**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of pertinent facility documents on 7/14/25 and 7/15/25, it was determined the facility failed to a.) date and label respiratory equipment used for oxygen delivery and nebulizer treatments and b.) change equipment used for oxygen delivery and nebulizer treatments for 7 of 8 residents (Residents #1, #2, #3, #4, #5, #10 and #11) reviewed for respiratory care. This deficient practice was evidenced by the following:On 7/14/25 at 10:13 AM, surveyor conducted rounds on the oxygen, the Tracheotomy/Ventilator (trach/vent), and treatment tubing, with the Registered Nurse/Unit Manager (RN/UM) of the trach/vent unit and observed the following: 1. Resident #10 was observed in bed awake. Resident #10 was non-verbal, and unable to respond to questions. The surveyor observed a nebulizer setup that was attached to a nebulizer machine. The tubing for the nebulizer setup was not dated. The in-line suctioning that was connected to the tracheostomy was observed to not have a date. The tubing that connected to the ventilator and trach was also not dated. The RN/UM verified that tubing was not dated. The RN/UM stated that all tubing should be dated. The RN/UM stated that respiratory therapy was responsible for changing tubing for the ventilator dependent residents.According to the admission Record (AR), Resident #10 was admitted with diagnoses including but not limited to: acute respiratory failure, tracheostomy (a surgical opening through the neck into the windpipe), and dependence on a respirator (ventilator).According to the Minimum Data Set (MDS), an assessment tool, dated 7/10/25, revealed Resident #10 had a Brief Interview for Mental Status Score (BIMS) of 00, which indicated that resident was severely cognitively impaired. The MDS also indicated that the resident was dependent for Activities of Daily Living (ADLs) and transfers. 2. Resident #1 was observed in bed awake, with the television on. Resident #1 was non-verbal, and unable to respond to questions. The surveyor observed nebulizer setup that was placed in an undated bag. The nebulizer tubing had a date of 6/23. The RN/UM verified the date was 6/23. The RN/UM stated that the tubing should be changed once a week and as needed.According to the AR, Resident #1 was admitted with diagnoses including but not limited to: acute respiratory failure, and dependence on a respirator.According to the MDS dated [DATE], Resident #1 had a BIMS score of 00, which indicated severe cognitive impairment. The MDS also indicated, Resident #1 was dependent for ADLs and transfers. 3. Resident #2 was observed to be awake in bed. Resident was non-verbal and was able to follow simple commands. The surveyor observed nebulizer setup that was placed in an undated bag. The nebulizer setup tubing was dated for 6/23.According to the AR, Resident #2 was admitted with diagnoses including but not limited to: chronic respiratory failure, tracheostomy, and dependence on a respirator.According to the BIMS score assessment tool dated 5/16/25, Resident #2 had a score of 00, indicating resident was severely cognitively impaired. 4. Resident #3 was observed to be asleep. The surveyor observed the nebulizer setup that was in oxygen bag that was dated 6/23. The nebulizer tubing was not dated. According to the AR, Resident #3 was admitted with diagnoses including but not limited to: chronic respiratory failure, tracheostomy, and dependence on a respirator.According to the MDS dated [DATE], Resident #3 had a BIMS score of 00, indicating Resident #3 was severely cognitively impaired. The MDS also indicated Resident #3 was dependent for ADLs and transfers. 5. Resident #4 was observed awake in bed. Resident was verbal but was un-able to answer questions regarding the tubing, however able to follow simple commands. The surveyor observed nebulizer setup was placed in an undated bag. The nebulizer tubing did not have a date.According to the AR, Resident #4 was admitted with diagnoses including but not limited to: Acute Respiratory Failure, Tracheostomy, and Dependence on a Respirator (Ventilator).According to the MDS dated [DATE], Resident #4 had a BIMs of 05, indicating Resident #4 was severely cognitively impaired. The MDS also indicated Resident #4 was dependent for ADLs and transfers. 6. Resident #5 was observed to be sitting up in bed awake. Resident #5 was able to follow simple commands but was non-verbal and unable to answer questions. The surveyor observed the nebulizer setup. The nebulizer tubing was placed in an undated bag, and the tubing did not have a date.According to the AR, Resident #5 was admitted with diagnoses including but not limited to: chronic respiratory failure, tracheostomy, and dependence on a respirator.According to the MDS dated [DATE], Resident #5 had a BIMS score of 00, indicating serve cognitive impairment. The MDS also indicated Resident #5 was dependent for ADLs and transfers. 7. Resident #11 was observed to be asleep in bed. The surveyor observed the oxygen set-up. The set-up included a humidification bottle attached to a compressor that sat on the bed side table. The humidification bottle was observed to be undated. The RN/UM stated that Resident #11 was not ventilator dependent and stated that the nurses changed the oxygen equipment, including tubing and humidification bottles and nebulizer setups, for all residents who were not ventilator dependent.According to the AR, Resident #11 was admitted with diagnoses including but not limited to: chronic respiratory failure and tracheostomy.According to the BIMS score assessment tool dated 1/30/25, Resident #11 had a BIMs of 3 indicating Resident #11 was severely cognitively impaired. During an interview with the RN/UM on 7/14/25 at 11:15 AM, she stated that dating equipment was important for infection control, and to make sure the integrity of the equipment was maintained and functioning properly. She further stated that the tubing was supposed to be changed every Monday on 11:00 PM to 7:00AM (11-7) shift.During an interview with the Respiratory Therapist (RT) on 7/14/25 at 11:22 AM, she stated that tubing should be changed weekly and dated. She also stated that if tasks were not completed on one shift, the RTs would endorse the task to be completed on the following shift during report. She denied receiving information regarding tubing needing to be changed from the previous shift. She stated the only reason the tubing would not be changed, was if they lacked the supplies to replace the tubing. She denied lacking supplies. The Surveyor observed supplies closet with RT, and the oxygen tubing and nebulizer tubing were fully stocked.During an interview with the RN/UM on 7/14/25 at 1:23 PM, she stated the Infection Prevention Nurse (IPN) completed rounds and checked that tubing was changed every Tuesday.During an interview with the Director of Nursing (DON) on 7/14/25 at 1:53 PM, he revealed that the IPN was responsible for making sure that the oxygen tubing and nebulizer equipment was changed weekly. He further stated that ultimately, he was supposed to monitor that all tubing was changed.During an interview with the IPN on 7/15/25 at 12:51 PM, she stated that oxygen and nebulizer tubing should be changed weekly on Mondays during the 11-7 shift. The IPN further explained that the list of tubing that needed to be changed was placed in the Narcotic book, on each medication cart. The IPN was informed of the outdated and undated tubing that was observed by the surveyor and the RN/UM. The IPN informed the surveyor that she was responsible for doing rounds and making sure tubing was changed. When the surveyor asked if the tubing was checked, the IPN stated that she checked a few of the residents that required tubing to be changed, but not everyone. The IPN stated that she was supposed to check all tubing.In the policy titled, Departmental (Respiratory Therapy)-Prevention of Infection, with a reviewed date 3/2021, states under the heading Steps in the Procedure Infection Control Considerations Related to Oxygen Administration: .2 Use sterile water for humidification per facility protocol. 3. [NAME] bottle with date and initials upon opening and discard after 24-four (24) hours.7. Change the oxygen cannula and tubing every seven (7) days or as needed. In the same policy under the heading, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and resident's name, between uses.9. Discard the administration set-up every seven (7) days. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to provide reasonable accommodation of resident needs specifically by failing to ensure that assistance was provided to open a mail for a resident with bilateral hand contractures for 1 of 39 residents, Resident #23, reviewed for resident rights. The deficient practice was evidenced by the following: 1. On 5/1/24 at 10:48 AM, the surveyor observed Resident #23 in bed, awake. The surveyor also observed that the resident was wearing hand splint (an orthotic device that is used to support and immobilize the hand, fingers and wrist) to both hands. The surveyor observed several unopened mails placed on top of the resident's nightstand and another one unopened mail placed on top of the bedside table. The surveyor interviewed the resident who stated that he/she would love for someone to open his/her mails for them in his/her presence. Resident #23 further stated that there were no staff who offered to open the mails for him/her. A review of the facility admission Record for Resident #23 revealed that the resident was admitted to the facility with diagnoses which included but were not limited to Contracture right and left hand, Generalized Osteoarthritis, Major Depressive Disorder and Dysphagia. A review of Resident #23's Quarterly Minimum Data Set (MDS) an assessment tool used to facilitate management of care, dated 4/27/24, reflected that the resident had a Brief Interview Mental Status (BIMS) score of 10 out of 15, which indicated that the resident had moderate cognitive impairment. A review of the physician's order (PO) dated 3/5/24 reflected a PO to Don right and left hand palmar grip splint after AM care as tolerated. Doff with PM care. On 5/2/24 at 10:35 AM, the surveyor interviewed Unit Manager #3 who stated that Resident #23 does not have any family or responsible party and was unaware who delivers the mail to the resident. On 5/2/24 at 2:11 PM, the surveyor discussed the above concern with the facility's Regional Registered Nurse (RRN), Licensed Nursing Home Administrator (LNHA), Assistant LNHA, and Regional LNHA. The RRN stated that the activity staff were responsible to distribute all the mails to the residents. On 5/9/24 at 10:02 AM, the surveyor interviewed the facility's Director of Recreation and Volunteers (DRV) who stated that as soon as the receptionist/front lobby received the mails, any activity staff on duty will be responsible of delivering mails to the resident's room. The DRV further stated that if the resident was unable to open their mail, the staff will ask and offer to the resident if they would like assistance in opening mails. A review of the facility's Policy and Procedure titled, Mail, Email and Package Distribution indicaed under Action Plan #3. Provided the resident with the choice of privately opening the mail or receiving assistance from the staff. There was no additional information provided. NJAC 8:39-27.5

Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 35 residents (Residents #18, 22, 57, and 64). This deficient practice was evidenced by the following: 1. Resident #18 was observed to have an Annual MDS (AnMDS) with an Assessment Reference Date (ARD) on 6/30/23 was due to be transmitted to CMS no later than 7/14/23. However, the AnMDS was not submitted to CMS until 8/4/23. A review of Quarterly MDS (QMDS) with an ARD on 8/20/23 was due to be transmitted to CMS no later than 9/3/23. However, the QMDS was not submitted until 9/12/23. A review of QMDS with an ARD on 11/16/23 was due to be transmitted to CMS no later than 11/29/23. However, the QMDS was not submitted until 12/6/23. 2. Resident #22 was observed to have an AnMDS with an ARD on 1/1/23 was due to be transmitted to CMS no later than 1/20/23. However, the AnMDS was not submitted to CMS until 2/02/23. A review of Significant Change MDS (ScMDS) with an ARD on 1/13/23 was due to be transmitted to CMS no later than 1/26/23. However, the ScMDS was not submitted until 2/3/23. A review of QMDS with an ARD on 4/8/23 was due to be transmitted to CMS no later than 4/21/23. However, the QMDS was not submitted until 5/8/23. A review of QMDS with an ARD on 7/2/23 was due to be transmitted to CMS no later than 7/15/23. However, the QMDS was not submitted until 7/28/23. A review of QMDS with an ARD on 9/15/23 was due to be transmitted to CMS no later than 9/28/23. However, the QMDS was not submitted until 10/3/23. A review of AnMDS with an ARD on 12/12/23 was due to be transmitted to CMS no later than 12/25/23. However, the AnMDS was not submitted until 1/3/24. 3. Resident #57 was observed to have an admission MDS (AdMDS) with an ARD on 12/20/23. The AdMDS was due to be transmitted to CMS no later than 1/4/24. However, the AdMDS was not submitted to CMS until 1/17/24. 4. Resident #64 was observed to have an AnMDS with an ARD on 10/28/23 was due to be transmitted to CMS no later than 11/12/23. However, the AnMDS was not submitted to CMS until 11/17/23. A review of the undated Final Validation Report for Residents #18, 22, 57, and #64 given by the MDS Coordinator/Registered Nurse (MDSC/RN) revealed that Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). On 5/06/24 at 10:15 AM, the surveyor interviewed the MDSC/RN, who stated that she worked in the facility for almost 21 years and followed the RAI Manual. She was aware that the MDS assessments were all submitted and accepted late. On 5/07/24 at 1:27 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing. The surveyor notified the facility management of the above findings and concerns. NJAC 8:39 - 11.2(e)3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/02/24, at 1:00 PM, the surveyor observed Resident #57 sitting in the wheelchair, alert and oriented, and able to answer the surveyor's inquiry. Resident #57's medical records revealed the following information: According to the admission Record (an admission summary) (AR), Resident #57 was admitted to the facility with diagnoses that included but were not limited to acute pyelonephritis (kidney infection). The Quarterly Minimum Data Set (QMDS), dated [DATE], indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored 14 out of 15, which indicates that the resident is cognitively intact. Review of Section D Resident Mood Interview (PHQ-2 to 9) of the 3/15/24 MDS, signed by the SW on 3/21/24, revealed that there was no documentation of a PHQ-2 to 9 assessment interview performed on the ARD of 3/15/24. A review of admission MDS (AdMDS) dated [DATE], section D PHQ-2 to 9, signed by the social worker (SW) on 1/09/24, revealed that the CSC- PHQ-2 to 9 Evaluation Effective Date: 12/13/2023 17:25 given by the SW was done eight (8) days before the ARD of 12/20/23. 3. On 4/29/24 at 11:44 AM, the surveyor observed Resident #64 in bed, awake, and unable to answer the surveyor's inquiry. Resident #64's medical records revealed the following information: According to the AR, Resident #64 was admitted to the facility with diagnoses that included but were not limited to dementia (impairment of memory) unspecified severity with agitation. The QMDS, dated [DATE] for Resident #64, indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates that the resident's cognition is severely impaired. Review of Section D Staff Assessment of Resident Mood (PHQ-9-OV) of the 3/31/24 QMDS for Resident #64, signed by the SW on 4/24/24, revealed no record of a PHQ-9-OV interview performed for the ARD dated 3/31/24. A review of Modification (02) of Significant Change MDS (ScMDS) dated [DATE] for Resident #64, section D PHQ-9-OV, signed by the SW on 1/30/24, revealed no record of a PHQ-9-OV interview done on the ARD 1/09/24. 4. On 4/29/24 at 11:09 AM, the surveyor observed Resident #37, who had just come out from the bathroom, sitting in a wheelchair. Resident #37's medical records revealed the following information: Review of Resident #37's AR revealed that they were admitted to the facility with diagnoses that included but were not limited to mental disorders not otherwise specified. The AdMDS dated [DATE] for Resident #37, indicated that the facility assessed the resident's cognitive status using BIMS. The Resident #64 scored 15 out of 15, which indicates that the resident's cognition is intact. Review of Section D PHQ-2 to 9 of the 4/05/24 AdMDS for Resident #37, reveals that it was signed by the SW on 4/11/24, but the CSC- PHQ-2 to 9 Evaluation Effective Date: 4/01/2024 14:07 submitted by the SW was done five (5) days before the ARD of 4/05/24. 5. On 4/29/24 at 10:21 AM, the surveyor observed Resident #22 lying in bed, awake and alert but unable to answer the surveyor's inquiry. Resident #22's medical records revealed the following information: Review of Resident #22's AR reveals that they were admitted to the facility with diagnoses that included but were not limited to dementia. Review of the QMDS dated [DATE] for Resident #22, indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates that the resident's cognition is severely impaired. A review of the Annual MDS (AnMDS), dated [DATE] for Resident #22, section M, Determination of Pressure Ulcer (PU) Risk/Injury Risk, does not reflect the stage two (2) PU to the left buttock. The Weekly Skin Review, with effective dates of 12/19/22 and 12/26/22, is revealed under indicate site(s) below left buttock 1.5 cm x 2.5 cm. and an effective date of 12/12/22 and 12/5/22 left buttock 2 cm x 3 cm respectively. On 5/06/24 at 10:12 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) about Resident #22's stage 2 PU to the left buttock that did not reflect in the AnMDS on 1/01/23. The MDSC/RN stated that she had missed capturing the PU on the 1/1/23 MDS. 6. On 4/29/24 at 10:21 AM, the surveyor observed Resident #18 lying in bed, awake, alert, and able to answer the surveyor's inquiry. Resident #18's medical records revealed the following information: According to the AR, Resident #18 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (too much sugar in the blood) without complication. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 12 out of 15, which indicates a moderately impaired cognition. Review of the QMDS Section D PHQ-2 to 9, signed by the SW on 3/07/24, revealed that the SW PHQ-2 to 9 interviews were done twenty-five (25) days before the ARD of 3/31/24. On 5/06/24 at 10:12 AM, the surveyor interviewed the MDSC/RN about the process of PHQ-2 to 9 assessments. She stated that they do not need to follow the ARD; facility management told them that the PHQ-2 to 9 can be done before the ARD. The MDSC/RN stated that the resident could be interviewed before the ARD. On 5/06/24 at 11:30 AM, the surveyor interviewed the SW Director regarding the process of PHQ-2 to 9 assessments; she stated that her process is that she does not follow the ARD. She explained the process was to interview the residents on the first day of admission into the facility. The SW stated that the BIMS is evaluated along with the PHQ-2 of 9 at least within 48-72 hours of the resident's admission into the facility. The SW revealed that the Regional MDS educated her that the assessment, including PHQ-2 to 9, should be done at least 48 hours of a resident's admission. The SW did not provide any further information regarding the PHQ-2 to 9 interviews for Residents #57, #64, and #22. On 5/07/24 at 1:02 PM, the surveyor team met with the regional clinical nurse, administrator, and assistant administrator regarding the concern. No further information was provided. NJAC 8:39-33.2(d) Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 39 residents, Resident #207 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 5/03/24 at 11:16 AM, the surveyor reviewed the closed medical chart for Resident #207 whose discharge MDS was coded for discharge to an acute hospital. The surveyor reviewed the 2/27/24 progress notes under general notes (GN), indicating that Resident #207 Left Against Medical Advice (AMA) around 2:30 pm with all his/her belongings. Review of Resident #207's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to lymphedema, sequelae of cerebral infarction, and mood disorder. Review of the A section of the 2/27/23 Discharge MDS for Resident #207 revealed that section A2105 Discharge Status documented, 04. Short-Term General Hospital. On 5/03/24 at 12:08 PM, the surveyor interviewed the Register Nurse(RN), MDS coordinator (MDS #1). MDS#1 explained, That Resident #207 left the facility AMA. MDS#1 revealed that the facility social worker (SW) who entered their information must have entered that incorrectly. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023). This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. Code 99, Not Listed On 5/6/24 at 9:50 AM, the Regional Clinical Nurse (RCN) provided the surveyors with a facility policy titled, Certifying Accuracy of the Resident Assessment with a revision date of 1.2024. Review of the section, Policy interpretation and implementation section, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. On 5/07/24 at 1:02 PM, the surveyor team met with the RCN, licensed Nursing Home Administrator (LNHA), and Assistant Administrator (AA) regarding concerns. The RCN stated all MDS assessment and paperwork should be filled out correctly and acknowledged there was an error regarding Resident #207 discharge status. No further information provided.

