Based on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by failing to provide a resident with respect and dignity during wound care. This deficient practice was identified 1 of 16 residents reviewed (Resident #231). The deficient practice was evidenced by the following: On 1/27/25 at 11:12 AM, the surveyor observed Resident #213 in their room. The resident was observed with a gauze (gauze wrap is a sterile material used to wrap or cover wounds) wrapped around their right elbow. During the interview the resident stated they had a skin tear prior to coming into the facility. Resident #231 was agreeable to allow the surveyor to observe the wound care treatment. A review of Resident #231 medical record revealed that the resident had diagnosis that included but were not limited unspecified fall, anemia (a deficiency of healthy red blood cells in blood), and hypertension (high pressure in the arteries). A review of the admission MDS, (an assessment tool used to facilitate the management of care) with an assessment reference date of 1/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident is cognitively intact. A review of the January 2025 Physician Orders Sheet (POS) revealed an order for wound care. The PO was dated 1/23/25, Vashe 0.033% irrigation solution (1 application) solution irrigation topical. Cleanse right elbow wound with Vashe, pat dry, apply Medihoney, cover with a non-stick gauze pad and wrap with kling daily. On 1/28/25 at 11:51 AM, the surveyor observed the Registered Nurse (RN#1) perform wound care on Resident #231's right elbow. The surveyor then observed RN #1 write a date and her initials with a pen directly on the resident's surgical tape which had already been placed on the residents wound site (right elbow). Surveyor asked RN #1 if writing the date and her initials on the tape while on the resident provided the resident dignity and respect? RN #1 stated, she should have written the date and her initials on a separate piece of tape and then place that on the resident's covered wound site. On 1/29/25 at 9:50 AM, the Director of nursing (DON) provided the surveyor with a facility policy titled, Quality of Life - Dignity with a revised date of 1/24/24. Under the procedure section of the policy it states, 1. Resident shall be always treated with dignity and respect. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .11. Demeaning practices and standards of care that compromise dignity are prohibited. On 1/29/25 at 12:32 PM, the Licensed Nursing Home Administrator (LNHA) and DON met with the survey team to review concerns found during the survey. The DON stated RN #1 did not follow the correct procedure for initialing and dating for a resident's wound and would in-service the staff. No further comments provided. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39-4.1(a)(12)(28), 17.3(c), 17.4(d)

Repeat deficiency Based on observation, interview, and record review of other facility documentation, it was determined that the facility failed secure medications within the medication cart. This deficient practice was observed during wound care observation and was evidenced by the following: On 1/28/25 at 11:51 AM, the surveyor observed Registered Nurse (RN#1) provide wound care on Resident #213. RN#1 was observed gathering medication from the medication cart outside of Residents #213's room. Once RN#1 gathered all medications and supplies from the medication cart, the surveyor observed RN#1 close the drawer to the medication cart and walk away. Surveyor asked RN#1 if they had locked the medication cart. RN#1 went back to the medication cart and stated, I forgot to lock the cart. That was a mistake on my part On 1/29/25 at 9:50 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Storage of medications with a revised date on 5/1/2017. Under the procedure section of the policy it states, 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 1/29/25 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to review concerns found during the survey. The DON stated the medication carts should always be locked whenever the nurse is stepping away from the cart. No further comments provided. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39- 29.4(a) (d)(h), 29.7(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 2 of 15 residents reviewed (Resident #35 and #13). This deficient practice was evidenced by the following: 1. On 1/27/25 at 11:00 AM, the surveyor observed Resident #35 sitting in the wheelchair inside the recreation room, unable to answer the surveyor's inquiry. On 1/27/25 at 1:25 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #35, which revealed the following: A review of the Face Sheet (FS; an admission summary) reflected that Resident #35 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) dated 6/18/24 indicated that the facility assessed the residents' cognitive status, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating that the resident had severe impairment in cognition. A further review of the Q/MDS revealed that the resident received anti-anxiety and antidepressant medications on a routine basis. A review of the most recent Physician Order Sheet (POS) reflected a physician's order of the following medications: 1. Risperidone 0.5 mg. by mouth daily with an order date of 2/23/24 and discontinued on 3/16/24. 2. Xanax 0.25 mg. by mouth daily with an order date of 4/7/24 for anxiety. A review of the resident's individualized person-centered care plan (CP) with an effective date of 12/11/23 to 8/28/24 reflected under problems that I am at risk for complications related to the use of psychotropic medication. I am on Risperidone. The goal reflected that the resident would have no complications related to the use of Risperidone in the next 90 days. Further review of the CP does not reflect the discontinued use of Risperidone on 3/16/24 and the use of the anti-anxiety medication Xanax, with a start order of 4/7/24. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern but did not provide further information. 2. On 1/27/25 at 11:35 AM, the surveyor observed Resident #13 lying in bed, alert and awake. The surveyor observed that the resident had a cup of water on the table. Resident #13 stated they have dialysis every Tuesday, Thursday, and Saturday pick-up at 10:00 am. On 01/30/25 at 09:05 AM, the surveyor observed Resident #13 awake and had just finished breakfast. The surveyor observed that the resident had a 16-ounce cup of water on the table. The resident was aware that they were under a fluid restriction and added that they were noncompliant and disagreed with the restriction. On 1/29/25 at 1:18 PM, the surveyor reviewed the hybrid medical record of Resident #13, which revealed the following: A review of the FS reflected that Resident #13 was admitted with diagnoses that included but were not limited to chronic kidney disease (CKD-kidney stopped working), Stage 4 (severe), and dependence on dialysis (a treatment for the failing kidney). A review of the recent Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 14 out of 15, which indicated that the resident had intact cognition. A review of the most recent POS reflected a physician's order of fluid restrictions of 1200 ml (milliliters) in 24 hours with an order date of 12/14/24. A review of the resident's individualized person-centered CP with an effective date of 5/1/24 to present reflected under problems, Dialysis: I am on Dialysis on Tuesday, Thursday, and Saturday. Further review of the CP does not indicate that the residents are noncompliant with fluid restrictions. On 1/30/25 at 9:10 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding the above concern. The CNA stated that he knew the resident was on fluid restriction and would give the resident the allowed fluids. He added that the resident would ask for more water, and he felt bad about it. The CNA revealed that the resident had been on fluid restriction since entering the facility. On 1/30/25 at 10:31 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above concern. The DON stated that the resident has a history of non-compliance with the fluid restriction. A review of the facility policy titled Resident Care Plan with the revised date of October 2024 stated under Procedure: The resident care plan will reflect the resident's expressed wishes regarding care and treatment goals. The resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. When such refusal are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. 1. Resident care plan will be developed for all care planning issues including but not limited to: c. Resident's risk factors .d. Resident's needs . NJAC-8:39 11.1 NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to consistently monitor, document, and evaluate the ongoing benefits of continued use of psychoactive medications for 3 of 5 residents reviewed for unnecessary medications (Resident #3, #4, and #35). This deficient practice was evidenced by the following: 1. On 1/27/25 at 10:43 AM, the surveyor observed Resident #3 out of bed to the wheelchair inside the activity room, able to answer the surveyor's inquiry. On 1/29/25 at 11:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #3, which revealed the following: A review of the Face Sheet (an admission summary) reflected that Resident #3 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 12/20/24 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had an intact cognition. A further review of the A/MDS revealed that the resident received antipsychotic and antidepressant medications on a routine basis. A review of the most recent Physician Order Sheet (POS) with the start date of 12/13/24 reflected a physician order of the following: 1. Quetiapine 25 mg (milligram) give one tablet by mouth one time daily, and the order was discontinued on 1/17/24 and increase the dosage to Quetiapine 50 mg give one tablet by mouth one time daily for a mood disorder on 1/17/24 and 2. Sertraline 100 mg is given one tablet by mouth for depression. There was no further documentation to reflect that the resident was being monitored routinely with the use of psychotropic medications after the increase of dosage of Quetiapine 25 mg to 50 mg from December 13, 2024, to January 17, 2024. A review of the January 2025 Medication Administration Record (MAR) revealed that the nurses signed that Resident #3 was administered Quetiapine 50 mg by mouth for mood disorder at 8:00 PM and Sertraline 100 mg by mouth daily for depression at 9:00 PM. The January 2025 MAR did not reflect the target behavior and potential side effects of the psychotropic medication. A review of the recent Psychiatric Progress Note dated 1/21/25 revealed under assessment/plan to continue to monitor mood and behavior for changes. A review of the resident's individualized person-centered care plan (CP) with an effective date of 12/14/24 to present reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring for adverse reactions, and monitoring behavior every shift. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease behaviors and symptoms associated with depression of the resident. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern. The UM/RN revealed that the nurses documented the side effects only if the resident had a side effect but did not provide documentation of the targeted behavior monitoring. 2. On 1/27/25 at 10:01 AM, the surveyor observed Resident #4 sitting in the wheelchair inside the room, able to answer the surveyor's inquiry. On 1/27/25 at 11:29 AM, the surveyor reviewed the hybrid medical record of Resident #4, which revealed the following: A review of the FS reflected that Resident #4 was admitted with diagnoses that included but were not limited to sepsis (body response to infection) and diabetes mellitus (high sugar level). A review of the recent quarterly Minimum Data Set (Q/MDS) dated [DATE] indicated that the facility assessed the residents' cognitive status, with a BIMS score of 13 out of 15, indicating that the resident had intact cognition. A further review of the Q/MDS revealed that the resident received antidepressant medications on a routine basis. A review of the most recent POS with the start date of 7/25/24 reflected a physician's order of amitriptyline 50 mg to give one tablet by mouth daily for depression. A review of the January 2025 MAR revealed that the nurses signed that Resident #4 was administered amitriptyline 50 mg, one tablet by mouth daily for depression at 7:00 PM. The January 2025 MAR did not indicate the target behavior and potential side effects of the psychotropic medication. A review of the resident's individualized person-centered CP with an effective date of 7/18/24 to present reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring behavior every shift, and monitoring for adverse reactions, side effects, and changes in mental status. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease symptoms associated with depression of the resident. 3. On 1/27/25 at 11:00 AM, the surveyor observed Resident #35 sitting in the wheelchair inside the recreation room, unable to answer the surveyor's inquiry. On 1/27/25 at 1:25 PM, the surveyor reviewed the hybrid medical record of Resident #35, which revealed the following: A review of the FS reflected that Resident #35 was admitted with diagnoses that included but were not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the recent Q/MDS dated [DATE] indicated that the facility assessed the residents' cognitive status, with a BIMS score of 5 out of 15, indicating that the resident had severe impairment in cognition. A further review of the Q/MDS revealed that the resident received anti-anxiety and antidepressant medications on a routine basis. A review of the most recent POS reflected a physician's order of the following medications: 1. Risperidone 0.5 mg. by mouth daily with an order date of 2/23/24. 2. Xanax 0.25 mg. by mouth daily with an order date of 4/7/24. 3. Sertraline 75 mg. by mouth daily with an order date of 12/18/24. 4. Mirtazapine 15 mg by mouth daily with an order date of 1/20/25 5. Ativan 0.25 mg by mouth daily as needed with an order date of 1/21/25 The April 2024 MAR revealed that the nurses signed the above medications for Resident #35. There was no further documentation to reflect that the resident was being monitored and evaluated routinely with the use of the above psychotropic medications between the period of February 2024 and January 2025. A review of the resident's individualized person-centered CP with an effective date of 12/11/23 to 8/28/24 reflected under problems that the resident is at risk for complications related to the psychoactive medication used. The goal reflected that the resident would have no complications for 90 days. The interventions included administering the medications as ordered by the physician, monitoring behavior every shift, and monitoring for adverse reactions, side effects, and changes in mental status. The CP did not reflect specific target behaviors for the use of psychotropic medication and non-pharmacological interventions to decrease symptoms associated with the resident's behavior. A review of the Behavior/Psychotropic medication changes provided by the DON does not reflect a consistent monitoring of target behavior, potential side effects and evaluate the ongoing benefits of continued use of psychoactive medications. On 1/29/25 at 11:30 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the above concern. The UM/RN revealed that the nurses documented the side effects only if the resident had a side effect but did not provide further information regarding the targeted behavior monitoring. On 1/29/25 at 12:47 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding the above concern. The DON stated that the nurses documented if there was a side effect noted to the resident with the use of psychotropic medications, and if there was no side effect, there was no documentation. The LNHA and DON did not provide further information. A review of the facility policy with the revised date 5/11/23 titled Behavioral Symptoms, under the Procedure: 11: f. iv Monitoring is necessary as long as the drug is being used to identify side effects and to identify opportunities to reduce the drug dosage or discontinue the use of the drug. NJAC 8:39-29.3(a); 29.8; 33.2(a)

