Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with Federal guidelines for 1 of 15 residents, Resident #8 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 1/22/24 at 11:41 AM, the surveyor observed Resident #8 sitting in a wheelchair with other residents in the day room for recreational activity. The resident was resting in the wheelchair with there eyes closed. There was no urinary catheter observed. On 1/24/24 at 9:40 AM, the surveyor reviewed the electronic and paper medical record for Resident #8. An admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, right sided weakness following cerebral infarction (stroke), vascular dementia, anxiety disorder, urinary tract infections, hydronephrosis with renal and ureteral calculous obstruction, and overactive bladder. A review of a Quarterly MDS assessment, dated 11/27/23, Resident #8 was documented as rarely/never understood and the resident was unable to complete a Brief Interview for Mental Status (BIMS). In Section H (Bladder and Bowel) of the MDS, under H0100. Appliances, Resident #8 was coded as having an indwelling catheter (including suprapubic catheter and nephrostomy tube). A review of the Order Summary Report for Resident #8 revealed there were no physcian orders for indwelling catheters. On 1/24/24 at 12:40 PM, the surveyor interviewed a Registered Nurse (RN) who cared for Resident #8 about the resident having a catheter. The RN stated the resident previously had a nephrostomy (small tube that helps drain urine) from your kidney. The RN reviewed Resident #8's medical record and explained the resident last had a nephrostomy in March 2022 which was removed in May 2022. The RN stated the resident did not have a nephrostomy tube or other indwelling catheter since that time. On 1/24/24 at 12:56 PM, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON confirmed that Resident #8 previously had a nephrostomy and did not have an indwelling catheter at the time of the MDS assessment. The DON stated she would review the resident's medical records and follow up with the MDS coordinator who was currently not on-site at the facility. On 1/24/24 at 1:21 PM, the DON informed the surveyor that she spoke to the MDS coordinator and acknowledged that the resident should not have been coded for an indwelling catheter. The DON further stated it was a data entry error by the MDS coordinator and the MDS assessment would be modified. On 1/24/24 at 2:30 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and DON about the above concerns. The DON and LNHA acknowledged MDS assessments should be coded accurately. No further information was provided. NJAC 8:39-33.2 (d)

Based on observation, interview, and review of medical records, it was determined that the facility failed to follow professional standards of practice by a.) not acquiring physician's order (PO) for the administration of Oxygen, b.) not administering the medication as ordered by the Physician and c.) by not following the facility's policy for (Peripherally Inserted Central Catheter) PICC line medication administration. This deficient practice was observed for 1 of 15 residents reviewed, Resident #19, Resident #5 and Resident #127 as 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. 1. On 1/22/24 at 11:35 AM, the surveyor observed Resident #19 lying on the bed in the resident's room. The surveyor inspected the Oxygen tubing dated 1/21/24 and the Oxygen concentrator which was set at 2 liter(L)/minute (min.) On 1/23/24 at 8:40 AM, the surveyor observed Resident #19 awake, lying on bed. The surveyor inspected the Oxygen concentrator which was set at 2L/min. The oxygen was delivered continuously via nasal canula. The surveyor reviewed Resident #19's hybrid medical records. The admission record (AR) reflected that Resident #19 was admitted to the facility with medical diagnoses which included but was not limited to Fracture of Upper End of right tibia; Hyperlipidemia; Chronic Obstructive Pulmonary Disease; and Hypertension. A review of the admission Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 12/3/2023 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating that the resident was cognitively intact. On 1/24/24 at 10:50 AM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1) assigned to Resident #19 who stated that for any resident who was on oxygen, it must be documented in the electronic treatment administration record. The surveyor interviewed the facility's Director of Nursing (DON) who stated that there was no Physician's Order (PO) for Resident #19's continuous use of oxygen. A review of the facility's Policy and Procedure titled, Oxygen Administration reflected under preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. On 1/24/24 at 2:50 PM, the surveyor met with the facility's Licensed Nursing Home Administrator and DON. The DON acknowledged that there was no PO for Resident #19 who was on continuous oxygen. 