Based on observation, interview, record review and policy review it was determined the facility failed to document PO (by mouth) intake of a resident who is NPO (nothing by mouth). This deficient practice was observed for 1 of 9 residents reviewed for Nutrition, Resident #40, and was evidenced by the following: On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed and their ongoing Tube Feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device that is placed with its tip in the stomach or small intestine) machine. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Muscle Weakness. A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate management of care, dated 7/2/24, revealed the resident's Brief Interview of Mental Status score could not be obtained due to cognitive impairment. A review of the October 2024 Physician's Order Summary revealed a physician's order dated 10/5/23 for, NPO diet, NPO texture, NPO consistency. A review of Resident #40 care plan (CP) with a reviewed date of 9/27/24 revealed under the nutrition portion of the CP with a Focus statement titled, Resident is at risk for malnutrition related problem secondary to enteral feeding tube/PEG as their primary source of nutrition and hydration r/t NPO status. A review of the most recent progress notes (PN) from the Registered Dietitian (RD) dated 9/27/24 at 6:58 AM stated, RD enteral/quarterly review: Diet order: NPO. Enteral Order: Glucerna 1.2 via G-tube at 75 milliliters per hour (ml/hr)., Total volume to infuse: 1500ml. Free water flush 160ml every 6 hours plus medication pass. This provides 1800 calories, 90 grams protein, and 1850 ml fluid plus medication pass. Recommendations: Continue current nutrition Plan of care (POC), Monitor tolerance to EN support. Goals: Maintain PO meal and snack intake >50% through next review date. See care plan for detailed goals and interventions. Will continue to monitor PO intake. On 10/11/24 at 12:07 PM, the surveyor interviewed the RD#1 via a phone call who stated, Resident #40 was NPO (nothing per orem (mouth) and does not take food or medication via mouth. The RD further stated that she made a mistake documenting to Maintain PO meal/snack intake >50% through next review date in her PN. The facility was unable to provide the surveyor with a policy regarding accuracy of documentation. On 10/15/24 at 12:02 PM, the survey team met with the Licensed Nursing Home Administrator , Director of Nursing, Chief Nursing Officer, and Regional Nurse Educator to discuss the above concerns. All agreed that the residents who had a physician's order for NPO should not have goals or recommendations regarding PO intake in the RD's notes. No further information provided. NJAC 8:39- 29.3 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/9/24 at 10:05 AM and 10/16/24 at 11:50 AM, the surveyor observed Resident #45 seated in a wheelchair in the dining room, unable to respond to the surveyor's questions. Resident #45 did not observe the resident wearing a hand splint to the left hand on both days. On 10/16/24 at 9:45 AM, the surveyor reviewed the eMR of Resident #45, which revealed the following: A review of the AR reflected that Resident #45 was admitted to the facility with diagnoses that included but were not limited to Hemiplegia (complete loss of strength on one side of the body) and Hemiparesis (partial weakness on one side of the body) following non-traumatic subarachnoid hemorrhage (bleeding in the brain) affecting left non-dominant side. A review of the most recent Q/MDS, dated [DATE], reflected that Resident #45 had a BIMS score of 7 out of 15, indicating severely impaired cognition. Further review of the Q/MDS under Section GG titled, Functional Limitation in Range of Motion reflected that the resident had impairment on one side of the upper extremity (shoulder, elbow, wrist or hand). A review of the resident's October 2024 OSR reflected a PO dated 4/2/24 for Left palm Splint: Apply after breakfast, remove before dinner check skin integrity to left hand before applying and after removal of the splint in the morning for Splint and remove per schedule. On 10/16/24 at 11:50 AM, the surveyor interviewed CNA #2, who stated that the resident was supposed to wear a carrot splint (a type of orthotic device that is used to position the finger away from the palm to protect the skin from moisture, pressure and nail puncture). CNA #2 went to the resident's room to look for a splint and found the splint on the bedside table. CNA #2 stated that she was unaware Resident #45 had to wear the splint in the morning. On 10/16/24 at 12:01 PM, the surveyor interviewed the LPN#2, who stated that the resident was supposed to wear a splint and added that the CNA's were supposed to put it on the resident and the nurses will document it to reflect that the resident's splint was applied. On 10/16/24 at 12:05 PM, the surveyor interviewed the Director of Rehab/Occupational Therapy (DOR/OT), who stated that Resident #45 had an order for the carrot splint for the left hand; she stated that all the staff, including nurses and the CNAs on the morning shift, was in service of how to put on the splint. On 10/16/24 at 1:15 PM, the survey team met with the LNHA, DON, Chief Nursing Officer (CNO), and Regional Nurse Educator (RNE) to discuss the concern. The staff agreed that if there's an order for devices, the resident should be wearing them. A review of the facility policy titled Splinting Procedure with a reviewed/revised date of December 2023 stated under 8. Nursing staff in-serviced on appropriate application techniques and monitoring requirements specifically associated with equipment . 3. On 10/9/24 at 11:49 AM and 10/17/24 at 10:05 AM, the surveyor observed Resident #96 in bed with eyes closed. On both observation days, Resident #96 was not observed wearing their heel boots on both feet. On 10/16/24 at 1:12 PM, the surveyor reviewed the eMR of Resident #96, which revealed the following: A review of the AR reflected that Resident #96 was admitted to the facility with diagnoses that included but were not limited to Bipolar (a mental illness that causes extreme mood swings) Disorder. A review of the recent Q/MDS, dated [DATE], reflected that Resident #96 had a BIMS score of 10 out of 15, indicating moderately impaired cognition. A review of the resident's October 2024 OSR reflected a PO dated 7/8/24 to Apply heel booties to b/l (bilateral) feet daily while in bed every shift for preventative care. On 10/17/24 at 10:05 AM, the surveyor interviewed CNA#3 regarding the heel boots. CNA #3 went to the resident's bedside table to get them and apply the heel boots to the resident. On 10/17/24 at 10:10 AM, the surveyor interviewed CNA #4 who stated that the resident had their blanket on and CNA#4 did not see whether the resident were wearing the heel booties. On 10/17/24 at 10:20 AM, the surveyor interviewed LPN #3, who confirmed that Resident #96 had a PO for heel booties to both feet while in bed after checking the eMR. On 10/17/24 at 11:00 AM, the surveyor interviewed the DON regarding the above concern. The DON acknowledged that if the resident had a PO for heel boots, it should be followed as stated in the PO. A review of the Facility policy's Medication and Treatment reviewed/revised date of January 2024, Pressure Ulcer/Skin Breakdown-Clinical Protocol reviewed/revised date of December 2023, and Splinting Procedure reviewed/revised date of December 2023, did not address complete orders and accountability documentation for heel boots. NJAC 8:39-27.1(a) Based on observation, interview, record review, and review of other documentation, it was determined that the facility failed to: a.) consistently follow a physician's order (PO) for the application of a hand splint to the left arm, b.) consistently document accountability for the placement of heel booties, and c.) follow the residents individualized comprehensive care plan (ICCP). The deficient practice was identified for 3 of 3 residents (Resident #51, #45 and #96) reviewed for positioning and mobility. This deficient practice was evidenced by the following: 1. On 10/9/24 at 11:05 AM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. On 10/10/24 at 12:30 PM, the surveyor observed Resident #51 in bed. There were two heel boots on the bedside table. The surveyor reviewed Resident #51 electronic Medical Record (eMR). A review of the residents admission Record (AR) (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to Dysphagia (difficulty swallowing), Hypertension (elevated blood pressure) and Dementia (loss of memory). A review of the residents most recent Quarterly Minimum Data Set (Q/MDS), a tool used to facilitate the management of care, dated 7/16/24, revealed a Brief Interview for Mental Status (BIMS) score 00 out of 15, which indicated a severely impaired cognition. A review of the October 2024 Order Summary Report (OSR), revealed a PO dated 7/15/24 for bilateral heel booties with no time frame and accountability record for the application or removal for the heel booties. A review of the October 2024 electronic Medication Administration Record (eMAR) and the electronic Treatment Administration Record (eTAR) did not reflect the above PO. A review of the ICCP, revealed a care plan that the resident had the potential for skin breakdown related to total dependence for activities of daily living and incontinence, that included an intervention dated 2/26/24 for heel boots to bilateral feet. On 10/15/24 at 12:42 PM, the surveyor interviewed the Rehabilitation Director, who stated applying the heel boots to the resident are the responsibility of the nursing department. On 10/15/24 at 1:00 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1), who stated that when she cared for the resident she did not know where to document for the application of the heel boots. On 10/15/24 at 1:06 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that for residents who wear heel booties there would be an area on the eMAR or on the eTAR that the nurse would sign for and know what to do for the resident. LPN #1 and the surveyor reviewed the residents eMAR and eTAR and which did not reflect the documentation for the resident's heel booties. On 10/16/24 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) in the presence of the survey team and was informed that the booties were not observed on the resident for the two observation days and that there was no documentation on the eMAR/eTAR for the application for the heel boots.

Based on observation, interview, and record review it was determined that the facility failed to ensure nutritional evaluation for a resident on a 3-day calorie count were addressed in a timely fashion. This deficient practice was identified for 1 of 8 residents reviewed for Nutrition (Resident #20), and was evidenced by the following: On 10/10/24 at 10:07 AM, the surveyor observed Resident #20 awake in their room. During the surveyor's interview, Resident #20 stated, the food was horrible and were lacking flavor. The resident further added they have not seen the Registered Dietitian (RD) to address these concerns and believed they may have lost weight. A review of Resident #20 Face Sheet (an admission record) revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), and Gastritis. A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 8/6/24 reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. A review of the resident's Physician's Orders (POs) from the electronic medical record (EMR) for September 2024 included a PO dated 9/11/24, Calorie Count x 3 days Observe at each meal, fluids, po, and snack acceptance. With meals for calorie count, hold TF document percentage (%) consumed. A review of the Nutrition Progress Note dated 9/11/2024 at 10:11 AM stated, . Plan/Recommendations: Initiate a three-day calorie count to assess their nutritional intake. Reassess the appropriateness of continuing tube feedings based on calorie count and weight data. Further review of Resident #20's progress notes revealed no evaluation of the 3-day calorie count was observed until 10 days later following the completion. On 10/11/24 at 9:50AM, the Assistant Director of Nursing (ADON) provided the surveyor with a paper copy of Resident #20's 3-day calorie from 9/12-9/14/24. The surveyor observed there was no meal percentage recording for lunch and dinner on 9/14/24. On 10/11/24 at 10:08 AM, the surveyor interviewed the RD, who stated they work 100% remotely and do not come into the facility. The RD stated, following completion of the calorie count, the RD will assess the resident's meal intake and document a progress note discussing the results and further recommendations for the resident, if any are needed. The RD further stated following the completion of the calorie count, the progress note must be written within a day or two after completion of the 3-day calorie count. The RD added that 10 days between the completion of Resident #20's calorie and progress note was an oversight and should have been completed in a timely manner. No further information was provided. On 10/15/24 at 8:30 AM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Calorie Counts with a revised date of February 2024. Under the policy interpretation and implementation section, 8. The completed form will be returned to the Dietitian. The Dietitian will review daily caloric intake and average the caloric intake over the three-day period .11. The Dietitian will assess adequacy of caloric intake. If necessary, interventions will be initiated in accordance with current Standards of practice. On 10/15/24 at 12:02 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Chief Nursing Officer, and Regional Nurse Educator to review the above concern. The LHNA stated, they were aware of the late RD evaluation note. No further information was provided. NJAC 8:39 - 11.2(e)(1)(f), 17.1(c), 17.2(c)(d), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's routine pain level assessment was being completed and documented according to the facility's policy and standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #16) reviewed for pain management. This deficient practice was evidenced by the following: On 10/9/24 at 9:45 AM, the surveyor observed Resident #16 awake in bed. The resident reported they had pain to their wound on the back. The resident further stated that they request to take pain medication frequently. On 10/9/24 at 12:17 PM, the surveyor reviewed Resident #16's electronic medical record and revealed the following information: A review of the admission Record (an admission summary) reflected that Resident #16 was admitted to the facility with diagnoses that included but were not limited to Chronic Osteomyelitis (inflammation of the bone), Open Wound Left Lower Leg, Pressure ulcer of sacral region unstageable, Pressure ulcer of left heel stage 3, and Paraplegia (inability to voluntarily move the lower parts of the body). A review of the most recent Annual Minimum Data Set (A/MDS), an assessment tool used to facilitate the management of care, dated 8/27/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS reflected under Section J. Pain Management, reflected that Resident #16 was on pain medication regimen. A review of the October 2024 Order Summary Report (OSR) reflected the following pain management which included but were not limited to the following Physician's Orders (PO): Morphine Sulfate ER (extended-release) tablet 15 mg (milligram), give 1 tablet by mouth every 12 hours for pain. with an order date of 3/8/24. Oxycodone Hydrochloride (HCl) oral tablet 5 mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. with an order date of 6/27/24. Acetaminophen tablet 325 mg: give 2 tablets by mouth every 6 hours as needed for mild pain. with an order date of 8/23/24. There were no PO to document the resident's pain assessment and/or pain monitoring. On 10/15/24 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated the resident was alert and oriented, and was able to verbalize if they were in pain. The LPN further added that the resident would request for the pain medication almost every day. The LPN stated they don't complete a pain assessment every shift. On 10/15/24 at 12:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and discussed the above concern. All acknowledged that there was no pain assessment and/or pain monitoring. A review of the facility policy titled Pain Assessment and Management with a reviewed/revised date of January 2024 under General Guidelines 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. NJAC 8:39-27.1(a)

Based on observation, interview, record review, it was determined that the facility failed to monitor and document any potential side effects (SE) for a resident who was psychotropic medication as per Physician's Order (PO). This deficient practice was identified for 1 of 5 residents (Resident #94) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 10/9/24 at 11:28 AM, the surveyor observed Resident #94 in bed with eyes closed. On 10/10/24 at 11:38 AM, the surveyor reviewed the electronic medical record of Resident #94, which revealed the following: A review of Resident #94's admission Record (an admission summary) reflected that Resident #94 was admitted to the facility with diagnoses that included but were not limited to unspecified Dementia (loss of memory), unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety (feeling of uneasiness). A review of the most recent Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care, dated 9/26/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status score of 3 out of 15, which indicated that the resident had severe cognition impairment. Further review of the Q/MDS under Section N: High-Risk Drug Classes reflected that resident was on Anti-Psychotic medication. A review of Resident #94's September and October 2024 electronic Medication Administration Record (eMAR) included the following PO: Olanzapine (antipsychotic medication) tablet 5 mg (milligram) give 1 tablet by mouth at bedtime for dementia, with a start date of 7/11/2024. A review of the psychiatric progress note (PPN) dated 7/15/24 documented the resident's diagnosis which included but not limited to, Depression, Dementia, Insomnia (inability to sleep), Psychosis (loss of contact with reality) and Mood Disorder. Further review of the PPN revealed Resident #94 was on Zyprexa (antipsychotic medication) 5mg PO (by mouth) at bedtime for target symptoms including, anxiety, depression, hitting, kicking, and throwing. The surveyor did observe a PO to monitor Resident #94 for any psychotropic medication use SE. On 10/11/24, at 10:59 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the eMAR did not have a PO for monitoring or assessing the psychotropic medication use SE. On 10/16/24 at 10:20 AM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing (DON) regarding the above concern. The DON acknowledged that there was no PO for monitoring or assessing the psychotropic medication use SE. The surveyor reviewed the facility's policy titled Psychoactive Medication Use, with the reviewed/revised date of December 2023 stated under Policy Interpretation and Implementation, 14. Nursing staff shall monitor for and report side effects and adverse consequences of psychoactive medications to the Attending Physician. NJAC 8:39-27.1(a)

Based on observations, interviews, and review of facility policy, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to remove the weekly menus posted from resident's rooms who had a physician's order (PO) for NPO (nothing per orem (mouth)). This deficient practice was identified for 3 of 3 residents (Resident #40, #88, and #141) reviewed that had a PO for NPO. The deficient practice was evidenced by the following: 1. On 10/10/24 at 10:13 AM, the surveyor observed Resident #141 seated on a Geri-chair (geri-chair is a large, padded chair that is designed to help seniors with limited mobility) in their room awake with their ongoing tube feeding (TF) (a way of providing nutrition directly into the gastrointestinal tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine) machine. The surveyor further observed the facility's weekly menu posted on the wall next to Resident #141's bed. A review of Resident #141 medical records revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia (difficulty in swallowing), Gastrostomy (tube inserted directly into the stomach to assist with feeding), Depression, and Muscle Weakness. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/24/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severely impaired cognition. A review of the October 2024 Physician Orders Sheet (POS) revealed a PO dated 9/21/23, NPO diet, NPO texture, NPO consistency. A review of Resident #141 care plan (CP) with a reviewed date of 9/25/24 revealed under the nutrition portion of the CP a Focus titled, Resident is at risk for malnutrition related problem secondary to diagnosis and past medical history of dysphagia, gastrostomy, reliance on TF/PEG to meet nutrition al and hydration need r/t (related to) NPO status. 2. On 10/10/24 at 10:50 AM, the surveyor observed Resident #40 with eyes closed in bed with their ongoing TF machine. The surveyor further observed the facility's weekly menu posted on the wall next to the resident's bed. A review of Resident #40's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Dysphagia, Gastrostomy, and Muscle Weakness. A review of the Quarterly MDS, an assessment tool used to facilitate management of care, dated 7/2/24, revealed the resident could not have a BIMS score due to cognitive impairment. A review of the October 2024 POS revealed a PO dated 10/5/23 for NPO diet, NPO texture, NPO consistency. A review of Resident #40 CP with a reviewed date of 9/27/24 revealed under the nutrition portion of the CP with a Focus statement titled, Resident is at risk for malnutrition related problem secondary to enteral feeding tube/PEG as their primary source of nutrition and hydration r/t NPO status. 3. On 10/10/24 at 11:30 AM, the surveyor observed Resident #88 awake in bed with their ongoing TF machine. The surveyor observed the facility's weekly menu posted in resident's room on wall, within sight of the resident. A review of Resident #88's medical record revealed that the resident was admitted to the facility with diagnosis that included but were not limited to Aphasia (a language disorder that affects your ability to speak and understand what others say), Gastrostomy, and Tracheostomy (hole that surgeons make through the front of the neck and into the windpipe (trachea) for breathing). A review of the Quarterly MDS, an assessment tool used to facilitate the management of care, dated 7/9/24, revealed the resident could not have a BIMS score due to cognitive impairment. A review of the October 2024 POS revealed an order dated 2/2/24, NPO diet, NPO texture, NPO consistency. A review of Resident #88's CP with a reviewed date of 7/10/24 revealed under the nutrition portion of the CP a Focus titled, Resident has enteral feeding tube/PEG as her primary source of nutrition and hydration r/t NPO status. On 10/15/24 at 9:46 AM, the surveyor interviewed the Recreation Director (RD), who stated their department placed the menus in the room, the recreation staff did not have a list of the resident's diets prior to placing the menus. The RD further stated they place a menu for every resident. The surveyor questioned the RD for any residents who had a PO for NPO/do not eat by mouth if it would be appropriate for those residents to have menus posted. The Recreation Director responded, No, it would not be appropriate for those residents to have menus On 10/15/24 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Quality of Life - Dignity with a revised date on 12/2023. The policy statement stated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Under the Policy interpretation and Implementation section of the policy it stated, 1. Resident shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .12. Shall treat cognitively impaired residents with dignity and sensitivity. On 10/15/24 at 12:02 PM, the survey team met with the LNHA, Director of Nursing, Chief Nursing Officer, and Regional Nurse Educator to discuss the above concerns. All agreed that residents who were currently with a PO for NPO should not have menus posted in their room as it is a dignity concern. No further information provided. NJAC 8:39-4.1(a)(12)(28), 17.3(c), 17.4(d)

Based on the interview and review of facility records, it was determined that the facility failed to consistently serve the residents a nourishing snack when there were more than 15 hours between dinner and breakfast mealtimes. This deficient practice was identified for 4 of 5 residents (Residents #29, #61, #132, and #144) who attended during the resident council meeting and was evidenced by the following: On 10/11/24 at 10:00 AM, the surveyor conducted a group meeting with 5 alert and oriented residents selected by the facility to attend the group meeting. Four of the five residents stated they did not receive bedtime snacks. On 10/10/24 at 11:19 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the kitchen provided the five units in different floors with bedtime snacks. She could not provide an information if there was an accountability system the nursing staff used to document and ensure the residents were served their bedtime snacks. The FSD stated they do not keep a snack log to document and cannot provide accountability for the snacks that were delivered to the nursing units that showed the daily snack schedule. The surveyor reviewed the for form titled, Resident Council Meeting Minutes dated 7/29/24, 8/26/24, and 9/30/24 which did not address the food and bedtime snacks. A review of the undated facility's policy titled, Meal Delivery Times list reflected the following: First-floor dinner was scheduled to arrive at 4:30 PM and breakfast at 7:30 AM, yielded a 15-hour time gap. The second-floor dinner was scheduled to arrive at 4:45 PM and breakfast at 7:45 AM, which yielded a 15-hour time gap. Third-floor dinner was scheduled to arrive at 5:00 PM and breakfast at 8:00 AM, yielded a 15-hour time gap. The fourth-floor dinner was scheduled to arrive at 5:15 PM and breakfast at 8:15 AM, yielded a 15-hour time gap. Fifth-floor dinner was scheduled to arrive at 5:30 PM and breakfast at 8:30 AM, yielded a 15-hour time gap. On 10/16/24 at 10:15 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). Both LNHA and DON acknowledged that the facility should have a log to document or records the bedtime snacks provided to the residents. A review of the facility policy titled, Snacks, with a reviewed/revised date of December 2023, included the following: It is the center policy to provide: 3) bedtime (HS-hours of sleep) snacks to residents. NJAC 8:39-17.2 (f); 17.2 (f) 1

Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: During the initial tour of the kitchen, the surveyor, together with the facility's Dietary Manager (DM) on 10/9/2024 at 10:15 AM, the surveyor observed the following: Upon entering the room where the dish machine was located, the surveyor observed 2 dietary staff inside cleaning the dishes that were used during breakfast. The surveyor asked the DM to turn on the dishwasher machine. When the DM turned on the dishwasher, the surveyor observed a significant amount of water splashing towards the drying rack where there were trays placed. The DM stated to the surveyor to step back because the dishwasher had water splash. The DM stated that the rack that was placed next to the dishwasher was a drying rack used to dry the meal trays. The surveyor observed the drying rack that was placed right next to the dishwasher machine exposing the trays of water splash from the dish machine. In the drying rack, there were several trays that was observed to be wet nesting and were stacked together in two and three. The DM stated to the surveyor, the trays were used to serve the resident's meals. The DM further stated that the trays were placed there after being washed to dry. The DSD acknowledged that the trays were not supposed to be stacked together to allow them to completely dry. On 10/15/24 at 12:02 PM, the surveyor discussed the above concern to the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Chief Nursing Officer, and the Regional Educator. On 10/16/24 at 10:05 AM, the LNHA stated to the surveyor that the facility does not have a policy and procedure regarding tray drying. The LNHA further stated to the surveyor that the DM agreed that the trays must not be stacked to allow for them to completely dry. No further information was provided. NJAC 8:39-17.1(a);17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to act upon rehab referral of nursing in accordance with standards of clinical practice for one (1) of two (2) residents, (Resident#103) reviewed for a limited range of motion (ROM). 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. On 5/30/23 at 9:32 AM, the surveyor observed Resident #103 laying on the bed with right hand limitation. The surveyor asked the resident about a splint in use for their right hand, the resident stated I never tried it. The resident further stated that the right hand limitation was not something new and did not want to have a splint. The surveyor reviewed the medical records of Resident #103 and revealed the following: The admission Record (or face sheet, an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to essential hypertension, muscle weakness (generalized), hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness to the right side of the body due to stroke), anxiety disorder, schizophrenia unspecified (a disorder that affects a person's ability to think, feel, and behave clearly). The most recent quarterly Minimum Data Set (qMDS) with an Assessment Reference Date (ARD) of 4/18/23, showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that the resident's cognition was intact. The 4/18/23 qMDS showed on Section G Functional Status, the resident was coded one (1) on the upper extremity which means that the resident had a functional limitation in ROM, an impairment on one side of the upper extremity. A review of the individualized care plan with a focus on ADL (activities of daily living) self-care performance deficit r/t (related to) stroke created on 10/17/20 that included interventions not limited to ensure urinal is on resident's functional side (left side) created on 10/20/21. The Therapy Notification Form (Nursing) (TNF/N) with an effective date of 4/14/23 at 01:04 PM showed that the Director of Nursing (DON) initiated the nursing referral to rehab for other concerns for OT (Occupational Therapy), electronically signed by Certified Occupational Therapy Assistant on 4/19/23. Further review of the 4/14/23 TNF/N revealed the following information: Other Concerns For OT: increased contracted right arm, requesting new wheelchair. Provided new 18 (18 inches) W/C (wheelchair) with patient name tagged. Patient due for quarterly review, to be re-assessed for skilled OT services. OTR (Occupational Therapist Registered) Furthermore, there was no documentation in the medical records that the resident was assessed for Skilled OT services after the TNF/N was electronically signed on 4/19/23 and acted upon the nursing referral regarding the increased contracted right arm. On 6/02/23 at 11:58 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Director of Clinical Compliance (RDCC), and Assistant Administrator (AA) and were made aware of the above findings. The surveyor asked the facility management to provide documentation that the nursing referral regarding increased contracted right arm was acted upon and addressed by Skilled OT, the LNHA stated that he will get back to the surveyor. On 6/05/23 at 9:15 AM, the LNHA provided a copy of the OT Evaluation & Plan of Treatment dated 8/09/22 with the reason for referral for quarterly review to assess for a decline in functional status and the need for Skilled OT intervention. The 8/09/22 copy included that the UE (upper extremity) ROM was impaired, the patient was noted with flexion contraction at elbow and hand, refused assessment of shoulder; LUE (left upper extremity) and ROM=WFL (within functional limit). Assessment Summary: Impressions: with no decline noted in functional status at this time and is not a candidate for skilled OT intervention, required maximum encouragement to participate in the quarterly review, and refused ROM assessment to address contracture management. On 6/05/23 at 10:09 AM, the survey team met with the LNHA, DON, Regional Administrator, and Chief Nursing Officer (CNO). The LNHA stated that the Occupational Therapist should have evaluated the resident and documented the refusal of the resident when the DON referred the resident on 4/14/23 for increased contracture to the right arm. The LNHA acknowledged that the therapist should not assume that the resident will refuse the evaluation because the resident had a history of refusal on 8/09/22. The LNHA further stated that there should have documentation of the therapist's evaluation. On 6/05/23 at 12:20 PM, the surveyor interviewed the Director of Rehab/Occupational Therapist (DoR/OT) in the presence of the LNHA. The DoR/OT informed the surveyor that the OTR screened the resident on 4/18/23 for the nursing referral of the DON to rehab on 4/14/23 and was signed and locked on 4/19/23 by the DoR/OT. The DoR/OT stated that the OTR provided the wheelchair to the resident did not pick up nor evaluated the resident. She further stated that the OTR did not document the resident's refusal for the screen, and the OTR should have documented in the electronic medical records of the OT's assessment (screen) and if the resident refused, the refusal should have been documented as well. The DoR/OT informed the surveyor that no documentation of the screen, which is why she educated the OTR again about documentation. On that same date and time, the DoR/OT stated that it was the facility's practice in Rehab that the therapist sees the resident upon admission, as needed, when warranted, if there's a report of decline and referral from nursing/doctor, and then annually. The LNHA stated that he agreed that there should have a documentation about the refusal of the resident. The surveyor asked the facility team for a copy of the facility's Rehab Assessment Policy. The DoR/OT stated that she did not have a copy of that Rehab Assessment Policy, and the LNHA stated that he will check and get back to the surveyor. On 6/05/23 at 12:45 PM, the DoR/OT informed the surveyor that according to LNHA, it was the facility protocol that the therapist sees the resident upon admission, when warranted, due to decline or nursing referral, and annually according to our practice but we don't have a policy about Rehab Assessment. On 6/07/23 at 12:33 PM, the survey team met with the LNHA, DON, and RDCC. The LNHA stated, We discovered that refusal was not documented, when the resident was screened by the OTR on 4/18/23 for increased contracture to the right arm. He further stated that the resident refused today to be seen when attempted by the rehab department for evaluation. On 6/08/23 at 01:18 PM, the survey team met with LNHA, DON, CNO, Regional Administrator, AA, and RDCC, there was no additional information provided by the facility management, and did not refute the findings. NJAC 8:39-3.2(a)(b), 11.2(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a) follow the Nurse Practitioner's (NP's) order for a stat (an abbreviation of statim means immediately) order of xray and b) notify the physician or nurse practitioner of the results that fall outside the clinical reference ranges (abnormal results) in accordance with standards of clinical practice to ensure the facility identify and provide needed care and services in accordance to resident's goals for care of one (1) of 34 residents reviewed, (Resident #95). 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. On 5/26/23 at 7:43 AM, the surveyor observed Resident#95 laying on the bed with eyes closed, the cockup splint (used as a post-traumatic rehabilitation aid to get the injured wrist back in shape) on top of the nightstand. The surveyor reviewed Resident #95's medical record. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential hypertension (high blood pressure), type two diabetes (abnormal blood sugar level), insomnia (common sleep disorder), unspecified dementia with other behavioral disturbance (cognitive impairment), major depressive disorder, anxiety disorder, and age-related nuclear cataract bilateral (the center of the eye's lens becomes thick and discolored). The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 3/28/23 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The qMDS revealed that staff assessment for mental status was conducted due to the resident's unable to complete the interview and showed that the resident's cognitive skills for daily decision-making had a score of 2 (two) which indicated that the resident's cognition was moderately impaired. Further review of the 3/28/23 qMDS revealed that on Section G Functional Status, the resident had no impairment of Range of Motion (ROM) to both lower and upper extremities. The Progress Note (PN) of Registered Nurse#1 (RN#1) dated 4/07/23 at 7:29 PM showed that the resident at approximately 6 PM was found crying in the hallway and when asked by the RN, the resident showed his/her right hand. RN#1 noted a hematoma above the right wrist, applied ice, notified the nursing supervisor and the responsible party, and left a message to the doctor. RN#1 documented also that a stat x-ray was ordered by Nurse Practitioner#1 (NP#1), the resident denied pain and declined pain medication. The PN dated 4/08/23 at 5:00 AM of NP#1 revealed that the nurse called to report x-ray results ordered earlier (4/07/23) after the facility found a forearm hematoma. NP#1 documented that the result was an acute oblique mildly displaced fracture of the distal radial diaphysis (also known as wrist fracture, which is a break of the part of the radius bone which is close to the wrist), overlying soft tissue edema, and swelling. The Assessment and Plan included that the resident will send to the ED (Emergency Department) and place a call to ED for initial handoff. A review of the printed electronic Medication Review Report (eMRR) date range of 4/01/23 through 5/31/23 that was provided by the Licensed Nursing Home Administrator (LNHA) showed an order date of 4/10/23 for a stat repeat x-ray right arm, forearm, right wrist r/o (rule out) fx (fracture). The 4/10/23 Order Audit Review showed that the Assistant Director of Nursing (ADON) created the 4/10/23 at 4:04 PM order for repeat stat x-ray right arm, forearm, and right wrist to r/o fx ordered by NP#2. The Radiology Results Report (RRR) showed that there was no x-ray done on 4/10/23. There were results for the right wrist, complete 3+ (three plus) views dated 4/13/23 with impressions: No wrist fx/dislocation. Distal radial shaft fx not visualized on wrist films. Moderate arthritic change of the first metacarpal trapezium scaphoid and radiocarpal articulations, mild in the remainder of the wrist. Osteoporosis. Diffuse soft tissue swelling over the distal forearm and wrist. According to the 4/13/23 RRR the x-ray examination date was done on 4/13/23 at 11:04 AM and the reported date was 4/13/23 at 11:34 AM. A review of the 4/10/23 through 4/13/23 PN did not show documentation from the nurses why the stat order of x-ray of NP#2 was not done not until 4/13/23. The PN dated 4/17/23 of NP#2 showed that Resident#95 was seen for follow-up to a recent unwitnessed fall and an acute right wrist fx. Initial in-house imaging (4/07/23) and ER (emergency room) imaging (4/08/23) showed fx of the distal radial diaphysis. Repeat in-house x-ray (4/13/23) show no fx/dislocation. Will repeat x-ray once more d/t (due to) inconsistent imaging results. The RRR examination date 4/17/23 at 5:32 PM reported date 4/17/23 at 5:56 PM revealed impressions: unhealed hairline spiral fx of the distal radial shaft.No significant change since 4/07/23. A review of the 4/17/23 through 4/19/23 PN did not show documentation from the nurses that the 4/17/23 abnormal x-ray results were relayed to the physician or NP#2 (who ordered the x-ray). The Therapy Notification Form (Nursing) (TNF/N) with an effective date of 4/14/23 at 2:22 PM with the following information: A. Physical Therapy (PT) 1. Please check all that apply for this referral=blank (no information checked off) 2. Other concerns for PT=blank (no information written) B. Occupational Therapy (OT) 1. Please check all that apply for this referral=blank (no information checked off) 2. Other concerns for OT=wrist splint screen. Patient to be evaluated and trialed for wrist cockup splint. Signed by OTR (Occupational Therapist) C. Speech Therapy (ST) 1. Please check all that apply for this referral=blank (no information checked off) 2. Other concerns for ST=blank (no information written) D. Falls 1. Please check all that apply for this referral=blank (no information checked off) 2. Other concerns regarding fall=blank (no information written) E. Staff Member Making Referral 1. Director of Nursing (DON Signed by: Certified Occupational Therapy Assistant (esigned or electronically signed) on 4/19/23. A review of the PN showed that NP#2 follow-up notes and visits after 4/17/23 was on 4/19/23. The 4/19/23 follow-up PN of NP#2 showed that the repeat x-ray on 4/17/23 showed unhealed hairline spiral fx of the distal radial shaft. The 4/19/23 PN of NP#2 included medical decision making that the medical record was reviewed and interpreted diagnostic results, discussed with staff regarding new pertinent/abnormal findings, details of the problem, staff concerns, and formulation of the medical plan of care. The 4/19/23 PN also included Assessment and Plan for cock up splint to be applied to the wrist, once available, will continue with ace wrap at this time, PT/OT as indicated, pain management and to continue to monitor the resident. On 6/05/23 at 11:22 AM, the surveyor interviewed the Director of Rehab (DoR) in the presence of LNHA. The DoR stated that on 4/14/23 (TNF/N) by the DON, the DoR (also the same person esigned the TNF/N) signed it but it did not mean that the resident was seen on 4/19/23. The DoR further stated that the resident was seen by OTR on 4/18/23. The DoR informed the surveyor that the Rehab department will not be able to see the resident without the physician's order. On 6/05/23 at 01:05 PM, during an interview of the surveyor with NP#2, NP#2 informed the surveyor that she was contracted by the facility via her company (an outside contractor) to see residents at the facility with the approval of the participating physicians which included Resident#95. NP#2 stated that part of her responsibilities, to coordinate primary care for the resident either acute or chronic, including reviews and orders of laboratory and other diagnostic tests. On that same date and time, NP#2 confirmed that she ordered a repeat x-ray on 4/10/23 and stated that with an expectation that the x-ray will be done the same day. The surveyor asked NP#2 why the 4/10/23 x-ray that she ordered was not done not until 4/13/23 and if she was aware of the reason why there was a delay, and NP#2 did not respond. Furthermore, NP#2 informed the surveyor that she ordered another repeat x-ray on 4/17/23 because the 4/13/23 x-ray results were negative for fx. NP#2 stated that if the x-ray was done on 4/17/23 and resulted on 4/17/23 fx, the facility should have called her about the abnormal report. She further stated that she was not sure, I do not recall that the facility called me for results, on 4/17/23. NP#2 acknowledged that the x-ray results were received on 4/19/23 for 4/17/23 and that she remembered that on 4/19/23 she was at the facility and that was the time that she communicated to therapy her orders and the plan. On 6/05/23 at 01:49 PM, the surveyor notified the LNHA and the Regional Administrator (RA) in the presence of another surveyor of the above findings and interview with NP#2. On 6/07/23 at 12:33 PM, the survey team met with the LNHA, DON, and Regional Director of Clinical Compliance (RDCC). The LNHA stated that he did not have a response from the delayed x-ray stat order on 4/10/23 that was done on 4/13/23 and that the 4/17/23 results were not relayed to NP#2. He further stated that he will get back to the surveyor. On 6/08/23 at 9:45 AM, the surveyor interviewed the ADON. The ADON acknowledged that on 4/10/23 NP#2 ordered the stat order for a repeat x-ray and confirmed that she was the one who created that order in the electronic medical records. The ADON further stated that the stat order should be done immediately or on the same day. The surveyor asked the ADON why there was a delay in doing a stat x-ray order on 4/10/23 and it was not done not until 4/13/23. The ADON stated I do not know, why there was a delay. She further stated that if there will be a delay, it should be documented in the medical records, practically yes it should be documented in the progress notes. On 6/08/23 at 10:17 AM, the LNHA provided a copy of the facility's Change in Condition or Status. The surveyor asked and followed up on the facility's policy and procedure with regard to notifying the physician of the laboratory and x-ray results. The LNHA stated that he was not sure if the facility have that kind of policy and that he will get back to the surveyor. On 6/08/23 at 10:22 AM, the surveyor called and left a message for RN#2 to return the call of the surveyor for an interview. RN#2 was the nurse assigned to the resident who worked 7 PM-7 AM on 4/17/23. On 6/08/23 at 10:24 AM, the surveyor called and was unable to leave a message for the LPN because the voicemail box of the LPN was full. The LPN was the nurse assigned to the resident who worked 7 AM-7 PM on 4/17/23. On 6/08/23 at 10:59 AM, the survey team met with the LNHA, RA, DON, ADON, AA, and Chief Nursing Officer (CNO). The CNO informed the survey team that NP#2 was communicated about the results of 4/17/23 x-ray reports on 4/18/23 as seen in the email exchanges between the DoR, Physiatrist, and NP#2. The CNO stated that she agreed that if a stat was ordered, it should have been done immediately or within the day. She further stated that yeah for sure it should have been called on that same day for results on 4/17/23. The CNO stated that I am not discounting the issue, and that there should be a notification to the physician or NP#2 immediately when abnormal results were reported on 4/17/23. In addition, the CNO acknowledged that there was no documentation that the nurse notified the physician on 4/17/23. A review of the facility's Change In Condition or Status Policy with a revised date of 01/2023 provided by the LNHA included that the facility shall promptly notify the resident, attending physician, and representative of changes in the resident's medical/mental condition and/or status. On 6/08/23 at 01:18 PM, the survey team met with the LNHA, DON, CNO, RA, Assistant Administrator, and RDCC and there was no additional information provided by the facility management. The facility management did not refute the findings. In addition, the surveyor called and left a message for the second time to RN#2 and there was no return call from RN#2. The surveyor was unable to leave a message for LPN because the LPN's phone voicemail box was full. NJAC 8:39-13.1(d), 27.1(a)

Based on observations, interviews, record review, and review of pertinent facility documents, the facility failed to a) ensure the indwelling urinary catheter (tube that is inserted for continuous drainage of the bladder) drainage tubing was stored in a manner to prevent Urinary Tract Infection (UTI) and b) develop and implement a care plan (CP) that included interventions that addressed catheter care based on current professional standards of practice to prevent UTI for 1 (one) of 2 (two) residents reviewed for urinary catheter care or UTI (Resident #164). The deficient practice was evidenced by the following: Reference: The Healthcare Infection Control Practices Advisory Committee guidance titled GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 with an updated date of June 6, 2019, includes the following: III. Proper Techniques for Urinary Catheter Maintenance A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system . 1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment . B. Maintain unobstructed urine flow . 1. Keep the catheter and collecting tube free from kinking . 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . 3. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the nonsterile collecting container . C. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system . E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . G. Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate . On 5/22/23 at 11:01 AM, the surveyor observed Resident #164 laying in a bed that was low to the floor. The surveyor observed that the resident's indwelling catheter tubing was laying on the floor. The surveyor observed pale yellow cloudy urine in the tubing. On 5/25/23 at 10:36 AM, the surveyor observed Resident #164 laying in a bed that was low to the floor. The surveyor observed that the resident's indwelling catheter tubing was not laying on the floor but that the indwelling catheter bag was in a blue privacy bag and the bag was on the floor. The surveyor did not observe urine in the tubing. On 5/30/23 at 11:03 AM, the surveyor observed Resident #164 laying in a bed that was low to the floor. The surveyor observed that the resident's indwelling catheter tubing was on the floor and the indwelling catheter bag that was in a blue privacy bag was also on the floor. The surveyor did not observe urine in the tubing. A review of the admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; encephalopathy (a broad term for any brain disease that alters brain function or structure), dysphagia (difficulty swallowing foods or liquids) and diabetes mellitus (a disease of inadequate control of blood levels of glucose). A review of the admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, dated 4/05/23, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which reflected that the resident's cognition was severely impaired. Further review of the AMDS indicated under section H for bladder and bowel, that the resident had an indwelling catheter and that urinary continence (the ability to control movements of the bladder) was not rated (resident had a catheter). A review of the Medication Review Report (physician orders) included the following active order: Foley catheter 14 French with 10 cc balloon for urinary retention (a condition in which you cannot empty all the urine from your bladder). On 5/30/23 at 11:22 AM, the surveyor interviewed Resident #164's assigned Certified Nurses Aide (CNA) regarding indwelling catheter care. The CNA stated that she cleans around the catheter, drains the urine from the bag, measures the amount of urine and tells the nurse. She added that the indwelling catheter bag is placed in a privacy bag on the side of the bed. The surveyor then asked the CNA to observe Resident 164's indwelling catheter tubing and drainage bag that was in a privacy bag on the floor. The CNA confirmed that the indwelling catheter tubing was on the floor and that the tubing should not be on the floor. The CNA stated that the resident's bed was in a low position to prevent a fall so she could not put the indwelling catheter bag and tubing higher. On 5/30/23 at 11:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the placement of the indwelling catheter tubing. The LPN stated that the indwelling catheter tubing and drainage bag should never be placed above the bladder. She added that the tubing or the privacy bag should not be on floor. The surveyor then asked the LPN to observe Resident 164's indwelling catheter tubing on the floor. The LPN confirmed that the indwelling catheter tubing was on the floor and stated that it should not be on the floor. The LPN then placed the indwelling catheter tubing and privacy bag in a manner that both were not on the floor. On 5/31/23 at 11:05 AM, the surveyor interviewed the Infection Preventionist Nurse(IPN) regarding the placement of a indwelling catheter tubing and drainage bag. The IPN stated that it should be placed below level of bladder in a privacy bag off the floor. She added that the indwelling catheter tubing should not be on the floor. On 6/01/23 at 12:57 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), Director of Nursing (DON), and Regional Administrator (RA) the above findings and observations of Resident #164's indwelling catheter tubing on the floor. On 6/02/23 at 11:59 AM, in the presence of the survey team, the AA, DON and Regional Director of Clinical Compliance (RDCC), the LNHA stated that the facility was in the process of looking into an alternative catheter bag. The LNHA confirmed that the indwelling catheter tubing should not be on the floor and that the staff was in-serviced. A review of the resident's individualized CP reflected a focused area with an initiated date of 4/04/23, that the resident had an indwelling catheter. The resident's CP Goal was that the resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. The CP's Interventions/Tasks included the following: Establish voiding patterns. Monitor fluid intake to determine if natural diuretics such as coffee, tea, or cola is contributing to increased urination and incontinence (inability to control the flow of urine from the bladder or a person leaks urine by accident). Monitor/document for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. The CP did not include interventions based on current professional standards of practice for the care of a indwelling catheter to prevent a UTI. Some of the interventions that were included referenced incontinence and voiding pattern which would be interventions for a resident that did not have an indwelling catheter. An indwelling catheter provides continuous drainage of the bladder. On 6/02/23 at 9:47 AM, the surveyor interviewed the Registered Nurse (RN) who was assigned to Resident #164 regarding the resident's CP. The RN stated that she was an agency nurse and that she did not do the CP. The surveyor asked the RN if the intervention of establish voiding patterns would be an appropriate intervention for Resident #164 who had an indwelling catheter. The RN stated that the resident had a catheter in place and that the resident was not voiding on their own. The surveyor asked the RN if the interventions that referenced incontinence would be an appropriate intervention for Resident #164 and what interventions would be in place for an indwelling catheter. The RN confirmed that incontinence should not be referenced for a resident with an indwelling catheter. She added that output should be monitored, make sure the catheter was draining and that the tubing was not kinked and off the floor. On 6/5/23 at 9:44 AM, the surveyor interviewed the DON regarding the process of the CP. The DON stated that the process was to initiate the CP on admission and that he took ownership of on the part of nursing. He added that each discipline does their own part. He then stated that a baseline CP was done on admission and that within the certain timeframe the MDS would trigger areas and that he would check it and add to it if needed. The surveyor asked the DON what would be examples of interventions for a resident that had an indwelling catheter. The DON stated that to make sure the catheter was free from obstruction and had no kinks in the tubing, consult as recommended. The surveyor then asked the DON to view Resident #164's CP and asked the DON if establish voiding patterns and the references to incontinence were appropriate interventions. The DON stated that the resident was not incontinent when they had a catheter. On 6/7/23 at 01:20 PM, in the presence of the survey team, the surveyor told the LNHA, DON and RDCC the concern regarding the CP interventions for Resident #164. On 6/08/23 at 11:12 AM, in the presence of the survey team, LNHA, Assistant DON, AA, RA, RDCC and Chief Nursing Officer, the DON (in response to the concern) stated that the incontinence referred to monitoring for leaking around the indwelling catheter. The surveyor then asked if establish voiding patterns was an appropriate intervention for an indwelling catheter. The DON stated that it was to make sure the catheter was draining each shift with output. The surveyor then asked the DON if the interventions that were on Resident #164's CP were appropriate. The DON stated that the interventions were appropriate interventions for a catheter CP. A review of the facility provided policy titled, Urinary Catheter Care with a reviewed/revised date of 12/2022, included the following: Infection Control .2. b. Be sure the catheter tubing and drainage bag are kept off the floor. A review of the facility provided policy titled, Care Plans, Comprehensive, Person-Centered with a reviewed/revised date of 12/2022, included the following: 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident , are the endpoint of an interdisciplinary process. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area (s), not just addressing only symptoms or triggers. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to: a.) ensure physician orders for oxygen were implemented, and b.) maintain sustainability by following their plan of correction from the last recertification survey for the same deficient practice, and c.) perform appropriate hand hygiene during tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe) care observation consistent with professional standard of practice and Centers for Disease Control & Prevention (CDC) guidelines. This deficient practice was identified for 1 (one) of 2 (two) residents reviewed for respiratory care (Resident #111). The evidence was as follows: According to the last recertification survey date of 02/18/22, the facility failed to follow a physician's order for oxygen (O2). The facility submitted a plan of correction with a completion date of 3/11/22, which included that the Director of Nursing (DON) immediately in-serviced all nurses on O2 and trach policy. According to the CDC Hand Hygiene in Healthcare Settings, Healthcare Providers guidance, last reviewed: January 8, 2021, information on when to perform hand hygiene included but was not limited to immediately before touching a patient, when hands are visibly soiled, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, and after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. On 5/22/23 at 11:42 AM, the surveyor observed Resident #111 lying on the bed fitted with a trach (tracheostomy) collar. The resident responded to the surveyor's questions through gestures. At that time, the surveyor observed the O2 concentrator (a device used to provide oxygen therapy to people that require greater oxygen concentrations) was set at 6 (six) liters per minute (LPM) with a Humidity indicator set at 50%. On 5/24/23 at 10:36 AM, the surveyor observed Resident #111 asleep. At that time, the surveyor observed the O2 concentrator was set between 6 (six) and 8 (eight) LPM with a Humidity indicator set at 40%. On 5/24/23 at 10:45 AM, the Assistant Director of Nursing (ADON) identified the O2 concentrator was set at 7 (seven) LPM, and Humidity was set at 40%. The surveyor reviewed the medical record for Resident #111. The admission Record (or face sheet; an admission summary) reflected that the resident had been admitted with diagnoses which included chronic respiratory failure, unspecified whether with hypoxia (low level of oxygen in body tissues; causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate .) or hypercapnia (too much carbon dioxide in the body's blood), atrial fibrillation, cerebral infarction (disruption of blood flow to the brain), other seizures and aphasia (loss of ability to understand or express speech). The annual Minimum Data Set, an assessment tool used to facilitate the management of care, dated 4/11/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident had severely impaired cognition. A review of the Order Summary Report included the following: -O2 with Humidity at 35% via tracheostomy -no orders for O2 in LPM -Trach care q (every) shift and prn (as needed) The resident's individualized care plan revealed under Interventions/Tasks indicated O2 setting: Humidified O2 at 6 (six) LPM via trach collar that was on initiated 5/26/21. On 5/24/23 at 10:52 AM, the surveyor interviewed the Registered Nurse (RN). The RN stated that she arrived two hours ago, and the O2 was already going on before she came in. On 5/24/23 at 11:10 AM, during an interview with the surveyor, the ADON stated all the nurses were in-serviced and competencies were completed to provide tracheostomy care for Resident #111. The ADON further stated that the resident had a Treatment Administration record that was used for the resident's care. On 5/24/23 at 11:37 AM, the surveyor and the ADON reviewed the physician's order. The ADON confirmed that the O2 with a Humidity level of 40% was incorrect because the physician's order reflected 35%. The ADON stated, I will verify with the Respiratory Therapist (RT) why the setting is different, I will check the O2 saturation, and conduct an assessment. The ADON stated the correct O2 humidity was important because it could affect the resident's breathing. On 5/24/23 at 12:30 PM, during an interview with the survey team, the Director of Nursing (DON) stated that the RT could make a recommendation, but the Physician was not required to follow the recommendation. The DON confirmed the O2 with Humidity should have followed the Physician's Order. The DON stated he would inform the Physician. On 6/01/23 at 9:46 AM, during an interview with the surveyor, the LPN/Educator (LPN/E) stated she would be providing tracheostomy care to Resident #111. On 6/01/23 at 10:04 AM, two surveyors observed Resident #111's tracheostomy care performed by the LPN/E. The LPN/E disinfected the side table that was inside the resident's room, placed a barrier on top of the side table, and identified the side table as her sterile field to the surveyors. The LPN/E then performed handwashing and went to the nightstand table on the other side of the bed where there were treatment supplies also on top of the nightstand. Afterward, the surveyors and the LPN/E heard a knock outside the resident's door. The LPN/E then pulled the resident's curtain that was used for privacy, opened the door, and close it back after talking to another staff outside the door. The LPN/E returned to prepare her supplies without performing hand hygiene after direct contact with the resident's environment (privacy curtain and doorknob). The LPN/E used the nightstand table that was not disinfected, opened the tracheal care kit and donned the sterile gloves without performing hand hygiene. The LPN/E continued to prepare her supplies. Afterward, the LPN/E turned on the suction machine and connected the suction catheter to the port of the suction tubing to suction the resident. At that time, the surveyors requested to speak with the LPN/E outside the resident's room. During an interview with the surveyors, the LPN/E stated that tracheostomy care was a sterile technique that required proper hand hygiene. The LPN/E informed the surveyors that she was in charge of educating the nurses on the proper technique for tracheostomy care. Furthermore, the LPN/E stated when she touched the curtain and the doorknob, her hands were then contaminated. She further stated she should have performed hand hygiene before donning the sterile gloves. The LPN/E stated, I should have stopped, I forgot to bring the Alcohol-based hand rub and I did not have it in Resident #111's room with me to use prior to donning the sterile glove. On that same date at 10:21 AM, during an interview with the surveyors, the Infection Preventionist Nurse (IPN) stated that the RT was responsible for educating the LPN/E. On 6/01/23 at 12:53 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Administrator (RA), and Assistant Administrator (AA) and were made aware of the above findings. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, Regional Director of Clinical Compliance (RDCC), and AA. The LNHA stated that the LPN/E was re-educated by the IPN after the tracheostomy observation yesterday. The LNHA stated that the RT was called to in-service (educate) the LPN/E and corrected the fraction of inspired oxygen (FI02). The LNHA acknowledged that the physician's order should have been followed. At that time, the LNHA informed the surveyors that hand washing in-service was completed, facility-wide. A review of the facility provided policy, O2 Administration reviewed/revised 12/2022 included: The purpose of this procedure is to provide guidelines for safe O2 administration. Under Preparation, section 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for O2 administration. A review of the facility provided policy, Tracheostomy Care reviewed/revised 01/2023 included: Procedure Guidelines; Preparation and Assessment 3. Wash Hands, and 4. Put exam gloves on both hands. NJAC 8:39-19.4 (a)(n), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident's preference for nectar thickened water was honored (Resident #157). This deficient practice was identified for 1 (one) of 1 (one) resident reviewed for choices and was evidenced by the following: On 5/23/23 at 12:52 PM, the surveyor interviewed Resident #157. The resident stated that he/she asked and did not receive a nectar thickened water, I have requested multiple times and they keep giving me nectar thickened milk and nectar thickened apple juice. I have requested from the [Certified Nursing Assistant] CNA. I called my CNA, and she told me they don't have nectar thickened water in the building. The surveyor reviewed the medical record for Resident #157. The admission Record (an admission summary) reflected that the resident had been admitted with diagnoses which included dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), type 2 diabetes without complications, cerebral infarction due to unspecified occlusion (decreased blood flow to the brain). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 3/28/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. The assessment indicated that the resident required extensive assistance with eating and drinking with one-person physical assist. A review of the Registered Dietician (RD) Progress Note, a Nutrition/Dietary note dated 5/12/23 for Resident #157 included that the resident was having trouble swallowing regular liquid. The RD noted that the resident would be downgraded to nectar thick liquid. The physician Order Summary Report (OSR) for all physician orders (PO) from admission to the facility as of 5/23/23, under Dietary, reflected regular diet, chopped texture, nectar thick liquid consistency. The resident's individualized Care Plan reflected interventions that the resident prefers nectar thick liquid and will honor resident's preference. On 5/23/23 at 12:55 PM, the surveyor observed Resident #157 request for nectar thickened water from the CNA. The CNA stated I left you nectar thickened juice. We don't have nectar thickened water. On that date and time, the surveyor requested to speak with the CNA and walked together towards the nurses' station. At that time, during an interview with the surveyor, the CNA stated she had asked the regular nurse yesterday about the nectar thickened water for Resident #157. The CNA stated the regular nurse had informed her that the facility did not have nectar thickened water in stock yesterday. She also stated she did not call dietary because that was outside her scope as a CNA. I informed the nurse. The CNA admitted she did not ask the nurse for the nectar thickened water that morning for Resident #157. On 5/23/23 at 12:59 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned on the Fourth floor who was seated in the nurses' station. The LPN informed the surveyor that she had administered Resident #157's medications that morning with nectar thickened milk and juice. The LPN stated she was aware of the resident who wanted the nectar thickened water but there was none in stock. At that time, the LPN stated she would call the kitchen and ask for nectar thickened water. The LPN informed the surveyor that dietary did not have nectar thickened water in stock. The LPN stated she would inform the Director of Nursing (DON). At that time, the Infection Preventionist Nurse (IPN) who was also at the nurses' station was observed checking inside the refrigerator and inside the shelving around the refrigerator. The IP stated we do not have nectar thickened water in the refrigerator. On 5/23/23 at 01:25 PM, during an interview with the surveyor, the Dietary Supervisor (DS) stated she was unable to provide a delivery receipt because it is not an item I order for the resident. We do not use a thickener pack or stock pre-thickened water. We do not use a thickener pack because we do not provide food items that require nectar thickened water. On 5/23/23 at 01:35 PM, the surveyor interviewed the RD. The RD stated that nectar thickened water should be provided by nursing. The RD informed the surveyor that the thickening powder should be on the unit, the nurse can use the thickening powder to thicken the water. When a resident requests for nectar thickened water, this must be provided by nursing. The RD stated it was not appropriate for the nurse to state we do not have nectar thickened water in stock. On 5/24/23 at 10:55 AM, the surveyor interviewed the Regional Administrator (RA). The RA confirmed that the facility had the thickened powder in stock. The RA informed the surveyors that all the nurses were in-serviced yesterday for thickening powder for water. At that time, the RA showed the surveyors a box of thickened powder, purchase orders for the water, thick, nectar dated 02/20/23 and thickener, nectar green dated 4/17/23. On 5/24/23 at 12:17 PM, the surveyor interviewed the DON who stated the thickener for the water was available and it should have been given as it was available. The DON clarified that the Nurse was referring to the pre-packaged unit of water and not the mixed packet. Resident #157 was receiving hydration thru their PEG tube (percutaneous endoscopic gastrostomy; feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall). At that time, the surveyor asked the DON why the nectar thickened water was not provided to the resident, when the thickener for the water was available. The DON stated that was the reason for the in-service (education) provided to the nurses yesterday. The DON confirmed that it should have been available for the resident as their preference and moving forward it would be provided to Resident #157. A review of the facility provided policy, Thickened Liquids, reviewed/ revised on 12/2022, included, under section 4. Residents who require thickened liquids will be provided pre-packaged thickened liquid (per the ordered consistency), or will be provided liquids thickened prior to service by a staff member who has completed education in thickening liquids. A review of the facility provided policy, Care Plans, Comprehensive, Person-Centered reviewed/revised 12/2022, included, section 7. The care planning process will: subsection c. Incorporate the resident's personal and cultural preferences in developing the goals of care. NJAC 8:39-17.4 (c), (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/22/23 at 10:50 AM, the surveyor observed Resident #143 sitting on a wheelchair, pleasant and conversant with the surveyor. The surveyor reviewed the medical record for Resident #143. The AR reflected that Resident #143 had been admitted to the facility with diagnoses which included myocardial infarction (lack of blood flow to the heart), asthma, chronic kidney disease stage 3 unspecified, acute kidney failure, and pulmonary hypertension (when the pressure in the blood vessels from the heart to the lungs is high), The annual MDS dated [DATE] reflected that the resident had a BIMS of 15 out of 15, which indicated the resident had a fully intact cognition; and under section O, O0300 Pneumococcal Vaccine revealed 0 not received and reason of 3 not offered. A review of Resident #143's active Care Plan (CP) printed on 6/01/23 did not reveal any focus, goals or interventions for vaccinations. A review of Resident #143's electronic Medical Record (eMR), under miscellaneous did not reveal a Pneumococcal Immunization informed consent form (a form that contained education about the vaccine, documented permission to administer or documented declination). A review of the Admission/readmission Assessment, section A. admission Details, subsection 6. Immunization up to date, did not reflect information on pneumovax. On 5/30/2023 at 11:20 AM, during an interview with the surveyor, the social worker informed the surveyor that during admission she completes the in-take packet that included vaccination information for influenza and pneumococcal. On 6/01/23 at 9:32 AM, the surveyor interviewed the DSS. The DSS informed the surveyor that vaccination information is entered into the eMR and the hardcopy was submitted to the Assistant DON. On 6/02/23 at 12:56 PM, the concern regarding Resident #143' not receiving, no documentation of the vaccine being offered, no documentation of refusal or education provided relating to the Pneumococcal vaccine was brought to the attention of the LNHA, the DON and the RDCC. On 6/05/23 at 10:08 AM, the LNHA confirmed that the Pneumococcal Vaccine was not offered. The LNHA also stated that the DSS did not attempt to contact the family because she had a hard time reaching the family member and now the resident has a guardian. At that time, the LNHA stated the resident was still able to exercise his/her likes, dislikes, and preferences. The LNHA confirmed it should have been offered as long as the resident did not have it in the last five years. The LNHA stated moving forward the informed consent forms would be placed in the medical record. A review of the facility's Pneumococcal Vaccine Policy reviewed/revised 01/2023 revealed that it was the facility's policy to offer residents pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. NJAC 8:39-19.4 (i) Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident #95 and #143), reviewed for vaccination status and was evidenced by the following: Centers for Disease Control & Prevention (CDC) recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: (last reviewed 02/13/23). 1. On 5/22/2023 at 11:00 AM, the surveyor observed Resident #95 walking around the third floor hallway. The surveyor reviewed Resident #95's medical record. The resident's admission Record (AR; or face sheet; admission summary) reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential hypertension (high blood pressure), type two diabetes (abnormal blood sugar level), insomnia (common sleep disorder), unspecified dementia with other behavioral disturbance (cognitive impairment), major depressive disorder, anxiety disorder, and age-related nuclear cataract bilateral (the center of the eye's lens becomes thick and discolored). The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 3/28/23 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The qMDS revealed that staff assessment for mental status was conducted due to the resident's unable to complete the interview and showed that the resident's cognitive skills for daily decision-making had a score of 2 (two) which indicated that the resident's cognition was moderately impaired. Section O in the qMDS revealed that the resident had no pneumococcal (pneumonia) vaccine and was coded 3 (three) which indicated that the pneumonia vaccine was not offered. Further review of the resident's MDS showed that on the following MDS assessments, Section O was coded 3 (three) which indicated that the pneumonia vaccine was not offered: ARD 6/27/22 Quarterly ARD 9/27/22 Significant Change ARD 12/27/22 Quarterly A review of the resident's immunization history in the resident's electronic medical record revealed that there was no evidence that the resident had been administered the pneumonia vaccination and it was offered. On 6/01/23 at 9:15 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) in the presence of another surveyor. The MDSC/RN informed the surveyor that it was the responsibility of the MDSC/RN and the per diem MDS staff to answer Section O for flu and pneumonia vaccination. The MDSC/RN stated that information for vaccination was in the electronic medical records in the immunization tab, electronic Medication Administration (eMAR), and/or in the consent form that the resident or the responsible party signed for the vaccine. She further stated that if Section O was coded not offered it means that there was no documentation that the resident had the vaccine or the resident was offered the vaccine because we only get information from the medical records. On that same date and time, the surveyor asked the MDSC/RN what was the facility's practice and policy about offering flu, pneumonia, and other vaccines to residents. The MDSC/RN stated, I believe that we discussed that the facility offers the flu and other vaccines to everybody (all residents). She further stated that I'm not sure the facility's policy with regard to pneumonia vaccine, we don't usually offer it I think. At this time, the surveyor notified the MDSC/RN about the 3/28/23, 12/28/22, 9/27/22, and 6/27/22 Section O in MDS that the pneumonia vaccine was coded not offered. The MDSC/RN stated that if it was coded not offered then there were no documentation it was offered. On 6/01/23 at 12:53 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Administrator (RA), and Assistant Administrator (AA) and were made aware of the above findings. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, Regional Director of Clinical Compliance (RDCC), and AA. The LNHA stated that the pneumonia vaccine was not offered because I believe the Social Worker in the past had a hard time reaching the family, anyway it's not relevant now, and that the pneumonia vaccine should have been offered. The LNHA further stated that the current Social Service Director (SSD) now did not attempt to reach the family member. The current SSD should have reached out to the family and offered the vaccine. The LNHA informed the survey team that it was their facility policy to offer pneumonia vaccine to the residents unless it was medically contraindicated. 6/08/23 01:18 PM The survey team met with the LNHA, DON, Chief Nursing Officer, RA, AA, RDCC, and DON and there was no additional information provided by the facility team.