**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 1. follow acceptable standards of clinical practice for accurately administering and documenting medication administered for 2 of 4 residents, Resident #34, and Resident #97 observed during medication administration, and 2. follow a physician's order (PO) to treat varying pain levels for 1 of 5 residents, Resident #171, reviewed for pain management. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/1/24 at 8:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) #1 prepare medications for administration to Resident #34. The surveyor observed LPN #1 remove the medication, Vimpat oral solution, (a medication used to treat seizures), from the medication cart and verify the medication dosage on the resident's electronic medication administration record (eMAR). The surveyor observed LPN #1 verify the PO for Vimpat 10mg/ml oral solution (Lacosamide) Give 12 ml via PEG-Tube ((percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall) every 12 hours for seizure disorder documented on the May 2024 eMAR. The surveyor observed LPN #1 pour the medication into a calibrated plastic medication dose cup. LPN #1 informed the surveyor that the amount of medication is between the markings of 10 milliliters (ml) and 15 ml, assuring the surveyor that it was 12 ml. When LPN #1 was prepared to administer the Vimpat to Resident #34, the surveyor interrupted the administration of Vimpat by LPN #1. LPN #1 informed the surveyor that there was no exact mark for 12 ml. LPN #1 open the medication cart and located a calibrated dose syringe (a device used to accurately measure a specific amount) that was provided by the manufacturer for accurately dosing the Vimpat. LPN #1 was observed disposing the Vimpat in the dose cup and accurately measuring the accurate dose with the calibrated dose syringe that had a marking reflecting 12 ml for administration to Resident #34. On 5/2/24 at 10:02 AM, the surveyor interviewed LPN #1 regarding measuring liquid medications. LPN #1 stated that she normally uses a medication dose cup to measure liquids if they are an amount she can see on the cup. LPN #1 added that for doses of medication not marked on the medication cup, she would use another measuring device that can measure the exact amount. LPN #1 explained that Resident #34 had a previous order for Vimpat 10 ml that was recently discontinued that she could be measured in the medication cup. The surveyor inspected a medication dose cup from a medication cart. The medication dose cup had markings that reflected 2.5 ml, 5 ml, 7.5 ml, 10 ml, 15ml, 20 ml, 25 ml, and 30 ml. A review of the Vimpat manufacturer product information reflected under Dosage and Administration, line 2, DOSAGE AND ADMINISTRATION VIMPAT may be taken with or without food. When using VIMPAT oral solution, it is recommended that a calibrated measuring device be obtained and used. A household teaspoon or tablespoon is not an adequate measuring device. Healthcare providers should recommend a device that can measure and deliver the prescribed dose accurately and provide instructions for measuring the dosage. A review of Resident #34's medical records revealed the following information: Review of Resident #1's documented admission to the facility with diagnoses that included but were not limited to Conversion Disorder with Seizures or Convulsions and Cerebral Palsy. A review of Resident #34's Most Recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated 3/6/24, reflected that the resident had a Brief Interview Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe cognitive impairment. A review of Resident #34's Care Plan (CP) dated 3/15/24 reflected that the resident had a seizure disorder and will be free of seizures. In addition the CP documented, Give medications as ordered. Monitor/document for effectiveness and side effects. and, Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. with initiated dates of 2/15/22. The surveyor reviewed Resident #34's medical record. The current Physician's Order (PO) dated 4/30/24, was for Vimpat Oral Solution 10 mg/ml Give 12 ml via PEG-Tube every 12 hours for seizure was noted on the April and May 2024 electronic medical record (eMAR). The previous PO for Vimpat 10 ml was verified on the April 2024 eMAR. This PO was discontinued on 4/30/24 for Vimpat Oral Solution 10 MG/ML Give 10 ml via PEG-Tube every 12 hours for seizure. Review of the Nursing progress notes dated 4/26/24, reflected the statement resident stable, and there was no further documentation related to Resident #34 experiencing any seizure activity. On 5/1/24 at 1:30 PM, the surveyor discussed the dosing accuracy with Licensed Nursing Home Administrator (LNHA) and Regional Clinical Nurse (RCN). The LNHA and Regional Clinical Nurse acknowledged the discrepancy in dosing accuracy and did not provide any further information at that time. 2. On 5/1/24 at 9:26 AM, the surveyor observed LPN #3 administer medications to resident #97. The surveyor observed an order for Potassium Chloride Oral packet 10MEQ (potassium packet) (a medication used as a supplement or replacement of potassium to the body) documented on the resident's May 2024 eMAR. LPN #3 informed the surveyor that the potassium packet was unavailable and that he would call the pharmacy to see if it could be delivered as soon as possible. LPN #3 explained that Resident #97 had a previous order for a Potassium 20 MEQ but that it was reduced to Potassium 10 meq. LPN #3 documented on the resident's eMAR that the potassium packet was not given with a code of seven (7). The resident's May 2024 eMAR reflects that a code of seven (7) entered by the nurse indicates other/see nurse notes The surveyor reviewed Resident's eMAR for April 2024 and May 2024. The April eMAR reflected an order for Potassium ER Tablet Extended Release 20 meq, Give 1 tablet by mouth one time a day for hypokalemia, originally ordered 4/10/24, ordered and indicated as administered. The April eMAR also reflects an order for Potassium Oral packet 10 meq, Give 10 meq by mouth in the morning for prevent hypokalemia, originally ordered 4/16/24, documented as administered daily except for 4/29/24. Review of the May 2024 eMAR reflected the order for Potassium Oral packet 10 meq, ordered 4/16/24, Give 10 meq by mouth in the morning for prevent hypokalemia ordered and indicated as not given on 5/1/24. On 5/2/24 at 11:30 AM the surveyor interviewed, by telephone, the Pharmacist (RPh) employed by the provider pharmacy who services the facility. The RPh stated that the 4/16/24 order for 10MEQ dose of potassium in powder packets were not available, the facility was notified, and it was not delivered. The RPh explained that on 4/17/24, 4/18/24, 4/19/24 and 4/24/24 several calls were made to the facility, but no one was available. The RPh stated that on 4/25/24 an email referring to this matter was generated to the facility. The RPh indicated that the Potassium 10 meq packets were never delivered to the facility. The Potassium packets indicated as administered on the April 2024 eMAR were found to be unavailable but were initialed as given by the medication nurses on the eMAR. The surveyor reviewed the facility policy titled Administering Medications dated Reviewed 1/2024. The policy reflected on line 2. Medications must be administered in accordance with the orders, including any required time frame and line 5. The individual administering the medications must check the label against the Physician's order to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 5/6/24 the surveyor reviewed the policy for Unavailable Medications dated 1/1/2024 provided by the RCN. The RCN also provided statements from several nurses including LPN #3, that the nurses were administering divided doses of a 20MEQ potassium tablet broken in half, administered the half tablet to Resident #97 and disposed of the other half of the tablets. Review of the policy reflected at line 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications and at line 4.b. notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. On 5/2/24 at 12:17 PM the survey team met with the Regional Clinical Nurse (RCN) and Licensed Nursing Home Administrator (LNHA). The surveyor relayed the information provided by the provider pharmacy to the RCN and administrator. No further information in reference to the medication error or unavailable medications. Surveyor: ADUNA, [NAME] 3. On 5/1/24 at 10:37AM, Resident #171 was observed in the room with eyes closed. The surveyor reviewed Resident #171's hybrid medical record. Review of Resident #171's AR revealed that they were admitted to the facility with diagnoses that included but were not limited to Cellulitis of right lower limb, Myiasis, Peripheral Vascular Disease, and Venous Insufficiency. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 3/11/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that the resident had intact cognition. On 4/30/24 at 11:48 AM, the surveyor reviewed the resident's April 2024 Order Summary Report (OSR) which revealed a PO dated 10/6/23 for Ibuprofen Oral Tablet 800mg (Ibuprofen) Give 1 tablet by mouth every 8 hours as needed for Mild Pain and a PO dated 2/14/24 for Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. Review of the January, February, March, and April 2024 electronic Medication Administration Record (eMAR) revealed that Resident #171 received some doses of Ibuprofen Oral Tablet 800mg 1 tablet for documented pain scale rates between 4 to 8. On 5/2/24 at 10:26 AM, the surveyor interviewed Resident #171's Licensed Practical Nurse #5 (LPN #5), who was assigned to the resident. LPN #5 stated that she considered mild pain to be rated from 1-6. On 5/2/24 at 10:38 AM, the surveyor interviewed Unit Manager #3 (UM #3) who stated that she considered mild pain to be rated from 1-5. UM #3 further stated that she was not sure what pain scale level the nurses on the unit were using. On 5/2/24 at 2:11 PM, the surveyor discussed the above concern with the facility's Regional Registered Nurse (RRN), Licensed Nursing Home Administrator (LNHA), Assistant LNHA, and Regional LNHA. The RRN agreed that for a pain level between 4-8, it was not considered mild pain, but rather moderate to severe pain levels. A review of the facility's policy and procedure titled, Pain-Clinical Protocol did not address specifically the definition and category of mild pain. NJAC 8:39- 29.2 (d)

**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 ensure that pain level assessments were completed according to facility policy for 2 of 4 residents, Resident #77 and #92 who were reviewed for pain management. This deficient practice was evidenced by the following: 1. On 4/29/24 at 11:45 AM, the surveyor interviewed Resident #92 in the 1st floor dayroom, who stated they receive Methadone for daily pain management. On 5/6/24 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse #7 (LPN#7) who explained that residents on routine pain medication, pain level should be assessed and documented only if the resident appears in pain. Review of an admission Record (an admission summary) revealed that Resident #92 was admitted to the facility with diagnoses that included but were not limited to: pain in right foot, pain in left foot, and opioid dependence. A review of the admission Minimum Data Set Assessment (MDS), an assessment tool, used to facilitate the management of care, dated 3/11/24, revealed that the resident had a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident had intact cognition. Review of section N (Medications) of the admission MDS dated [DATE], also revealed that the resident received a scheduled pain medication. Review of the Physician's Orders revealed an order dated 5/6/24 for the following pain medication: Methadone HCl Oral Tablet 10 Milligram (MG) (Methadone HCl). Give 9 tablet by mouth one time a day for Pain Management. Further review of the physician's order, March 2024, April 2024, and May 2024 electronic medication administration records (eMAR) which did not show an order or documentation for pain assessment and monitoring. Review of the resident's March 2024, April 2024, and March eMARs revealed that Resident #92 received the Methadone medication every day with no pain assessment documented. A review of resident's care plan (CP) with a completion date of 3/18/24 revealed a CP for pain with an intervention that stated, complete pain assessment on admission and per facility policy to determine the nature of the discomfort. 2. On 4/29/24 at 11:16 AM, the surveyor interviewed Resident #77 in their room. The resident stated they experienced leg pain for which they received Methadone three times daily for pain management. A review of the resident's medical record revealed the following information. The 2/15/24 Quarterly MDS revealed the resident scored of 14 out of 15 on the BIMS test indicating the resident had an intact cognition. Review of Section I (Active Diagnoses) of the 2/15/24 Quarterly MDS indicated the resident had diagnoses of contracture of the right knee and arthritis. Review Section J (Health Conditions) of the 2/15/24 Quarterly MDS indicated the resident had not experienced pain in the past five days. Review of the April 2024 Physician's Orders included an order for the following pain medication: Methadone HCl Oral Tablet 10 Milligram (MG) (Methadone HCl). Give 4 tablet by mouth three times a day for Pain Management. Further review of the physician's order failed to reveal an order for pain assessment and monitoring. A review of the resident's pain care plan, initiated 11/16/23 and revised 4/29/24, included an intervention complete pain assessment on admission and per facility policy to determine the nature of the discomfort . On 4/29/24 at 12:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Pain-Clinical Protocol with a revised date of 1/2024. Under the monitoring section of the policy it stated, 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift. On 5/1/24 at 10:18 AM the surveyor interviewed Registered Nurse #1. She stated the resident gets a once a week pain assessment which is not documented. On 5/1/24 at 10:32 AM the surveyor interviewed Unit Manager #1. She stated a quarterly pain assessment is documented in the electronic medical record. She further stated that a daily, weekly, or monthly pain assessment is not done. On 5/7/24 at 10:10 AM the surveyors discussed concerns regarding missing pain assessments with the Licensed Nursing Home Administrator and the Regional Clinical Nurse. On 5/8/24 at 12:00 PM the Regional Clinical Nurse stated that pain assessments by nursing should be completed at each shift utilizing the facility pain scale. No further information was provided. NJAC 8:39-27.1(a)

Deficiency Text Not Available

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/29/24 at 09:25 AM, the surveyor in the presence of the Certified Dietary Manager (CDM) and Regional CDM (RCDM) observed the following during the kitchen tour: 1. Upon entering the kitchen the surveyor observed the CDM and Chef both wearing earrings that hung more than one inch (in) from their earlobes. The RCDM acknowledged both the CDM and Chef were wearing jewelry that is prohibited in the kitchen area, both staff members removed their earrings. 2 During the kitchen inspection, the surveyor observed inside the walk-in freezer, frost build up on one of two fans as well as multiple boxed items stacked above 18 inches from ceiling. The CDM stated they have the fan cleaned and have the frost removed, the CDM further stated they will rearrange the boxes, so they are stored below the 18 inches from the ceiling. 3. The surveyor observed inside the walk-in refrigerator, a blackish colored debris build up on two of two fans. The CDM stated, the maintenance department oversees cleaning the fans and they would be alerted immediately. On 5/1/24 at 12:54 PM, the CDM provided the surveyor with multiple facility policies including Uniform Policy, Receivable and Storage Policy, and Reporting Equipment/Maintenance Needs Policy. The Uniform Policy with a revised date of 5/8/17 states under the procedure section, Jewelry should be limited to a wedding band. The Receivable and Storage Policy with a revised date of 9/2023 states under the procedure section, Store all items at least 6 inches off the floor, 18 inches from the ceiling and away from the refrigerator, freezer, and dry storage area walls. The Reporting Equipment/Maintenance Needs Policy with a revised date of 11/2023 states under the procedure section, Food Service Director or Designee will identify equipment or maintenance needs as needed. On 5/2/24 at 2:06 PM, the survey team met with Licensed Nursing Home Administrator (LNHA), Regional Clinical Nurse (RCN), Assistant LNHA (ALNHA) to discuss concerns. The RCN stated they will investigate the kitchen concerns and get back to the surveyor. On 5/7/24 at 10:08 LNHA, RCN and ALNHA met with the survey team for follow up to previous concerns. The LHNA stated they in-serviced the staff for jewelry, no further comment. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18a. On 4/29/24 at 12:29 PM the surveyor reviewed the admission Record for Resident #109. The resident was admitted to the facility with diagnoses that included but were not limited to Chronic Atrial Fibrillation and Bipolar Disorder. A review of the MDS dated [DATE], reflected that Resident #109 had a BIMS score of 15 out of 15, indicating the resident has no cognitive impairment. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #109 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of December 2023 through March 2024. A review of the electronic Order Review History revealed that the attending physician (MD#1) had reviewed the PO and signed by Wet Ink on the date 4/10/24 only. The Sign Source was reflected as Web Application and Sign Method as Password at Login. 18b. A review of the Physician's Progress Notes (PPN) in the electronic medical record revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 4/26/2024, 4/22/2024, 4/18/2024, 4/10/2024, 4/6/2024 and 4/2/2024 but with a created date of 5/3/2024. 2. PPN with an effective date of 4/24/2024, but with a created date of 5/6/2024. 3. PPN with an effective date of 3/29/2024, 3/25/2024, 3/20/2024, 3/16/2024, 3/12/2024 and 3/8/2024 but with a created date of 5/3/2024. 4. PPN with an effective date of 3/4/2024, but with a created date of 5/2/2024. 5. PPN with an effective date of 2/27/2024, but with a created date of 5/2/2024. 19a. On 5/6/24 at 11:10 PM, the surveyor observed Resident #144 in a wheelchair. When the surveyor interviewed, Resident #144 was noted alert and responsive. The surveyor reviewed the admission Record for Resident #144. The resident was admitted to the facility with diagnoses that included but were not limited to Peripheral Vascular Disease and Major Depressive Disorder. A review of the MDS dated [DATE], reflected that Resident #144 had a BIMS score of 15 out of 15, indicating the resident has no cognitive impairment. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #144 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of September 2023 and February 2024. A review of the electronic Order Review History revealed that the attending physician (MD#1) had reviewed the PO and signed by Wet Ink on the following dates: 10/2/23, 11/17/23, 12/1/23, 1/24/24, 3/11/24 and 4/10/24. The Sign Source was reflected as Web Application and Sign Method as Password at Login. 19b. A review of the PPN's in the electronic medical record revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 4/24/2024, but with a created date of 5/3/2024. 2. PPN with an effective date of 4/17/2024, but with a created date of 5/2/2024. 3. PPN with an effective date of 3/13/2024, but with a created date of 3/25/2024. 4. PPN with an effective date of 2/14/2024, but with a created date of 3/4/2024. 5. PPN with an effective date of 1/10/2024, but with a created date of 3/4/2024. 6. PPN with an effective date of 12/6/2023, but with a created date of 12/26/2023. 7. PPN with an effective date of 11/5/2023, but with a created date of 12/26/2023. The facility provided no further documentation for all the residents reviewed. NJAC 8.39-23.2(b) 13. On 05/02/24, at 1:00 PM, the surveyor observed Resident #57 sitting in the wheelchair, alert and oriented, and able to answer the surveyor's inquiry. Resident #57's medical records revealed the following information: According to the admission Record (an admission summary) (AR), Resident #57 was admitted to the facility with diagnoses that included but were not limited to acute pyelonephritis (kidney infection). The Quarterly Minimum Data Set (QMDS), dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 14 out of 15, which indicates that the resident is cognitively intact. A review of monthly Physician Orders (PO) revealed that the primary physician had not hand-signed or electronically signed the orders for December 2023, January 2024, February 2024, and March 2024. 14. On 04/29/24 at 11:44 AM, the surveyor observed Resident #64 in bed, awake, and unable to answer the surveyor's inquiry. Resident #64's medical records revealed the following information: According to the AR, Resident #64 was admitted to the facility with diagnoses that included but were not limited to dementia (impairment of memory) unspecified severity with agitation. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates that the resident is cognitively severely impaired. A review of the monthly PO revealed that the primary physician had not hand-signed or electronically signed the orders for January 2024 and February 2024. 15. On 04/29/24 at 11:09 AM, the surveyor observed Resident #37, who had just come out from the bathroom, sitting in a wheelchair. Resident #37's medical records revealed the following information: According to the AR, Resident #37 was admitted to the facility with diagnoses that included but were not limited to mental disorders not otherwise specified. The Annual MDS (AMDS), dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 15 out of 15, which indicates that the resident is cognitively intact. A review of the monthly PO revealed that the primary physician had not hand-signed or electronically signed the orders for April 2024. 16. On 04/29/24 at 10:21 AM, the surveyor observed Resident #22 lying in bed, awake, alert, and unable to answer the surveyor's inquiry. Resident #22's medical records revealed the following information: According to the AR, Resident #22 was admitted to the facility with diagnoses that included but were not limited to dementia. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates severely impaired cognition. A review of the monthly PO revealed that the primary physician had not hand-signed or electronically signed the orders for February 2024. 17. On 04/29/24 at 10:21 AM, the surveyor observed Resident #18 lying in bed, awake, alert, and able to answer the surveyor's inquiry. Resident #18's medical records revealed the following information: According to the AR, Resident #18 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (too much sugar in the blood) without complication. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 12 out of 15, which indicates that the resident has moderately impaired cognition. A review of the monthly PO revealed that the primary physician had not hand-signed or electronically signed the orders for February 2024.11a. The surveyor interviewed Resident #92 on 4/29/24 at 11:45 AM in dayroom. Resident stated they did not recall seeing their Medical Doctor (MD) recently. A review of the medical record revealed the following information. The resident was admitted with diagnoses including but not limited to pain in right foot, pain in left foot, and opioid dependence. The 3/1/24 Annual Minimum Data Set (AMDS), the resident scored a 14 out of 15 for the BIMS test indicating the resident had no cognitive deficits. A review of monthly physician orders revealed the primary physician had not hand-signed or electronically signed monthly orders for December 2023, February 2024, March 2024, and April 2024. 11b. A review of the PPN's in the electronic medical record revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 4/5/2024, but with a created date of 4/30/2023. 2. PPN with an effective date of 3/6/2024, but with a created date of 3/25/2024. 3. PPN with an effective date of 12/12/2023, but with a created date of 12/17/2023. 4. PPN with an effective date of 10/11/2023, but with a created date of 11/12/2023. 5. PPN with an effective date of 9/22/2023, but with a created date of 9/26/2023. 6. PPN with an effective date of 7/11/2023, but with a created date of 7/26/2023. 12a. The surveyor interviewed Resident #56 on 4/29/24 at 11:32 AM in dayroom. Resident stated they did not recall seeing their Medical Doctor (MD) in few months. A review of the medical record revealed the following information. The resident was admitted with diagnoses including but not limited to type 2 diabetes, hypertension, and peripheral vascular disease. The 4/3/24 AMDS, the resident scored a 13 out of 15 for the BIMS test indicating the resident had no cognitive deficits. A review of monthly physician orders revealed the primary physician had not hand-signed or electronically signed monthly orders for December 2023, February 2024, March 2024, and April 2024. 12b. A review of the PPN's in the electronic medical record revealed the following had a LATE ENTRY designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 4/5/2024, but with a created date of 4/30/2023. 2. PPN with an effective date of 3/6/2024, but with a created date of 3/25/2024. 3. PPN with an effective date of 2/10/2024, but with a created date of 3/3/2024. 4. PPN with an effective date of 1/10/2024, but with a created date of 2/4/2024. 5. PPN with an effective date of 12/12/2023, but with a created date of 12/17/2023. 6. PPN with an effective date of 10/11/2023, but with a created date of 11/12/2023. On 5/2/24 at 10:05 AM, the surveyor conducted a phone interview with NP#1. The NP stated they will see all the resident's and type their progress notes but will leave the note in draft and sign off up to 10 days before signing off. The surveyor reviewed the progress notes differences with between the effective and created dates of Resident #92, with some being a difference of 30 days. The NP had no further comments. On 5/2/24 at 2:06 PM, the survey team met with the LNHA, RCN and AA to discuss concerns. All staff stated they were unaware that the NP was backdating PPN and would in-service all NPs immediately. On 5/3/24 at 12:29 PM, the LNHA provided the surveyor with a facility policy titled, Physician Visits. Under the policy interpretation and implementation, it states, 3/ Non-physician practitioners (Physician Assistant, Nurse Practitioner) may perform required visits (initial and follow-up), sign orders and sign certifications as permitted by state and federal regulations. On 5/7/24 at 10:08 PM, the survey team met with facility staff, no further comments made regarding NP backdating. 9. On 5/1/24 at 10:37 AM, the resident was observed in the room with eyes closed. The surveyor reviewed Resident #171's hybrid medical record. Resident #171 was admitted to the facility with diagnoses that included but not limited to Cellulitis of right lower limb, Myiasis, Peripheral Vascular Disease, and Venous Insufficiency. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 3/11/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that the resident had intact cognition. A review of the PPN's in the electronic medical record revealed the following had a LATE ENTRY (Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry.) designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 3/7/24, but with a created date of 3/11/24 2. PPN with an effective date of 2/14/24, but with a created date of 3/4/24. 3. PPN with an effective date of 11/27/23, but with a created date of 12/26/23. 4. PPN with an effective date of 2/13/24, but with a created date of 2/15/24 10. On 4/29/24 at 11:57 AM, the surveyor observed the resident in bed with eyes closed. Review of the admission Record (a one-page summary of important information about the patient) (AR) reflected Resident #460 was admitted with diagnosis that included but were not limited to Acute Pulmonary Edema, Congestive Heart Failure, Chronic Pulmonary Embolism and Dementia. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 4/29/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 09 out of 15 indicating that the resident had moderately impaired cognition. A review of the PPN's in the electronic medical record revealed the following had a LATE ENTRY designation which indicates the notes were not written on the effective date (Date of service): 1. PPN with an effective date of 4/23/2024, but with a created date of 5/2/24. 3. On 4/29/24 at 11:16 AM, the surveyor observed Resident # 172 in bed in their room with their eyes closed and the resident was unable to be interviewed. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #172 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of September 2023 through March 2024. A review of the resident's Face Sheet with diagnoses that included Anoxic Brain Damage, Chronic Respiratory Failure, Cardiac Arrest, Tracheostomy, Gastrostomy, and Dependence on Respirator Ventilator Status. A review of the QMDS, an assessment tool used to facilitate care management dated 4/1/24, indicated that the resident was severely cognitively impaired. 4. On 4/29/24 at 11:06 AM, the surveyor observed Resident # 183 in bed in their room with their eyes closed and the resident was unable to be interviewed. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #183 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of February 2024 and March 2024. A review of the resident's Face Sheet with diagnoses that included Anoxic Brain Damage, Asthma, Epilepsy, Quadriplegia, Tracheostomy, and Gastrostomy. A review of the QMDS, an assessment tool used to facilitate care management dated 3/31/24, indicated that the resident was severely cognitively impaired. 5. On 4/30/24 at 9:45 AM, the surveyor observed Resident # 86 in bed in their room and was pleasant upon interview. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #86 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of October 2023 through March 2024. A review of the resident's Face Sheet with diagnoses that included Heart Failure, Dependence eon renal Dialysis, Peripheral Vascular Disease, Chronic Viral Hepatitis C, and End Stage Renal Disease. A review of the Annual Minimum Data Set (AMDS), an assessment tool used to facilitate care management dated 3/8/24, indicated that the resident was cognitively intact. 6. On 4/29/24 at 10:59 AM, the surveyor observed Resident # 134 in bed in their room and was pleasant upon interview. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #134 which revealed that the resident's primary care physician had not signed the resident's monthly orders from the months of October 2023 through March 2024. A review of the resident's Face Sheet with diagnoses that included Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Ventilator, Peripheral Vascular Disease and Hydronephrosis. A review of the QMDS, an assessment tool used to facilitate care management dated 2/12/24, indicated that the resident was severely cognitively impaired. On 5/2/24 at 12:23 PM, the surveyor interviewed the Licensed Practical Nurse (LPN # 1), who stated that the physician's sign monthly orders in the electronic medical record and could not provide any further information. 7. On 5/1/24 at 10:12 AM, the surveyor observed Resident #105 self propelling in a wheelchair. When interviewed, Resident #105 was noted alert and responsive. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #105. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #105. A review of the admission Record (one page summary of important information about a resident) for Resident #105. The resident was admitted to the facility with diagnoses that included but were not limited to anemia, asthma, major depressive disorder, adjustment disorder with anxiety, other psychoactive substance dependence, hypertension (high blood pressure) and low back pain. A review of the QMDS, an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that Resident #105 had a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. A review of the resident's monthly physician's orders (PO) revealed that the attending physician (MD#4) had electronically signed the monthly PO on 4/19/24, 12/12/23 and 8/17/23. In addition, the Nurse Practitioner (NP#2) who collaborated with MD#4 had signed the monthly PO on 3/12/24, 2/8/24, 11/11/23 and 9/26/23. There were no monthly PO signed in January 2024. On 5/2/24 at 1:06 PM, the surveyor interviewed the NP#2 who worked in collaboration with the MD#4 via a telephone call. The NP#2 informed the surveyor that she completed an electronic progress note each time she visited which was monthly and as needed. The NP#2 added that she also signs monthly physician's orders but was unsure if there was a timeframe that the physician completed visits and progress notes and signed the monthly orders. The NP#2 further stated that everything was electronic, and that administration would be able to provide me with the documentation. On 5/2/24 at 2:09 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administration (AA), Regional Clinical Nurse (RCN) and Assistant Director of Nursing. The RCN stated that she thought the monthly PO were electronically signed by MD and NP and would have to check. On 5/7/24 at 10:10 AM, the survey team met with the LNHA, AA and RCN. The AA stated that the physician visits had not been completed timely or sequenced with the NP and that all the physicians were reeducated. The AA added that he thought the physician orders could be signed every other month by the NP. On 5/8/24 at 11:57 AM, the survey team met with the LNHA, RCN, AA and [NAME] President of Clinical Nursing. The RCN stated that the facility policy for physician orders being signed was included in the undated facility policy for Physician Visits that had been provided. There was no further documentation provided by the facility. 8. On 5/1/24 at 11:00 AM, the surveyor observed Resident #30 self propelling in a wheelchair. When interviewed, Resident #30 was noted alert and responsive. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #30. A review of the admission Record (one page summary of important information about a resident) for Resident #30. The resident was admitted to the facility with diagnoses that included but were not limited to pneumonia, malnutrition, cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), schizophrenia and human immunodeficiency virus (HIV). A review of the Quarterly Minimum Data Set , an assessment tool used to facilitate the management of care, dated 3/31/24, reflected that Resident #30 had a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. A review of the resident's Order Review revealed that as of 4/12/24 the next order review was 20 days overdue. A review of the electronic Order Review History revealed that the attending physician (MD#1) had reviewed the PO and signed by Wet Ink on the following dates: 10/2/23 11/17/23 12/1/23 1/24/24 3/12/24 A review of the monthly PO titled Order Summary Report that were in the resident's physical chart revealed the following: -the active orders as of 10/1/23 were signed electronically on 11/17/23 by the MD#1. -the active orders as of 11/1/23 were physically signed on 12/1/23 by NP#1. -the active orders as of 12/1/23 were physically signed on 1/24/24 by MD#1. -the active orders as of 2/29/24 were physically signed on 3/12/24 by NP#1. -the active orders as of 3/31/24 were physically signed on 4/17/24 by NP#1. There were no Order Summary Reports physically signed in the resident's chart for April and January 2024. On 5/2/24 at 9:48 AM, the surveyor, in the presence of the survey team, interviewed the NP#1 who worked in collaboration with the attending physician (MD#1) via a speaker telephone call. The NP#1 stated that he entered all visits electronically and could not speak to the frequency of physician visits. The NP#1 added that the MD#1 signed the physician orders on paper. On 5/2/24 at 12:17 PM the surveyor, in the presence of the survey team, interviewed the MD#1 via a speaker telephone call. The MD#1 stated that he was in the facility once a week and that NP#1 completed the physician notes and that he signed the physician orders physically. On 5/2/24 at 2:09 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administration (AA), Regional Clinical Nurse (RCN) and Assistant Director of Nursing. The RCN stated that the physicians frequently visited and thought there was electronic physician's progress notes signed by the MD and NP and would have to check. On 5/7/24 at 10:10 AM, the survey team met with the LNHA, AA and RCN. The AA stated that the physician visits had not been completed timely or sequenced with the NP and that all the physicians were reeducated. The AA added that he thought the physician orders could be signed every other month by the APN. The AA added that MD#1 physically signs the monthly physician orders and would check for Resident #30. On 5/8/24 at 11:57 AM, the survey team met with the LNHA, RCN, AA and [NAME] President of Clinical Nursing (VPCN). The RCN stated that the facility policy for physician orders being signed was included in the facility policy for Physician Visits that had been provided. The VPCN stated that if an attending physician was physically signing the monthly orders for a resident, then signed PO would be in the resident's chart. There was no further documentation provided by the facility. A review of the undated facility policy for Physician Visits provided by the LNHA reflected that the Attending Physician must make visits in accordance with applicable state and federal requirements. In addition, the policy reflected: 2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. 3. Non-physician practitioners (Physician Assistants and Nurse Practitioner) may perform required visits (initial and follow-up), sign orders and sign certifications/re-certifications as permitted by state and federal regulations. 4. After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) day, an alternate schedule of visits may be established, nut not to exceed every sixty (60) days. A physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. Based on interview and record review it was determined that the facility failed to ensure that a). the residents' primary physician signed and dated monthly physician orders for residents under their care and b). facility failed to ensure that the resident's nurse practitioner (NP) accurately dated physician progress notes (PPN) during their visit to ensure that the resident's current medical regimen was up to date. The deficient practice was identified for 19 of 35 residents, Residents #53, #77, #172, #183, #86, #134, #105, #30, #171, #460, #92, #56, #57, #64, #37, #22, #18, #109, and #144 reviewed for physician orders and NP visits. The findings are as follows. 1. The surveyor interviewed Resident #53 on 4/30/24 at 10:00 AM. The resident was awake and alert in bed. A review of the medical record revealed the following information. The resident was admitted with diagnoses including but not limited to spina bifida and peripheral vascular disease. The 4/26/24 Quarterly Minimum Data Set (QMDS), assessment tool reflected the resident scored a 15 out of 15 for the Brief Interview for Mental Status (BIMS) test indicating the resident had no cognitive deficits. A review of monthly physician orders revealed the primary physician had not hand-signed or electronically-signed monthly orders for December 2023, February 2024, March 2024, and April 2024. 2. The surveyor interviewed Resident #77 on 5/1/24 at 10:00 am. The resident was awake and alert in bed. A review of the medical record revealed the following information. The 2/15/24 QMDS, assessment tool reflected the resident scored 14 out of 15 on the BIMS test indicating the resident had no cognitive deficits. Section I indicated the resident had diagnoses including but not limited to contracture of the right knee and pyogenic arthritis. A review of monthly physician orders revealed the primary physician had not hand-signed or electronically-signed monthly orders for December 2023 and February 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17. On 4/29/24 at 12:49 PM, the surveyor observed Resident #109 in bed. When the surveyor interviewed, Resident #109 was noted alert and responsive. The surveyor reviewed the admission Record for Resident #109. The resident was admitted to the facility with diagnoses that included but were not limited to Chronic Atrial Fibrillation and Bipolar Disorder. A review of the MDS dated [DATE], reflected that Resident #109 had a BIMS score of 15 out of 15, indicating the resident has no cognitive impairment. A review of the Physician's progress notes reflected the following: Physician progress notes, reflecting the words LATE ENTRY, dated 4/26/24, 4/22/24, 4/18/24, 4/10/24, 4/6/24 and 4/2/24 with a created date of 5/3/24 completed by the NP #1 A Physician progress note reflecting the words LATE ENTRY, dated 4/24/24 with a created date of 5/6/24 completed by the physician MD #1. Physician progress notes, reflecting the words LATE ENTRY, dated 3/29/24, 3/25/24, 3/20/24, 3/16/24, 3/12/24 and 3/8/24 with a created date of 5/3/24 completed by NP #1. Physician progress notes, reflecting the words LATE ENTRY, dated 3/4/24 with a created date of 5/2/24 completed by NP #1. Physician progress notes, reflecting the words LATE ENTRY, dated 2/27/24 with a created date of 5/2/24 completed by NP #1. Further review of the resident's electronic medical record (EMR) did not reflect any further Physician progress notes completed by the physician. There was no documented evidence that the physician visited and examined Resident #109 at least every 60 days. 18. On 4/30/24 at 10:07 AM, the surveyor observed Resident #187 in bed. When interviewed, Resident #187 was noted alert and responsive. The surveyor reviewed the admission Record for Resident #187. The resident was admitted to the facility with diagnoses that included but were not limited to Essential Hypertension, fracture of left tibia and Major Depressive Disorder. A review of the admission MDS dated [DATE], reflected that Resident #187 had a BIMS score of 15 out of 15, indicating the resident had no cognitive deficits. A review of the Physician's progress notes reflected the following: A Physician progress note, dated 4/10/24,reflecting the words LATE ENTRY with a created date of 4/21/24 completed by the physician (MD #5). Physician progress notes, dated 4/30/24, 4/24/24, 4/22/24, 4/20/24, 4/17/24, 4/15/24 and 4/12/24 completed by APN #1. Physician progress notes, dated 3/20/24, 3/18/24, 3/14/24, 3/12/24, 3/8/24, 3/6/24 and 3/4/24 completed by APN #1. Physician progress notes, dated 2/28/24, 2/26/24, 2/23/24, 2/20/24, 2/19/24, 2/16/24, 2/14/24, 2/12/24, 2/8/24 and 2/7/24 completed by APN #1. A Physician progress note / History and Physical (a note made when a resident is first seen in the facility) dated 2/5/24 completed by APN #1. Further review of the resident's electronic medical record (EMR) did not reflect any further Physician progress notes completed by the physician. The EMR reflected a note with a discharge date of 5/9/24. There was no documented evidence that the physician visited and examined Resident #187 at least every 60 days. 19. On 4/29/24 at 12:49 PM, the surveyor observed Resident #144 in a wheelchair. When the surveyor interviewed, Resident #144 was noted alert and responsive. The surveyor reviewed the admission Record for Resident #144. The resident was admitted to the facility with diagnoses that included but were not limited to Peripheral Vascular Disease and Major Depressive Disorder. A review of the MDS dated [DATE], reflected that Resident #144 had a BIMS score of 15 out of 15, indicating the resident has no cognitive impairment. A review of the Physician's progress notes reflected the following: A Physician progress note, reflecting the words LATE ENTRY, dated 4/24/24, with a created date of 5/3/24 completed by the physician MD #1. A Physician progress note reflecting the words LATE ENTRY, dated 4/17/24 with a created date of 5/2/24 completed by the physician NP #1. Physician progress notes, reflecting the words LATE ENTRY, dated 3/13/24, with a created date of 3/25/24 completed by NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 2/14/24 with a created date of 3/4/24 completed by NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 1/10/24 with a created date of 3/4/24 completed by NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 12/6/23 with a created date of 12/26/23 completed by NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 11/5/23 with a created date of 12/26/23 completed by NP #1. Further review of the resident's electronic medical record (EMR) did not reflect any further Physician progress notes completed by the physician. There was no documented evidence that the physician visited and examined Resident #144 at least every 60 days. 20. On 4/29/24 at 11:39 AM, the surveyor observed Resident #191 in bed. When the surveyor interviewed, Resident #191 was noted alert and partially responsive. The resident was able to respond to surveyor basic questions with yes, no, gestures and facial expressions. The surveyor reviewed the admission Record for Resident #191. The resident was admitted to the facility with diagnoses that included but were not limited to Degenerative Disease of Nervous System and Sickle Cell Disease. A review of the admission MDS dated [DATE], reflected that Resident #191 had a BIMS score of 9 out of 15, indicating the resident has moderate cognitive impairment. A review of the Physician's progress notes reflected the following: A Physician progress note, dated 4/10/24 , reflecting the words LATE ENTRY with a created date of 4/22/24 completed by the physician (MD #5). Physician progress notes, dated 4/18/24 and 4/3/24 completed by APN #1. Physician progress notes, dated 3/21/24, 3/18/24, 3/15/24, 3/13/24, 3/11/24, 3/8/24, 3/6/24, 3/5/24, 3/4/24 and 3/1/24 completed by APN #1. Physician progress notes, dated 2/27/24, 2/26/24 and 2/25/24,completed by APN#1. A Physician progress note / History and Physical (a note made when a resident is first seen in the facility) dated 2/21/24 completed by APN #1. Further review of the resident's electronic medical record (EMR) did not reflect any further Physician progress notes completed by the physician. There was no documented evidence that the physician visited and examined Resident #191 at least every 60 days. 21. Complaint NJ00163003 On 5/7/24 at 12:02 PM, the surveyor reviewed the electronic medical record for Resident #512. The record reflected the resident was discharged from the facility on 8/4/23. The surveyor reviewed the admission Record for Resident #512. The resident was admitted to the facility with diagnoses that included but were not limited to Type 2 Diabetes and Peripheral Vascular Disease. A review of the Quarterly MDS dated [DATE], reflected that Resident #512 had a BIMS score of 12 out of 15, indicating the resident has moderate cognitive impairment. A review of the Physician's progress notes reflected the following: A Physician progress note reflecting the words LATE ENTRY, dated 7/11/23 with a created date of 7/26/23 completed by nurse Practioner (NP) NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 6/6/23, with a created date of 6/15/23 completed by NP #1. A Physician progress note, reflecting the words LATE ENTRY, dated 5/9/23 with a created date of 5/9/23 completed by NP #1. A Care Coordination note, dated 4/10/23 with a created date of 4/10/23 completed by NP #3. A Care Coordination note, dated 3/10/23 with a created date of 3/11/23 completed by APN #2. A Care Coordination note dated 1/27/23 with a created date of 1/27/23 completed by APN # 2. Further review of the resident's electronic medical record (EMR) did not reflect any further Physician progress notes completed by the physician. There was no documented evidence that the attending physician, MD #1 visited and examined Resident #512 at least every 60 days. On 5/3/24 at 12:29 PM, the Administrator provided the facility policy titled Physician Visits to the survey team. The surveyor reviewed the facility policy which reflected on the first line, The Attending Physician must make visits in accordance with applicable state and federal regulations. It also reflected: 1. The attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. 4. After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty (60) days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. N.J.A.C. 8:39-23.2(c) 13. On 4/29/24 at 11:44 AM, the surveyor observed Resident #64 in bed, awake, and unable to answer the surveyor's inquiry. Resident #64's medical records revealed the following information: According to the admission Record (an admission summary) (AR), Resident #64 was admitted to the facility with diagnoses that included but were not limited to dementia (impairment of memory) unspecified severity with agitation. The QMDS dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates that the resident is cognitively severely impaired. A review of the Physician's Progress Notes (PPN) reflected that APN #1 completed the following notes on the following dates: 4/10/24, 3/6/24, 2/14/24, 1/21/24, 1/17/24, 1/13/24, 1/8/24, 1/3/24, 12/26/23, and 11/27/23. 14. On 4/29/24 at 11:09 AM, the surveyor observed Resident #37, who had just come out from the bathroom, sitting in a wheelchair. Resident #37's medical records revealed the following information: According to the AR, Resident #37 was admitted to the facility with diagnoses that included but were not limited to mental disorders not otherwise specified. The AMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 15 out of 15, which indicates that the resident is cognitively intact. A review of the PPN reflected that the APN had completed the following notes on the following dates: 5/6/24 and 4/26/24. 15. On 4/29/24 at 10:21 AM, the surveyor observed Resident #22 lying in bed, awake, alert, and unable to answer the surveyor's inquiry. Resident #22's medical records revealed the following information: According to the AR, Resident #22 was admitted to the facility with diagnoses that included but were not limited to dementia. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 0 out of 15, which indicates that the resident is cognitively severely impaired. A review of the PPN reflected the APN #1 completed the following notes on the following dates: 4/10/24, 3/13/24, 2/14/24, 1/10/24, 12/26/23, and 11/27/23. 16. On 4/29/24 at 10:21 AM, the surveyor observed Resident #18 lying in bed, awake, alert, and able to answer the surveyor's inquiry. Resident #18's medical records revealed the following information: According to the AR, Resident #18 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (too much sugar in the blood) without complication. The QMDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored 12 out of 15, which indicates that the resident has moderately impaired cognition. A review of the PPN reflected that APN #1 completed the following notes on the following dates: 4/17/24, 3/6/24, 2/14/24, 1/10/24, 12/26/23, and 11/27/23. 10. On 4/29/24 at 11:19 AM, the surveyor observed Resident #35 in bed asleep. The surveyor reviewed the admission Record for Resident #35. The resident was admitted to the facility with diagnoses that included but were not limited to chronic respiratory failure with hypoxia, tracheostomy, and paraplegia. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/25/24, reflected that Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating the resident had no cognitive deficits. A review of the Physician's progress notes (PPN) reflected the following: 4/19/2024 PPN completed by Advanced Practice Nurse (APN#1). 3/7/24 PPN completed by APN#1. 