Based on observation, interview, and record review it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan (CP) for a resident in the facility. This deficient practice was identified for 1 of 1 resident reviewed for comprehensive care plans (Resident #99) who had a diagnosis of Type 2 Diabetes Mellitus. This deficient practice was evidenced by the following: On 2/01/23 at 11:15 AM, the surveyor observed Resident # 99 in bed. The resident stated he/she was a diabetic and was on insulin medication. A review of Resident #99's medical record revealed the following: The Face Sheet (an admission summary) revealed that Resident #99 was admitted to the facility with diagnoses that included but not limited to Type 2 Diabetes Mellitus with specified complications (DM), Covid-19, and Multiple Myeloma. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date of 1/18/23 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated that the resident was cognitively intact. The admission MDS further revealed that the resident had an active diagnosis of DM and was on Insulin injections. A review of Resident #99's CP did not include that the resident was a diabetic and was on insulin injections. A review of the facility policy titled, Diabetes - Clinical Protocol revealed under Monitoring and Follow-Up, 4. The Physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration record and care plan. A review of the facility policy titled Care Plans, Comprehensive Person-Centered under Policy Interpretation and Implementation, 8. The comprehensive, person-centered care will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; o. Reflect the recognized standards of practice for problem areas and conditions. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. A review of the facility policy titled Comprehensive Assessment and Care Delivery Process revealed under Policy Interpretation and Implementation, 3 Information analysis, b. Define conditions and problems that are causing, or could cause, other problems. (1) Identify potential causes or contributing factors of problems and symptoms, including: (a) Medical. C. Define current treatment and services; link with problems/diagnoses. On 2/07/23 at 11:38 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) assigned to the First Floor-North Unit. The RN/UM stated that the admission CP are completed by the admitting nurse within 48 hours and that the unit manager will review and add any additional CP if needed. The RN/UM further revealed that residents who had a diagnosis of DM should have a CP. The RN/UM could not explain why Resident #99 did not have a CP addressing his/her diagnosis of DM and insulin medication. On 2/09/23 at 11:06 AM, the team met with the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, Director of Nursing (DON), and Infection Preventionist. The surveyor discussed the above concern. The surveyor asked if a resident who had a diagnosis of DM should have a care plan. The DON stated, Yes, there should be a care plan. Sometimes diabetes and blood sugar may be under the wound care plan but it should be care planned. On 2/13/23 at 11:00 AM, the team met with the LHNA, Assistant LNHA, and DON. No additional information was provided. NJAC 8:39-11.2 (e)(2)

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that the respiratory equipment was dated properly and b.) develop a comprehensive, person-centered care plan for a resident who was receiving continuous oxygen (O2). This deficient practice was observed for 1 of 4 residents (Resident #71) reviewed for respiratory care. This deficient practice was evidenced by the following: On 2/1/23 at 11:59 AM, during the initial tour, the surveyor observed Resident #71 in bed with O2 in use via a face mask set at 4 liters per minute (LPM) attached to a humidified O2 concentrator (a medical device used for delivering O2). The O2 tubing was dated 1/26/23. On 2/7/23 at 12:04 PM, the surveyor observed Resident #71 in bed with O2 in use via face mask set at 4 LPM attached to a humidified O2 concentrator. There was no date indicated on the O2 tubing when it was last changed. On 2/8/23 at 12:30 PM, the surveyor observed Resident #71 in bed with O2 in use via a face mask set at 4 LPM attached to a humidified O2 concentrator. There was no date indicated on the O2 tubing when it was last changed. A review of Resident 71's medical record revealed the following: The Face Sheet (an admission summary) revealed that Resident #71 was admitted to the facility with diagnoses that included but not limited to (primary) Corticobasal basal degeneration (a rare condition that can cause gradually worsening problems with movement, speech, memory, and swallowing), Unspecified Dementia without Behavioral disturbance, and Unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date of 1/7/23, reflected that Resident #71's Brief Interview of Mental Status was not completed due to cognitive impairment. A further review of qMDS under Section O. Treatment and Procedures, indicated