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure certified nurse aide (CNA) credentials were verified upon hire. This deficient practice was identified for 4 (four) of 5 (five) newly hired staff reviewed, (CNA #1, CNA #2, CNA #3 and CNA #4) and was evidenced by the following: On 6/07/23 at 01:48 PM, the surveyor reviewed the facility provided employee files of five randomly selected newly hired employees. The review included the following: CNA #1 with a date of hire (doh) of 3/21/23 had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. CNA #2 with a doh of 3/27/23 had a NJDOH online Public Registry license verification printout which was dated 4/21/23 which was after the doh. CNA #3 with a doh of 5/15/23 had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. CNA #4 with a doh of 5/8/23 did not have a NJDOH online Public Registry license verification printout. There was no documented evidence that the status of the four newly hired CNA's licenses were verified prior to the staff having direct contact with residents of the facility. On 6/08/23 at 9:27 AM, the surveyor interviewed the Director of Human Resources (DHR) regarding the process for hiring new employees. The DHR stated that for nursing staff, she would check their credentials, licenses and vaccinations. She then stated that all employees receive a background check before they start working. She added that she uses another system that monitors their license but it does not show if the license is active. She then stated that she would verify if their license was active and print out the verification sheet and keep it in their file. The surveyor asked if the date was on the verification sheet. The DHR stated that when you print out the license verification, it had the date on it to show the date you did it. On 6/08/23 at 10:22 AM, the surveyor showed the DHR the CNA's files. The DHR stated that she did not know why CNA #2 had a date that was after the doh. She then stated she did not know why the other CNA's did not have a date. The DHR did not know why CNA #4 did not have a printout. On 6/08/23 at 10:38 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) the concern that there was no documented evidence that the 4 (four) CNA's had their license verification done prior to their doh. The LNHA stated that he did not think it was required to have a date on the them [printouts] but that he would check. On 6/08/23 at 11:00 AM, in the presence of the survey team, the Assistant Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Compliance and Chief Nursing Officer, the LNHA stated that the DHR checks the newly hired staff's license before they start work and that she printed it but that she did not print it with a date. He then stated that CNA #2's printout must have been an updated copy. The LNHA then added that he did not think it was required to have dates on the printouts. The facility did not have a policy for the new hire process. A review of the facility provided policy titled, Policy for Resident Abuse Investigation with a reviewed/revised date of 10/2022 included the following: SCREENING: Employees are screened via Department of Health License Verification Line and are in-serviced on facility's abuse policies as part of orientation and thereafter as part of regular in-service program. Background check is conducted by outside service of all employees prior to hire . [Facility] does not employ individuals who have been Found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment of residents by a court of law; or Have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of property; or Have a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriation of resident property. N.J.A.C. 8:39-43.15(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#00163298 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate, a.) timely report, (Resident#372 and #117) and b.) a hematoma of unknown origin on 4/07/23 of Resident#95. This deficient practice was identified for three (3) of seven (7) residents reviewed for abuse and was evidenced by the following: 1. A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 4/10/23 at 9:00 PM, with an event date of 4/07/23 at 11:56 PM. The incident was reported as an allegation of resident-to-resident abuse. The event was described as follows: While Resident #372 was transferring from bed to wheelchair, Resident #117 allegedly pulled Resident #372's wheelchair from underneath him/her. This resulted in Resident #372's fall with no injury. The FRE showed there was no plan of care or planned interventions prior to the event. Further review of the event reflected that Resident #117 was sent to the hospital for psychiatric evaluation, psychology and psychiatric consults were ordered. The residents were moved to separate unit and would remain in separate units. The report also reflected the prescriber, responsible parties, and Ombudsman were notified. The surveyor reviewed the medical record for Resident #372. The admission Record (AR; or face sheet; an admission summary) reflected that the resident had been admitted with diagnoses which included venous insufficiency (chronic; peripheral), thrombocytosis (increased platelet), muscle weakness, acquired absence of the right leg, above the knee, muscle weakness and unsteadiness on feet. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 4/25/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Further review of the qMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident #372 required extensive assistance (resident involved in activity; staff provide weight-bearing support) for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), and transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) with 1 (one) person physical assist from staff. The individualized Care Plan (CP) revealed a focus that included, Resident #372 with a high risk for falls related to amputation and muscle spasms. The interventions included: anticipate and meet the resident's needs, the resident's call light is within reach and the resident needed prompt responses to all requests that were initiated on 10/20/22. Psych consult and Psychology consults were added to the interventions after the resident-to-resident abuse that was initiated on 4/11/23. The facility provided PN for Resident #372, dated 4/07/23 at 02:24 AM by Registered Nurse#1 (RN#1), documented the following: At 11:50 PM [4/06/23], the patient reported to the nurse . At 12:00 AM, the supervisor arrived on the unit At 12:30 AM, the police arrived At 12:40 AM, telehealth with doctor conducted patient reported pain [scale of] 6 (six) out of 10, Tylenol was given by nurse. Doctor told patient he/she does not need to go to the ER (emergency room), she will order x-rays . At 01:00 AM, transport arrived to bring resident to the hospital, resident declined. Patient was sitting on the wheelchair resting, non-labored breathing. The facility provided PN by the Registered Nurse/Supervisor (RN/S) on 4/07/23 at 12:55 AM, reflected Late Entry The resident stated his/her roommate pulled his/her wheelchair from underneath him/her while he/she was transferring causing him/her to fall on the floor; An assessment was conducted and rendered no redness, or alteration in skin integrity; The assessment indicated the resident was able to flex and extend bilateral upper/lower extremities. Emergency Response arrived on the unit. Further review of the PN by the RN/S reflected telehealth was conducted via dual video Conference/Assessment was completed, and new orders of x-Rays were provided for the resident. Neurological Assessments were also ordered. The PN revealed that Neurological screens were provided on 4/08, 4/09 and 4/10. The documentation of Neurological Monitoring sheets by the nurses were not provided. The PN also reflected that on 4/10/23 Nurse Practitioner#1 (NP#1) reviewed the x-rays with results of no fracture/dislocation on bilateral ribs, left shoulder, right shoulder; the lumbar spine did not indicate a fracture. The bilateral hip result showed no dislocation or obvious fracture, CT/MRI (computed tomography/ computed tomography; medical imaging methods that creates images of the internal body that includes bones and soft tissue) is recommended if occult (hidden) fracture is suspected. A review of the risk assessment dated [DATE] at 6:19 AM, indicated that Resident #372 had a predisposed physiological factor of gait imbalance and a predisposed situation of above the right knee amputation. 2. The surveyor reviewed the medical record for Resident #117. The AR reflected that the resident had been admitted with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), hypertension, other seizures, other abnormalities in gait and mobility, muscle weakness, need for assistance with personal care, anxiety disorder, depression, vitreous opacities, unspecified eye (floaters that blocks light from reaching retina which may cause mild to severe vision loss), other symptoms and signs appearance and behaviors. The qMDS dated [DATE], reflected that the resident had a BIMS of 8 (eight) out of 15, which indicated the resident had a moderately impaired cognition. Further review of the qMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident # 117 required supervision (oversight, encouragement, or cueing) for walk in room (how resident walks between locations in his/her room) and walk in corridor (how resident walks in corridor on unit with setup help from staff). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) (excludes to/from bath/toilet)) reflected limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) required 1-person physical assistance from staff. The individualized CP revealed a focus that included, Resident #117 had limited physical mobility related to neurological deficits. The interventions included, Resident #117 required extensive assist by staff to walk using a walker, date initiated 11/01/21. A review of the PN reflected the following: -4/04/23 at 5:40 PM, pacing back and forth on the unit, combative with staff, verbally abusive with staff, hitting staff, fall precautions maintained. Very difficult to redirect, refer to psych for evaluation. -4/05/23 at 12:20 PM, combative, verbally abusive to staff, very difficult to be redirected, refused nursing care and treatment, wandering on the unit, continue to be redirected, referred to psych for evaluation. -4/06/23 at 7:15 AM, behavior monitoring in progress. Redirected multiple times -4/06/23 at 16:03 resident alert and verbal. Observed with anxiety and agitation. Constant redirection required and provided. Resident refused to follow verbal redirection . -4/06/23 at 7:49 PM, patient continues to be on behavior monitoring, As needed Ativan (antianxiety medication) given . -4/06/23 at 12 AM, reflected Late Entry, RN/S documented she was called to the unit by assigned nurse to assess the resident within the room for aggressive behavior towards roommate .Resident #117 was asked to leave in [dialect redacted]. The resident refused and became aggressive with staff, Ativan 1 (one) mg (milligram) was administered at 11 PM, which rendered ineffective by behavior. [redacted] notified dual /video conference assessment completed. - 4/07/23 at 00:31 AM, the telehealth assessment and plan included the NP sent Resident #117 to the Emergency Department (ED). -4/07/23 at 01:30, RN#1 authored a PN that included the following: At 9 PM, all due meds [medications] given and tolerated At 10 PM, wandering hallway going into resident's rooms, redirected . At 11 PM, pt [patient] anxious, wandering the hallway going into other resident's room, Ativan 1 (one) mg given. At 12 AM, supervisor arrived to the unit, patient laying in bed refusing to get up and leave the room to be placed in another room At 12:30 AM, the police arrived, pt remained non compliant At 12:50 AM, ems took patient to hospital breathing non labored. Responsible party and Medical Doctor notified by supervisor A review of the electronic Administration Record, reflected Resident #117 received Ativan 1 (one) mg on 4/06/23 at 4:20 PM, documented as effective. The following dose was signed administered on 4/07/23 at 12:50 AM, documented as ineffective. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 4/05/22 revealed Resident #117 was referred to OT for reasons that included: increased, decrease in strength, functional mobility, reduced ability to safely ambulate, reduced balance, decreased neuromotor control, decreased coordination, decreased judgement, cognitive deficits . The facility provided, Summary of Investigations reflected that when Resident #117 was interviewed, the resident was unable to remember the incident during an interview with a [dialect redacted] speaking staff, due to cognitive impairment. The Summary of Investigations reflected that Resident # 372 was in bed and went to transfer. That was when Resident #117 moved the wheelchair out of Resident #117's path. Resident #372 added that the sudden transfer of the wheelchair caused the alleged fall. Resident #372 called the police and gave a statement. The Emergency Response (Police) report was not provided. The facility provided Summary of Investigations reflected Certified Nursing Aide#1 (CNA#1) was interviewed. CNA #1's statement reflected what she had heard on the night of the Resident # 372's reported un-witnessed fall. A review of the schedule for 4/06/23, reflected there was one RN and two CNAs assigned to Resident #372's unit from 11 PM to 7 AM. CNA #2's statement and other ancillary staff 's statement and interviews were not documented within the summary of investigation. A review of CNA assignment sheet dated 4/06/23 11 PM to 7 AM shift, revealed CNA #2 was assigned to Resident #374's room, beds 1, 2, and 3. There were no documented interviews of other residents within the investigation summary report provided. On 5/30/23 at 12:49 PM, during interview with the survey team, the Director of Nursing (DON) stated we used a form called Unusual Occurrence for statements from the CNA, nurses, and risk management. The DON stated that all notes on investigation were in the resident's PN. The DON also stated that the resident's roommates would also be interviewed. At that time the Licensed Nursing Home Administrator (LNHA), stated the staff and residents were interviewed verbally and documented immediately. The facility places all of the interventions, investigation and conclusion were also documented. The CP was also updated. The LNHA stated that the nurses have to monitor the residents for an undetermined amount of time. At that time, the LNHA was unable to inform the surveyors where the monitoring is documented to prevent an incident from occurring again. On that same date and time, in the presence of the survey team, DON and LNHA, the surveyor requested for all the staff statements relating to the FRE. On 06/02/23 at 10:14 AM, during an interview with the surveyors, the LNHA stated there were no incidents or accidents or reportable for Resident #372 and #117 in the last 6 months. On 6/07/23 at 11:31 AM, during an interview with the survey team, the LNHA stated there should have been more statements collected. The LNHA stated that the other nurses on this shift should have been interviewed. The LNHA acknowledged that the investigation was not thorough, and the investigation process could be improved. The above finding and concerns were discussed with the LNHA. On 6/07/23 at 12:35 PM, the LNHA confirmed the resident-to-resident abuse reported occurred on 4/06/23 as opposed to the reported date of 4/07/23. The LNHA confirmed the investigation could have been better and more interviews should have been conducted. A review of the facility provided policy, Assessing Falls and Their Causes reviewed and revised 01/2023 under Steps in Procedure; After a Fall: section 1. If a resident has just fall or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 3. On 5/26/23 at 7:35 AM, the surveyor asked the Regional Director of Clinical Compliance (RDCC) about Resident#95's incident/accident reports, and the RDCC stated that she will get back to the surveyor. On 5/26/23 at 7:43 AM, the surveyor observed the resident laying on the bed with eyes closed, the cockup splint (used as a post-traumatic rehabilitation aid to get the injured wrist back in shape) on top of the nightstand. On 5/30/23 at 12:03 PM, a review of Resident #95's Risk Assessment investigation report dated 4/07/23 was provided by the LNHA revealed that on 4/07/23 at approximately 6 PM, the resident was found crying at the hallway wherein RN#2 asked the resident why she was crying and the resident showed their right hand, the RN noted hematoma above the right wrist. The resident's description showed that the resident was unable to give a description. The Risk Assessment also showed that the resident was not taken to the hospital. The injuries observed at the time of the incident showed that the injury location was right hand back, the injury type and injury location was blank and there was no documented measurement and description of the hematoma. The investigation also indicated that there were no witnesses found. In addition, the attached care plan in the provided investigation showed that the focus was that the resident was at risk for falls r/t (related to) poor safety awareness, pacing initiated on 6/18/20 with an intervention initiated 4/10/23 moved closer to the nurses station. There was no intervention dated 4/07/23 to reflect the incident about the unknown, unwitnessed hematoma. The LNHA's provided Risk assessment dated [DATE] did not include statements from staff. Further review of the above investigation of Resident #95's unknown hematoma and the unwitnessed incident report revealed there was no documented statement from the other residents on the same unit, direct care staff, and any ancillary staff who may have had contact with the resident. On 5/31/23 at 9:53 AM, the DON provided another Risk Assessment investigation copy of the unknown hematoma to the right hand dated 4/07/23 at 6 PM. The information in the 4/07/23 Risk Assessment that was provided by the DON was the same as what the LNHA provided on 5/30/23 except for the question: Resident Taken to Hospital which had an answer now with Y (Yes). The provided Risk Assessment of the DON included Unusual Occurrence Statements from CNA#4 and Licensed Practical Nurse (LPN). The staff investigative statements were as follows: 1) One statement from CNA #4 that included The nurse notified me that Resident#95 had an injury to his/her right arm. I was feeding residents and collecting trays afterward. 2) A second statement from the LPN included Nurse/CNA reported resident in hallway crying and holding his/her right wrist. Resident unable to say what happened. Telehealth was called. Portable x-ray ordered. Family notified. 3) A third statement from DON typewritten dated 4/10/23 (three days after the incident), indicated that Resident #95 was interviewed by the DON in the presence of the Director of Maintenance (DOM) as a Spanish interpreter. The statement from the DON showed that the resident was asked regarding the bruising to the right wrist area. The resident was questioned about what happened and the resident responded that he/she fell out of their bed onto their arm. Further review of the Staff Investigative statements of Resident #95's incident report revealed there was no documented statement from the other residents on the same unit or any ancillary staff who may have had contact with the resident on 4/07/23. The staff statements did not include information on who, when, where the resident was last seen and what was the resident doing before the incident happened. In addition, there was no further investigation on 4/10/23, after three days, when the DON found out from the interview with a Spanish interpreter to determine the root cause and analysis of the fall incident. The surveyor reviewed Resident #95's medical record. The resident's AR reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential hypertension (high blood pressure), type two diabetes (abnormal blood sugar level), insomnia (common sleep disorder), unspecified dementia with other behavioral disturbance (cognitive impairment), major depressive disorder, anxiety disorder, and age-related nuclear cataract bilateral (the center of the eye's lens becomes thick and discolored). The resident's most recent qMDS with an Assessment Reference Date (ARD) of 3/28/23 reflected that the resident had a BIMS score of 99 which indicated the resident was unable to complete the interview. The qMDS revealed that staff assessment for mental status was conducted due to the resident's unable to complete the interview and showed that the resident's cognitive skills for daily decision-making had a score of 2 (two) which indicated that the resident's cognition was moderately impaired. A review of the resident's individualized CP with an initiated date of 6/18/20 reflected a focus area that the resident had a potential impairment to skin integrity r/t (related to) fragile skin and on 3/16/23 with skin tear to right lower back. There was no evidence that the 4/07/23 right wrist hematoma was identified and included in the care plan. There was no evidence that there were interventions identified and created on 4/07/23 to reflect the unknown hematoma incident. Further review of the resident's personalized CP with an initiated date of 4/21/23 reflected a focus area that the resident had an ADL (activities of daily living) self-care performance deficit r/t dementia with an intervention initiated on 4/21/23 that resident was on NWB (no weight bearing) to the right hand, provided wrist cockup splint, and to be worn after AM (morning) care and removed PM (afternoon) care. In the electronic medical records, PN dated 4/07/23 at 7:29 PM by RN#2 revealed that at approximately 6 PM, the resident was found crying in the hallway and noted a hematoma above the right wrist. In the PN dated 4/07/23 at 7:45 PM by NP#2 showed that the resident was evaluated via telehealth because of the hematoma and swelling to the resident's right lower arm above the wrist and that the resident was not sent to the ED. NP#2 ordered for stat x-ray of the arm and hand. The note of NP#2 also showed that the staff did not know how it happened, no reported fall, and the resident had dementia and can not tell what happened. On 5/31/23 at 10:58 AM, the surveyor notified the above findings to the DON. The surveyor interviewed and asked the DON about the 4/07/23 investigation because the injuries observed at the time of the incident and injury type in the Risk Assessment were not complete which did not include the measurements and description of the hematoma. The surveyor asked the DON if a skin assessment was done on 4/07/23. The surveyor asked also the DON why there was no documentation of what were the interventions after the resident returned from the hospital on 4/08/23. The DON stated that he will get back to the surveyor. On 5/31/23 at 11:13 AM, the surveyor interviewed the DOM who informed the surveyor that his primary language was Spanish. The DOM stated that the resident was Spanish speaking and cognitively impaired. The DOM indicated that the resident does not remember names, times, or dates, and stated that Resident#95 just talked to me because I speak Spanish, other than that I know he/she is confused. He further stated that I know it's in April but I can't remember what exact date when the DON asked him to be the interpreter for the resident. On that same date and time, the DOM informed the surveyor that when he and the DON went to the resident, the resident was asked about what happened, the resident responded that the resident rolled over the bed to the floor and got up. The surveyor then asked the DOM if the resident was asked what was the resident doing before the resident rolled over the bed when the resident fell, if was there someone in the room, and other information that will determine the root cause analysis of the fall incident that resulted in the injury. The DOM stated that after that question about what happened and the resident responded, the DOM and the DON left the resident and there were no further questions asked to the resident. On 6/01/23 at 8:49 AM, The surveyor called and left a message to CNA#4, the CNA who wrote a statement on 4/07/23. On 6/01/23 at 9:46 AM, The surveyor interviewed the LPN who informed the surveyor that she was also the facility educator and does med pass and care of residents. The LPN stated that she remembered the 4/07/23 incident of the resident because it so happened that she was on the 3rd floor at that time when it happened while doing routine rounds as a covering supervisor on that day. The LPN found the resident crying in the hallway with some residents passing by, and the resident was stating in Spanish dolor, dolor, (dolor means pain in Spanish) while the resident touched their right hand. The LPN further stated that at that time the right wrist was slightly swollen, we don't know what happened and where the resident got the hematoma. The surveyor then asked the LPN if the resident had a fall incident on that same date, and the LPN responded that the resident did not fall. On that same date and time, the LPN informed the surveyor that I think the CNA was busy with something but not sure if the CNA was passing trays or helping other residents. The LPN acknowledged it was an injury of unknown origin at that time, and I know from other facilities if that was the case, they go back 72 hours lookback of staff statements. The surveyor asked the LPN if there were staff statements 72 hours from the time of the incident, the LPN stated: I'm not sure if that is what we do here also and don't know if that was done because 4/07/23 was a Friday and I was off during the weekend. Furthermore, the surveyor asked the LPN if there was a skin assessment done on 4/07/23. The LPN stated that there should be a skin assessment for that incident, and the skin assessment should be part of the Risk Assessment. She was unable to remember the name of the nurse at that time who did the Risk Assessment, the LPN stated It was an agency nurse who did the Risk Assessment and the nurse should have included the description of the injury including the measurement, color and what part of the body and if there were other injuries to the other part of the body. At that time, the surveyor notified the LPN that the Risk Assessment did not include the measurement and other descriptions of the injury. The surveyor asked the LPN why the 4/07/23 Risk Assessment did not include the description of injuries and if she as a Supervisor at that time checked if the Risk Assessment was complete. The LPN stated, I don't know. The LPN indicated that after that day she did not know what else happened because she was off the weekend. On 6/01/23 at 11:20 AM, the surveyor called both RN#2 and CNA#4 for the second time. CNA#4's voicemail was full. On 6/01/23 at 11:38 AM, the surveyor received a return call from RN#2. The surveyor interviewed the RN in the presence of another surveyor. The RN informed the surveyor that she was an agency nurse and worked at the facility one time only and was unable to remember when she worked. The RN stated that she remembered it was on the 3rd floor 7 AM-7 PM shift. She acknowledged that the nurses at the facility work 12 hours shift and the CNAs works eight hours shift. RN further stated that she remembered that she was passing medications (meds) I think and the CNAs were passing trays, Spanish speaking Resident # 95 was in the hallway, and had a scratch, I think it was a skin tear but we do not know what happened and why the resident had it but the doctor was called and the supervisor. RN stated that I can't remember who was the supervisor and I did the incident report in the Risk Assessment on the computer on the same date. She further stated the resident was ambulatory, We called the responsible party about the incident, and after that I don't know what else happened. On that same date and time, the surveyor asked RN#2 if she remembered doing a skin assessment since the incident was of unknown origin, the RN stated that whatever in the computer in Risk assessment that's what she documented. RN#2 acknowledged that the skin impairment was an injury of unknown origin. She further stated that since the skin impairment was in the hand she did not think that the other part or whole body should be assessed for possible injury. The RN indicated that she was not sure if it was a bruise or skin tear because she was not sure what was on the right hand. In addition, the RN stated that the right hand should have documentation of the size or measurement of impairment and a description of the injury, and if it was not documented in her Risk Assessment, she claimed that she probably forgot to do so. Furthermore, RN#2 informed the surveyor that the resident did not fall and we don't know what happened and why the resident sustained the injury. She further stated that there should be a staff statement at least 24 hours or 72 hours before the incident since it was unknown but not sure if the supervisor did it and asked for it. On 6/01/23 at 12:53 PM, the survey team met with the LNHA, DON, Regional Administrator (RA), and Assistant Administrator (AA) and was made aware of the above findings. The surveyor asked the facility team why there was a discrepancy with the Risk assessment concerning the question of the resident being taken to the hospital with two different answers different on two submitted copies of LNHA and DON. The surveyor asked the facility team why the Braden Scale for Predicting Pressure Sore Risk (BSPPSR) was initiated on 4/07/23 at 12:50 PM signed and locked on 5/26/23 which the DON claimed was the skin assessment done to the resident for 4/07/23 unknown hematoma incident that happened approximately 6 PM. The surveyor also asked the facility team why the Morse Fall Scale was done on 4/08/23 and was also signed and locked on 5/26/23 after the surveyor's inquiry. On that same date and time, the surveyor asked the facility team why there were no v/s (vital signs; blood pressure, heart rate, respiratory rate, and temperature) taken and recorded at the time of the incident at 6 PM. The LNHA stated that he will get back to the surveyor. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, RDCC, and AA. The LNHA stated that the Risk Assessment on 4/07/23 was not locked. The LNHA further stated that when the DON noticed on 5/26/23 that the investigation was not locked, the DON went in and signed it off that was where the discrepancy for the question of if the resident was taken to the hospital responses were different. On that same date and time, the LNHA acknowledged that there were discrepancies from the provided documents to the surveyor and the LNHA stated that the facility should have done better with documentation and gathering of statements for the investigation. At that same time, the surveyor asked the facility team why there was no investigation for a fall when the team concluded after three (3) days that the incident of unknown origin hematoma was from a fall incident. The LNHA stated that we concluded it was from a fall that the resident sustained hematoma. The LNHA agreed that the interventions should have been done when the team concluded that the hematoma was from the fall and should have further investigated the fall. The LNHA further stated that the investigation was not properly documented we should have done more including the appropriate interventions other than moving the resident closer to the nursing station. Furthermore, the DON stated that I do agree that the investigation should have been thorough. The LNHA further stated that definitely the investigation was lacking information. A review of the facility's Policy for Resident Abuse Investigation with a reviewed/revised date of 10/2022 provided by the LNHA in the Entrance binder of the facility included that in any investigation, in any instance of mistreatment, neglect, or abuse of residents, misappropriation of their property, or injuries of unknown source an incident report is completed. Surveillance procedures for any injuries sustained are followed. Appropriate supervisory personnel is notified, and the investigation begins promptly after the report of a problem. Statements or interviews of the resident, suspect (if identified), any eyewitnesses, and any circumstantial witnesses are taken. Relevant documentation is reviewed. The alleged victim is examined promptly and the finding is documented in the report. Injuries of unknown origin, are investigated by going back 24 hours and speaking to all direct care personnel, to see if when and how the bruise occurred can be ascertained. On 6/08/23 at 01:18 PM, the survey team met with the LNHA, DON, Chief Nursing Officer (CNO), RA, and AA, and there was no additional information provided by the facility. NJAC-8.39-4.1(a)5; 9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/22/23 at 11:35 AM, during initial tour of the fifth floor unit, the surveyor observed Resident #162 lying in bed. Resident #162 had a wander guard bracelet (an alarm system used for a resident that wanders or has exit seeking behaviors) visible to the left ankle. On 5/30/23 at 12:27 PM, the surveyor reviewed Resident #162's medical record. The AR indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). The resident's Medication Review Report (physicians orders) dated 6/06/23 included the following order: Roam alert: check placement q shift (every shift). There was no order to check the function of the wander guard bracelet with a start date of 02/24/23. The significant change in status MDS, dated [DATE], indicated a BIMS score of 3 out of 15, which reflected that the resident's cognition was severely impaired. The MDS indicated under Section E Behavior that the resident wandered 4 (four) to 6 (six) days. Further review indicated under section P for Restraints and Alarms, Wander/elopement alarm was not used. The section was coded incorrectly. A review of Resident #162's Elopement Risk Evaluation dated 02/13/23 indicated that the resident was at risk for elopement and that interventions that were started was roam alert ordered. On 6/01/23 at 12:01 PM, the surveyor interviewed the MDSC/RN regarding Resident #162's Significant Change MDS dated [DATE] that was coded incorrectly. The MDSC/RN stated that she had just now found the mistake because she had heard staff talking about Resident #162 and the wander guard. She stated that she wanted to make sure the MDS was accurate. She then stated that another staff member that was a per diem (as needed) worker had done Resident #162's MDS and that she made a mistake. The MDSC/RN stated that she just did a modification to Resident #162's 4/11/23 MDS. The MDS modification was done after the surveyor's inquiry. On 6/02/23 at 12:46 PM, in presence of the survey team, the surveyor notified the LNHA, AA, DON, RDCC the concern that Resident #162's MDS was inaccurate. On 6/07/23 at 01:23 PM, the LNHA did not have any response regarding the concern of the inaccurate MDS. On 6/08/23 at 01:18 PM, the survey team met with LNHA, DON, Chief Nursing Officer (CNO), Regional Administrator, AA, and RDCC, there was no additional information provided by the facility management. NJAC 8:39-33.2 (d) Based on observation, interview, record review, and review of pertinent facility documentation, 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, for three (3) of 34 residents, (Resident #40, #103, and #162) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified 12/01/21, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of the source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. 