Repeat deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/27/25 at 9:55 AM, while on the 4th floor in the kitchenette the surveyor observed the following: in refrigerator #1 had an individual cheesecake without a cover and missing a use by date, an open jar of molasses without an open/use by label, and in freezer #2 a paper cup with a brown frozen substance not dated and without a use by label. On 1/27/25 at 10:15 AM, while on the 2nd floor in the kitchenette the surveyor observed the following in refrigerator #1: a zip lock bag of sliced pickles and red cup with oatmeal-like substance both missing labels and use by dates. On 1/27/25 at 10:20 AM, the surveyor interviewed the Unit Manager (UM), who stated all items in the refrigerator and freezers should be covered as well as have a label with an open and use by date. The UM further stated the kitchenette areas are checked by the nurses and certified nursing assistants, but unable to explain why those items had not been labeled. On 1/29/25 at 12:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Food Storage with reviewed date of 10/2024. Under the policy section it states, All leftovers are labeled, dated, and used within three days and then discarded. If there is any question about a product's storage or expiration, discard the product. On 1/29/25 at 12:32 PM, the survey team met with the LNHA and Director of Nursing (DON) to review concerns. The DON stated all the refrigerator and freezers in the three kitchenettes have been checked and any foods that did not have a label have been discarded. On 1/30/25 at 2:00 PM, the survey team met with the LNHA and DON for the exit conference. The facility did not provide any further pertinent information. NJAC 8:39-17.2(g)

Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure a medication was administered to the manufacturer's cautionary specifications and in accordance with professional standards of clinical practice. The deficient practice was identified for one (1) of three (3) nurses administering medications to one (1) of four (4) residents during the medication administration observation and was evidence by the following. A review of the manufacturer's specifications for Lopressor (Metoprolol Tartrate) under section 2.1 titled Hypertension. Individualize the dosage of Lopressor tablets. Lopressor tablets should be taken with or immediately following meals. On 11/02/23 at 8:31 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #35. The RN prepared seven medications which included Metoprolol 25 milligram (mg; medication to reduce high blood pressure). At 8:42 AM, the surveyor observed the resident sleeping and the breakfast tray was not in the room. At 8:56 AM, the RN confirmed with the surveyor that she was ready to administer the medications to Resident #35, proceeded into the resident's room and attempted to awaken the resident. The surveyor requested to speak with the RN outside the room. At 9:01 AM, the surveyor and the RN reviewed the resident's bingo card (a multidose card containing individually packaged medications) for Metoprolol tartrate 25 mg. The bingo card had an affixed cautionary label that indicated Take with Meal. At that time, the surveyor and the RN reviewed the electronic Medication Record (eMAR) together. The eMAR included the order for Metoprolol which did not reveal a cautionary to administer the medication with a meal. At that time the RN stated she should not have attempted to administer the medication without the resident having a meal. The RN stated that the medication could be better absorbed with a meal or decrease nausea when taken with a meal. The RN stated that she missed the cautionary on the bingo card. At that time, the RN asked the RN/Charge Nurse (CN) for Resident #35's breakfast tray. At that time, in the presence of the surveyor and the RN, the RN/CN confirmed that Resident #35's breakfast tray was not in the room, the hallway, or the dining room, but would speak with the other staff about it. At 10:22 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager stated the cautionary on the bingo card should have been followed. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the concern regarding the nurse not following the proper administration of Metoprolol by following the cautionary affixed to the resident's bingo card. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON acknowledged the cautionary for the Metoprolol should have been read and followed. The DON informed the survey team that the cautionary would be added to the Medication Administration Record to help the nurses with proper administration of medication. A review of the facility provided policy Medication Administration and General Guideline dated 11/21/22 included the following: Policy; Medications are administered as prescribed in accordance with State Regulations, using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in [drug reference] otherwise authorized personnel should refer to Drug Reference material provided by facility. NJAC 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a) ensure a root cause analysis conclusion was included in a resident's fall investigation/incident report and b) implement and document in the resident's care plan a new intervention after a resident's fall in order to prevent any additional falls for one (1) of two (2) residents reviewed for falls (Resident #35). This deficient practice was evidenced by the following: On 10/31/23 at 11:54 AM, the surveyor observed Resident #35 seated in a wheelchair at the end of the hall looking out the window. The surveyor reviewed Resident #2's medical record. The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; hemiplegia (paralysis of one side of the body) following cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain) affecting right dominant side, unsteadiness on feet, difficulty in walking and muscle weakness. Resident #35's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/13/23, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which reflected that the resident's cognition was moderately impaired. Further review indicated the resident had a reentry into the facility from an acute hospital and that the resident had a fall with a major injury. A review of the New Jersey Universal Transfer Form dated 6/30/23 indicated that Resident #35 was transferred to the hospital and the reason for transfer was fell and injured his/her left wrist. A review of the facility provided Full Occurrence Report, an investigation/incident report, dated 6/30/23, revealed under the notes section that Resident #35 was found on the floor and that the resident had fallen. The resident had left wrist pain and was sent to the hospital. Under the Conclusion Statement section was N/A (not applicable). Under the Recommendations section was None Noted. The investigation/incident report did not contain a root cause analysis conclusion or recommendations/interventions to prevent any additional falls. The Fall Risk assessment dated [DATE], indicated Resident #35 was high risk for falls. A review of Resident #35's individualized comprehensive care plan (CP) reflected a problem, with a created date of 12/21/2022, of at risk for falls which included actual falls dated 01/05/23, 02/23/22 and 4/04/23. The 6/30/23 fall was not listed. The interventions listed included additional interventions that were added after each of the falls on 01/05/23, 02/23/22 and 4/04/23. There was no additional intervention added after the 6/30/23 fall or any documented evidence that the interventions already in place were reviewed in order to prevent any additional falls. On 11/02/23 at 10:53 AM, the surveyor interviewed Resident #35's assigned Certified Nursing Assistant who stated that the resident was a fall risk and had a bed that was low to the ground. On 11/02/23 at 11:16 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN) of the third floor unit regarding the process after a resident had a fall. The RN/CN stated that the resident would be assessed, the family and physician would be notified and the resident would be sent to the hospital if warranted. She then stated that the fall would be reported and that a risk watch (incident report) assessment and a fall risk assessment would be done. The RN/CN stated that the unit manager would do an investigation which included a conclusion and that an intervention would be put in place if one was needed. On that same date and time, the surveyor asked the RN/CN if Resident #35 had a fall. The RN/CN stated that the resident fell and broke their wrist on 6/30/23 and that he/she was evaluated at the hospital but was not admitted . The surveyor then asked who would update the CP and if the expectation was to have an added intervention after a fall. The RN/CN stated that the CP was done by the unit manager and that she would expect an intervention. The RN/CP then stated that Resident #35 received physical therapy after the fall to improve transfers, frequently was reminded to ask for help, frequently checked, non slip socks or shoes worn and bed in the lowest position. She added that the resident got confused and tended to transfer self. On 11/02/23 at 11:26 AM, the surveyor interviewed the RN/Unit Manager (RN/UM) of the third floor unit regarding the process for CP and falls. The RN/UM stated that every three (3) months the CP was updated and if there were changes or an incident like fall. She added that if there was a fall then an intervention should be added near the date of fall. The RN/UM stated that at morning meeting the interdisciplinary team discussed the fall and interventions. She stated that the fall would be investigated, concluded and an intervention added. At that same time, the surveyor asked the RN/UM to view Resident #35's CP and to confirm that the 6/30/23 fall was not listed and that an additional intervention was not added. The RN/UM confirmed the CP was not updated and stated that during that time she was working the 3-11 shift and that there was a different UM. She stated that whoever was in charge at that time should have had the fall listed and then added an intervention. The surveyor asked what the importance of adding the fall and an additional intervention was. The RN/UM stated that the importance was so everyone would be alert to prevent the resident from falling again. The RN/UM stated that she knew the resident was very impulsive but that they could try to stop the resident from falling again. Furthermore, the surveyor then showed the RN/UM the investigation/incident report that had no conclusion or recommendations. The RN/UM stated that there should have been a conclusion. On 11/02/23 at 01:14 PM, in the presence of the survey team, the surveyor asked the Director of Nursing (DON) if the investigation/incident report provided was the full and complete investigation. The DON stated that it was the full investigation minus the neuro checks which would be in the computer. The surveyor asked where the conclusion and statements would be. The DON stated that the nurse would write it in the report. On 11/03/23 at 10:28 AM, the surveyor interviewed the DON regarding the process of the CP and falls. The DON stated that when a resident had a fall then the CP should be updated with an intervention that pertained to the fall. She added that hopefully the CP would be updated by the next morning but that sometimes the investigation may take longer. The DON stated that the conclusion should be done within 72 hours. The surveyor then showed the DON Resident #35's CP and investigation/incident report for the 6/30/23 fall. The DON confirmed that there was no conclusion listed on the investigation/incident report and that there was no update to the CP after the 6/30/23 fall. The DON stated that there should have been a conclusion and an added intervention to the CP unless all possible interventions were already in place and if that was the case then that should have been documented. On 11/03/23 at 11:30 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Nurse Consultant #1 (RNC #1), Clinical Implementation Analyst (CIA) and Executive Director (ED) the concern that Resident #35's 6/30/23 fall investigation/incident report did not contain a root cause analysis conclusion and the CP was not updated to include an added intervention to prevent another fall. On 11/08/23 at 11:25 AM, in the presence of the survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON confirmed that the Resident #35's investigation/incident report for the 6/30/23 fall did not have a conclusion and that the CP was not updated. She added that she did not have an explanation for why it had not had a conclusion or why the CP was not updated. The DON confirmed that there should have been a conclusion and the CP should have been updated. A review of the facility provided policy titled, Incident Reporting, with a revised date of 02/01/2021, included the following: Policy: It is the policy of the community that all incidents are properly reported, recorded and analyzed for causative factors and trends. Corrective and/or preventative measures shall be implemented as indicated .3. Analyze all incidents for risk potential implementing corrective and/or preventative actions as required . Incident Report Investigation Forms: 1. An investigation shall be initiated on all reported incidents. An Incident Investigations Report form shall be completed at the time of the incident. 