2. On 1/23/24 at 8:40 AM, the surveyor observed LPN #2 administer medication to Resident #5. The surveyor observed LPN #2 dispensed 2 tablets from a bottle labeled, Cranberry 500 mg + Vitamin C 200mg. The surveyor reviewed Resident #5's hybrid medical records. The AR reflected that Resident #5 was admitted to the facility with medical diagnoses which included but was not limited to XXXXXXXXXXXXXXXXXX. The resident had a current PO which reflected in the January 2024 electronic Medication Administration Record for Cranberry Oral Tablet 500 milligrams (mg) give 2 tablet by mouth one time a day for UTI prevention with an order date of 1/2/24. The surveyor observed LPN #2 dispensed 2 tablets from a bottle with a label indicating, Cranberry 500 mg + Vitamin C 200mg. On 1/23/24 at 10:05 AM, the surveyor interviewed LPN #2 who acknowledged that the medication she administered did not match the current PO for Resident #5. No further information was provided. 3. On 1/22/24 at 11:50 AM, the surveyor observed Resident #127 lying on the bed in the resident's room. The surveyor reviewed Resident #127's hybrid medical records. The AR reflected that Resident #127 was admitted to the facility with medical diagnoses which included but were not limited to Acute Osteomyelitis, Pressure Ulcer of left heel; Type 2 Diabetes Mellitus and Hyperlipidemia. A review of the A/MDS, an assessment tool used to facilitate the management of care, dated 1/25/24 reflected that the resident had BIMS score of 14 out of 15 indicating that the resident was cognitively intact. A review of the progress notes dated 1/18/2024 which documented that Resident #127 had an intact left arm PICC line patent for intravenous (IV) antibiotics. A review of the electronic Medication Administration Record (eMAR) reflected a PO dated 1/18/2024 for Ceftriaxone Sodium Injection Solution Reconstituted 1 gram (GM). Use 1 GM intravenously one time a day for wound care for 4 days. The medication was administered by LPN #2 as reflected in the eMAR. Further review of the eMAR reflected a PO dated 1/18/24 to, Flush IV with 10 milliliter (ml) and 5 ml heparin every night shift for 8 days. The medication was administered from January 18, 2024 through January 23, 2024 by a LPN. The surveyor reviewed the facility's policy and procedure titled, PICC Medication Administration Policy with a review date of 7/7/23 which reflected under Policy, The catheter must be flushed after each use by an Registered Nurse (RN) only. Further review of the policy indicated, Note: Only RN's with IV certification can access a PICC line, infuse medications, care for and maintain it. However, an LPN can prepare IV medication, spike and hang the medication on the pole, but will not connect it to PICC. The surveyor interviewed the facility's DON who confirmed that the LPNs who administered the IV medication through the PICC line were not IV certified. On 1/24/24 at 2:50 PM, the surveyor met with the facility's Licensed Nursing Home Administrator and DON. The DON agreed that the medication should not have been administered by a non IV certified LPN. NJAC 8:39- 29.2 (d)

Complaint NJ #: 163054 Based on interview and review of the Nurse Staffing Report it was determined that the facility failed to ensure that a required Registered Nurse (RN) was present at the facility 7 days a week for at least 8 consecutive hours a day for 4 of 14 days reviewed. This deficient practice was evidenced by the following: Per the Interpretive Guidance §483.35(b) Facilities are responsible for ensuring they have an RN providing services at least 8 consecutive hours a day, 7 days a week. However, per Facility Assessment requirements at F838, §483.70(e), facilities are expected to identify when they may require the services of an RN for more than 8 hours a day based on the acuity level of the resident population. If it is determined the services of an RN are required for more than 8 hours a day. Facilities may choose to have differing tours of duty (e.g. 8 hour- or 12-hour shifts) for their licensed nursing staff. Regardless of the approach, the facility is responsible for ensuring the 8 hours worked by the RN are consecutive within each 24-hour period. Review of the Nurse Staffing Report completed by the facility for the week of 3/12/23 to 3/25/23 revealed the facility had no RN coverage on any shift for the following days: 3/12/23, 3/18/23, and 3/19/23. Review of the Nurse Staffing Report completed by the facility for the week of 1/14/24 to 1/20/24 revealed the facility had no RN coverage on any shift for 1/15/24. On 1/24/24 at 2:15 PM, during an interview with the surveyors, the Director of Nursing (DON) agreed that there should be a RN in the facility daily for 8 consecutive hours. The DON stated that she was previously the only RN employed by the facility. No further information was provided. NJAC 8:39-25.2(h)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/22/24 at 9:10 AM, the surveyor in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. In the food preparation area, the surveyor observed the microwave with a white and yellowish debris throughout the microwave. 