2/15/24 PPN completed by APN#1. 1/31/24 PPN completed by APN#1. 1/7/24 PPN completed by APN#1. 12/21/23 PPN completed by APN#2. 11/25/23 PPN completed by APN#1. There was no documented evidence that the physician visited and examined Resident #35 at least every 60 days. 11. On 4/29/24 at 11:45 AM, the surveyor interviewed Resident #92 in dayroom. Resident stated they did not recall seeing their Medical Doctor (MD) recently. The surveyor reviewed the admission Record for Resident #92. The resident was admitted with diagnoses including but not limited to pain in right foot, pain in left foot, and opioid dependence. The 3/1/24 Annual Minimum Data Set (AMDS), the resident scored a 14 out of 15 for the BIMS test indicating the resident had no cognitive deficits. A review of the PPN reflected the following: 4/5/24 PPN completed by Nurse Practitioner (NP#1) 3/6/24 PPN completed by NP#1 12/12/23 PPN completed by NP#1 10/11/23 PPN completed by NP#1 9/22/23 PPN completed by NP#1 There was no documented evidence that the physician visited and examined Resident #92 at least every 60 days. 12. On 4/29/24 at 11:32 AM, the surveyor interviewed Resident #56 in dayroom. Resident stated they did not recall seeing their Medical Doctor (MD) in few months. The surveyor reviewed the admission Record for Resident #56. The resident was admitted with diagnoses including but not limited to type 2 diabetes, hypertension, and peripheral vascular disease. The 4/3/24 AMDS, the resident scored a 13 out of 15 for the BIMS test indicating the resident had no cognitive deficits. A review of the PPN reflected the following: 3/6/24 PPN completed by NP#1 2/10/24 PPN completed by NP#1 1/10/24 PPN completed by NP#1 12/12/23 PPN completed by NP#1 There was no documented evidence that the physician visited and examined Resident #56 at least every 60 days. 8. On 5/1/24 at 10:37 AM, the resident was observed in the room with eyes closed. The surveyor reviewed Resident #171's hybrid medical record. Resident #171 was admitted to the facility with diagnoses that included but not limited to Cellulitis of right lower limb, Myiasis, Peripheral Vascular Disease, and Venous Insufficiency. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 3/11/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that the resident had intact cognition. A review of the Physician's progress notes reflected that there was no documented evidence that the physician visited and examined Resident #171 at least every 60 days from November 2023 through April 2024. 9. On 04/29/24 11:57 AM, the resident was observed in the room with eyes closed. The surveyor reviewed Resident #72's hybrid medical record. Resident #72 was admitted to the facility with diagnoses that included but not limited to Seizures, Chronic Ischemic Heart Disease, Hypertension, Benign Prostatic Hypertrophy. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 4/28/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 06 out of 15 indicating that the resident had intact cognition. A review of the Physician's progress notes reflected that there was no documented evidence that the physician visited and examined Resident #72 at least every 60 days from November 2023 through April 2024. 4. On 4/29/24 at 11:16 AM, the surveyor observed Resident # 172 in bed in their room with their eyes closed and the resident was unable to be interviewed. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #172 which revealed that the resident's primary care physician had not written a progress note from September 2023 to March 2024. A review of the resident's Face Sheet with diagnoses that included Anoxic Brain Damage, Chronic Respiratory Failure, Cardiac Arrest, Tracheostomy, Gastrostomy, and Dependence on Respirator Ventilator Status. A review of the QMDS, an assessment tool used to facilitate care management dated 4/1/24, indicated that the resident was severely cognitively impaired. 5. On 4/29/24 at 11:06 AM, the surveyor observed Resident # 183 in bed in their room with their eyes closed and the resident was unable to be interviewed. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #183 which revealed that the resident's primary care physician had not written a progress note for the month February 2024. A review of the resident's Face Sheet with diagnoses that included Anoxic Brain Damage, Asthma, Epilepsy, Quadriplegia, Tracheostomy, and Gastrostomy. A review of the QMDS, an assessment tool used to facilitate care management dated 3/31/24, indicated that the resident was severely cognitively impaired. 6. On 4/30/24 at 9:45 AM, the surveyor observed Resident # 86 in bed in their room and was pleasant upon interview. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #86 which revealed that the resident's primary care physician had not written a progress note for the month of January 2024. A review of the resident's Face Sheet with diagnoses that included Heart Failure, Dependence eon renal Dialysis, Peripheral Vascular Disease, Chronic Viral Hepatitis C, and End Stage Renal Disease. A review of the Annual Minimum Data Set (AMDS), an assessment tool used to facilitate care management dated 3/8/24, indicated that the resident was cognitively intact. 7. On 4/29/24 at 10:59 AM, the surveyor observed Resident # 134 in bed in their room and was pleasant upon interview. The surveyor reviewed the hybrid medical records (paper and electronic) for the Resident #134 which revealed that the resident's primary care physician had not written a progress note from November 2023 to March 2024. A review of the resident's Face Sheet with diagnoses that included Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Ventilator, Peripheral Vascular Disease and Hydronephrosis. A review of the QMDS, an assessment tool used to facilitate care management dated 2/12/24, indicated that the resident was severely cognitively impaired. On 5/2/24 at 12:23 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that the physician's should be writing progress notes in the electronic medical record and could not provide any further information. 2. On 5/1/24 at 10:12 AM, the surveyor observed Resident #105 self -propelling in a wheelchair. When interviewed, Resident #105 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #105. The resident was admitted to the facility with diagnoses that included but were not limited to anemia, asthma, major depressive disorder, adjustment disorder with anxiety, other psychoactive substance dependence, hypertension (high blood pressure) and low back pain. A review of the Quarterly Minimum Data Set , an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that Resident #105 had a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. A review of the Physician's progress notes reflected the following: 4/4/24 Physician progress notes were completed by Nurse Practitioner (NP#2). 2/15/24 Physician progress notes were completed by NP#2. 12/12/23 Physician progress notes were completed by NP#2. 9/26/23 Physician progress notes were completed by the NP#2 8/26/23 Physician progress notes were completed by NP#2. 8/17/23 Physician progress notes were completed by the attending physician (MD#4). There were no Physician progress notes for March or January 2024 and October or November 2023. There was no documented evidence that the physician visited and examined Resident #105 at least every 60 days. On 5/2/24 at 1:06 PM, the surveyor interviewed the NP#2 who worked in collaboration with the MD#4 via a telephone call. The NP#2 informed the surveyor that she completed an electronic progress note each time she visited which was monthly and as needed. The NP#2 added that she also signs monthly physician's orders but was unsure if there was a timeframe that the physician completed visits and progress notes and signed the monthly orders. The NP#2 further stated that everything was electronic, and that administration would be able to provide the documentation. On 5/2/24 at 2:09 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administration (AA), Regional Clinical Nurse (RCN) and Assistant Director of Nursing. The RCN stated that the physicians frequently visited and thought there was electronic physician's progress notes signed by the MD and NP and would have to check. On 5/7/24 at 10:10 AM, the survey team met with the LNHA, AA and RCN. The AA stated that the physician visits had not been completed timely or sequenced with the APN and that all the physicians were reeducated. The AA added that he thought the physician orders could be signed every other month by the APN. On 5/8/24 at 11:57 AM, the survey team met with the LNHA, RCN, AA and [NAME] President of Clinical Nursing. The RCN stated that the facility policy for physician orders being signed was included in the undated facility policy for Physician Visits that had been provided. There was no further documentation provided by the facility. 3. On 5/1/24 at 11:00 AM, the surveyor observed Resident #30 self -propelling in a wheelchair. When interviewed, Resident #30 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #30. The resident was admitted to the facility with diagnoses that included but were not limited to pneumonia, malnutrition, cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD), schizophrenia and human immunodeficiency virus (HIV). A review of the Quarterly Minimum Data Set , an assessment tool used to facilitate the management of care, dated 3/31/24, reflected that Resident #30 had a Brief Interview for Mental Status score of 15 out of 15, indicating an intact cognition. A review of the Physician's progress notes reflected the following: 4/10/24 Physician progress notes completed by NP#1. 3/13/24 Physician progress notes completed by NP#1. 3/10/24 Physician progress notes completed by NP#1. 3/5/24 Physician progress notes completed by the NP#1. 2/14/24 Physician progress notes completed by NP#1. 12/26/23 Physician progress notes completed by NP#1. 11/27/23 Physician progress notes completed by NP#1. 10/27/23 Physician progress notes completed by NP#1. 8/18/23 Physician progress notes completed by NP#1. There was no physician progress notes for January 2024 or for September 2023. There was no documented evidence that the physician visited and examined Resident #30 at least every 60 days. On 5/2/24 at 9:48 AM, the surveyor, in the presence of the survey team, interviewed the NP#1 who worked in collaboration with the attending physician (MD#1) via a speaker telephone call. The NP#1 stated that he entered all visits electronically and could not speak to the frequency of physician visits. The NP#1 added that the MD#1 signed the physician orders on paper. On 5/2/24 at 12:17 PM the surveyor, in the presence of the survey team, interviewed the MD#1 via a speaker telephone call. The MD#1 stated that he was in the facility once a week and that NP#1 completed the physician notes and he signed the physician orders physically. On 5/2/24 at 2:09 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator (LNHA), Assistant Administration (AA), Regional Clinical Nurse (RCN) and Assistant Director of Nursing. The RCN stated that the physicians frequently visited and thought there was electronic physician's progress notes signed by the MD and NP and would have to check. On 5/7/24 at 10:10 AM, the survey team met with the LNHA, AA and RCN. The AA stated that the physician visits had not been completed timely or sequenced with the NP and that all the physicians were reeducated. The AA added that he thought the physician orders could be signed every other month by the APN. The AA added that MD#1 physically signs the monthly physician orders and would check for Resident #30. On 5/8/24 at 11:57 AM, the survey team met with the LNHA, RCN, AA and [NAME] President of Clinical Nursing (VPCN). The RCN stated that the facility policy for physician orders being signed was included in the facility policy for Physician Visits that had been provided. The VPCN stated that if an attending physician was physically signing the monthly orders for a resident, then they would be in the resident's chart. There was no further documentation provided by the facility. A review of the undated facility policy for Physician Visits provided by the LNHA reflected that the Attending Physician must make visits in accordance with applicable state and federal requirements. In addition, the policy reflected: 2. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. 3. Non-physician practitioners (Physician Assistants and Nurse Practitioner) may perform required visits (initial and follow-up), sign orders and sign certifications/re-certifications as permitted by state and federal regulations. 4. After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) day, an alternate schedule of visits may be established, nut not to exceed every sixty (60) days. A physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation. Based on interview and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 21 of 36 residents (77, 105, 30, 172, 183, 86, 134, 171, 72, 35, 92, 56, 64, 37, 22, 18, 109, 187, 144, 191, 512) reviewed for physician visits and was evidenced by the following: 1. On 4/29/24 at 11:16 AM, the surveyor observed Resident #77 in bed. When interviewed, Resident #77 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #77. The resident was admitted to the facility with diagnoses that included but were not limited to right knee contracture and pyogenic arthritis. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/15/24, reflected that Resident #77 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident had no cognitive deficits. A review of the Physician's progress notes reflected the following: 3/13/24 Physician progress notes completed by Advanced Practice Nurse (APN). 2/25/24 Physician progress notes completed by APN. 2/05/24 Physician progress notes completed by APN. 1/23/24 Physician progress notes completed by APN. 1/07/24 Physician progress notes completed by APN. 12/30/23 Physician progress notes completed by APN. 11/28/23 Physician progress notes completed by APN. There was no documented evidence that the physician visited and examined Resident #77 at least every 60 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint Intake #NJ153708 Based on record review, interviews, and facility policy review, it was determined that the facility failed to report an injury of unknown origin to the required entities for 1 (Resident #3) of 3 residents reviewed for injuries of unknown origin. Specifically, the facility failed to report to the state agency when Resident #3 was identified to have bruising on the hand that was later identified as fractured fingers. Findings included: The facility's policy, titled, Unusual Occurrence Reporting, revised January 2021, indicated, As required by federal or state regulation, our facility reports unusual occurrences [that] occurred at the facility premises or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. The policy further specified, Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. A review of Resident #3's admission Record revealed the facility admitted the resident with diagnoses that included Alzheimer's dementia, disorders of bone density and structure, difficulty walking, primary disorder of muscle, and osteoporosis with pathological fractures of the left hand. A review of the five-day Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had severely impaired cognitive skills for daily decision making, per the Staff Assessment for Mental Status. The resident required extensive to total assistance with their activities of daily living (ADLs). The resident had no falls prior to the assessment. A review of Resident #3's Care Plan, initiated on 01/19/2022, indicated the resident was at risk for falls related to gait and balance problems. Interventions included to anticipate and meet the resident's needs; be sure call light was within reach and encourage the resident to use it for assistance as needed; and the resident needed prompt response to all requests for assistance. The Care Plan, initiated on 03/28/2022, revealed Resident #3 was non-compliant with wearing a splint on their left hand. The Care Plan, initiated on 03/30/2022, indicated Resident #3 was resistive to care. Interventions included: If the resident resisted with ADLs, reassure the resident, leave, and return 5 to 10 minutes later and try again; padded siderails to prevent injury; two staff members to assist with hygiene care; provide consistency in care to promote comfort with ADLs; and maintain consistency in timing of ADLs, caregivers and routine, as much as possible. A review of the Progress Notes, revealed a nurse's note, dated 03/28/2022, indicating Resident #3's left hand and fingers were observed to be swollen with a bluish discoloration when the nurse went to check the resident's blood sugar at 7:30 AM. The note indicated Resident #3 only spoke Spanish/Portuguese, and the resident told a Spanish-speaking Certified Nurse Aide (CNA) they had fallen and had complaints of pain to the left hand, left hip, and left leg. The note indicated the resident was seen by the Nurse Practitioner (NP), who ordered x-rays. A review of the Progress Notes revealed a physician progress note, dated 03/28/2022, indicating Resident #3 had bruising with swelling and pain of unknown cause to their left hand, including the left second and third fingers. The plan was to obtain x-rays. A