2. Document in the Comments/Conclusion section if facts relating to the cause of the incident are actually known. Possible causes may be investigated but not documented until substantiated by facts . Quality Monitoring and Management: 1. The Executive Director/Administrator, Director of Nurses/AL Nurse Manager will review all Incident Reports which have occurred in the community/facility, on a monthly basis. 2. A determination will be made as to what corrective and/or preventative measures, if any, will be implemented by the facility staff. 3. Documentation of such determination will be submitted to the Quality Improvement Committee . Risk Watch Reporting Process: . 3. Administrator/DON or designee begins the Review stage a. Reviews Full Report . c. Review for appropriate recommendations, add or modify as needed, and record whether they have been implemented . 4. Unit Manager/Supervisor, DON, or designee generates Daily Safety Review or Occurrence Log in RiskWatch (Analysis menu) for discussion of recent occurrences at daily stand up meeting (Ongoing) a. Communicate relevant information to affected staff b. Update care plans as necessary . 7. Risk Watch Incident Reports along with Medical Charts will be reviewed by the Administrator/DON or designee at the end of each month. a. All data entry will be reviewed i.e. recommendations, interventions, etc. for effectiveness and final outcomes. A review of the facility provided policy titled, Falls Management Program, with a revised date of 12/22/2022, included the following: 11. Post fall a. The interdisciplinary team, at the daily report or Falls Committee, will review the post-fall assessment, incident report, any employee/elder statements, post-fall investigation, post-fall summary, and current interventions to evaluate if they were appropriately implemented, still relevant, and effective. The ECP (elder care plan) will be modified accordingly. All changes to the ECO will be communicated to the direct caregivers . 12. All falls are investigated and trended for possible causative factors utilizing the Risk Watch Analysis and reported to the community Quality Improvement Committee along with appropriate action plans. A review of the facility provided policy titled, Resident care Plan (RCP), with a revised date of 6/29/2023, included the following: Policy: It is the policy .to ensure that the care planning process is systematic, comprehensive, interdisciplinary and timely and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional status. Procedure: . 9. The effectiveness of the RCP must be regularly evaluated based on progress towards goals. The RCP will be modified as necessary based on the evaluation process . 11. The RCP will be updated at the Resident Care Conference and as necessary to address the resident's needs. N.J.A.C. 8:39-27.1 (a)

NJ00168293 Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility staff failed to: a) properly assess bed rails (side rail/enabler) safety to prevent harm to a cognitively impaired resident by not screening the resident properly during admission, ensuring correct installation, usage, and maintenance, b) obtain a physician order, c) educate and obtain consents from the resident/responsible party regarding risk/benefit of using bed rails, and evaluating alternatives before using bed rails prior to installation, d) monitor, inspect, and supervise the usage of bed rails, and e) follow facility policy and procedures. This deficient practice was identified for one (1) of one (1) resident reviewed for bed rails and was evidenced by the following: A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 10/09/23 at 11:48 AM, with an event date of 10/05/23 [unidentified time of event]. The event description included the following: On 10/05/23, the Power of Attorney (POA) spoke with Resident #251 who was told that he/she was hit by a male nurse. The POA did not report to any staff as she did not believe that this had occurred. The POA mentioned to the Director of Nursing (DON) on 10/08/23 regarding Resident #251's statement regarding the young male. The male Certified Nursing Assistant (CNA) on that resident's assignment was immediately removed from the schedule as a precaution but this description fits several staff members. The surveyor reviewed the closed medical records for Resident #251. A review of Resident # 251's admission record reflected the resident was admitted to the facility with a diagnosis that included unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), without behavior/psychosis/mood/anxiety, chronic kidney disease, malignant neoplasm (cancer that can grow or spread) of the prostate, muscle weakness and difficulty walking. According to the admission Minimum Data Set, an assessment tool used to facilitate management of care dated, 9/21/23, Resident #251 was documented as having a Brief Interview for Mental Status score of 99 out of 15, indicating that the resident was unable to complete the interview. The MDS also revealed that Resident #2 required extensive assistance for Activities of Daily Living (ADLs). A review of the Side Rail Screen dated 9/14/23, under the question, Does the facility use side rail? The documented response was No. Under, Comments/Recommendations/Additional Interventions: was blank, signed by Registered Nurse#1 (RN#1). A review of the Side Rail Screen dated 9/20/23, under the question, Does the facility use side rail? The documented response was No. Under, Comments/Recommendations/Additional Interventions: Patient uses enablers while in bed for repositioning, signed by RN #2. The Physician Order Sheet for October 2023 did not reflect an order for bed rails (side rails/enabler). A review of the medical record did not reflect an education and a signed informed consent was obtained regarding the benefits and potential hazards of bed rail usage from the resident/resident representative prior to installation of the bed rails. No additional document was provided. Further review of Resident #251's closed record did not reflect a copy of the maintenance department's inspection of the bed rail. No additional information was provided. The Care Plan reflected interventions dated 10/06/23, included, continue two persons assistance during care, and pad upper side rails with pillows for extra protection. An undated intervention was the use of an enabler for bed repositioning. A review of the facility provided Full Occurrence Report dated 10/08/23 at 12:10 AM, reported by RN #3 documented that Resident #251 had bruises on the left eyebrow that spread to upper and lower eyelids, bruises on the left hip was observed while the resident was being toileted. The resident was unable to explain how it happened. The DON documented on 10/23/23 at 01:07 PM the following: A lengthy conversation with the POA occurred about the resident's skin being frail and easily bruised. In a discussion of the risk versus benefit of side rails [bed rails], the resident used them to position self and the tendency of the resident top pull their body into them that caused bruising. The POA wished to continue the use of side rails and agreed to monitor the resident. The facility did not have padded side rails in stock, and they were ordered. The side rails were padded with pillows in the interim. The resident was observed removing the pillows and any other padding interventions tried. On 10/08/23, the resident sustained more bruising to the hip and eyebrow area from his restless behaviors and attempting to get up unattended. The resident was sent out [to the hospital] and admitted with Urinary Tract Infection. On 11/02/23 at 01:18 PM, during an interview with the surveyor, the DON stated that she had spoken with the POA and discussed the bruising from the side rails and documented the conversation regarding the resident who laid close to the bed rails, the interventions of ordering a Velcro side rail, change the bed to a raised perimeter mattress. The bed frame was rubbing on his hip area and thought the extra cushion would help. On 11/02/23 at 01:20 PM, during an interview with the surveyor, the Registered Nurse/ Unit Manager (RN/UM) stated she somewhat recalled the resident, but some time had passed. She recalled the resident was care planned to have two person assists during care. The two-person assist in the morning would either be two CNAs or a CNA with a Licensed Practical Nurse (LPN) or an RN, and the night shift would be a CNA and an LPN or an RN. The RN/UM further stated that this was our process to prevent abuse in our facility in the case of a resident who had behaviors of hitting staff. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the concern regarding the improper assessment of Resident#251's side rails/enabler prior to installation, the concerns regarding the failure to obtain a physician order, obtain a signed informed consent from the resident or resident's representative prior to installation, proof of inspection from the maintenance department, rehabilitation department as part of the interdisciplinary team, failure to follow facility policy and procedure. At that time, the DON informed the surveyors that the bed rails were coded as enablers which caused the cascade of bed rails screens to not be performed. The DON also stated that the bed rails coded as enablers were discovered in September 2023 and a Quality Assurance and Performance for Improvement (QAPI; a data-driven and proactive approach to quality improvement that included QA and Performance Improvement to ensure services are meeting quality standards and assuring care reached a certain level) was also initiated. The incident for Resident #251 occurred on 10/05/23. On 11/8/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON acknowledged that on 9/15/23 and 9/20/23 an assessment was completed however was documented as an enabler which blocked the remainder of the assessment. At that time, the DON stated that she re-audited the entire building after the surveyor's inquiry for bed rails marked as enablers. On 11/08/23 at 12:43 PM, during an interview with the surveyor, the Physical Therapist (PT)/Rehabilitation Director (RD) stated that she did not receive any referral from nursing to evaluate the resident's ability to use or remove the side rail or what padding should be used. The PT/RD also stated that the resident was cognitively confused and was not capable to unlock or move the bed rail up or down. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the DON stated that they stood behind their conclusion on the reportable from 10/06/23, that the bruises were related to the use of the side rail. I have witnessed the resident use the side rail, the resident was intermittently cognitively and physically more functional. A review of the facility provided; Side Rail/Enabler Information/Instruction, undated, reflected the following: 1. Complete a Side Rail assessment on admission, quarterly or any time a rail will be used for the first time on a resident. All rails whether it is an enabler, or a side rail follows the same rule and same regulation. 2. Physician Order for the use of side rails/enabler. You must indicate which type is used and which sides . 4. All rails/enabler usage needs consent .If the resident has a BIMS less than 12, you must get consent from family representative. You must explain risk versus benefit of side rail use. This includes risk of injury, risk of entrapment, risk of bruising. A review of the facility policy Side Rails and Bed Safety, revised on 6/2023 included the following: Policy [facility name redacted] shall strive to provide a safe environment for residents while they are in bed. 1. The residence sleeping environment shall be assessed by the interdisciplinary team considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and that environment. 2. To prevent death injuries from the bed and related equipment including the frame, mattress, side rails, headboard footboard and bed accessories the community shall promote the following approaches: a. Inspection by maintenance staff of all bed related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment. d. Ensure that side rails are properly installed using manufacturers instructions and other pertinent safety guidance to ensure proper fit . e. Identify identify additional measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness .) 3. The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee or appropriate action . 4 Maintenance and monitoring of the bed, mattress, and accessories should be ongoing . 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to use . 8. Side Rails may be used if assessment and consultation with the attending physician have determined that they are needed to help manage a medical symptom or condition or help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for one (1) of two (2) residents reviewed for hospice care, (Resident #17). This deficient practice was evidenced by the following: On 10/30/23 at 11:30 AM, during the tour, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that Resident #17 was cognitively impaired and on hospice care. On 10/30/23 at 11:51 AM, the surveyor observed Resident #17 in bed asleep. The surveyor reviewed Resident #17's medical records. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had diagnoses that were not limited to essential hypertension (elevated blood pressure), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), presence of cardiac pacemaker (Pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heartbeat), unspecified OA (osteoarthritis; A disease that causes inflammation and pain in the joints), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the resident's significant change Minimum Data Set (scMDS), an assessment tool used to facilitate the management of care with an assessment reference date (ARD) of 9/23/23, Section C Cognitive Patterns revealed a cognitive skills for daily decision making was coded as three (3) which reflected that the resident's cognitive status was severely impaired. The scMDS also showed that the resident was in hospice. The personalized care plan revealed that the resident was admitted to hospice services on 3/19/22. On 11/02/23 at 11:29 AM, the surveyor interviewed LPN#1 in the presence of LPN#2. LPN#1 informed the surveyor that the hospice aide comes to the facility every Monday, Wednesday, and Friday. LPN#1 stated that the hospice nurse comes in at least once a week. On that same date and time, LPN#1 showed the binder for hospice. Both nurses and the surveyor observed that the last hospice notes were dated 9/13/23 and there were no further notes after that. LPN#2 double-checked the physical chart and stated that she did not see other hospice notes. LPN#2 further stated that she knew that the hospice nurse comes once a week and writes notes on the paper [which will be left as a facility copy in the physical chart of the resident] and also on the hospice nurse's tablet (is a fully functional personal computer geared for pen-enabled, handwriting-enabled, and speech-enabled applications). Then LPN#2 informed the surveyor that the hospice nurse was currently in the building and would have the hospice nurse talk to the surveyor about her notes. At this time, the surveyor asked LPN#2 if she had access to the hospice nurse's notes on the hospice nurse's tablet, and LPN#2 responded No. The surveyor then asked LPN#1 and LPN#2 if the hospice nurse's visit notes considered the resident's part of medical records and should be available and accessible to the facility, LPN#2 stated I can't answer that. Further review of the hospice binder revealed there were no hospice nurse visit notes after 9/13/23 through 11/02/23. On 11/02/23 at 11:36 AM, the surveyor interviewed the Hospice Registered Nurse (HRN) in the 4th floor nursing station. The HRN informed the surveyor that she was the assigned nurse for the resident and visits once a week and that she had other residents in the facility other than the resident. The HRN stated that she documents on her tablet and in the paper carbonized (duplicate paper) visit notes [the one left in the facility]. The HRN further stated that the paper visit notes that were left at the facility were the facility requirement and the one she documented in her tablet was the hospice requirement that she had to comply with. At that same time, the surveyor notified the HRN of the above findings and concerns regarding the missing hospice visit notes in the hospice binder. The HRN stated that she did not know why her remaining September and October notes were not in the chart because she did leave them with the facility nurse. On 11/03/23 at 11:17 AM, the survey team met with the Licensed Nursing Home (LNHA), Director of Nursing (DON), Regional Nurse Consultant #1 (RNC#1), Clinical Implementation Analyst (CIA), and Executive Director (ED). The surveyor notified the facility management of the above findings and concerns regarding the missing hospice visit notes. On 11/08/23 at 9:46 AM, the surveyor reviewed the medical records [chart] of the resident and observed the missing hospice visit notes that were printed on 11/06/23 at 10:28:17 (10:28 AM) for notes 10/26/23, 10/19/23, 10/12/23, 10/05/23, 9/29/23, 9/21/23. On 11/08/23 at 9:51 AM, the surveyor interviewed the DON in the 4th-floor nursing station regarding the resident's hospice notes. The DON informed the surveyor that all residents in the hospice were audited after the surveyor's inquiry about Resident # 17's missing hospice visit notes from the hospice nurse. The DON stated that there were missing hospice visit notes and found out that there were a few hospice residents who did not have or had missing hospice notes. She further stated that it was Resident #17 who had the most missing hospice visit notes. On that same date and time, the DON informed the surveyor that the HRN provided a copy of the missing notes after the surveyor's inquiry. The DON stated that either she or the HRN did not know where the hospice notes that were left at the facility were and it was not found [facility copies]. The DON acknowledged that the hospice notes should have been in the medical records of the resident. On 11/08/23 at 10:49 AM, the survey team met with the LNHA, DON, RNC#1 and RNC#2, CIA, [NAME] President of Clinical Services (VPoCS), and ED (came in after at 11:15 AM). The DON informed the surveyor that the facility acknowledged the findings of the surveyor about missing hospice notes in the medical records of the resident. A review of the facility provided Hospice Coordination of Care Policy with a revised date of 10/30/23 included that the facility and hospice will identify the specific services that will be provided by each entity, and this information will be communicated in the plan of care. The hospice and facility will communicate with each other when any changes are indicated or made to the plan of care. On 11/08/23 at 02:33 PM, the survey team met for an Exit conference with LNHA, RNC#1 and #2, VPoCS, CIA, and ED. The facility management had no additional information about the concern above. NJAC 8:39-35.2 (d)(5)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that Certified Nursing Assistants (CNAs) received 12 hours of mandatory annual in-service training/education that included specific topics for one (1) of five (5) CNA files reviewed (CNA #1). The deficient practice was evidenced by the following: The surveyor reviewed the in-service education hours for five randomly selected CNA files, which were provided by the facility which included the following: The facility provided Training Hours transcripts (record of inservices that were done through a computer education program) for four (4) of the five (5) requested CNAs. The facility could not provide any documented evidence that CNA #1, with a date of hire of 8/09/10 received any in-service training from 8/09/22 to 8/09/23. On 11/02/23 at 01:54 PM, during surveyor interview, the Licensed Nursing Home Administrator (LNHA) stated that CNA #1's last day of work at the facility was in July 2023 and that he did not come back yet because he was asked not to return to work until he finished his mandatory education. On 11/03/23 at 9:57 AM, the surveyor interviewed the Director of Nursing (DON) regarding education. The DON stated that the facility did not have an educator right now that oversaw the process and that the facility was working on a better process for education. She stated that it was a collaborative process right now and that the Director of Human Resources was overseeing the computer system that contained education and the Infection Preventionist was overseeing nonclinical education. She added that she was also working on some of the education. On 11/03/23 at 11:32 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, Regional Nurse Consultant #1 (RNC #1), Clinical Implementation Analyst (CIA) and Executive Director (ED) the concern that CNA #1 did not have the annual mandatory 12 hours of inservice/education. On 11/08/23 at 10:59 AM, in the presence of the survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON stated that CNA #1 did not have any education for the time frame requested and that CNA #1 worked per diem (as needed) for the facility and worked less than 180 hours. She added that he was not allowed to work until his education was completed. On that same date and time, the surveyor asked what the expectation was for when the education was to be done. The RNC #1 stated that the education could be by the end of year. He added that the expectation was as long as the education was complete before the compliance date. The RNC #1 stated that ideally the education would be staggered [throughout the year] but that per diem staff may not be able to come in for the education. The surveyor then asked the facility to provide CNA #1's Training Hours transcripts for the previous year, the timeframe of 8/09/21 to 8/09/22. On 11/08/23 at 01:18 PM, in the presence of the survey team, LNHA and RNC #2, the DON stated that she could not locate any in-service training/education for the timeframe of 8/09/21 to 8/09/22 for CNA #1. On 11/08/23 at 01:53 PM, in the presence of the survey team, the facility administration team confirmed that they could not provide any documented evidence that CNA #1 had any in-service training for either timeframe of 8/09/21 to 8/09/22 or 8/09/22 to 8/09/23. On 11/08/23 at 02:20 PM, in the presence of the survey team, the DON stated that she had found in a file a test that CNA #1 had completed which was dated 11/16/21 which was for a poster education fair. The surveyor asked the DON to provide the employee sign in sheet that would correspond to the inservice/education which would include the length of time the education took. There was no documented evidence of how long the poster education fair or the poster sign test would have taken. On 11/08/23 02:33 PM, in presence of survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON confirmed that the facility could not provide documented evidence of how many hours the poster fair and test took to complete. The facility could not provide documented evidence that CNA #1 had the annual mandatory 12 hour inservice/education from 8/09/21 to 8/09/22 or from 8/09/22 to 8/09/23. A review of the facility provided policy titled, In Service Training, with a revised date of 6/20/23, included the following: Policy: It is the policy of this community to conduct in-service training programs for all personnel on a regularly scheduled basis. Procedure: 1. In-service training programs are planned and conducted for the development and improvement of skills of all personnel. It may include, but is not limited to: . The policy did not address mandatory annual education for CNAs. N.J.A.C. 8:39-43.17 (b)

Based on interviews, record review, and review of the facility provided documents, it was determined that the facility failed to a) identify irregularity for a total of twelve months and b) act upon the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications (Resident #17). This deficient practice was evidenced by the following: On 10/30/23 at 11:51 AM, the surveyor observed Resident #17 in bed asleep. The surveyor reviewed Resident #17's medical records. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had diagnoses that were not limited to essential hypertension (elevated blood pressure), unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), presence of cardiac pacemaker (pacemakers are electronic devices that stimulate the heart with electrical impulses to maintain or restore a normal heartbeat), unspecified OA (osteoarthritis; a disease that causes inflammation and pain in the joints), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of the resident's significant change Minimum Data Set (scMDS), an assessment tool used to facilitate the management of care with an assessment reference date (ARD) of 9/23/23, Section C Cognitive Patterns revealed a cognitive skills for daily decision making was coded as three (3) which reflected that the resident's cognitive status was severely impaired. The Order Status (OS) active orders as of 6/23/22 showed that the resident had an order of Morphine (a non-synthetic narcotic with a high potential for abuse and is derived from opium) concentrate 100 mg/5 ml (20 mg/ml; milligrams/milliliters) oral sol (0.25 ml=5 mg) oral for pain as needed (PRN) every three (3) hours (hrs) for pain. The OS also included an active order for Tylenol 325 mg tablet (tab), (2 tabs=650 mg) every 8 hrs PRN for mild pain and Tramadol (belongs to a class of drugs known as opioid analgesics) 50 mg one tab every 8 hrs PRN for moderate pain. The above order for PRN Morphine was transcribed to the electronic Medication Administration Record (eMARS) from June 2022 through November 2023. A review of the Consultant Pharmacist-Medication Regimen Review (or MRR) permanent record from 6/15/22 through 10/18/23 [in the paper chart] showed that there were no recommendations identified regarding the order for PRN Morphine for pain. On 11/02/23 at 11:29 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) and LPN #2. The surveyor asked the nurses who were responsible for consultant pharmacist reviews, and LPN #1 stated that it was the nurse. LPN #1 further stated that the nurse notified the physician of the CP's recommendations. On that same date and time, LPN #1 informed the surveyor that for residents with multiple PRN pain medications, the PRN medications should be sequenced to mild, moderate, and severe pain. On 11/02/23 at 01:36 PM, the surveyor asked the Director of Nursing (DON) for a copy of the facility's policy regarding MRR in the presence of another surveyor. On 11/03/23 at 9:57 AM, the surveyor interviewed the Consultant Pharmacist/Owner (CP/O) via phone conference in the presence of the survey team. The CP/O informed the surveyor that he and the other CP were both responsible for residents' monthly MRR. The CP/O stated that the monthly MRR was submitted via email to the DON, Licensed Nursing Home Administrator (LNHA), and other designated people in the facility [usually the Unit Manager]. He further stated that the reports were being submitted within 24 hours. On that same date and time, the CP/O informed the surveyor that part of his responsibility was to check residents with multiple PRN pain medications, to make sure that they were properly sequenced. The surveyor then notified the CP/O of the above findings and concerns regarding the PRN Morphine order that was ordered on 6/23/22 for pain and was not sequenced for mild, moderate, and severe pain. The CP/O acknowledged that it should have been identified as an irregularity for not being sequenced for PRN pain medication. He further stated that he will get back to the surveyor and that he will double check the order himself because the resident was in hospice. On 11/03/23 at 11:17 AM, the survey team met with the LNHA, DON, Regional Nurse Consultant #1 (RNC#1), Clinical Implementation Analyst (CIA), and Executive Director (ED). The surveyor notified the facility management of the above findings and concerns regarding PRN Morphine. On 11/03/23 at 12:11 PM, the CP/O called back in the presence of the survey team. The CP/O informed the surveyor that after checking his notes and records, he found out that on 6/25/23 there was a CP's recommendation to sequence the PRN pain medications, and it looks like that it was not addressed. At that same time, the surveyor asked the CP/O why the CP recommended it on 6/25/23 to sequence the PRN pain medications when the order for PRN Morphine was since 6/23/22. The CP/O responded, We address what we see in our review. Furthermore, the surveyor asked the CP/O why the 6/25/23 recommendation to sequence the PRN pain medications was not included in the medical records that the surveyor reviewed, and the CP/O had no response. Then, the CP/O stated that he would send the 6/25/23 CP MRR to the surveyor to show the CP's recommendation. On 11/03/23 at 12:27 PM, the CP/O sent via email the copy of the Consultant Pharmacist Medication Regimen Review for recommendations created between 6/01/23 and 6/26/23 includes routing for nursing dated 6/25/23 which included Multiple PRN medications are noted for the same or overlapping indications. Please sequence the following medication: Tylenol and Morphine. The 6/25/23 recommendations follow-through and the nurse's signature were both blank, which indicated that the recommendations were not acted upon. On 11/08/23 at 9:51 AM, the surveyor interviewed the DON in the 4th-floor nursing station. The surveyor showed the DON the Consultant Pharmacist-Medication Regimen Review in the resident's chart for the date 6/25/23 14 day PRN-. The surveyor also notified the DON of the provided copy of the CP/O for the date 6/25/23 wherein there was a recommendation for nursing regarding PRN sequencing of medications Tylenol and Morphine. The DON stated that the 14 day PRN did not specify for what medication and that usually it was for psychoactive PRN medications not for PRN pain medications. At that same time, the DON stated that the CP should have documented the recommendations of PRN sequencing of pain medications in the sheet that was reviewed by the surveyor in the resident's medical chart for the nurse to be able to determine what to follow up with the physician. The DON further stated that she will check the records in her office to verify if the facility received the 6/25/23 recommendations of the CP that were provided to the surveyor by the CP/O via email, and will get back to the surveyor. On 11/08/23 at 10:49 AM, the survey team met with the LNHA, DON, RNC#1, CIA, [NAME] President of Clinical Services (VPoCS), RNC#2, and ED [came at 11:15 AM]. The DON stated that it was an expectation that the CP would document in the chart where the sheet of MRR monthly recommendations located the CP's recommendations. The DON acknowledged that the 6/25/23 visit and recommendations of the CP did not include the PRN Morphine sequencing for pain medication. On that same date and time, the surveyor asked the facility management why the provided copy of the facility and the CP/O for 6/25/23 recommendations that were not in the chart of the resident at the time of review were not acted upon. The DON stated, I do not have a good answer. A review of the facility provided Medication Regimen Reviews Policy with a revised date of 8/17/21 that was provided by RNC#2 included that the CP shall review the medication regimen of each resident at least monthly. The Procedure included: 1. The CP will perform an MRR for every resident in the facility. 