2. Next to the refrigerator/freezer the surveyor observed an Air Condition (AC #1) unit with a heavy buildup of a brown colored dust-like debris on the air outlet grill of the AC. 3. Above the 3 compartment sink, the surveyor observed AC #2 with a heavy buildup of a brown colored dust-like debris on the air outlet grill of the AC. The FSD explained that the debris in the microwave was from the weekend staff, unable to state why nobody had cleaned the microwave. The FSD revealed that the microwave should be cleaned after each meal and/or when visibly soiled. The FSD verified that the maintenance department is responsible for maintaining and cleaning the AC units. On 1/22/24 at 10:30 AM, the surveyor interviewed the Maintenance Director (MD) who stated that cleaning should be performed monthly but did not have a documented schedule. The MD revealed that the ACs where cleaned last month but could not provide any documented proof that this occurred. On 1/24/24 at 9:55 AM, the FSD provided the surveyor with a facility policy titled, Clover Rest Home Sanitation of Small Equipment, no created or revised date noted. Under the policy section it states, Small equipment will be cleaned and sanitized as needed to maintain good sanitation and prevent foodborne illness. Under the procedure section of the policy it states, Nonfood contact surfaces will be cleaned & wiped with a sanitizing solution .Microwave will be cleaned as needed, a minimum of once daily. Inside and outside will be cleaned & wiped with a sanitizing solution. On 1/24/24 at 2:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA acknowledged that all equipment in the kitchen should be cleaned and sanitized when visibly soiled. No further information was provided. NJAC 8:39-17.2(g)

Based on observations and interview on 01/25/2024 and 01/26/2024, it was determined that the facility failed to provide at least 80-square feet per Resident bed in multi-bedded rooms or 100-square feet in a single bedded room as evidenced by the following: On 01/25/2024 during the survey entrance at approximately 10:01 AM, a request was made to the Administrator and Director of Maintenance (DOM) to provide a copy of the facility lay-out which identifies the various rooms and smoke compartments in the facility. A review of the facility provided lay-out identified the facility is a three-story (3) building with a basement. There are eighteen (18) Resident sleeping rooms and common areas on the first floor. Starting on 01/25/2024 at approximately 10:40 AM, in the presence of the facility's DOM, the surveyor observed, measured and recorded the following Resident rooms: A-Wing Resident rooms: A-1 measured 61 square feet per resident bed A-2 measured 91.54 square feet per single bedded room A-3 measured 63.5 square feet per resident bed A-4 measured 47.5 square feet per resident bed B-Wing Resident rooms B-1 measured 75.7 square feet per resident bed B-2 measured 74.57 square feet per resident bed B-3 measured 73.2 square feet per resident bed B-4 measured 72.7 square feet per resident bed B-5 measured 63.85 square feet per resident bed B-6 measured 58.23 square feet per resident bed B-7 measured 58.35 square feet per resident bed B-8 measured 58.6 square feet per resident bed The facility's DOM confirmed the findings at the times of inspection. The Administrator (via telephone) and DOM was informed of the deficiency during the Life Safety Code survey exit on 01/26/2024 at approximately 12:05 PM. NJAC 8:39 -31.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of medical records (MR) and pertinent facility documents on 1/19/23 and 1/25/23, it was determined that the facility failed to reassess and provide care for pressure ulcers in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed for pressure ulcer care. The deficient practice is evidenced by the following: 1. According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Pneumonia and Anemia. The Minimum Data Set (MDS), an assessment tool, dated 2/13/22, revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognitive status and required extensive assistance with Activities of Daily Living (ADL). The Nursing Evaluation Collection (NEC), an admission nursing assessment form, revealed that Resident #3 had a reddened sacrum/buttock and an unstageable left foot wound covered with eschar. The Order Summary Report (OSR), a physician