review of a Radiology Results Report, dated 03/28/2022, indicated Resident #3 had fractures of the fourth and fifth fingers on the left hand and the age of the fractures could not be determined. A review of the incident report, dated 03/28/2022, indicated the resident could be combative and resistive to care. A review of the facility's investigation of the bruise, dated 03/28/2022, indicated the nurse reported Resident #3's left hand was swollen and discolored. The investigational summary indicated the resident's siderails on the bed were to be padded to prevent injury. A review of the witness statements from staff that cared for Resident #3 and were working prior to and at the time of the 03/28/2022 incident revealed the resident did not have a fall, and the resident was not involved in any type of known incident. A review of the Progress Notes revealed a general note, dated 03/29/2022, indicating x-ray results were received and called to the physician with orders to send the resident to the hospital for evaluation. The note indicated Resident #3 was sent out to the hospital for evaluation at 12:07 AM and returned back to the facility at 5:18 AM with a splint on their fingers. The note indicated the resident was combative with the Emergency Medical Service (EMS) staff, attempting to hit them, and removed the splint. A review of the Progress Notes revealed a physician progress note, dated 03/29/2022, indicating Resident #3 had fractures to the fourth and fifth fingers with swelling and bruising and the age of the fractures could not be determined. The note indicated the plan was to splint the hand and fingers, and that the resident had been noncompliant so far. The note further indicated to apply ice to the resident's hand three times a day, elevate the left hand, and discontinue the subcutaneous heparin due to the risk being greater than the benefits. The note indicated the staff reported the resident was noncompliant with the splint, ripped it off, and would not allow staff to reapply it. The note indicated the resident had a history of noncompliance, agitation, and aggressive behavior. A review of the Progress Notes revealed a physician progress note, dated 03/30/2022, indicating the resident's left fourth and fifth finger fractures were suggestive of a pathological process due to osteopenia and osteoporosis after review of all the information and radiological findings. A copy of the report submitted to the state agency for an injury of unknown origin was requested from the facility on 01/23/2023 and was not provided by the end of the survey. During an interview on 01/25/2023 at 9:38 AM, the Director of Nursing (DON) stated at first they thought Resident #3 obtained the bruising from a fall, since that was what the resident reported to their Spanish-speaking CNA, but after the investigation that included the Physician Assistant (PA) and the Medical Director (MD), it was determined the resident did not fall but had a pathological fracture (fracture that occurred due to a disease). The DON stated the resident was on an anticoagulant (blood thinning medication) and was combative. She stated the intervention they put into place was to pad the siderails on the bed, and the resident was to wear a splint on their hand, which they were non-compliant with. The DON stated she did not consider the incident to be something that would need to be reported to the state since they had determined the cause but then did agree that it should have been reported before the investigation occurred and not during or after. During an interview on 01/25/2023 at 12:44 PM, the Administrator stated Resident #3 was on an anticoagulant that caused the bruising, and the fracture was determined to be pathological. He stated it was an injury of unknown origin when it was found and should have been reported, per their policy. New Jersey Administrative Code § 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review facility documents, it was determined that the facility failed to maintain the rights of a resident during medication administration. This was found with 1 of 7 residents observed during medication pass, Resident # 14. The deficient practice was evidenced by the following: On 2/3/22 at 8:21 AM, the surveyor observed a Licensed Practical Nurse (LPN) preparing medication for Resident #14. The LPN crushed the following medication; Klonopin 0.5 mg (a medication used to treat anxiety, panic disorders, and seizures) Chewable Aspirin 81 mg, Cogentin 0.5 mg (a medication that helps decrease muscle stiffness), Depakote Sprinkles 125 mg (a medication used to treat seizures and bipolar disorder), Trileptal 300 mg (a medication used to treat seizures), and Risperdal 0.25 mg (a medication used to treat Schizophrenia, bipolar disorder, or irritability associated with autistic disorder). After crushing the medication the LPN put the crushed medication in a cup of Ensure (a liquid nutritional supplement) and stirred it. The LPN then brought the drink into the resident's room and stated Here's your Ensure. The resident sat up and drank all of the Ensure with the medication in it. On 2/3/22 at 8:31 AM, the surveyor asked the LPN why he crushed the medication and put it in the Ensure drink. The LPN said [The resident] won't take the medication. [The resident] doesn't think [the resident] needs the medication. [The resident] thinks [the resident] is still driving trucks. The doctor wrote an order that we can crush the medication and put it in the Ensure. The doctor is aware that the resident is getting the medication without [the resident's] knowledge. On 2/3/22 at 9:00 AM, the surveyor reviewed the resident's medical record which revealed the following: A physician's order sheet (POS) with an order that read May crush medication and put it in Ensure two times a day. The order date was 11/30/21. The POS also had an order that read Ensure Plus 8 oz. PO three times a day for supplement. The order date was 1/30/22. The most recent completed assessment, the admission Minimum Data Set assessment dated [DATE], indicated that the facility performed a Brief Interview for Mental Status (BIMS) which the resident scored an 11 out of 15 which indicated that the resident had moderate cognitive impairment. A Social Worker note dated 2/5/22 that read BIMS assessment completed today. Resident BIMS score 0.0. BIMS category: Severely Impaired. On 2/3/22 at 1:30 PM, the survey team spoke with the Director of Nursing (DON), The Administrator, and three regional nurses. The surveyor explained the concern with the LPN administering medication to Resident #14 in a liquid supplement and not telling the resident that the resident was receiving medication. The DON stated It's not proper. I have to speak to the nurse and the doctor about that. It's not right. It's not proper. On 2/9/22 at 10 AM, the surveyor reviewed the facility's undated policy and procedure titled Resident Rights Policy and Procedure. Under Policy it read It is the Facility's policy to ensure that each resident shall be entitled to all the rights as is required by applicable statutes and regulations. Under Procedure it read All the Facility residents are entitled to the following rights d. To refuse medication and treatment after the resident has been informed, in a language that the resident understands, of the possible consequences of this decision. NJAC 8:39-4.1 (a) 4

**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 nail care for residents who were unable to do it themselves. This was found with 2 of 2 residents reviewed for range of motion, Resident # 23, and Resident # 128. The deficient practice was evidenced by the following: 1. On 1/31/22 at 10:33 AM, the surveyor observed Resident #23 laying in bed. The resident had contractures of the left and right hand and right arm. The nails on the right hand appeared long. The surveyor was unable to see the fingers on the left hand due to the hand being in a closed position. On 2/1/22 at 10:45 AM, the resident was in bed watching television. The hands were contracted. The nails were long on the right hand. The surveyor was unable to see the fingers on the left hand. On 2/2/22 at 9:00 AM, the surveyor reviewed the resident's medical record which revealed the following: An annual Minimum Data Set assessment dated [DATE] which had a Brief Interview for Mental Status Assessment where the resident scored an 11 out of a possible 15. This indicated that the resident had moderate cognitive impairment. On 2/8/22 at 9:24 AM, the surveyor asked Certified Nursing Assistant # 1 (CNA) if she could help the surveyor see the residents fingers. CNA #1 was having trouble opening the residents hands. The surveyor asked CNA #1 how she cleaned the residents hands. CNA #1 said she put the wash cloth under the hands, into the palms, and through the digits. The surveyor asked CNA #1 when she cut the resident's nails. CNA #1 said she never cuts resident's nails. The surveyor asked CNA #1 who cuts the resident's nails. CNA #1 said someone at night must cut the resident's nails because sometimes when she would come in there would be nails all over the bed. On 2/8/22 at 9:31 AM, the surveyor asked the Licensed Practical Nurse (LPN) to observe the resident's hands. The LPN gently opened the resident's hands. The LPN agreed that the resident's nails were long on both hands. The thumb nail on the right hand was black and over grown into a backward position. The LPN said he hadn't noticed the thumb nail before. The surveyor asked the LPN when was the last time he did a skin check for the resident. The LPN said he did skin checks weekly but he didn't check the resident's hands when he did a skin check. The surveyor asked the LPN who was responsible for cutting the resident's finger nails. The LPN said the Podiatrist was responsible for cutting the residents finger nails. On 2/8/22 at 9:50 AM, the surveyor asked the Unit Manager/Licensed Practical Nurse (UM/LPN) who was responsible for cutting the residents nails. The UM/LPN said the CNAs were responsible for cutting the resident's nails. On 2/8/22 at 10:17 AM, the UM/LPN went into the residen'ts room to cut the residents fingernails. The surveyor went into the resident's room and observed the UM/LPN cutting the nails. The resident was cooperating. The resident stated I know my nails are long and have to be cut. On 2/8/22 at 10:30 AM, the UM/LPN came out of the resident's room and said the resident was letting her cut the resident's nails but the resident kept saying it hurt so she would stop and go back to it. The UM/LPN agreed that having long fingernails could further complicate the condition of the resident's contracted hands. On 2/9/22 at 10:10 AM, the surveyor observed the wound doctor examine the resident's hands. The wound doctor confirmed that there was no wound on the resident's hands. The wound doctor said the resident had an extreme case of a fungal infection which caused the right thumb nail to grow out of control. The wound doctor said the best approach would be for him to inject a numbing agent into the thumb, cut the nail back, and then maintain the growth by trimming it periodically. The surveyor asked how long it would have taken the nail to become that overgrown. The wound doctor said that it would take years for the nail to get like that. On 2/8/22 1:50 PM, the surveyor spoke to CNA #2 who said that she didn't have time to cut anyone's nails because they didn't have enough staff. She further stated It is ten to two and I haven't finished washing my residents yet and I haven't had lunch. On 2/8/22 at 2:00 PM the surveyor asked CNA #2 where she would look to see what care tasks each resident required and where they documented the care that was given. CNA #2 showed the surveyor the Activities of Daily Living (ADL) Flow Sheet for January 2022. There was no ADL flow sheet for February 2022 in the binder that held the ADL flow sheets. For the whole month of January 2022 there were only 4 entries that showed that care was provided. The sheet indicated that on those shifts the resident received a bed bath. The opposite side of the sheet where the resident's care needs should have been checked off was left blank. There was no care need information. 2. On 1/31/22 at 11:22 AM, the surveyor observed Resident #128 laying in bed awake, the resident did not respond when spoken to. The resident's fingers appeared contracted. The fingers appeared tight against the palms on both hands. On 2/4/22 at 11:11 AM, the surveyor observed the resident in bed. The resident did not respond when spoken to. The fingers remained in a closed position on both hands. On 2/8/22 at 10:43 AM, the surveyor checked the resident's hands with the LPN. There were no wounds on the hands. The hands were clean. The nails were long and dirty on most fingers. On 2/8/22 at 10:44 AM, the surveyor checked the resident's hands with the UM/LPN. The UM/LPN agreed that the residents nails were long and some were long and dirty. The UM said it was the CNAs responsibility to cut the resident's nails. The UM/LPN agreed that the residents nails needed to be cut. On 2/8/22 at 11:30 AM the surveyor reviewed the resident's medical record which revealed the following: A quarterly Minimum Data Set assessment dated [DATE] which had a Brief Interview for Mental Status Assessment where the resident scored a 5 out of a possible 15. This indicated that the resident had severe cognitive impairment. On 2/9/22 at 11:00 AM the surveyor reviewed the Activities of Daily Living (ADL) Flow Sheet for January 2022. There was no ADL flow sheet for February 2022 in the binder that held the ADL flow sheets. For the whole month of January 2022 there were only 4 entries that showed that care was provided. The sheet indicated that on those shifts the resident received a bed bath. The opposite side of the sheet where the resident's care needs should have been checked off was blank. There was no care need information. On 2/9/22 at 11:20 AM, the surveyor reviewed the facility's policy and procedure titled Activities of Daily Living, updated 6/2021. Under Policy it read Patient's ADLs are evaluated by a licensed nurse and members of the interdisciplinary team upon admission and with significant change. A program of assistance and instruction in ADL skills is implemented as appropriate. Assistive devices and adaptive equipment are provided as needed. ADL care is documented every shift by the nursing assistant on an ADL flow sheet. Under Practice Standards it read 1. Facility must ensure that: 1.2 A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygeine. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to store insulin vials consistent with manufacturer specifications and failed to properly label a vial of insulin. This was found with 2 of 5 medication carts inspected. The deficient practice was evidenced as follows: On 2/1/22 at 12:34 PM, the surveyor inspected the third floor medication cart for the C Side in the presence of the Registered Nurse who was assigned to the cart. There was a vial of Lispro insulin that was unopened in the cart. The bag that contained the vial of insulin had a sticker on it that read Refrigerate until opened. There was also a vial of Lantus insulin that was in the cart unopened. There was a sticker on the box that held the vial that said Refrigerate until opened and on the bag that held the box and the vial that read Refrigerate until opened. On 2/1/22 at 12:45 PM, the surveyor inspected the third floor medication cart for the A Side in the presence of the Licensed Practical Nurse that was assigned to the cart. There was a vial of Humalog insulin that was unopened in the cart. The bag that held the insulin had a sticker on it that read Refrigerate until opened. There was also an opened insulin vial. The vial or the box that held the vial had no pharmacy label with a resident's name. The bag that held the box and vial had a pharmacy label on it with a resident's name. On 2/3/22 at 1:34 PM, the surveyor spoke to the Director of Nursing (DON) and the Administrator. The surveyor shared the concern with the unopened insulin being stored in the medication cart instead of the refrigerator and the insulin with no pharmacy label with a resident's name that matched the pharmacy label on the bag that held it. The DON confirmed that the insulin vials that were unopened should have been in the refrigerator and the vial of insulin should have had a pharmacy label on it with a resident's name that matched the label on the bag. On 2/9/22 at 12:00 PM, the surveyor reviewed the facility's undated policy and procedure titled 7.0 Insulin Pen Labeling & Packaging. The regional nurse that provided it stated This is from the pharmacy for pens and vials. They have nothing specific for vials. Under Policy it read Insulin pens are to be individually labeled and placed in a reclosable plastic bag to control the spread of infection. The surveyor then reviewed the facility policy and procedure with a review date of 11/2021 and titled Medication Storage. Number 6 read Medication will be stored at the appropriate temperature in accordance with manufacturer and pharmacy labeling. NJAC 8:39-29.4 (a), (h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to have sufficient nursing staff to meet the needs of residents. The facility did not schedule enough staff to ensure residents' activities of daily living (ADL) needs were met for 2 residents, #137 