Complaint #NJ 00182926 Based on interviews, medical records reviews, and review of other pertinent facility documentation, on 06/03/25, 06/05/25, and 06/19/25, it was determined that the facility failed to revise a care plan after an annual assessment for a cognitively impaired resident that needed assistance with meals. The facility also failed to follow its Care Plan policy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. A review of the resident's annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/18/2025, revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severe cognitive impairment. The MDS further indicated that Resident #6 required Substantial/ Maximum assistance with eating. A review of Resident # 6's Care Plan (CP) did not reveal the level of assistance the resident required when eating. A review of Resident #6 Progress Notes (PN) revealed a nursing note dated 01/12/25, at 10:56 P.M, that revealed that the resident, Requires complete total care with [Activities of Daily Living] at all times. Review of the IDCP (Interdisciplinary Care Planning)/Care Conference Note, dated 01/23/25 at 11:36 A.M., revealed that the Director of Nursing (DON), documented that the resident was a Max assist x1 with ADL . During an interview on 06/05/25 at 2:17 P.M, the DON stated that he and the Assistant Director of Nursing (ADON), were responsible for updating care plans. He stated that the CP was important because it showed that the needs of the resident were being addressed. He further stated, The MDS and the care plan should reflect the same information. In the presence of the surveyor, the DON reviewed Section GG of Resident #6's MDS and stated that the resident was a max assist related to eating. The DON also reviewed the IDCP/Care Conference note, and stated that, Max assist x1 with ADLs includes eating. He also reviewed Resident #6's CP and stated that the CP should have reflected the max assist for eating, and that he should have updated it. Review of the facility Care Plan policy, revised 2/21/25, revealed that, .all residents admitted to the facility will have comprehensive person-centered care plans that provide for their needs . The CP policy further revealed under section 10 that, Care plans will be updated in a timely manner and necessary revisions made when there are changes in conditions. NJAC: 8:39-11.1; 11.2(i); 27.1(a)

COMPLAINT #NJ00179350, NJ00182926 Based on interviews, medical record review, and review of other pertinent facility documents on 6/3/25, 6/5/25, and 6/19/25 it was determined that the facility failed to consistently document in the Documentation Survey Report on care provided to dependent residents according to facility policy and protocol for 3 of 3 residents (Resident #1, Resident #5, and Resident #6) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: Dementia, Muscle weakness, Diabetes Mellitus Type 2 The surveyor reviewed Resident #1's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/25, which indicated that Resident #1 had a BIMS of 9 out of 15, indicating moderate cognitive impairment. The MDS further indicated that the resident required assistance with Activities of Daily Living (ADLs). A review of Resident # 1's Documentation Survey Report v2 (DSR) dated May 2025, for completion of ADL under Intervention / Task did not indicate that Personal Hygiene was documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation: 5/3/25, 5/4/25, 5/7/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/17/25, 5/18/25, 5/24/25, 5/25/25, 5/30/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 5/2/25, 5/5/25, 5/6/25, 5/9/25, 5/10/25, 5/11/25, 5/16/25, 5/17/25, 5/19/25, 5/20/25, 5/21/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/30/25, 5/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation: 5/2/25, 5/3/25, 5/4/25, 5/9/25, 5/10/25, 5/15/25, 5/16/25, 5/17/25, 5/22/25, 5/23/25, 5/24/25, 5/30/25, 5/31/25. 2. According to the AR, Resident #5 was admitted with diagnoses including but not limited to Seizures, Muscle weakness and difficulty walking. A review of the quarterly MDS, an assessment tool dated 5/21/25, revealed that Resident #5 had a BIMS score of 9 out of 15, indicating that Resident #5 had moderate cognitive impairment. The MDS further indicated that the resident required assistance with ADLs. A review of Resident # 5's DSR, dated May 2025, for completion of ADL under Intervention / Task did not indicate Personal Hygiene was documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation 5/3/25, 5/4/25, 5/7/25, 5/9/25, 5/10/25, 5/11/25, 5/14/25, 5/16/25, 5/18/25, 5/20/25, 5/24/25, 5/25/25, 5/30/25, 5/31/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 5/2/25, 5/3/25, 5/5/25, 5/9/25, 5/10/25, 5/11/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/22/25, 5/24/25, 5/25/25, 5/30/25, 3/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 5/2/25, 5/3/25, 5/9/25, 5/10/25, 5/15/25, 5/16/25, 5/22/25, 5/23/25, 5/24/25, 5/25/25, 5/30/25 3. According to the AR, Resident #6 was admitted with diagnoses including but not limited to Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. A review of the resident's annual MDS, an assessment tool used to facilitate the management of care, dated 01/18/2025, revealed that Resident #6 had a BIMS score of 3 out of 15, which indicated the resident had severe cognitive impairment. The MDS further indicated that the resident required assistance with ADLs. A review of Resident # 6's DSR, dated January 2025, for completion of ADL under Intervention / Task did not indicate that, Personal Hygiene, and Toilet Use were documented at the following times: ADL- Personal Hygiene: During the 7:00AM to 3:00PM shift, the following days did not have documentation 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25 During the 3:00PM to 11:00PM shift, the following days did not have documentation. 1/2/25, 1/3/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. ADL-Toilet Use: During the 7:00AM to 3:00PM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/22/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 3:00PM to 11:00PM shift, the following days did not have documentation. 1/2/25, 1/3/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During the 11:00PM to 7:00AM shift, the following days did not have documentation. 1/1/25, 1/2/25, 1/3/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, 1/29/25, 1/30/25, 1/31/25. During an interview with the surveyor on 6/5/25, at 11:21AM, the Certified Nursing Assistant (CNA) stated, that all care provided to the resident was documented in the [electronic medical record]. She further stated, Documentation is important to know what type of care was provided to the resident. It effects their condition. In the presence of the surveyor the CNA reviewed the DSR for Resident #6, and stated that there should not be blanks on the form, All [boxes] should be filled in. During an interview with the surveyor on 6/5/25 at 12:12 P.M. The Licensed Practical Nurse (LPN) stated that CNAs were responsible for providing and documenting ADL care. He stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible to follow up and ensure that ADL documentation was completed. He further stated that if a CNA was not documenting, he would report that to the DON. During an interview with the DON on 6/3/25, at 4:44 P.M., he stated that CNAs were responsible for documenting in the electronic record. He further stated that there, Should not be any blanks in the [electronic medical record]. Review of facility's Charting and Documentation policy, revised on 2/15/25, revealed in the policy statement that, Proper documentation and charting will be maintained on each resident . It further revealed under section 7 of the Documentation in [Electronic Medical Record] that, All skilled and unskilled services must be documented . Review of the facility's Activities of Daily Living policy, revised on 3/7/25, revealed that, The purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his or her performance of activity of daily living. It further revealed under the Documentation of Care Provided that the Certified Nursing Assistants (CNAs) document all the care they provided to the residents assigned to them during their shift in [the electronic medical record]. NJAC: 8:39-27.1(a); 35.2(d)6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #24. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. On 3/21/24 at 11:03 AM, the surveyor observed Resident #24 in the dining area (also known as the activity room) laying in the geri chair (or geriatric chair, which is a large padded chair with wheeled bases and is designed to assist seniors with limited mobility) with eyes closed and the body covered with a blanket. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #24 as follows: According to the admission Record (admission summary), Resident #10 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), unspecified osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), unspecified glaucoma (a group of eye conditions that can cause blindness), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's comprehensive MDS (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/13/23 revealed in Section C Cognitive Status Brief Interview for Mental Status (BIMS) score of 3 out of 15 which reflected that the resident's cognition was severely impaired. The cMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight loss of 5% or more in the last month or a loss of 10% in the last six months. Section M Skin Conditions showed that Resident #24 had Unstageable Deep Tissue Injury (DTI, pressure ulcer, defined as 'purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) that was a facility acquired wound. The quarterly MDS (qMDS) with an ARD of 9/14/23 included that Resident #24 had no significant weight loss and the skin was intact. Further review of the MDS revealed that the 12/13/23 cMDS was noted with two areas of changes in resident's assessment status as evidence of significant weight loss and presence of DTI which was not present in the qMDS dated [DATE]. A review of the Weight Summary revealed on 12/08/23 the resident's weight was 121.5 pounds (lbs) with warning notes that included the following: -5.0% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] -7.5% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] A review of the IDCP (Interdisciplinary)/CARE Conference Note with an effective date of 12/21/23 included Nutritional Status that was electronically signed by the Dietitian on 01/05/24 that the resident was triggered for a significant weight loss x 1 (one) month (8%). A review of the Multi Wound Chart Details (a wound consult visit notes) dated 12/13/23 included that Resident #24 had a DTI to the left medial heel. On 3/25/24 at 11:46 AM, the survey team met with the MDS Coordinator (MDSC). The MDSC informed the surveyors that the facility had no specific policy regarding MDS, the facility follows the RAI Manual. The MDSC stated that if there will be two or more changes either improvement or decline in the resident's status, that will be the criteria that the MDS assessment for SCSA will be done. On that same date and time, the surveyor asked the MDSC why the resident's cMDS on ARD 12/13/23 was not an SCSA considering the above changes and decline in the resident's status in comparison to qMDS on 9/14/23. The MDSC stated that it was probably a mistake, and acknowledged that the 12/13/23 cMDS should be a SCSA. On 3/25/24 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC). The surveyor notified the facility management of the above findings and concerns. On 3/26/24 at 02:15 PM, the survey team met with the CNC, LNHA, DON, IPN, and MDSC. The facility management did not respond to the above findings and concerns. NJAC 8:39-11.2(i)

Based on observation, interview and review of the medical record and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to assess the fall risk for a resident that was at risk for falls and had a fall according to the facility policy for 1 of 2 residents reviewed for falls (Resident #63). This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a 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 with in 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 review of Resident #63 admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), muscle weakness (decreased strength in the muscles) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #63's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/15/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated that Resident #63's cognition was severely impaired. Further review of Section J Health Conditions indicated that under J1800 Resident #63 had a fall since admission/entry or reentry or the prior assessment. A review of Resident #63's electronic medical record under the evaluations section indicated that the last Fall Risk Evaluation was done on 11/1/23. There was not another quarterly Fall Risk Evaluation done which would have been due to be done on 2/1/24. The surveyor was unable to open or view the 11/1/23 Fall Risk Evaluation. On 3/21/24 at 11:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding fall risk assessments (evaluations). The LPN stated that the fall risk was done on admission and then quarterly. She added that the admission nurse did the admission fall risk and that the night nurse did the quarterly. The LPN stated that the fall risk assessment would be in the electronic medical record. On 3/21/24 at 12:59 PM, the surveyor interviewed the Director of Nursing (DON) and asked where the fall risk assessment was located. The DON, in the presence of the Assistant DON (ADON), stated that the fall risk assessment should be under the evaluations section in the electronic medical record. On 3/21/24 at 01:52 PM, in the presence of the survey team, the surveyor requested the Licensed Nursing Home Administrator (LNHA) and the DON print Resident #63's fall risk assessments since the last recertification survey that was in September 2023. The surveyor told the LNHA and DON that the surveyor could not open or view the actual fall risk assessment. On 3/22/24 at 8:40 AM, the LNHA provided the surveyor a copy of 2 fall risk evaluations with effective dates of 11/01/23 and 02/01/24. The surveyor reviewed the last one which had an effective date of 02/01/24 but it did not have a created date on it. The surveyor then reviewed Resident #63's electronic Progress Notes that were linked to the fall risk evaluation. The 02/01/24 Fall Risk Evaluation had a created date of 3/21/24. The 02/01/24 Fall Risk Evaluation was created after surveyor inquiry. On 3/22/24 at 9:45 AM, in the presence of another surveyor, the surveyor asked the DON when the 02/01/24 Fall Risk Evaluation was created. The DON viewed Resident #63's electronic medical record and stated that the LPN assigned to the resident created the Fall Risk Evaluation yesterday (3/21/24). The surveyor asked the DON if the Fall Risk Evaluation should have been done prior to surveyor inquiry. The DON stated that it should have been done prior. On 3/25/24 at 12:31 PM, in the presence of the survey team, the surveyor told the LNHA, DON, Infection Preventionist and Clinical Nurse Consultant the concern that Resident #63's fall assessment was not done in February when it was due to be done quarterly. On 03/26/24 at 9:38 AM, in the presence of the survey team, the surveyor asked the LNHA and DON if the fall risk assessment should have been done prior to surveyor inquiry. The LNHA stated it was still in the quarter. The facility provided additional printed fall risk evaluations. A review of the additional documents indicated a fall risk assessment that had an effective date of 12/23/23 and 3/23/24 (dated after surveyor inquiry). The surveyor reviewed Resident #63's electronic Progress Notes that were linked to the fall risk assessment. The 12/23/23 Fall Risk Evaluation had a created date of 3/23/24 (dated after surveyor inquiry). On 3/26/24 at 11:40 AM, in the presence of the survey team, the surveyor asked the DON when the additional fall risk evaluations with effective date of 12/23/23 and 3/23/24 were done. The DON stated that the they both were created in March 2024. The DON added that it was a late entry. The facility did not provide any additional information. A review of the facility provided policy titled Falls, Resident: Prevention Program with a revised date of 3/20/24, included the following: Policy: All residents will be assessed for fall risk on admission. All residents will be reassessed at least quarterly in conjunction with their MDS evaluation, or in the event of change in status. Procedure: 1. The licensed nurse will complete a Fall Risk Assessment for each new admission and quarterly in conjunction with their MDS evaluation. N.J.A.C. 8:39-27.1 (a)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine for 1 of 6 residents reviewed for immunizations (Resident #63). The deficient practice was evidenced by the following: The surveyor reviewed Resident #63's medical record. A review of Resident #63 admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), muscle weakness (decreased strength in the muscles) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #63's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 02/15/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated that Resident #63's cognition was severely impaired. Further review of Section O Special Treatments, Procedures, and Programs indicated that under O0300 Resident #63's pneumococcal vaccine was up to date. A review of Resident #63's electronic medical record under the Immunization tab included the following: Pneumovax Dose 1 (pneumococcal vaccine): Immunization Req. It did not indicate a date that it was given as complete or a date with historical to indicate that the resident had the vaccination in the past. On 3/21/24 at 11:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding pneumococcal vaccination. The LPN stated that the nurse would request proof of the vaccination. She added that if the resident did not receive the vaccination then she would get an order from the physician and give the vaccination. On 3/21/24 at 01:50 PM, in the presence of the survey team, the surveyor requested the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) provide information on Resident #63's vaccinations. On 3/21/24 at 02:08 PM, the surveyor reviewed the hybrid medical record. There was a Resident Consent Form Influenza (FLU)/Pneumococcal Vaccines which included the resident's representative signature under I consent to receive the pneumococcal vaccine. There was no date next to the signature. On the top of the form was the resident's representative signature under I consent to receive the flu (influenza) vaccine. There was 11- -23 (November 2023) written on the date line. On 3/22/24 at 10:31 AM, the surveyor reviewed Resident #63's electronic medical record. The Misc (Miscellaneous) section contained a Resident Consent Form Influenza (FLU)/Pneumococcal Vaccines that included per phone conversation with resident's representative dated 01/09/24 I consent to receive the pneumococcal vaccine. On 3/25/24 at 11:25 AM, the DON provided the surveyor a document that included the following: Immunization Resident #63- .PNA (Pneumococcal) Vaccine the consent was signed by the daughter, not given. On 3/25/24 at 11:47 AM, in the presence of the survey team, the surveyor interviewed the MDS Coordinator (MDSC) regarding what req meant on Resident #63's immunization section. The MDSC stated that it meant request. On 3/25/24 at 12:31 PM, in the presence of the survey team, the surveyor told the LNHA, DON, Infection Preventionist (IP) and Clinical Nurse Consultant the concern that Resident #63 was not offered and given the pneumococcal vaccination prior to surveyor inquiry. On 3/26/24 at 9:47 AM, in the presence of the survey team and LNHA, the DON stated that the vaccination should have been offered and given. The DON stated that he was not sure why it was not given. On 3/26/24 at 10:56 AM, in the presence of the survey team, the surveyor interviewed the IP regarding the process for pneumococcal vaccination. The IP stated that the admitting nurse would find out if the resident was up to date with the vaccination. She added that if not sure of the status then they would check with the physician if the resident would benefit from receiving it and get an order to give it. The facility provided the surveyor a document that indicated Resident #63 received the pneumococcal vaccination on 3/22/24 which was after surveyor inquiry. The facility did not provide any additional information. A review of the facility provided policy titled, Immunization Protocol, Resident with a revised date of 3/21/2023, included the following: Policy: All residents will be offered the opportunity to be immunized for both influenza and pneumococcal disease. The influenza vaccine will be offered to the resident on an annual basis. The pneumococcal disease vaccine will be offered per physician order. Procedure: Upon admission, all residents will be interviewed as to their current immunization status. This information will be recorded on the resident's Immunization Record and in red ink within the Nursing History. The information will be maintained in the resident's medical record. All residents not immunized will be reviewed quarterly at the Infection Control Meeting and will be offered appropriate vaccinations. N.J.A.C. 8:39-19.4(i)

Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 7 of 19 residents (Resident #41, 9, 53, 3, 50, 66, and #10) and reviewed for resident assessment. According to the Long-Term Care RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool and a federally mandated process for clinical assessment of all residents. It must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. This deficient practice was evidenced by the following: On 3/19/24, at 9:30 AM, the surveyor reviewed the facility task that includes residents' MDS assessments, which was triggered under the survey facility task as MDS record over 120 days old. 1. Resident #41 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/30/24, which was due to be transmitted to CMS no later than 2/13/24. However, the QMDS was not submitted to CMS until 3/6/24. 2. Resident #9 was observed to have a QMDS with an ARD on 2/1/24, which was due to be transmitted to CMS no later than 2/15/24. However, the QMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 11/1/23 was due to be transmitted to CMS by 11/15/23. The QMDS was not submitted to CMS until 12/5/23. 3. Resident #53 was observed to have Annual MDS (AMDS) with an ARD on 1/28/24, which was due to be transmitted to CMS no later than 1/11/24. However, the AMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 10/30/23 was due to be transmitted to CMS by 11/14/23. The QMDS was not submitted to CMS until 12/5/23. 4. Resident #3 was observed to have AMDS with an ARD on 1/26/24, which was due to be transmitted to CMS no later than 1/13/24. However, the AMDS was not submitted to CMS until 3/6/24. 5. Resident #50 was observed to have QMDS with an ARD on 1/25/24, which was due to be transmitted to CMS no later than 1/12/24. However, the QMDS was not submitted to CMS until 3/6/24. 6. Resident #66 was observed to have QMDS with an ARD on 1/26/24, which was due to be transmitted to CMS no later than 1/13/24. However, the QMDS was not submitted to CMS until 3/6/24. 7. Resident #10 was observed to have AMDS with an ARD on 1/28/24, which was due to be transmitted to CMS no later than 1/11/24. However, the AMDS was not submitted to CMS until 3/6/24. A review of QMDS with an ARD on 10/30/23 was due to be transmitted to CMS by 11/14/23. The QMDS was not submitted to CMS until 12/5/23. A review of the MDSC's undated Final Validation Report for Residents #41, 9, 53, 3, 50, 66, and #10 revealed that The submission date is more than 14 days after Z0500B on this new assessment. On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC informed the surveyors that the facility has no specific policy regarding MDS and follows the RAI Manual. The MDSC stated that submissions were late because the discipline needed to complete their assessment. On 3/25/24 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC). The surveyor notified the facility management of the above findings and concerns. On 3/26/24 at 02:15 PM, the survey team met with the CNC, LNHA, DON, IPN, and MDSC. The facility management did not respond to the above findings and concerns. NJAC 8:39 - 11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 03/20/24 at 11:40 AM, the surveyor observed Resident #9 in bed lying comfortably alert, oriented with confusion, and able to answer the surveyor's inquiry. The surveyor reviewed Resident #9's hybrid (combination of paper and electronic) medical record as follows: A review of the admission Record (an admission summary) (AR) documented that Resident #9 was admitted to the facility with diagnoses that included but were not limited to essential hypertension (high blood pressure). The resident's most recent Quarterly MDS (QMDS) assessment, dated 2/1/24, reflected that Resident #9 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognition impairment. Section O Special Treatments, Procedures, and Programs revealed that Resident #9, the pneumococcal vaccination (which helps protect against serious illnesses like pneumonia and meningitis), was up to date. There is no record that a pneumococcal vaccine was given to Resident #9. The immunization record shows that the resident's son refused the pneumococcal vaccination on 6/1/23. A review of QMDS dated [DATE], section D Resident Mood Interview (PHQ-9), signed by the social worker on 2/6/24, revealed no record of a PHQ-9 assessment interview done on the ARD of 2/1/24. A review of QMDS dated [DATE], section E Behavioral Symptoms, signed by the social worker on 2/6/24, revealed no Behavioral Symptoms assessment interview on the ARD of 2/1/24. On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC stated that the pneumococcal vaccination should reflect the accurate status of the resident's vaccination history and that the resident had refused the vaccine. 3. On 03/21/24 at 10:47 AM, the surveyor observed Resident #57 sitting in bed, alert and oriented, able to answer the surveyor's inquiry. The surveyor reviewed Resident #57's hybrid medical record as follows: A review of the AR documented that Resident #57 was admitted to the facility with diagnoses that included but were not limited to leukemia (a cancer of the blood). The resident's most recent admission MDS (AMDS) assessment, dated 12/21/23, reflected that Resident #57 had a BIMS score of 15 out of 15, indicating intact cognition. A review of AMDS dated [DATE], section D PHQ-9, signed by the social worker on 12/23/23, revealed no record of a PHQ-9 assessment interview done on the ARD of 12/21/23. A review of AMDS dated [DATE], section E Behavioral Symptoms, signed by the social worker on 12/27/23, revealed no Behavioral Symptoms assessment interview on the ARD of 12/21/23. On 03/26/24 at 11:11 AM, the surveyor interviewed the Registered Nurse (RN) who worked in the facility for 18 years as a charge nurse and works closely with the MDSC. The RN stated that she tried as much as possible to check the MDS assessment before submitting it. She checked and reviewed the look-back period. The surveyor asked the RN where to find the assessment, such as PHQ-9 and Behavioral assessment. The RN showed the surveyor the Evaluations tab in the electronic medical record but could not find PHQ-9 and Behavioral interview assessment for Resident #9 QMDS dated [DATE] and Res. #57 AMDS dated [DATE], respectively. On 03/27/24 at 9:50 AM, the surveyor interviewed the MDSC and stated that the social worker completed MDS assessment sections C, D, E, and Q and that the interview should be conducted on the ARD date, 12/21/23. 4. On 3/20/24 at 12:22 PM, the surveyor observed Resident #63 seated in a wheelchair in the dayroom eating lunch. The surveyor reviewed Resident #63's electronic medical record. A review of Resident #63 AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body), muscle weakness (decreased strength in the muscles) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #63's quarterly MDS, an assessment tool used to facilitate the management of care, dated 02/15/24, reflected that the resident had a BIMS score of 03 out of 15, which indicated that Resident #63's cognition was severely impaired. Further review of Section O Special Treatments, Procedures, and Programs indicated that under O0300 Resident #63's pneumococcal vaccine was up to date. A review of Resident #63's electronic medical record under the Immunization tab included the following: Pneumovax Dose 1 (pneumococcal vaccine) Immunization Req. It did not indicate a date that it was given as complete or a date with historical to indicate that the resident had the vaccination in the past. On 3/21/24 at 01:50 PM, in the presence of the survey team, the surveyor requested the LNHA and DON provide information on Resident #63's vaccinations. On 3/25/24 at 11:25 AM, the DON provided the surveyor a document that included the following: Immunization Resident #63- .PNA Vaccine the consent was signed by the daughter, not given. On 3/25/24 at 11:47 AM, in the presence of the survey team, the surveyor interviewed the MDSC regarding the process for MDS. The MDSC stated that she inputted the data and that a Registered Nurse would review the information to make sure it was accurate before the MDSC submitted the MDS. The surveyor asked the MDSC where the vaccination status was located that she entered into the MDS. The MDSC stated that she looked in the electronic medical record under the immunization section. She then stated that if the information was not in the electronic medical record that she would ask the resident or the resident representative. The surveyor then asked the MDSC what req meant on on Resident #63's immunization section. The MDSC stated that it meant request. The surveyor then asked the MDSC the reason Resident #63's MDS was coded up to date for the pneumococcal vaccine when the resident did not receive the vaccination. The MDSC stated that she would have to look into it. On 3/25/24 at 12:31 PM, in the presence of the survey team, the surveyor told the LNHA, DON, Infection Preventionist and Clinical Nurse Consultant the concern that Resident #63 was not offered the pneumococcal vaccination prior to surveyor inquiry and that the MDS was coded inaccurately to indicate that Resident #63's pneumococcal vaccination was up to date when the resident had not received the vaccination. On 3/26/24 at 9:47 AM, in the presence of the survey team and LNHA, the DON stated that the MDSC was in-serviced and that she corrected Resident #63's MDS. A review of the printed MDS that the facility provided indicated that the printed view was different from the electronic view. On 3/26/24 at 11:04 AM, the surveyor showed the MDSC the different codes in the viewable and printed version of the MDS. The MDSC confirmed that the viewable version in the electronic medical record was a 1 and that indicated a yes for up to date and that the printed version indicated a 1 and that indicated a no for up to date. The MDS Coordinator stated that the correct answer that she inputted was a yes for up to date. On 3/26/24 at 02:16 PM, in the presence of the survey team, the surveyor told the LNHA, DON, IP and Clinical Nurse Consultant the concern that the MDS printout was different then the transmitted version in the electronic medical record. On 3/27/24 at 9:13 AM, the LNHA provided an email from the company for the electronic medical record. The email dated 3/26/23 included the following: We believe we have identified a defect affect Section O0300A printing as No on the print version of the MDS, and it is currently under review. We will notify you of any updates via email as they become available. Currently, there is no workaround for this problem. However, it is important to note that while the response from the MDS assessment is appearing correctly. The facility did not provide any additional information. 5. On 3/21/24 at 11:03 AM, the surveyor observed Resident #24 in the dining area (also known as the activity room) laying in the geri chair (or geriatric chair, which is a large padded chair with wheeled bases and is designed to assist seniors with limited mobility) with eyes closed and the body covered with a blanket. The surveyor reviewed the hybrid medical records of Resident #24 as follows: According to the AR, Resident #10 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), unspecified osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), unspecified glaucoma (a group of eye conditions that can cause blindness), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's comprehensive MDS (cMDS) with an ARD of 12/13/23 revealed in Section C Cognitive Status with BIMS score of 3 out of 15 which reflected that the resident's cognition was severely impaired. Section O Special Treatments, Procedures, and Programs revealed that Resident #24 was offered and declined the pneumococcal vaccination (which helps protect against serious illnesses like pneumonia and meningitis). The immunization record in the electronic medical record (eMR) revealed that Resident #24 had the pneumococcal vaccine on 6/02/23. The above pneumococcal vaccine was signed as administered in the June 2023 electronic Medication Administration Record (eMAR). On 3/25/24 at 11:46 AM, the survey team met with the MDSC. The MDSC informed the surveyors that the facility had no specific policy regarding MDS, the facility follows the RAI Manual. The MDSC stated that the pneumococcal vaccination on 12/13/23 should reflect the accurate status of the resident's vaccination history that the resident had received the pneumococcal vaccine. On 3/25/24 at 12:27 PM, the survey team met with the LNHA, DON, Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC). The surveyor notified the facility management of the above findings and concerns. On 3/26/24 at 02:15 PM, the survey team met with the CNC, LNHA, DON, IPN, and MDSC. The facility management did not respond to the above findings and concerns. NJAC 8:39-11.2(e)1 Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 5 of 19 residents reviewed (Resident # 69, # 9, # 57, #63, and # 24). The deficient practice was evidenced by the following: 1. The surveyor reviewed Resident # 69's records. The resident was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/23/24, the resident was assessed as being discharged to the hospital. A review of Resident # 69's progress notes dated 2/23/24 revealed the resident had actually been discharged home, against medical advice. On 3/25/24 at 11:49 AM, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the MDS under section A, which is she completes, for Resident #69 should have indicated discharge to home and that it was an error that it indicated discharge to the hospital. During an interview on 3/25/24 at 12:15 PM, the surveyor brought the above concerns to the attention of the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA).