2. Routine reviews will be done monthly . 7. The CP will document his/her findings and recommendations on the monthly drug/medication record review report . 9. The CP will provide to the DON and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions. 10. Copies of drug/regimen review reports, including physician responses, will be maintained as part of the permanent medical record . To Nursing: 1. The CP will provide a report within seven (7) working days of the review. 2. Nursing will provide a response within two (2) weeks of receipt of report. 3. Nursing will retain a copy of the report pending Nursing documentation review. On 11/08/23 at 02:33 PM, the survey team met for an Exit conference with LNHA, RNC#1 and #2, VPoCS, CIA, and ED. The facility management had no additional information about the concern above. NJAC 8:39- 29.3 (a)(1)

Based on observation, interview, and record review of other facility documentation, it was determined that the facility failed to provide appropriate Pharmaceutical Services and ensure a) a biological was properly labeled with an expiration date, b) removal of a discontinued biological from active inventory for a discharged resident (Resident # 23), c) medications were secured within the medication cart, and d) a narcotic medication for Resident #38 was properly labeled with an expiration date. This deficient practice was observed in two (2) of two (2) refrigerators located in the medication storage room, and one (1) of two (2) medication carts inspected and was evidenced as follows. A review of the manufacturer's specifications for Daptomycin (an antibiotics that can treat infections) under section 2.7 titled, Preparation and Administration of Daptomycin for Injection. In-Use Storage Conditions for Daptomycin for Injection Once Reconstituted in Acceptable Intravenous Diluents Stability studies have shown that the reconstituted solution is stable in the vial for 12 hours at room temperature and up to 48 hours if stored under refrigeration at 2°C to 8°C (36 to 46°F). The diluted solution is stable in the infusion bag for 12 hours at room temperature and 48 hours if stored under refrigeration. The combined storage time (reconstituted solution in vial and diluted solution in infusion bag) should not exceed 12 hours at room temperature or 48 hours under refrigeration. 1. On 11/01/23 at 11:08 AM, in the presence of Registered Nurse #1 (RN #1) the surveyor inspected the Medication Room refrigerator on the third floor. During the inspection, the surveyor observed an intravenous (IV) medication bag of Daptomycin 500 milligram (mg)/50 milliliter (ml), with an affixed label for Resident #23 dated 10/16/23 with a use by date of 10/15/24. On the reverse side of the IV medication bag had another affixed label that revealed a prepared date of 10/17/23 at 4:00 PM and a use by date of 10/24/23 at 4:00 PM. The expiration dates on the affixed labels on the front and back of the bag were different. 2. At that time, RN #1 informed the surveyor that Resident #23 was discharged from the facility. RN #1 stated that the medication should not have been intermingled with the active inventory and should have been returned to the pharmacy for disposal. At that time, the RN explained the process for discontinued medications. She stated that the discontinued medications were separated from the active inventory and kept locked in the medication room. All nurses on all shifts were responsible in ensuring discontinued and expired medications were removed from active inventory. She further stated that the discontinued medication should not be administered to another resident and went against the five (5) rights of medication administration. RN#1 stated that she would inform her supervisor and inform the pharmacy to pick up the IV for return. At 11:27 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) confirmed the discontinued medication for the discharged resident should have been removed from the active inventory. The surveyor reviewed the medical record for Resident #23. The electronic Medication Administration Record (eMAR) for November 2023, included orders for IV Daptomycin 500 mg/50 ml started on 10/14/23, and discontinued on 10/19/23. A review of the transfer/discharge/expiration for Resident #23 revealed the resident was discharged on 10/19/23 at 12:20 PM. 3. On 11/01/23 at 11:31 AM, the surveyor observed the high side medication cart on the 4th floor parked in front of the nurses' station, located across the elevators. There were two nurses in the station. The Licensed Practical Nurse assigned to the cart was facing the computer located in front of the dining area. At that time, the surveyor greeted the nurses and requested to inspect the high side cart. The surveyor asked the nurse why the medication cart was unlocked, and the Licensed Practical Nurse #1 (LPN#1) assigned to the medication cart stated she did not mean to leave it unlocked. 4. On 11/01/23 at 11:45 AM, the surveyor began the inspection of the refrigerator located in the medication storage room on the 4th floor. At that time, in the presence of LPN#1, the surveyor observed a bag that contained a prefilled Lorazepam (used to treat anxiety) gel 0.5 mg syringe with an affixed labeled for Resident #38, dated 7/06/23, and a use by date of 07/05/24. The prefilled syringe had an affixed label with a date of 7/31/23. At that time, LPN #2 walked into the medication room. LPN #1 and LPN #2 inspected the syringe and could not explain the different dates on the bag against the 7/31/23 date on the syringe. At that time, LPN #2 stated she would call the pharmacy and inquire about the discrepancy between the dates. On 11/1/23 at 01:02 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that he had contacted the pharmacy. The LNHA stated that he had learned from the provider pharmacy that the inscribed date on the affixed label of the prefilled syringe was the expiration date. The pharmacy provider had omitted the description, use by date. The Lorazepam gel 0.5 mg syringe had expired. The surveyor reviewed the Medical Record for Resident #38. A review of the resident's Physician Order sheet for November 2023, included an order for Lorazepam gel 0/5 mg/1 ml, started on 7/17/23. A review of the Individual Patient's Controlled Drug Record reflected two syringes of Lorazepam were recorded as received on 10/03/23, one of which was administered on 10/20/23. On 11/03/23 at 11:17 AM, during a meeting with the survey team, the Director of Nursing (DON), the LNHA, the Clinical Implementation Analyst (CIA), the Regional Nurse Consultant (RNC), and the Executive Director (ED), the surveyor discussed the storage and labeling concerns. On 11/08/23 at 10:49 AM, during a meeting with the survey team, the DON, the LNHA, the CIA, the RNC #1, the RNC #2, the [NAME] President of Clinical Services, and the ED, the RNC #1 stated that they would follow the expiration date on the affixed label on the Daptomycin with the Resident #23's name and not the reverse side. The same label that indicated the expiration was 10/15/24, almost a year from the 10/16/23, prescription order date. At that time, RNC #1 stated that the medication was not expired based on the affixed label with the Resident's name. The expiration date on the Daptomycin provided by the pharmacy was not consistent with the Daptomycin's manufacturer's specification for storage and stability. At that time, the DON confirmed the discontinued medication for the discharge resident should not have been with the active inventory since the resident was discharged at the time of the unit inspection. At that time, the RNC #1 stated the dating on the Lorazepam prefilled syringe was not an error. At that time, the DON stated the pharmacy had informed the facility that the words use by was omitted. The expectation was the use by date would match the affixed label on the bag and the syringe. The provider pharmacy had sent a replenishment of prefilled Lorazepam gel syringes for Resident #38. The facility provided documentation that the expired Lorazepam gel was wasted and was not administered to the resident after surveyor inquiry. A review of the facility provided skilled nursing policies and procedures for storage medications revised 5/1/17 included the following: Policy: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Procedure 3. Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. NJAC 8:39- 29.4(a) (d)(h), 29.7(a)

Based on the interview and review of pertinent documentation, it was determined that the facility failed to ensure that the a) employed designated Infection Preventionist (IP) had at least part time position for one (1) of three (3) IP and b) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for three (3) of three (3) employees reviewed for IP. This deficient practice was evidenced by the following: A review of CMS QSO-19-10-NH, dated 3/11/19, included but was not limited to Background: Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP (infection prevention and control program). Specialized Training for Infection Prevention and Control: In order to receive . a certificate of completion, learners must complete all modules and pass a post-course exam . The Nursing Home Infection Preventionist Training Course is available on CDC's (Centers for Disease Control and Prevention) TRAIN website .Completion of this course will provide specialized training in infection prevention and control. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available. On 10/30/23 at 9:08 AM, the survey team entered the facility and was welcomed by the Assistant Administrator (AA). The AA informed the survey team that there was a COVID-19 positive nurse last Friday (10/27/23), all residents were tested and they were negative. On 10/30/23 at 10:04 AM, the two surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference. Both the LNHA and the DON informed the surveyors that the facility had a designated part-time IP (IP#1) and completed the required training and certificate of an IP. The surveyor asked the LNHA and the DON to provide a copy of the IP's resume, signed job description, and copy of the required training certificate. A review of the designated IP#1 CDC Nursing Home Infection Preventionist Training Course (web-based) required training for IP revealed that it was completed on 6/27/23. A review of the Job Description Acknowledgment for the position of an IP showed that IP#1 did not sign and it was not dated. A review of IP#1's employee file revealed that he was hired on 6/01/23 as per diem IP. On 11/02/23 at 9:46 AM, the surveyor interviewed the DON in the presence of the survey team about the requirement for an IP, and the DON stated that she would get back to the surveyor. On 11/02/23 at 11:50 AM, the surveyor interviewed IP#1 in the presence of another surveyor regarding his job title and qualifications as an IP. IP#1 informed the surveyor that he started in the facility as a part-time IP first week of June 2023. He further stated that his background was a graduate of Public Health. On 11/03/23 at 11:17 AM, the survey team met with the LNHA, DON, Regional Nurse Consultant #1 (RNC#1), Clinical Implementation Analyst (CIA), and Executive Director (ED). The surveyor notified the facility management of the above findings and concern with regard to an IP requirement and that IP#1 was hired as per diem IP on 6/01/23 (according to the payroll authorization form) and assumed the position of an IP prior to completion of the CDC certificate as a requirement for an IP. On 11/03/23 at 01:01 PM, the DON in the presence of the survey team stated that IP#1 was a covering per diem IP because the full-time IP was on leave. The DON further stated that as a DON she also can cover as an IP and the Unit Manager (UM). Then the surveyor asked the DON if she knew that the UM could be the IP while covering for the designated IP#2 who was on leave, and why the facility management did not use the UM as an IP in order to comply with the IP requirement. At that same time, the DON stated that they [facility management] did not know before that it was a requirement to have a 5-year experience to be able to be an IP not until the surveyor's inquiry. The DON further stated that that was why usually the IPs are the nurses because they have the experience. The surveyor asked for a timeline of the facility's designated IP since the last recertification from August 2021 through November 2023, including their resume, signed job description, and copy of education training and certificate. The DON stated that she would get back to the surveyor. On 11/06/23 at 9:28 AM, the LNHA provided a copy of the Infection Preventionist timeline as follows: IP#1=from 6/01/23 through the present (hired as PRN [as needed] to cover IP#2 while out on leave) [this was