that the resident received oxygen treatments in the facility. The February 2023 Physician's Order Form revealed that there was an order dated 4/1/22 for O2 at 4LPM via face mask continuous; clean O2 equipment and change tubing weekly on Thursdays on 11:00 PM to 7:00 AM shift. The surveyor reviewed the resident's comprehensive care plans which did not reflect a care plan for Resident #71's continuous oxygen use. On 2/8/23 at 12:33 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) was brought inside Resident #71's room. During the interview, the LPN/UM stated that Resident #71 was on continuous oxygen and that the O2 tubings are changed weekly every Thursdays by the night shift nurse. The LPN/UM acknowledged that the O2 tubing was not dated. She stated, it should be dated to ensure that it was changed. At around the same date and time, the LPN/UM stated that she was responsible for initiating and revising the residents' care plans in her assigned unit. The surveyor and the LPN/UM reviewed the resident's care plans. She acknowledged that there should have been a care plan for Resident #71 who was on continuous oxygen. A review of the facility policy titled Departmental (Respiratory Therapy)- Prevention of Infection with a review date of 1/2023 under General Guidelines: 3. Change respiratory tubing and date, humidification bottle, nebulizer kits on a weekly basis when opened. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a review date of 1/2023 under Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. It further indicated under Policy Interpretation and Implementation, 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; k. Reflect treatment goals, timetables, and objectives in measurable outcomes; 12. The comprehensive, person-centered care plan is developed within (7) days of the completion of the required comprehensive assessments (MDS). On 2/9/23 at 11:08 AM, the team met with the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, Director of Nursing (DON), and Infection Preventionist (IP). The surveyor discussed the above concern. On 2/13/23 at 11:38 AM, the team met with the LNHA, Assistant LNHA, IP, DON, and ADON. No additional information was provided. NJAC 8:39-11.2(b)(e); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to set the appropriate weight in an air mattress used to promote wound healing for 1 of 3 residents reviewed for pressure ulcer according to professional standards of practice. This deficient practice was evidenced for Resident #19 and 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 3/9/21 at 11:12 AM, the surveyor toured with the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident #9 was cognitively impaired, required total assistance with activities of daily living (ADL), and had a community acquired pressure ulcer from the recent re-hospitalization. She indicated that the wounds were the same, and that the resident is on a specialized mattress to promote wound healing. On that same date and time, both the surveyor and the LPN/UM observed that the resident was lying on an air mattress. The air mattress was set at 180 pounds (lbs) and 25 cycles. The LPN/UM stated that the resident was not 180 lbs; The mattress was not set according to manufacturer's specific instructions. She further stated I don't know why it was set at 180 lbs. I'm not sure what was the 25 cycles means. The LPN/UM stated that it was the nurse's responsibility to make sure that the air mattress weight was correct. A review of the resident's Face Sheet (an admission summary), indicated that the resident had diagnoses which included, Diabetes, Dementia without behavioral disturbance, Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), and Unspecified protein-calorie malnutrition (the lack of sufficient energy or protein to meet the body's metabolic demands). A review of the 11/27/20 Significant Change/ Minimum Data Set (SC/MDS), an assessment tool used to facilitate the management of care, indicated the resident had severely impaired cognition. A review of the March 2021 Physician's Order showed an order dated 2/15/21 for air mattress check function and placement every shift. A review of the March 2021 Treatment Administration Record (TAR) showed that the above order was signed by the nurses routinely. On 3/12/21 at 10:51 AM, the surveyor and the LPN/UM went to the resident's room and checked the air mattress. The surveyor and the LPN/UM observed the resident's air mattress was set at 80 lbs and 20 cycles. The LPN/UM informed the surveyor and stated, I immediately corrected it and changed the weight to 80 lbs on that same date after the surveyor's inquiry. She further stated, honestly, I don't know when asked by the surveyor how did she know that the cycle of air mattress should be at 20. At that same time, the LPN/UM informed the surveyor that no one knew who changed the weight to 180 lbs and 25 cycles at the time the surveyor and LPN/UM observed it. She further stated that she will get back to the surveyor