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to implement an intervention timely that was recommended by the wound physician. This deficient practice was identified for one of one resident (Resident #28) reviewed. This deficient practice was evidenced by the following: On 3/18/24 at 11:02 AM, the surveyor observed the Resident #28 lying in bed on an air mattress. The resident responded to questions in a faint voice. The resident gave permission to speak with the spouse who was in the room. The spouse stated, [The resident] came here because of a stroke about six months ago. On 3/18/24 at 11:26 AM, the surveyor interviewed the daughter who stated, [the resident] was in the hospital in New York for gastrointestinal bleed and has renal cancer that metastasized to the brain. The resident also had another brain bleed and had radiation therapy recently in the hospital. [the resident] has a sacral wound, stage four, from the hospital from a year ago. On 3/20/24 at 11:25 AM, observed the resident lying in bed, on an air mattress. The resident stated, I am fine for now, I have no complaints. On 3/20/24 at 11:28 AM, interviewed License Practical Nurse (LPN) #1 from Unit A, who worked in the facility for seven years. The LPN stated, The resident gets out of bed (OOB) M-W-F between 1-4 PM with Hoyer (mechanical lift) transfer. The resident gets therapy. The sacral wound has not declined, it's stable. On 3/21/24 at 12:49 PM, observed the resident lying in bed. The resident stated, I ate good today and I feel fine. The resident's daughter who was in the room stated, They mentioned yesterday that the wound team will look into a wound VAC (vacuum assisted closure, to remove excess exudate and promote healing). The nursing supervisor spoke to me on Monday and mentioned at this point that they are keeping the wound sterile for possible application of a wound VAC. I spoke to the wound doctor's office on Monday, and they said there's no indication of infection and would determine soon for possible wound VAC. I am waiting to hear back when that would be applied. On 3/21/24 at 12:57 PM, interviewed LPN #1, who stated, The sacral treatment order is cleaning and packing with Dakin's solution, doctor [name redacted] and his assistant did wound rounds yesterday. The wound is improving, and the treatment orders are the same. I haven't got any orders yet about the wound VAC. On 3/21/24 at 1:02 PM, interviewed Registered Nurse (RN), Director of Nursing (DON), who stated, The resident is being followed by a wound care team. The wound report comes to me every week and I review it. If there's a new treatment, I am updating the orders for anything new. I haven't seen anything yet for an order of a wound vac. A record review of the admission Record in the Electronic Health Record (EHR) reflected the Resident #28 was admitted to the facility with medical diagnoses which included but not limited to: dysphagia following nontraumatic intracerebral hemorrhage (difficulty swallowing due to bleeding in the brain); protein calorie malnutrition; diabetes mellitus type II with hyperglycemia and chronic kidney disease; gastrostomy tube(feeding tube); dysarthria (difficulty speaking); kidney cancer; secondary lung, and bone cancer; and anemia (low red blood cells). According to the Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 1/15/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe impaired cognition. The assessment further reflected that the resident had a Stage four sacral wound on admission, tube feeding and on a mechanically altered diet and required maximal to total assistance with Activities of Daily Living (ADLs). The resident's care plan initiated on 1/8/24 indicated Resident #28 had a sacral pressure ulcer on admission related to immobility. A review of the Order Summary in the resident's EHR reflected Multivitamin & Mineral Oral Liquid (Multiple Vitamins w/ Minerals) Give 15 ml by mouth one time a day for Supplements, ordered on 3/19/24; Zinc Sulfate Oral Tablet 220 (50 Zn) MG (Zinc Sulfate) Give 1 capsule via G-Tube two times a day for Wound Healing for 14 Days, ordered 3/18/24; Sacral Wound cleanse with wound Dakin's, pack with Daikin's Soaked Kerlix, and foam dressing daily. Zinc Oxide to peri wound, reposition side to side, monitor for changes. every night shift for Wound Healing-Start Date 03/14/2024. A review of the wound consult team notes dated on 1/10/24 reflected sacral wound Stage 4 measuring 2.5x2x1.5cm, 30% slough (dead cells), 60% granulation (new tissue) and 10% muscle; Wound consult notes on 2/14/24 reflected measurements of 2x1.5x2cm, 10% slough, 90% granulation, undermining (extending to the muscle) at 1 o'clock and recommendation for wound VAC protocol; Wound consult notes on 2/21/24 reflected recommendations for wound VAC protocol; Wound notes on 3/13/24 recommended wound VAC for sacral wound; Wound consult notes on 3/20/24 reflected measurements of 3x2x1.8cm, 90% granulation, 10% bone, undermining at 12 o'clock and recommend wound VAC; Updated wound consult notes on 3/20/24 after surveyor inquiry reflected treatment orders clean and pack with Dakin's solution until wound VAC is available. Wound consult notes from 2/14/24 through 3/20/24 (total of four weeks), indicated recommendations for wound VAC for sacral wound with no evidence from the facility of an order or treatment clarification. A review of the 1/8/2024 3:41 PM LPN #2 documented on the Braden Scale for Predicting Pressure Ulcer Risk Evaluation note in the EHR reflected Braden Score of 13 indicating moderate risk for skin impairment. A Braden score of 10 on 3/22/24 indicating high risk for skin impairment. A review of the RN Health Status Note Text on 3/22/24 at 4:20 PM: Resident lying in bed awake, alert, verbally responsive to simple questions, denied pain or discomfort, no moaning or facial grimacing noted, respiration easy and regular, no distress. Resident's spouse and daughter visiting. Informed resident, spouse, and daughter that I am going to do wound care to sacral wound and apply wound VAC, procedure explained, questions answered, resident, spouse and daughter agreed. Resident positioned on left side, old dressing removed, moderate amount of sero-sanguineous drainage noted, sacral wound cleaned with NS, wound VAC applied at 125 mm/Hg continuous suction, tolerated procedure well, repositioned for comfort, off load wound, no distress. I informed resident's spouse and daughter that state surveyors would like to observe wound care on Monday, and I asked them for their consent, resident's spouse and daughter declined. A review of the RN Health Status Note Text on 3/22/24 at 5:51 PM: I offered resident's spouse and daughter that I can call MD to order pain medication prior to wound care, resident's spouse and daughter declined, they want to continue PRN (as needed) pain management. Will continue to monitor. On 3/25/24 at 9:15 AM, the surveyor interviewed the DON regarding what was the plan of the wound team from February 14, 2024, to current recommendations for wound VAC protocol written on the wound report, the DON stated, It was written on the bottom of the report and the wound doctor never communicated to me about his plan for the wound VAC and there was no order. On 3/25/24 at 10:45 AM, the surveyor observed the resident sleeping on the bed with air mattress and a wound VAC applied to sacral wound. The resident's daughter and spouse were in the room and the daughter stated, The wound VAC application was to start the wound healing, it's now at the point where it's the next step and it was applied last Friday. On 3/25/24 at 10:55 AM, the surveyor interviewed LPN #2, who has been working at the facility for five years stated, The wound VAC was started last Friday, and I didn't hear anything about the wound VAC prior to last Friday. On 3/25/24 at 11:14 AM, the surveyor called the wound doctor [name redacted] regarding recommendation of wound VAC protocol from 2/14/24 and call went into voicemail. On 3/25/24 at 12:02 PM, the surveyor requested permission from the daughter and spouse regarding sacral wound observation and the family refused. On 3/25/24 at 12:15 PM, the surveyor interviewed the assistant medical director, [name redacted] from the wound consultation group, with the survey team present, the doctor stated, I am the one who reviews the wound reports weekly, but I have not seen the resident. The wound VAC was on back order in February 2024. Our doctor should have documented it on the wound report. We should have documented better and done a separate treatment because Dakin's solution can actually impair wound healing if wound has granulation tissue, there's a better wound treatment. The facility did not provide any documentation of the wound VAC being on back order or that the recommendation for wound VAC was clarified by the facility. On 3/26/24 at 9:46 AM, the surveyor met with the License Home Administrator (LNHA) and the DON in the presence of the survey team and discussed the concern regarding the delay in application of the wound VAC from 2/14/24 through 3/20/24. The surveyor interviewed the DON regarding the wound note on 2/14/24 pertaining to the wound VAC, the DON stated, I should have questioned and followed up with the doctor to clarify what he meant by wound VAC protocol. On 3/26/24 at 10:49 AM, the surveyor interviewed the wound doctor, [name redacted] in the presence of the survey team. The doctor stated, The standard wound VAC needs to be applied for Wound VAC protocol. I believe the resident went to the hospital and came back. The wound has no infection, minimal slough, it's improving. It's the facility's protocol to acquire the VAC but that sometimes takes a couple of days. It's not jeopardizing their treatment until they get the VAC. Continue the same treatment until the VAC comes was the plan. I spoke to my scribe about documentation, and he told me he put that note in the report. Dakin's is the appropriate treatment while waiting for a VAC. We can work on the notes better, I agree with you that it should have been communicated to the facility and documented initially that a VAC was recommended and should have been implemented once the VAC was available. A review of the facility policy and procedure titled Wound Care: Decubitus/Pressure Ulcers with revision date of 2/8/24 revealed, Each resident will have preventative measures instituted to prevent the development of or further deterioration of skin integrity. The wound doctor will recommend treatment based on his assessment during wound rounds. NJAC 8.39-25.2(c); 27.1(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure a.) implementation of interventions designed by the occupational therapist to stimulate functional performance, and prevent further decline, and b.) the interdisciplinary team provided timely revision to the care plan (CP). This deficient practice was identified for one (1) of one (1) resident reviewed for limited range of motion, Resident #29 and was evidenced by the following: 1. On 3/25/24 at 10:33 AM, the surveyor observed the resident with one foot out of the blanket, the chest, and both hands were covered with a blanket. On 3/26/24 at 9:24 AM, the surveyor and the Certified Nursing Assistant (CNA) assigned to the resident, entered the resident's room. The resting hand splint (RHS; a medical device, functional hand brace, wrist, and finger immobilizer) was observed next to the resident's bedside table. The CNA stated that she had fed the resident, who at that time threw the RHS on to the floor. At that time, the CNA described the resident as dependent, required total care, was contracted, and had a splint for the hand which the resident often refused. At 9:30 AM, the surveyor and the CNA reviewed the electronic communication record (eCR; brand redacted) together. The eCR was the system the CNA's used to document tasks associated with activities of daily living (ADL), via touch screen. The eCR did not reflect a task associated with a splint. At that time, the CNA stated that the documentation of the donning and doffing of the splint was not assigned to her. The CNA stated that she reported to the medication nurse on duty who then documented on the electronic Medical Record (eMR) the donning, doffing and refusals of the medical device [splint]. The surveyor reviewed the hybrid medical record for Resident #29. A review of Resident #29's admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included unspecified convulsions, cerebellar stroke syndrome (a stroke that can cause problems with movement, vision, speaking, thinking and behavior), and unspecified dementia (memory problems). A review of Resident #29's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 03/05/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that Resident #29's cognition was severely impaired. Further review of section O. 0500 Restorative Nursing Program, under section C for splint or brace assistance was marked, zero. This number indicated the number of days the restorative program was performed, in the last 7 calendar days, for the resident. According to the Occupational Therapy (OT) and Plan of Treatment (PT) dated 12/2/23, the resident was seen for the quarterly assessment. The assessment indicated that the resident presented with left sided weakness, spasticity (stiff or rigid muscle) of the shoulder, elbow and hand and lower left extremity. The patient required total assistance of all aspects of ADL, to mobilize out of bed onto the geri chair (an adaptive chair) and for feeding tasks. The resident received services one to three times per week. A review of the OT Discharge summary dated [DATE], revealed that on 1/2/24, the resident was discharged from receiving rehabilitative services. The discharge recommendations included. -safely wear a resting hand splint on left hand, up to 8 hours - an elbow extension splint (a medical device to relieve contracture for those with paralysis or significant unbalanced muscle strength on the left elbow, up to 8 hours -will improve ability to safely, and efficiently perform eating tasks with partial/moderate assistance . A review of the Order Summary Report (OSR), the list of active physician orders (PO) as of 3/25/24, included an order for left wrist extension splint (LWES; a medical device that prevents unwanted flexion and extension of the wrist while allowing movement of the fingers and thumb) - On during day shift. Off during night shift. Check skin integrity every shift, every day, and night shift, started on 10/8/22. Further review of the OSR did not reflect a physician order for the following: - resting hand splint (RHS), left hand - elbow extension splint (EES), left elbow On 3/26/24 at 11:07 AM, during an interview with the surveyor, the Certified Occupational Therapy Assistant (COTA)/Director of Rehabilitation (DOR) stated she had no access to the eMR and the eCR. She was unable to view what was donned or doffed by the nursing staff and/or refused by the resident. At that time, the COTA/DOR stated, We don't check the eMR, and that it was the responsibility of the Director of Nursing (DON) to monitor nursing tasks. At 11:41 AM, the surveyor and the COTA/DOR entered the resident's room and confirmed the RHS was in the room and that the elbow splint was not in the room. At 11:44 AM, the surveyor and the COTA/DOR entered the C-wing dining/day room. The surveyor observed the resident seated in a geri chair, reclined, and a hand roll within the left palm. The COTA/DOR assessed the resident and confirmed the resident had a hand roll within the left palm, however the resident was not wearing a left EES, left hand RHS and LWES. At 11:58 AM, the COTA/DOR stated that the evaluating therapist was part-time and was not in the building at that time. She would reach out to let him know about the missing orders. At that time, the surveyor, and the Licensed Practical Nurse (LPN) reviewed the electronic Treatment Administration Record together for the PO of the LWES - On during day shift. Off during night shift. Check skin integrity every shift, every day, and night shift, started on 10/8/22. The order reflected a check mark for the day shift. At that time, the LPN acknowledged that the order for the LWES and skin check should have been separated, for clarity of tracking. The LPN also confirmed the resident was not wearing the LWES and had a hand roll without an order. A review of the succeeding quarter, OT and PT evaluation dated 3/11/23, under current referral included that Nursing staff had been educated on the continuance of the need to don splints to prevent further contracture . Nursing is managing patient's contracture impairment. 2. A review of the quarterly Interdisciplinary Care Plan (IDCP) Care Conference Note of the last two quarters dated 12/7/23, and 3/15/24 under section 10. Restraint/Devices/Side Rail Review did not reflect any documentation relating to medical devices from nursing. The record also did not show a tab where rehabilitative services were able to enter information. On 3/26/24 at 11:07 AM, during an interview with the surveyor, the COTA/DOR stated as part of her responsibilities, she participated in the quarterly IDCP team meetings. At that time, the COTA/DOR informed the surveyor that once a resident was discharged with medical device recommendations, the CNAs were educated by the evaluating therapist. Followed by an evaluation of the CNA's competency of donning and doffing a splint or positioning a wedge or cushion. We then put it on the CP because we want it to carry over. A review of the Treatment Administration Record (TAR) for January 2024, February 2024, and March 2024, did not reflect refusals of the application of the LWES and did not include the tracking of the donning, doffing of the following: - resting hand splint (RHS), left hand - elbow extension splint (EES), left elbow A review of the resident's Care Plan (CP) included a focus that indicated the resident was at risk for left hand contracture dated/revised on 6/12/23; the interventions reflected that the resident would demonstrate increased range of motion of the left hand to increase functional bed mobility and self-care tasks dated/revised on 6/12/23. Further review of the CP goals included that the resident would wear the left resting hand splint during the PM (nighttime) hours to prevent contracture and increase joint mobility dated/revised on 3/1/24. The CP did not include the LWES, the EES and the hand roll. On 3/26/24 at 2:16 PM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Infection Preventionist (IP), the Nursing Consultant and MDS Coordinator (MDSC), the surveyor discussed the concern regarding the failure to develop and implement the OT's recommendations of promoting functional stabilization and preventing contracture from 1/2/24, including the IDCP team's quarter review of 3/15/24. The concern regarding the failure to ensure revision of the individualized CP was also discussed. On 3/27/24 at 9:33 AM, during a follow- up interview with the surveyor, the COTA/DOR stated she attended the quarterly IDCP team meetings but did not document on the conference note. She instead verbally communicated with the IDCP team and emailed the rehabilitation team of the plan for the resident. At that time, the surveyor asked the COTA/DOR why the omissions of the medical device recommendations were not acted upon on 1/2/24 and at the quarterly meeting on 3/15/24. At that time, the COTA/DOR stated that nursing had not verbalize that the medical devices were missing, and the order for the LWES from 10/8/22, was incorrect. She acknowledged the OT recommendations should have been acted upon at the time of the recommendation on 1/2/24, and the errors including omissions, should have been captured for correction at the quarterly meeting on 3/15/24. At that time, the COTA/DOR stated the communication between nursing and rehabilitation services could be better. We started a QAPI (Quality Assurance and Performance Improvement, a data driven and proactive approach to quality improvement) yesterday. No further information was provided. A review of the facility provided policy, Restorative Program, Resident: Ambulation Function Maintenance dated 3/22/24, included the following under Procedure. 1. The therapy Department, in collaboration with Nursing initiates the Functional Maintenance Program for Ambulation. The program goal is set in collaboration with Therapy, Nursing, and the individual resident. 2. As per specific recommendation from therapy .The specific recommendation shall be documented on the resident's plan of care. A review of the facility provided policy, Care Plan, Rehabilitation Services dated 2/8/24, included Procedure under section 9. Care Plans will be updated in a timely manner and necessary revision made when there are changes in condition. NJAC 8:39-11.2 (e)(1)(2), 27.1(a)