not previously provided to the surveyor and did not notify the surveyors during the entrance conference that IP#1 was a per diem IP covering for IP#2 not until surveyor's inquiry] IP#2=from 4/18/22 through present IP#3=from 8/2021 through 4/18/22 On 11/08/23 at 10:14 AM, the LNHA provided a copy of IP#2's employee files and revealed that IP#2 was hired on 4/18/22 as a full-time IP of the facility. On 11/08/23 at 10:40 AM, IP#1 provided a copy of IP#2's CDC Nursing Home Infection Preventionist Training Course (web-based) for a total of 19.75 contact hours that was completed on 5/16/22. Further review of the above findings showed that IP#2 assumed the position of a full-time IP on 4/18/22 prior to obtaining a completed training course for an IP on 5/16/22. On 11/08/23 at 10:49 AM, the survey team met with the LNHA, DON, RNC#1 and RNC#2, CIA, [NAME] President of Clinical Services (VPoCS), and ED (joined the meeting at 11:15 AM). The VPoCS acknowledged that the CDC certification was part of the requirement of an IP. The surveyor notified the facility management of the above findings that IP#1 and IP#2 both assumed the position as an IP before completing the CDC web-based education and prior to obtaining the certificate. On that same date and time, the surveyor followed up on IP#3's resume, signed job description, and certificate. On 11/08/23 at 12:59 PM, the DON in the presence of the survey team stated that IP#4 will be the IP as of today until we [facility] figure out with IP#1. The DON provided also a copy of IP#3's signed Job Description Acknowledgment for Infection Preventionist Coordinator dated 5/13/21. On 11/08/23 at 01:50 PM, the DON provided a copy of IP#3's CDC Nursing Home Infection Preventionist Training Course (web-based) that showed that IP#3 completed the 19.3 contact hours on 8/03/21. On 11/08/23 at 01:53 PM, the survey team met with the LNHA, VPoCS, CIA, DON, ED, and RNC#1 and #2. The surveyor notified the facility management of the concern regarding IP#3 assumed the position of an IP as shown in the signed Job Description acknowledgment on 5/13/21 prior to completing the CDC Nursing Home Infection Preventionist Training Course (web-based) on 8/03/21. On that same date and time, the facility management confirmed that IP#3 assumed the position of an IP before completing the requirement of training in CDC after the surveyor showed to the facility management the provided documents of the DON. A review of the facility provided Infection Preventionist Policy that was provided by the DON with a revised date of 11/28/17 did not include the requirements of an IP based upon the IP's education, experience, training, and position according to the CMS, NJDOH, and CDC guidelines. On 11/08/23 at 02:33 PM, the survey team met for an Exit Conference with LNHA, DON, VPoCS, CIA, ED, and RNC#1 and #2. The facility management had no additional information provided and did not refute the findings. NJAC 8:39-19.1(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: The surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Training Hours Transcripts showed the following: CNA #1 had a hire date of 8/09/10. The facility could not provide a Training Hours Transcripts. CNA #1 did not have QAPI training. CNA #2 had a hire date of 8/09/10. According to the Training Hours Transcripts, CNA #2 did not have QAPI training. CNA #3 had a hire date of 10/13/14. According to the Training Hours Transcripts, CNA #3 did not have QAPI training. CNA #4 had a hire date of 9/08/16. According to the Training Hours Transcripts, CNA #4 did not have QAPI training. CNA #5 had a hire date of 10/09/21. According to the Training Hours Transcripts, CNA #5 did not have QAPI training. On 11/02/23 at 01:54 PM, during surveyor interview, the Licensed Nursing Home Administrator (LNHA) stated that CNA #1's last day of work at the facility was in July 2023 and that he did not come back yet because he was asked not to return to work until he finished his mandatory education. The LNHA further stated that CNA #2 was on a medical leave since December 2022. On 11/03/23 at 9:57 AM, the surveyor interviewed the Director of Nursing (DON) regarding education. The DON stated that the facility did not have an educator right now that oversaw the process and that the facility was working on a better process for education. She stated that it was a collaborative process right now and that the Director of Human Resources was overseeing the computer system that contained education and the Infection Preventionist was overseeing nonclinical education. She added that she was also working on some of the education. On 11/03/23 at 12:49 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, Regional Nurse Consultant #1 (RNC #1), Clinical Implementation Analyst (CIA) and Executive Director (ED) the concern that the five CNAs did not have education on QAPI. On 11/08/23 at 11:07 AM, in the presence of the survey team, LNHA, CIA, RNC #1, RNC #2, ED and [NAME] President of Health Services (VPoHS), the DON stated that the QAPI education was not completed for the five CNAs. She added that the poster fair that was done did not contain the topic of QAPI. A review of the facility provided policy titled, In Service Training, with a revised date of 6/20/23, included the following: Policy: It is the policy of this community to conduct in-service training programs for all personnel on a regularly scheduled basis. Procedure: 1. In-service training programs are planned and conducted for the development and improvement of skills of all personnel. It may include, but is not limited to: . o. Others that become necessary or appropriate. The list did not include QAPI. A review of the facility provided policy titled, Quality Assessment Performance Improvement Program, with a revised date of 8/23/17, included the following: Procedure: . 20. Education and training will be provided to the QAPI Committee members on the quality process, QAPI improvement principles, data collection and root cause analysis. QAPI Team members will receive training on group facilitation to support and assist in the QAPI and PIP (performance improvement projects) process. The policy did not include all facility staff. N.J.A.C. 8:39-33.1

**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 store potentially hazardous foods in a manner to prevent food borne illness as evidenced by the following: On 10/30/2023 at 9:59 AM, in the presence of the Food Service Manager (FSM) the surveyor observed the following: 1. In the tray line freezer, room service the surveyor observed a pack of vegetable burgers undated and opened, and six (6) trays of pastries prepared by the baker, the FSM was unable to state when the package was received, opened, or expiration date. 2. In the room service storage, cold prep, [soda brand] refrigerator the surveyor observed shredded mozzarella cheese that was opened and undated. The FSM was unable to state when the package was received, opened, or expiration date. 3. In the freezer walk in the surveyor observed 10 trays with frozen cupcakes and cookies not labeled with a prepared date or a use by date. The FSM was unable to state when the trays were prepared or would expire. On 11/01/23 at 11:20 AM, the FSM provided the surveyor with the Food and Supply Storage Policy #B003, date issued 5/95, revised date 01/23 page 1 and 2 which included: Policies: All food, non -food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for the human consumption. Procedures: -Most, but not all, products contain an expiration date. The words sell by, best by, enjoy-by or use-by should precede date. Foods past the use by, sell by, best-by or enjoy by date should be discarded. - Cover, label and date unused portions and open packages. Complete all sections on an orange label or use the [name]/ Fresh date labeling system. Products are good through the close of business on the date noted on the label. -Refer to the Food Storage Chart in this policy to determine discard dates for food items. Freezer Storage: Food prepared in house, and then stored frozen should be kept no longer than three months. Commercially produced foods may be held frozen until the manufacturer's expiration date, or for three months if no expirations date on the package. Once the packaging around the food has been opened, food must be used within three months. At 11/06/23 at 10:23 AM, the surveyor discussed the kitchen concerns with the facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). On 11/08/2023 at 12:00 PM, the DON provided a written statement to the survey team which read . Concern: Kitchen; labeling of food, unsealed food, undated food. Response: We do not have any supporting documents to defend this deficient practice. The kitchen is a third-party entity and cannot be part of our facility survey as they are not employed by the facility. On 11/08/23 at 02:33 PM, the survey team met for an Exit conference with LNHA, Regional Nurse Consultant #1 and #2, and [NAME] President of Clinical. The facility management informed the survey team that there was no additional information. NJAC 8:39-17.2(g)

**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 a resident with individualized continence care for a resident who had episodes of incontinence. The deficient practice occurred for 1 of 1 residents reviewed for bowel and bladder (Resident #158) and was evidenced by the following: On [DATE] at 12:53 PM, the surveyor conducted a resident meeting with four residents in attendance. During the meeting Resident #158, stated he/she was now in a diaper because he/she was not taken to the toilet in time. On [DATE] at 8:52 AM, the surveyor interviewed Resident #158, while the resident was seated in a wheelchair inside the resident's room and during the breakfast meal. The surveyor inquired as to the resident's preferences regarding using the toilet. The resident stated if he/she could stand he/she would use the toilet and that he/she used the urinal during the night. Resident #158 stated he/she had a diaper on now, and the staff must have decided themselves to put a diaper on him/her because nobody had asked him/her if he/she wanted to wear a diaper. Resident #158 stated that there was a urinal in the bathroom in a bag and that the staff did not leave the urinal within the resident's reach and he/she did not know why the urinal could not be kept within his/her reach. At that time, the surveyor observed a urinal inside of a plastic bag and was hanging by the resident's toilet inside the resident's bathroom. At [DATE] at 9:07 AM, the surveyor interviewed a certified nurse aide (CNA) assigned to provide care for Resident #158. The CNA stated that Resident #158 was able to stand up and hold on for support and that the resident used the urinal by him/herself. The CNA stated the resident did not wear underwear and wore just a diaper. The CNA stated that the resident could not use the urinal if the resident wore a diaper, and that the resident was able to call for assistance when the resident needed to use the bathroom. The surveyor reviewed the medical record for Resident #158 which revealed the following information: Resident #158 had diagnoses that included amyotrophic lateral sclerosis (a disease resulting in progressive muscle wasting and weakness), retention of urine (unspecified) and dysphagia (difficulty swallowing). A quarterly Minimum Data Set (an assessment tool to assist with the provision of care), dated [DATE], revealed the resident had a Brief Interview of Mental Status score of 13 which indicated the resident was cognitively intact. The Activities of Daily Living (ADL) section indicated the resident required extensive assist of one person for toilet use. The Bladder and Bowel section revealed the resident was occasionally incontinent of urine, was not on a urinary toileting program and was always continent of bowels. A Nursing and Therapy Communication Form, dated [DATE], revealed Resident #158 may use stand lift for bathroom transfers. The [DATE] Physician Order Sheet, under the Other Orders section revealed an order dated [DATE] for weight bearing as tolerated, three times daily. There was no order for continence care. On [DATE] at 9:30 AM, the Registered Nurse, Unit Manager (RN/UM). Provided the surveyor with a copy of the current Care Plan Report (CPR) for Resident #158. The CPR revealed a problem, that the resident needed assistance with ADL's due to weakness and limited mobility due to a recent hospitalization/surgery. The goal was to be able to participate with ADL's in the next 90 days. There was no problem or interventions listed on the CPR related to incontinence or incontinence care. At that time the surveyor conducted a follow-up interview with the CNA regarding the presence of a separate CPR that was used by the CNA's regarding Resident #158's ADL's and that related to incontinence and included the resident's use of diapers. The CNA stated there was no separate CPR for the CNA's. On [DATE] at 9:46 AM, the surveyor conducted a follow-up interview with Resident #158 in the resident's room. The surveyor inquired to the resident the resident's toileting preferences. The resident stated I rather the urinal then the diaper. On [DATE] at 9:49 AM, while in Resident #158's room with the Registered Nurse (RN #1) assigned to the resident, the surveyor inquired if the resident was wearing a diaper. The RN #1, with the resident's permission, pulled the top band of the resident's pants down and revealed something blue and RN #1 stated, that is a diaper. On [DATE] at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) regarding how the determination was made for a resident to wear diapers. The DON stated diapers were used for incontinence and the nurse determined if a resident wore diapers. The DON further stated that there was no formal process, or assessment to determine what type of incontinence product was used for a resident. The DON stated if a resident had episodes of urinary incontinence and was able to use a urinal, the staff should not be putting a diaper on the resident. The DON stated if the resident required incontinence care the CPR should include that information. The surveyor inquired to the DON the continence status of Resident #158 and the DON stated per the [DATE] nursing monthly summary, the resident had episodes of urinary and bowel incontinence and pads and briefs were used at times. The DON stated she was unable to provide documentation to the surveyor of a formal assessment or a process that was used to determine how the decision was made to use diapers for Resident #158. The Resident Care Plan (RCP) policy, effective [DATE], revealed the policy was to ensure that the care planning process was systematic, comprehensive, interdisciplinary, and timely and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional status. The RCP will be