order record, revealed the following: Apply skin prep to wound in left foot every day and evening shift for unstageable wound which started on 2/16/22. Apply Silvadene cream 1% to sacral ulcer topically every shift which started on 2/24/22. The care plan (CP) for the risk for skin breakdown and left foot ulcer was initiated on 2/16/22. Goals and interventions included but were not limited to: Administer treatment to left foot, monitor effectiveness; pressure reducing cushion to the wheelchair; notify MD of any skin concerns and initiate treatment promptly. The Progress Note (PN) revealed the following: on 2/11/22, the Director of Nursing (DON) documented an unstageable wound to the top of the left foot with eschar, and reddened buttocks. On 2/24/22, the attending Nurse Practitioner (NP) documented multiple minimal stage 2 pressure sacral ulcers, measurement as per nursing notes. There was no documentation in the PN to indicate that the wounds were reassessed and measured after they were initially noted on 2/11/22 for the left foot wound and on 2/24/22 for the sacral wound. The February 2022 Electronic Medical Record (ETAR) revealed that the treatment for the left foot wound started on 2/16/22. The ETAR reflected to apply skin prep to left foot ulcer every day and evening. There was no documentation that the treatment was performed on 2/17/22 day and evening, 2/20/22 day, 2/24/22, and 2/26/22 evenings. The treatment for the sacral ulcer was started on 2/24/22 every shift, and there was no documentation on 2/24/22 and 2/26/22 evening, and 2/28/22 night. Additionally, there was no documentation in the ETAR for weekly skin assessments or wound measurement. During an interview with the License Practical Nurse (LPN) on 1/19/23 at 1:13PM, she stated that the nurse who assessed the wound on admission is responsible for calling the primary physician (PP) for wound treatment orders and entering the orders in Electronic MR (EMR). She explained that wound treatments performed by the nurses is documented in the ETAR, and if not documented, it means it was not done. Additionally, resident who requires an air mattress needs a physician's order with setting instructions. The order is entered into the EMR and nurses document every shift in the TAR to show that air mattress was checked. She further explained that the former Assistant DON used to complete the weekly wound assessment/measurement (WWAM) until the end of 2021. After that, the staff nurses or the DON began doing it. However, the LPN could not explain why there was no wound treatment ordered for the left foot wound until 2/16/22 and no weekly wound assessment. During an interview with the NP post survey on 2/15/23 at 12:18 PM, she stated that she expects nurses to call her or the PP for treatment orders for new or existing pressure wounds. She could not recall the Resident but stated that there should have been an order for the left foot wound if she was notified. During an interview with the DON on 1/19/23 at 1:35 PM, she stated that the attending nurse must call the PP for wound treatment orders. WWAM must be documented in the EMR by the nurses, and if not documented, it was not performed. Weekly wound assessment does not require a doctor's order. The DON could not explain why Resident #1 was not provided treatment for left foot wound until 2/16/22, and WWAM was not documented in the EMR or PN. However, she acknowledged that the treatment should have been initiated and weekly wound measurement should have been done. A review of the facility policy on Pressure Ulcers/Skin Breakdown- Clinical Protocol revised 4/2018 indicated that the nurse shall describe and document/report full assessment of the pressure sore .the physician will order pertinent wound treatments and help identify medical interventions related to the wound management. NJAC 8:39-27.1(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined that the facility failed to develop a comprehensive care plan with interventions for a diagnosis and medication management for type two diabetes mellitus for one (Resident #27) of 12 residents reviewed for care planning. This deficient practice had the potential to affect all residents. Findings included: 1. The facility admitted Resident #27 with diagnoses of type two diabetes mellitus (DM), chronic obstructive pulmonary disease, chronic respiratory failure, hyperlipidemia, and anxiety. A review of Resident #27's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A further review indicated a diagnosis of DM, and Resident #27 received insulin injections during the last seven days from the time of assessment. A review of Resident #27's care plan, dated 09/22/2021, revealed no focus care area for DM, insulin use, or any other interventions of care for DM. A review of Resident #27's Medication