2. On 3/21/24 at 10:47 AM, the surveyor observed Resident #57 sitting in bed, alert and oriented, able to answer the surveyor's inquiry. The surveyor reviewed Resident #57's hybrid medical record as follows: A review of the AR documented that Resident #57 was admitted to the facility with diagnoses that included but were not limited to leukemia (a cancer of the blood). The resident's most recent admission MDS (AMDS) assessment, dated 12/21/23, reflected that Resident #57 had a BIMS score of 15 out of 15, indicating intact cognition. The AMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight of 175 pounds. A review of the Care plan showed a focus on Nutrition, initiated on 12/19/23 and revised on 3/20/24, with interventions that included but were not limited to, monitoring weights and reporting any significant changes to the IDCP team. A review of the Weight Summary revealed the following: On 2/2/24 at 12:55, 165.8 Lbs. (pounds) On 2/1/24 at 16:57, 175.0 Lbs. The 2/20/24 Nutrition/Dietary Note in the PN showed that Resident #57 was triggered for a significant weight loss x 1 month (5.5%). The PN did not include that the reweigh was planned, attempted, and refused by the resident. On 3/26/24 at 10:33 AM, the surveyor, in the presence of the team, interviewed the dietitian over the phone. She stated that the resident should have been weighed when the discrepancy was noted. The dietitian confirmed that there was no re-weigh after 2/2/24 with nine (9) pounds lost. She added that she would tell Nursing to re-weigh the resident. She stated that she informed the NP regarding the weight loss. On 3/27/24 at 11:23 AM, the surveyor interviewed the NP, who has been working in the facility for a year. She stated that the dietitian or nursing did not inform her of the resident's weight loss; if she does, she will order lab work and re-weigh the resident. A review of the facility's Weighing the Resident Policy with a revision date of 3/21/24 that was provided by the RD included that the weights of residents are taken on admission and monitored monthly. If clinically indicated, weights are monitored more often as needed or as the physician orders. The purpose is to record the actual weight of residents and to keep accurate records of weight gain or loss. Included in the procedure: chart weight on the appropriate form in the chart, any increase or decrease of more than five pounds should be called to the Charge Nurse's attention and reweigh. Document weight and notify the dietician as needed. On 3/26/24 at 02:15 PM, the survey team met with the Clinical Nurse Consultant, LNHA, DON, Infection Preventionist Nurse, and the MDS Coordinator (MDSC). The facility management did not respond to the above findings and concerns. NJAC 8:39-11.2(d)(e)(1)(f), 17.1(c), 17.2(d), 27.1(a) Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a) follow through with the Dietitian's recommendation for one (1) of two (2) residents (Resident #24), b) ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss according to the standard of clinical practice for one (1) of two (2) residents (Resident #24), and c) ensure that the re-weigh was done according to the standard of clinical practice and facility policy for two (2) of two (2) residents, Resident #24 and #57, reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 3/21/24 at 11:03 AM, the surveyor observed Resident #24 in the dining area (also known as the activity room) laying in the geri chair (or geriatric chair, which is a large padded chair with wheeled bases and is designed to assist seniors with limited mobility) with eyes closed and the body covered with a blanket. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #24. According to the admission Record (admission summary), Resident #10 was admitted to the facility with a diagnosis that included but was not limited to essential hypertension (abnormally high blood pressure that's not the result of a medical condition), unspecified osteoarthritis (a degenerative disease that worsens over time, often resulting in chronic pain), unspecified glaucoma (a group of eye conditions that can cause blindness), type 2 diabetes mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's comprehensive Minimum Data Set (cMDS), and assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/13/23 revealed in Section C Cognitive Status Brief Interview for Mental Status (BIMS) score of 3 out of 15 which reflected that the resident's cognition was severely impaired. The cMDS Section K Swallowing/Nutritional Status revealed that the resident had a weight loss of 5% or more in the last month or a loss of 10% in the last six months. The personalized care plan showed a focus on Nutrition that was initiated on 12/15/20 and revised on 3/21/24 with interventions that included but were not limited to monitor my weights and lab (laboratory) as avail (available) initiated on 12/15/20. A review of the Weight Summary revealed that on 12/08/23 the resident's weight was 121.5 pounds (lbs) with warning notes that included the following: -5.0% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] -7.5% change [comparison weight 11/10/23, 132.0 lbs, -8%, -10.5% lbs] A review of the IDCP (Interdisciplinary)/Care Conference Note with an effective date of 12/21/23 included Nutritional Status that was electronically signed by the Dietitian on 01/05/24 that the resident was triggered for a significant weight loss x 1 (one) month (8%) and the Dietitian recommended for albumin (test measures the amount of the protein albumin in the blood) level. The Clinical Dashboard in the electronic medical record (eMR) for a facility bulletin board showed that on 12/21/23, the Dietitian created documentation for the resident's recommendation for an albumin level. A review of the Order Summary Report (OSR) for December 2023, January 2024 through March 21, 2024, showed that there was no order for an albumin level. The Results tab in the eMR showed that the last lab done was on 10/04/23. The 12/21/23 Nutrition/Dietary Note in the Progress Notes (PN) showed that Resident #24 was triggered for a significant weight loss x 1 month (8%). The PN did not include that the reweigh was planned, attempted, and refused by the resident. Further review of the PN revealed that there was no documentation from the Physician, Nurse Practitioner, and Nurses about the 12/21/23 notes of the Dietitian about the significant weight loss and the albumin level that was recommended. In addition, the PN did not include documentation that the resident was offered and declined the reweigh and albumin level check. On 3/21/24 at 11:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) in the presence of two surveyors. The LPN informed the surveyor that Resident #24 was cognitively impaired, at times required assistance from staff with eating, appetite varied, and most of the time appetite was good. The LPN stated that the resident was on Glucerna shake and the resident takes it well. On that same date and time, the LPN stated that she was not aware of the resident's significant weight loss. She further stated that she was not sure if the weight meeting existed at the facility. At that same time, the surveyor asked the LPN what was the facility's process and standard of practice with regard to weight loss. The LPN informed the surveyor that the Dietitian would notify the nurse verbally of the weight loss and recommendations. The LPN stated that she can also see the Dietitian's recommendations in the Clinical Dashboard in the eMR for weight loss. She further stated it was the nurse's responsibility to call the physician for the recommendation to obtain an order which included an order for lab if that was the recommendation of the Dietitian. The LPN also stated that if the doctor declined the recommendation it was an expectation that the nurse would document it in the PN. At this time, the surveyor asked the LPN why the 12/21/23 recommendation of the Dietitian for an albumin level in the Clinical Dashboard that the LPN showed was not followed. The surveyor also asked why there was no documentation that the physician was called about the recommendation. The LPN responded, I do not know what happened. On 3/21/24 at 11:45 AM, the surveyor interviewed the Registered Dietitian (RD, also known as the Dietitian). The RD informed the surveyor that the facility's process regarding weight loss generally, the RD enters the weight in the eMR specifically in the weight section, and if there was a five (5) pounds plus or minus weight discrepancy, a reweigh will be done. The RD stated that she also verified and assessed the resident on what happened and why there was significant weight change or weight loss. She further stated that the Nurse Practitioner (NP) of the resident's primary physician will be notified via a [name of an app] (a messaging app that uses the internet to send messages, images, audio, or video) of a list of residents with weight changes that included significant weight loss. On that same date and time, the RD informed the surveyor that there was an IDCP weight meeting where the RD, Director of Nursing (DON), and MDS Coordinator (MDSC) participated, and discussed weight loss. The RD stated that there was no specific date when the IDT met and there was no documentation of the meeting. The RD further stated that the nurses would call the doctor and put the orders that included the recommendations for blood work and supplements as applicable. The surveyor then asked the RD if she followed up on her recommendations and if it was documented. The RD responded Yes, I follow up, but I do not document if the recommendations were not followed through, because the RD did not want other people to be blamed. At that same time, the surveyor notified the RD of the above findings and concerns. The RD stated that she knew Resident #24 and that the resident started to trend down with weight. The RD further stated that she liberalized the resident's diet today, and increased the fortified food. The surveyor asked the RD why her recommendation on 12/13/23 to check for albumin level for significant weight loss was not followed, and the RD did not respond. On 3/21/24 at 01:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the facility management of the above concerns and findings regarding weight loss. On 3/25/24 at 10:19 AM, the surveyor interviewed the NP. The NP informed the surveyor that she was not notified of the resident's significant weight loss and the recommendation to check the albumin level. The NP stated that usually when the RD recommended, the NP and physician approved and they (NP and physician) documented it in the eMR. The NP acknowledged that if it was not documented in the eMR about the significant weight loss, it meant that she was not aware. At that same time, the NP stated that she was not aware of the facility's policy to reweigh the resident if there was a significant weight loss. The surveyor notified the NP of the above findings and concerns. On 3/25/24 at 10:34 AM, the surveyor interviewed the DON in the presence of the NP. The DON stated that it was an expectation if a resident had a weight loss, the RD would evaluate the resident and provide recommendations, and nursing and physician would be notified. The RD will notify the DON of the significant weight loss and recommendations as well. The DON informed the surveyor that he was not aware of the significant weight loss of Resident #24 that was documented by the RD on 12/21/23 and 02/22/24. At that same time, the DON stated that the last weight meeting was held late last year, and unable to remember the date because it was informal and not documented. He further stated that he did not remember that in the last weight meeting in December 2023, the resident's significant weight loss was discussed, which was why he was not aware of the resident's weight loss problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) maintain the necessary care and maintenance of a respiratory equipment and b.) provide a physician's order for respiratory care in accordance with professional standards of practice for one of one resident, (Resident #58) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/18/24 at 10:35 AM, the surveyor observed the Resident #58 lying in a low bed to the ground. A nebulizer mask was on the bedside table in a bag and the label on the tubing was dated 3/11/24. The resident was pleasant, alert, and oriented to person, place and time. The resident stated, I am here because I have pneumonia (an infection of the lungs) and I need to get my breathing better again. On 3/20/24 at 11:03 AM, the surveyor observed the resident in the therapy gym using the bike with no evidence of difficulty breathing while biking. On 3/20/24 at 11:07 AM, the surveyor interviewed the Registered Nurse (RN), who has been working in the facility for 18 years. The RN stated,The resident's pneumonia was treated when the resident was first admitted . The resident's pulse oxygen saturation is good and does not use the oxygen now, only as needed. We generally change the oxygen and nebulizer tubing weekly on Sunday nights. On 3/20/24 at 11:15 AM, the surveyor and the RN entered the resident's room. The surveyor observed the nebulizer mask in the resident's drawer in a plastic bag. The tubing was dated 3/11/24. The RN stated, I was not here on Sunday night, so it was not changed. I will change it now and get an order. The physician order sheet (POS) reflected no order for tubing changes for over nine weeks. The surveyor observed the resident sitting on the bed and the resident stated, I feel a little tired and my breathing is a little hard, I just finished therapy. The RN stated ten minutes later, I checked the resident's oxygen saturation, and it was 97%. On 3/20/24 at 12:06 PM, the admission Record review in the Electronic Health Record (EHR) reflected medical diagnoses which included but were not limited to pneumonia; centrilobular emphysema (chronic lung disease); chronic obstructive pulmonary disease (copd); lung cancer. A review of the Order Summary revealed: Change nebulizer kits every weekly on Sunday every night shifts every Sunday for nebulizer, ordered 3/20/24 at 12:49 PM, (after surveyor inquiry). Change oxygen tubing (nasal cannula) every weekly while oxygen in use as needed for oxygen change every 7 days, ordered 3/20/24 at 12:53 PM, (after surveyor inquiry). Budesonide inhalation suspension 0.5 MG/2ML (Budesonide (Inhalation) 1 vial inhale orally via nebulizer two times a day for COPD The resident should rinse mouth after use of Budesonide to decrease the risk of oral fungal infection. ordered 3/4/24. Yupelri inhalation solution 175 MCG/3ML (Revefenacin) 1 vial inhale orally via nebulizer one time a day for COPD, ordered 3/4/24. Formoterol Fumarate inhalation nebulization solution 20 MCG/2ML (Formoterol Fumarate) 1 vial inhale orally via nebulizer two times a day for COPD, ordered 1/14/24. Albuterol Sulfate inhalation aerosol powder breath activated 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for wheezing, ordered 1/13/24. Cefdinir oral capsule 300 MG (Cefdinir) give 1 capsule by mouth two times a day for pneumonia for 3 Days-Start Date 1/14/2024 and completed 1/17/24. Oxygen @ 2 liters per minute continuously at night. Okay to wean off oxygen during waking hours if saturations above 94% every shift for oxygen-start date 1/14/2024 0700-discharge date [DATE]. A review of the resident's Admission/5Day Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/20/24 reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. A review of the 2/23/24 plan of care notes from the primary physician on revealed pulmonary-denies cough, shortness of breath, orthopnea (shortness of breath while lying flat in bed). A review of the 3/20/24 Nurse Practitioner's (NP) plan of care notes revealed assessment and plan: COPD- chronic, stable, continue with Formoterol Fumarate Inhalation Nebulization Solution and Albuterol Sulfate Inhalation Aerosol Powder and Budesonide Inhalation Suspension. On 3/21/24 at 11:20 AM, the surveyor observed an oxygen sign on the resident's door, an oxygen concentrator near the bedside and nebulizer tubing dated 3/20/24. The resident was sitting on the bed and stated, I feel fine today, my breathing is better, I use that nebulizer machine for my lungs. On 3/21/24 at 11:28 AM, the surveyor interviewed the License Practical Nurse (LPN), who had been working at the facility for 7 years. The LPN stated, A resident with oxygen will have a sign on the door that says oxygen is in use. We change the tubing for oxygen and nebulizers on Sunday during the night shifts, nebulizer mask goes in a plastic bag. I know she was on antibiotic for a few days on admission and was treated. There is no breathing issue currently, oxygen saturation has been really good. A review of the facility policy and procedure titled Oxygen/Nebulizer Administration: Nasal Cannula or Mask revision date 3/22/23 revealed, Mask/cannula and tubing should be dated upon opening. Change weekly or as needed. On 3/21/24 at 01:45 PM, the surveyor and with the presence of the survey team met with the Licensed Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the above observations and concern with the nebulizer maintenance and regulations. The DON acknowledged that the tubing should have been changed weekly as per the facility's policy. NJAC 8.39-25.2(c)3

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by ensuring that an expired controlled drug (Lorazepam gel) was removed from active inventory after 1/22/24 and had accurate corresponding documentation for the removal and administration for Resident #39 in one (1) of three (3) medication carts observed during the medication storage inspection. 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. The deficient practice was evidenced by the following: On 3/25/24 at 10:32 AM, the surveyor, with the Licensed Practical Nurse (LPN), observed in the medication cart, in a controlled drug locked box, a light sensitive bag labeled for Resident #39 that had one (1) oral syringe containing Lorazepam 0.5 milligram (MG)/0.5 milliliter (ML), (an anti-anxiety medication compounded in gel form and stored in an oral syringe to be used topically). The surveyor with the LPN reviewed the Individual Patient's Controlled Drug Record (IPCDR) which corresponded that there was one (1) remaining Lorazepam gel syringe. At that time, the surveyor, with the LPN, reviewed the label on the Lorazepam gel syringe for expiration dating. The LPN stated that the expiration date on the label of the Lorazepam gel syringe was 1/22/24. The surveyor, with the LPN, then observed the label on the light sensitive bag that had the one (1) Lorazepam gel syringe which identified Beyond Use Date: 2024-01-22. The LPN then stated that the Lorazepam gel should have been removed from the medication cart because it was expired. The LPN stated that Resident #39 was administered the Lorazepam gel as needed (PRN) and was used infrequently. Further review of the IPCDR revealed that the Lorazepam gel was removed from inventory on 1/28/24, 2/13/24, 3/3/24, 3/8/24, and 3/11/24. At that time, the LPN explained that she would be removing the Lorazepam gel, along with the IPCDR, and would give it to the Director of Nursing (DON) or the Assistant DON for destruction. The LPN stated that controlled drug inventory counts were completed every shift which was every 12 hours (Q12H) and documented on the Controlled Substance Tally Sheet. The LPN added that expiration dating should be checked during the shift-to-shift count. A review of the Controlled Substance Tally Sheet for March 2024 that was located in the controlled drug logbook on the medication cart revealed that shift to shift counts were completed. There was no recorded evidence that the Lorazepam gel was expired and to be removed from inventory. The surveyor reviewed the medical record for Resident #39. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/15/24, reflected the resident had a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition. A review of the admission Record revealed diagnoses which included dementia with agitation and anxiety disorder. A review of the Order Summary Report (OSR) revealed a physician's order (PO) with a start date of 10/2/23 for Lorazepam 0.5 MG/0.5 ML Administer 0.5 MG(0.5 ML) topically Q12H PRN for agitation/anxiety. A review of the January and February electronic medication administration record (EMAR) revealed that there was no documentation that the Lorazepam gel was administered. A review of the March EMAR revealed that the Lorazepam gel was administered on 3/4/24 at 2:58 AM. There were no other entries for administration noted. A review of the electronic progress notes (EPN) revealed an entry dated 3/4/24 at 2:58 AM indicating that the Lorazepam gel was administered. There were no other EPN entries for January or February indicating that the Lorazepam gel was administered. On 3/25/24 at 11:58 AM, the surveyor observed Resident #39 in the activity room in a wheelchair holding a doll and participating in a group activity. On 3/25/24 at 12:14 PM, the surveyor interviewed the LPN who stated that the IPCDR should correspond with the EMAR for the dates and times that the controlled drug was removed from inventory and then administered. The LPN explained that when the EMAR was signed for administration of a PRN medication the EPN would automatically be populated with an entry to indicate the reason for administration. Therefore, for every PRN EMAR administration there should be an EPN. The LPN then stated that she had administered the PRN Lorazepam gel in the past but thought that was two (2) to three (3) months ago. The LPN also stated that she felt that Resident #39 had improved with less anxious behaviors because there were changes in routine medications. The LPN added that the PRN Lorazepam gel was effective when administered. On 3/25/24 at 12:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor requested that the DON review the resident's EMAR for January, February and March to coincide with the documentation on the IPCDR for removals of Ativan gel. On 3/26/24 at 9:20 AM, the surveyor interviewed the DON who acknowledged that there were no entries on the EMAR that corresponded with the IPCDR for the Lorazepam gel. On 3/26/24 at 9:37 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON stated that the Lorazepam gel should have been removed after 1/22/24 and thought the label was difficult to read the expiration date. In addition, the DON stated that the EMARs had not reflected the administration of the Lorazepam gel according to the IPCDR. The DON verified that the EMAR and EPN should correspond with the IPCDR. In addition, the DON stated that he spoke with the nurse regarding the March EMAR which reflected an administration date of 3/3/24. The DON explained that the nurse had worked on 3/4/24 and inadvertently wrote 3/3/24 on the IPCDR. The DON added he was continuing to speak with the nurses who signed for the removal of the Lorazepam gel. On 3/26/24 at 10:23 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that he was not the usual CP for the facility but was able to answer any questions. The CP stated that a unit inspection was completed every month by the CP and any expired medications that were found would be reported to nursing for removal. The CP added that controlled medications were spot checked during the unit inspection. The CP also stated that a spot check of the IPCDRs and EMARs were completed and that the documentation of a removal of a controlled drug should match the EMAR whether the controlled drug was administered or refused. A review of the Unit Inspection Reports for the unit completed by a CP dated 1/25/24, 2/27/24, and 3/19/24 revealed that there was no recorded documentation of the expired Lorazepam gel. A review of the current facility policy for Administration of Medications with a revision date of 2/14/24 provided by the DON reflected To administer medication safely and efficiently. In addition, the policy reflected Once resident has been identified: .Re-read label . The policy further reflected to Make appropriate entry on eMAR and Narcotic Control Sheet, if applicable. A review of the current facility policy for Medication: Controlled Drug with a revision date of 2/22/24 provided by the DON reflected When a controlled drug is administered to a resident, in addition to the following the proper procedure for charting medication, the declining inventory sheet must also be signed. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(g)(k), 29.7(c)

Based on interview, and record review, it was determined the facility failed to follow professional standards and practices to accurately document in the medical record an ordered medication a resident was being administered. The concern was cited for 2 (Residents #57 and #377) of 19 residents reviewed and is evidenced by the following. 483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are (ii) accurately documented. 1. On 3/19/24 at 12:51 PM, the surveyor reviewed the medication orders for resident #377 in the electronic medical record (EMR). The medication orders reflected that resident #377 had a physician's order for and was being administered Lantus insulin (Lantus) (a long-acting injectable medication used to treat diabetes). On 03/20/24 at 9:51 AM, the surveyor reviewed the EMR for resident #377. The review included documentation recorded by the attending physician and associated nurse practitioners reflected as Plan of Care (POC) notes, Physician Progress Notes and Chronic Care Management Notes. The surveyor identified six (6) out of eleven (11) instances where the documentation did not accurately reflect the insulin (an injectable medication used to treat diabetes) resident #377 was receiving. The Physician's Progress Notes dated 11/17/23, 1/1/24, 1/19/24 and 2/16/24 reflected Humalog insulin (Humalog) (a short-acting injectable medication used to treat diabetes). The Chronic Care Management Monthly note entered by an NP dated 12/18/23 reflected Humalog sliding scale. The Chronic Care Management Monthly notes entered by an NP dated 1/24/24 and 2/22/24 did not reflect any insulin order. The POC note entered by an NP dated 2/26/24 as a Late Entry reflected Lantus and ISS (insulin sliding scale). The Chronic Care Management Monthly notes entered by an NP dated 12/13/23, 1/17/24 and 3/20/24 reflected Lantus. Humalog is described as a fast-acting insulin that starts to work in fifteen (15) to thirty (30) minutes and lasts three (3) to four (4) hours. Lantus is described as a long-acting insulin that starts to work in one (1) to two (2) hours and continues working in the body for twenty (20) to twenty-four (24) hours. On 3/25/24 at 12:25 PM, the surveyor discussed this concern with facility administration. On 3/26/24 at 9:38 AM the Director of Nursing provided documentation in the form of a Physician's progress note reflecting that the physician corrected the record to reflect the resident receiving Lantus. The surveyor asked the administration team if the physician gave any reason for the discrepancies. The administrator stated, there was no specific reason other than human error. No further evidentiary information was provided by the facility. 2. On 03/21/24 at 10:47 AM, the surveyor observed Resident #57 sitting in bed, alert and oriented, able to answer the surveyor's inquiry. The surveyor reviewed Resident #57's hybrid (combination of paper and electronic) medical record as follows: A review of the AR documented that Resident #57 was admitted to the facility with diagnoses that included but were not limited to leukemia (a cancer of the blood). The resident's most recent admission MDS (AMDS) assessment, dated 12/21/23, reflected that Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Section O Special Treatments, Procedures, and Programs revealed that Resident #57, the influenza vaccine (which helps protect against the influenza viruses) was received outside of the facility, and pneumococcal vaccination (which helps protect against serious illnesses like pneumonia and meningitis), was up to date. A review of Resident #57's electronic medical record under the immunization tab did not show that the Influenza and Pneumovax dose did not indicate a date given as complete or a date with historical to indicate that the resident had the vaccination in the past. On 3/21/24 at 01:50 PM, in the presence of the survey team, the surveyor requested the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to provide information on Resident #57's vaccinations. On 3/25/24 at 11:25 AM, the DON provided the surveyor with a document stating, Immunization Resident #57 PNA - resident verbalized received vaccine in the community but could not remember when. Flu-per wife received Flu vaccine at primary MD's office. On 03/26/24 at 09:55 AM, the DON asked for a copy of the resident's immunization record from a family member. He added that the immunization tab was updated and that the immunization record copy was uploaded to the miscellaneous tab of the electronic record after the surveyor's inquiry. NJAC 8:39-35.2(d)9

Based on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for the PBJ Report submission for Fiscal Year (FY) Quarter 1 2024 (October 1-December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area indicating the facility failed to submit data for the first Fiscal Year Quarter to CMS. The dates of the first quarter included October 1, 2023, through December 31, 2023. On 3/19/24 at 10:00 AM, the Licensed Home Administrator (LNHA) informed the survey team that the facility used a third party to submit the PBJ Staffing Data Report to CMS. The third party did not provide a CMS validation or any proof of submission to CMS for staffing reported for the FY Quarter 1 2024. On 3/27/24 at 11:15 AM, the surveyor interviewed the LNHA, in the presence of another surveyor, regarding communication of staffing with CMS and he stated, We submitted everything with this third party, and they communicate with CMS. I don't have any documentation or proof on hand to reflect that CMS received the data for the FY Quarter 1 2024. The survey team explained the concern to the LNHA that CMS did not have the data. The LNHA was not able to provide additional proof of documentation indicating the third party communicated to CMS. On 3/27/24 at 12:00 PM, the surveyor requested the policy and procedure from the LNHA for PBJ submission/communication to CMS. The facility's policy and procedure were received from the LNHA on 3/27/24 at 12:30 PM, the policy titled PBJ Reporting, with the revised date of 2/8/24 did not indicate the timeframe of submitting data to CMS and who was responsible for submission. NJAC 8:39-41.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 11:41 AM, the surveyor inspected the C-unit medication storage room and observed in the refrigerator the medication, Tubersol, which was opened and dated [DATE]. At that time, the surveyor interviewed the LPN who stated that Tubsersol was to be discarded 30 days after the medication was opened. On [DATE] at 2:38 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) over the telephone who stated that all medications and containers stored in a medication room that were not appropriately labeled, dated, and identified should have been thrown away. The CP further stated that the medication Tubersol was to be discarded 30 days after opening per the manufacturer recommendations. On [DATE] at 10:04 AM, the surveyor interviewed the DON who stated that nothing should have been left open in the medication room and medications that were in the medication room needed to be appropriately labeled and dated. The DON further stated that the medication Tubersol was only good for 30 days after opening and should have been discarded. Review of the facility's Education Attendance Sheet dated [DATE], reflected the educational topic, Medication Storage - No unlabeled medications should be kept in the medication rooms or medication carts. Review of the facility's Medication Storage Policy and Procedure, dated [DATE], indicated that, Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the customers, in accordance with state Department of Health guidelines and are accessible only to licensed nursing and pharmacy personnel. The facility's Medication Storage Policy and Procedure further indicated, Medications will be stored in the original, labeled containers received from the pharmacy. No medication is to be transferred from one container to another. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. NJAC 8:39-29.4(a)1.2.3.4.5.6.7.8.9.10.(f) Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately label, date and store biologicals and b.) discard medications after the manufacturer specified use by date. This deficient practice was identified during 2 of 2 medication storage room (B-unit medication storage room and C-unit medication storage room) inspections and was evidenced by the following: 1. On [DATE] at 11:54 AM, the surveyor inspected the medication storage room on the B Unit. The surveyor observed one unlabeled clear orange pill bottle which contained an unidentified clear liquid. The surveyor interviewed the Licensed Practical Nurse (LPN) at the time of inspection who stated that she could not identify what type of liquid was being stored in the clear orange pill bottle on the counter of the medication storage room. On [DATE] at 12:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Clinical Nursing Registered Nurse Liaison who were all in agreement that unlabeled clear orange pill bottles containing unidentified substance should not to be stored in the medication storage room. The LNHA and DON reviewed the picture that the surveyor took of the unlabeled pill bottle which contained an unidentified clear liquid and the DON stated that they do not have any pill bottles that look like that in the facility and that it must be a staff member's personal pill bottle, however it should not be stored in the medication storage room.

Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units, (B unit). The deficient practice was evidenced as follows: On 09/07/23, the surveyor observed the following during lunch meal pass on the B-unit: At 12:36 PM, in the pantry room, a Recreation Aide (RA) removed the ice scoop from the wall holder and scooped ice from a cooler, poured the ice into a cup, replaced the ice scoop to the holder, placed the cup on a meal tray and placed the tray on Resident #16's bedside table in his/her room. The RA returned to the pantry and retrieved a meal tray and placed it on Resident #46's side table in his/her room. In the same room, the RA then pulled the privacy curtain around Resident #57, turned, and rested her left hand on Resident #46's pillow that was behind his/her head while the resident was seated in a recliner chair. The RA pulled the recliner chair to reposition the resident in the room, moved the bedside table in front of the resident, touched the resident's shoulder with her right hand, retrieved the meal tray from the side table and placed the meal tray on the bedside table in front of Resident #46, then used the handle on the side of the bedside table to lower the table in front of the resident. The RA removed the food lid, removed the silverware from the plastic bag, placed the fork in the resident's food, pulled up a chair next to the resident and sat down. The RA then picked up the resident's fork and fed the resident a bite of meat, placed the fork on the tray, opened their milk carton, picked up the fork and fed the resident a bite of meat, went to the air conditioning unit and pressed a button, retrieved the power cord and plugged it into the electrical outlet, then again pressed a button on the air conditioning unit, returned to the resident and picked up his/her fork and fed the resident a bite of food. No hand hygiene (HH) was observed at any time during the observation. On 09/07/23 at 12:46 PM, the surveyor interviewed the RA who stated she was also a Certified Nursing Assistant (CNA) and that her role was to assist to feed the resident. She stated during meal tray pass that staff performed handwashing before entering the pantry room, if they touched anything, or if they performed a task for the resident. The surveyor made the RA aware of the meal pass observation. The RA acknowledged that she did not perform HH correctly and stated that it was important to perform proper HH during the meal pass to prevent illness from germs. On 09/07/23 at 12:55 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that staff performed HH before and after the whole meal tray pass and was unsure if HH should have been done between passing each tray. The surveyor made the LPN aware of the meal pass observation. The LPN stated that the RA should have performed HH when she left the first resident's room, after the resident was touched, after plugging in the air conditioning unit, when the curtain was touched, and when the table was touched. The LPN further stated that it was important to perform HH correctly to prevent passing bacteria. On 09/08/23 at 09:50 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that HH was performed between each meal tray pass. The surveyor made the LPN/IP aware of the meal pass observation from 09/07/23. The LPN/IP stated that HH was not performed correctly and that HH was important for infection control. On 09/08/23 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON) who stated that HH was performed in between each resident and when objects were touched. The surveyor made the DON aware of the meal pass observation from 09/07/23. The DON acknowledged that HH was not performed correctly and that HH was important for infection control. On 09/14/23 at 12:17 PM, the Licensed Nursing Home Administrator and administrative team were made aware of the 09/07/23 B unit RA meal tray pass observation. On 09/07/23 at 12:30 PM, the surveyor observed the lunch dining observation on the B Unit dining room. The surveyor observed multiple staff members passing out food trays to the residents sitting at the tables in the dining room. The surveyor observed that staff were obtaining the food tray from the cart, would provide the resident the tray, set up the tray (open containers, cut up food etc.), then would immediately go back out to the cart and obtain another tray for another resident and then would set that other resident up for lunch. The surveyor did not observe any employee in the dining room performing hand hygiene in between distributing resident meals. On 09/07/23 at 12:41 PM, the surveyor interviewed the Staffing Coordinator/CNA (SC) who was observed by the surveyor distributing resident food trays and setting up residents for their meals in the B Unit dining room. The SC explained to the surveyor that after you set the residents up and prepare the food tray you for one resident then you would proceed to get the next tray and set the next resident up for lunch. She then admitted to the surveyor that she did not sanitize her hands after setting up resident after resident for meals. She stated that it would have been important to sanitize hands between residents' meal distribution to prevent the spread of infection. On 09/08/23 09:49 AM, the surveyor interviewed the LPN/IP who explained that when staff are distributing food trays to the residents, they should be performing hand hygiene between each resident. She stated that the importance of performing hand hygiene was to not spread germs or infection. Review of facility documentation, Competency Validation, Handwashing Technique, dated 09/15/22, revealed the RA passed the return demonstration. Review of facility documentation, Hand Hygiene Competency Validation, dated 02/09/23, revealed the RA was competent with return demonstration. Review of facility documentation, In-Service Education Attendance Sheet, dated 03/20/23, revealed the RA attended the 30-minute hand hygiene in-service. Review of facility policy, Handwashing, Staff, with a revision date of 03/21/23, revealed, Policy: To prevent the transmission of infections diseases, all personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure .before handling food and when hands become soiled. NJAC 8:39-19.4 (m)(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09/06/23 at 11:37 AM, 09/07/23 at 10:30 AM, and 09/08/23 at 11:31 AM, the surveyor observed Resident #63 in his/her room with a gastrostomy tube (G tube, a tube inserted through the abdomen that allows nutrition directly to the stomach) attached to a tube feeding that was infusing via a feeding pump that was attached to an IV pole. There were several areas of dried tan drainage observed on the feeding pump, IV pole and base of the IV pole which was consistent with the tube feeding formula that was used for the resident's feeding. The surveyor reviewed the medical record for Resident #63. Review of Resident #63's admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to: intracerebral hemorrhage (a ruptured blood vessel that causes bleeding inside the brain), dysphagia (difficulty swallowing), and a gastrostomy tube. Review of Resident #63's Quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care dated 08/12/23, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderately impaired cognition. The MDS also revealed that the resident was dependent for all activities of daily living and had a feeding tube. Review of Resident #63's Order Summary Report revealed a physician order dated 07/13/23 for Jevity 1.5 cal via G tube at 95 ml/hr (milliliters per hour) for 16 hours or until TV (total volume) of 1520 infused. Review of Resident #63's September 2023 Medication Administration Record (MAR) reflected the above physician's order and was documented as administered. On 09/08/23 at 11:43 AM, the surveyor interviewed the Registered Nurse (RN) caring for Resident #63. The RN stated the resident received nothing by mouth and that all nutrition was administered via the feeding tube. The RN stated that it was the housekeeper's responsibility to clean the pump and IV pole but that she would clean them if they were dirty. The RN further stated that any time that she worked, and the equipment needed to be cleaned, that she would clean them. The surveyor escorted the RN to the resident's room and observed the feeding pump and IV pole. The RN acknowledged the tan dried drainage and stated it should not have been there and that she would wash it. The RN stated that it was important to keep resident equipment clean for infection control. On 09/08/23 at 11:55 AM, the surveyor interviewed the Housekeeper (HK) who stated his responsibility was to clean resident rooms daily and wipe equipment daily. The surveyor provided three days of photos of Resident #63's dirty tube feeding pump and IV pole. The HK stated the feeding pump and IV pole should not have been dirty and stated that it should have been, clean, spotless, and wiped down, to keep the resident safe and for the prevention of cross contamination. On 09/08/23 at 12:07 PM, in the presence of the Director of Nursing (DON), the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that it was the nurse's responsibility to wipe down the feeding pump and IV pole if it was visibly soiled and that once the resident no longer needed the equipment, the HK cleaned it and stored it in the supply closet on the unit. The surveyor provided three days of photos of Resident #63's dirty tube feeding pump and IV pole. The LPN/IP acknowledged that the feeding pump and IV pole were dirty and stated that if the equipment was soiled that it was the nurse's responsibility to wipe it and that it was important to keep the equipment clean to avoid germs and contamination. On 09/13/23 at 2:29 PM, the surveyor interviewed the HD who stated that the Housekeeping Department would clean IV poles when they were noticeably soiled and that he would make rounds after staff and then would make a cleaning schedule when he observed that the tube feeding poles needed to be cleaned. The HD then stated that he would not expect his HK staff to clean the tube feeding poles daily because the staff focused more on cleaning the bottom of the eating tables, the bed rails, and topical surfaces. He further stated that he performed rounds every day but some days he could miss something. Review of the facility policy, Daily cleaning resident rooms, with a revision date of 9/8/23, revealed Purpose: To maintain a clean and safe resident care environment in accordance with commonly accepted infection control practices and criteria for cleaning and disinfection. Procedure: 1. Daily cleaning of resident rooms includes but is not limited to the following: cleaning and sanitizing high touch areas .cleaning any identified spills other dirty surfaces. 7. Visibly dirty surfaces and non-critical medical equipment may be cleaned with mild detergent followed by application of EPA approved disinfectants. A review of the facility policy, Cleaning and storage of non-critical medical equipment, with a review date of March 9, 2023, revealed Purpose: To maintain a clean and safe resident care environment in accordance with commonly accepted infection control practices and criteria for cleaning and disinfection. Procedure: 6. Visibly dirty surfaces and non-critical medical equipment may be cleaned with mild detergent followed by application of EPA approved disinfectants. Review of the facility's In-Service Education Attendance Sheet dated 09/11/23, reflected that staff were in-serviced on Disinfection of the Environment and Equipment and the facility's Cleaning and storage of non-critical medical equipment Policy and Procedure reviewed 03/09/23. The facility's Cleaning and storage of non-critical medical equipment Policy and Procedure indicated, To maintain a clean and safe resident care environment in accordance with commonly accepted infection control practices and criteria for cleaning and disinfection: 1. Non-critical medical equipment is defined as equipment which can be safely cleaned and disinfected by use by others. Examples of such equipment are nebulizers, concentrators and IV pumps. Review of the facility's In-Service Education Attendance Sheet dated 09/12/23, reflected that staff were in-serviced on the facility's Daily Cleaning Resident Rooms Policy and Procedure dated 09/08/23. The Daily Cleaning Resident Rooms Policy and Procedure indicated that daily cleaning of the resident rooms included, but were not limited to, cleaning and sanitizing high touch areas, like bedrails, bed side tables, doorknobs, toilet handles, and light switches. Collecting and removing trash bags, sweeping, and mopping the floors. Cleaning any identified spills other dirty surfaces. Cleaning a disinfecting bathroom toilets, sinks, tubs, and showers. The Daily Cleaning Resident Rooms Policy and Procedure further indicated, Visibly dirty surfaces and non-critical medical equipment may be cleaned with mild detergent followed by application of EPA approved disinfectants. Review of the facility's Environmental Policy, Resident dated 03/20/23, indicated, It is the goal of [NAME] Park RHCC to provide cheerful home-like environment while ensuring the safety of the residents, staff and equipment at the facility. Review of the facility's Maintenance Policy and Procedure dated 03/22/23, indicated, It is the goal of [NAME] Park RHCC to provide cheerful home-like environment while ensuring the safety of the residents, staff and equipment at the facility. Review of the undated Housekeeping Assistant Job Description indicated, The primary purpose of this job is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the Administrator and/or the Director of Housekeeping, to assure that the facility is maintained in a clean, comfortable, and safe manner. Review of the undated Maintenance Director Job Description indicated, The primary purpose of this position is to maintain the orderly functioning of all equipment in the facility including laundry, heating, air conditioning, and elevators as well as purchasing necessary supplies for repairs, maintenance, and emergencies within budgetary guidelines. The MD Job Description further reflected that the MD was to perform all repairs that did not fall under the purview of the housekeeping staff, to maintain up-to-date knowledge of any Federal, and State regulations, modify department policies and assure compliance, and supervise repairs and routine maintenance of the building and all the departmental equipment. NJAC 8:39 - 31.4(a)(f) Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 3 of 3 nursing units, (A-unit, B-unit, and C-unit) reviewed for environmental concerns and for 1 of 1 resident, (Resident #63) reviewed for tube feedings. This deficient practice was evidenced by the following: 1. On 09/06/23 at 12:11 PM, the surveyor toured the C-unit, entered room C5 and observed that the white molding on the bottom of the wall which was in contact with the floor was stained with yellow and black discolorations. In addition, the top of the molding behind the bed's headboard that was positoned on the same wall as the door entryway was chipped off, exposing discolored brownish-black wood. The surveyor further observed green privacy curtains throughout room. Two of the privacy curtains were observed with brown and red stains throughout. The doors between the connecting hallway between rooms C5 and C6 were observed with white and black indentations along the bottom half of the door. Further observations in room C5 identified that the tile in the room closest to the molding was discolored with black scratches and indentations. On 09/06/23 at 1:20 PM, the surveyor entered room C6 on the C-unit and observed a bed on the right-hand side of the room. The bed was pushed up against the wall and was placed in front of a shut door. The doorknob and call bell system were observed to be protruding from the wall and were positioned over the center of the resident's bed. The surveyor further observed brownish-black discoloration on the tile next to the wall behind the door, an apple sized hole was observed in the shades, and there were multiple scratches and indentations throughout the molding on the wall by the floor. On 09/07/23 at 8:46 AM, the surveyor observed on the A-unit in room [ROOM NUMBER], the headboard to the resident's bed was pressed up against the wall to the left of the entryway door. The length of the bed was against the wall and under the window. The surveyor observed the walls surrounding the bed had a long rectangular area that exposed unsanded white spackle which was uneven with the wall's exterior. The surrounding wall was painted a light-colored green. On 9/7/23 at 9:08 AM, the surveyor observed on the B-unit in room [ROOM NUMBER] a white towel underneath the air conditioner in the resident's room. In addition, the surveyor observed in front of the resident's bed, unsanded white spackle on the wall, with green paint surrounding the area. On 9/7/23 at 9:50 AM, the surveyor observed on the B-unit in room [ROOM NUMBER] a hole in the wall, exposing white plaster underneath the light socket. On 09/08/23 at 11:50 AM, the surveyor observed on the C-unit in room C5, reddish and brown stains throughout the privacy curtains. On 09/13/23 at 2:28 PM, the surveyor interviewed with Housekeeping Director (HD) who stated that he had a schedule in place to change the privacy curtains in the resident's rooms. The HD further stated that when the privacy curtains in the resident's rooms were observed to be stained, they could be changed right away by staff. The HD told the surveyor that he made rounds everyday after his housekeeping staff cleaned the resident's room to check on their work, but some days could, miss something. The HD then stated to the surveyor, Honestly, I would not expect the housekeeping staff to clean the privacy curtains daily. This contradicted the HD previous statement. The surveyor asked the HD why he would not have that expectation from staff. At that time, the HD stated that he focused more on cleaning the bottom of the tray tables in the resident's rooms, bed rails, and topical surfaces. On 09/14/23 at 10:36 AM, the surveyor observed on the C-unit in room C6, brown splatter above the bed next to the window and on the wall at the head of the resident's bed. The brown splatter was observed to be in a circular formation. The surveyor further observed next to the same bed that an air conditioner unit was placed in the window. Next to the window the surveyor observed a brown piece of wood covering the window. There was a brown piece of wood covering up the portion of the window that would have been exposed to the outside. The wood was surrounded by white caulk and spackle. The surveyor further observed that the windowsill had grey and brown debris on top of it. On 09/14/23 at 10:47 AM, the surveyor interviewed the Maintenance Director (MD) who stated that he made rounds throughout the facility regularly and inspected the resident's rooms. The MD told the surveyor that he would keep a running list of things that needed to be fixed, would go to Home Depot, get supplies, and then fix the issue. The MD then gave the example that the rooms needed to be painted. The MD further explained that before painting the walls, the walls needed to be spackled, sanded, and then painted so that the wall was even. The MD could not speak to why the resident's room with exposed white plaster were not sanded and painted. On 09/14/23 at 11:04 AM, the surveyor conducted a follow up interview with the MD who stated that the white material surrounding the brown piece of wood was caulking and he was supposed to come in to paint the wood but did not yet. The MD did not speak to time frames of how long the wood was left exposed in the resident's room. On 09/15/23 at 9:57 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that since he took over the facility in January 2023, he had renovated multiple rooms throughout the facility, hired a new MD, purchased new beds and over bed tables. The LNHA further stated that the MD was in the process of plastering the walls and painting over them. The LNHA stated that the HD was also replacing the privacy curtains in the resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 of 20 resident's, (Resident #8) reviewed for accurately coding the MDS. The deficient practice was evidenced by the following: On 09/06/23 at 12:06 PM, the surveyor observed Resident #8 seated in his/her reclining chair in the main dining/activity room on the C unit. The resident was observed bopping their head to music that was playing in the background. The surveyor reviewed the medical record for Resident #8. Review of the resident's admission Record indicated that the resident had resided at the facility for several years and had diagnoses which included but were not limited to bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and hypertension. Review of the resident's September 2023 Order Summary Report reflected a physician's order dated 07/31/22, for the antipsychotic medication Olanzapine five (5) milligrams, give one (1) tablet by mouth at bedtime for bipolar disorder. Review of the resident's Psychiatric Progress Note (PPN) dated 03/21/23, reflected that a Gradual Dose Reduction (GDR) of the resident's medication Olanzapine was clinically contraindicated. Review of the resident's quarterly MDS dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated the resident had severely impaired cognition. A further review of the resident's quarterly MDS, Section N - Medications - N0450 - Antipsychotic Medication Review reflected that no GDR had been documented by a physician as clinically contraindicated. The date the physician had documented that the GDR was clinically contraindicated on the MDS was blank. Review of the resident's PPN dated 05/16/23, further reflected that a GDR of the resident's medication, Olanzapine was clinically contraindicated. Review of the resident's annual MDS dated [DATE], reveled that the resident had a BIMS score of 07 out of 15 which indicated the resident had severely impaired cognition. A further review of the resident's annual MDS, Section N - Medications - N0450 - Antipsychotic Medication Review reflected that no GDR had been documented by a physician as clinically contraindicated. The date the physician had documented that the GDR was clinically contraindicated on the MDS was blank. On 09/13/23 at 11:16 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert, had labile (easily altered) emotions, and was seen by a psychiatrist. The CNA further explained that there was no trigger that would alter the resident's emotions and that one minute the resident would be happy and laughing and the next minute the resident would cry. The CNA told the surveyor that when she identified that the resident's emotions were becoming more labile and the resident was agitated, she would notify the nurse. On 09/13/23 at 11:27 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident had a diagnosis of bipolar disorder, was alert to self, could make simple needs known, was pleasantly confused, and at times would present with disorientation. The LPN further stated that at times the resident would have verbal outburst but was easily redirected by staff and stable on his/her medications. On 09/14/23 at 12:00 PM, the surveyor interviewed the Minimum Data Set Coordinator (MDSC) who stated that Resident #8's quarterly and annual MDS were filled out correctly because the doctor documented that a GDR was clinically contraindicated and since a GDR was not performed, it was not required to be documented on the MDS. The surveyor reviewed the CMS's RAI Version 3.0 Manual in the presence of the MDSC who stated that she coded the resident's quarterly and annual MDS correctly. On 09/15/23 at 10:01 AM, the surveyor interviewed the Director of Nursing who stated the resident's medications should have been accurately coded on the MDS's and were not. Review of CMS's RAI Version 3.0 Manual Section N: Medications indicated that the intent of the antipsychotic medication review was to assist facilities to evaluate the use and management of medications. The RAI Manual further explained that each aspect of antipsychotic medication use and management had important associations with quality of life and quality of care for the resident. Section N0450: Antipsychotic Medication Review indicated in the steps for assessment to review the resident's medical record to see if a GDR had been attempted and if a GDR had not been attempted to review the resident's medical record to determine if the physician documented that a GDR was clinically contraindicated. Review of the facility's Education Attendance Sheet dated 09/14/23, indicated that the MDS Coordinator was educated on the correct procedures for filling out Section N - Medications. Review of the facility's undated Job Description for MDS Coordinator indicated that the MDS Coordinator was responsible for completing and assuring the accuracy of the MDS process for all residents. NJAC 8:39-11.1

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to clarify a Physician's Order (PO) for the dosage of a medication on the electronic Medication Administration Record (eMAR) for several months. This deficient practice was identified during the medication pass observation for 1 of 6 residents, (Resident #16) reviewed and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and 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. On 09/07/23 at 09:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #16 at the medication cart. The surveyor reviewed the September 2023 eMAR in the presence of the LPN which reflected a PO dated 12/20/22, for the medication Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 milliliters (ml). At the time of dispensing the Magic Mouthwash, the surveyor observed the LPN pour the Magic Mouthwash into a 30 ml plastic medicine cup, take the 30 ml cup and pour the Magic Mouthwash into a 6 ounce (oz) plastic cup. The surveyor further observed the LPN fill the 30 ml plastic cup a second time with Magic Mouthwash and pour it into the 6 oz plastic cup. This indicated there was now 60 ml of Magic Mouthwash in the 6 oz plastic cup. The LPN then stopped and stated that she would have to call the resident's physician to review the PO because she did not think it was the correct dose of the medication. At 09:54 AM, the surveyor reviewed the September 2023 eMAR with the LPN. The PO indicated, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. At that time, The LPN stated that the dose (amount) of the medication was missing from the PO and was not displayed on the eMAR. The LPN further stated that the dose of the medication was required within the PO, so the nurse knew the accurate amount of the medication to dispense for the resident. At 09:56 AM, the surveyor reviewed the Magic Mouthwash medication bottle in the presence of the LPN which indicated a dose of 15 ml on the bottle. At that time, the LPN stated that the dose for the Magic Mouthwash should have been clarified within the PO on the eMAR. The surveyor reviewed the medical record for Resident #16. Review of the resident's admission Record indicated the resident had resided at the facility for several years and had diagnoses which included but were not limited to: malignant neoplasm of major salivary gland (cancer of the glands that produce saliva in a person's mouth), malignant neoplasm of tonsils, trigeminal neuralgia (chronic pain condition that affects the nerve that carries sensations from the face to the brain), and hypertension. Review of the resident's September 2023 Order Summary Report revealed a PO dated 12/20/22 for Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle and spit 15 mls. Review of the resident's December 2022 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the December 2022 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900 (9:00 AM), 1200 (12:00 PM), 1700 (5:00 PM), and 2100 (9:00 PM) from 12/21/22 to 12/31/22. Review of the resident's January 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the January 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 01/01/23 to 01/31/23. Review of the resident's February 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the February 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 02/01/23 to 02/28/23. Review of the resident's March 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the March 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 03/01/23 to 03/31/23. Review of the resident's April 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the April 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 04/01/23 to 04/30/23. Review of the resident's May 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the May 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 05/01/23 to 05/31/23. Review of the resident's June 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the June 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 06/01/23 to 06/30/23. Review of the resident's July 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the July 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 07/01/23 to 07/31/23. Review of the resident's August 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the August 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 08/01/23 to 08/31/23. Review of the resident's September 2023 eMAR revealed a PO dated 12/20/22 for the medication, Magic Mouthwash with Benadryl, Lidocaine, Maalox four times a day swish, gargle, and spit. Please dispense 250 ml. A further review of the September 2023 eMAR reflected that the nurses were signing for the administration of the Magic Mouthwash at 0900, 1200, 1700, and 2100 from 09/01/23 to 09/06/23. On 09/08/23 at 10:40 AM, the surveyor interviewed the facility's Medical Director (MD) who stated that the eMAR should reflect the dosage of the medication, so the nurse knew the amount of medication to dispense. The MD further stated that if the PO did not reflect the correct dosage, the nurse should have called the physician to clarify. On 09/08/23 at 11:19 AM, the surveyor interviewed the Director of Nursing (DON) who stated that nurses were to administer medication based off the six rights of medication administration which included: the right resident, the right medication, verify the indication for usage of the medication, the right dose of the medication, the right time, and the right route. The DON further stated that if the PO did not reflect that on the eMAR, the process would be to call the resident's physician and clarify the order. NJAC 8:39-29.2(a),(d)