and #23, who were dependent on staff for ADLs. The deficient practice is evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift. (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties; and (3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum . A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the weeks beginning 1/16/22 and 1/23/22 revealed the following: The facility was not in compliance with the State of New Jersey minimum staffing requirements of CNAs during the 7:00 AM - 3:00 PM shift for 14 days beginning 1/16/22 and ending 1/29/22 as evidenced by the following: - 01/16/22 had 10 CNAs for 156 residents on the day shift, required 20 CNAs. - 01/17/22 had 10 CNAs for 156 residents on the day shift, required 20 CNAs. - 01/18/22 had 12 CNAs for 156 residents on the day shift, required 20 CNAs. - 01/19/22 had 10 CNAs for 156 residents on the day shift, required 20 CNAs. - 01/20/22 had 9 CNAs for 156 residents on the day shift, required 20 CNAs. - 01/21/22 had 12 CNAs for 158 residents on the day shift, required 20 CNAs. - 01/22/22 had 10 CNAs for 158 residents on the day shift, required 20 CNAs. - 01/23/22 had 10 CNAs for 158 residents on the day shift, required 20 CNAs. - 01/24/22 had 11 CNAs for 159 residents on the day shift, required 20 CNAs. - 01/25/22 had 11 CNAs for 159 residents on the day shift, required 20 CNAs. - 01/26/22 had 11 CNAs for 159 residents on the day shift, required 20 CNAs. - 01/27/22 had 11 CNAs for 159 residents on the day shift, required 20 CNAs. - 01/28/22 had 9 CNAs for 167 residents on the day shift, required 21 CNAs. - 01/29/22 had 10 CNAs for 167 residents on the day shift, required 21 CNAs. Additionally, the facility was deficient in total staff for residents on 1 of 14 evening shifts as follows: -01/29/22 had 15 total staff for 167 residents on the evening shift, required 17 total staff. On 2/1/22 at 10:10 AM, the surveyor interviewed Resident #137. The resident stated they were waiting to get washed. The resident stated the previous day they got washed in the afternoon even though they told staff they preferred to get washed at 9:00 AM. CNA #1 stated they are working short of staff and it is impossible for three CNAs (the amount of CNAs scheduled for the unit on 2/1/22) to honor everyone's preferences. On 2/1/22 at 10:45 AM, the surveyor interviewed CNA #2 who was assigned to Resident #23. The CNA stated she had 15 residents on her assignment that day. The CNA further stated she tried her best (to take care of residents in a timely manner) but she had a lot of residents and could only move so fast. On 2/8/22 at 1:50 PM, the surveyor interviewed CNA #3 regarding residents' nail care. She stated she doesn't have time to cut residents' nails because there is not enough staff. She stated she had not finished washing her residents (at 1:50 PM) and had not taken a lunch break. On 2/9/22 at 12:30 PM, the surveyor discussed the staffing ratio concerns with the Director of Nursing (DON) and the Staffing Coordinator (SC). The SC stated she was aware of the current required staffing ratios and aware that the facility has been short on staff. The DON and the SC discussed the various ways the facility is recruiting new staff. The SC stated 2 new CNAs were hired the previous day. The facility policy titled Staffing, updated 10/21, indicated the facility provides enough staff with the skills and competency necessary for all residents in accordance with resident care plans and the facility assessment. NJAC 8:39- 25.2

Based on observation, interview, and record review it was determined that the facility failed to follow effective infection control practices to reduce the spread of infection during the 2/3/22 medication pass. The deficient practice was identified for 2 nurses, Licensed Practical Nurse (LPN) #1 and #2, of 6 nurses observed during the Medication Administration Task and is evidenced as follows: On 2/3/22 at 8:40 AM, the surveyor observed LPN #1 prepare to administer medications to a resident. LPN #1 determined the blood pressure machine battery needed to be charged. LPN #1 obtained a blood pressure machine from LPN #2, who was administering medications on an adjacent hallway on the same unit. LPN #1 did not sanitize the blood pressure machine before or after measuring the resident's blood pressure. When questioned by the surveyor, LPN #1 stated she would sanitize the machine before using it on the next resident. The surveyor completed the medication pass observation of LPN #1 at 9:00 AM and immediately approached LPN #2 to begin the next medication pass observation. LPN #2 stated he needed to retrieve the blood pressure machine from LPN #1. LPN #2 returned to the medication cart with the blood pressure machine. LPN #2 donned gloves, did not sanitize the blood pressure machine, entered the resident's room and used the machine on the resident. LPN #2 removed the gloves, and without performing hand hygiene, began to pour medications for administration to the resident. LPN #2 removed medications from inside the medication cart, including a bottle of eye drops in a plastic zip lock bag and a box of tissues. After pouring the medications, LPN #2 donned gloves and touched multiple drawer pulls on the medication cart and locked the cart with gloved hands. The nurse placed the eye drop container in the zip lock bag and the box of tissues on the resident's over bed table. There were numerous personal items of the resident's on the over bed table. LPN #2 administered oral medications and eye drops to right and left eyes with the soiled gloves. LPN #2 removed his gloves and washed his hands in the resident's bathroom. He lathered his hands outside of running water for 15 seconds. LPN #2 confirmed facility policy required at least 20 seconds of lathering outside of running water. LPN #2 removed the eye drop bottle, plastic zip lock bag, and tissue box from the resident's over bed table and returned them to the inside of the medication cart without first sanitizing the surfaces. The surveyor interviewed LPN #2 after the medication pass observation and reviewed the breaks in infection control practices with the nurse. He expressed understanding of the omissions concerning hand hygiene, sanitizing medical equipment after use, and sanitizing items before returning them to the medication cart. On 2/3/22 at 9:20 AM, the surveyor returned to interview LPN #1 who stated it would have been best practice to sanitize the blood pressure machine immediately after use. On 2/3/22 at 9:30 AM, the surveyor discussed the infection control concerns with the LPN Unit Manager. He expressed understanding and stated he would educate LPN #1 and #2. On 2/3/22 at 1:30 PM, the surveyor reported the concerns to the Administrator, Director of Nursing (DON), and regional staff persons. On 2/7/22 at 9:45 AM the DON provided the surveyor with the following facility policies: 1. Handwashing/Hand Hygiene, updated 1/2022, included directives to perform hand hygiene after removing gloves. The policy indicated that hands are to be vigorously lathered with soap for a minimum of 20 seconds. The policy further directed that hand hygiene is the final step after removing and disposing of personal protective equipment. 2. Cleaning and Disinfecting Non-Critical Resident Care items, revised/reviewed 10/2021, indicated reusable items (i.e. stethoscopes, durable medical equipment) are cleaned and disinfected between residents. NJAC 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, from 2/01/22 to 2/03/22, it was determined that the facility failed to maintain a clean and sanitary environment. This deficient practice was identified for 3 of 3 resident occupied floors in the facility. This deficient practice was evidenced by the following: 1. Resident room [ROOM NUMBER] dirty ceiling vent 2. Resident room [ROOM NUMBER] baseboard heater falling apart (missing covers) 3. Resident room [ROOM NUMBER] packaged terminal air conditioner (PTAC) unit dirty 4. Resident room [ROOM NUMBER] PTAC louvers dirty 5. Resident room [ROOM NUMBER] dirty PTAC unit, with food embedded into top grill 6. Resident room [ROOM NUMBER] dirty PTAC unit, with food embedded into top grill 7. Resident room [ROOM NUMBER] ceiling tiles stained and dirty by the window 8. Resident room [ROOM NUMBER] holes in the sheetrock wall 9. Resident room [ROOM NUMBER] cove base falling off the lower wall 10. Resident room [ROOM NUMBER] bathroom ceiling tiles stained 11. Resident room [ROOM NUMBER] bathroom sink falling off the wall mount bracket 12. Resident room [ROOM NUMBER] linoleum sheet flooring damaged 13. Resident room [ROOM NUMBER] broken PTAC unit 14. Resident room [ROOM NUMBER] dirty ceiling tiles 15. Resident room [ROOM NUMBER] broken glass on resident photo 16. Resident room [ROOM NUMBER] damaged PTAC unit 17. Resident room [ROOM NUMBER] missing privacy curtain An interview with the Maintenance Director during the observations, where he stated and agreed that the above findings were confirmed. The Administrator was notified of the findings at the Life Safety Code exit conference on 2/03/22. NJAC 8:39-31.4(a)

Based on observation, interview, and record review, conducted from 2/01/22 to 2/03/22 in the presence of the Maintenance Director, it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in safe and optimal condition. This deficient practice was evidenced for 102 of 102 PTAC units observed by the following: While touring the facility from 9:00 AM to 1:00 PM, the surveyor observed that PTAC units had clogged and dirty filters in the following resident rooms: 335, 334, 333, 332, 331, 330, 329, 328, 327, 326, 325, 324, 323, 322, 321, 320, 318, 317, 316, 315, 314, 313, 312, 311, 310, 309, 308, 307, 306, 305, 304, 303, 302, and 301 235, 234, 233, 232, 231, 230, 229, 228, 227, 226, 225, 224, 223, 222, 221, 220, 218, 217, 216, 215, 214, 213, 212, 211, 210, 209, 208, 207, 206, 205, 204, 203, 202, and 201 135, 134, 133, 132, 131, 130, 129, 128, 127, 126, 125, 124, 123, 122, 121, 120, 118, 117, 116, 115, 114, 113, 112, 111, 110, 109, 108, 107, 106, 105, 104, 103, 102, and 101 When interviewed at the time of the observations, the Maintenance Director agreed that the PTAC filters should not be like that in the facility. A log indicated that PTAC filters was not provided and no policy and procedure on the maintenance of PTAC units were provided at that time. The Administrator was notified of the deficiency at the Life Safety Code exit conference on 2/03/22. NJAC 8:39 - 31.2(e)

Based on observation and interview from 2/01/22 to 2/03/22, in the presence of the Maintenance Director, it was determined that the facility failed to ensure that wooden handrails were installed, secured and splinter free in all required locations. This deficient practice was evidenced by the following: From 2/01/22 to 2/03/22, while touring the facility from 9:45 AM to 12:15 PM, the surveyor observed wooden handrails that were not secured and splinter free on Floors #3, #2, #1 and ground floor in all areas of the facility. At that same time, an interview was conducted during the observations with the Maintenance Director, who had agreed and confirmed that the areas observed did have wooden handrails that needed to be sanded, finished, installed and secured. The Administrator was notified of the deficiency at the Life Safety Code exit conference on 2/03/22. NJAC 8:39-31.2(e)

5 . Resident #32's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021, December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 6 . Resident #41's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021, December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 7 . Resident #51's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021, December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 8. Resident #71's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021, December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 9. Resident #86's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021, December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 10. Resident #99's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 11. Resident #100's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for December 2021 and January 2022 monthly physician's orders was not in the chart and there was no electronic signature. 12. Resident #144's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021 and December 2021 monthly physician's orders was not in the chart and there was no electronic signature. Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 18 of 33 residents (Resident #48, #59, #76, #34, #100, #51, #71, #144, #41, #32, #86, #99, #149, #128, #137, #78, #55, and #60) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition there were no electronic signatures under the physician's orders for the following residents: 1. Resident #48's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021 and December 2021. In addition, the monthly physician's orders for January 2022 and February 2022 were not in the chart and there were no electronic signatures. 2. Resident #59's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021 and December 202. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 3. Resident #76's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician orders for November 2021 and December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 4. Resident #34's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021 and December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. On 2/4/22 at 11:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Managers (LPN/UM #1 and #2) from the first floor and third floor. Both LPN/UM#1 and #2 confirmed January Order Summary Reports were not on the chart and further stated 11-7 nurse was responsible for putting the monthly orders in residents chart. 13. Resident #78's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 14. Resident # 128's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for October 2021, November 2021, or December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 15. Resident # 137's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for October 2021, November 2021, or December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 16. Resident # 149's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 17. Resident #55's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for September 2021, October 2021, November 2021, and December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. 18. Resident #60's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2021. In addition, the January 2022 and February 2022 monthly physician's orders were not in the chart and there were no electronic signatures. On 2/4/22 at 12:38 PM, the surveyors discussed the above findings with the Director of Nursing and Administrator. On 2/7/22 at 10:00 AM the surveyor interviewed the LPN/UM #3 on the second floor. The LPN/UM #3 confirmed the January and February Order Summary Reports were not in the chart. He stated the 11-7 staff person is responsible for putting the orders in the chart. On 2/7/22 the Director of Nursing provided the surveyors with the facility policy titled Physician Orders, reviewed 10/2021. The policy indicated all orders must be signed by an authorized, credentialed physician or other authorized practitioner in accordance with state regulations regarding prescriptive privileges. NJAC 8:39-23.2

