on the tray for that type of therapeutic diet. During an interview on 5/8/23 at 12:21 p.m., the Surveyor interviewed the Dietician. The Dietician stated the DD would be the person to provide training to the DAs on what food was appropriate for the tray. The Dietician stated that the staff would check the texture but not necessarily the specific food. The Dietician stated meals should be modified to the specific diet for the resident. During an interview on 5/08/2023 at 3:07 p.m., the Surveyor asked the Administrator and the Director of Nursing (DON) if there were training on CCD diets. The Administrator stated, We just have training on chop diet; the DON added, There is no training on CCD, only chopped. At the time of the survey the facility was unable to provide evidence that staff were trained on CCD. NJAC: 8:39-17.4 (a)(e)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 10/12/21 at 9:42 AM, the surveyor toured the kitchen with the Food Service Manager (FSM) and observed the following: In the milk walk-in refrigerator 1. One opened nine-pound container of feta cheese labeled received 9/27/21. There was no date when the feta cheese was opened or when to use by. The FSM stated that the cheese should be used within seven days of opening and discarded. 2. One chocolate cake labeled and dated 10/6/21 and 10/8/21. The FSM stated that the chocolate cake should have been discarded on 10/8/21. 3. One five-pound opened cottage cheese container. The container had a printed use by date of 9/4/21. 4. Four five-pound unopened cottage cheese containers with a use by date of 9/4/21. 5. One opened container of blueberry muffin batter. The container had no received, opened, or use by date. 6. One container of peeled hard-boiled eggs labeled delivered on 9/8/21. There was no labeled opened date or use by date. The FSM stated that she was unsure how many days the eggs were good for after opened but would find out that information. On 10/12/21 at 10:01 AM, the surveyor observed a large bin of breadcrumbs outside the dry storage area. The bin contained a scoop directly in the breadcrumbs. The FSM confirmed that the scoop should not be stored directly in the food. On 10/12/21 at 10:03 AM, the surveyor and the FSM observed in the dry storage area the following: 1. Three 111-ounce (oz) cans of three bean salad, the cans were dented. 2. Three 107-oz cans of crushed pineapple, the cans were dented. 3. One 106-oz can of diced peaches, the cans were dented. On 10/13/21 at 11:23 AM, the surveyor interviewed the FSM who stated that the feta cheese and cottage cheese should be discarded after seven days of being opened and that the hard-boiled eggs should be used within one week. On 10/19/21 at 10:11 AM, the Licensed Nursing Home Administrator, in the presence of the facility's administration and survey team, acknowledged the surveyor's findings. A review of the facility's undated Dating and Labeling Policy included to: label products in storage with date package was opened; ready to eat foods must be dated with a seventy-two hour use by date or discarded when expired; label all goods with date received; and discard all foods that expire immediately. A review of the facility's undated Receivable and Storage Policy included to: ensure that all foods are securely covered, dated, and labeled. A review of the facility's undated Dented Can Policy, included in the procedure to: identify all unacceptable dented cans; upon discovery use a black marker to label can with current date and vendor's name; and place all dented cans on a designated shelf marked Dented Cans. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to: a.) ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on five of five medication carts and 2 of 3 medication carts reviewed for medication storage (Unit 1 and 2 high sides). This deficient practice was evidenced by the following: 1. On 10/14/21 at 10:19 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the nursing Unit 3's October 2021 Narcotic Shift Count log which revealed the following: 10/1/21 11 PM - 7 AM shift; 10/3/21 3 PM - 11 PM shift; and 10/6/21 3 PM - 11 PM shift Is the count correct column was blank. 10/13/21 7 AM - 3 PM shift, the column for correct count and the nurse's signature for going off duty was blank. 10/14/21 11 PM - 7 AM, going off duty nurse signature was blank At this time, the surveyor interviewed LPN #1 who stated that both the incoming and outgoing nurses on the shift performed a narcotic count together; then completed and signed the Narcotic Shift Count together in their designated area to verify the count. On 10/14/21 at 10:35 AM, the surveyor reviewed the October 2021 Narcotic Shift Count logs for all three nursing units' medication carts which revealed the following: Unit 1 low side medication cart: 10/14/21 3 PM - 11 PM shift, was pre-signed by the going off duty nurse. Unit 1 high side medication cart: 10/13/21 7 AM - 3 PM shift, the number (#) of count sheets was blank. 10/13/21 3 PM - 11 PM shift, is the count correct, # of count sheets, and nurse's signature coming on duty was blank. 10/14/21 11 PM - 7 AM and 7 AM - 3 PM shifts, were completely blank. Unit 2 low side medication cart: 10/1/21 7 AM - 3 PM and 10/2/21 11 PM - 7 AM, shifts is count correct were blank. On Unit 2 high side medication cart: 10/7/21 11 PM - 7 AM shift, is count correct was blank. On 10/14/21 at 11:23 AM, the surveyor interviewed the Director of Nursing (DON), who confirmed that both nurses had to complete and sign the Narcotic Shift Count logs together because they were both verifying the count as indicated by the facility policy. A review of the facility's Controlled Substances policy dated updated 3/2021 included that nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 2. On 10/14/21 at 11:42 AM, the surveyor in the presence of LPN #2 conducted a narcotic count on the nursing Unit 2 high side medication cart and observed the following: A review of Resident #6's Individual Patient Controlled Substance Administration Record for Oxycodone 5 milligram (mg) tablet (pain medication) dated received 9/24/21, reflected that out of the 60 tablets delivered, 27 tablets remained. Under the balance of 49 row, dated administered on 10/3/21 at 6:00 PM, the nurse who administered the medication did not sign. A review of Resident #15's