updated at the resident care conference and as necessary to address the resident's needs. NJAC 8:39-27.1(a)

Based on observation, interview, record review and document review, it was determined, that the facility failed to administer the correct amount of oxygen (O2) to residents per the physician's order. This deficient practice was identified for two of two residents reviewed (Resident #50 and Resident #53) for respiratory care and was evidenced by the following: 1.) On 07/13/21 at 10:12 AM, the surveyor observed Resident #53 sitting upright in his/her bed wearing O2 via nasal cannula (a device used to deliver supplemental oxygen, which consists of a lightweight tube on one end and another end that splits into two prongs that is placed in an individual's nostrils). The surveyor observed that the O2 tubing was connected to a water bottle on the O2 concentrator located next to the resident's bed and the oxygen flow rate was set at 4.5 Liters (L) per minute. The surveyor asked the resident how he/she was feeling, and the resident stated, tired. On 07/14/21 at 9:58 AM, the surveyor observed the resident in his/her room seated in a wheelchair. The surveyor observed that the resident was wearing O2 at three (3) L per minute via nasal cannula. On 07/15/21 at 9:28 AM, the surveyor observed the resident seated in a wheelchair in his/her room. The resident was wearing O2 at two (2) L per minute via nasal cannula. The surveyor reviewed the medical record for Resident #53. Review of the resident's Face Sheet (An admission Summary) reflected that the resident was recently admitted to the facility and had diagnoses which included, but were not limited to, congestive heart failure (a chronic condition where the heart doesn't pump blood as good as it should preventing blood from oxygenating the body), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain body functions), other disorders of the lung, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lung and heart), and kidney failure. Review of the admission Minimum Data Set (MDS) an assessment tool dated 06/21/21, indicated that Resident #53 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 which indicated the resident had a severe cognitive impairment. A further review of the resident's MDS, Section O - Special Treatments, Procedures, and Programs indicated that the resident had oxygen therapy. Review of the resident's July 2021 Physicians Order Sheet (POS) indicated that the resident had a Physician's Order (PO) dated 06/11/21 for O2 at two (2) L per minute via nasal cannula continuous. Review of the resident's July 2021 Treatment Administration Record (TAR) reflected that the nurses were signing on the day, evening, and night shift that the resident was wearing oxygen at two (2) L per minute via nasal cannula continuously. Review of the resident's Care Plan Report dated 06/22/21 to present, revealed a problem area that the resident was at risk for respiratory compromise because of acute CHF, acute hypoxic respiratory failure, pulmonary hypertension, and other disease processes. The goal of the resident's Care Plan was that the resident would show no signs and symptoms of acute respiratory distress. The interventions for the resident's Care Plan included to monitor signs and symptoms of distress and notify the MD, to monitor vital signs every shift and as needed, and to administer oxygen as ordered by the primary medical doctor. On 07/15/21 at 10:23 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert and oriented, could make needs known, was very slow moving, and was short of breath at times. The CNA further stated that she thought the resident wore O2 and three (3) L per minute but was unsure of the exact flow rate of the O2. The CNA stated that she would never adjust the O2 rate on the concentrator because that was the licensed nurse's job to do so. The CNA stated that her job was to make sure the O2 tubing was correctly in the residents' nostrils and she would check to make sure the O2 tubing was not on the floor. On 07/15/21 at 10:54 AM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that she was familiar with the resident and the resident was alert and oriented with periods of forgetfulness. The RN stated that the resident had a past medical history of cardiac and respiratory issues and required the continuous use of O2 at two (2) L per minute via nasal cannula. The RN further stated that the resident would never touch the O2 concentrator to adjust the flow rate of the O2. The RN stated that it was the nurse's responsibility to ensure that the resident's O2 was flowing at a rate of two (2) L per minute. On 07/15/21 at 10:59 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Resident #53 received O2 at two (2) L per minute via nasal cannula continuous for a diagnosis of congestive heart failure and the O2 was prescribed by a physician. The RN/UM further stated that it was the nurses responsibility to make sure the O2 was set at the appropriate flow rate per the PO and if the oxygen needed to be increased, the physician would need to be called and a new order for the use of the O2 would need to be put into place. 2.) On 07/13/21 at 10:45 AM, the surveyor observed Resident #50 lying in bed, with oxygen tubing placed in his/her nares. The surveyor observed an O2 concentrator in the room which was set at an O2 flow rate of three (3) L per minute. The head of the resident's bed was elevated, and the surveyor observed that the resident was receiving O2 at three (3) L per minute via nasal cannula. On 07/14/21 at 9:53 AM, the surveyor observed the resident laying in bed in his/her room wearing O2 via nasal cannula. The flow rate on the O2 concentrator was observed to be set at three (3) L per minute. On 07/15/21 at 9:54 AM, the surveyor observed the resident laying in bed in his/her room wearing O2 via nasal cannula. The surveyor observed the flow rate on the O2 concentrator was set at 2.5 L per minute. The surveyor reviewed the medical record for Resident #50. Review of the resident's Face Sheet indicated that the resident was newly admitted into the facility and had diagnoses which included but were not limited to pneumonitis due to inhalation of food or vomit (infection in lungs), quadriplegia (paralysis of all four limbs), muscle weakness, and dysphagia (difficulty swallowing). Review of the MDS an assessment tool dated 06/28/21, indicated that Resident #50 had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. A further review of the resident's MDS, Section O - Special Treatments, Procedures, and Programs indicated that the resident had oxygen therapy. Review of the July 2021 POS indicated that the resident had a PO dated 06/28/21 for O2 at two (2) L per minute via nasal cannula as needed for shortness of breath or O2 saturation less than 90%. Review of the July 2021 TAR reflected a PO for O2 therapy as needed at two (2) L per minute via nasal cannula for shortness of breath or O2 saturation less than 90%. There was no documentation on the July 2021 TAR that reflectd the use of the prn O2. A further review of the July 2021 TAR reflected a PO for Vital Signs every shift. The documentation on the July 2021 TAR reflected that the nurses were checking the resident's O2 saturation with a pulse oximeter (noninvasive device used to check O2 saturation) during the day, evening, and night shifts. Review of the resident's O2 saturation readings reflected that the resident O2 saturation was never below 92%. Review of the resident's Care Plan Report dated 06/28/21 to present revealed a problem area that the resident was at risk for respiratory compromise related to shortness of breath and pneumonia. The goal of the resident's Care Plan was that the resident would remain free from respiratory distress with medical intervention through the next 90 days. The interventions for the residents Care Plan included to monitor for changes in breathing pattern and notify the MD as needed, monitor oxygen level, and apply oxygen as needed. On 07/19/21 at 11:54 AM, the surveyor interviewed Resident #50's RN who stated that the resident was alert and oriented with periods of forgetfulness. The RN stated that the resident was on two (2) L of O2 per minute as needed for shortness of breath or for an O2 saturation less than 90%. The RN further stated that the residents O2 saturation was checked at least once per shift. On 07/19/21 at 12:02 PM, the surveyor interviewed the RN/UM who stated that the resident was on O2 at two (2) L per minute via nasal cannula as needed. The RN/UM stated that the resident's oxygen saturation was checked every shift by the nursing staff and if the residents O2 saturation was below 90%, the nurses could administer the oxygen as needed. The RN/UM did not speak to the continued use of the O2 or if the nurses were checking the resident's O2 saturation while the resident was wearing O2. Review of the facility's Oxygen Therapy Policy and Procedure revised 05/18/12 indicated to, Check oxygen flow to ensure that the correct amount of oxygen is being delivered. NJAC 8:39-27.1 (a)

Based on interview and review of facility documentation, it was determined that the facility failed to evaluate the performance of all Certified Nursing Aides (CNA) on an annual basis, and failed to provide regular in-service education based off of the performance reviews. This deficient practice was identified for 3 of 5 CNA personnel records reviewed (CNA #1, #2 & #3) and was evidenced by the following: On 7/19/21 at 11:39 AM, the surveyor reviewed the personnel records of 5 randomly selected CNA's which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 12/06/1999. According to CNA #1's personnel record, there were no annual performance reviews conducted within the past year. The most recent performance review was completed March 1, 2018. CNA #2 had a hire date of 08/12/2013. According to CNA #2's personnel record, there were no annual performance reviews conducted within the past year. The most recent performance review was completed March 1, 2018. CNA #3 had a hire date of 01/17/2016. According to CNA #3's personnel record, there were no annual performance reviews conducted within the past year. The most recent performance review was completed 03/2017 (no specific date indicated). On 07/20/21 at 11:29 AM the surveyor interviewed the Human Resources Manager (HR). The HR stated the performance appraisals should be done yearly to evaluate the performance of a staff member, and if the staff member wasn't performing well the facility would provide a corrective action plan for that staff member. The HR confirmed that the above listed dates were correct for the most recent CNA's performance appraisals and could not locate any other performance review documents. On 07/22/21 at 11:45 AM the surveyor interviewed the Director of Nursing (DON) who stated she had not completed an annual performance appraisal for CNA #1, CNA #2 or CNA #3. The DON stated performance appraisals for all employees were completed once annually and the completion date was not related to each employees specific date of hire. Review of a Performance Management Policy, dated 01/01/1998, revealed it was the facility policy to review the job performance of each employee at least once before the conclusion of the introductory period and at least every 12 months thereafter. After a transfer or promotion, performance should be reviewed within the first six months in the new position and every twelve moths thereafter. The purpose of the Performance Management process was to review the employee's competencies or performance criteria, completion of goals and objectives and the implementation of a step by step development plan. The performance Management program was a cycle of planning, managine, then appraising performance. NJAC 8:39-43.17(b)

Based on observation, interview and document review it was determined that the facility failed to honor a resident's meal preferences. This deficient practice occurred for 1 of 4 residents who attended a resident council meeting (Resident #158) and was evidenced by the following: On 07/15/21 at 10:24 AM, during a surveyor conducted resident council meeting, Resident #158 stated he/she received too much food and it was stamped directly on the menu to receive small portions. On 07/15/21 at 11:44 AM, the surveyor observed the kitchen tray line in progress during the lunch meal preparation. The surveyor observed the dietary staff place Resident #158's tray ticket on a tray and the surveyor observed Small Portions was stamped on the tray ticket twice. The tray ticket had 1 portion of minced penne pasta/meat sauce listed. The surveyor observed a Dietary Staff (DS) use a 4 ounce spoodle (slotted measured scoop) to portion out the meat and a slotted spoon without a portion size on it, to portion out the pasta. At that time the surveyor interviewed the Food Service Manager (FSM) regarding the portion sizes and scoops that should be utilized. The FSM referred to the portion sizes listed on the menu which was located directly next to the tray line. The portion sizes revealed 1 cup for the penne and 3 ounces for the meat sauce. The FSM stated the DS should have used the correct scoops for portion control and a 3 ounce scoop should have been used for the meat if it was a regular portion. The FSM stated the portion sizes posted were for the regular portions and maybe to give half for smaller portions. The surveyor requested the specific portion sizes for a small portion menu and they were not provided. On 07/19/21 at 1:00 PM the surveyor interviewed the Registered Dietitian (RD) from the hospital who stated she was familiar with the menus and portion sizes. The RD stated the menus with portion sizes for the small portions should be accessible at the tray line and they should be followed. The surveyor requested the portion sizes from the RD and they were not provided. Review of a Meal service for Patients policy, dated 02/01/1994, revealed Any special food request made by patients/residents during mealtime will be called to the Food and Nutrition Services Department by the nursing staff. Patient/resident meal preferences will be honored including requests for small or large portions. NJAC 8:36 17.4(a)1