1. On 5/26/23 at 7:39 AM, the surveyor observed Resident #40 seated on their bed. On 5/26/23 at 8:26 AM, the surveyor interviewed the Physical Therapist (PT) who informed the surveyor that the Rehab Manager (RM) was out for a previously scheduled education arrangement that was out-of-state. The PT stated that the facility has an RNP (Restorative Nursing Program) and the assigned Restorative Aide (RA) that takes care of the ambulation and range of motion (ROM). She further stated that the splinting was the Certified Nursing Aide's (CNA) responsibility. On 5/26/23 at 8:34 AM, the surveyor interviewed the RA who informed the surveyor that she's been working in the facility as RA for five (5) months and responsible for RNP and documentation for RNP ambulation and ROM. She further stated that each unit has a binder for their RNP and she kept a copy also in the Rehab Department. On that same date and time, the RA showed the RNP binder that was arranged according to units (1st, 2nd, 3rd, 4th, and 5th floor) that included Resident # 40's RNP for ROM. The surveyor reviewed the medical records of Resident #40 and revealed the following: The admission Record (AR; or face sheet; an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to essential hypertension, muscle weakness (generalized), need for assistance with personal care, anxiety disorder unspecified, and major depressive disorder recurrent, mild. The most recent annual MDS (aMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 5/09/2023, showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that the resident's cognition was intact. The aMDS Section O Special Treatments, Procedures, and Programs, the RNP for ROM were coded 0 which means that there was no RNP for ROM performed in the last 7 (seven) calendar days. The seven calendar days was the lookback period for RNP ROM. Further review of the quarterly MDS Section O, RNP for ROM showed the following: ARD 02/07/23 Quarterly=coded as 0 A review of the Documentation Survey Report from January 2023 through May 2023 RNP log for AROM for BUE/BLE x 10 reps x 3 sets in all planes showed the following: February 2023=the resident was documented to participate for 15 minutes on Day 7 AM-3 PM on dates 5/02/23, 5/03/23, and 5/07/23. There was no documentation in the log that on dates 5/01/23, 5/04/23, 5/05/23, and 5/06/23 that the RNP was offered, refused, the mentioned dates were blank. May 2023=the log showed that from 5/02/23 through 5/09/23 the RNP was blank. There was no documentation from 5/02/23 through 5/09/23 that the RNP was offered and refused as specified in the instructions below the form. Further review of the above RNP showed that the quarterly MDS with an ARD of 2/07/23 should have been coded 3 (three) because the resident participated on RNP for AROM for BUE/BLE for 15 minutes each day on dates 5/02/23, 5/03/23, and 5/07/23 within the last 7 (seven) days of MDS lookback. On 6/01/23 at 9:15 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) who informed the surveyor that she was part of the RNP meeting. The MDSC/RN stated that the RNP meeting was every second Tuesday of the month, and attendees included her, the Director of Nursing (DON), the Director of Rehab (DoR), the Assistant Director of Nursing (ADON), the RA, and sometimes the Licensed Nursing Home Administrator (LNHA). On that same date and time, the surveyor notified the MDSC/RN of the above findings with regard to the accuracy of the RNP captured in the MDS. The MDSC/RN stated that it was probably a software issue which was why the RNP was not captured in Resident#40's MDS. She further stated that she will discuss these findings with the facility management and will get back to the surveyor. On 6/01/23 at 10:26 AM, the surveyor observed Resident#40 seated on their bed. The resident stated that the facility staff, unable to remember the name, comes daily to do his/her exercises for his extremities and there was no concern. On 6/01/23 at 12:04 PM, the MDSC/RN informed the surveyor in the presence of the survey team that the reason why the RNP was not captured in the MDS was because of the issue on the software, usually the information in the electronic medical records does not automatically transfer to the MDS. The MDSC/RN stated that now I have to manually check when submitting the MDS to make sure that the information was accurate. I wasn't aware that the software was not capturing the MDS information from the Quarterly Assessments that were being done in the electronic medical records. On that same date and time, the MDSC/RN stated that the MDS ARD 02/07/23 for RNP was an oversight on my part. She further stated that I should have documented that the resident was on RNP on the Quarterly assessment dated [DATE] that was signed and locked on 2/15/23 that the resident was on RNP, I don't know what happened. The MDSC/RN stated it was an error on the facility's part for not capturing the RNP in the MDS, and acknowledged that it was a concern for the accuracy of MDS. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, Regional Director of Clinical Compliance (RDCC), and Assistant Administrator (AA). The LNHA stated that Resident#40 information not pulling over to the MDS, as an immediate response moving forward were doing a monthly meeting. The LNHA further stated that the MDSC/RN who will be attending the meeting will be responsible for checking the MDS for RNP to make sure that the information was accurate. On 6/07/23 at 8:49 AM, the LNHA stated that according to MDSC/RN that there was no specific facility policy for MDS, and that the facility follow the RAI (Resident Assessment Instrument) Manual of the MDS. 2. On 5/30/23 at 9:32 AM, the surveyor observed Resident #103 laying on the bed with right hand limitation, with bilateral half side rails in use. The surveyor reviewed the medical records of Resident #103 and revealed the following: The AR showed that the resident was admitted to the facility with a diagnosis that included but was not limited to essential hypertension, muscle weakness (generalized), hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (weakness to the right side of the body due to stroke), anxiety disorder, schizophrenia unspecified (a disorder that affects a person's ability to think, feel, and behave clearly). The most recent quarterly MDS (qMDS) with an ARD of 4/18/23, showed that the resident had a BIMS score of 15 out of 15 which reflected that the resident's cognition was intact. The 4/18/23 qMDS showed on Section G functional Status, the resident was coded one (1) on the upper extremity which means that the resident had a functional limitation in range of motion, an impairment on one side of the upper extremity. Further review of the MDS showed the following: A. ARD 01/17/23 qMDS Section C Cognitive Patterns, the interview was signed on 02/06/23 by the Social Worker (SW), 20 days after the ARD. The 01/17/23 qMDS Section J Health Conditions, pain interview was signed on 01/28/23 by the Per Diem MDS/Registered Nurse (PDMDS/RN), 11 days after the ARD. B. ARD 10/18/22 aMDS Section C Cognitive Patterns, the interview was signed on 10/20/22, 2 (two) days after the ARD. A review of the Quarterly Assessment in the electronic medical record, with an effective date of 01/11/23 showed that Section C for the BIMS interview was signed by the SW on 02/06/23. A review of the Annual/Significant Change Assessment in the electronic medical record, with an effective date of 10/13/22 revealed that Section C for the BIMS interview was left blank and was not done. On 6/07/23 at 9:32 AM, the surveyor interviewed the MDSC/RN with regard to MDS and quarterly assessments that were in the electronic medical records. The surveyor asked the MDSC/RN what UDA means which can be seen in the assessment tab of the electronic medical records. The MDSC/RN stated that UDA means user define assessment and will show when the quarterly assessments in correspondence to MDS will be done according to the MDS ARD. The MDSC/RN explained that I open quarterly assessment in the form of UDA and make sure that all disciplines knew about it. The MDSC/RN further stated I make sure that each quarterly and annual or comprehensive assessment in the UDA in the assessment tab of the electronic medical records, were signed and locked. The surveyor asked the MDSC/RN when the UDA for quarterly and annual assessment should be locked and signed, the MDSC/RN stated that ideally it is done before the ARD, if not at least when as timely as possible. The surveyor asked the MDSC/RN when is as timely as possible, then the MDSC/RN stated that ideally within the ARD, but sometimes it is after. The MDSC/RN further stated that if the information in the UDA was after the lookback period, I don't use it in MDS. She indicated that the interview in the UDA set up quarterly assessments corresponds to the MDS and when the interview in the MDS was signed, it means that the interview was done on that date. At that same time, the MDSC/RN stated that she was responsible for answering Sections G Functional Status and J Health Conditions in the MDS. The MDSC/RN showed the surveyor her personal small notebook with scribble notes for different residents and did not include dates on some pages and did not have specific questions for each section of MDS including Pain assessment for Section J. The MDSC/RN indicated that the personal small notebook notes information was not part of the medical record of the resident. She further stated that the collection date of the interview in the MDS will be the stamped date that showed in the MDS. The MDSC/RN confirmed that the interview in the MDS should be within the lookback period of the ARD not after the ARD. Furthermore, the MDSC/RN informed the surveyor that she started at the facility to do MDS on November 2022. The MDSC/RN further stated that the UDA assessments should have been signed and locked, and should have been done within the ARD, not after the ARD. On 6/07/23 at 10:33 AM, the surveyor called and left a message for PDMDS/RN to call the surveyor for an interview. On 6/07/23 at 10:40 AM, the surveyor interviewed the SW in the presence of the survey team. The SW informed the surveyor that she was responsible for answering Sections C Cognitive Patterns, Section D Mood, Section Q Participation in Assessment and Goal Setting. The SW stated that she use a paper for an interview and then transfer to the UDA quarterly assessment, and MDS on the same day of the interview. She further stated that when she interviews residents she does not bring her computer which is why she uses paper for documenting the interview for Sections C, D, and Q. The SW informed the surveyor that the interview for Section C should be within the ARD, and the lookback for this section should be within 7 (seven) days. At this time, the surveyor asked the SW why Resident#103's 01/17/23 qMDS Section C interview was signed and done on 02/06/23, 20 days after ARD, and the 10/18/22 aMDS Section C interview was signed and done on 10/20/22, 2 (two) days after the ARD. The SW stated that the resident would not talk to me, and did not want to answer my questions, that what most likely what happened. She further stated that she wanted to give the resident a chance and that the SW keeps going back to the resident to get the interview that the SW needed. Furthermore, the surveyor asked the SW if there was a response in the MDS that the SW can use that the resident refused and did not want to complete the interview. The SW responded yes, and that she should have followed the guidelines in MDS and initiated the Staff Assessment for Mental Status when the resident did not complete and refused to answer the questions of the SW. She further stated that she should have coded Section C accurately because MDS should reflect the resident's current status according to the ARD within the lookback period, and that was MDS all about. On 6/07/23 at 12:32 PM, the surveyor asked the MDSC/RN if there will be additional information about Resident#103's Sections C and J's interviews. The MDSC/RN stated that there were no additional information she can provide and no other assessment or interview for the MDS that have a collection date within or during the ARD date that was asked by the surveyor for the above MDS. She further stated that whatever the MDS interviews that were signed on ARD 10/18/22 and 01/17/23, it was the date of the interview. The MDSC/RN acknowledged that the MDS interviews on Sections C and J on ARD 01/17/23 and 10/18/22 were signed beyond the ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to a.) implement interventions, clarify a physician's order to consistently monitor behaviors and document an incident in the medical record to prevent resident to resident altercations for one (1) of seven (7) residents reviewed for abuse (Resident #24); b.) ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for one (1) of one (1) resident reviewed for elopement (Resident #162); and c.) conduct an investigation and determine causal factors of a fall incident that resulted in a hematoma for one (1) of nine (9) residents, (Resident #95) reviewed for incident and accident. This deficient practice was evidenced by the following: 1. On 5/26/23 at 10:00 AM, the surveyor reviewed the facility provided Reportable Event Record/Report (FRE or Facility Reportable Event) for an altercation between Resident #24 and Resident #270 which occurred on 3/01/23 at 4:00 PM which included the following: Type of Incident: Resident-to-Resident Abuse Resident Name: Resident #270 a) Describe the event, to include timeframes/risk factors related to the incident/event (relevant resident Dx (diagnosis): At approximately 4:00 PM on Wednesday 3/01/23 Resident #270 entered Resident #24's room and allegedly touched Resident #24's belongings. Resident #24 admitted to scratching Resident #24 on the neck after Resident #270 refused to leave Resident #24's room. b) Prior to the event, was a plan of care developed that addressed this issue, and were planned interventions in place when the event occurred. No c) What interventions were implemented after the incident/event? For example, supervision, resident sent to hospital, CNA suspended. Please describe investigative findings/conclusions: Residents were separated. Resident #270 moved to another floor. Stop sign hung at Resident #24's room. Attached to the FRE document the facility provided was a Summary of Investigation that was not signed or dated by the Director of Nursing (DON) or Licensed Nursing Home Administrator (LNHA) and included the following: Conclusion: Scratch was result [of] Resident #270 invading the personal space of Resident #24 and touching the belongings of Resident #24. It is concluded incident is an isolated incident. Further review of the incident report/risk management document of the incident that the facility provided including the following on the bottom of the document: .NOT PART OF THE MEDICAL RECORD . The surveyor reviewed Resident#24's medical record. The admission Record (AR; or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; acute kidney failure (when the kidneys suddenly become unable to filter waste products from the blood), metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Resident #24's quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 02/07/23, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which reflected that the resident's cognition was severely impaired. The individualized Care Plan (CP) reflected a focused area with an initiated date of 11/04/21, of Resident #24 had impaired behaviors related to: Mood swings or changes, refusing due medications despite encouragement, refusing of care offered by staff. 3-11-2022: physical aggression towards resident. Interventions which with an initiated on 11/4/21 included: Avoid power struggles and confrontation; Document efforts at encouraging appropriate cares, treatments and residents response/ compliance; Encourage verbal communication/ simple words to communicate wants and needs; Follow facility protocol for inappropriate behaviors; Monitor for changes in mood and behavior; Praise socially appropriate behavior; Provide medication as ordered, monitor for effectiveness of dosage; Redirect from negative behaviors to more appropriate pursuits. Interventions with an initiated date of 3/01/23 included: stop sign placed outside of the door; psychology/psychiatry consult ordered. Further review of the CP showed that there were no new interventions implemented on or around the physical aggression towards a resident on 3/11/22 that was documented on the CP, to further prevent Resident #24 becoming physically aggressive toward another resident. There was no documented incident on the CP to indicate the reason two new interventions were implemented on 3/01/23. A review of Resident #24's electronic Progress Notes (PN) did not include an entry on 3/01/23 that described the resident to resident altercation that occurred. On 5/31/23 at 9:09 AM, in the presence of the survey team, the surveyor asked the LNHA if the incident report/risk management was part of a resident's medical record. The LNHA stated that it was not part of the medical record. The surveyor then asked the LNHA if the incident report/risk management was not part of the medical record and if there was no documentation of the incident in the electronic medical record, did it mean that the incident did not occur. The LNHA stated that it meant that it was not documented properly. On 6/06/23 at 10:31 AM, the surveyor via phone, interviewed Licensed Practical Nurse (LPN) #1 who was listed on the 3/01/23 staffing schedule for unit that the altercation occurred regarding the process for a resident to resident altercation. LPN #1 stated that if it was his resident, he would perform an assessment of the residents and implement interventions. He then stated that he would notify the supervisor, write an incident report/risk management, call the doctor and family and write a progress note in the electronic record. He did not recall the incident. On 6/06/23 at 11:02 AM, the surveyor via phone interviewed Certified Nurse Aide (CNA) #1 regarding the altercation between Resident #24 and Resident #270. CNA #1 stated that she had heard there was an altercation but that she did not witness it and it was not her assigned room. She stated that when she came around the corner a resident told her that Resident #24 had hit Resident #270. CNA #1 stated that she went and got the CNA assigned to the residents and that they called the Staff Educator (SE) if she remembered correctly. On 6/06/23 at 12:24 PM, the surveyor interviewed the SE regarding the altercation. The SE stated that she sometimes cover for a supervisor. The SE confirmed that she was called regarding the incident but that she called the DON and Assistant DON (ADON) and they took over. The surveyor asked the SE if documenting the incident in a progress note in the resident's medical record would be part of the process. The SE stated yes. On 6/06/23 at 12:40 PM, the surveyor interviewed the DON regarding the process after a resident to resident altercation. The DON stated that the staff would make sure everyone was safe and separate the residents that were involved. The staff would call for assistance and notify the supervisor, DON or LNHA. The nurse is expected to determine the root cause, maintain safety, and document the incident in the computer in an incident report. He added there should be a progress note. The DON stated that if he could recall correctly a CNA informed him and the Assistant DON and that when they went to the unit Resident #270 was in the hallway after staff removed the resident from Resident #24's room and Resident #270 had an opening on right side neck. On that same date and time, the DON stated that he asked staff what happened and that the staff stated that Resident #270 wandered into Resident #24's room. The DON did not recall if someone observed Resident #270 enter into the room. The DON stated that the two residents were immediately separated and Resident #270 was moved to another unit. The DON stated that they determined that the root cause was Resident #270 being confused and wandered into another room. He added to keep another resident out of Resident #24's room a stop sign netting was placed at the door to keep a resident from wandering in. At that same time, the surveyor asked the DON if an incident report/risk management was part of a resident's medical record. The DON stated no. The surveyor asked the DON if an incident like resident to resident altercation should be in a resident's medical record and if the DON knew the reason it was not in Resident #24's medical record. The DON stated that he would have to look into that. The surveyor then asked the DON if the 3/01/23 incident should have been in Resident #24's CP since the 3/11/22 incident was listed in the CP. The DON stated that he would have to get back to the surveyor on that. On 6/07/23 at 10:05 AM, the surveyor requested the LNHA to provide the complete incident investigation for the 3/11/22 incident that was listed on Resident #24's CP. On 6/07/23 at 11:28 AM, the surveyor reviewed the facility provided FRE that was dated 3/11/22 which included the following: Resident-to-Resident Abuse Resident Name: Resident #24 a) Describe the event, to include timeframes/risk factors related to the incident/event (relevant resident Dx (diagnosis): At around 01:00 AM an unsampled resident entered Resident #24's room. Staff heard commotion from room and when they entered room found unsampled resident with small scratch below eye. b) Prior to the event, was a plan of care developed that addressed this issue, and were planned interventions in place when the event occurred. No. No previous history of physical aggression. c) What interventions were implemented after the incident/event? For example, supervision, resident sent to hospital, CNA suspended. Please describe investigative findings/conclusions: Residents were separated, MD notified, full body assessment. 30 min checks initiated for both residents. Attached to the FRE document the facility provided was a Summary of Investigation dated 3/11/22 that included the following: Conclusion: In conclusion, this was an isolated incident where Resident #24 hit an unsampled resident when the unsampled resident entered Resident #24's room. Residents were separated and care plans were updated appropriately. On 6/07/23 at 01:12 PM, the surveyor reviewed Resident #24's February 2023 Medication Administration Record/Treatment Administration Record (MAR/TAR) to see if there was behavior monitoring for Resident #24 prior to incident on 3/01/23. The February 2023 MAR/TAR included the following order: BEHAVIORS - MONITOR FOR THE FOLLOWING: Increased restlessness, delusions, paranoia. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift Document: 'Y' if any of the above observed, specify behavior in progress notes. Document: 'N' if no behaviors observed. The order was not clear in regards to what to document a Y or N if the resident had restlessness, delusions or paranoia observed. The beginning of the order indicated to document Y if [behavior] was monitored and none of the above [restlessness, delusions, paranoia] observed and later in the order it indicated to document Y if any of the above [restlessness, delusions, paranoia] observed, specify behavior in progress notes. The order should have been clarified with the physician. On 6/07/23 at 01:26 PM, in the presence of the survey team, the surveyor notified the LNHA, DON and Regional Director of Clinical Compliance (RDCC) the concerns regarding the FRE which included the following: that the incident was not documented in Resident #24's medical record; there was no intervention implemented after the 3/11/22 altercation to prevent another altercation from happening; the incident of 3/01/23 was not listed on the CP; the investigation conclusion for the 3/01/23 incident was listed as an isolated incident even though there was the exact same incident that occurred on 3/11/22; and Resident #24's behavior monitoring order that was not clarified. On 6/08/23 at 9:15 AM, the surveyor interviewed the SE who was the nurse assigned for medication pass on the unit that the resident to resident altercation had occurred, regarding the process of behavior monitoring. The SE stated that there would be an order for behavior monitoring and it would be in the resident's MAR/TAR. The surveyor showed the SE Resident #24's February 2023 MAR/TAR and asked the SE what the Y and N meant. The SE stated that she would think the N would mean that the resident did not have any of the behaviors. She then stated that the beginning of the seemed backwards and that bottom part [of the order] would be the appropriate way to document if the resident had any of the behaviors [listed]. The SE stated that if she were to see that physicians order that she would call the physician to have the order clarified. She added that someone should have picked it up and clarified the order. On 6/08/23 at 9:53 AM, the surveyor interviewed the ADON regarding Resident #24's behavior monitoring order and to look at the February 2023 MAR/TAR. The ADON stated that in the order the first Y was to monitor and the second Y was for if there was a behavior to document in the progress note and what intervention taken. The ADON then stated that the N meant that no behavior was observed. The surveyor then asked the ADON to look at Resident #24's February 2023 MAR/TAR again. The ADON stated that the order could have been clarified. The surveyor asked the ADON if the order should have been clarified. The ADON stated that apparently the staff did not think anything was wrong with it. On 6/08/23 at 11:13 AM, in the presence of the survey team, DON, ADON, Assistant Administrator (AA), RDCC and the Chief Nursing Officer (CNO), the LNHA stated that he had no further information regarding the concerns related to the FRE. The surveyor then asked if the altercation should be in the resident's medical record since the incident report/risk management was not part of the medical record. The LNHA confirmed that the incident report/risk management was not part of the resident's medical record and that the incident should be in the progress notes of the resident's medical record. On that same date and time, the surveyor asked the LNHA the reason why one of the incidents was listed on the CP and the later incident was not. The LNHA stated that he thought it was because the plan of care was already in place. At that same time, the surveyor then asked if the physician's order for behavior monitoring should have been clarified. The CNO stated that the order was a confusing template. She then stated that most of the nurses would write no and that the template should have been changed to be more clear. She added that she had thought it was already changed in this facility. The surveyor then asked if the conclusion on the second FRE for Resident #24's altercation should have been listed as an isolated incident since the same incident had happened had occurred earlier. The LNHA stated that since there was a large amount of time between the two incidents they would consider it a separate incident. A review of the facility provided policy titled, Behavior Assessment, Intervention and Monitoring with a reviewed/revised date of 01/2023 included the following: Monitoring 1. If the resident is being treated for altered behavior or mood, any improvements or worsening in the individual's behavior, mood, and function will be documented in the clinical record. 2. The IDT (interdisciplinary team) will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . A review of the facility provided policy titled, Policy for Resident Abuse Investigation with a reviewed/revised date of 10/2022 included the following: Prevention: .occurrences of abuse incidents are analyzed and presented to QAPI committee to determine what changes, if any, are needed to prevent further occurrences. Situations in which abuse .are more likely to occur are identified and correction or intervention is made . [Facility] identifies residents whose personal histories render them at risk for abusing other residents and develop, on an as needed basis, intervention strategies to try to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessing the interventions on a regular basis. Assessment, care planning and monitoring of residents are done, so that those with needs and behaviors which might lead to conflict .such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents rooms, .are identified Investigation: .Residents involved in the investigation are monitored closely to avoid further disruption of daily quality of life. Interventions are implemented by Social Services department and Nursing Administration with resident and representative . 2. On 5/22/23 at 11:35 AM, during initial tour of the fifth floor unit, the surveyor observed Resident #162 lying in bed. Resident #162 had a wander guard bracelet (an alarm system used for a resident that wanders or has exit seeking behaviors) visible to the left ankle. On 5/26/23 at 8:22 AM, the surveyor interviewed CNA #2 regarding Resident #162 and the wander guard bracelet. CNA # 2 stated that the resident was confused and would wander. She added that Resident #162 had not been wandering much lately. The surveyor asked CNA #2 if there was anything she did with the wander guard bracelet. CNA # 2 stated that she always made sure the wander guard bracelet was on the resident. On 5/30/23 at 11:29 AM, the surveyor interviewed LPN #2 regarding Resident #162 and the wander guard bracelet. LPN #2 stated that the resident had been wandering a lot but that the resident was not wandering as much now. She added that the resident would wander the unit but not go on the elevator. At that time, LPN #2 stated that the process for a resident with a wander guard bracelet was to redirect them. She added that if a resident were to go near the elevator the wander guard bracelet would trigger the elevator to alarm and stop the elevator from working. The surveyor asked LPN #2 what she was responsible for in regards to Resident #162's wander guard bracelet. She stated that she checked the placement of the wander guard bracelet daily on her shift. The surveyor then asked the nurse, who was responsible to check the function of the wander guard bracelet. LPN #2 stated that she was not sure who tested the wander guard bracelet's function. She stated that if the resident had come by the elevator that the wander guard bracelet had worked and had always alarmed. She added that if the wander guard bracelet did not alarm then she would call maintenance to have it checked. The surveyor reviewed Resident #162's medical record. The AR indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; metabolic encephalopathy (occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (a disease of inadequate control of blood levels of glucose), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). The resident's Medication Review Report (physicians orders) dated 6/06/23 included the following order: Roam alert: check placement q shift (every shift). There was no order to check the function of the wander guard bracelet with a start date of 02/24/23. The significant change in status MDS, dated [DATE], indicated a BIMS score of 3 out of 15, which reflected that the resident's cognition was severely impaired. The MDS indicated under section E Behavior that the resident wandered 4 (four) to 6 (six) days. Further review indicated under section P for Restraints and Alarms, Wander/elopement alarm was not used. The resident's individualized CP reflected a focused area with an initiated date of 02/16/23, of Resident #162 is at risk of getting lost, injured, sustaining bodily harm from retaliation, falling, or elopement with danger of exposure to elements r/t (related to) Dementia. The interventions included the following: Photo placed on Wander Risk List at front desk; Provide reality Orientation as appropriate and not upsetting; and roam alert (wander guard bracelet) placed. There were no interventions indicated to check for placement or function of the wander guard bracelet. The electronic Medication Administration Record and Treatment Administration Record for April 2023 and May 2023 indicated that Resident #162's wander guard bracelet had been checked for placement each shift (two times a day). There was no documentation that the function of the wander guard had been checked. A review of Resident #162's Elopement Risk Evaluation dated 02/13/23 indicated that the resident was at risk for elopement and that interventions that were started was roam alert ordered. On 5/31/23 at 11:43 AM, the surveyor interviewed the Director of Maintenance (DoM) regarding the wander guard bracelet. The DoM stated that he used a new bracelet that was not yet placed on a resident and checked all the doors to make sure the alarm would trigger weekly. He added that he checked three doors to the outside and two elevator doors and he documented the check in a log book. The surveyor asked the DoM if he checked the functioning of the wander guard bracelets that were placed on the residents. The DoM stated that he did not check the functioning of the wander guard bracelets. He added that he would guess that the nurses were responsible to do that. A review of the document titled Wander guard log 2023 that was provided by the DoM included the following that was done: Check all doors make sure, wanderguard its fully functional. Check Main Panel (make sure code works when deactivating alarm). Further review indicated that the Main entrance, Backdoor, Elevator #1, Elevator #2 and Ramp door were checked weekly. There was no indication that the wander guard bracelets were checked on the document. On 5/31/23 at 12:15 PM, the surveyor interviewed the DON regarding the process for a resident that wandered or exit seeked. The DON stated that an assessment would be done to see if the resident was an elopement risk. He stated that if a resident was wandering on the unit or was attempting to wander off the unit we would notify physician and if deemed appropriate would get an order for a roam alert wander guard bracelet to be applied. The DON stated that nursing checked the placement of the wander guard bracelet every shift to make sure the bracelet was on the resident. He stated that function was checked by maintenance by making sure the sensors on the doors would alarm weekly. The surveyor asked the DON who was responsible to check the function of the wander guard bracelets that were on a resident. The DON stated that he had to double check who and how the wander guard bracelets that were on a resident were checked for function. On 6/01/23 at 10:10 AM, during surveyor interview, the DON stated that the Medical Records Clerk (MRC) checked the function of the wander guard bracelet that was placed on a resident and that she brought the resident to the elevator in the wheelchair to make sure the bracelet triggered the alarm. He added that the MRC documented the weekly check in a log book. On 6/01/23 at 10:12 AM, the surveyor interviewed the MRC regarding the process of checking the wander guard bracelet. The MRC stated that every week on Mondays she would go to Resident #162 and check if wander guard bracelet was on the resident. She then stated that she would bring Resident #162 to the elevator to see if the wander guard bracelet would trigger the alarm. The surveyor then asked the MRC if she documented the weekly check. The MRC showed the weekly checks for Resident #162 that were documented. A review of the document titled Roam Alert which was provided by the MRC indicated that Resident #162's wander guard bracelet was checked weekly for function but it did not indicate how the function was checked. On 6/01/23 at 11:05 AM, the surveyor interviewed LPN # 3 regarding the process of checking the function of the wander guard bracelets. LPN # 3 stated that she believed that someone brought Resident #162 to the elevator to trigger the alarm. She added that she did not know if there was another way to check the function. On 6/01/23 at 11:29 AM, in front of the survey team, the surveyor asked the LNHA and DON to provide the survey team a wander guard bracelet that was not applied on a resident and the manufacturers instructions. On 6/01/23 at 11:51 AM, the LNHA provided the survey team a binder from the wander guard bracelet manufacturer. A review of the binder included the following: [Bracelet] The [bracelet] transmits messages to the controller when it is in proximity to a controlled door. The controller cane set to lock the door, preventing the resident from exiting the protected area, when the [bracelet] message is received. If the door is open and the [bracelet] is in proximity to the door, the system generates an alarm . [Bracelet] Battery Life .Note: [Bracelet] battery life can be tested by the [device]. It is recommended to use the [device] to check the [bracelet] battery at least once a week. [Device] The [device] performs the following activities: [bracelet] activation, checking [bracelet] battery level . Checking the .Battery Level 1. Turn on the [device] by short-pressing the power button. 