Individual Patient Controlled Substance Administration for Diazepam 2 mg tablet (anxiety medication) dated received 9/22/21, reflected that out of 60 tablets delivered, 16 tablets remained. Under the balance of 32 row, dated administered on 10/6/21 at 6:00 PM, the nurse who administered the medication did not sign. On 10/14/21 at 12:27 PM, the surveyor in the presence of LPN #3 conducted a narcotic medication review of the nursing Unit 1's high side medication cart which revealed the following: A review of Resident #360's Individual Patient Controlled Substance Administration Record for Oxycodone 10 mg tablets dated received 10/13/21, reflected that out of the 60 tablets delivered, 58 tablets remained. A physical inventory count revealed that there were 57 Oxycodone tablets remaining. At this time, LPN #3 stated that the missing dose was administered to the resident earlier that morning but was not properly signed out on the controlled substance administration record. The LPN stated that at the time the medication was removed from inventory, she should have signed the administration record. On 10/15/21 at 9:20 AM, the surveyor interviewed the DON regarding the process for count inaccuracies. The DON responded that in the event of an inaccurate narcotic count, the nurse and unit manager reconciled to see if there was a medication that was administered and not signed for. The nurses were also expected to inform the DON immediately. On 10/19/21 at 10:19 AM, the DON in the presence of the Licensed Nursing Home Administrator, Administrator in training and survey team confirmed that all three controlled medications were administered, but the controlled substance administration records were not completed accordingly. A review of the facility's Controlled Substances policy dated updated 3/2021, included that an individual resident controlled substance record must be made for each resident receiving a controlled substance and will include the signature of the nurse administering the medication. A further review of the policy included that the Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This deficient practice was observed in 3 of 3 medication carts on 3 of 3 nursing units and 1 of 2 medication storage rooms reviewed for medication storage and was evidenced by the following: On 10/14/21 at 9:51 AM, the surveyor in the presence of Licensed Practical Nurse (LPN #1) observed nursing Unit 3's medication cart which contained a total of 16 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #1 collected these pills as they were discovered, counted, and were disposed of using the medication cart drug buster bottle. At this time, LPN #1 informed the surveyor that medication carts were cleaned monthly by housekeeping and that the nurses assigned to each cart ensured medication pills were not loose in the drawers. LPN #1 further stated that she checked for loose pills a couple days out of the week. On 10/14/21 at 11:42 AM, the surveyor in the presence of LPN #2 observed nursing Unit 2's high side medication cart which contained a total of 66 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #2 collected these pills as they were discovered, counted them, and disposed of these medications using the medication cart drug buster bottle. At this time, LPN #2 stated that the nurses checked the medication carts for loose medications every shift and during medication pass and they were expected to dispose of loose medication pills in the drug buster. LPN #2 further stated that housekeeping keeps a schedule for medication cart cleaning which was posted at the nurses' station. Nurses were given a new medication cart which they transferred all medication into while housekeeping performed the monthly cart cleaning. On 10/14/21 at 12:27 PM, the surveyor in the presence of LPN #3 observed nursing Unit 1's high side medication cart which contained a total of six (6) loose medication pills of various colors and sizes in the bottom of the drawers. LPN #3 collected these medication pills as they were discovered, counted, and disposed of using the medication cart drug buster bottle. At this time, LPN #3 stated that with multiple nurses using these carts and the crowding of medication in the carts, medication can pop out of the bingo cards. LPN #3 further stated that, the only thing we do is check the narc (narcotic) box and checking for loose pills in the cart was not what we do. On 10/15/21 at 9:42 AM, the surveyor in the presence of LPN #4 observed nursing Unit 1's medication storage room. In the medication refrigerator they observed: one opened box of tuberculin purified protein derivative (an injectable medication used to test for tuberculosis infection) dated 10/11, which contained two opened vials. One vial was dated 10/11 and the second opened vial was not dated. When the surveyor asked LPN #4 how long this medication was good for once opened, the LPN stated, 90 days, I think. At this time, the LPN took this box of medication along with the two opened vials it contained to the LPN/Unit Manager (UM) and the Licensed Nursing Home Administrator (LNHA). The LPN/UM acknowledged that this vial should have been dated once opened, and that it was good for 30 days once opened. The LPN/UM stated that since they were unsure of when this vial was opened, it would be thrown out. On 10/15/21 at 9:00 AM, LPN #2 provided the surveyor with a copy of the housekeeping October 2021 medication cart cleaning schedule titled Nursing Cart Carbolization Schedule which indicated that Unit 1's high side medication cart was signed carbolized on 10/11/21 and Unit 2's high side medication cart was scheduled to be carbolized on 10/18/21. On 10/19/21 at 10:19 AM, the Director of Nursing (DON) in the presence of the LNHA, Administrator in training, and survey team, acknowledged these findings. A review of the facility's Storage of Medications policy dated updated 1/2021, included that drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The policy also included that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. A review of the undated Consultant Pharmacy Provider's Expiration Dates for Opened Medications list provided by the DON, included that tuberculin purified protein derivative was to be refrigerated at all times and discarded 30 days after first use. N.J.A.C. 8:39-29.4