regarding who changed the cycle from 25 to 20. On 3/12/21 at 1:00 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and discussed the above observations and concerns. The surveyor asked for additional information about the air mattress, and the DON stated that they will get back to the surveyor on Monday, 3/15/21. Both the LNHA and DON acknowledged that the staff should have been educated about the air mattress. On 3/15/21 at 9:24 AM, the Licensed Practical Nurse (LPN) informed the surveyor that he was the regular nurse of Resident #9. The LPN stated that it was the nurse's responsibility to change the weight in the air mattress of the resident and sign the TAR that he checked the air mattress every shift. He further stated that I don't know what happened when asked by the surveyor why the right weight was not set on 3/9/21. On 3/15/21 at 9:30 AM, the LPN/UM informed the surveyor that it was the wound doctor who changed the cycle from 25 to 20. The LPN/UM stated that according to the wound doctor, 20 to 25 cycles were appropriate for the resident. She further stated that she did not have an education about the air mattress manufacturer's specifications with respect to the correct settings. She indicated that now I know that the cycles are meant for minutes of alternating pressure. On 3/15/21 at 12:58 PM, the surveyor called the wound doctor and spoke to the office staff. The office staff from the wound doctor stated that she will relay the message to the doctor to call back the surveyor. The wound doctor did not return the surveyors call. On 3/16/21 at 12:25 PM, the surveyors met with the LNHA, AA, DON, IPN, Assistant Director of Nursing (ADON). The DON stated that there was no negative effect on the resident. A review of the undated facility Prevention of Pressure Ulcer/Injuries Policy, provided by the LNHA, included Support Surfaces and Pressure Redistribution: use of an alternating air pressure or low air loss mattress assist in the prevention and care of pressure injuries. The inflation and deflation of inflatable air tubes imitate the patient's movements by relieving under-body pressure must be set according to manufacturer's recommendation. Monitoring: 1. Daily checks of alternating air pressure or low air mattress placement and functions every shift. 2. Ensure that low air mattress inflation pressure is set according to the patient weight. NJAC 8:39-11.2 (b)

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete, accurate, and readily accessible medical records. This deficient practice was identified for 1 of 24 residents reviewed, Resident#24, and was evidenced by the following: This deficient practice was evidenced by the following: On 3/9/21 at 11:10 AM, during the tour, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that Resident #24 was on hospice care. The resident was lying on an air mattress. At that same date and time, the LPN/UM stated that the hospice nurse does the virtual visit once a week. She further noted that the facility's protocol was to have hospice nurses do virtual visits due to COVID positive in the facility and promote the resident's safety. A review of the resident's Face sheet (an admission summary) disclosed that the resident had diagnoses that included Alzheimer's disease, Anxiety, Hypertension (elevated blood pressure), and Arthritis (is the swelling and tenderness of one or more joints). A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 12/14/20, indicated a Brief Interview for Mental Status (BIMS) scored at 99, indicating that Resident#24 was unable to be interviewed. The QMDS further indicated that the resident was on Hospice. A review of the March 2021 Physician's Order revealed an order for Morphine (the most abundant natural opioid found in opium, used as a pain reliever) 5 milligram (mg) sublingually (SL) every 8 hours (hrs) around the clock for pain and Morphine 5mg SL three times a day as needed (PRN) for moderate-severe pain. A review of the Hospice Nurse (HN) Plan of Care Information (HN) provided by the LPN/UM in the binder showed no notes for January 2021. The only notes in the binder for 2021 were notes dated 2/26/21 and 3/2/21 that included a fax cover sheet from hospice dated 3/10/21. Further review of the HN notes dated 3/2/21 showed that the Opioid Care plan was documented as PRN. There was no care plan for the standing order of opioids. On 3/12/21 at 11:23 AM, the LPN/UM informed the surveyor that the hospice notes were filed in the hospice binder. She stated that it was her responsibility to make sure that the virtual notes and all other documents about the resident's care regarding hospice will be filed in the binder as part of the resident's medical records. At that same date and time, the surveyor and the LPN/UM checked the hospice binder and did not find the hospice nurse's weekly virtual visit notes for January February 2021 except for dates 2/26/21 and 3/2/21. The LPN/UM stated, I don't know what happened, why there were missing notes. Furthermore, the