Based on observation, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 09/05/23 at 10:25 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. On a metal rack in the refrigerator, there was an opened box labeled bacon with the inner plastic bag open and the bacon visible and exposed to air. The FSD acknowledged that the bacon should not have been exposed to air and stated that it was important to make sure the bacon was covered properly to avoid sickness. 2. On the bottom shelf on a metal rack in the freezer, there were four (4) five-pound freezer sealed bags of dark reddish chunks of meat with no label and no dates. The FSD identified the meat as cubed beef and acknowledged that the packages were not labeled and dated. The FSD stated that the packages should have been labeled and had an orange sticker with the pull date marked. On the same shelf was one (1) ten-pound package marked cooked corned beef with no use by date. The FSD acknowledged the package was undated and stated that it was important for all the food to be labeled and dated so that the staff were aware when it should have been used to avoid sickness. 3. The meat slicer was observed covered with a black plastic bag. The FSD stated that once the slicer was used that it was cleaned and covered. The FSD removed the black plastic bag and there was white debris on the base and brown debris on the slicer blade, which the FSD acknowledged. The FSD stated that it was important for the equipment to be kept clean because if bacteria had grown, it could have caused illness. 4. On the second shelf in the coffee area, there were three (3) piles of unwrapped, exposed coffee filters resting directly on the shelf. The FSD acknowledged the coffee filters were not stored properly and stated that they should have been stored in a box for the prevention of contamination. A review of the undated facility policy, Food Storage, revealed, Procedure: 7. C. Food should be dated as it is placed on the shelves .d. Date marking to indicate the date or day by which a ready-to-eat, time/temperature control for safety food should be consumed, sold or discarded will be visible on all high-risk food.14. Refrigerated food storage: f. All foods should be covered, labeled, and dated. 15. Frozen foods: c. All food should be covered, labeled, and dated. A review of the facility policy, Cleaning Instructions: Coffee, Beverage, Juice, Frozen Yogurt or Ice Cream Machines, dated 2017, revealed, Procedure: Coffee Machines: 2. All paper products should be stored in a dry location and handled properly. NJAC 8:39-17.2(g)

Based on interview and record review, the facility failed to obtain physician ordered antidiabetic and/or antibiotic medications in a timely manner for two (Resident (R) 1 and R8) of four sampled residents whose medications were reviewed. This had the potential for R1 to have uncontrolled blood sugars and for R8 to have an untreated infection which could lead to serious medical complications for both residents. Findings include: 1. Review of a document provided by the Director of Nursing (DON) titled admission Record indicated R1 was admitted with diagnoses that include type II diabetes mellitus. Review of R1's Physician Orders, dated 11/01/22 and located under the Orders tab of the electronic medical record (EMR), revealed Trulicity (an antidiabetic medication), 0.75 milligrams (mg)/0.5 milliliters (ml) subcutaneously every Wednesday, was ordered for R1 due to increased blood sugar levels. Review of R1's Medication Administration Records (MARS), dated 11/16/22 and located under the Orders tab of the EMR, revealed no documentation R1 received the ordered Trulicity. Review of R1's Orders - Administration Note, dated 11/16/22 at 8:08 AM and located under the Progress Notes tab of the EMR, indicated, . Trulicity . Waiting on the pharmacy . Review of R1's MARS, dated 11/23/22 and located under the Orders tab of the EMR, revealed no documentation R1 received the ordered Trulicity. Review of R1's Orders - Administration Note, dated 11/23/22 at 12:35 PM and located under the Progress Notes tab of the EMR, indicated, . Trulicity . Waiting on the pharmacy . Review of R1's MARS, dated 11/30/22 and located under the Orders tab of the EMR, revealed no documentation R1 received the ordered Trulicity. Review of R1's Orders - Administration Note, dated 11/30/22 at 10:35 AM and located under the Progress Notes tab of the EMR, indicated, . Trulicity . Waiting on the pharmacy . Review of R1's MARS, dated 12/07/22 and located under the Orders tab of the EMR, revealed no documentation R1 received the ordered Trulicity. Review of R1's Orders - Administration Note, dated 12/07/22 at 12:17 PM and located under the Progress Notes tab of the EMR, indicated, . Trulicity . Waiting on the pharmacy . Review of R1's Physician Orders, dated 12/14/22 and located under the Orders tab of the EMR, revealed Trulicity 1.5mg/0.5ml was ordered for R1 due to his blood sugar levels remaining elevated. Review of R1's Orders - Administration Note, dated 12/14/22 at 12:25 PM and located under the Progress Notes tab of the EMR, indicated, . Trulicity . Waiting on the pharmacy . Review of R1's Medication Administration Records (MARS), dated 12/21/22 and located under the Orders tab of the EMR, revealed R1 received the ordered Trulicity. Review of R1's MARS dated 12/28/22 and located under the Orders tab of the EMR, revealed R1 received the ordered Trulicity. Review of R1's Progress Notes, dated 10/15/22 through 12/31/22 and located under the Progress Notes tab of the EMR revealed no documentation Nurse Practitioner (NP) 1 or the Medical Director had been notified R1 did not receive the ordered Trulicity on 11/16/22, 11/23/22, 11/30/22, 12/07/22, and 12/14/22. During an interview on 04/18/23 at 9:41 AM, Licensed Practical Nurse (LPN) 1 stated if a medication was not available for administration, the nurse should call the pharmacy and, if the medication could not be obtained quickly, then call the physician. LPN1 stated there were emergency medication kits available that contained often used medications and those medications could be used when ordered medications were not available. Continuing the interview on 04/18/23 at 9:50 AM, LPN1 reviewed the EMR for R1 and confirmed she could not find documentation noting why R1 had not received the ordered Trulicity or what the nurses had done at those times. During an interview on 04/18/23 at 3:36 PM, the Director of Nursing (DON) reviewed R1's clinical record and confirmed R1 did not receive the ordered Trulicity on 11/16/22, 11/23/22, 11/30/22, 12/07/22, and 12/14/22. The DON stated he had no idea why he had not been informed of these situations. The DON stated his expectation was staff would call the pharmacy if a medication was not available for administration and then call the physician and then contact him. During an interview on 04/19/23 at 9:00 AM, LPN3 stated R1 had received the Trulicity on 11/02/22 and 11/09/22 as ordered. LPN3 stated on 11/16/22, the Trulicity was not available for administration, so she had called the pharmacy and had been informed it was an insurance issue. LPN3 stated she had notified the NP1 and did not document the notification. LPN3 stated she did not remember if she had notified the DON. LPN3 stated the NP1 had been notified each time R1 did not receive the Trulicity but she had failed to document the notification. During an interview on 04/19/23 at 10:49 AM, the DON stated there was no documentation to show the facility received the Trulicity and that was documented as being given on 12/21/22 and 12/28/22. During an interview on 04/19/23 at 10:42 AM, the Medical Director stated his expectation for medications to be available for administration and for the physician to be notified if a medication was unavailable for a resident. The Medical Director stated he was not sure what had happened in this case unless it was an insurance issue, but the prescribing provider should have been informed. 2. Review of a document provided by the DON titled admission Record indicated R8 was admitted to the facility with diagnoses that included type II diabetes mellitus and protein calorie malnutrition. Review of R8's Progress Note, dated 04/11/23 and located under the Progress tab of the EMR, revealed R8 was sent to the emergency room at 1:45 PM and returned to the facility at 10:38 PM. Review of R8's hospital After Visit Summary, dated 04/11/23 and provided by the administrator, revealed R8 had been diagnosed with COVID-19, metapneumovirus, and acute cystitis. It was documented R8 was to begin taking Keflex (an antibiotic), 500 mg by mouth three times daily for seven days. Review of a pharmacy Order Details form, dated 04/12/23 at 12:52 AM and provided by the DON, revealed the pharmacy had received the physician's order for Keflex for R8. Review of MARS, dated 04/12/23 and located under the Orders tab of the EMR, revealed R8 did not receive the first dose of Keflex until 04/12/23 at 2:00 PM. This was approximately 13 hours after the order had been received by the pharmacy. During an interview on 04/18/23 at 9:41 AM, Licensed Practical Nurse (LPN) 1 stated if a medication was not available for administration, the nurse should call the pharmacy and then the physician if the medication could not be obtained quickly. LPN1 stated there were emergency kits available with some medications used in the facility, including antibiotics. LPN1 stated the nurse on duty should have checked the emergency kit for the antibiotic. LPN1 confirmed it was over 15 hours before R8 received the first dose of Keflex after returning to the facility. During an interview on 04/18/23 at 3:21 PM, the DON stated if a resident returned to the facility with new medication orders, the nurse was to contact the physician, write the order, and that triggered the pharmacy to deliver the medication. The DON stated the facility's policy on medications was if the medication did not come in a timely manner, the nurse should look in the emergency kit to see if the medication was available, and if not, then call the pharmacy for an emergency delivery. The DON confirmed the first dose of Keflex was administered approximately 11 hours after the order was received by the pharmacy and over 15 hours after R8 returned to the facility. The DON stated that was not timely. The DON stated the nurse should have let him know, checked the emergency kit, and notified the pharmacy if necessary. During an interview on 04/19/23 at 10:42 AM, the Medical Director stated staff should have looked to see if the antibiotic was available in the emergency kit. The Medical Director stated the time interval for administering the antibiotic was too long. During an interview on 04/19/23 at 10:46 AM, the facility's Infectious Diseases physician stated R8 should have received the antibiotic within six hours of his return to the facility due to the pharmacological properties of the antibiotic. NJAC : 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/9/22 at 9:21 AM, the surveyor observed a Licensed Practical Nurse (LPN) complete a wound treatment on the buttock of Resident # 41. After the LPN was done with the treament she used alcohol based hand gel, took a marker out of her pocket, and initialed and dated the border dressing that she had applied to the resident's buttock. On 6/9/22 at 10:15 AM, the surveyor reviewed the resident's medical record which revealed the following: A current Physician's Order Sheet (POS) with an order with a start date of 6/3/22 that read Cleanse right buttock with saline. Apply Xeroform, cover with foam dressing daily. Reposition side to side and monitor for changes. one time a day for pressure ulcer. The POS had diagnoses which included Sepsis, Unspecified Organism, and Type 2 Diabetes. A quarterly Minimum Data Set assessment dated [DATE] indicated that the resident scored a 7 when the Brief Interview for Mental Status was done. This indicated that the resident had severe cognitive impairment. On 6/13/22 at 1:34 PM, the surveyor spoke with the Director of Nursing, the Administrator, and the Corporate Nurse about the wound treatment observation, they agreed that the nurse should not have written on the dressing when it was on the resident. The surveyor reviewed the facility's policy and procedure titled Wound Ulcer Treatment dated 1/28/22, which revealed that it is the policy of this facility to maintain the resident's privacy and dignity during wound treatment and staff is to remove gloves and place them in disposable bag, wash hands with soap and water, apply tape to secure the dressing in place and to apply the date to the tape before applying the dressing. NJAC 8:39-4.1 (a) 12 Based on observation, interview, and record review it was determined that the facility failed to preserve the dignity of 2 of 14 residents, Resident #35 and #41. The deficient practice is evidenced as follows: 1. On 6/6/22 at 11:27 AM, the surveyor observed Resident #35 awake in bed. A urinary drainage bag was visible hanging from the bed facing the open doorway to the hall. The drainage bag was not stored in a privacy bag. On 6/07/22 at 12:00 PM, the resident was seated in a recliner chair at the bedside. The resident's urinary drainage bag was visible from the hallway. The drainage bag was stored in a clear plastic bag and hung from the chair. The resident stated to the surveyor that he/she was unaware of the placement of the collection bag. On 6/07/22 at 2:00 PM, the surveyor interviewed the Certified Nursing Assistant. She stated the urinary collection bag should be placed in a clear plastic bag. On 6/07/22 at 2:06 PM, the surveyor interviewed the unit Registered Nurse/Infection Preventionist (RN). The RN stated the urinary drainage bag should be placed in a privacy bag for dignity purposes. She stated the facility had many of them in stock and she would retrieve one from central supply. She further stated the urinary drainage bag should not be stored in a clear plastic bag. The surveyor reviewed the hybrid medical record which revealed the following information. The 4/18/22 quarterly Minimum Data Set assessment tool indicated the resident had no cognitive impairment (Section C). The resident utilized an indwelling urinary catheter (Section H). Sections I and J included diagnoses of myasthenia gravis (a chronic, progressive disease resulting in muscle weakness), benign prostatic hyperplasia, and obstructive uropathy. The indwelling urinary catheter care plan, revised 5/4/22, did not address placement of the collection bag in a privacy bag. On 6/9/22 at 1:30 PM, the surveyor discussed dignity concerns with the Administrator and his administrative team. The surveyor reviewed policies for Catheter Care, dated 5/8/18 and Privacy During the Delivery of Care dated 5/12/22 and neither policy addressed the use of a privacy bag.

2. On 6/6/22 at 10:30 AM, the surveyor inspected the Unit A medication cart and found a bottle of Fluticasone Propionate 50 mcg Nasal Spray received from the pharmacy on 3/1/22 and opened on 3/14/22. An unopened bottle contains 120 doses. The bottle found appeared full and belonged to Resident #30. The surveyor also found a new unopened bottle of Fluticasone Propionate 50 mcg Nasal Spray in the medication cart received on 5/12/22 from the pharmacy. The surveyor in the presence of the RN, compared the two bottles of Fluticasone (opened and new bottle). The RN agreed that the bottle opened on 3/14/22 appeared almost full. The RN stated that if there is a problem with administration of medication, nursing should document missed dose or refused. The surveyor reviewed the EMAR for March, April, May and June 2022. The Physician's order read, Fluticasone Propionate Suspension 50 mcg 1 spray in each nostril every morning and at bedtime for stuffy nose. The bottle of medication was a 60 day supply and should have been completed on May 14, 2022 if the medication was administered daily. Nursing had documented daily on all 4 months that the medication was administered. 3. On 6/7/22 at 10:25 AM, the surveyor observed Resident #55 sleeping in bed in their room. The surveyor could not interview Resident #55. The surveyor interviewed LPN#2, who was assigned to care for Resident #55. LPN#2 informed the surveyor that Resident #55 goes to hemodialysis on Tuesday, Thursday, and Saturday at approximately 2:00 PM. The surveyor reviewed Resident #55's hybrid medical records that revealed the following: According to the admission Record, Resident #55 was admitted with diagnoses that included End Stage Renal Disease (ESRD) with dependence on renal dialysis, Type 2 Diabetes Mellitus and Hypertension (HTN). The admission Minimum Data Set (MDS) an assessment tool dated 4/29/22, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 12 out of 15. The resident was assessed to be moderately impaired. The surveyor reviewed the April, May and June 2022 EMAR that included Physician's orders for: a. Isosorbide Mononitrate ER 60 mg 1 tablet via percutaneous endoscopic gastrostomy (PEG)-tube daily for HTN. Hold for Systolic Blood Pressure (SBP) less than 110. Review of the documentation on the EMAR demonstrated that the Isosorbide Mononitrate ER 60 mg was administered once in April 2022 when the medication should have been held due to low SBP. The Mononitrate ER 60 mg was documented as held 5 times in May 2022 without documenting any of the SBP needed to determine if the medication should be administered. b. Carvedilol 25 mg 1 tablet via PEG-tube twice daily for HTN. Hold for SBP less than 110 and Heart Rate (HR) less than 60. Review of the documentation on the EMAR demonstrated that the Carvedilol 25 mg was administered once in April 2022, 3 times in May when the medication should have been held, due to low SBP. The Carvedilol 25 mg was documented as held 5 times in May 2022 without documenting any of the SBP needed to determine if the medication should be administered. The Carvedilol was documented as administered 8 times in June 2022 without the documentation of SBP or HR on the EMAR to determine if the medication should be administered. c. Amlodipine Besylate 10 mg 1 tablet via PEG-tube daily for HTN. Hold for SBP less than 110. Review of the documentation on the EMAR demonstrated that the Amlodipine 10 mg was documented as held 6 times in May 2022 without documenting any of the SBP needed to determine if the medication should be administered. d. Hydralazine HCl 100 mg 1 tablet via PEG-Tube three times a day for HTN. Hold for SBP less than 110 and on dialysis days on Tues., Thurs., and Sat days. Review of the documentation on the EMAR demonstrated that the Hydralazine HCl 10MG was administered on 9 dialysis days when the medication should have been held in May 2022. On 6/8/22 at 2:00 PM, the surveyor discussed this issue with the RN. The RN could not explain why these medications were administered or how the nursing staff was able to bypass the EMAR, which had prompts requiring documentation of SBP and HR. The RN stated that all parameters should be documented at the time of medication administration. On 6/15/22 at 1:35 PM the surveyor met with the Director of Nursing (DON), Administrator and RN. No further information was provided. NJAC 8:39-29.2(a); 8:39-29.2(c) Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regard to a.) safely securing medications, b.) accurately documenting medication administration, c.) correctly following physician's orders. The deficient practice is evidenced by the following. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 6/06/22 at 10:50 AM the surveyor observed Resident #35 awake in bed with a medicine cup containing 10 pills on the over bed table. The resident told the surveyor that earlier that morning the resident stated to the unit Registered Nurse/Infection Preventionist (RN) that the resident was not ready to take the medication. The resident instructed the RN to leave the medication at the bedside and they would take them when ready. The resident stated the RN normally waits until the resident takes the medication. On 6/06/22 at 10:55 AM the surveyor brought the RN into the resident's room. The RN confirmed she left the medications at the resident's bedside. She stated she was very busy and didn't want to be late passing medications to other residents. The RN stated the resident promised her they would take the medications and the RN left the room before the resident took them. The RN stated she documented in the Electronic Medication Administration Record (EMAR) that the medications were given when the resident had not yet taken the medicine. She stated the facility policy is to wait to observe that the resident takes the medication before leaving the room and before documenting in the EMAR. The RN told the surveyor there was one confused ambulatory resident on the unit whose room was at the far end of the unit from Resident #35. Neither the surveyor or the RN observed any residents in the hallway outside of Resident #35's room. Resident #35 stated no residents were in the vacinity while the medications were unsecured on the over bed table. On 6/7/22 at 1:30 PM the surveyor discussed with the Administrator and his administrative team the concerns of leaving medications unattended at the resident's bedside and documenting the medications as given when they were not yet taken by the resident.