2. Place the [bracelet] within the LF range of the [device] (less than 12 or 0.3 meter) . 3. The [device] displays the [bracelet] battery level .If the [bracelet] battery is low, the battery LED will be red .for at least two seconds. Data sheet for [Device] .Battery Status Any staff member can quickly and easily verify [bracelet] battery status without disturbing residents or forcing them to walk to a door monitored .Simply hold the [device] near the [bracelet]. A green or red LED indicated the battery status. On 6/02/23 at 9:47 AM, the surveyor interviewed Registered Nurse (RN) #1 who was an agency nurse, regarding the process for checking the function of a wander guard bracelet. RN #1 stated that some facilities have a device that checked function and battery life and that usually night shift nurse would do the check. She added that she was not sure what the facility here did. The surveyor then asked RN #1 if it would be appropriate to bring a resident to an elevator to check the function. RN #1 stated that she had not seen it done that way and that she did not think that would be an appropriate way because that would show them the exit. On 6/02/23 at 9:58 AM, the surveyor interviewed the MRC again about the process she did to check the function of the wander guard bracelet. The MRC stated that she would place Resident #162 in a wheelchair if the resident was not already in the wheelchair. She would then push the wheelchair toward the elevator and when Resident #162 was about 1 (one) foot away from the elevator door the alarm on the door would sound. At that same time, the surveyor asked the MRC what the purpose of the wander guard bracelet was. The MRC stated that the purpose was for a resident that wandered or tried to leave, the alarm would alert and that it was for safety reason. The surveyor then asked the MRC what it was she was checking. The MRC stated that she was checking the functioning and if it were in place. The surveyor then asked the MRC if she was checking the battery life of the wander guard bracelet. The MRC stated that she was not checking the battery life, just the function. The surveyor then asked the MRC where it was that you would not want a resident that wandered or exit seeked to go. The MRC stated that you would not want them to go to an exit door and the elevator. The surveyor then asked the MRC if she thought the way she was checking the function was appropriate. The MRC stated that she thought it was appropriate. On 6/02/23 at 10:09 AM, the surveyor asked the DoM if he had a device that could check the function and battery life of the wander guard bracelet. The DoM stated that he had a tester that was a remote that activated and checked the battery on each bracelet and that he had an electronic tablet that showed the status of the bracelets. The surveyor asked the DoM if he used the device to check the function and battery life of the wander guard bracelets on the resident. The DoM stated that he did not use it for the wander guard bracelets that were on the residents. He added that he was not sure if anyone else used it. On 6/02/23 at 10:28 AM, the DoM brought the device to the survey team. On 6/02/23 10:36 AM, the surveyor interviewed the DON. The DON confirmed that the MRC was taking Resident #162 to the elevator to check the function of the wander guard bracelet and that the DoM was checking the function of the alarmed doors. The surveyor asked the DON what the reason was that the manufacturer's provided device was not being used to check the function and [NAME] life. The DON stated that the device was not being used and that the way they were checking worked. The surveyor then asked the DON if he had read the manufacturer's instruction and recommendation regarding the wander guard bracelet. The DON stated that he had not read it. The surveyor then asked the DON if the recommendations should be followed. The DON stated that it was the manufacturer's recommendation but that they do not obviously have to use the recommendation. The surveyor asked the DON how the facility ensured that the battery was functioning from week to week. The DON stated that the nurse checked placement every shift and that the function was tested on ce a week by taking the resident wearing the wander guard bracelet to the elevator. On that same date and time, the surveyor asked the DON what the purpose of the wander guard bracelet. The DON stated that the purpose was to make sure safety first and was put on someone who was deemed to be exit seeking off the unit. The surveyor then asked the DON how a resident would exit the unit. The DON stated that a resident would exit the unit by the elevator. The surveyor then asked the DON if a resident was exit seeking would you redirect the resident from the exit or elevator. The DON stated that we would redirect them from the exit or elevator. The surveyor then asked the DON if taking an exit seeking resident to an elevator was appropriate. The DON stated that it was appropriate because the resident had the ability to go to the elevator on their own. On 6/02/23 at 11:58 AM, in the presence of the survey team, the surveyor notified the LNHA, AA, DON, RDCC the concern regarding the wander guard bracelet not being checked for battery life and the way the function was being checked. On 6/05/23 at 10:36 AM, in the presence of the survey team, DON, RA and CNO, the LNHA stated that he reviewed with the team the recommendation from the manufacturer of the wander guard bracelet. He then stated that on Friday the DoM started to use the device to check the function and battery life of the wander guard bracelets. The LNHA stated that they went by the wander guard bracelet had a three year battery with an expiration date. He added that they were doing[TRUNCATED]

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) dispensed and administered controlled substance (narcotic) medication were accurately accounted for (Unsampled Resident #170, #122, and #19), b.) discontinued medication was removed from active inventory (Resident #80), which were identified separately in 2 (two) of 3 (three) medication carts, and c.) failed to maintain a system of record keeping that ensured an accurate inventory and reconciliation of controlled dangerous substance (narcotics medications), with high potential for abuse and are tracked with detail observed during medication storage inspection. The deficient practice was evidenced by the following: 21 CFR 1305.16(b) Whenever any used or unused DEA Forms 222 are stolen or lost (other than in the course of transmission) by any purchaser or supplier, the purchaser or supplier must immediately upon discovery of the theft or loss, report the theft or loss to the Special Agent in Charge of the Drug Enforcement Administration in the Divisional Office responsible for the area in which the registrant is located, stating the serial number of each form stolen or lost 1) On 6/05/23 at 11:41 AM, the surveyor and the Registered Nurse (RN) began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located on the fourth floor. On 6/05/23 at 11:44 AM, in the presence of the RN, the surveyor observed Resident #170's Oxycodone (controlled pain medication) Immediate Release (IR) 5 milligram (mg) bingo card (a multidose card containing individually packaged medications) that contained 13 tablets. A review of the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #170's Oxycodone IR 5 mg tablet indicated a balance of 14 tablets and was last signed by the administering nurse on 6/04/23 at 5:02 PM. The following line reflected a date of 6/05/23 but did not reflect the time and the administering nurse's signature. On 6/05/23 at 11:59 AM, in the presence of the RN, the surveyor observed Resident #122's Buprenorphine-Naloxone Film 8-2 mg (Suboxone; controlled medication to treat Opioid use disorder) in a labeled clear plastic bag that contained 54 films. A review of the declining inventory log for Resident #122's Buprenorphine-Naloxone Film 8-2 mg film indicated a balance of 55 films and was last signed by the administering nurse on 6/04/23 at 5:00 PM. At that time, the RN stated she gave both resident's their medications that morning and had not signed. At that time, in the presence of the RN, the surveyor observed Resident #19's Buprenorphine-Naloxone Film 8-2 mg (Suboxone) in a labeled clear plastic bag that contained 6 (six) films. A review of the declining inventory log for Resident #119's Buprenorphine-Naloxone Film 8-2 mg film indicated a balance of 6 (six) films and was last signed by the administering nurse on 6/4/23 at 5:00 PM. At that time, during an interview with the surveyor, the RN stated she did not sign after removing the medication from the narcotic box. The RN stated the narcotic logs should have been signed as soon as she removed the narcotic medication from the narcotic box. The RN stated I was rushing and did not get to sign after administration. 2) On 6/05/23 at 12:40 PM, the surveyor and the Licensed Practical Nurse (LPN) began the non-narcotic inspection of the medication cart located on the first floor. At that time, the surveyor observed an eye drop bottle in a labeled clear plastic bag for Resident #80. The label indicated that the eye drop was neomycin-Polymixin B - Dexamethasone (Maxitrol; a combination of antibiotic, used to treat bacterial eye infection and a steroid, used to treat swelling).The label also reflected that Maxitrol was dispensed by the provider pharmacy on 4/28/23. The surveyor and the LPN reviewed the electronic Medical Record together which revealed Resident #80's Maxitrol was discontinued on 5/03/23. At that time, during an interview with the surveyor, the LPN stated the medication should have been removed because a medication error could have occurred by administration to Resident #80 or another resident. At that time, the LPN informed the surveyor that she would remove the eye drop from the cart and inform the Director of Nursing (DON) if we can return the eye drop. The LPN stated that all the nurses on all shifts were responsible to ensure all discontinued medications were not present with active inventory medications. 3. On 6/05/23 at 8:51 AM, in the presence of two surveyors, the DON stated they had an electronic (back-up) machine that contained emergency medications for the residents. The back-up did not contain narcotics since May 2022 as decided by the facility. The DON stated that stat (immediate) medications were delivered within two hours from the provider pharmacy. At that time the surveyor requested for the Inventory on hand report of the back-up machine, 222 forms and destruction logs. A review of the Inventory on hand report reflected the following: -Alprazolam (antianxiety medication) 0.25 mg on hand [quantity] of #1 (one) tablet -Lorazepam (antianxiety medication) 0.5 mg on hand [quantity] of #1 (one) tablet -Oxycontin (controlled narcotic pain medication) 10 mg on hand [quantity] of #1 (one) tablet On 6/07/23 at 9:49 AM, the Licensed Nursing Home Administrator (LNHA) stated he was on the phone with the pharmacy provider who confirmed verbally that there was no narcotics within the electronic back-up machine. The concern regarding the discrepancy between the statement and the Inventory on hand report was discussed with the LNHA, DON and Assistant Director of Nursing (ADON). At that time, the DON stated the pharmacy provider enters the building every two weeks to conduct a cycle count. On 6/07/23 at 9:49 AM, in the presence of two surveyors, the DON and the ADON began the cycle count for the back-up machine. On 6/07/23 at 10:18 AM, the DON and the ADON completed the cycle count for the back-up machine and the two surveyors did not observe narcotics contained within the back- up machine. On 6/07/23 at 11:20 AM, the surveyor interviewed the Assistant Administrator (AA). The AA stated the accounting and reconciliation was through the pharmacy and the ADON was in-charge of that task. On 6/07/23 at 11:26 AM, the surveyor interviewed the DON. The DON acknowledged that the back-up cycle count should have been zero'd out since there was no quantity on-hand. A review of the Controlled Substance Destruction Request form dated destroyed on 7/21/22 reflected the following: -Fentanyl patch (controlled pain medication) 25 microgram [quantity] of #2 tablets -Oxycontin 10 mg [quantity] of #3 tablets -Tramadol (controlled pain medication) 50 mg [quantity] of #5 ½ tablets -Clonazepam (antianxiety medication) 0.5 mg [quantity] of #3 tablets -Lorazepam 0.5 mg [quantity] of #1 tablet -Alprazolam (antianxiety medication) 0.25 mg [quantity] of #1 tablet A review of the Drug Enforcement Agency (DEA) Form 222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, with high potential for abuse and tracked with detail reflected the following: Order Form Number 210500321 3 (three) of 3 (three) [a photo image] Further review revealed the facility did not execute Part 5. Controlled Substance Receipt 1. The purchaser fills out this section on its copy of the original form. 2. Enter the number of packages received and date received for each line item. Order Form Number 210500320 2 (two) of 3 (three), not found Order Form Number 210500319 1 (one) of 3 (three), not found On 6/07/23 at 01:32 PM, in the presence of the survey team, the LNHA, the DON, and the Regional Administrator (RA), were made aware of the above findings. At that time, the LNHA clarified that the photo image was sent by the pharmacy provider and the facility copy could not be located. The DEA FORM-222 was needed to reconcile the destruction of the narcotics conducted on 7/21/22 by the DON and ADON. On 6/08/23 at 11:04 AM, in the presence of the survey team, the LNHA stated the pharmacy had not found copies of the DEA Form-222 to identify if the forms were executed, not executed, or voided. On 6/08/23 at 11:58 AM, in the presence of the survey team. The LNHA stated he was still waiting for documents from the provider pharmacy regarding the missing DEA FORM-222. At that time, the surveyor informed the facility that they may email the surveyor until the next day to submit the missing DEA FORM-222. On 6/08/23 at 01:17 PM, the AA stated she had left a message with the local DEA office to learn the protocol and to report the missing DEA-222 forms. No further information was provided. A review of the facility provided policy, Controlled Substances, revised 12/2022, included under Policy Statement: The facility shall comply with all laws and regulations and other requirements related to handling, storage, disposal and documentation of Schedule II and other controlled substances. A review of the facility provided policy, Administering Medication, reviewed/revised 12/2022, included under Policy Interpretation and Implementation, section 20. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. date and time the medication was administered; g. The signature and title of the person administering the drug. A review of the facility provided policy, Storage of Medications, reviewed/revised 12/2022, included under Policy Interpretation and Implementation, section 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On 6/09/23 at 12:54 PM, there was no further information was provided by the facility management. NJAC 8:39-27.1(a), 29.4(g)(k), 29.7(c)

2. On 5/26/23 at 7:35 AM, the surveyor asked the RDCC about Resident# 137's incident/accident reports, and the RDCC stated that she will get back to the surveyor. The surveyor reviewed Resident #137's medical record. Resident #137's AR reflected that the resident was admitted to the facility had diagnoses which included but were not limited to malignant neoplasm of kidney (also called kidney cancer or renal cell adenocarcinoma), schizophrenia (a serious mental disorder in which people interpret reality abnormally), alcohol abuse, and cocaine abuse. The resident's most recent qMDS with an ARD 4/25/2023 reflected that the resident had a BIMS score of 15 out of 15 which indicated the resident's cognition was intact. The PN dated 5/15/23 at 6:57 AM by LPN#2 revealed that on 5/14/2023 at 09:40 PM, the resident had a witnessed verbal altercation with Resident #64 and was struck in the head with a cane by resident #64. Resident #137 was noted to have swelling in the left eye and redness. LPN#2 obtained vital signs and initiated Neurologic checks on resident #137. The PN dated 5/14/23 at 10:00 PM by RN#2 revealed that on 5/14/2023 at 9:40 PM, Resident #137 was sitting in a chair in the hallway after being notified by the LPN that there was an altercation. The resident was noted to have left facial swelling near eye and redness. The RN assessed the injury and noted that vision was not impaired, the resident did not complain of blurred vision and said he/she could see. The resident refused to go to the hospital for medical treatment. The RN initiated neurological assessment and telehealth video call for resident #137. On 5/30/23 at 11:30 AM, the survey team met with the LNHA and Chief Nursing Officer (CNO). The LNHA stated that the surveyors were given all the documents pertaining to the Facility Reportable Events (FRE) and if the surveyor did not have it, then it was not done. A review of the facility provided 5/14/23 investigation and FRE of Resident#137 showed that there was no Neurological Assessment documents provided. On 6/01/23 at 11:56 AM, the surveyor requested Neurological checks of Resident #137 from the DON and the RA. The DON stated that he will get back to the surveyor. On 6/01/23 at 12:53 PM, the DON and the RA provided the surveyor the Neurologic observations/vital sign checklist after surveyor inquiry. A review of the facility's Retention of Medical Records Policy with a revised date of 12/2022 that was provided by the LNHA included that medical records shall be retained by the facility in accordance with current applicable laws. A review of the facility's Neurological testing Policy with an updated date of 2/2023 that was provided by the LNHA included that if a resident is suspected of having a head injury, a full neurological exam will be performed. NJAC 8:39- 11.1, 35.2 (a)(c)(d)(4,5,6,10) FRE NJ#00164221 Based on the interview and review of the medical record and other facility documentation, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices that are accurately documented, readily accessible, systematically organized for two (2) of 37 residents reviewed (Resident #95 and #137) and ensure that the medical record contained a record of the resident's assessments, and the comprehensive plan of care and services provided. Resident#95's Nurse Practitioner#2 (NP#2) Progress Notes from 4/10/23, 4/12/23, 4/13/23, 4/17/23, 4/19/23, 4/24/23, and 4/27/23 were not uploaded in the electronic medical records, not until 6/01/23. This deficient practice was evidenced by the following: 1. On 5/26/23 at 7:35 AM, the surveyor asked the Regional Director of Clinical Compliance (RDCC) about Resident#95's incident/accident reports, and the RDCC stated that she will get back to the surveyor. The surveyor reviewed Resident #95's medical record. The resident's admission Record (AR; or face sheet; admission summary) reflected that the resident was admitted to the facility had diagnoses which included but were not limited to muscle weakness, essential hypertension (high blood pressure), type two diabetes (abnormal blood sugar level), insomnia (common sleep disorder), unspecified dementia with other behavioral disturbance (cognitive impairment), major depressive disorder, anxiety disorder, and age-related nuclear cataract bilateral (the center of the eye's lens becomes thick and discolored). The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 3/28/23 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The qMDS revealed that staff assessment for mental status was conducted due to the resident's unable to complete the interview and showed that the resident's cognitive skills for daily decision-making had a score of 2 (two) which indicated that the resident's cognition was moderately impaired. The Progress Notes (PN) dated 4/07/23 at 7:29 PM by Registered Nurse#1 (RN#1) revealed that at approximately 6 PM, the resident was found crying in the hallway and noted a hematoma above the right wrist. The RN was also the nurse who prepared the Risk Assessment report. The sound physician telehealth dated 4/07/23 at 7:45 PM by the provider Nurse Practitioner#1 (NP#1) showed that the resident was evaluated via telehealth because of the hematoma and swelling to the resident's right lower arm above the wrist and that the resident was not sent to the ED (Emergency Department). NP#1 ordered for stat x-ray of the arm and hand. On 5/30/23 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) provided a copy of the Hematoma of unknown origin investigation dated 4/07/23 at 18:00 (6 PM) which the LNHA indicated that the form provided was called Risk Assessment. The Risk Assessment included an attachment of the care plan, a Braden Scale for Predicting Pressure Sore Risk dated 4/07/23 12:50 PM, and a Morse Fall Scale dated 4/08/23 12:49 PM. At that same date and time, the surveyor asked the LNHA if there were staff statements on the 4/07/23 incident. The LNHA stated that he will get back to the surveyor. On 5/30/23 at 12:03 PM, the surveyor reviewed the provided copy of the Hematoma of unknown origin investigation that was dated 4/07/23. According to the investigation provided by the LNHA, Resident#95 sustained an unknown hematoma to the right wrist on 4/07/23, had an x-ray order of the right wrist, and the resident was not taken to the hospital. On 5/31/23 at 9:53 AM, the Director of Nursing (DON) provided another Risk Assessment investigation copy of the unknown hematoma to the right hand dated 4/07/23 at 6 PM. The information in the 4/07/23 Risk Assessment that was provided by the DON was the same as what the LNHA provided on 5/30/23 except for the question: Resident Taken to Hospital which had an answer now with Y (Yes). The provided Risk Assessment of the DON included Unusual Occurrence Statements from Certified Nursing Aide#1 (CNA#1) and Licensed Practical Nurse#1 (LPN#1). Attached to the Risk Assessment also was the 4/10/23 typewritten documentation of the DON that included that the DON and the Director of Maintenance (DoM) interviewed the resident regarding the incident about what happened. On 5/31/23 at 10:58 AM, the surveyor interviewed and asked the DON about the 4/07/23 investigation because the injuries observed at the time of the incident and injury type in the Risk Assessment were not complete which did not include the measurements and description of the hematoma. The surveyor asked the DON if a skin assessment was done on 4/07/23. The surveyor asked also the DON why there was no documentation of what were the interventions after the resident returned from the hospital on 4/08/23. The DON stated that he will get back to the surveyor. Further review of the PN in the electronic medical records provided by the LNHA on 6/01/23 at 9:33 AM showed that there were no notes from NP#2 from 4/04/23 through 4/28/23. On 6/01/23 at 8:42 AM, the surveyor asked the LNHA for a copy of the resident's skin assessment for the 4/07/23 investigation of a hematoma of unknown origin and the LNHA stated that he will get back to the surveyor. On 6/01/23 at 12:53 PM, the survey team met with the LNHA, DON, Regional Administrator (RA), and Assistant Administrator (AA) and were made aware of the above findings. The surveyor asked the facility team why there was a discrepancy in the Risk Assessments that were provided by the LNHA on 5/30/23 and DON on 5/31/23 for the question of the resident was taken to the hospital, one answer was N (no) and the other one was Y (yes). The surveyor also asked why the Braden Scale for Predicting Pressure Sore Risk (BSPPSR) dated 4/07/23 at 12:50 PM which the DON claimed was the facility skin assessment for the incident that happened on 4/07/23 at 6 PM. The surveyor asked the facility team why the BSPPSR dated 4/07/23 and the Morse Fall Scale (MFS) dated 4/08/23 were both signed and locked on 5/26/23 which was after the surveyor's inquiry of the incident. Also, the surveyor asked the facility team, why there were no documented vital signs on the time and date of the incident on 4/07/23. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, RDCC, and AA. The LNHA stated that the Risk Assessment on 4/07/23 was not locked. The LNHA further stated that when the DON noticed on 5/26/23 that the investigation was not locked, the DON went in and signed it off that was where the discrepancy for the question of if the resident was taken to the hospital responses were different. On that same date and time, the surveyor asked the facility team how long the facility should complete, lock and sign the Risk Assessment investigation, and what it means that the investigation was locked and signed. The DON informed the surveyor that once you lock the Risk Assessment, it means that you signed off that the assessment was complete. The DON stated that obviously the investigation, Risk Assessment, and all other assessments including the BSPPSR and MFS should have been locked asap (as soon as possible) to confirm that the investigation was completed on time. The DON stated that he signed and locked the investigation for 4/07/23 on 5/26/23. The DON did not respond when asked by the surveyor how many days it should have been closed and what asap means in terms of days. Furthermore, the LNHA acknowledged that there were discrepancies from the provided documents to the surveyor and the LNHA stated that the facility should have done better with documentation and gathering of statements for the investigation. On 6/05/23 at 01:05 PM, the DON introduced NP#2 to the survey team and informed the surveyor that NP#2 wanted to talk about the 4/07/23 incident of the resident, and the DON left afterward. At that same time, NP#2 informed the surveyors that she was notified by the DON on 4/10/23 about the incident to the resident's right wrist and that she had follow-up visits on 4/12/23, 4/13/23, 4/17/23, and 4/19/23 where she had documented assessment and plans including orders for repeat xrays. On 6/07/23 at 11:48 AM, the surveyor reviewed again the electronic medical records to verify the information provided by NP#2 with regards to her visit on 4/10/23 and follow-up visits from 4/12/23 through 4/19/23 which the surveyor did not see from the provided printed documents of the LNHA on 6/01/23 at 9:33 AM when the surveyor asked for the printed copy of the resident's PN from 4/6/23 through 5/19/23. Upon the surveyor's review of the PN in the electronic medical records, it showed that the PN had NP#2's notes for 4/10/23, 4/12/23, 4/13/23, 4/17/23, and 4/19/23 as digitally signed on 6/01/23. On 6/07/23 at 12:33 PM, the survey team met with the LNHA, DON, and RDCC and were made aware of the above findings concerning NP#2's notes. The DON stated that 6/01/23 of NP#2's notes was the date the April 2023 notes were uploaded. Both the DON and the LNHA acknowledged that the April 2023 NP#2's notes should have been uploaded to the electronic medical records timely not after almost two months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 5/22/23 at 9:53 AM, during an Entrance Conference, the Licensed Nursing Home Administrator (LNHA) in the presence of the Assistant Administrator (AA), and the Director of Nursing (DON) stated that the facility census was 172. On 5/24/23 at 9:19 AM, the surveyor interviewed the LNHA. The LNHA stated that the Legionella Water Management Program was under the task of the Facility Maintenance Director (FMD). He further stated that the testing was conducted by an outside vendor and the results were reported to the LNHA. At that time, the LNHA provided the vendor laboratory certificate result, and the Cleaning Log for the First-floor shower room to the surveyor. A review of the Laboratory Certificate Result from the facility's vendor reflected that the First-floor shower room, 1 (one) of 6 (six) sample point was collected on 02/21/2023 at 12:01 PM. The analyte/test method was for L. pneumophila (Legionella; a bacteria that can cause a serious type of pneumonia, transmitted through small droplets of water in the air) that resulted in 30 MPN (most probable number)/100 ml with a comment of PR. The comment table revealed PR - any numerical result is a cause for concern. A review of the First-floor cleaning log did not indicate what was being cleaned or flushed. At that time, the concern regarding the detection of Legionella pneumophila was communicated to the LNHA. On 5/25/23 at 12:50 PM, during an interview with two surveyors, the LNHA stated the laboratory report that indicated 30 MPN/100 ml of Legionella was found in the first-floor shower room, maybe on the shower head. The LNHA stated the policy indicated that the Water Management Program will be reviewed at least once a year, or sooner if any of the following occurs. The LNHA confirmed the testing samples were delivered on 02/22/23, and he deferred to the vendor's recommendation. On that same date and time, the LNHA stated that he was advised that the location of the result was found in a specific area and not in other areas. The LNHA further stated that he was advised by corporate to clean the area with bleach and to continue with cleaning and flushing. He also stated he was instructed by corporate not to re-test. The LNHA stated that he felt after 3 (three) months of cleaning would be the time to re-test. The LNHA stated he had no basis for the 3 (three) months and that was the advise he received from corporate. At that time, in the presence of two surveyors, the LNHA stated he did not report the result to the local department because the issue was local to that device. He further stated he was not sure if he had consulted with the facility's IPN. Furthermore, the LNHA stated that the Legionella was discussed in the Quality Assurance Performance Improvement (QAPI) meeting on April 27, 2023. The LNHA informed the surveyors that the QAPI was ran by the Assistant Administrator (AA) and he had no knowledge as to who prepared the QAPI action plan for Legionella. When the surveyor asked the LNHA if the IPN should have been involved in the QAPI plan for Legionella, the LNHA had no response. A review of the facility provided QAPI plan, under action plan, reflected, Test conducted in February 2023. Result at 1st floor shower showed strains of Legionella. Total numbers do not exceed acceptable level of 30%. Shower head was removed, bleached, water flushed. Will be repeated and test repeated in May. A review of the facility provided communication from the vendor dated 5/24/23, included: [name redacted] advises our customer [name redacted] to flush the line and retest the site of positive detection and proper flushing should remediate the isolated issue. If after the next test, we see positive still lingering we will come to the facility and preform [perform] a complete facility remediation. No further retest information or result was provided. On 5/25/23 at 01:32 PM, two surveyors interviewed the IPN. The IPN informed the surveyors that she worked in the facility as the infection Preventionist since February of 2023. The IPN stated she heard something from the LNHA and corporate about the Legionella but was not involved in the planning and surveillance. The IPN confirmed she did not receive information back in February 2023. She further stated that she signed her job description. On that same date and time, the IPN stated that she was out of the country during the April 2023, QAPI meeting. The IPN stated that Legionella was part of the infection control and that she should have been involved in the QAPI plan. The IPN reiterated that she did not prepare the QAPI action plan for Legionella for the meeting held on 4/27/23. She acknowledged that part of infection control task of the IP is to follow through the surveillance. On 5/25/23 at 01:45 PM, in the presence of two surveyors, the IPN stated she did not inform the Medical Director and the local public health authorities about the results of Legionella. She further stated that there were no resident who tested positive for Legionella because we did not test the residents. On 5/25/23 at 01:51 PM, the surveyor interviewed the AA in the presence of another surveyor. The AA stated she did not know who prepared the report. She further stated, it was not a significant concern and if it was, we would have notified the IPN. At that same time, the AA stated that generally infection control was directed by the IPN. The AA also stated that Legionella was part of infection control. The AA confirmed that the IPN should have been aware of all infection control information in the building. A review of the facility provided policy, Legionella Water Management Program, reviewed/revised 01/2023, included: Policy Statement; Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation, section 2. The water management team will consist of at least the following personnel: a) The infection Preventionist . 