LPN/UM informed the surveyor that the resident was on a standing and PRN orders for Morphine. She stated that she should have checked the accuracy and availability of hospice notes. She further stated that she should have clarified with the HN about the care plan for opioids that it should be both a routine order and PRN. On 3/12/21 at 1:10 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Administrator (AA), Infection Preventionist Nurse (IPN) and discussed the above concerns. On 3/15/21 at 9:33 AM, the LPN/UM informed the surveyor that she received all missing notes from the HN's virtual visits. The LPN/UM indicated that there were no new recommendations. The HN faxed the corrected care plan for opioids that included the routine and PRN order Morphine for pain management. At that same time, the LPN/UM stated that moving forward, she would make sure that the hospice notes will be check to make sure that it was submitted and filed in the resident's medical records binder on time. On 3/15/21 at 3:20 PM, the HN informed the surveyor via a phone conversation that Resident#24 was doing better and would eventually be discharged from hospice. She stated that she usually sends the virtual visit notes bi-weekly via fax. She further said, I don't know what happened, why the virtual notes for January, February were not filed and not available in the facility. Furthermore, the HN informed the surveyor that she had fax all virtual notes on 3/12/21 that were missing as requested by the facility after the surveyor's inquiry. She further stated that she also sent the corrected care plan via fax to include the routine standing order for Morphine. A review of the facility Hospice Program Policy provided by the LNHA with a revised date of July 2017 included Hospice services are available to residents at the end of life. Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record-keeping requirements, to hospice staff furnishing care to the residents. On 3/16/21 at 12:25 PM, the surveyors met with the LNHA, DON, AA, IPN, Assistant Director of Nursing (ADON). The facility provided no additional information. NJAC 8:39-35.2 (d)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted guidelines for infection prevention and control. This deficient practice was identified for 1 of 4 staff members observed donning and doffing. The evidence was as follows: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/23/21 included, HCP [Healthcare Personnel] must receive training on and demonstrate an understanding of: when to use PPE, what PPE is necessary, how to properly don (put on), use and doff (remove) PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, limitations of PPE. It further included that HCP should perform hand hygiene before putting on and removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process .Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene .Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use .Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. On 3/11/21 at 11:55 AM, the surveyor observed a housekeeper on 1 South which was a dedicated unit for Persons Under Investigation for COVID-19 (PUI), exit room [ROOM NUMBER] wearing a blue disposable gown and gloves. The housekeeper removed the gloves and gown right outside of room [ROOM NUMBER]. The housekeeper then placed the gloves and gown into the housekeeping trash bin. The housekeeper then opened the housekeeping cart without performing hand hygiene to look for alcohol-based hand sanitizer to perform hand hygiene. The surveyor observed only two alcohol-based hand sanitizers mounted to the wall on the PUI unit. On 3/11/21 at approximately 12:00 PM, the surveyor interviewed the housekeeper, who stated that the trash can for the gloves and gown are inside the bathroom of room [ROOM NUMBER]; I put it inside my housekeeping cart trash. The surveyor inquired if she had any training on how to put on, remove, and discard PPE. The housekeeper stated, yes. The housekeeper could not speak to why she didn't remove the gown and gloves before leaving the room. On 3/12/21 at 1:10 PM, the survey team met with the Administrator, Assistant Administrator, Director of Nursing, and the Infection Control Preventionist and discussed the above observation and concern. On 3/15/21 at 1:35 PM, the DON stated that the housekeeper was re-educated regarding donning and doffing and that the housekeeper didn't think she was in the hallway since she was right outside the room when she took off her gown. The DON and the Administrator acknowledged that the housekeeper should not have placed the blue disposable gown inside the housekeeping cart trash bin. A review of the facility's undated Policy for Personal Protective Equipment-Donning and Doffing included that the policy's purpose was to prevent the spread of infections .remove gloves and discard them into a waste receptacle in the room .if the gown is disposable, discard it into the waste receptacle inside the room and wash the hands. NJAC 8:39-5.1(a)