**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 provide care and services during the treatment of a pressure ulcer in a manner to facilitate healing by following infection control protocols and failed to follow the physician's treatment order. This was found with 1 of 3 residents reviewed for pressure ulcer treatment, Resident # 41. The deficient practice was evidenced by the following: On 6/9/22 at 9:21 AM the surveyor observed a wound treatment to the right buttock of Resident # 41. The Licensed Practical Nurse (LPN) prepared supplies on the treatment cart in the doorway of the resident's room. The LPN removed border gauze from the treatment cart and stated the recommendation from the wound team was to use foam dressing but we don't have foam dressing. Central supply knows that the order is for foam dressing. The wound team does not know that we don't have foam dressing but we can make them aware and they can change the order if they want to. The nurse then stated, The treatment is usually done on the night shift so After gathering the supplies the LPN cleaned the over bed table with a disinfectant wipe and set up a clean field, she then washed her hands for 40 seconds then rinsed her hands. When rinsing, her hands went in the water that was pooling in the bottom of the sink. When done rinsing she dried her hands with a paper towel. There was an open toothbrush on the sink. The surveyor asked the LPN whose toothbrush that was. The LPN stated she did not know who it belonged to. The bathroom that the LPN used to wash her hands was the bathroom that was shared between two rooms, the resident receiving the wound treatment and the room next door to the resident. After washing her hands the LPN went to the resident's bedside where the clean field was set up. The LPN opened a bottle of saline and poured it on the gauze over the garbage while she held the gauze. The LPN proceeded to clean the wound with the saline soaked gauze, she wiped the wound four times, first inner one swipe then outer one swipe, then the last two times, the nurse wiped inside the wound, then outside the wound, then inside the wound then outside the wound, with the same gauze. After cleaning the wound the LPN dried the wound with dry sterile gauze, she patted the wound, inner, outer, inner, outer multiple times. She then applied the xeroform (a sterile, non-adhering dressing consisting of absorbant fine mesh gauze) and covered it with a border gauze, not the foam dressing in accordance with the physician's order. After completing the wound treatment the LPN washed her hands for 40 seconds then when rinsing, her hands went into the water that was pooling in the bottom of the sink. When done rinsing she dried her hands with a paper towel. On 6/9/22 at 9:57 AM when the wound treatment was done the surveyor asked the LPN if she was a full time nurse at the facility. The LPN said yes, she worked 12 hour shifts but not always on the same unit. The surveyor asked the LPN if she ever did wound treatments on her shift. The LPN said yes she did. On 6/9/22 at 10:15 AM, the surveyor reviewed the resident's medical record which revealed the following: A current Physician's Order Sheet (POS) with an order with a start date of 6/3/22 that read Cleanse right buttock with saline. Apply Xeroform, cover with foam dressing daily. Reposition side to side and monitor for changes. one time a day for pressure ulcer. The POS had diagnoses which included Sepsis, Unspecified Organism, and Type 2 Diabetes. A quarterly Minimum Data Set assessment dated [DATE] indicated that the resident scored a 7 when the Brief Interview for Mental Status was done. This indicated that the resident had severe cognitive impairment. On 6/13/22 at 1:34 PM the surveyor spoke with the Director of Nursing, the Administrator, and the Corporate Nurse about the wound treatment observation. The Corporate Nurse stated The nurse should have called the physician if the foam dressing was not available, she should have called the physician and received a new order for an appropriate dressing to be used that was in stock. The Corporate Nurse also confirmed that the nurse should have used a one swipe technique when cleaning the wound and should not have put her hands in the pooling water at the bottom of the sink. On 6/14/22 at 11:00 AM the surveyor reviewed the facility's policy and procedure titled Wound Ulcer Treatment with a revision date of 1/28/22. Under Procedure #2 read Gather all supplies-check Physician's Order for the wound treatment #11 read Moisten sterile/clean dressings or swabs and cleanse the wound, if ordered, moving from top to bottom or from center of the wound outward. Use a new swab or gauze pad for each cleansing motion. Clean the area around the wound as well. # 12 read Use a gauze pad to dry the wound with the same motion as in step 11 . NJAC 8:39-19.4 (a); 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 6/6/22 at 11:25 AM, the surveyor observed Resident #42 in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy) attached to an oxygen concentrator. The surveyor observed that the oxygen concentrator was set to 3 LPM. On 6/7/22 at 11:55 AM, the surveyor observed Resident #42 in bed wearing a nasal cannula attached to an oxygen concentrator. The surveyor observed that the oxygen concentrator was set to 3 LPM. On 6/8/22 at 9:32 AM, the surveyor interviewed the Registered Nurse (RN). The surveyor asked why Resident #42 wore oxygen. The RN stated that Resident #42 wore oxygen because they felt anxious and became short of breath. On 6/8/22 at 9:41 AM, the surveyor requested that the RN accompany her into Resident #42's room. The surveyor asked how many liters of oxygen the resident was receiving per minute. The RN stated, 3 liters. The surveyor asked if this was appropriate. The RN stated that it was appropriate. On 6/8/22 at 9:45 AM, the surveyor asked the RN to look at Resident #42's Clinical Physician Orders with her. The surveyor asked the RN what the physician's order was for oxygen. The RN stated, 2 liters. The RN stated that she would change the setting on the oxygen concentrator back to 2 LPM. The surveyor reviewed Resident #42's hybrid medical record which revealed the following: The admission Record which included that the resident was admitted to the facility with diagnoses that included but were not limited to Fracture of Right Femur (a partial or complete break in the bone of the thigh) and Hypertension (high blood pressure). The resident's most recent quarterly Minimum Data Set (MDS), an admission record used to facilitate the management of care indicated that a Brief Interview for Mental Status (BIMS) score of 99 which indicated that Resident #42 was unable to complete the interview. The MDS indicated that the resident appeared to have an OK short-term and long-term memory. The MDS also indicated that Resident #42 used oxygen while a resident. A review of a 6/1/22 Progress Note written by the Nurse Practitioner indicated that Resident #42 had lung cancer and was dependent on oxygen. A further review of the Clinical Physician Orders indicated that Resident #42 had a 5/17/22 active order for Supplemental oxygen at 2LPM continuous via nasal cannula. On 6/13/22 at 1:18 PM, the surveyor expressed her concerns to the Licensed Nursing Home Administrator (LNHA) and DON. No additional information was provided. A review of the facility policy, Oxygen Administration with a review date of 10/12/21 indicated that licensed staff should check the physician's order for liter flow and method of administration and should check the oxygen flow rate on all residents on oxygen therapy during rounds and compare it against the physician's order at the start and at the end of each shift. NJAC 8:39-29.2(d) Based on observation, interview, and review of facility documentation, it was determined the facility failed to ensure two residents were receiving supplemental oxygen as prescribed by the physician. This was found for 2 of 2 residents reviewed for oxygen, Resident #53 and Resident #42, and was evidenced by the following: On 6/07/22 at 10:08 AM, the surveyor observed Resident # 53 in bed receiving Oxygen via a nasal canula (a medical device to provide supplemental oxygen therapy) attached to an oxygen concentrator, which was on and set at 3 liters per minute (LPM). The oxygen tubing was dated 6/7/22. The surveyor reviewed Resident #53's medical record which revealed the following: The admission record which reflected that Resident #53 was admitted to the facility on [DATE] with diagnoses that included Covid-19, Dysphagia Oropharyngeal Phase, Muscle Weakness, Respiratory Failure, and Anxiety Disorder. The June 2022 Physician's Order form, which showed that Resident #53 had a Physician's order for the administration of oxygen (O2) at 2 LPM via NC (Nasal Cannula) continuously every day and night shift. On 6/7/22 at 10:15 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 in the resident's room. LPN #1 stated the resident had an order for oxygen at 2 LPM. LPN #1 confirmed the oxygen was running at 3 LPM. LPN #1 further stated, the respiratory therapist told her to increase the oxygen concentration to keep their O2 at least 97%, but the order was not updated to reflect that. On 6/9/22 at 9:45 AM, the surveyor conducted a phone interview with the Respiratory Therapist (RT) #1. RT #1 stated they saw all the residents weekly and recalled that Resident # 53's oxygen order was for two LPM. The surveyor informed RT #1, that they observed the oxygen concentrator set at 3 LPM on June 7th, 8th, and 9th. RT #1 stated, he was not made aware of any changes and should have been informed if there was a respiratory issue with the resident. On 6/9/22 at 10:15 AM, the surveyor reviewed Resident #53's medical record. The resident's Medical Administration Record (MAR) and Treatment Administration Record (TAR) were signed by the LPN, for O2 set at 2 LPM on the days where the surveyor observed the oxygen set at 3 LPM. On 6/13/22 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON) who stated they would expect to the O2 concentration to match the physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/7/22 at 10:25 AM, the surveyor observed Resident #55 sleeping in bed in their room. The surveyor could not interview Resident #55. The surveyor interviewed LPN#2, who was assigned to care for Resident #55. LPN#2 informed the surveyor that Resident #55 goes to hemodialysis on Tuesday, Thursday, and Saturday at approximately 2:00 PM. LPN#2 explained that Resident #55 had recently returned from the hospital, where he/she underwent a surgical procedure to create an arteriovenous (AV) graft site (preferred access used for dialysis) on the right arm for dialysis access. Since the AV graft was not yet usable, Resident #55 was still receiving hemodialysis through their permcath. The surveyor reviewed Resident #55's hybrid medical records that revealed the following: According to the admission Record, Resident #55 was admitted with diagnoses that included ESRD with dependence on renal dialysis. The admission MDS dated [DATE], revealed that the facility performed a BIMS which indicated that the resident had a score of 12 out of 15. The resident was assessed to be moderately impaired. The June 2022 Order Summary Report revealed a physician's order for hemodialysis every Tuesday, Thursday, and Saturday at 2:00 PM. On 6/7/22 at 11:20 AM, the facility presented three Hemodialysis Report forms that the facility used to receive communication from the dialysis center for Resident #55. The dates included on the Hemodialysis Reports were 5/26/22, 6/2/22, and 6/4/22 completed by the dialysis center. The forms lacked any information post dialysis once the resident returned to the facility. On 6/7/22 at 11:30 AM, when the surveyor inquired about any previous Hemodialysis Reports, the Registered Nurse (RN) on the unit, explained that all previous forms were lost. The RN revealed that when Resident #55 was transferred to the hospital on 5/26/22, the dialysis book (which included all the previous forms) was lost. The RN added that when a resident returns to the facility vitals and Permcath port check should be evaluated as well as documented on the Hemodialysis Report form. The Progress Notes (PN) referring to Resident #55 located in the EMR were reviewed from 4/22/22 to 6/7/22. The PN revealed that the nurses did not document the assessment of the resident's vital signs when the resident returns from dialysis, to ensure there were no complications. It was demonstrated that during the months of April 2022 except 4/23/22 and 4/30/22; May 2022 except for 5/21/22 and 5/27/22 there were no documented assessments of vitals when Resident #55 returned from dialysis. It was indicated that from June 1-7, 2022, there were no documented assessments of vitals when Resident #55 returned from dialysis. The care plan area titled Hemodialysis r/t ESRD reviewed, specified Monitor VITAL SIGNS prior and upon returning from dialysis. Notify MD (Medical Doctor) of significant abnormalities. Review of the Dialysis Management Policy with a revision date of 1/1/2022 stated The [facility name] has designed and implemented processes which strive to ensure the comfort, safety, and appropriate management of hemodialysis residents. Included in the body of the Dialysis Management Policy were these Procedures: 5. Assure facility completed dialysis communication form accompanies resident to dialysis on treatment days, to communicate resident information and coordinate between dialysis center and facility. 6. Dialysis center personnel to complete dialysis communication form and return to facility. 7. Upon return from dialysis center, review information provided on dialysis communication form. Communicate and address as appropriate. Complete post-dialysis information and place in resident's medical record. 8. Post-dialysis, assess access site. Document bleeding, pain, redness, and swelling. 10. Obtain resident's dry weight from dialysis center, post treatment. 11. Maintain fluid restrictions, as ordered. Record intake if fluid restriction is ordered. On 6/9/22 at 1:45 PM the surveyors discussed the above concerns with the Administrator and Director of Nursing who could provide any further information or explain why the required information and documentation was missing. NJAC 8:39 - 27.1(a) Based on observation, interview, and record review, it was determined that the facility failed to 1.) consistently ensure the Hemodialysis Reports were completed by both the facility and dialysis center; 2.) failed to assess residents returning from the dialysis center for any complications; 3.) follow physician's orders regarding management of medications. The deficient practice was observed for 2 of 2 residents (Resident #25 and #55) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 6/6/22 at 12:40 PM, the surveyor observed Resident #25 seated at the dining room table waiting for the noon meal. The resident was pleasant when interviewed. The resident informed the surveyor that he/she goes to hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) every Tuesday, Thursday, and Saturday. The resident further stated that the pickup time was after lunch and returns to the facility between 5 PM and 6 PM. The surveyor reviewed Resident #25's hybrid medical records (paper and electronic, EMR) that revealed the following: According to the admission Record, Resident #25 was admitted with diagnoses that included End Stage Renal Disease (ESRD). The Annual Minimum Data Set (MDS) an assessment tool dated 3/23/22, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 14 out of 15. The resident was assessed to be cognitively intact. The June 2022 Order Summary Report revealed a physician's order for hemodialysis every Tuesday, Thursday, and Saturday. Chair time was scheduled for 2 PM and the resident was to be picked up at 1 PM. Resident #25 received hemodialysis by way of an access site called a permcath (a special intravenous line that is inserted into the blood vessel in the neck or upper chest). The Hemodialysis Report forms that the facility used to communicate with the dialysis center have two sections to be filled out when the resident goes to dialysis. The top portion revealed the resident's pre-dialysis vital signs (blood pressure, pulse, and respirations) and the remaining part of the form was designated for the dialysis center to document weights pre and post dialysis and any additional information. There were three dates on the Hemodialysis Report, 5/19/22, 5/26/22 and 6/2/22 that were not completed by the dialysis center. The Progress Notes located in the EMR were reviewed from 3/1/22 to 6/9/22 that revealed the nurses do not document when the resident leaves the facility for the dialysis center, do not consistently document the resident's return from dialysis, and do not document the assessment of the resident's access site (permcath) and obtain vital signs to ensure there was no complications. It was observed that during the months of March 2022; April 2022; all of May 2022 except for 5/26/22 where the nurse documented the resident returned from dialysis, however no assessment documentation; and from June 1-9, 2022, there was one entry on 6/2/22 that the resident was status post dialysis, no assessment of the access site included, nor vital signs were obtained. The care plan titled [the resident] Hemodialysis Dialysis r/t renal failure included an intervention to monitor intake and output. According to the Order Summary sheet, Electronic Medication Administration Record (EMAR) and Electronic Treatment Record (ETAR), there was no physician's order for monitoring intake and output and no documentation that intake and output was being monitored. The care plan does not include an intervention to monitor the resident's blood pressure and access site post dialysis. On 6/8/22 at 11:38 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the Hemodialysis Reports are to be completed by the dialysis center before the resident returns to the facility. She stated that when the forms are not filled out, the center would be notified, and asked to fax over a copy of the report. LPN #1 stated they don't always send the copy to the facility. LPN #1 further stated that there was no process to do a post dialysis assessment when the resident returns from the dialysis center. She stated that we look at the resident and they look fine. LPN #1 confirmed that the resident returned from the dialysis center between 6:30 PM - 6:45 PM. On 6/13/22 at 1:00 PM the surveyor spoke with LPN #1 and asked her where the intake and output was documented for Resident # 25. LPN #1 said there was no physician's order for intake and output and it should not have been on the care plan to document the intake and output. She said it was an error.

Based on observation and interview of facility staff it was determined that the facility failed to ensure that the daily posting of licensed nurses and certified nursing assistant staffing, and the resident census, was posted daily at the beginning of the shift. This deficient practice was observed on 2 days of the survey and was evidenced by the following: On 6/6/22 and 6/7/22, the surveyor did not observe the Nursing Home Resident Care Staffing Report posted in the facility. On 6/8/22 at 1 p.m., the surveyor asked the Director of Nursing (DON) where the staffing report was posted. The DON stated he would find out and then directed the surveyor to the Staffing Coordinator about the staffing report. On 06/08/22 at 1:07 PM., the surveyor interviewed the Staffing Coordinator about where the staffing report was posted. The Staffing Coordinator brought the surveyor to the location where the staffing report would have been posted. The area was only accessible to staff and the Nursing Home Resident Care Staffing Report was not observed posted. The Staffing Coordinator stated they were unable to print out the staffing report and had tried calling the State for assistance. The Staffing Coordinator stated when the issue started, she informed the Administrator who directed her to contact the State. The Staffing Coordinator stated the State helped her with her access to the system, but she was still not able to print the staffing report. The Staffing Coordinator stated that prior to not being able to print the staffing report, she would post the staffing report in the location shown to the surveyor. On 6/8/22 at 2:02 PM, the staffing coordinator could not provide any email correspondence with the State. The staffing coordinator further stated that a Human Resources staff member helped with the issue of printing and that she was now able to print the staffing report. The staffing coordinator stated the issue of not being able to print report began two to three weeks ago. The staffing coordinator acknowledged the staffing report should be in a visible area of the facility for everyone to see and stated the staffing report would now be posted at the reception desk in the main lobby. On 6/16/22 at 11:30 a.m., the surveyor informed the Administrator and DON regarding concerns with the posting of the Nursing Home Resident Care Staffing Report. There was no additional information provided. NJAC 8:39-41.2

Based on observation, interview, and record review it was determined that the facility failed to properly remove expired medications and medications with shortened expiration dates (expired). This deficient practice was observed in 1 of 2 medication carts inspected and in the back up storage area, as evidenced by the following: On 6/6/22 at 10:10 AM, the surveyor inspected Unit C, medication cart and the findings were as follows: 1. The surveyor noted insulin Levemir 100 units/milliliter (u/ml) which was delivered to the facility for Resident #36 on 4/10/22 from the provider pharmacy. The documented opening date for the Levemir 100 u/ml 10 ml bottle was 4/19/22. Levemir 100 u/ml insulin has a 28 day expiration date once opened. This would have deemed this medication to have been expired after May 16, 2022. 2. The surveyor noted insulin Levemir 100 units/milliliter (u/ml) which was delivered to the facility for Resident #41 on 4/8/22 from the provider pharmacy. The documented opening date for the Levemir 100 u/ml 10 ml bottle was 4/13/22. Levemir 100 u/ml insulin has a 28 day expiration date once opened. This would have deemed this medication to have been expired after May 10, 2022. 3. The surveyor noted a Fluticasone Propionate and Salmeterol Inhalation 100 mcg/50 mcg dated opened on 11/14/21 for Resident #12. Review of the April, May and June 2022 Physician's Orders revealed that there were no current orders for this medication for Resident #12. On 6/6/22 at 12:12 PM the surveyor informed the Director of Nursing (DON) of the findings. The DON stated that insulin has a 28 day expiration. The insulin should have been removed from the medication cart and replaced with new insulin. When the surveyor informed the DON of the Fluticasone Propionate and Salmeterol Inhalation 100 mcg/50 mcg, the DON stated that this medication was discontinued a long time ago and should have been removed from the medication cart and discarded. On 6/9/22 at 11:08 AM, the surveyor accompanied the Housekeeping Director to the back up storage area and several medications were found to be expired: 1. 2 x 42 Omeprazole 20 mg expired 9/2021 2. 1 x 100 Vitamin B6 50 mg expired 4/22 3. 3 x 100 Vitamin D3-50 50,000 International Unit (IU) expired 4/21 On 6/8/22 at 1:15 PM, the issue was presented to the Administrator and DON. There was no further information supplied by the facility in response to the abnormalities presented. On 6/15/22 at 11:15 AM, the surveyor interviewed the Regional CP who explained that there were some financial issues which caused the absence of a May 2022 Unit Inspection of the facility. The Regional CP explained that the Consultant Pharmacist performed unit inspections at the facility on 4/28/2022 and then again on 6/6/2022. On 6/16/22 at 8:40 AM, the surveyor received the policy and procedure for Expired Non-Narcotic Medications and OTC (P&P). The policy part of the P&P states, To ensure that expired non-narcotic medications and over the counter medications (OTC) are appropriately destructed. The procedure part of the P&P states, 1. 11-7 shift nurses will check med carts and med rooms to any expired non-narcotic medications and OTC medications that are expired. 3. The expired meds will be destructed by two nurses using the drug buster. On 6/15/22 at 1:15 PM, the issues were once again presented to the Administrator and DON. There was no further information supplied by the facility in response to any of the abnormalities presented. NJAC 8:39- 29.4(b)2