5. The water management program includes the following elements: a. An interdisciplinary water management team . A review of the facility provided job description of the Infection Preventionist, responsibilities included the following: -Coordinating the infection control program which includes surveillance, analysis of data, developing reports, educating staff, and implementing policies and procedures. -Use epidemiological principles and statistical methods to design, implement and evaluate infection prevention and control strategies. -Provides consultation and education to staff, physician, and community leaders in respect to Infection Prevention and Control. -Notifies the County and/or State Health Department of any reportable diseases, adhering to all internal county and state procedures. -Ensures the infection prevention and control procedures meet CMS, state, local and CDC regulations, standards or guidelines. 2. On 5/26/23 at 7:57 AM, the surveyor observed that the [NAME] transported the linens to the 4th-floor unit and the bedsheet fell off the floor while transferring it from his clean cart to the unit's clean linen cart. Immediately, the [NAME] picked up the bedsheet from the floor and directly placed it in between clean linens and bedsheets in the unit's clean linen cart and continued transferring the remaining linen sheets. The 4th-floor clean linen cart was between room [ROOM NUMBER] and the exit door. During an interview, the [NAME] informed the surveyor that he works in the Housekeeping department for 15 years. He stated that if the linens fell off the floor, they should be discarded into the dirty linen supply and should not be mixed with clean linens. The surveyor then asked [NAME] why he put back into the unit clean linen cart the sheet that fell off the floor. The [NAME] stated that it was the bedsheet that fell off the floor. At that time, the [NAME] took the bedsheet that fell off the floor from the unit's clean linen cart and put it in the clean linen cart that he brought into the unit where there were a few clean linens left. The [NAME] further stated I'm probably rushing, that was why he put back the dirty bedsheet that fell off the floor into the unit's clean cart. The surveyor asked the [NAME] what he will do now. The [NAME] did not respond and continued to finish transferring linens from his cart to the 4th-floor linen cart. Afterward, the surveyor did not find an available nurse in the unit except for the DON. The surveyor approached the DON who was currently observing the dining area on the 4th floor with residents inside the dining area. The surveyor notified the DON of the findings and observation. The DON stated that the [NAME] should not put back the dirty bedsheet that fell off the floor back into the clean linen cart and all the linens that the porter put the dirty sheet should be discarded and considered dirty. At that same time, the surveyor and the DON observed the [NAME] pushing his linen cart to another end of the unit and did not remove the remaining linens in the unit's linen cart. In addition, both the surveyor and the DON observed a face towel fell on the floor while the [NAME] pushed his linen cart, and the [NAME] picked up the face towel off the floor and placed it on top of his linen cart. The DON instructed the porter to remove all linen supplies that the [NAME] transferred to the unit's clean linen cart and discard them since it was contaminated with a bedsheet that fell off the floor. The DON further stated to the surveyor that he will talk to the Housekeeping Director and make sure to re-educate the staff about the proper handling of linens. 05/26/23 at 8:57 AM, the surveyor asked the Regional Director of Clinical Compliance (RDCC) for a copy of the facility's policy with regard to Handling of Linen and she stated that she will get back to the surveyor. On 6/01/23 at 9:42 AM, the surveyor interviewed the IPN regarding the [NAME] who handled the linens on the 4th floor on 5/26/23. The IPN informed the surveyor that she was notified on the same date it happened and education was provided immediately to the Porter. The IPN stated that the porter acknowledged that he should have not put the contaminated bed sheet that fell on the floor with the rest of the clean linens and bedsheets in the linen cart of the 4th-floor unit. The IPN further stated that the [NAME] should have placed the contaminated bed sheets from the floor in a bag, disinfect the linen cart, and discarded the other linens and bedsheets because they got into contact with a contaminated bed sheet that fell on the floor according to the facility practice to prevent infection. On 6/01/23 at 12:53 PM, the survey team met with the LNHA, DON, Regional Administrator (RA), and AA and made them aware of the above findings. A review of the facility's Laundry and Bedding, Soiled Policy with a review/revised date of 01/2023 and included that soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen and that soiled laundry and bedding should be placed in a contaminated laundry bag or container. On 6/02/23 at 11:58 AM, the survey team met with the LNHA, DON, RDCC, and AA. There was no additional information provided by the facility management and did not refute the findings. NJAC 8:39-19.1, 19.4(a)(e), 21.1(b)(d)(e) Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) that the Infection Preventionist Nurse (IPN) was aware and involved in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread, this deficient practice has a potential to affect the 172 residents in the facility and b.) that the linens were handled in accordance to standards in order to maintain hygienically clean laundry and prevent the spread of infection for one (1) of five (5) units, (4th-floor unit). This deficient practice was evidenced by the following:

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to provide regular nail care to a resident who required assistance with Activities of Daily Living (ADL). This deficient practice was identified for 1 of 1 resident, (Resident #80) reviewed for ADLs and was evidenced by the following: On 02/09/22 at 11:09 AM, the surveyor observed Resident #80 lying in bed on an air mattress watching television. The surveyor observed that the resident's finger nails on both hands extended approximately 1/4 inch above his/her fingertips. The surveyor further observed that the resident's fingernails were yellow and there was a black substance underneath the majority of the resident's finger nails on both hands. The surveyor asked the resident if anyone at the facility had cut his/her nails or offered to cut his/her nails and the resident stated, no. On 02/11/22 at 10:06 AM, the surveyor observed the resident lying in bed. The surveyor observed that the resident's finger nails on both hands extended approximately 1/4 inch above his/her fingertips. The surveyor further observed that the resident's fingernails were yellow and there was a black substance underneath the majority of the resident's finger nails on both hands. On 02/14/22 at 10:25 AM, the surveyor observed the resident in his/her room watching television. The surveyor observed that the fingernails on the resident's bilateral hands were long, jagged and had a black substance underneath them. The fingernails extended approximately 1/4 inch above the resident's fingertips. The surveyor asked the resident if the staff cut his/her fingernails and the resident stated, nope. The surveyor asked the resident if he/she would like the staff to cut his/her fingernails and the resident stated, yes. On 02/14/22 at 12:10 PM, the resident's Certified Nursing Aide (CNA) observed the resident's fingernails in the presence of the surveyor. The CNA stated that the resident's fingernails were long and needed to be cut so the resident didn't scratch himself/herself. The CNA further stated that the resident's nails were cut on an as needed basis when it was identified that they were long. On 02/14/22 at 12:13 PM, the surveyor interviewed Resident #80 in the presence of the resident's Licensed Practical Nurse (LPN) and asked the resident if he/she wanted his/her fingernails cut. The resident stated, yes. The surveyor and LPN exited the resident's room. The surveyor interviewed the LPN who stated that the resident's fingernails were long, discolored and needed to be cut. The LPN further stated that the CNAs were responsible for cutting the residents fingernails as needed when they were long. The surveyor asked the LPN if the facility had an accountability record for nail care and the LPN stated that the nurses did not sign for nail care. On 02/17/22 at 1:34 PM, the surveyor interviewed the Administrator who stated that the residents would have nail care completed on their shower days. The surveyor reviewed the medical records for Resident #80. A review of the resident's admission Record (an admission Summary) reflected that the resident was admitted to the facility in December 2021 and had diagnoses which included, but were not limited to muscle weakness, cognitive communication deficit, uncomplicated opioid abuse, and unspecified psychosis not due to a substance or known physiological condition. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/08/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated the resident had a moderate cognitive impairment. A further review of the resident's MDS, Section G - Functional Status reflected that the resident required one-person physical assist for personal hygiene. A review of the resident's Care Plan (CP) revised on 12/02/2021, reflected that the resident had an ADL self-care performance deficit related to a recent hospitalization. The goal of the resident's CP was the resident would improve current level of function in self care tasks/ADLs through the review date. The interventions for the resident's CP included that the resident needed limited assistance with personal hygiene. A review of the facility's Supporting Activities of Daily Living Policy and Procedure revised 12/2021, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility's Care of Fingernails/Toenails Policy and Procedure revised 12/2020, indicated that nail care included daily cleaning and regular trimming and the purpose of nail care was to prevent skin problems around the nail bed, infections, and scratching which could leave injury to the skin. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). On 2/14/22 9:49 AM, the surveyor observed Resident #139 lying in bed with the head of the bed elevated. The surveyor observed that the resident had a tracheostomy tube. The resident was alert and smiled at the surveyor. On 2/15/22 at 11:00 AM, the surveyor observed the LPN #2 perform tracheostomy care in the presence of the Assistant Director of Nursing (ADON). The LPN#2 did not listen to the resident's lung sounds or prepare a suction catheter kit prior to performing tracheostomy care. The surveyor observed the LPN#2 place a clear trash bag on the foot of the resident's bed, gather supplies, and clean the resident's overbed table. The surveyor further observed the LPN remove the tubing that provided humidification and O2 to the resident. At that time, Resident #139 turned red and coughed up a large amount of thick, white mucous. At that time, the surveyor observed the resident's O2 level decrease to 88%. The LPN#2 took her gloved hand, a drainage sponge and pulled the thick, white mucous out of the resident's tracheostomy without attempting to suction the resident. The ADON reapplied the O2 and humidification tubing to the resident's tracheostomy area and the resident's O2 saturation increased to 97%. At 1:30 PM, the surveyor interviewed the LPN#2 who stated that she did not think the resident needed to be suctioned prior to performing tracheostomy care or listen to the resident's lungs sounds because the resident was suctioned earlier around 9 AM or 9:20 AM. I should have listened to the lung sounds. If I had listened to his/her lung sounds, maybe, I would have suctioned him/her. LPN#2 further stated the resident is suctioned on a as needed basis. The LPN#2 did not speak to what type of evaluation or care would be required when the resident presented with signs and symptoms of respiratory distress during care. A review of the resident's admission Record reflected Resident #139 resided at the facility for several years and had diagnoses which included but were not limited to chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and O2), cerebral infarction, (also known as a stroke; refers to damage to tissues in the brain due to a loss of oxygen to the area), altered mental status (a disruption in how your brain works that causes a change in behavior), dysphasia, (difficulty swallowing), and need for assistance with personal care. A review of the quarterly MDS dated [DATE], reflected that the resident's cognitive skills for daily decision making were severely impaired. A review of the resident's February 2022 electronic MRR reflected a PO dated 12/17/21, for tracheostomy care every shift and as needed. A review of the resident's February 2022 electronic Treatment Administration Record (eTAR) reflected that the nurses were signing on the day and night shifts that tracheostomy care was performed. A review of the residents CP dated 3/30/21, reflected a focus area that the resident had a tracheostomy. The goal of the resident's CP indicated the resident would have clear and equal breath sounds bilaterally through the review date. Interventions for the resident included to suction the resident as necessary. According to the facility's Tracheostomy Policy revised 07/2021, indicated that the need for suctioning was first to be established by evaluating the resident's breath sounds, respiratory rate and pulse oximetry (a test used to measure the oxygen level in the blood). NJAC 8:39-19.4(a);27.1(a) Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) appropriately follow a Physician's Order (PO) for the use of oxygen, b.) maintain oxygen equipment to prevent the spread of infection, c.) appropriately perform respiratory and tracheostomy (an opening surgically created through the neck into the windpipe) care in accordance with professional standards of practice, and d.) follow facility policy and procedures for tracheostomy care and suctioning. This deficient practice was identified for 2 of 2 residents reviewed, (Resident #19 and Resident #139) and was evidenced by the following: 1. On 2/09/22 at 11:36 AM, the surveyor observed Resident #19 in his/her room, seated in a wheelchair. The surveyor introduced herself to the resident and the resident swatted the surveyor away and stated his/her name. The surveyor observed that the resident was wearing Oxygen (O2) at five (5) Liters Per Minute (LPM) via nasal cannula. The surveyor observed that the resident's O2 tubing was not labeled and dated. The surveyor further observed that the O2 concentrator went up to five (5) LPM. On 2/11/22 at 10:00 AM, the surveyor entered the resident's room. The resident was not observed in his/her room at the time. The surveyor further observed that the O2 concentrator was turned off. The O2 tubing was observed not labeled and dated and was draped over the O2 concentrator with the prongs of the nasal cannula that entered the resident's nares in direct contact with the O2 concentrator. At 10:09 AM, the surveyor observed Resident #19 self- propelling in his/her wheelchair into the main dining room on the unit. The resident was wearing a surgical mask and no oxygen. On 2/14/22 at 9:57 AM, the surveyor observed the resident seated in his/her wheelchair in the hallway outside of their room not wearing O2. The surveyor observed that the O2 Concentrator in the resident's room was turned off. The surveyor further observed that the part of the O2 tubing that went into the resident's nares was in direct contact with the O2 concentrator. The surveyor observed a piece of scotch tape with the date 2/13/22, written on it and attached to the O2 tubing. On that same date at 10:02 AM, the surveyor interviewed the resident who stated that sometimes he/she would wear the O2 at four (4) LPM and he/she would put it on themselves when he/she felt like it was needed. The resident further stated that he/she hadn't been wearing it as much anymore and hadn't been short of breath. The resident did not know how frequently the O2 tubing was change by the facility staff. On that same date at 11:06 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident wore O2, did not put it on himself/herself and the staff would put the O2 on for the resident. The CNA further stated that the resident's nurse would adjust the amount of O2 for the resident. The CNA stated that she made sure the residents head was elevated when she provided care, but she never touched the O2 because it was the nurse's responsibility to do so. On that same date at 11:19 AM, the surveyor entered the resident's room with the resident's Licensed Practical Nurse (LPN#1). The resident was observed wearing the O2 tubing that was previously observed in direct contact with the O2 concentrator in his/her nares. The surveyor and the LPN#1 observed that the resident's O2 was flowing at five (5) LPM via nasal cannula. The surveyor and LPN#1 exited the resident's room. At that time, the surveyor interviewed the LPN#1 who stated that the resident would turn on the oxygen by himself/herself. The LPN#1 further stated that the Physician's Order (PO) for the O2 should be followed when a resident was using oxygen. The LPN#1 stated that a zip lock bag that shuts should be placed next to the O2 concentrator so the tubing could be placed inside to keep the nasal cannula tubing clean. The LPN#1 further stated that the facility process was to change out the O2 tubing weekly on Sunday night shift and the O2 tubing should always be dated and labeled. The LPN#1 could not speak to if the there was a PO for dating and labeling the oxygen tubing. The surveyor reviewed the medical record for Resident #19. A review of the resident's admission Record (an admission Summary) reflected that the resident had resided at the facility for several years and had diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD), muscle weakness, chronic viral hepatitis C, and opioid dependence. A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/23/2021, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A review of the resident's February 2022 electronic Medication Review Report (MRR) reflected a PO dated 1/19/2022, to apply O2 via nonrebreather mask at 10 LPM and to titrate down the O2 with a nasal cannula as needed to maintain an oxygen saturation greater than 92% every shift for hypoxia (lack of O2) and COPD. A review of the resident's January 2022 electronic Medication Administration Record (eMAR) reflected that the nurses signed that the resident was administered the O2 via nonrebreather mask at 10 LPM and to titrate down the O2 with a nasal cannula as needed to maintain an oxygen saturation greater than 92% on the night shift starting on 1/14/22, and the day and night shifts throughout the rest of the month of January 2022. A review of the February 2022 eMAR reflected that the nurses signed that the resident was administered the O2 via nonrebreather mask at 10 LPM and to titrate down the O2 with a nasal cannula as needed to maintain an oxygen saturation greater than 92% on the day and night shifts from 02/01/22 to 02/13/22 and on the day shift on 02/14/22. A review of the resident's Care Plan (CP) revised on 1/19/22, reflected a focus area that the resident had O2 therapy related to respiratory illness. The goal of the resident's CP was the resident would show no signs and symptoms of poor oxygen absorption through the review date. The interventions for the resident's CP indicated to apply O2 via nonrebreather mask at 10 LPM and to titrate down the O2 with a nasal cannula as needed to maintain an oxygen saturation greater than 92%. On 2/14/22 at 12:03 PM, the surveyor conducted a follow up interview with the resident's LPN#1 who stated that the resident's oxygen order was to titrate the O2 to 10 LPM as needed. The LPN#1 looked at the O2 concentrator in the presence of the surveyor and stated that the concentrator did not go up to 10 LPM. On 2/14/22 at 12:47 PM, the surveyor interviewed the facility's Advanced Practitioner Nurse (APN) who stated that last month the resident had pneumonia and a COPD exacerbation. The APN stated that the resident refused to go to the hospital, so he/she was placed on a non-rebreather mask for O2 at 10 LPM and the nursing staff was to titrate the resident's O2 to maintain an O2 saturation greater than 92%. The APN further stated that the resident would request the O2 for comfort. The APN stated that the PO for the O2 should have been updated to reflect the residents current need for O2, she was unaware of how frequently resident's O2 tubing should be change, and the O2 tubing should be changed anytime that it was contaminated. On 2/17/22 at 1:35 PM, the surveyor interviewed the Director of Nursing (DON) who stated that there should be a PO for labeling and dating O2 tubing and O2 tubing should be kept in a bag when not in use to minimize the spread of infections. A review of the facility's Oxygen Administration Policy and Procedure revised 12/2021 indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**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 all medications were administered without error of 5% or more. During the medication observation on 2/11/22, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 29 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.9 %. This deficient practice was identified for 1 of 6 residents, (Resident #132), that were administered medications by one (1) of four (4) nurses. The deficient practice was evidenced as follows: 1. On 2/11/22 at 8:25 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #132. The LPN reviewed the electronic medication administration record (EMAR) and removed from the medication cart a bottle of Thiamin (Vitamin B1) (a vitamin supplement) 100 milligram (MG) tablets and a bottle of Folic Acid (a vitamin supplement) 1000 micrograms (MCG). The LPN stated that both medications were house stock medications provided by the facility. On 2/11/22 at 8:34 AM, the LPN stated that she was going to administer the (5) oral medications that she had prepared, which included one tablet of Vitamin B 1100 MG and one tablet of Folic Acid 1000 MCG to Resident #132. At that time, the surveyor asked the LPN to review the EMAR before administering the medications to the resident. The surveyor with the LPN reviewed the EMAR which revealed a physician's order (PO) for Nephro-vite tablet 0.8 MG (B complex-C-Folic Acid), give one tablet by mouth one time a day for supplement. The LPN stated that she thought the Vitamin B1 and Folic Acid tablets were the correct medications. The LPN was unable to speak to the PO for Nephro-vite(a multivitamin supplement containing a combination of B vitamins, folic acid, and Vitamin C). The LPN stated, I have only been working here two days. The surveyor asked the LPN to review the PO for Nephro-vite with a supervisor. The EMAR had not reflected a PO for Vitamin B1 or Folic Acid. (ERROR#1) The surveyor reviewed the medical records for Resident #132. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/1/22, reflected that the resident was admitted on [DATE] and had diagnoses which included anemia, renal insufficiency, orthostatic hypotension, dementia, and mood disorder Further review of the MDS, reflected that a brief interview for mental status (BIMS) could not be obtained. The staff performed a cognitive assessment which reflected that the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. A review of the resident's February 2022 Medication Review Report reflected a PO with a start date of 10/28/21, for Nephro-vite tablet 0.8 MG (B complex-C-Folic Acid), give one tablet by mouth one time a day for supplement. There was no PO for Vitamin B1 or Folic Acid. A review of a list titled Over the Counter Medications, provided by the Director of Nursing (DON) revealed that Nephro-vite was a medication provided by the facility as a house stock medication. On 2/11/22 at 11:47 AM, the surveyor interviewed the LPN regarding the PO for Nephro-vite. The LPN stated that she spoke with a supervisor and showed the surveyor that there was a bottle of Nephro-vite tablets in the house stock section of the medication cart. The LPN stated, I must have read the order wrong. The LPN again stated, I have only been working here two days. The LPN also stated that she had completed an orientation. On 2/14/22 at 12:26 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she routinely does medication observations and inservices on medication administration techniques at the facility. The CP added that the DON would be able to provide the documentation of medication passes and inservices that were completed and include the content of what she had inserviced. A review of the Medication Pass Inservice dated 2/8/22, performed by the CP reflected that the LPN was inserviced on medication administration and included to check the medication three times. On 2/15/22 at 1:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to review the medication administration results. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The LNHA stated that the nurses received orientation, medication observations and inservices and were then assigned to be alone on a medication cart when they were ready. The LNHA added that if a nurse wanted additional time before passing medications on their own, then the facility would provide additional training. The LNHA added that the LPN had received additional inservicing after 2/11/22. A review of a Medication Pass Observation Worksheet, provided by the DON, was completed on 2/8/22 with the LPN. The worksheet reflected that the LPN was observed by a staff member and in compliance with medication administration and was aware that the label of the medication should be checked three times and the medication should be administered with the correct dose. On 2/17/22 at 1:33 PM, the surveyor team met with the LNHA and the DON. The DON stated that the nurses were expected to follow a PO and clarify a PO if necessary. A review of the manufacturer's specifications for Nephro-vite reflected that the medication is a combination of vitamins and minerals. 2. On 2/11/22 at 8:25 AM, the surveyor observed the LPN preparing to administer five (5) oral medications to Resident #132 which included one capsule of 125 MG of Depakote Sprinkles (a medication used to prevent seizures or a mood stabilizer). The LPN stated that according to the EMAR the resident had to have the medications crushed. The surveyor observed the LPN crush the five (5) oral medications which included the Depakote Sprinkles 125 MG capsule. On 2/11/22 at 8:34 AM, the LPN stated that she was going to administer the five (5) oral medications which included the Depakote Sprinkles capsule that she had crushed to Resident #132. At that time, the surveyor asked the LPN to review the EMAR before administering the medications to the resident. The surveyor with the LPN reviewed the EMAR which revealed a physician's order (PO) for Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium), give one capsule by mouth two times a day for mood disorder, may open capsule. In addition, the surveyor with the LPN reviewed the label of the Depakote Sprinkle capsules for the resident. The label from the provider pharmacy revealed cautionary instructions to swallow whole or sprinkle on a small amount of food. The LPN stated, I have only been working here two days. The LPN added that she thought maybe she was supposed to open the capsule, but she was unsure how the Depakote Sprinkles should be administered. The surveyor asked the LPN to review how the Depakote Sprinkles should be administered with a supervisor. (ERROR#2) The surveyor reviewed the medical records for Resident #132. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/1/22, reflected that the resident was admitted on [DATE], and had diagnoses which included anemia, renal insufficiency, orthostatic hypotension, dementia, and mood disorder. Further review of the MDS, reflected that a brief interview for mental status (BIMS) could not be obtained. The staff performed a cognitive assessment which reflected that the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. A review of the resident's February 2022 Medication Review Report reflected a PO start date of 10/28/21, for Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium), give one capsule by mouth two times a day for mood disorder, may open capsule. On 2/11/22 at 11:47 AM, the surveyor interviewed the LPN regarding the cautionary instructions for the Depakote Sprinkles capsule. The LPN stated that she spoke with a supervisor and should not have crushed the capsule. The LPN added that she should have opened the capsule and put the contents of the capsule in the applesauce. The LPN again stated, I have only been working here two days. The LPN also stated that she had completed an orientation. On 2/14/22 at 12:46 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she routinely does medication observations and inservices on medication administration techniques at the facility. The CP added that the DON would be able to provide the documentation of medication passes and inservices that were completed and include the content of what she had inserviced. A review of the Medication Pass Inservice dated 2/8/22 performed by the CP reflected that the LPN was inserviced on medication administration and included to check the medication three times. On 2/15/22 at 1:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to review the medication administration results. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The LNHA stated that the nurses received orientation, medication observations and inservices and were then assigned to be alone on a medication cart when they were ready. The LNHA added that if a nurse wanted additional time before passing medications on their own, then the facility would provide additional training. The LNHA added that the LPN had received additional inservicing on 2/11/22. A review of a Medication Pass Observation Worksheet, provided by the DON, was completed on 2/8/22 with the LPN. The worksheet reflected that the LPN was observed by a staff member and in compliance with medication administration. In addition, the worksheet reflected that the LPN was aware that medications were to be administered in compliance with cautionary statements and to review if a medication can be crushed before crushing. On 2/17/22 at 1:33 PM, the surveyor team met with the LNHA and the DON. The DON stated that the nurses were expected to follow a PO and clarify a PO if necessary. A review of the manufacturer's specifications for Depakote Sprinkles capsule revealed that if the capsule cannot be swallowed whole, open it, and sprinkle the medication into pudding or applesauce. A review of the facility policy, Administering Medications dated as revised 12/2021 reflected that medications shall be administered as prescribed and in accordance with all orders. In addition, the individual administering the medication must check the label three times to verify the right medication and the right method of administration before giving the medication. NJAC 8:39-11.2(b), 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/11/22 at 9:53 AM, the surveyor observed Resident #22 self-propel in his/her wheelchair into his/her private room. The resident stated that he/she was going to dialysis today (Friday), was usually was picked up to leave around 1:00 PM and would return to the facility around 6:00 PM. The surveyor reviewed the medical record for Resident #22. A review of the resident's admission Record (an admission Summary) reflected that the resident was admitted to the facility in October 2021, and had diagnoses which included but were not limited to heart failure, muscle weakness, end stage renal disease, uncomplicated alcohol abuse, personal history of COVID-19, and dependence on renal dialysis. A review of the resident's admission MDS dated [DATE], reflected that the resident's BIMS was 5 out of 15 which indicated the resident had impaired cognition. A further review of the resident's MDS, Section O - Special Treatments indicated that the resident received dialysis treatments. A review of the February 2022 electronic medication review report (eMRR) reflected a PO dated 1/18/22, for Calcium Acetate (Phosphate Binder) Capsule 667 MG, give two capsules by mouth with meals for supplement. Give at 0800 (8:00 AM), 1200 PM, 1700 (5:00 PM) on non-dialysis days Tuesday, Thursday, and Sunday. Then at 8:00 AM, 12:00 PM, and 1900 (7:00 PM) on hemodialysis days Monday, Wednesday, Friday. A review of the January 2022 electronic medication administration record (eMAR) indicated that the nurses were signing that the resident was receiving the Calcium Acetate at 667 MG, two capsules at 5:00 PM on Mondays, Wednesdays, and Fridays from 1/9/22 through 01/31/22. A further review of the January 2022 eMAR did not reflect that the Calcium Acetate was plotted to be administered to the resident at 7:00 PM as the PO specified. A review of the February 2022 eMAR revealed that the nurses were signing that the resident was receiving the Calcium Acetate at 667 MG, two capsules at 5:00 PM on Mondays, Wednesdays, and Fridays from 2/01/22 through 2/15/22. A further review of the January 2022 eMAR did not reflect that the Calcium Acetate was plotted to be administered to the resident at 7:00 PM as the PO specified. A review of the resident's Care Plan (CP) revised on 11/19/21, reflected a focus area that the resident required dialysis related to end stage renal disease and received dialysis services on Monday, Wednesday, and Friday at 2:30 PM. The goal of the resident's dialysis CP indicated that the resident would have immediate intervention should any signs and symptoms of complications from dialysis through the next review date. The interventions for the resident's CP included to encourage the resident to go to scheduled dialysis appointments and to monitor labs and report to the doctor as needed. The resident's dialysis CP did not reflect that the resident's medications should be plotted according to his/her dialysis schedule. On 2/16/22 at 10:57 AM, the surveyor interviewed the residents Certified Nursing Aide (CNA) who stated that the resident was alert to person, place, and time, and could make his/her needs known. The CNA further stated that the resident went to dialysis three times weekly on Monday's, Wednesday's, and Friday's and was picked up between 1:00 PM to 1:30 PM for transport to the dialysis center. The CNA further stated that regardless of what time the resident was placed on the dialysis machine he/she demanded to be taken off the dialysis machine at 6:00 PM and would arrive back to the facility anywhere from 6:15 PM to 6:45 PM. On 2/16/22 at 11:06 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident went to dialysis on Monday's, Wednesday's, and Friday's and left the facility around 2:00 PM. The LPN further stated that the resident would return to the facility around 6:45 PM to 7:00 PM. The LPN stated that the resident's medications should be plotted according to the resident's dialysis schedule so the resident could receive their medications on time and when they were in the facility. The surveyor reviewed the eMAR in the presence of the LPN who stated that the Calcium Acetate medication should have been plotted according to the resident's dialysis schedule and administered with food for it to work effectively for the resident. On 2/17/22 at 1:35 PM, the Administrator stated that the resident's medications should have been plotted according to their dialysis schedule. A review of the facility's Care of Patients on Dialysis Policy and Procedure reviewed 07/21 indicated, Ensure that medication times correspond with dialysis schedule. The facility's Care of Patients on Dialysis Policy and Procedure further revealed that medications were to be adjusted for dialysis times as ordered by the physician. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d) Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by clarifying physician orders and adjusting medication times of administration to accommodate for dialysis scheduled times. This deficient practice was identified for 2 of 5 residents reviewed for dialysis, (Resident #22 and #31), and was evidenced by the following: REFER TO F 756 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 2/9/22 at 11:55 AM, the surveyor interviewed the RN#1 who stated that Resident #31 was out of the facility at dialysis (a procedure that uses special equipment to clean the blood). The RN#1 added that the resident was alert and oriented and was picked up for dialysis by 10 AM on Monday, Wednesday and Friday and returned to the facility approximately 3 PM. The surveyor reviewed the medical record for Resident #31. A review of an admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/3/22, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's admission Record revealed a diagnosis of end stage renal disease (ESRD) (a longstanding kidney disease which causes kidneys to fail causing waste and excess fluid to build up in the blood). A review of the resident's interdisciplinary care plan (IDCP) revealed that the resident needs hemodialysis due to ESRD with an initiated and revision date of 11/23/21 (a prior admission date). A review of the Dialysis Communication Forms dated 1/28/22, 2/4/22, 2/7/22, 2/9/22, 2/11/22, and 2/14/22 that were completed by the facility and dialysis center indicated that the resident had received dialysis. A review of the Medication Review Report reflected a physician's order (PO) dated 1/27/22 for Dialysis M-W-F chair time 10:30 AM. A review of the February 2022 electronic medication administration record (eMAR) revealed three PO's for Renvela (a medication used to prevent high phosphate levels in the blood for people who are on dialysis due to kidney disease) as follows: The first PO had a start date of 2/5/22 for Renvela 800 MG, give one tablet by mouth three times a day every Mon, Wed, Fri for supplement, give with meals at specific time on hemodialysis (HD) days with a discontinuation date of 2/9/22. The eMAR reflected that on 2/7/22 at 8 AM the Renvela was not administered. A review of the corresponding nursing electronic progress note (EPN) dated 2/7/22 at 9:51 AM indicated duplicate for the Renvela PO. The second PO had a start date of 2/9/22 for Renvela 800 MG, give one tablet by mouth three times a day every Mon, Wed, Fri for supplement, give with meals at specific time on HD days. The eMAR was blocked off so that signatures for administration were allowed on only dialysis days. The eMAR reflected that on 2/7/22 (a dialysis day) at 12 NOON a code #1 was noted for administration of Renvela indicated that the medication was not administered because 1=Absent from home without meds. The third PO had a start date of 2/5/22 for Renvela 800 MG, give one tablet by mouth three times a day for supplement, give with meals three times a day on non-hemodialysis days Tue-Thurs-Sat-Sun. The eMAR was not blocked off and allowed signatures for administration on dialysis days as well as non-dialysis days. The eMAR reflected that on 2/9/22 (a dialysis day) at 12 NOON a code #9 was noted for the administration of Renvela indicating that the medication was not administered because 9=other/see progress notes. A review of the corresponding nursing electronic progress note dated 2/9/22 at 12:38 PM indicated that the reason the medication was not administered was dialysis. Further review of the eMAR, revealed that on 2/9/22 and 2/11/22 (dialysis days), the Renvela 800 MG was signed as administered at 8 AM for the Renvela PO for dialysis days, in addition to the Renvela PO for non-dialysis days. This reflected that two 800 MG tablets were administered at 8 AM on 2/9 and 2/11, which had not corresponded with the PO. In addition, the eMAR reflected that on 2/11/22 (a dialysis day) the Renvela was administered at 12 NOON (a time when the resident was out of the facility at the dialysis center) and signed by the Registered Nurse (RN#1) for the Renvela PO for non-dialysis days. On 2/14/22 at 12:26 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she does make recommendations to adjust medications to accommodate dialysis times. The CP stated that the nurses should know that any resident who had to go out for dialysis had to have their medication times reviewed and adjusted to accommodate the resident being out of the facility. The CP added that the nurses would call the physician to clarify orders for the times of administration depending on the medication. The CP stated that she does a monthly drug regimen review and had entries electronically and sends a finalized report to the DON. The CP had not completed a review for February yet. A review of the CP Impact Review for Resident #31 dated 1/28/22 reflected to administer on dialysis days Calcium Acetate (Phos-lo) (another medication used to prevent high phosphate levels in the blood for people who are on dialysis due to kidney disease) at 8 am, 12 pm and when the resident returns from dialysis and has dinner. On 2/15/22 at 10:40 AM, the surveyor interviewed Resident #31. The resident stated that on Monday, Wednesday, and Friday she was usually picked up by 10 AM to go to dialysis and returned to the facility at approximately 3 PM. The resident stated that he/she has been here a couple of weeks and was familiar with the facility because he/she had been here once before but had gone home. The resident stated that the nurses brought his/her medications but was unable to say which medications he/she received. The resident stated that she thought sometimes his/her medications were late but was unable to specify which medications and at what time. On 2/15/22 at 11:19 AM, the surveyor interviewed the RN#1 who stated that Resident #31 had been on the first floor when admitted and that she had administered medications to the resident. The RN#1 added that she had recently been hired and had been working on the unit for approximately a week. The surveyor with the RN#1 reviewed the February eMAR and the RN#1 acknowledged her signature on the eMAR for the administration of Renvela for the dates of 2/9/22 and 2/11/22 (dialysis days). The RN#1 also acknowledged that she had signed for the administration of Renvela on 2/9 and 2/11 at 8 AM for the PO for dialysis days and for non-dialysis days. The RN#1 stated that she thought on dialysis days she was to administer two 800 MG tablets of Renvela. The RN#1 was unable to speak to the entry of the Renvela PO on dialysis days and non-dialysis days and thought she was following the PO. In addition, the RN#1 stated that she signed for the Renvela dose on 2/11/22 (a dialysis day) at 12 PM because she thought the resident was possibly picked up late and administered the medication one hour before with a snack. The RN#1 could not speak to why she was signing the PO for a non-dialysis day when it was a dialysis day. 02/15/22 10:54 AM, the surveyor interviewed the RN#2 who stated that she currently administered medications to Resident #31 because the resident had been transferred to her floor and that the resident was alert and oriented. The RN #2 stated that she administered the resident's medications before dialysis which included one Renvela 800 MG at 8 AM and then another Renvela when the resident returned from dialysis. The RN#2 stated that on non-dialysis days the times were different because the resident was in the facility for breakfast, lunch, and dinner when the Renvela was supposed to be administered. The RN#2 stated that the medications were supposed to be adjusted to accommodate the resident being out to dialysis. The RN#2 could not speak to the entry of the Renvela PO for dialysis and non-dialysis days. On 2/15/2022 at 1:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review the findings of the Renvela administration for Resident #31. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The DON stated that the Renvela PO needed to be clarified and whichever nurse had taken the PO should have clarified the PO. The DON acknowledged that the Renvela PO was not clarified and inaccurately being documented for administration of the medication. The DON added that the nurses were expected to review with the physician all medication orders and accommodate for the times the resident was out to dialysis and clarify for dialysis days and non-dialysis days. On 2/17/2022 at 1:33 PM, the survey team met with the LNHA and DON. The LNHA acknowledged that the medications were not accurately adjusted to accommodate dialysis times. The DON stated that Resident #31 when first admitted had a different medication (Calcium Acetate) plotted correctly to allow for dialysis times and then there was a change in the medication to Renvela. The DON stated that the nurses should follow a PO and clarify the PO if necessary. A review of the facility policy dated as revised 12/2021 for Administering Medications reflected that medications are to be administered in a timely manner as prescribed. Further review reflected that medications are to be administered within 1 hour of the prescribed time or at a specified prescribed time which included before a meal or after a meal. In addition, the individual administering the medication must check the label three times to verify the right time before giving a medication.

**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 pharmaceutical services to ensure that acceptable professional standards of clinical practice were followed for medication administration in accordance with a Physician's Order (PO) to hold a medication (Midodrine) according to blood pressure parameters from November 2021 until surveyor inquiry February 2022. This deficient practice was identified for 1 of 6 residents reviewed for medication administration, (Resident #132) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/11/22 at 8:25 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) preparing to administer medications to Resident #132. The LPN#1 stated that she had already obtained the resident's blood pressure which had a result of a systolic blood pressure (SBP) (the maximum or top number of the blood pressure measurement) of 124 over a diastolic (the lowest or bottom number of the blood pressure measurement) BP of 80. The LPN#1 then stated that she was not going to administer the Midodrine (a medication used to increase the BP) because the physician's order (PO) indicated to hold the Midodrine if the SBP was greater than 120. The surveyor reviewed the medical record for Resident #132. A review of the resident's quarterly Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care), dated 1/1/22, reflected that the resident was admitted on [DATE] and had diagnoses which included anemia, renal insufficiency, orthostatic hypotension, dementia, and mood disorder Further review of the MDS, reflected that a brief interview for mental status (BIMS) could not be obtained. The staff performed a cognitive assessment which reflected that the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. A review of the February Medication Review Report reflected a PO with a start date of 11/5/21 for Midodrine Hydrochloride, 5 milligrams (MG), give one tablet by mouth three times a day (TID) every Monday, Wednesday, Friday for hypotension, Hold for SBP greater than 120. In addition, there was another PO with a start date of 11/6/21 for Midodrine Hydrochloride, 5 milligrams (MG), give one tablet by mouth three times a day (TID) every Tuesday, Thursday, Saturday, Sunday for hypotension, Hold for SBP greater than 120. A review of the November 2021, December 2021, January 2022, and February 2022 electronic medication administration records (EMAR) for Resident #132 revealed that the Midodrine had been administered for SBP results that were greater than 120. The EMAR indicated administration of a medication with a check mark and nurses initials. The November 2021 EMAR revealed 14 of 90 doses that were inaccurately administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 11/11/21 at 9 AM for a SBP of 127. on 11/11/21 at 2 PM for a SBP of 127. on 11/12/21 at 8 AM for a SBP of 127. on 11/12/21 at 4 PM for a SBP of 127. on 11/12/21 at 10 PM for a SBP of 128. on 11/14/21 at 9 PM for a SBP of 127. on 11/15/21 at 8 AM for a SBP of 124. on 11/15/21 at 4 PM for a SBP of 124. on 11/17/21 at 8 AM for a SBP of 126. on 11/23/21 at 9 PM for a SBP of 143. on 11/24/21 at 8 AM for a SBP of 125. on 11/25/21 at 9 PM for a SBP of 126. on 11/26/21 at 8 AM for a SBP of 135. on 11/29/21 at 4 PM for a SBP of 140. The December 2021 EMAR revealed 6 of 93 doses that were inaccurately administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 12/1/21 at 4 PM for a SBP of 125. on 12/3/21 at 4 PM for a SBP of 135. on 12/13/21 at 8 AM for a SBP of 130. on 12/13/21 at 4 PM for a SBP of 130. on 12/13/21 at 10 PM for a SBP of 130. on 12/24/21 at 10 PM for a SBP of 123. The January 2022 EMAR revealed 12 of 93 doses that were inaccurately administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 1/3/22 at 10 PM for a SBP of 125. on 1/6/22 at 9AM for a SBP of 131. on 1/6/22 at 2 PM for a SBP of 131. on 1/8/22 at 9 AM for a SBP of 129. on 1/8/22 at 2 PM for a SBP of 129. on 1/14/22 at 8AM for a SBP of 137. on 1/17/22 at 10 PM for a SBP of 134. on 1/20/22 at 9 AM for a SBP of 136. on 1/20/22 at 2 PM for a SBP of 136. on 1/24/22 at 4 PM for a SBP of 128. on 1/25/22 at 9 AM for a SBP of 137. on 1/28/22 at 4 PM for a SBP of 129. The February 2022 EMAR revealed 6 of 31 doses that were inaccurately administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 2/2/22 at 10 PM for a SBP of 122. on 2/4/22 at 8 AM for a SBP of 136. on 2/4/22 at 4 PM for a SBP of 136. on 2/9/22 at 8 AM for a SBP of 122. on 2/9/22 at 4 PM for a SBP of 122. on 2/10/22 at 9AM for a SBP of 138. On 2/15/22 at 11:12 AM, the surveyor interviewed LPN#2 who stated that a check mark on the EMAR meant that a medication was administered, and the nurse's initials were also indicated. The surveyor with the LPN#2 reviewed the EMAR for the Midodrine PO. The LPN#2 stated that according to the PO if the SBP was greater than 120 then the Midodrine was to be held. The LPN#2 reviewed a SBP parameter on the EMAR for 136 that had a check mark indicating that the medication was administered and stated that the medication should have been held. The LPN#2 added that there was a code number instead of a check mark that the nurses would enter in the EMAR indicating that a medication was held due to being outside the parameters for administration. The LPN#2 could not speak to the dates of 11/24/21 and 1/14/22 that had her initials for corresponding SBP of 125 and 137. On 2/16/22 at 11:24 AM, the surveyor with the LPN#3 reviewed the EMAR for Resident #132 for the Midodrine PO. The LPN#3 stated that the check mark indicated that the medication was administered. The LPN#3 added that the nurses were to read a PO and follow the PO. The surveyor with LPN#3 reviewed the EMAR for the dates of: - 1/20/22 at 9 am and 2 PM that had SBP results of 136, - 1/25/22 at 9 AM that had SBP results of 137 and - 2/4/22 at 8 AM and 4 PM that had SBP results of 136. The LPN#3 acknowledged that aforementioned dates and times were her initials for the administration of Midodrine. The LPN#3 stated that she should have held the medication. Further review of the resident's EMAR revealed that all the dates listed above had a check mark and there were no code numbers entered that corresponded to the medication being held. On 2/16/22 at 1:21 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to review the findings of the administration of the Midodrine for Resident #132. On 2/17/22 at 10:20 AM, the surveyor interviewed the LPN#1 who stated that she had administered medications to Resident #132 on 2/11/22 and had followed the PO to hold the Midodrine for a SBP greater than 120. The LPN#1 could not speak to her initials for the administration of Midodrine on 2/10/22 at 9 AM for a SBP of 138. On 2/17/22 at 1:33 PM, the survey team met with the LNHA and the DON who acknowledged that the Midodrine had been administered outside of the parameters indicated in the PO. The DON stated that the nurses should follow a PO and clarify the order if necessary. The DON added that the physician was notified and the Midodrine PO was being changed. A review of the facility policy, Administering Medications dated as revised 12/2021 reflected that medications shall be administered as prescribed and in accordance with all orders. In addition, the individual administering the medication must check the label three times to verify the right medication and the right method of administration before giving the medication. REFER to F756 NJAC 8:39- 11.2(b), 29.2(a)(d), 29.3(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/11/22 at 9:53 AM, the surveyor observed Resident #22 self-propel in his/her wheelchair into his/her private room. The resident stated that he/she was going to dialysis today (Friday), usually was picked up to leave around 1:00 PM and would return to the facility around 6:00 PM. The surveyor reviewed the medical record for Resident #22. A review of the resident's admission Record (an admission Summary) reflected that the resident was admitted to the facility in October 2021, and had diagnoses which included but were not limited to heart failure (the inability of the heart to pump blood throughout the body), muscle weakness, end stage renal disease, uncomplicated alcohol abuse, personal history of COVID-19, and dependence on renal dialysis. A review of the resident's admission MDS dated [DATE], reflected that the resident's BIMS was 5 out of 15 which indicated the resident had impaired cognition. A further review of the resident's MDS, Section O - Special Treatments indicated that the resident received dialysis treatments. A review of the February 2022 electronic medication review report (EMRR) reflected a PO dated 1/18/22 for Calcium Acetate (Phosphate Binder) Capsule 667 MG, give two capsules by mouth with meals for supplement. Give at 0800 (8:00 AM), 1200 PM, 1700 (5:00 PM) on non-dialysis days Tuesday, Thursday, and Sunday. Then at 8:00 AM, 12:00 PM, and 1900 (7:00 PM) on hemodialysis days Monday, Wednesday, Friday. A review of the January 2022 EMAR indicated that the nurses were signing that the resident was receiving the Calcium Acetate at 667 MG, two capsules at 5:00 PM on Mondays, Wednesdays, and Fridays from 1/9/22 through 1/31/22. A further review of the January 2022 EMAR did not reflect that the Calcium Acetate was plotted to be administered to the resident at 7:00 PM as the PO specified. A review of the February 2022 EMAR revealed that the nurses were signing that the resident was receiving the Calcium Acetate at 667 MG, two capsules at 5:00 PM on Mondays, Wednesdays, and Fridays from 2/01/22 through 2/15/22. A review of the January 2022 monthly Consultant Pharmacist Report provided by the DON indicated that the report included activities between 1/1/22 and 1/31/22 revealed a recommendation for Resident #22 to nursing services, Ca Acetate give 8 12 5 non dialysis days and 8 12 and when returns from dialysis on dialysis days. On 02/17/22 at 10:26 AM, the surveyor interviewed LPN#4 who stated that the CP would come to the facility to review the resident's medications. LPN#4 was unsure of how frequently the CP came to the facility or whose responsibility it was to follow through with the CP recommendations. On 02/17/22 at 11:00 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the CP reviewed the resident's medications monthly, made recommendations in writing and would speak to staff when irregularities were identified. The ADON stated that the DON and Administrator were responsible for completing the CP recommendations by placing a call to the resident's physician, reviewing the recommendation with the physician, and make changes to the resident's medication regimen based off the physician's order. On 02/17/22 at 12:09 PM, the surveyor interviewed the DON who stated that the CP came monthly to the facility to review the resident's medications. The DON further stated that the CP would e-mail a report of recommendations to him and the ADON and the two of them would collaborate to complete the report. The DON stated that he and the ADON would go unit to unit, call the resident's physician, make the physician aware of the CP recommendation and make changes after receiving an order from the physician. The DON further stated that he would not document the communication between the resident's physician in the resident's medical record. The DON stated that the purpose of following through with recommendations made by the CP was to make sure the facility was compliant with medications being timed and administered appropriately. On 02/17/22 at 1:12 PM, the surveyor interviewed the facility's CP who stated that she reviewed medications to make sure that there was no duplicate therapy and medications were administered at correct times. The CP stated that she expected a resident who went to dialysis to have their medications plotted according to their dialysis schedule. The CP stated that after she reviewed the resident's medications, she would e-mail her report to the Medical Director, DON, and ADON and once the report was submitted, the expectation would be for her recommendations to be reviewed with the resident's physicians and completed in a timely manner. A review of the facility's Medication Therapy Policy and Procedure revised 12/21 indicated, The Consultant Pharmacist shall review each resident's medication regimen monthly, as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. The facility shall review medication-related issues as part of its Quality Assurance Committee and activities. The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring. NJAC 8:39-29.3(a)(1) Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Consultant Pharmacist recommendations were acted upon in a timely manner regarding a.) the use of a medication to treat low blood pressure (Midodrine) was identified to not be administered in accordance with the physician prescribed hold parameters for a period of four (4) months and b.) a medication for a resident who went to dialysis was plotted according to the resident's dialysis schedule. This deficient practice was identified for 2 of 5 residents reviewed for Consultant Pharmacist reviews (Resident #132 and Resident #22) and was evidenced by the following: REFER TO F 755 REFER TO F 698 1. On 2/11/22 at 8:25 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) preparing to administer medications to Resident #132. The LPN#1 stated that she had already obtained the resident's blood pressure which had a result of a systolic blood pressure (SBP) (the maximum or top number of the blood pressure measurement) of 124 over a diastolic (the lowest or bottom number of the blood pressure measurement) BP of 80. The LPN#1 then stated that she was not going to administer the Midodrine (a medication used to increase the BP) because the physician's order (PO) indicated to hold the Midodrine if the SBP was greater than 120. The surveyor reviewed the medical record for Resident #132. A review of the resident's quarterly Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care), dated 1/1/22, reflected that the resident was admitted on [DATE] and had diagnoses which included anemia, renal insufficiency, orthostatic hypotension, dementia, and mood disorder Further review of the MDS, reflected that a brief interview for mental status (BIMS) could not be obtained. The staff performed a cognitive assessment which reflected that the resident had a short- and long-term memory problem with a severely impaired decision-making capacity. A review of the February Medication Review Report reflected a PO with a start date of 11/5/21 for Midodrine Hydrochloride, 5 milligrams (MG), give one tablet by mouth three times a day (TID) every Monday, Wednesday, Friday for hypotension, Hold for SBP greater than 120. In addition, there was another PO with a start date of 11/6/21 for Midodrine Hydrochloride, 5 milligrams (MG), give one tablet by mouth three times a day (TID) every Tuesday, Thursday, Saturday, Sunday for hypotension, Hold for SBP greater than 120. A review of the November 2021, December 2021, January 2022, and February 2022 electronic medication administration records (EMAR) for Resident #132 revealed that the Midodrine had been administered for SBP results that were greater than 120. The EMAR indicated administration of a medication with a check mark and nurses initials. The November 2021 EMAR revealed 14 of 90 doses that were not administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 11/11/21 at 9 AM for a SBP of 127. on 11/11/21 at 2 PM for a SBP of 127. on 11/12/21 at 8 AM for a SBP of 127. on 11/12/21 at 4 PM for a SBP of 127. on 11/12/21 at 10 PM for a SBP of 128. on 11/14/21 at 9 PM for a SBP of 127. on 11/15/21 at 8 AM for a SBP of 124. on 11/15/21 at 4 PM for a SBP of 124. on 11/17/21 at 8 AM for a SBP of 126. on 11/23/21 at 9 PM for a SBP of 143. on 11/24/21 at 8 AM for a SBP of 125. on 11/25/21 at 9 PM for a SBP of 126. on 11/26/21 at 8 AM for a SBP of 135. on 11/29/21 at 4 PM for a SBP of 140. The December 2021 EMAR revealed 6 of 93 doses that were not administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 12/1/21 at 4 PM for a SBP of 125. on 12/3/21 at 4 PM for a SBP of 135. on 12/13/21 at 8 AM for a SBP of 130. on 12/13/21 at 4 PM for a SBP of 130. on 12/13/21 at 10 PM for a SBP of 130. on 12/24/21 at 10 PM for a SBP of 123. The January 2022 EMAR revealed 12 of 93 doses that were not administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 1/3/22 at 10 PM for a SBP of 125. on 1/6/22 at 9AM for a SBP of 131. on 1/6/22 at 2 PM for a SBP of 131. on 1/8/22 at 9 AM for a SBP of 129. on 1/8/22 at 2 PM for a SBP of 129. on 1/14/22 at 8AM for a SBP of 137. on 1/17/22 at 10 PM for a SBP of 134. on 1/20/22 at 9 AM for a SBP of 136. on 1/20/22 at 2 PM for a SBP of 136. on 1/24/22 at 4 PM for a SBP of 128. on 1/25/22 at 9 AM for a SBP of 137. on 1/28/22 at 4 PM for a SBP of 129. The February 2022 EMAR revealed 6 of 31 doses that were not administered according to the PO. The following were the dates and times with the corresponding SBP results that were greater than 120: on 2/2/22 at 10 PM for a SBP of 122. on 2/4/22 at 8 AM for a SBP of 136. on 2/4/22 at 4 PM for a SBP of 136. on 2/9/22 at 8 AM for a SBP of 122. on 2/9/22 at 4 PM for a SBP of 122. on 2/10/22 at 9AM for a SBP of 138. On 2/14/22 at 12:26 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she does a monthly drug regimen review and had entries electronically and sends a finalized report to the Director of Nursing (DON). The CP stated that she had not completed a review for February yet. A review of the Monthly Consultant Pharmacist Report provided by the DON indicated that the report included CP activities between 11/1/21 and 11/30/21 revealed that there were no recommendations made for Resident #132. A review of the Monthly Consultant Pharmacist Report provided by the DON indicated that the report included CP activities between 12/1/21 and 12/30/21 revealed a recommendation for Resident #132 to nursing services Midodrine should have been held a few times for SBP greater than 120. A review of the Monthly Consultant Pharmacist Report provided by the DON indicated that the report included CP activities between 1/1/22 and 1/31/21 revealed a recommendation for Resident #132 to nursing services Midodrine should have been held several times SBP greater than 120, please speak with nurses. On 2/15/22 at 11:12 AM, the surveyor interviewed LPN#2 who stated that a check mark on the EMAR meant that a medication was administered, and the nurse's initials were also indicated. The surveyor with the LPN#2 reviewed the EMAR for the Midodrine PO. The LPN#2 stated that according to the PO if the SBP was greater than 120 then the Midodrine was to be held. The LPN#2 reviewed a SBP parameter on the EMAR for 136 that had a check mark indicating that the medication was administered and stated that the medication should have been held. The LPN#2 added that there was a code number instead of a check mark that the nurses would enter in the EMAR indicating that a medication was held due to being outside the parameters for administration. The LPN#2 could not speak to the dates of 11/24/21 and 1/14/22 that had her initials for corresponding SBP of 125 and 137. On 2/16/22 at 11:24 AM, the surveyor with the LPN#3 reviewed the EMAR for Resident #132 for the Midodrine PO. The LPN#3 stated that the check mark indicated that the medication was administered. The LPN#3 added that the nurses were to read a PO and follow the PO. The surveyor with LPN#3 reviewed the EMAR for the dates of; 1/20/22 at 9 am and 2 PM that had SBP results of 136, 1/25/22 at 9 AM that had SBP results of 137 and 2/4/22 at 8 AM and 4 PM that had SBP results of 136. The LPN#3 acknowledged that those dates and times were her initials for the administration of Midodrine. The LPN#3 stated that she should have held the medication. Another review of the resident's EMAR revealed that all the dates listed above had a check mark and there were no code numbers entered that corresponded to the medication being held. On 2/16/22 at 1:21 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to review the findings of the administration of the Midodrine for Resident #132. On 2/17/22 at 10:20 AM, the surveyor interviewed the LPN#1 who stated that she had administered medications to Resident #132 on 2/11/22 and had followed the PO to hold the Midodrine for a SBP greater than 120. The LPN#1 could not speak to her initials for the administration of Midodrine on 2/10/22 at 9 AM for a SBP of 138. On 2/17/22 at 1:33 PM, the survey team met with the LNHA and the DON who acknowledged that the Midodrine had been administered outside of the parameters indicated in the PO. The LNHA stated that a Quality Assurance Performance Improvement (QAPI) was started. The LNHA stated that there was no policy regarding the procedure for the CP reports. The DON stated that the nurses should follow a PO and clarify the order if necessary. The DON added that the physician was notified and the Midodrine PO was being changed. The DON stated that he was responsible for reviewing the CP reports and following up on recommendations. The DON stated that he tries to do the CP reports as soon as he gets them and complete them usually in a week. The DON added that the CP usually notifies him of a medication error and he would speak with the nurses about the error. The DON had not provided any follow up that was completed for the CP recommendations from December 2021 and January 2022.