Administration Record (MAR), dated October 2021, revealed an order for Humalog Solution 100 unit/milliliter (mL) and inject as per sliding scale. The sliding scale indicated the following: if BS (blood sugar) of 0-150, give zero units; if BS of 151-200, give two units; if BS of 201-250, give three units; if BS of 251-300, give four units; if BS of 301-350, give five units; if BS of 351-400, give six units; and if BS was greater than 400, contact the physician. The order indicated to inject subcutaneously four times a day (QID) for DM. During an interview on 10/20/2021 at 10:20 AM, the MDS Coordinator stated a resident's care plan was developed based on the care areas triggered by the admission MDS assessment. The MDS Coordinator further stated a diagnosis of DM would trigger a care plan with interventions listed. The MDS Coordinator acknowledged that Resident #27 admitted on [DATE] and did not have a care plan for DM and did not know why. The MDS Coordinator then stated she would create one at that time. The MDS Coordinator stated it was important to have a care plan for DM so all staff would know the resident's diagnosis and could monitor for any signs and symptoms of hypoglycemia or hyperglycemia such as altered mental status and skin or foot integrity. During an interview on 10/20/2021 at 2:55 PM, the Director of Nursing (DON) stated Resident #27 had a diagnosis of DM, and insulin administration should be included in the resident's care plan. She further stated it was important to include DM and the interventions in place in the care plan, so staff knew what to look for in signs and symptoms of hypoglycemia or hyperglycemia. Also, staff needed to know when to call the physician if a resident's blood glucose was greater than 400. The DON then stated the MDS Coordinator had been in that position for over a year, and the MDS Coordinator was expected to initiate a care plan for DM and insulin administration. During an interview on 10/21/2021 at 9:15 AM, the Administrator stated he expected a complete and accurate comprehensive care plan for all residents, so staff knew how to care for each resident. A review of the facility's policy titled, Care Planning - Interdisciplinary Team Policy, dated 09/2013, revealed, the interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident .comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. New Jersey Administrative Code § 8:39-11.2 (e) 1

Based on record review, staff interviews, and facility policy review, it was determined the facility failed to revise and update a care plan related to a nephrostomy tube for one (Resident #10) of 12 residents reviewed for care planning. Findings included: 1. The facility admitted Resident #10 with diagnoses that included urethral stones and obstruction, history of urosepsis, and chronic nephrostomy (an opening that is made between the kidney and the skin on your back to allow urine to drain from the kidney). A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/25/2021, indicated Resident #10 was rarely/never understood. The resident had both long-term and short-term memory impairment and was severely cognitively impaired. Resident #10 had a nephrostomy tube. A review of the care plan, dated 02/24/2021, indicated Resident #10 had a nephrostomy tube inserted due to poor kidney function, urosepsis, and stones. There were goals of being and remaining free from catheter-related trauma through the next review date of 08/23/2021 and showing no signs or symptoms of urinary infection through the next review date of 08/23/2021. Interventions on 02/24/2021 included flushing the drainage tube two times per week with 10cc (cubic centimeters) of saline. A review of the current physician's orders indicated an order to flush the nephrostomy drainage tube daily with 10cc of saline on the day shift to keep the nephrostomy tube patent. The start date was 03/26/2021. A review of the record revealed there was no updated care plan reflecting the flushing of the nephrostomy catheter every day. During an interview with the MDS Coordinator on 10/20/2021 at 10:20 AM, she stated care plans should be completed timely. During an interview with the Director of Nursing (DON) on 10/20/2021 at 2:50 PM, she stated she would expect the care plan would be updated to reflect how the resident's nephrostomy tube was to be cared for. During an interview with the Administrator on 10/21/2021 at 9:20 AM, he stated the MDS Coordinator updated all care plans, and he would expect the care plan would be updated timely and be accurate. A review of the facility's policy titled, Nephrostomy and Cystostomy Tube Care and Maintenance, dated 2020-2021, indicated, residents with nephrostomy or cystostomy tubes will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. New Jersey Administrative Code § 8:39-11.2 (i)