Based on observation, interview, record review and policy review, it was determined that the facility failed to store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 6/6/22 at 10:50 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - Six #10 sized cans of mixed fruit with 1-inch sized dents on the upper lip, - Two #10 sized can of mixed fruit with 2-inch sized dents on the body of the cans, -One #10 sized can of mandarin oranges with a 1-inch sized dent on the upper lip of the can, -One #10 sized can of mandarin oranges with a 2-inch sized dent on the upper lip of the can, -One #10 sized can of sliced beets with 4-inch sized dents on the body of the can, 2. In the walk-in refrigerator, the surveyor observed 24 raw shell eggs in an egg carton which was on a shelf located directly above a container of cooked, hard-boiled eggs. The FSD stated that the raw eggs should not have been stored above any cooked food items. 3. On another shelf in the walk-in refrigerator, the surveyor observed a 1/2 full bottle of Texas sauce with an open dated of 3/28/22 and a 1/2 full bottle of Barbeque sauce with an open date of 5/25/22. The FSD stated that these items should not be on shelf and should have been discard after 14 days of them being opened. 4. The surveyor opened the ice machine lid and inspected the inside. The surveyor observed a brown and black colored substance on the plastic barrier flat inside the ice machine, which was touching the ice inside the machine. The FSD stated that the plastic barrier flat should have been clean. The FSD stated that she usually inspects the ice machine each day and forgot to check it today. On 6/9/22 at 2:00 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing. The surveyor reviewed the facility's updated policy and procedure titled Food Storage. The policy indicated to store cooked foods above raw foods to prevent contamination and all foods should be covered, labeled and dated and will be consumed by their safe use by dates. The surveyor reviewed the facility's updated policy and procedure titled Production, Storage and Dispensing of Ice. The policy indicated that ice will be produced, stored and dispensed in a manner to avoid contamination. The procedure indicated that the ice dispenser will be cleaned inside and outside at least monthly and/or as needed. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a complete and accurate record related to code status and allergies for 2 of 21 residents reviewed for medical records (Residents #61, and #45), as evidenced by the following: 1. On 6/8/22 at 9:45 AM, the surveyor observed Resident #61 seated in a chair and watching television in the resident's room. A review of the resident's hybrid medical record revealed the following information: The admission Record revealed that Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to Type 2 Diabetes Mellitus Without Complications (High Blood Sugar) and Alzheimer's Disease (A brain disorder that causes problems with thinking, memory, and behavior). The Quarterly Minimum Data Set (QMDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive deficit. On 6/14/22 at 1:00 PM, upon reviewing Resident #61's code status in the physician's orders and dashboard in the resident's Electronic Medical Record (EMR), a DNR/DNI (Do Not Resuscitate/Do Not Intubate) order dated 3/15/22 and a Full Code (If a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) order dated 2/2/22 were both in place. A review of A New Jersey Practitioner Order for Life-Sustaining Treatment (NJ POLST) DNR/DNI form dated 3/28/22 was in the resident's physical chart. On 6/14/22 at 1:37 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) and asked her where she would check for a resident's code status. The LPN stated, I would look in [the electronic record] first. It usually has the most up-to-date code status information. The LPN further stated that if she is unable to locate a resident's code status in the EMR, she checks the resident's physical chart. When the surveyor showed the LPN the active Full Code and DNR/DNI orders in Resident #61's EMR, the LPN acknowledged that there were two conflicting active code statuses in the resident's EMR. The LPN stated, It looks like [the resident] came in with a full code, and a month after there's an order for DNR/DNI and they didn't discontinue the Full Code order. The LPN acknowledged that there should not have been two different active code statuses in the resident's EMR. No other information was provided. 2. On 06/07/22 at 11:36 AM, the surveyor observed Resident #45 seated in a chair well-groomed and watching television in the resident's room. A review of the resident's hybrid medical record revealed the following information: The admission Record revealed that Resident #45 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction due to unspecified occlusion or stenosis of unspecified Cerebral Artery, SL Major Depressive Disorder, Recurrent, Moderate, Essential Primary Hypertension, Type 2 Diabetes Mellitus Without Complications (High Blood Sugar), Hyperlipidemia (Unspecified), and Unspecified Glaucoma. The QMDS dated [DATE] revealed a BIMS score of 9 out of 15, which indicated that the resident had severe cognitive deficit. The hybrid medical record did not contain a POLST when checked on 06/07/22 at 11:36 AM. The current comprehensive care plans included a care plan for a POLST with instructions for full code status and the provision of artificial fluids if necessary. The EMR dashboard identified the resident was listed as a FULL CODE not a DNR. The EMR dashboard identified the resident as having No Known Allergies. The physical (paper) medical record was reviewed. The medical binder had 2 stickers attached - a red and black sticker identifying the resident as DNR and a sticker identifying the resident as Allergic to Sulfa Antibiotic. The surveyor interviewed the Administrator on 06/08/22 at 1:35 PM regarding the POLST who confirmed that the POLST should have been in the hybrid medical record. On 6/10/22, the POLST was completed by the Certified Social Worker and placed in the hybrid medical record. On 6/14/22 at 10:50 AM, the surveyor interviewed the RN assigned to the resident and asked where she would check for a resident's code status and any known allergies. The RN stated that she would always look in the EMR first. The RN checked EMR and confirmed that Resident #45 was FULL CODE and No Known Allergies. The surveyor asked what the process would be if the computer was down. The RN stated she would check the resident's physical chart. When the surveyor showed the RN the DNR sticker and the Allergy sticker for Sulfa Antibiotic in Resident #45's physical chart, the LPN acknowledged that there were two conflicting code statuses in the resident's EMR and the physical chart. The RN stated the stickers on the physical chart should have been removed when recycled for the new resident. The RN acknowledged that there should not have been two different code statuses between the resident's EMR and physical chart. The RN stated medical records is responsible for building the new charts. On 06/14/22 at 11:16 AM the Admissions Director (AD) was interviewed and asked about the chart process, AD stated the chart is made up by her but with basic information about the resident. The surveyor advised the AD of the DNR and Allergy stickers on a physical chart for Resident #45 and that the EMR had FULL CODE and No Known Allergies. The AD stated the receptionist takes off the stickers and there was an issue with the last receptionist not following the process and was let go because of it. On 6/14/22 at 3:19 P.M., the Administrator and the Director of Nursing provided the surveyor with paperwork that the chart had been changed from DNR/Sulfa Allergy to a FULL CODE/No Known Allergies. The DNR and Sulfa stickers were removed from the chart. The surveyor observed the resident's chart with the corrected code status 6/15/22 at 11:00 AM. On 6/14/22 at 2:41 PM, the surveyors discussed the concerns on the conflicting physician orders of the code status and allergies in the resident's EMR with the administrator and his administrative staff. The Director of Nursing/Registered Nurse (DON/RN) acknowledged that there should not have been two different active code statuses in the resident's EMR and that the Full Code order should have been discontinued when the DNR/DNI order was in place for the resident. He additionally stated the resident's allergies should be consistently documented throughout the electronic and paper charts. On 6/15/22 at 8:57 AM, the surveyor reviewed the facility policy, Code Status Documentation Policy with a revised date of 6/12/22 and revealed under Policy: To resident's code status will be accurately documented to ensure that information is accessible to health care provider during emergency to avoid delay of treatment. Procedure: 1. Code status will be documented in the EHR and physical chart. 3. The nurse will ensure that a physician's order is obtain for the code status. 4. The social worker must audit the code status monthly to ensure that the information is accurate and will update when necessary. Updated information for any changes will be communicated to the nurse to ensure that physician's order will reflect the changes. NJAC 8:39-23.2 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The surveyor reviewed Resident # 43's hybrid medical record of which revealed the following: The resident's admission Record listed diagnoses that included anxiety disorder and depression. The admission MDS assessment, dated 4/6/22, indicated the facility assessed the resident's cognitive status using a BIMS. The resident scored a 15 out of 15 which indicated that the resident was cognitively intact. The MDS assessment also indicated the resident had active diagnoses of anxiety disorder and depression and was receiving antidepressants and antianxiety medications. A psychiatry progress note, dated 6/7/22, indicated Resident #43 was receiving Paxil for depression and Clonazepam for anxiety. It also indicated the resident reported intermittent anxiety. A review of the physician's orders and the medication administration record of Resident #43 revealed the resident was receiving Paxil 40 mg (PARoxetine HCl) Give 1 tablet by mouth one time a day, order date of 3/31/22 and ClonazePAM Tablet 0.5 MG Give 1 tablet by mouth two times a day, order date of 6/4/22. On 6/10/22 at 10:29 am, the surveyor interviewed LPN # 6, about the care planning process. LPN # 6 stated to her knowledge from she started working at facility the RN would initiate care plans, and then the LPNs would update and add to them. LPN # 6 further stated care plans would be updated when there were significant changes with residents. The surveyor asked LPN # 6 for Resident # 43 who was receiving medication for depression and anxiety, if it would be expected for the resident to have a care plan. LPN acknowledged that the resident should have care plans related to psychoactive medications (a medication that affects the mind) and related diagnoses. On 6/10/22 at 10:40 AM, the surveyor interviewed unit IPRN, about the care planning process for residents. She stated when a resident is admitted or readmitted to the facility, the admitting nurse initiates or revises the care plan. She further explained the previous DON was writing the care plans up until May, at which time they left employment. She stated the new DON will be reviewing all residents for comprehensive care planning going forward. The IPRN stated it would be expected for the resident to have a psychoactive care plan. On 6/13/12 at 1:12 PM, the surveyor met with Administrator, the DON, and IPRN discuss care plan concerns for Resident #43. 7. The surveyor reviewed Resident # 47's hybrid medical record which revealed the following: The resident's admission Record listed diagnoses that included generalized muscle weakness, Type 2 Diabetes Mellitus, and depression. The admission MDS assessment, dated 4/7/22, which indicated the facility assessed the resident's cognitive status using a BIMS. The resident scored a 11 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS assessment also indicated that the resident was at risk of developing pressure ulcers/injuries, the resident was receiving antidepressants and insulin injections. A review of the physician's orders revealed: A physician's order, dated 6/3/22, which read: TX to Left buttock : NSS wash , santyl , foam dressing daily. A physician's order, dated 6/3/22, which read: TX to Right buttock : NSS wash , Santyl , foam dressing daily. A physician's order, dated 5/5/22, which read: Lexapro Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day. A physician's order, dated 5/16/22, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale subcutaneously before meals and at bedtime. The wound consultant notes, dated 6/1/22, indicated Resident #47 had pressure ulcers to buttocks. A review of the resident's CP revealed: There was no CP related to pressure ulcers or risks of skin breakdown for the resident. There was no care plan related to Resident #47 diagnosis of Type 2 Diabetes Mellitus or resident receiving insulin medication. There was a care plan with a focus that read [Resident #47] is at nutritional risk secondary to fluctuating appetite likely related to depression. There was no other care plan related to Resident #47 receiving antidepressant medication or diagnosis of depression. On 6/8/22 at 11:26 AM, the surveyor interviewed LPN # 7 about the care planning process and who was responsible for care plans. LPN # 7 stated the previous DON used to be responsible for developing care plans, and the nurses would update care plans based on changes in the resident's status. LPN # 7 further stated now the nurses develop care plans and update the care plans if needed. LPN # 7 stated any changes with residents or anything new to add will be updated right away. The surveyor asked LPN # 7 about the resident' s wounds. LPN # 7 reviewed the EMR and stated the wound was first documented on 5/6/22 as moisture dermatitis. On 6/9/22 at 12:45 PM, the surveyor interviewed LPN # 7 about care plans for residents with wounds or at risk for skin breakdown. LPN # 7 stated residents at risk for skin breakdown should have a care plan. LPN # 7 further acknowledged residents with an actual or new wound should have a care plan. The surveyor asked LPN # 7 if the Resident #47 had a care plan in place. LPN # 7 reviewed the EMR and confirmed there was no care plan related to pressure ulcer or skin integrity for the resident. LPN # acknowledged Resident #47 should have had a care plan related to skin breakdown and actual wounds. LPN # 7 stated she would follow up with the unit RN about creating a care plan for the resident. On 6/10/22 at 10:29 AM, the surveyor interviewed LPN # 7, about the care planning process. LPN # 7 stated to her knowledge from she started working at facility the RN would initiate care plans, and then the LPNs could update and add to them. LPN # 7 further stated care plans would be updated when there were significant changes with residents. The surveyor asked LPN # 7 for Resident # 47 who was receiving medication for depression, if it would be expected for resident to have a care plan. LPN # 7 acknowledged that the resident should have care plans related to psychoactive medications (a medication that affects the mind) and related diagnoses. On 6/10/22 at 10:40 AM, the surveyor interviewed IPRN, about the care planning process for residents. She stated when a resident is admitted or readmitted to the facility, the admitting nurse initiates or revises the care plan. She further explained the previous DON was writing the care plans up until May, at which time they left employment. She stated the new DON will be reviewing all residents for comprehensive care planning going forward. The IPRN stated it would be expected for the resident to have a psychoactive care plan. On 6/15/22 at 12:55 PM, the surveyor informed the Administrator and his administrative staff discuss concerns of care plans for the resident. The facility policy for baseline care plans and comprehensive care plans, last reviewed 10/20/21, indicated each resident is to receive a baseline care plan within 48 hours to address all immediate care needs. Additionally, a comprehensive care plan is to be implemented for each resident's physical, psychosocial, and functional needs. The surveyor reviewed the facility's policy and procedure titled, Wound Care Protocol with a revised dated of 1/28/22, which read Care planning must be formulated for all residents with actual or potential wound(s). NJAC 8:39-11.2(e) 8. On 6/7/22 at 11:36 AM, the surveyor observed Resident #51 in the resident's room sitting in a wheelchair. Resident #51 informed the surveyor that he/she was recently hospitalized . A review of the resident's hybrid medical record revealed the following information: The admission Record revealed that Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to Iron Deficiency Secondary to Blood Loss (Chronic) and Renovascular Hypertension. A review of Resident #51's paper chart titled New Jersey Universal Transfer Form dated 4/15/22 revealed that the resident was transferred to the hospital due to Resident vomiting large amount of coffee ground emesis, complaining of abdominal pain. A review of Nurse's Progress Notes dated 4/17/22 revealed that the resident was readmitted to the facility with a diagnosis of GI Bleed. The Annual MDS dated [DATE] revealed a BIMS score of 11 out of 15, which indicated that the resident had moderate cognitive deficit. The June 2022 Order Summary Report included a 5/29/21 physician's order for Aspirin Tablet Chewable 81 mg 1 tablet by mouth one time a day and a 3/16/21 physician's order for Clopidogrel Bisulfate Tablet 75 mg 1 tablet by mouth one time a day which placed the resident at a higher risk for bleeding. The surveyor reviewed the resident's CP. There was no care plan developed regarding the resident's use of the medications. On 6/13/22 at 1:18 PM, the surveyor discussed the concerns with the administrator and his administrative staff and acknowledged that there was no care plan initiated for the resident upon readmission to the facility. No further information was provided. On 6/14/22 at 9:22 AM, the surveyor interviewed the LPN # 5 assigned to the resident and acknowledged that there should have been a care plan initiated for the resident who had a history of GI Bleed and is taking medications that placed the resident at a higher risk for bleeding. 6. On 6/6/22 at 10:41 AM, two surveyors toured the unit with the LPN # 4. The LPN # 4 told the surveyors that Resident #42 was COVID-19 positive and was on transmission-based precautions (TBP) which are special measures that are put in place to prevent the spread of infection. On 6/6/22 at 11:24 AM, the surveyor observed a sign on Resident #42's door which read, Please see nurse before entering room. On 6/6/22 at 11:25 AM, the surveyor observed Resident #42 in bed wearing a nasal cannula (a medical device to provide supplemental oxygen therapy) attached to an oxygen concentrator. The surveyor observed that the oxygen concentrator was set to 3 LPM. The surveyor reviewed Resident #42's hybrid medical record. The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to Fracture of Right Femur (a partial or complete break in the bone of the thigh) and Hypertension (high blood pressure). The resident's most recent quarterly MDS an admission record used to facilitate the management of care revealed a BIMS score of 99 which reflected that Resident #42 was unable to complete the interview. The MDS indicated that the resident appeared to have an OK short-term and long-term memory. The MDS also indicated that Resident #42 used oxygen while as a resident. A review of a 6/1/22 Progress Note written by the Nurse Practitioner indicated that Resident #42 had lung cancer and was dependent on oxygen. A Laboratory Result dated 5/31/22 revealed that Resident #42 tested positive for COVID-19 via a reverse transcription PCR (a laboratory method used to make many copies of a specific genetic sequence for analysis) test for COVID-19. The Clinical Physician Orders indicated that Resident #42 had a 6/3/22 active order for Quarantine precaution x 14 days monitor for sob (shortness of breath), cough, and temp for covid positive results. A further review of the Clinical Physician Orders indicated that Resident #42 had a 5/17/22 active order for Supplemental oxygen at 2LPM continuous via nasal cannula. The care plan initiated on 1/13/22 failed to address Resident #42's respiratory function or oxygen use. The care plan also failed to address the specific goal and intervention for Resident #42 while they were using supplemental oxygen. A further review of the care plan also failed to address that the resident was positive for COVID-19 or that they were placed on TBP. The care plan also failed to address the specific goal and intervention for Resident #42 while they were COVID-19 positive and on TBP. On 6/8/22 at 9:41 AM, the surveyor interviewed the Registered Nurse (RN). The surveyor stated that Resident #42 had COVID-19 and that they used supplemental oxygen. The surveyor asked if there should be care plans in place because the resident was COVID-19 positive, was on TBP, and used supplemental oxygen. The RN stated, definitely. The surveyor asked the RN how soon after a positive COVID-19 test should a care plan be initiated. The RN stated, right away. On 6/13/22 at 1:18 PM, the surveyor expressed her concern to the Administrator and his administrative staff The surveyor asked if administration would expect to see care plans initiated and implemented. The DON stated, yes. 7. On 6/6/22 at 11:14 AM, the surveyor observed Resident #32 in bed. The resident was awake, alert, and oriented but appeared thin. The surveyor observed Resident #32's medical record. The admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to Encounter for Palliative Care (care focused on providing relief from the symptoms and stress of serious illness), and Dementia. The resident's most recent significant change in status MDS, revealed a BIMS score of 8 out of 15, reflecting moderately impaired cognition. The MDS also indicated that Resident #32 was receiving hospice care while as a resident. The Order Recap Report indicated a 4/1/22 active physician order for, Hospice evaluate and treat. The care plan initiated on 4/1/2019 failed to address that Resident #32 was admitted to hospice or was receiving palliative care. The care plan also failed to address the specific goal and intervention for Resident #32 while they were admitted to hospice or were receiving palliative care. On 6/8/22 at 9:41 AM, the surveyor interviewed the RN # 2. The surveyor asked if the RN # 2 would expect to see that a resident on hospice had a care plan in place to address that they were receiving hospice or palliative care services. The RN # 2 stated that she would expect for one to be in place. On 6/13/22 at 1:18 PM, the surveyor expressed her concern to the Administrator and his administrative staff. The surveyor asked if administration would expect to see a care plan initiated and implemented. The DON stated, yes. 5. On 6/07/22 at 10:08 AM, the surveyor observed Resident # 53 in bed with Oxygen nasal canula in place and the concentrator was running at 3 liters per minute. Resident stated, they were having occasional pain in knee when they were doing therapy and was receiving pain patch on pain their left knee but is no longer receiving the patch. The surveyor reviewed Resident #53's medical record. The admission record reflected that Resident #53 was admitted to the facility on [DATE] with diagnoses that included but not limited to Covid-19, Dysphagia Oropharyngeal Phase, Muscle Weakness, Respiratory Failure, and Anxiety Disorder. The surveyor reviewed the June 2022 Physician's Order form, which showed that Resident #53 had a Physician 's order from the administration of O2 (Oxygen) at 2L/min via NC (Nasal Cannula) continuously every day and night shift, Lidocaine Patch 4 % apply to left knee topically one time a day for pain management and remove per schedule, and Seroquel Tablet 25 MG (Quetiapine Fumarate) give 1 tablet via PEG-Tube every 12 hours for Psychosis. At 10:15 AM, the surveyor interviewed LPN # 3 in resident's room. LPN #3 stated the resident has an order for oxygen at 2 liters per minute but observed and confirmed the oxygen was running at 3 liters per minute. LPN #3 stated the resident is currently receiving Tylenol for pain, but they were receiving a Lidocaine patch for left knee pain, but that was discontinued yesterday, also receiving Seroquel twice a day for anxiety, which normally is helpful for the resident. At 1:00 PM, the surveyor reviewed Resident #53's CP, which showed that the facility did not develop a care plan that included the use of Oxygen, Pain Medication, and/or Anxiety/Psychotropic medications. On 6/09/22 at 09:57 AM, the surveyor re-interviewed LPN #3. LPN #3 stated the DON should review the medical record and initiate the resident's care plans. LPN #3 unable to produce care plans from pain, respiratory for continuous oxygen use, and anti-psychotic medication. LPN #3 stated, it's very possible the pain care plans were not made for those issues. On 6/10/22 at 10:31 AM, the surveyor team interviewed the IPRN. IPRN stated, when a patient is admitted , the nurse initiates the baseline care plan, but the DON was previously completing the comprehensive care plan. The new DON will be reviewing all residents for care plan. IPRN further stated, they would have expected there to be care plans for those areas. The surveyor reviewed the policy and procedure for Oxygen Administration with a review date of 10/21/21, which revealed that it is the policy of this facility to provide comfort to residents by administering oxygen when insufficient oxygen is being carried by the blood to the tissues, and staff should check the physician's order for the liter flow and method of administration and licensed staff will check the oxygen flow rate on all residents on oxygen therapy during rounds and compare it against the physician's order at the start and end of each shift. The surveyor reviewed the policy and procedure for Pain Assessment and Management revised on 3/28/21, which revealed comfort and sensitivity in a caring environment shall be offered to all residents, verbal and nonverbal expressions of pain and discomfort will be addressed property, and an order to set forth guidelines in determining the presence and severity of pain and to develop an individualized resident pain management program. 2. On 6/7/22 at 9:55 AM, the surveyor observed Resident #28 seated in bed in the resident's room. On 6/9/22 at 11:04 AM, the surveyor reviewed Resident # 28's medical record. Resident #28 was admitted to the facility on [DATE] with diagnoses that included but not limited to Traumatic Subarachnoid Hemorrhage, Hypertension, Psychosis and Anemia. Further review of the resident records revealed that Resident #28 was admitted under Hospice care as of 12/20/21 for Senile Degeneration of Brain. The resident's most recent quarterly MDS, an assessment record used to facilitate the management of care, dated 3/19/22 revealed a BIMS score of 03 which indicated that Resident #28 had severely impaired cognition. The surveyor reviewed the Interdisciplinary CP for Resident #28, which had no coordination of care between Hospice and the facility. On 6/9/22 , the surveyor interviewed the LPN # 2 assigned to the resident who stated that another nurse was responsible for updating the care plans if there was any changes. On 6/13/22 at 1:00 PM, the surveyor discussed hospice care plan concerns with the Administrator and his administrative staff who agreed that there was no care plans initiated for the resident upon admission to hospice. No further information was provided. 3. On 6/7/22 at 10:30 AM, the surveyor observed Resident #62 in bed with eyes closed. On 6/13/22 at 12:21 PM, the surveyor reviewed Resident #62 's medical record. Resident #62 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to Protein-Calorie Malnutirtion; History of COVID-19; Hypertension and Dementia. Further review of the resident records revealed that Resident #62 was admitted under Hospice care as of 7/28/21 for Senile Degeneration of Brain. The resident's most recent quarterly MDS, an assessment record used to facilitate the management of care, dated 5/7/22 revealed that Resident #62 had severely impaired cognition. The surveyor reviewed the CP for Resident #62 which had no coordination of care between Hospice and the facility. On 6/9/22, the surveyor interviewed the LPN # 2 assigned to the resident who stated that another nurse was responsible for updating the care plans if there were any changes. On 6/13/22 at 1:00 PM the surveyor discussed hospice care plan concerns with the Administrator and his administrative staff who agreed that there were no care plans initiated for the resident upon admission to hospice. No further information was provided. Based on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan for residents at the facility. This deficient practice was identified for 10 of 21 residents reviewed for comprehensive care plans (Resident #55, #42, #28, #32, #51, #43, #47, #62, #4, and #53), and was evidenced by the following: On 6/7/22 at 10:25 AM, the surveyor observed Resident #55 sleeping in bed in their room. The surveyor could not interview Resident #55. On 6/8/22 at 9:35 AM, the surveyor interviewed the Licensed Practical Nurse # 1 (LPN), who was assigned to care for Resident #55. The LPN # 1 informed the surveyor that Resident #55 goes to hemodialysis on Tuesday, Thursday, and Saturday at approximately 2:00 PM. The LPN # 1 explained that Resident #55 had recently returned from the hospital, where he/she underwent a surgical procedure to create an arteriovenous (AV) graft site ( access used for dialysis) on the right arm for dialysis access. Review of the medical records revealed that Resident #55's AV graft was not correctly being monitored, checking bruit and thrill (Feel for a vibration, also called a pulse or thrill. With a stethoscope, listen for a swishing sound, or bruit). On 6/8/22 at 10:30 AM, the surveyor interviewed the LPN # 1. The LPN # 1 stated that the facility should be monitoring the AV graft for bruit and thrill sounds. The LPN # 1 verified that this was not occurring nor was there any documentation ordering the monitoring. On 6/9/22 at 9:30 AM, the LPN # 1 advised the surveyor that the AV graft was not usable. Resident #55 was still receiving hemodialysis through their permcath (special IV line into the blood vessel in your neck or upper chest just under the collarbone used for hemodialysis access). The surveyor reviewed Resident #55's hybrid medical records that revealed the following: According to the admission Record, Resident #55 was admitted with diagnoses that included End Stage Renal Disease (ESRD) with dependence on renal dialysis. The admission Minimum Data Set (MDS) an assessment tool dated 4/29/22, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 12 out of 15. The resident was assessed to be moderately impaired. The June 2022 Order Summary Report revealed a physician's order for hemodialysis every Tuesday, Thursday, and Saturday at 2:00 PM. Review of the Nurse's Progress Notes on admission dated 4/22/22 specifies, Perma cath noted to right upper chest, dressing clean, dry, resident on hemodialysis at [Dialysis Center] on Tuesdays, Thursdays, and Saturdays at 4 PM. Review of the Nurse's Progress Notes following hospitalization dated 6/1/22 revealed, Resident was brought back from [hospital name] after having a right upper external AV graft placement on 5/27. Review of the Nurse's Progress Notes dated 6/9/22 establishing, Check AVF Site for Bruit and Thrill. None Noted. Access not functioning. Permcath used for Hemodialysis. Review of the most recent care plan (CP), section titled, [Resident #55] needs dialysis hemodialysis related to End Stage Renal Disease. The CP identified, Do not draw blood or take B/P in right arm with graft. There was no documentation referring to Resident #55's graft not functioning. Resident #55 only has use of a permcath for dialysis access, which is not mentioned in the CP. The CP was never updated with an accurate dialysis access port (Permcath), that should be monitored. 4. On 6/06/22 at 12:09 PM, the surveyor observed Resident #4 awake and alert in bed watching television. The unit Registered Nurse/Infection Preventionist (IPRN) stated the resident was receiving hospice services. A review of the hybrid medical record revealed the following information. The June 2022 Order Summary Report included a 3/2/22 physician's order for hospice services. The MDS assessment tools dated 2/11/22 and 5/14/22 indicated the resident was receiving hospice services. The resident's current comprehensive care plan did not include a care plan for hospice care and services. On 6/10/22 at 10:28 AM, the surveyor interviewed the unit IPRN. She stated there should be a hospice care plan for Resident #4. She stated when a resident is admitted or readmitted to the facility, the admitting nurse initiates or revises the care plan. She further explained the previous Director of Nursing (DON) was writing the care plans up until May, at which time they left employment. She stated the new DON will be reviewing all residents for comprehensive care planning going forward. On 6/13/22 at 1:00 PM, the surveyor discussed the hospice care plan concern with the Administrator and his administrative staff.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Mandatory COVID-19 Vaccination Policy and Procedure was implemented to track and document the vaccination status for all facility staff. The deficient practice was evidenced by the following: On 6/9/22 at 9:30 AM, the surveyor reviewed the COVID-19 Vaccination Matrix (VM) that the facility provided. The VM revealed that there were 89 total staff employed. The VM revealed that 89 staff received the primary vaccination series for the COVID-19 immunization. Of the 89 staff, 86 staff were due for the booster dose, 3 staff were not due for the booster dose and only 35 staff received the booster dose. The VM revealed that 38 staff of the 89 were up to date with the vaccination requirement. The facility is at 42.7% compliance with the vaccination requirement. On 6/9/22 at 1:34 PM, the surveyor reviewed the National Healthcare Safety Network (NHSN) data regarding the facility reported percentage of fully vaccinated staff for the week ending 5/29/22. The facility reported the percentage of staff fully vaccinated was 100% and the percentage of boosted staff was 48.9%. On 6/9/22 at 12:55 PM, the surveyor interviewed a Licensed Practical Nurse (LPN), who was wearing an N95 mask. The LPN stated that she did not get her booster dose when she was due for it and did not explain why. The surveyor reviewed the facility policy and procedure titled Employee Covid Vaccination policy dated 4/16/22 which revealed that all staff members were mandated to have a Covid-19 booster to be up to date with the required vaccination by April 11, 2022, and staff who were not up-to-date with Covid 19 vaccination with no medical or religious exemption would be removed from the schedule until Covid vaccination mandate requirement was complete. On 6/9/22 at 2:00 PM, the surveyor interviewed the Administrator who stated that he was aware that there were staff who were not up to date with vaccination as their policy and regulations mandate. He stated that he could not take those staff members off of the schedule because he needed the staff since the facility was short-staffed. The Administrator stated that the facility had a plan to address this concern. NJAC 8:39-19.1(b); 19.4(a)

6. The hybrid medical records of Resident #47 revealed the resident's physician had not hand signed or electronically signed the physician's orders for March 2022, April 2022, and May 2022. 7. The hybrid medical records of Resident #43 revealed the resident's physician had not hand signed or electronically signed the physician's orders for March 2022, April 2022, and May 2022. 8. Resident #51's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for March 2022, April 2022, and May 2022. 9. Resident # 61's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for March 2022, April 2022, and May 2022. 11. Resident #32's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for March 2022, April 2022, and May 2022. 12. Resident #42's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for March 2022, April 2022 and May 2022. On 6/8/22 at 11:26 AM, the surveyor interviewed Licensed Practice Nurse (LPN #1) assigned to Floor C about where the physicians sign the orders for residents. LPN #1 stated the physicians usually sign in the resident's electronic chart. On 6/8/22 at 1:59 PM the surveyor interviewed LPN #2 assigned to Floor A, and asked when the physician came in to sign the physician's orders and how they signed the orders. LPN #2 said when the physician came in he signed the paper chart but he hadn't been in for a while. The surveyor showed LPN #2 the POSs for March and April (May wasn't in the chart) and that they were not signed. LPN #2 said she knew the Director of Nursing (DON) asked the doctor to come in and sign his orders recently. On 6/15/22 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON) regarding the signing and location of physician signatures for monthly physician's orders. The DON stated the physician signs the monthly orders on the paper record. A review of the facility's policy titled Physician's Order dated 6/12/22 under Procedure #3 reads; The physician's order will be reviewed and signed by the physician monthly. All physicians' providers are given access in the EHR for electronic signature. If the physicians choose to do paper monthly review the 11-7 nurse will print the monthly POS at the end of the month and will be placed in the doctor's folder for signature monthly. NJAC 8:39-23.2 13. The hybrid medical records of Resident #53 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for February 2022, March 2022, April 2022 and May 2022. 3. The hybrid medical records of Resident #28 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for March 2022, April 2022 and May 2022. 4. The hybrid medical records of Resident #62 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for March 2022, April 2022, and May 2022. 5. Resident #55's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April 2022, May 2022, and June 2022. 10. Resident #41's medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for March 2022, or April 2022. There was no Physician's Order Sheet (POS) in the medical record for May 2022. Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 13 of 17 residents (Residents 4, 35, 28, 62, 55, 43, 47, 53, 61, 51, 41, 42, 32 ) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents' primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents. 1. The hybrid medical records of Resident #4 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April 2022 and May 2022. 2. The hybrid medical records of Resident #35 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for March 2022, April 2022, and May 2022. On 6/8/22 at 11:26 AM, the surveyor interviewed the unit Registered Nurse/Infection Preventionist (RN) regarding the location of physician signatures for monthly physician's orders. The RN stated the physician signs the monthly orders on the paper record.