Based on observation, interview and review of facility documents it was determined that the facility failed to dispose of trash in a sanitary manner. This deficient practice was evidenced by the following: When the surveyors entered the facility parking lot on 2/9/22, at approximately 9:00 AM, all surveyors observed that the dumpster's in the lot were uncovered and overflowing with debris. There were used surgical masks, disposable gloves, plastic silverware, Styrofoam containers and food waste strewn on the ground surrounding the dumpster's. On 2/9/22 at 9:38 AM, during the initial tour of the kitchen, the surveyor asked to see the dumpster area used by the food service department. The Food Service Director (FSD) stated that the dumpster's in the parking lot across the street were used by the whole facility. When asked who was responsible for keeping that area clean, the FSD stated that Dietary and Housekeeping were responsible. The FSD also mentioned that the facility planned to get a trash compactor. On 2/10/22 at 09:19 AM, the surveyor observed three green dumpster's in the parking lot for trash and two blue dumpster's for recyclables. One of the blue dumpster's contained food items. Once again, all of the dumpster's were uncovered, and surrounded by litter on the ground. None of these dumpster's had covers attached to them, so facility personnel were unable to seal them. The surveyor observed birds flying into the open dumpster's. This same condition was observed in the morning and afternoon on 2/14 and 2/15/22. On 2/15/22, the surveyors observed an additional waste management company taking care of the trash. On 2/16/22 at 11:35 AM, the surveyor interviewed the Housekeeping Director (HD). He stated that all departments would take their trash to the dumpster's. Housekeeping would take their trash in the morning and the afternoon. The HD stated, first thing we do is take it out and clean the area. He explained that the main problem was that there were no lids provided for the dumpster's. They should have a lid. Every day the wind comes. I'd have to have a guy there steadily to keep that area clean. We are going to get a compactor. Ask the Administrator. On 2/16/22 at 1:53 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) about the dumpster's in the parking lot. The LNHA stated, It's got to be cleaned. I plan to order a compactor. I tried to get a different type of dumpster, but it wouldn't fit in our parking lot. The lids on the dumpster's went missing. The LNHA further stated that he didn't know how long ago the dumpster covers disappeared. He added that the company that provided the dumpster's was going to send covers for them now, but I was trying to get a larger dumpster. The LNHA also explained that the facility added additional times to pick up the garbage. He employed another trash hauling company on 2/15/22 because he saw the condition of the parking lot and new that he had to do more . with disposable gloves and other medical waste on the grounds. On 2/17/2022 at 9:05 AM, the LNHA provided additional information which included estimates for a trash compactor, dated August 2020. The LNHA also provided a copy of an email, dated 2/15/22, indicating that the waste management company was working on getting lids for the five dumpster's as soon as possible. This email was written after the surveyors arrived and began inquiring about the unsanitary conditions involving the uncovered dumpster's. NJAC 8:39-19.7

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE), in accordance with Centers for Disease Control and Prevention (CDC) guidelines, before entering and after exiting a resident's room who was on Transmission Based Precautions (TBP) due to being a Person Under Investigation (PUI) and perform hand hygiene for 2 of 3 certified nursing aides (CNA) for 3 of 9 resident rooms on TBP, b.) appropriately don and doff PPE, in accordance with CDC guidelines, before and after exiting a resident's room who was on TBP due to being PUI and appropriately perform hand hygiene after doffing PPE while performing housekeeping services, for 1 of 9 residents on TBP, c.) maintain a social distanced hallway for the transportation to and from the Rehabilitation gym on the first floor with PUI residents non-compliant with TBP, and d.) consistently monitor 3 out of 32 residents (Resident #94, #64 and #130) reviewed for signs and symptoms of COVID-19 during an outbreak in the facility. These deficient practices were evidenced by the following: According to the U.S. CDC COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 9/10/2021, Managing Residents with Suspected or Confirmed SARS-CoV-2 Infection reflects that healthcare personnel caring for residents with suspected SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and NIOSH approved N 95 or equivalent higher-level respirator). In addition, the healthcare personnel are to remove gloves, gown, and dispose into a trash receptacle. Then the healthcare provider may exit the patient room and then perform hand hygiene. According to the U.S. CDC guidelines for Hand Hygiene in Healthcare Settings Hand Hygiene Guidance, updated 1/30/20, included Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: * Immediately before touching a patient * After touching a patient or the patient's immediate environment * After contact with blood, body fluids, or contaminated surfaces * Immediately after glove removal Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. According to the U.S. CDC guidelines for Transmission-Based Precautions dated 1/7/2016, indicated to Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. According to the U.S. CDC COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 9/10/2021, Evaluate and Managing Personnel and Residents indicates that healthcare personnel should, Actively monitor all residents upon admission and at least daily for fever .and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry . This document also reflects that for New Infection in Healthcare Personnel or Resident . -Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms. 1. On 2/9/22 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided a list of residents who were considered persons under investigation (PUI) due to COVID-19 and were placed on Transmission Based Precautions (TBP). The LNHA stated that they were PUI due to being a new admission and quarantined for 14 days. A review of the floor plan indicated that the first floor was the only floor with the PUI residents. On 2/9/22 at 10:21 AM, the surveyor, in the presence of another surveyor, interviewed the Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) on the first floor who informed the surveyors that the first floor had residents that were PUI for the COVID-19 virus because they were new admissions placed on TBP for 14 days after admission. The ADON/LPN added that there were bins in front of the doorways in the hall which contained PPE for the designated PUI rooms along with signage. The ADON/LPN also stated that the staff working on the first floor were required to wear a N95 mask, face shield/goggles at all times on the floor and when going to enter a PUI room had to don gloves and a gown. In addition, upon exiting a PUI room the staff were to doff the gown and gloves and perform hand hygiene. The surveyors were able to observe bins with PPE at the doorways of the PUI rooms and signage indicating STOP, COVID-19 Transmission Based Precautions, Entry to room requires gown, gloves, N95 respirator mask and goggle/face shield. The designated PUI rooms were as follows: #103, #106, #109, #110, #113, #115, and #116. On 2/9/22 at 10:56 AM, the surveyor, in the presence of another surveyor, observed a CNA#1 walking with Resident #245 back to his/her room [ROOM NUMBER]. The surveyors observed from the hallway the CNA#1 enter the room with the resident and discussed clothing that was in a box and then the CNA#1 exited the room. The surveyors observed a bin in the hallway with PPE and signage on the outside of the room. The surveyors had not observed the CNA#1 don or doff PPE or perform hand hygiene. On 2/9/22 at 11:01 AM, the surveyor interviewed the CNA#1 who stated that she should have donned and doffed a gown and gloves because the resident was a PUI and was on TBP. The CNA#1 stated that she had to redirect the resident back to his/her room because they were upset about clothing that the resident thought was not clean, but the clothing was in the original package. The CNA#1 stated that she was going to get a plastic bag for the resident to separate the clothing that the resident thought was not clean. The CNA#1 stated that the bin in the hallway and signage was because the resident was on isolation. The CNA#1 acknowledged that she should have donned and doffed a gown and gloves because the resident was a PUI and was on TBP. The CNA#1 also stated that she was supposed to perform hand hygiene upon exiting the room. On 2/9/22 at 11:34 AM, from the hallway, the surveyor observed two (2) CNA's delivering lunch trays to rooms. The surveyor observed CNA#2 coming out of room [ROOM NUMBER] wearing a N95 mask, goggles, gown, and gloves and spoke with CNA#3. Then, CNA#2 doffed the gown and gloves in the hallway and waited until CNA#3 brought a red covered garbage pail and placed it in the hallway outside room [ROOM NUMBER] and CNA#2 placed the gown and gloves in the red pail. The CNA#2 continued down the hallway. There was no observation of hand hygiene performed. The surveyor observed a bin with PPE in the hallway and signage in front of room [ROOM NUMBER]. On 2/9/22 at 11:43 AM, the surveyor observed, from the hallway, CNA#2 come out of room [ROOM NUMBER] at the door in the hallway wearing a N95, goggles, gown and gloves and then walked back into room [ROOM NUMBER]. The surveyor observed a bin with PPE and signage in the hallway for room [ROOM NUMBER]. At that time, the surveyors also observed a CNA#3 in room [ROOM NUMBER] wearing a N95 mask, goggles, gown, and gloves and before exiting doffed the gown and gloves and placed them in a small garbage pail in the room and performed appropriate hand washing technique and exited the room. The surveyor observed a bin with PPE and signage in the hallway for room [ROOM NUMBER]. On 2/9/22 at 11:46 AM, the CNA#2 walked out of room [ROOM NUMBER] wearing a N95, goggles gown and gloves and doffed the gown and gloves at the door in the hall and rolled the gown and gloves into a ball and proceeded to walk to room [ROOM NUMBER] and threw the balled gown and gloves in a small garbage pail in room [ROOM NUMBER]. The surveyor had not observed hand hygiene performed. The surveyor observed that the resident residing in room [ROOM NUMBER] was not in the room and there was no bin with PPE or signage for room [ROOM NUMBER]. On 2/9/22 at 11:48 AM, the surveyor interviewed CNA#2 who stated that she has worked in the facility for approximately a year and floats to different floors and has worked on the first floor before. The CNA#2 stated that she was supposed to wash her hands after exiting a PUI room. The CNA#2 acknowledged that she had not performed hand hygiene and should have. The CNA#2 stated that she did not think she could use alcohol-based hand rub (AHBR) after exiting a PUI room and could only wash her hands with soap and water. The CNA#2 stated that she usually doffed her gown and gloves and put them in a red garbage pail in the hallway but today had not seen any of the red garbage pails except for the one CNA#3 got for her. The CNA#3 acknowledged that she walked out of room [ROOM NUMBER] with the gown and gloves and threw them in room [ROOM NUMBER]'s garbage because she said that room [ROOM NUMBER] did not have a garbage pail and she used the garbage pail in room [ROOM NUMBER] because she knew that no one was in that room at the moment. The CNA#2 stated that she had been inserviced on infection control procedures but was unable to identify who had done the inservicing. On 2/9/22 at 11:52 AM, the surveyor interviewed CNA#3 who stated that there had been red garbage pails to place the gown and gloves in after he removed them but today, he had not seen any. The CNA#3 acknowledged that he had to get one for CNA#2 and was unsure why there was no garbage pails. The CNA#3 thought the red pails were either placed in the PUI rooms or in the hallway. The CNA#3 acknowledged that there were only small garbage pails in the rooms which was used for regular garbage and had to use those garbage pails today to doff his PPE in the PUI rooms. The CNA#3 stated that every time he entered a PUI room he had to don and before exiting had to doff PPE and wash his hands before leaving the room. On 2/10/22 at 10:11 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing/Infection Preventionist (DON/IP). The DON/IP stated that inservices on infection control were completed face to face as well as online inservicing. The DON stated that all staff should be aware of how to don and doff appropriately. The LNHA stated that there had been a full staff inservice program done for infection control recently. The LNHA stated that upon exiting a PUI room the staff was to remove their gown and gloves and place them in the large black garbage pails and the pails were placed inside the designated PUI rooms. The LNHA stated that each PUI room should have a dedicated large black garbage pail. The LNHA explained that the large red garbage pails were being used when there was COVID-19 positive residents. The LNHA also stated that there were ambulatory residents that were new admissions and because they were physically able to ambulate sometimes left their rooms and the staff was trained to encourage the residents to return to their rooms. On 2/15/22 at 1:27 PM, the survey team met with the LNHA and DON and discussed the findings of the infection control on the first floor. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The LNHA stated that training and inservices were completed on 2/8/22 and that the facility provides hands on training competencies for hand hygiene for all staff. A review of inservices on infection control procedures and hand washing competencies that were performed with staff in different departments was provided by the LNHA. A review of inservices dated 11/10/21 and 12/28/21 provided by the LNHA reflected that CNA#1 was in attendance and had instructions regarding wearing appropriate PPE before entering a PUI room and before exiting a PUI room to doff PPE. In addition, CNA#1 performed a Hand Washing Competency Validation on 12/14/21 and passed. There were no signatures found for CNA#2 for attendance at inservices or a hand washing competency. A review of a facility policy dated as revised 12/2021 for Personal Protective Equipment-Using Gowns provided on entrance by the LNHA indicated that gowns must be disposed in appropriate containers located in the room. A review of a facility policy dated as revised 12/2021 for Personal Protective Equipment-Using Gloves provided on entrance by the LNHA indicated that gloves were to be discarded in designated waste receptacles located in the room and to wash hands after the removal of gloves. A review of the facility policy Categories of Transmission-Based Precautions dated as revised 12/2021 reflected COVID-19 Transmission-Based Precautions included for staff entering the resident's room or providing care the use of N95 ask, eye protection, gown, and gloves. A review of the facility policy Handwashing/Hand Hygiene dated as revised 12/2021 reflected that hand hygiene was the primary means to prevent the spread of infections and all personnel were to follow the hand hygiene procedures. In addition, the policy reflected that hand hygiene was the final step after removing and disposing of PPE and gloves was not a replacement for hand hygiene. The policy also indicated that hand hygiene was to be performed before and after applying gloves and ABHR could be used before and after entering isolation precaution settings. 2. On 2/10/22 at 10:02 AM, the surveyor observed, from the hallway, a housekeeper (HK) in room [ROOM NUMBER] near the first bed, where Resident #31 resided in the second bed. The HK was wearing gloves, a N95 mask and face shield. The surveyor observed a bin with PPE and signage in the hallway. At that time, the HK came out of the room and removed her gloves and placed them in her housekeeping cart. Then, the HK proceeded to don a gown and new gloves. The surveyor had not observed hand hygiene be performed. The surveyor interviewed the HK who stated that she was the usual HK for the first floor and had been working for approximately five months. The surveyor asked the HK why she was inside a PUI room without a gown and the HK stated, I had to have a look at my surroundings. The HK stated that every time she entered a PUI room she donned and upon exiting she doffed. The HK stated that she was unsure where the nurses placed the PPE when they removed them, but she put her gowns and gloves in her housekeeping cart garbage. The HK acknowledged that she was to perform hand hygiene upon exiting a PUI room. On 2/10/22 at 10:11 AM, the survey team met with the LNHA and DON /IP. The DON/IP stated that inservices on infection control were completed face to face as well as online inservicing. The DON stated that all staff should be aware of how to don and doff appropriately. The LNHA stated that there had been a full staff inservice program done for infection control recently. The LNHA stated that upon exiting a PUI room the staff was to remove their gown and gloves and place them in the large black garbage pails and the pails were placed inside the designated PUI rooms. The LNHA stated that each PUI room should have a dedicated large black garbage pail. The LNHA explained that the large red garbage pails were being used when there was COVID-19 positive residents. The LNHA also stated that there were ambulatory residents that were new admissions and because they were physically able to ambulate sometimes left their rooms and the staff was trained to encourage the residents to return to their rooms. On 2/15/22 at 1:27 PM, the survey team met with the LNHA and DON and discussed the findings of the infection control on the first floor. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The LNHA stated that training and inservices were completed on 2/8/22 and that the facility provides hands on training competencies for hand hygiene for all staff. A review of a Self Learning Packet for Mandatory Orientation and Annual Inservice Program was signed by the HK and dated 2/8/22. The program included infection control inservicing regarding TBP, how to put on and take off PPE and hand washing. A review of a facility policy dated as revised 12/2021 for Personal Protective Equipment-Using Gowns provided on entrance by the LNHA indicated that gowns must be disposed in appropriate containers located in the room. A review of a facility policy dated as revised 12/2021 for Personal Protective Equipment-Using Gloves provided on entrance by the LNHA indicated that gloves were to be discarded in designated waste receptacles located in the room and to wash hands after the removal of gloves. A review of the facility policy Categories of Transmission-Based Precautions dated as revised 12/2021 reflected COVID-19 Transmission-Based Precautions included for staff entering the resident's room or providing care the use of N95 ask, eye protection, gown, and gloves. A review of the facility policy Handwashing/Hand Hygiene dated as revised 12/2021 reflected that hand hygiene was the primary means to prevent the spread of infections and all personnel were to follow the hand hygiene procedures. In addition, the policy reflected that hand hygiene was the final step after removing and disposing of PPE and gloves was not a replacement for hand hygiene. The policy also indicated that hand hygiene was to be performed before and after applying gloves and ABHR could be used before and after entering isolation precaution settings. 3. On 2/9/22 at 10:56 AM, the surveyor in the presence of another surveyor observed a CNA#1 walking with Resident #245 back to his/her room [ROOM NUMBER]. The resident was wearing a surgical mask. The surveyors observed a bin in the hallway with PPE and signage on the outside of the room. At that time, the surveyors observed the Rehabilitation (REHAB) gym for physical therapy (PT) at the end of the hallway with doors open and rooms #109, #110, and #113 in the same hallway. All three (3) rooms had bins with PPE and signage for TBP. On 2/9/22 at 10:45 AM, the surveyor, in the presence of another surveyor, observed Resident #247 walking with a walker down the hall past the nursing station with a CNA#3 following the resident. The CNA#3 helped the resident fix a chair to sit in in the hallway. The resident was wearing a surgical mask. On 2/9/22 at 10:49 AM the surveyor, in the presence of another surveyor interviewed Resident #247 who stated that he/she was not staying long and wanted to speak to someone about a discharge plan. A review of the PUI resident room list revealed that Resident #247 was in room [ROOM NUMBER] and was on TBP. On 2/9/22 at 11:01 AM, the surveyor interviewed the CNA#1 who was unable to speak to whether the residents in the PUI rooms were allowed to come out of their room. On 2/9/22 at 11:21 AM, the surveyor, in the presence of another surveyor, observed an unsampled resident from room [ROOM NUMBER] exit the room and sit in a chair across the hall from the room. The surveyors observed a bin in the hallway with PPE and signage for room [ROOM NUMBER]. The resident was wearing a surgical mask. On 2/9/22 at 11:22 AM, the surveyor interviewed the ADON/LPN who stated that he was aware that Resident #245 was non-compliant with staying in his/her room and was on TBP and was currently having a behavioral issue and was going to be transferred from the facility. The ADON/LPN stated that he was also aware of the unsampled resident being non-compliant with staying in the room and he/she was on TBP and that was due to being confused. The ADON/LPN added that the CNAs would encourage and redirect the residents that were PUI to return to their rooms. The ADON/LPN stated that Resident #247 was a PUI, alert and oriented and ambulatory with supervision and was unaware that he/she was being non-compliant regarding staying in the room. The ADON/LPN stated that the first floor had the REHAB gym for any resident in the facility that required PT at the end of the hallway. The ADON/LPN acknowledged that residents being transferred to the REHAB gym would have to pass through the hallway where the unsampled resident resided in room [ROOM NUMBER], Resident #245 resided in room [ROOM NUMBER] and Resident #247 resided in room [ROOM NUMBER] and the residents were on TBP and came out of their rooms. On 2/9/22 at 11:30 AM, the surveyor observed CNA#3 redirect the unsampled resident to return to their room#109. On 2/9/22 at 11:32 AM, the surveyors observed Resident #247 walking with a walker returning to his/her room and stopped at the doorway of room [ROOM NUMBER] and had a conversation with Resident #246 who resided in the room. The surveyors observed that there was no bin with PPE or signage for room [ROOM NUMBER] and Resident #246 was not a PUI. On 2/9/22 at 11:34 AM, the CNA#3 asked Resident #247 to not stop at other rooms and return to his/her room for lunch. During the times between 10:21 AM and 11:52 AM, the surveyors were able to observe residents from different floors being transported from the elevators to the Rehab gym and from the Rehab gym back to the elevators. The surveyors observed the doors to the Rehab gym open at the end of the hallway with rooms #109, #110 and #113 also near the end of the hall where the Rehab gym opening was located. On 2/10/22 at 10:11 AM, the survey team met with the LNHA and DON /IP. The LNHA stated that there were ambulatory residents that were new admissions and because they were physically able to ambulate sometimes left their rooms and the staff was trained to encourage the residents to return to their rooms. The surveyor reviewed the medical record for Resident #247. A review of the admission Record revealed that the resident was admitted on [DATE]. A review of the resident's interdisciplinary care plan (IDCP) revealed that the resident was under observation for COVID-19 with an end date of 2/19/22, and had an intervention to provide resident with PPE and education on its use. The IDCP had no mention of the resident being non-compliant with TBP. A review of the electronic progress notes indicated that the resident had signed out of the facility against medical advice on 2/10/22. On 2/15/22 at 1:27 PM, the survey team met with the LNHA and DON and discussed the findings of the infection control on the first floor. On 2/16/22 at 1:21 PM, the survey team met with the LNHA and DON. The LNHA stated that training and inservices were completed on 2/8/22, and that the facility provides hands on training competencies for hand hygiene for all staff. On 2/17/22 at 1:33 PM, the survey team met with the LNHA and DON. The LNHA stated that there was no policy for a procedure when a resident was non-compliant with TBP. The LNHA stated that the Rehab gym had been closed when the facility had COVID-19 positive residents. A review of an inservice dated 12/28/21, on Infection Control provided by the LNHA revealed that CNA#1 and CNA#3 were in attendance and the inservice included that if a PUI resident comes out of their room then the staff member was to educate the resident and if the resident refuses to comply then the staff member should report to a supervisor. A review of the facility policy Categories of Transmission-Based Precautions dated as revised 12/2021 reflected COVID-19 Transmission-Based Precautions included restricting the resident to his/her room and if the resident under COVID-19 TBP required movement outside the room due to medical necessity then information about the residents' suspected coronavirus would be communicated to other departments. 4. During the entrance conference on 2/9/2022, the LNHA stated that the facility had been in a COVID-19 outbreak that began on 12/21/2021. On 2/14/22 at 9:33 AM, the surveyor reviewed medical records to ensure that residents were being monitored for signs and symptoms of COVID-19 with the following findings: The surveyor reviewed the medical record for Resident # 94: According to the Face Sheet (an admission summary), Resident #94 was admitted with diagnoses that included but not limited to personal history of COVID-19 dated 3/1/2021, endocarditis, cirrhosis of liver and chronic obstructive pulmonary disease (COPD). Review of the resident's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/14/2021, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. Review of the resident's immunization records revealed that Resident #94 was vaccinated for COVID-19 dated 1/20/21, and 2/20/21, and a booster was provided on 11/16/2021. Review of the electronic Medication Review Report (MRR) for Resident #94 revealed physician orders (PO) dated 10/28/21, to test for COVID-19 in the event of symptom presentation or facility outbreak per public health guidance and a PO dated 12/05/2021, for vital signs every shift for monitoring. There was no specific physician order to monitor for signs/symptoms of COVID-19. A review of the resident's electronic Medication Administration Record (eMAR) and Weights and Vitals Summary (WVS) for January 2022, revealed that vital signs were only recorded once a day, instead of every shift, on the following days in January: 1/8, 1/9, 1/12, 1/13, 1/15, 1/24, 1/25, and 1/26/2022. Vital signs were not recorded at all for Resident #94 for the following days in January 2022: 1/1, 1/2, 1/3, 1/4, 1/5, 1/18, 1/22 and 1/23/2022. Review of the February 2022 eMAR and WVS revealed that the resident's vital signs were only documented for one shift on each of the following days in February 2022: 2/1, 2/2, 2/3, 2/4, 2/5, 2/6, 2/7, 2/8, 2/10, 2/11 and 2/12/2022. Further review of the February 2022 eMAR and WVS revealed that the resident's vital signs were not documented on 2/2 and 2/9/2022. Review of the facility's contact tracing for the COVID-19 outbreak revealed that Resident #94 was not involved in contact tracing due to the resident was not exposed to the virus during the outbreak. The facility provided evidence that Resident # 94 was tested twice a week for COVID-19 during the outbreak, and tested negative for COVID-19. On 2/16/22 at 10:58 AM, the surveyor interviewed Resident #94, who stated that he/she had COVID-19 a couple months back. The surveyor asked the resident how often the staff checked his/her temperature and oxygen saturation levels (a measure of the amount of oxygen carrying hemoglobin in the blood.) The resident replied, When I ask for it or every couple of days. They were doing it every day but . it's been a while. They did it today. They don't do it every day. The resident claimed to have no COVID-19 symptoms today .denied shortness of breath, fever and loss of taste. The surveyor reviewed the medical record for Resident # 64: According to the Face Sheet, Resident #64 was admitted with diagnoses that included but not limited to a fractured humerus, left arm (which had subsequently healed), Type 2 Diabetes Mellitus and atherosclerotic heart disease. Review of the resident's most recent MDS dated [DATE], reflected that Resident #64 had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. Review of the resident's immunization records revealed that Resident #64 was vaccinated for COVID-19 dated 12/7/2021, and 12/27/2021. A review of the resident's electronic MRR revealed a PO dated 11/23/2021, to test for COVID-19 in the event of symptom presentation or facility outbreak per public health guidance and a PO dated 11/23/2021, to monitor for signs/symptoms of COVID-19 including fever, cough, shortness of breath, muscles aches, diarrhea, chills, headache, sore throat, vomiting, loss of taste or smell every shift for infection control. Notify MD and document in progress notes if resident presents with any symptoms and a PO dated 11/23/2021, for vital signs every shift for monitoring. Review of the January 2022 eMAR and WVS indicated that the resident's vital signs were not documented for one shift on each of the following days: 1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/10, 1/11, 1/12, 1/14, 1/15, 1/16, 1/17, 1/19, 1/20, 1/21, 1/22, 1/24, 1/27, 1/28 and 1/31/2022. Review of the February 2022 eMAR and WVS revealed that the resident's vital signs were not documented for one shift on each of the following days: 2/1, 2/2, 2/4, 2/5, 2/6, 2/7, 2/8 and 2/11/2022. Further review of the February 2022 eMAR and WVS indicated that the resident's vital signs were not documented on 2/9/2022 and 2/17/2022. Review of the facility's contact tracing for the COVID-19 outbreak revealed that Resident #64 was not involved in contract tracing due to the resident was not exposed to the virus during the outbreak. The facility provided evidence that Resident #64 was tested twice a week for COVID-19 during the outbreak, and tested negative for COVID-19. On 2/16/22 at 10:19 AM, the surveyor interviewed Resident #64. The resident claimed to have no symptoms of COVID-19 including fever, shortness of breath, headache or loss of taste. The resident denied ever having COVID-19. Resident #64 stated that the staff tested him/her with a nasal swab twice a week. The resident stated that the staff would sometimes take his/her temperature, but not often. They don't do it every day. When the surveyor described the pulse oximeter, used for monitoring O2 saturations, Resident #64 indicated familiarity with the device. In regards to checking O2 saturation, Resident #64 stated, they check that, but not too often either. Not once a day. The surveyor reviewed the medical record for Resident # 130: According to the Face sheet, Resident #130 was admitted with diagnoses that included but not limited to endocarditis (infection of the heart's inner lining), Type 2 Diabetes Mellitus and metabolic encephalopathy (a chemical imbalance in the blood that affects the brain and can lead to personality changes). Review of the resident's most recent MDS dated [DATE], reflected that the resident had a BIMS score of 8 out of 15, indicating that the resident had moderate cognitive impairment. Review of the resident's immunization records revealed that Resident #130 was vaccinated for COVID-19 dated 12/27/2021, and 1/18/2022. A review of the resident's electronic MRR revealed a PO dated 12/18/2021, for vital signs every shift for monitoring, and a PO dated 2/16/2022, to monitor for signs/symptoms of COVID-19 including fever, cough, shortness of breath, muscles aches, diarrhea, chills, headache, sore throat, vomiting, loss of taste or smell every shift for infection control Notify MD and document in progress notes if resident presents with any symptoms. Review of the January 2022 eMAR and WVS indicated that vital signs were only documented for one shift per day on the following days: 1/1, 1/3, 1/4, 1/8, 1/9, 1/13, 1/15, 1/17, 1/19, 1/20, 1/24, 1/25, 1/29 and 1/31/2022. Vital signs were not documented on the following days: 1/5, 1/12, 1/18, 1/22 and 1/23/2022. Review of the February 2022 eMAR and WVS revealed that the resident's vital signs were not documented for one shift on each of the following days: 2/4, 2/5, 2/6, 2/7, 2/8, 2/10, 2/12, 2/15 and 2/17/2022. Vital signs were not documented on the following days: 2/1, 2/2, 2/3 and 2/9/2022. Review of the facility's contact tracing for the COVID-19 outbreak revealed that Resident # 130 was not involved in contact tracing due to the resident was not exposed to the virus during the outbreak. The facility provided evidence that Resident #130 was tested twice a week for COVID-19 during the outbreak, and tested negative for COVID-19. On 2/16/22 at 9:47 AM, the surveyor interviewed the Registered Nurse (RN) who was the charge nurse on the floor where Residents #94, #64 and #130 resided. The surveyor asked why the RN frequently documented NA (Not Applicable) on the [TRUNCATED]