2. Review of the admission Record reflected that Resident #46 was admitted to the facility with diagnoses that included, but were not limited to, respiratory failure and functional quadriplegia (inability to move arms and legs). On 02/12/20 at 10:30 AM, the surveyor conducted an initial tour of the Residential Estates nursing unit. Resident #46 was observed in his/her room, lying in bed on his/her back. The resident had a tracheostomy (a surgical opening in the windpipe). LPN #3 was in the resident's room and stood at the resident's bedside. At that time, the surveyor observed the facility's contracted Phlebotomist as she entered the room to draw Resident #46's blood. The Phlebotomist removed her coat and placed it on a chair. Without wearing any gloves and without performing hand hygiene, the Phlebotomist reached inside her black bag of supplies and removed an orange tourniquet, cotton balls, needles, band-aides and alcohol pads. After gathering these supplies, the Phlebotomist reached inside her shirt pocket and removed a pair of blue gloves which she then donned (applied) without performing hand hygiene. After she donned gloves, the Phlebotomist tied the tourniquet around Resident #46's left upper arm and cleansed the resident's hand with an alcohol pad. She then tore the glove tip off of the index finger and began to palpate (feel for a vein) the resident's left hand with the exposed index finger. When the Phlebotomist found a hand vein, she inserted the needle into the vein and drew the blood. She then removed the tourniquet from around the resident's arm and returned the tourniquet to the supply bag. Without removing her gloves, the Phlebotomist removed clean gloves from a clear plastic bag labeled, biohazard and placed the clean gloves into her black bag of supplies. She then labeled the blood specimen tubes and answered her phone. After a two-minute conversation, the Phlebotomist removed her gloves and then left the resident's room without performing hand hygiene. When interviewed on 02/12/20 at 11:00 AM, the Phlebotomist stated that she had worked for the company for about three months and that she had not been paying attention to what she was doing. The Phlebotomist also stated that she should have washed her hands prior to performing the blood draw and afterwards. The Phlebotomist stated that she always ripped the tip of the glove off in order to find the vein. She stated that touching the cleansed skin area with an unwashed, exposed finger, can cause contamination and infection. On 02/12/20 at 11:10 AM, the surveyor interviewed LPN #3 who was in the room during the blood draw. LPN #3 stated that although she was standing next to the resident's bed, she had not watched the Phlebotomist. LPN #3 stated that she did not know that she was required to watch contracted employees perform a task. During an interview conducted by the surveyor on 02/12/20 at 11:15 AM, RN/UM #2 stated that she was a new employee to the facility. RN/UM #2 stated that LPN #3 should have informed the Phlebotomist to wash her hands prior to touching the resident. RN/UM #2 also stated that LPN #3 should have monitored how the Phlebotomist performed the procedure. RN/UM #2 stated that she will educate her staff on monitoring contracted employees. During an interview conducted by the surveyor on 02/24/20 at 2:20 PM, the DON stated that she was currently filling the role of Infection Preventionist for the facility. The DON stated that staff had told her about the incident with the Phlebotomist and that she educated the Phlebotomist. The DON stated that LPN #3 should have known to monitor and correct the Phlebotomist regarding infection control and should have reported the incident to RN/UM #2. According to the facility's Hand Hygiene, policy, dated November 2017, staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. The policy indicated that hand hygiene was a general term that applied to either handwashing or the use of antiseptic hand rub, also known as alcohol-based hand rub and that .the use of gloves does not replace handwashing and to wash hands after removing gloves. NJAC 8:39-27.1 (a) Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate infection control practices for handling soiled linen and performing hand hygiene, in accordance with the facility's policies and procedures. This deficient practice was identified for 1 of 1 staff nurse and 1 of 1 contracted laboratory technician (Phlebotomist) observed and was evidenced by the following: 1. On 02/20/20 at 12:01 PM, the surveyor observed Resident #87 awake in bed. During an interview at that time, the resident stated, they are not helping me, my hip is infected. The resident pointed to a closet and said, They threw the thing that came from my hip into the closet floor. It is saturated with drainage from my hip. Open the closet. You will see it on the floor, open it. When asked what the item was, the resident stated that it was a towel he/she put on the hip wound to soak up the drainage from the wound. The resident stated that he/she threw the towel on the floor because it was saturated with wound drainage. The resident stated that a nurse came into his/her room, saw the soiled towel on the floor, picked the towel off the floor and threw it in the closet. The surveyor then opened the closet door and found the soiled soaked towel on closet floor. The surveyor noted a heavy foul smell in the closet. While the surveyor was still in the room, the resident's Licensed Practical Nurse (LPN #3) walked into the resident's room. On 02/20/20 at 12:17 PM, the surveyor interviewed LPN #3 who stated that she put the soiled towel in the closet because Resident #87 had requested cough medicine. She stated she placed the towel in the closet and then left to get the resident's cough medicine. LPN #3 opened the closet door, removed the soiled towel from the closet floor and placed it inside a plastic bag. At that time, the surveyor inquired about infection control practices for soiled linen. LPN #3 stated that the closet was not the right place to have put the soiled towel and that she had the intention of coming back to remove the towel from the closet. She acknowledged that placing the soiled towel in the closet was not appropriate. Review of the admission Record revealed the resident was admitted to the facility with diagnoses that included, but were not limited to, infection and inflammatory reaction due to other internal prosthetic devices and cellulitis (bacterial skin infection). Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 01/07/20, indicated that Resident #87 had a Brief Interview of Mental Status of 15, which meant the resident was not cognitively impaired. The MDS also showed that the resident had venous and arterial ulcers, required two-person assistance with bed mobility, did not walk, and required one-person assistance with personal hygiene. Review of the Order Summary Sheet, dated 02/24/20, included an active physician order, dated 02/21/20, to cleanse the left hip s/p [status post] hardware infection with NSS [normal saline solution], pat dry, apply silver alginate [absorbs drainage], and cover with a dry dressing daily. Every day for wound care and as needed. On 02/21/20 at 11:45 AM, the surveyor observed LPN #4 perform a wound treatment of Resident #87's left hip wound. The surveyor noted the wound was malodorous with a moderate amount of drainage. When interviewed on 02/24/20 at 2:08 PM, the Director of Nursing (DON) stated that it was a violation of infection control and facility policy for LPN #3 to place the soiled linen on the floor of the resident's closet. Review of the facility's Handling Soiled Linen policy, dated November 2017, reflected that all used linen should be treated as potentially contaminated and that linens that were visibly soiled with blood or large amounts of bodily fluids, required special handling. The policy indicated that transmission of pathogens can occur from the handling of contaminated linen and that soiled linen should be collected at the bedside, placed in a bag, and then placed in a designated receptacle. Review of the facility's Infection Prevention and Control Program Policy, dated November 2017, reflected that laundry and direct care staff shall handle, store, process and transport linens so as to prevent the spread of infection. The policy included that soiled linen would be collected at the bedside, placed in a linen bag and then placed in the soiled utility room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) maintain the residents' environment and equipment in a clean, sanitary condition and b.) ensure that the residents' care equipment was in good repair. This deficient practice was identified in 2 of 3 units inspected for clean homelike environment and was evidenced by the following: 1. On 02/12/20 between 9:32 AM and 2:18 PM, during the initial tour of the third floor unit, the surveyor observed that there was a dark brown thick stain at the bottom of the toilets and a light brown ring around the water line in the following bathrooms: room [ROOM NUMBER] Rooms 303-304 Rooms 305-306 room [ROOM NUMBER] room [ROOM NUMBER] Rooms 309-310 Rooms 311-312 Rooms 313-314 room [ROOM NUMBER] room [ROOM NUMBER] Rooms 321-322 Rooms 323-324 Rooms 325-326 Rooms 330-331 room [ROOM NUMBER] room [ROOM NUMBER] On 02/12/20 at 10:13 AM, the surveyor interviewed Resident #253 who resided in one of the rooms above. The resident stated that the toilet bowl was dirty. The surveyor observed a brown/black substance on the inside of the toilet bowl and a brownish ring around the water line inside the toilet. Review of the admission Minimum Data Set (MDS), an assessment tool dated 02/03/20, revealed that Resident #253 had a Brief Interview of Mental Status score of 14, meaning that the resident was cognitively intact. On 02/13/20 at 10:26 AM, the surveyor interviewed Housekeeper #1 regarding the toilet bowls. Housekeeper #1 demonstrated how she cleansed the toilet and stated that she was unable to remove the black/brown ring and dark stain in the toilet. Housekeeper #1 then sprayed the toilet with a cleansing product and attempted to clean with toilet brush but she was not able to remove the black/brown build up at the bottom of the toilet or the ring around the water line. She stated to the surveyor that she tried her hardest but was unable to remove the stain. On 02/13/20 at 10:40 AM, the surveyor interviewed Housekeeper # 2 on the third floor. She stated that she had worked at the facility for 11 years and that the stain was rust build up and that she was unable to remove the stains. She stated that the toilets were getting old and probably needed to be replaced. On 02/13/20 at 10:50 AM, the surveyor interviewed the Housekeeping Director (HD), who stated that she has been working at the facility for 13 years. She stated that the housekeepers were unable to remove the black/brown build up in the toilets with the cleaning products they had. She stated that they ordered stones for housekeeping staff to clean the toilets monthly as a special project. When asked for the schedule and the last time the toilet bowls were cleaned with the stones, she did not provide the special project assignment. On 02/13/20 at 11:29 AM, the surveyor interviewed the Regional Manager of Housekeeping (RHM) and he stated that he ordered the stones and was waiting for the order to come in. Review of the receipt, provided by the Administrator, showed the stones were ordered on 02/12/20, which was after surveyor inquiry. RHM stated that the stains were caused by hard water and that the facility should clean the toilets with a pumice stone monthly. He stated that the toilets appeared not to be maintained clean by using the pumice stone to remove the stains in the toilet and that the HD should be checking for the stains during her rounds. On 02/18/20 at 1:47 PM, the surveyor inspected all toilets, and noted that all the above toilets were cleaned and the stains were removed after surveyor inquiry. On 02/24/20 at 10:47 AM, the surveyor reviewed the facility's Hard Water Stains in Sink/Toilet document which was provided by the Administrator. The document showed that on 01/26/20, the Administrator identified that there was an escalation of issues of hard water stains in some sinks and toilets on the second floor. The document did not contain any further information regarding the plan to clean the above third floor toilets. The surveyor reviewed the facility's undated, Bathroom Cleaning Housekeeping In-Service Training document which indicated that daily cleaning will ensure optimum levels of cleanliness and sanitation. 2. On 02/12/20 at 12:28 PM, the surveyor observed Resident #140 seated in a wheelchair in the day room. The surveyor could not interview the resident due to the resident's cognitive deficit. Review of the admission MDS, dated [DATE], revealed that the resident had a Brief Interview of Mental Status score of 8, meaning that the resident had moderate cognitive impairment. On 02/13/20 at 9:41 AM, the surveyor went into the resident's room and observed that both bottom drawer fronts on the resident's dresser were missing. On 02/20/20 at 9:00 AM, the surveyor interviewed Resident #140's Certified Nursing Assistant (CNA #1) who was in Resident #140's room. CNA #1 stated that she came back to work on 02/12/20 and observed the missing drawers and that she informed the nurse but could not remember which nurse she told. On 02/20/20 at 9:10 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM #1) who stated that she reported the missing drawers twice before on the maintenance logging system in the computer but she could not remember the date she reported the missing drawers. On 02/20/20 at 9:15 AM, the surveyor interviewed Maintenance Worker #1 who stated that he does not remember if there was a work order for the dresser and that he usually closed a work order after he completed the work. On 02/20/20 at 09:20 AM, the surveyor interviewed the Maintenance Director who that the facility identified broken furniture and developed a plan to address the issue in the beginning of February 2020. He stated that they were going to swap out broken or missing furniture with furniture in rooms that had no residents. He stated that Resident #140's dresser was one of the ones identified as broken. He did not provide information for why the dresser was not swapped out for the resident. The surveyor reviewed an undated document titled, First Quarter 2020 QAPI, that was provided by the Administrator. The document included work orders that included Resident #140's dresser, which was identified as broken on 12/27/19 at 9:39 AM. There was no further information provided as to why the dresser was not swapped out until after surveyor inquiry on 02/20/20. On 02/20/20 at 9:40 AM, the surveyor informed the Administrator of the findings. On 02/24/20 at 10:47 AM, during a meeting with the facility administration, the Administrator stated that everybody in the facility knew the process for reporting resident furniture and equipment issues to maintenance. He also stated that the facility did not have a written protocol or policy for maintaining the residents' furniture.5. During a tour of the facility's Presidential Unit on 02/12/20 from 11:20 AM to 12:30 PM, the surveyor observed the following: In room [ROOM NUMBER], there was a large patch of cracked and missing floor tiles in front of the toilet. The dresser was chipped and exposed the wood underneath. In room [ROOM NUMBER], the glass window was missing and was covered with a piece of wood. There was a trash can underneath the bathroom sink and water from the sink was draining into the trash can. In room [ROOM NUMBER], the bottom dresser drawer was missing. In room [ROOM NUMBER], the cove base molding was missing. When interviewed on 02/24/20 at 11:56 AM, the Maintenance Director did not provide information regarding the above areas and how long they have been in disrepair. Review of the facility's Maintenance Policies and Procedures, dated 01/02/18, showed that the facility was supposed to provide preventive maintenance on equipment. NJAC 8:39-31.2 (a) 3. During the tour of the first floor nursing unit on 02/20/20 at 11:01 AM, the surveyor observed that the bathroom ceiling in room [ROOM NUMBER] had a large area of a brown colored stain. On 02/20/20 at 12:35 PM, the surveyor accompanied CNA #2 and Licensed Practical Nurse (LPN #1) into room [ROOM NUMBER]'s bathroom to observe brown stain on the ceiling. Both LPN #1 and CNA #2 stated that they were not aware of the stain and did not know what it was or how long the stain was there. CNA #2 stated that she was not a regular staff member on the unit. LPN #1 stated that she would report it to maintenance. At that time, the surveyor brought Maintenance Worker #1 to room [ROOM NUMBER] and showed him the bathroom ceiling. He stated that he was not made aware of the stained area. He also confirmed that the stain was from a water leak and that it was wet. He added that he would check the room above the bathroom to see if there was a leak. Maintenance Worker #1 stated that any staff who saw a problem in the building was supposed to report it to maintenance. 4. During the tour of the first floor on 02/12/20 at 11:30 AM, the surveyor observed Resident #92 who was seated in a Geri-chair (a large, padded reclining chair) in the dayroom. The surveyor noted that the leather covering on both of the arm rests and the foot rest was ripped and torn which exposed the foam material inside. The Geri-chair was observed in this same condition on 02/20/20 at 12:43 PM, where the resident was being fed lunch by CNA #3 in the dining room. At that time, the surveyor interviewed CNA #3 regarding the ripped arm and foot rests. CNA #3 stated that maintenance and the unit manager were aware of the chair's condition and that she thought it was going to be replaced. CAN #3 declined to answer further questions about the Geri-chair and did not provide information regarding the facility protocol for reporting broken residents chairs. Resident #92 was not able to be interviewed due to his/her cognitive status. On 02/20/20 at 12:51 PM, the surveyor accompanied RN/UM #2 into the dining room and together observed the Geri-chair's torn arm and foot rests. She acknowledged the ripped areas and stated that she was not made aware of the Geri-chair's condition. RN/UM #2 added that staff was supposed to inform her or maintenance if they saw any equipment in disrepair. RN/UM #2 also stated that she was not sure if maintenance was made aware of the condition of the resident's Geri-chair. On 02/21/20 at 2:36 PM, the Administrator stated that Resident #92 was provided a different Geri-chair after surveyor inquiry. On 02/24/20 at 1:26 PM, the Administrator stated that they identified the ripped arm and foot rests on 02/03/20 and determined that Maintenance was unable to make the required repairs. During an interview with the Maintenance Director on 02/24/20 at 11:56 PM, he stated that once they received a list of broken equipment, they usually fixed the problems as they were listed and not according to priority. He stated that they have a computer logging system and that maintenance staff checked their log about twice a day to obtain broken equipment lists. He stated that in addition to the computer log, they also received lists of broken equipment through hand written requests.