Based on observation, interview, and record review, it was determined that the facility failed to ensure required monthly visits by the Consultant Pharmacist (CP) in May 2022. This irregularity was identified for 14 of 15 residents reviewed by the survey team, Resident #4, #13, #28, #32, #35, #41, #42, #43, #45, #47, #51, #53, #61, and #62. The deficient practice was evidenced by the following: On 6/13/22 at 10:02 AM, the surveyor requested CP monthly reports for March, April, and May 2022 from the Director of Nursing (DON). The DON informed the surveyor that there were no CP reports for the month of May 2022. The DON submitted CP reports dated 3/30/22 and 4/30/22 to the surveyor. On 6/13/22 at 10:15 AM, the surveyor interviewed the facility Administrator (LNHA) who stated that the CP did not perform a Medication Regimen Review or Unit Inspection in May 2022. The LNHA could not explain why the CP had not visited the facility in May 2022. On 6/15/22 at 11:15 AM, the surveyor interviewed the Regional CP who explained that there were some financial issues which caused the absence of the May 2022 Medication Regimen Review (MRR) and Unit Inspection of the facility. The Regional CP stated that these issues were discussed with the LNHA in May 2022 but were not resolved until June 2022, causing the omission of May 2022 CP review of the facility. The surveyor interviewed the Regional CP in reference to the entries noted on the CP Evaluation sheet indicating 5/2022 no recommendations. The Regional CP explained that these were late entries, documented on 6/7/22 when the CP performed the MRR for June 2022. The Regional CP explained that the CP performing the MRR for the facility should have indicated that it was a late entry for May 2022 and performed in June 2022. 1. The surveyor reviewed Resident #4's Face Sheet (FS) (A one-page summary of important information about a patient) that listed the resident's diagnosis which included but was not limited to Hypertension, Anxiety, Depression and Cerebral Infarction. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 2. The surveyor reviewed Resident #13's FS that documented the resident's diagnosis which included but was not limited to Hypertension, Heart Failure, Chronic Atrial Fibrillation and Diabetes Mellitus. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 3. The surveyor reviewed Resident #28's FS that documented the resident's diagnosis which included but was not limited to Dementia, Hypertension, Psychosis and Acute Emboli's / Thrombosis. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 4. The surveyor reviewed Resident #32's FS that documented the resident's diagnosis which included but was not limited to Acute Respiratory Failure, Depression, Dementia, and Osteoporosis. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 5. The surveyor reviewed Resident #35's FS that documented the resident's diagnosis which included but was not limited to Hypertension, Diabetes Mellitus, and Emboli's / Thrombosis. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 6. The surveyor reviewed Resident #41's FS that documented the resident's diagnosis which included but was not limited to Hypertension, Dementia, Hyperlipidemia and Acute Respiratory Failure. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 7. The surveyor reviewed Resident #42's FS that documented the resident's diagnosis which included but was not limited to Hypertension, Fracture of right femur and muscle weakness. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 8. The surveyor reviewed Resident #43's FS that documented the resident's diagnosis which included but was not limited to Fracture of right femur, Depression, Anxiety, and Hypotension. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 9. The surveyor reviewed Resident #45's FS that documented the resident's diagnosis which included but was not limited to Cerebral Infarction, Depression, Hypertension, and Diabetes Mellitus. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 10. The surveyor reviewed Resident #47's FS that documented the resident's diagnosis which included but was not limited to Congestive Heart Failure, Depression, Hypertension, Chronic Kidney Disease and Diabetes Mellitus. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 11. The surveyor reviewed Resident #51's FS that documented the resident's diagnosis which included but was not limited to Dementia, Depression, Hypertension, and Diabetes Mellitus. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 12. The surveyor reviewed Resident #53's FS that documented the resident's diagnosis which included but was not limited to Respiratory Failure, Anxiety, Hypotension, and Gastrostomy. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 13. The surveyor reviewed Resident #61's FS that documented the resident's diagnosis which included but was not limited to Alzheimer's Disease, Depression, Hypertension, and Diabetes Mellitus. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. 14. The surveyor reviewed Resident #62's FS that documented the resident's diagnosis which included but was not limited to Gastrostomy, Epilepsy, Hypertension, and Dementia. Review of the CP Evaluation sheet revealed documentation by the CP monthly from 12/22/21 to 4/30/22. An entry was made for 5/2022 no recommendations, which was not an indication of a May 2022 MRR by the CP, but rather a late entry from the CP MRR performed on 6/7/22. NJAC 8:39 - 29.3 (a 1, 6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/7/22 at 11:45 AM, the surveyor arrived on the Floor A unit. The surveyor observed rooms with isolation bins by door with PPE supplies and signage that read stop please see nurse before entering. The surveyor interviewed LPN #3 about the residents on isolation on the unit. LPN #3 stated the residents on isolation precautions were new admissions or re-admissions and upon admission residents were placed on COVID-19 quarantine precautions for 14 days. The surveyor asked LPN#3 about the type of precautions taken for these residents. LPN#3 stated the residents were on contact and droplet precautions, and the staff were expected to wear gowns, gloves, N95 mask and face shield. On 6/7/22 at 11:50 AM, the surveyor observed CNA #3 exiting an isolation room wearing only a surgical mask. The surveyor interviewed CNA #3 about the isolation precautions for the resident in the room she just exited. CNA #3 stated the residents who come in as admissions were placed on precautions but could not say what type of isolation precautions the resident was on. The surveyor asked CNA #3 what PPE would be worn in the resident's room. The LPN stated gloves, gown, and mask should be worn. The surveyor asked CNA #3 what type of mask would be worn. CNA #3 stated she had been advised that a surgical mask was acceptable. She could not remember what staff person told her this. On 6/7/22 at 11:54 AM, the surveyor observed CNA #4 exiting an isolation room wearing a KN95 mask only. The surveyor interviewed CNA #4 about the isolation precautions for the resident in the room she just exited. The CNA stated the resident was on isolation. The surveyor asked about the PPE to be worn in the room. The CNA stated that before going into the room a gown, gloves, N95 mask, face shield, and foot covers were to be worn. CNA#3 further stated, I wanted to answer the call light for the resident .No, I didn't wear gown. On 6/7/22 at 12:05 PM, the surveyor interviewed LPN #3 regarding observations of the CNAs using inappropriate PPE for isolation rooms. The surveyor and LPN#3 observed CNA #5 exiting an isolation room only wearing a surgical mask. LPN #3 went to speak with CNA #5 about not using appropriate PPE. On 6/7/22 at 12:21 PM, the surveyor interviewed CNA #5 regarding an observation of exiting an isolation room. CNA #5 stated that the resident returned from the hospital and was on isolation. CNA #5 stated staff were expected to wear an N95 mask, gown, gloves, face shield and foot covers. The surveyor asked CNA #5 if she wore PPE besides surgical mask when she entered the resident's room and the CNA #5 replied, no. CNA #5 acknowledged she should have worn appropriate PPE, including an N95 mask, gown, gloves, and face shield when entering the isolation room. On 6/14/22 at 1:48 PM, the surveyor informed the Administrator, the DON, and the IP of the observed concerns. On 6/15/22 at 9:58 AM, the surveyor interviewed the IP about observed concerns of staff not using appropriate PPE entering rooms of residents on isolation. The IP stated isolation rooms have bins with PPE supplies by the door and signage on the door. The IP acknowledged staff entering rooms of residents on isolation should have donned full PPE, which includes a gown, N95 mask with surgical mask over it, face shield, gloves, and shoe covers if preferred, prior to entering the rooms. The surveyor reviewed the facility's policy titled Admission/Re Admission, dated 4/1/22, which read under Procedure, All new admissions/re admissions are placed in a single room and will be quarantined depending on the COVID test result and 3. Any resident that has been exposed in the hospital whether negative or positive will be quarantine for 14 days from date of admission. The policy did not specify the precautions for residents on quarantine. The surveyor reviewed the facility's policy titled, Infection Control Policy, dated 5/20/21, indicated that for residents on droplet precautions that a gown, gloves, N95 facemask, and goggles or face shield should be worn. 6. On 6/6/22 at 10:41 AM, two surveyors toured the B Unit with the LPN # 5. The LPN # 5 stated to the surveyors that there were several residents who were COVID-19 positive on the resident care unit. The surveyors observed that LPN # 5 was wearing a KN95 mask. The surveyor asked what personal protective equipment (PPE) the LPN wore inside the rooms of residents who were COVID-19 positive. The LPN # 5 stated that COVID-19 positive residents were on transmission-based precautions (TBP) which are special measures that are put in place to prevent the spread of infection. The LPN # 5 stated that she wore PPE including a KN95 mask inside the COVID-19 positive rooms. The surveyor asked if the LPN # 5 was fit tested (a series of steps used to determine the suitability of a respirator mask for a specific user) for a N95 mask. The LPN # 5 stated that she was fit tested by the facility but that the facility does not have the mask for which she was fit tested. On 6/6/22 at 11:34 AM, the surveyor observed a sign on the door to resident room [ROOM NUMBER] which stated, Please see nurse before entering room. The surveyor observed CNA # 7 emerge from the resident's room wearing a 3M 9502+ N95 mask. The surveyor asked CNA # 7 if the resident whose room she came out of had COVID-19. CNA #1 stated that the resident did have COVID-19. The surveyor asked if she was fit tested for the N95 mask that she was observed wearing. CNA # 7 stated that she was fit tested by the facility but for a different N95 mask, and that this mask is more, breathable. The surveyor asked if one N95 mask could be substituted for another. CNA # 7 stated that, you should wear the mask you're fitted for. On 6/8/22 at 9:50 AM, the surveyor observed KN95 masks in a PPE caddy outside of room [ROOM NUMBER], a room with a COVID-19 positive resident. On 6/8/22 at 9:26 AM, the surveyor observed a sign on the door to resident room [ROOM NUMBER] which stated, Please see nurse before entering room. The surveyor observed CNA # 8 inside the resident room wearing a gown, gloves, and a surgical mask over a respirator mask. The surveyor did not observe that CNA # 8 was wearing eye protection while inside the resident room. On 6/8/22 at 10:00 AM, the surveyor interviewed CNA # 8 in the hallway. The surveyor observed that the respirator mask on CNA # 8 was a KN95 mask. The surveyor asked what CNA # 8 was wearing in the COVID-19 positive room. CNA # 8 stated that she was wearing a KN95 mask in addition to her other PPE. The surveyor asked if this mask was appropriate to wear in a COVID-19 positive room CNA # 8 stated that it was. The surveyor asked why CNA # 8 was not wearing eye protection. CNA # 8 stated that she did not see a face shield in the PPE caddy outside of the room, so she did not put one on. On 6/8/22 at 10:58 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN). The surveyor asked why there were KN95 masks inside of PPE caddies outside of the rooms of COVID-19 positive residents. The IPN stated that KN95 masks should be worn inside of COVID-19 positive rooms. The surveyor asked if staff were fit tested for these masks. The IPN stated that staff were not. The surveyor asked if staff should be wearing a mask that they are fit tested for inside the rooms of COVID-19 positive residents. The IPN stated, yes. On 6/9/22 at 10:07 AM, the Housekeeping Director (HD) accompanied three surveyors to the supply rooms for PPE. The surveyors observed numerous boxes of 3M 8511 N95 masks and numerous boxes of KN95 masks in the storage areas. The surveyor observed 7 boxes of 20 [NAME] L-188 N95 masks in the supply rooms. At this time the surveyors interviewed the HD. The surveyor asked the HD who was responsible to stock PPE on resident units. The HD stated that he was. The surveyor asked how he decided which masks were brought up to nursing units. The HD stated that until recently he did not know the difference between KN95 masks and the different types of N95 masks and that it was a mistake to bring KN95 masks up to the resident unit and to stock them inside PPE caddies outside of COVID-19 positive resident rooms. The surveyor asked if there were any more [NAME] L-188 N95 masks in storage in the facility aside from the 7 boxes of 20 masks observed by the surveyor. The HD stated that there were not. On 6/9/22 at 10:49 AM, the surveyor reviewed the facility's Qualitative Fit Test Record which indicated which employees were fit tested for which respirator mask. The record revealed that all employees including the LPN # 5, CNA # 7, and CNA #8 were fit tested for the [NAME] L-188 N95 mask. The record failed to reveal that any employees were fit tested for any other N95 mask including the ones that were stocked in the facility. On 6/9/22 at 10:52 AM, three surveyors interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that the manufacturer ran out of [NAME] L-188 N95 masks so they sent the 3M 8511 N95 masks instead. The LNHA stated that this switch happened a few weeks ago. The LNHA stated that the facility completed fit testing for the 3M 8511 N95 masks this week. On 6/9/22 at 11:50 AM, the surveyor viewed the facility's PPE Burn Rate Spreadsheet for 5/22/22- 6/4/22. The spreadsheet indicated that on 5/22/22 the facility had 45 boxes of KN95 masks and on 6/4/22 that the facility had 38 boxes of KN95 masks. The spreadsheet indicated in a row titled, other that 3M 1860 N95 masks were also counted by the facility. The spreadsheet failed to indicate that any N95 masks were used by the facility during this time. The consumption of KN95 masks by the facility in this time was on average 0.54 cases per day. The consumption of 3M 1860 N95 masks was indicated by the spreadsheet as, no data. On 6/9/22 at 1:57 PM, the surveyor expressed her concerns regarding staff not wearing respirator masks that they were fit tested for, regarding staff observed not wearing proper PPE in COVID-19 isolation rooms, and regarding staff not being fit tested for the N95 masks that the facility stocked. On 6/14/22 at 12:55 PM, the surveyor observed CNA # 9 standing outside of a resident room [ROOM NUMBER] with a sign on it that read, Please see nurse before entering room. The surveyor observed that CNA # 9 was wearing a N95 mask with the straps of the mask tucked into the mask, not secured around his head or neck. The surveyor observed that CNA # 9 was wearing a surgical mask on top of his N95 mask, and that this mask was holding the N95 mask to his face. At this time the surveyor observed CNA # 9 knock on the door to the resident's room. The resident came to the door and handed CNA # 9 their lunch tray. The resident stood in the doorway to their room and spoke with CNA # 9 for two minutes. CNA # 9 was within 6 feet of the resident during this time. On 6/14/22 at 1:42 PM, the surveyor interviewed CNA # 9. The surveyor asked if the resident was positive for COVID-19. CNA # 9 stated that the resident was. The surveyor asked if the resident should be out of their room and in the doorway. CNA # 9 stated that they should not have been. The surveyor described the way that she observed CNA # 9's mask while he was in the hallway speaking with the COVID-19 positive resident and asked him why it was worn like that. CNA # 9 stated that the mask broke while he was in another resident's room and that he did not yet have a chance to change it. The surveyor asked if the mask should have been worn like that. CNA # 9 stated that this was not the correct way to wear a mask and that he should have changed into a new one. On 6/14/22 at 1:58 PM, the surveyor expressed her concern about CNA # 9 to the LNHA and DON. The facility's Infection Control Policy with a revised date of 5/20/21 indicated that for residents on droplet precautions (the type of TBP used for COVID-19 positive residents) that a gown, gloves, N95 facemask, and goggles or face shield should be worn. N.J.A.C. 8:39-19.4(a) 5.) On 6/6/22 at 10:00 AM, prior to the initial tour at the nursing units. The facility's DON stated COVID-19 positive residents resided in Unit B. He stated that Unit B staff must wear a face shield or goggles and an N95 respirator mask when in the hallway. He further stated if there was a need to go inside a COVID-19 positive resident's room, staff must wear face shield or goggles, N95 respirator mask with surgical mask over, disposable gown and disposable gloves. On 6/6/22 at 10:42 AM, the surveyor toured Unit B with LPN #5 who stated that there were several residents on the unit that are positive for COVID-19. The surveyor observed that LPN #5 was only wearing a KN95 mask (similar to a N95 respirator mask but has ear loops and is made to meet Chinese standards of medical masks) while walking in the unit B hallway. The surveyor also observed CNA #8 in the hallway wearing only a surgical mask. The surveyor interviewed CNA #8 who stated she only needed to wear a surgical mask when in the hallway. CNA #8 further stated that when she enters a COVID-19 resident's room, she would need to don a KN95 mask. The surveyor interviewed CNA #8, asking if she was fit tested for an N95 mask. She stated she could not recall if she was ever fit tested for an N95 mask. At 11:14 AM, the surveyor observed a staff person inside the COVID-19 positive room while interacting with the resident. The staff person was wearing a disposable gown, gloves and a KN95 mask. At 11:40 AM, the surveyor observed the staff person come out of the resident's room with a used gown, proceed to remove the gown outside of the resident's door, and then went back inside the COVID-19 room to discard the used gown in the designated garbage bin. The surveyor interviewed the staff person who stated that he was one of the facility's Occupational Therapists (OT). The OT agreed that he was not wearing any face shield or goggles while inside the COVID-19 positive room while performing the therapy. Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for: a.) improper use personal protective equipment (PPE), b.) improper hand hygiene during kitchen tour, c.) improper hand hygiene during a pressure ulcer treatment, and c.) improper storage of a urinary drainage bag. The deficient practices were evidenced by the following: 1. On 6/6/22 at 9:05 AM, upon entering the facility, the surveyor observed a Receptionist wearing a cloth face mask, the surveyor asked what kind of mask should be worn and the Receptionist stated she is not sure and will ask her Supervisor. At 10:50 AM, the surveyor inspected kitchen with the Food Service Director (FSD). In the food preparation area, the surveyor observed Food Service Worker (FSW) # 1 and FSW # 2 with surgical face masks worn under their chins and not covering their mouth and nose. The surveyor observed FSW # 1 pull her surgical mask up over her mouth and nose and with gloved hands, she grabbed a sheet pan of food and placed it inside an oven. The surveyor interviewed FSW#1 and FSW # 2 regarding face mask no worn over their mouth and nose and they both stated that they should have worn the mask correctly over their mouth and nose. FSW # 2 stated that she should have removed her gloves and washed her hands after touching her surgical mask. At 11:05 AM, the surveyor observed the FSD put soap on her hands and lathered her hands for 3 seconds, then she rinsed off her hands under running water. The surveyor asked the FSD how her hands should have been washed and she stated that she should have lathered her hands for 20 seconds. The FSD rewashed her hands and this time she only lathered the soap on her hands for 10 seconds then rinsed her hands under the water. The surveyor asked her why she only lathered for 10 seconds and the FSD stated that she must have counted to 20 too fast. On 6/9/22 at 2:00 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing (DON). The surveyor reviewed the facility's Outbreak Management Checklist for COVID-19, dated 12-17-21, which revealed that cloth face coverings are not personal protective equipment and are not appropriate substitutes for a surgical mask or respirator. 2. On 6/06/22 at 12:09 PM the surveyor observed Resident #4 awake and alert in bed watching television. On 6/07/22 at 9:45 AM the surveyor interviewed the unit RN/Infection Preventionist (RN). The RN stated the resident had multiple pressure and vascular ulcers. On 6/10/22 at 6:43 AM the surveyor observed the unit Licensed Practical Nurse #6 ( LPN #6) perform a pressure ulcer treatment for Resident #4. The LPN and surveyor reviewed the physician's order for the treatment. LPN #6 handwashed according to the facility policy. The clean field was set up on the resident's over bed table with no concerns. During the course of the treatment the LPN donned and doffed gloves 3 times without performing hand hygiene after doffing gloves, as follows: The LPN removed the soiled pressure ulcer dressing with gloved hands, removed the gloves and donned clean gloves without performing hand hygiene. LPN #6 then cleansed the wound without having washed her hands prior to donning gloves. The LPN removed her gloves and donned new gloves without performing hand hygiene. The LPN applied medicated gauze to the pressure ulcer without having performed hand hygiene before donning the new gloves. Wearing the same gloves, LPN #6 removed a pen from her uniform pocket, wrote the date on the topper dressing, placed the pen back into her pocket, and applied the topper dressing to the wound. LPN #6 doffed and donned new gloves without performing hand hygiene. Upon completion of the pressure ulcer treatment, LPN #6 performed hand washing according to the facility policy. The surveyor discussed with LPN #6 the concerns regarding changing gloves without performing hand hygiene and storing a pen used during the treatment in her pocket. She verbalized understanding of the infection control breaches. A review of the hybrid medical record revealed the following information. The June 2022 Order Summary Report included a 4/9/22 treatment order for a sacral wound. The order read cleanse the wound with saline, apply a single layer of Xeroform and apply a dry dressing every night shift. The 2/11/22 quarterly Minimum Data Set (MDS) assessment tool indicated the resident had 1 pressure ulcer and 2 venous or arterial wounds. The 5/4/22 wound care plan addressed multiple pressure and vascular wounds present on admission. On 6/14/22 at 1:45 PM the surveyor discussed with the Administrator and his administrative staff the infection control breaches related to hand hygiene and the storage of pens used during treatments. On 6/14/22 the surveyor reviewed the facility policy Wound Ulcer Treatment, revised 1/28/22. The policy indicated staff must perform hand hygiene after removing gloves. The policy did not address storing pens used for treatments in staff pockets. 3. On 6/06/22 at 11:26 AM the surveyor observed Resident #35 alert and awake in bed. At that time the surveyor observed an uncapped urinary drainage collection bag placed on a paper towel on the bathroom sink in the resident's bathroom. On 6/07/22 at 12:57 PM the surveyor observed an uncapped collection bag placed on the resident's bathroom sink. On 6/07/22 at 2:07 PM The surveyor accompanied the CNA #10 into the residents bathroom and confirmed the placement of the uncapped collection bag. CNA #10 stated she didn't leave it like that. She stated she was in the bathroom earlier and didn't notice it. She said it should be placed in a plastic bag or privacy bag when not in use. She did not state that the collection bag must be capped. 06/07/22 at 2:10 PM the surveyor interviewed the RN. She stated stored urine collection bags must always be capped. The RN stated she will re-educate all of the CNAs . A review of the hybrid medical record revealed the following information. The June 2022 Order Summary Report included a 10/29/21 physician's order for the placement of a suprapubic indwelling urinary catheter. The 4/18/22 quarterly MDS assessment tool indicated the resident had 2 urinary-related diagnoses, neurogenic bladder and obstructive uropathy (Section I). The resident was noted to utilize an indwelling urinary catheter (Section H). The 5/4/22 urinary catheter care plan did not include interventions regarding the storage of urinary catheter drainage collection bags. On 6/14/22 at 1:45 PM the surveyor discussed with the Administrator and his administrative staff the infection control breaches regarding the storage of uncapped urinary catheter drainage collection bags. On 6/16/22 the surveyor reviewed the facility policy Catheter Care: Changing and/or Emptying Collection Bag, revised 5/8/18. Steps 10 and 11 of the policy specified the stored collection bag must be capped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide 80 square feet per resident of living space in multi-bedded resident rooms. This was a repeat deficiency from the Recertification survey of 2019 as evidenced by the following: On 6/7/22 2:30 PM, the surveyor observed rooms #103, 109, 110, 111, and 203 were two bedded rooms. Rooms #103, 110, 111, and 203 were measured at 140 square feet instead of 180 square feet and room [ROOM NUMBER] was measured at 150 square feet instead of 160 square feet. The rooms were occupied by one resident with two beds in each room. The surveyor observed in rooms #104, 112, 204, 205, 209, 210, 211, and 212 were two bedded rooms. Rooms #104, 204, and 209 were measured at 150 square feet instead of 160 square feet. Also, rooms #112, 205, 210, 211, and 212 were measured at 140 square feet instead of 180 square feet. The rooms were occupied by two residents in each room. On 6/7/22 at 3:15 PM, the surveyor discussed the above concern with the Administrator and the Director of Nursing. The Administrator stated the rooms were only being used for single occupancy and when the new beds were delivered they were placed in the resident rooms mentioned above for storage. He further stated that the new beds were going to be moved into rooms when the old beds were removed. The Administrator had no response when the surveyor identified the rooms with two residents. On 6/14/22 at 11:28 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to room [ROOM NUMBER], who told the surveyor that the room was too small and it was too difficult to use the hoyer lift with two CNAs and two residents in the room at the same time. The facility indicated in their 2019 Plan of Correction the following the rooms are only to be occupied by one resident and no other residents would be admitted to the rooms. NJAC 8:39-31.1(d)