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and review of other pertinent documents, it was determined that the facility failed to follow standards of professional practice with respect to following physicians orders. This deficient practice was identified for 1 of 15 sampled residents, (Resident # 18), and was evidenced by the following: Reference: New Jersey Statutes, 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 well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 07/14/21 09:35 AM, the surveyor observed Resident #18 in bed, with the bed in the low position, and with his/her eyes closed. The surveyor observed two (2) fall prevention mats that were folded and rested on the bed frame. There was signage posted on the wall that indicated: No blood pressure (B/P) or blood work on left arm, S/P (status post) left mastectomy (removal of the left breast). On 07/14/2021 at 10:18 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #18 who stated the following: Resident #18 required extensive assistance with activities of daily living (ADL's) and was mostly non-verbal. The resident had the diagnoses of cancer to the right shoulder, had an open area on the left leg and multiple open areas on the chest. The CNA further stated that treatments were performed to those areas by the nurse. The CNA further stated that the resident got out of bed daily and could stand and pivot, but required a two person physical assist with transfers. The CNA stated that Resident #18 had combative behaviors and was resistant with care. On 07/14/21 at 10:36 AM, the surveyor reviewed Resident #18's clinical record and Face Sheet (An admission Record) which revealed that Resident #18 had diagnoses of anxiety disorder, unspecified dementia without behavioral disturbances, unspecified glaucoma and S/P left mastectomy. The annual Minimum Data Set (MDS ), an assessment tool dated, 12/02/20, and the quarterly MDS dated [DATE], revealed that Resident #18 had a severe cognitive impairment. On 07/16/21 at 10:30 AM, the surveyor reviewed Resident #18's clinical record which revealed a physician order dated 06/27/21, with an original order date of 12/31/18, that indicated the following: No B/P and no Blood draw left arm. Note: left mastectomy. The surveyor reviewed the Resident Vital Sign Report (RVSR) from 02/01/21 to 07/19/21, and observed that the nursing staff documented that they used the left arm to monitor Resident #18's blood pressure. On 07/18/21 at 11:30 AM, the surveyor reviewed the RVSR with the Director of Nursing (DON) who confirmed that staff were not consistently following the physician's order to not take Resident #18's B/P in the left arm. For example, in February 2021, staff used Resident #18's left arm (23) times, March 2021(18), April 2021(30), May 2021(15), June 2021 (26) and July 2021(18). On 07/19/21 at 11:21 AM, the surveyor interviewed the Registered Nurse (RN) located on the 4th floor who stated that she could not recall if it was an error in documentation, or if she failed to verify the physician's order. On 07/21/21 at 11:15 AM, the surveyor interviewed the RN Unit Manager (RNUM) for the 4th floor who revealed that the nursing staff involved, indicated that they were not paying attention to the specific signage posted on Resident #18s wall in his/her room. The RNUM stated the signage specifically instructed that no B/P should be taken on the left arm. The facility was unable to provide the surveyors a policy and procedure pertaining to the monitoring of blood pressure. NJAC: 8:39-29(2)(d)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document the non-pharmacological interventions (interventions to calm the resident that were not medicinal) for a resident with behaviors prior to the administration of an as needed anti-anxiety medication, b.) routinely document the behaviors associated with the administration of the as needed medication, c.) initiate a Care Plan with interventions to manage the residents behaviors, and d.) follow their facility's Behavior Management Policy and Procedure for residents presenting with behaviors. This deficient practice was identified for 1 of 5 residents reviewed (Resident #41) for unnecessary medications and was evidenced by the following: On 07/14/21 at 9:33 AM, the surveyor observed Resident #41 positioned in a reclining chair with his/her eyes closed. On 07/20/21 at 11:57 AM, the surveyor observed the resident calmly seated in a recliner chair in his/her room. The surveyor attempted to interview the resident. The resident was alert and smiled but did not speak to the surveyor in a coherent manner. At that time, the surveyor observed the resident's companion in the room and conducted an interview. The resident's companion stated that she cared for the resident every day in the morning for a few hours and there were two other companions who cared for the resident as well. The companion stated that the resident did not have behaviors in the day time, but she was in communication with the two other companions who came during the evening and night hours who told her that the resident would wake up in the middle of the night, try and get up out of bed, and would sometimes hallucinate. The companion stated that she thought the resident was receiving a medication to help with his/her behaviors but wasn't sure. The companion could not speak to nonpharmacological interventions used to soothe the resident because the resident never presented with behaviors when she was there. The surveyor reviewed the medical record for Resident #41. Review of the resident's July 2021 Physician Order Sheet (POS) reflected that Resident #41 was admitted to the facility and had diagnoses which included, but were not limited to, unspecified dementia with behavioral disturbances, depressive episodes, arthritis, insomnia (inability to sleep), and anxiety disorder. Review of the admission Minimum Data Set (MDS) an assessment tool dated 06/29/21, indicated that Resident #53 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated the resident had a severe cognitive impairment. Review of the Psychiatry Progress Note (PPN) dated 06/30/21, indicated that the resident had a past medical history of severe resistant depression, was confused, had a poor attention span, was unable to express himself/herself, had a diagnosis of anxiety, and had no behaviors since admission. The PPN further indicated that the resident's medications were reviewed and to continue with the same treatment plan. Review of the PPN dated 07/19/21, indicated that the resident had severe drug resistant depression and anxiety with multiple episodes of impaired sleep and restlessness. The PPN indicated that the resident had episodes of anxiety and agitation daily and needed frequent redirection from a private aide. The PPN further indicated that the anti-anxiety medication, Xanax 0.25 mg every six hours as needed was reviewed and recommended to be continued for the next 14 days due to the resident's behavioral episodes. Further review of the July 2021 POS reflected a Physician's Order (PO) dated 7/20/21 for the anti-anxiety medication, Xanax 0.25 mg, 1 tablet by mouth every six hours as needed (prn) for anxiety for 14 days. Review of July 2021 Medication Administration Record (MAR) for the prn usage of the medication, Xanax 0.25 mg revealed that the anti-anxiety medication was administered 16 times. On 07/01/21 at 1:15 AM On 07/02/21 at 17:24 (5:24 PM) On 07/03/21 at 0:31 (12:31 AM), due to restlessness and climbing out of bed On 07/03/21 at 16:26 (4:26 PM) On 07/04/21 at 21:00 (9:00 PM) On 07/06/21 at 15:44 (3:44 PM), administered for anxiety On 07/07/21 at 0:48 (12:48 AM) On 07/07/21 at 16:00 (4:00 PM) On 07/08/21 at 2100 (9:00 PM) On 07/10/21 at 20:21 (8:21 PM) On 07/12/21 at 22:30 (10:30 PM) On 07/15/21 at 1:05 PM On 07/15/21 at 20:25 (8:25 PM) On 07/17/21 at 20:04 (8:04 PM) On 07/18/21 at 22:05 (10:05 PM) and on 07/21/21 at 2:00 AM. According the July 2021 MAR the as needed medication Xanax was administered to Resident #41, 16 times the month of July. Two out of the 16 times the Xanax was administered there was a documented rational for the usage of the Xanax. Review of the July 2021 MAR indicated that the administration of Xanax was effective for the resident. A further review of the July 2021 MAR did not reflect nonpharmacological interventions provided to the resident prior to the administration of the medication. Review of the resident's July 2021 progress notes did not reflect documentation that corresponded with the July 2021 MAR for the administration of the Xanax. The nurses did not document in the resident's medical record regarding any anxoius behaviors that the resident displayed to neccessitate the administration of the Xanax. The nurses did not document any nonpharmacological interventions that were implemented prior to the administration of the Xanax. Review of the resident's Care Plan Report dated 06/21/21 to present, reflected a problem area that the resident was at risk for complications related to psychoactive medication use. The goal of the residents Care Plan indicated that the resident would have no complications related to psychoactive medication use for the next 90 days. The interventions included to monitor for adverse reactions, side effects, change in mental status and notify the MD. The resident's Care Plan did not reflect specific behaviors that the resident displayed that neccesitated the use of the psychoactive medication and did not include non-pharmacological interventions that were used by staff to calm the resident. On 07/20/21 at 12:06 PM, the surveyor interviewed the resident's 7:00 AM - 3:00 PM Certified Nursing Aide (CNA) who stated that the resident was alert to self and could make simple needs known at times. The CNA stated that the resident's orientation and behaviors depended on the time of day and the resident did not present with behaviors during her shift. The CNA further stated that if she was taking care of a resident with dementia, who presented with behaviors, she would approach the resident calmly, introduce herself to the resident, speak slowly, explain the care she was going to provide before she provided it, and sit with the resident to try and make the person feel comfortable. On 07/20/21 at 12:24 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that it was his first day working with the resident and he wasn't familiar with the resident's specific behaviors. The LPN stated that he was told that the resident would sleep during the day and was up at nighttime. The LPN further stated that administering a prn Xanax would not be his first choice when providing care and, medication should not be the first option to ease a person's anxiety. The LPN stated that if he administered a prn anti-anxiety medication it would only be because nonpharmacological interventions were ineffective. The LPN further stated that he would document in the resident's medical record all of the nonpharmacological interventions he had tried prior to administering the medication and he would also document the behaviors that the resident presented with for the need of the medication. The LPN stated that it was important to do this for a continuity of care and gave the example that other nurses could check the resident's nursing notes or care plan for interventions used that would help calm the resident if they weren't familiar with the person. The LPN further gave the example that some people responded well to soothing music or the smell of lavender and those resident specific interventions should be included in a resident's Care Plan. On 07/20/21 at 12:34 PM, the surveyor interviewed the resident's Registered Nurse/Unit Manager (RN/UM) who stated that the resident was alert at times, could make simple needs known, and was familiar with his/her companions. The RN/UM stated that the resident had behaviors where he/she became anxious, so when the residents companions were not available, the nurses would bring the resident in front of the nurses station so he/she could be supervised for safety. The RN/UM further stated that the nurses could visibly see the resident was anxious because of the resident's movements. The RN/UM gave the example that the resident would ring his/her hands together, become fidgety, and move around in his/her chair. The RN/UM stated that before administering a prn anti-anxiety medication, staff should first take care of the resident's basic needs such as toileting. The RN/UM stated that the staff would try and re-direct the resident with activities, but the resident had a short attention span. The RN/UM further stated that the nurses should be documenting on nonpharmacological interventions prior to administering the prn Xanax and also document the behaviors the resident presented with. On 07/21/21 at 9:35 AM, the surveyor conducted a follow-up interview with the RN/UM who stated that the staff constantly implemented and re-directed the resident but never documented that. The RN/UM stated that she reviewed the resident's medical record and identified that the nurses were not documenting on nonpharmacological interventions used prior to administering the medication Xanax. The RN/UM further stated that interventions used to calm the resident should be included in the resident's care plan. Review of the facility's Behavior Management Policy and Procedure revised 11/22/17 indicated, When behavioral symptoms occur, the licensed nurse, in conjunction with any other involved staff, will document the behavioral symptoms in the interdisciplinary progress notes/EMAR [Electronic Medical Record]. The facility's Behavior Management Policy and Procedure further indicated to initiate a Care Plan for the behaviors using non-drug interventions and revise the Care Plan as needed. NJAC 8:39 27.1(a)

Based on interview and document review it was determined that the facility failed to hold quarterly Quality Assessment and Assurance (QAA) meetings with the required members for the last four quarters. On 07/22/21 at 9:45 AM the surveyor interviewed the temporary facility Administrator (LHNA) and the Director of Nursing (DON). The DON stated the prior Administrator left the position in January. The DON stated the prior Administrator did not conduct formal QAA meetings. The DON provided the surveyor with two QAPI (Quality Assurance and Performance Improvement Plan) sign in sheets for meetings held on 04/27/21 and 07/21/21 and stated the meeting resumed on 04/27/21. The surveyor inquired to the DON as to why the medical director was not in attendance for the last two meetings. The DON stated he was not available in April because he was not at the facility and he had a conflict yesterday and could not attend. There was no designee in attendance for the medical director. The surveyor inquired to the DON and LNHA regarding the current QAPI plans and if staffing was included as a QAPI. The DON stated staffing was discussed but there was no formal QAPI program related to it. Review of the Quality Assessment Performance Improvement Program, dated, 10/01/00 revealed the policy is to provide consistent high quality resident care and services that meet or exceed our residents, families, staff and customers' expectations and to minimize the risk of adverse outcomes and injuries. The QAPI Committee is responsible for the identification of concerns, problems, and focus areas which may become topics for performance improvement teams. NJAC 8:39-33.1(b)