Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain a resident's dignity while providing feeding assistance. This deficient practice was identified for 1 of 29 residents observed for dignity (Resident #7), and was evidenced by the following: On 1/16/25 at 12:09 PM, during initial tour of the facility, the surveyor observed Resident #7 in bed in their room with a Certified Nurses Aid (CNA #3) providing feeding assistance to the resident. CNA #3 had the tray table with the lunch tray back and slightly to the side behind her while she stood over Resident #7 feeding them. CNA #1 was observed turning away from the resident to obtain a spoonful of food which was positioned away from the resident and she was not seated alongside the resident during this care. On 1/17/25 at 11:02 AM, the surveyor observed Resident #7 in their room, who informed the surveyor that the CNAs in the facility usually stood while assisting them with their meal. Resident #7 stated that one CNA sometimes sat on the side of the bed to assist them with feeding, which caused the resident to have to move their leg slightly so that the CNA could sit. On 1/22/25 at 10:56 AM, the surveyor reviewed Resident #7's medical record. A review of the Resident Face Sheet (an admission summary) indicated that the resident was admitted to the facility with diagnosis which included but was not limited to; legal blindness, weakness, cerebral infarction (stroke). A review of the resident's Physicians Orders Summary included a physician's order (PO) dated 10/29/2024, for a low fat, soft consistency diet. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/19/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. A review of Section GG - Functional Abilities, indicated that the resident required substantial/maximal assistance with eating, meaning the helper did more than half of the effort with feeding. On 1/22/25 at 11:59 AM, the surveyor observed CNA #2 assisting Resident #7 with their meal while standing over the resident in bed. On 1/22/25 at 12:00 PM, after CNA #2 finished with the resident's feeding assistance and left the resident's room, the surveyor interviewed CNA #2, who stated that it was proper procedure while assisting a resident with eating to sit in a chair next to the resident. CNA #2 stated it was important to ensure and maintain a comfortable and dignified meal experience for the resident. On 1/22/25 at 12:45 PM, the surveyor interviewed the Director of Nursing (DON), who stated that in order to maintain a dignified meal feeding experience, staff were expected to sit alongside the resident while assisting them with eating. The DON stated staff was also to present the meal to the resident so the resident could visually see what was offered rather than be told what was served. The surveyor informed the DON of the observations made of CNA #3 and CNA #2's feeding assistance, to which the DON confirmed was not appropriate. A review of the facility's Assistance with Meal policy with a last reviewed date of 12/23/24, included .residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example: a. not standing over residents while assisting them with meals . NJAC 8:39-4.1(a)(12)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documents, it was determined that the facility failed to a) revise an individual comprehensive care plan (ICCP) for a resident with floor mats and b) revise an ICCP for residents who received oxygen. This deficient practice was identified for 2 of 29 residents reviewed for care plans (Resident #71 and Resident #85), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that gives additional oxygen through the nose) at 2 liters per minute (lpm). The surveyor observed floor mats folded up in the resident's room. On 1/17/25 at 11:12 AM, the surveyor observed Resident #85 lying in bed awake looking around the room. Resident #85 was receiving oxygen via nasal cannula at 2 lpm. The surveyor observed floor mats located on both sides of the resident's bed. The resident's bed was in a low position with the call device within reach. On 1/17/25 at 11:20 AM, the surveyor reviewed the medical record for Resident #85. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; obstructive sleep apnea (sleep disorder that affects your breathing while you sleep), shortness of breath, Alzheimer's disease (brain disorder that causes memory loss), difficulty in walking, unspecified abnormalities of gait and mobility (abnormal walking pattern). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/3/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating a severely impaired cognition. A further review in Section GG, Functional Abilities, reflected the resident used a walker and wheelchair. It further reflected that the resident was completely dependent for transfers. A review of the Order Summary Report included a physician's order (PO) dated 1/8/25, for oxygen at 2 lpm via nasal cannula as needed if oxygen saturation (SPO2; percent of oxygen in someone's blood) was less than 92%. A further did not include a PO for bedside floor mats. A review of the ICCP included a focus area dated 8/14/24, that the resident was at risk for falls based on score risk (an assessment for fall risk). Interventions included but not limited to; maintain a clutter free environment, ensure proper footwear or socks with non-skid bottoms, schedule daily rest periods and routines. The ICCP did not include an intervention for floor mats to both sides of the bed. A further review revealed a focus area dated 8/21/24, that the resident had a respiratory disorder caused by chronic rhinitis (nose inflammation) and shortness of breath. Interventions included but not limited to; monitor respiratory symptoms per physician order, assess for signs and symptoms of respiratory distress, and keep head of bed elevated per physician's order. The ICCP did not include an intervention to administer oxygen. During an interview with the surveyor on 1/21/25 at 10:31 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM #3) identified that a ICCP should be updated with interventions as changes occurred and during the quarterly care plan meetings. LPN/UM #3 stated that focus areas on the care plan included items specific to the resident such as oxygen, falls, and wounds. The surveyor then asked LPN/UM #3 if floor mats should be on a resident's care plan as an intervention if a resident was at risk for falls, and LPN/UM #3 confirmed yes. LPN/UM #3 further stated an intervention to keep the bed in low position would also be in place. LPN/UM #3 acknowledged that Resident #85's ICCP did not include floor mats as an intervention and they were at risk for falls. LPN/UM #3 acknowledged that Resident #85's ICCP did not include oxygen administration as an intervention under the respiratory focus area. LPN/UM #3 stated that she was going to update the ICCP now to include the oxygen and floor mats for Resident #85. On 1/21/25 at 10:47 AM, the surveyor interviewed the Director of Nursing (DON) who stated the ICCPs included focus areas such as skin, falls, and pain. The DON further stated that if a resident used floor mats or oxygen it would be included on the ICCP as an intervention. On 1/23/25 at 10:43 AM, the Regional Nurse (RN), in the presence of the Director of Nursing (DON), Regional Administrator, and the survey team, confirmed that floor mats and oxygen should be on the ICCP listed as interventions. 2. On 1/17/25 at 12:04 PM, the surveyor observed Resident #71 in their bedroom sitting on the side of the bed. The surveyor observed an oxygen concentrator (device that delivers oxygen) near the resident's bed. Resident #71 stated that they put on their own oxygen at night and removed it in the morning. The resident stated that the facility did not provide a bag to store the oxygen tubing in when not in use. The oxygen tubing was observed lying on the resident's bed. The surveyor did not observe any bag to store the oxygen tubing. On 1/17/25 at 11:44 AM, the surveyor reviewed the medical record for Resident #71. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe), shortness of breath, wheezing (high pitched sound that occurs when the airways in the lungs become narrow), seasonal allergic rhinitis (allergic reaction that causes sneezing). A review of the most recent comprehensive MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, indicating a cognitively intact cognition. A review of the ICCP included a focus area dated 8/10/24, that the resident had a respiratory disorder caused by wheezing. Interventions included but not limited to; give nebulizer treatments as ordered, monitor for response, and assess for signs and symptoms of respiratory distress. The ICCP did not include an intervention to administer oxygen. On 1/21/25 at 10:47 AM, the surveyor interviewed the DON, who stated the ICCP's included focus areas such as skin, falls, and pain. The DON further stated that if a resident used floor mats or oxygen it would be included on the ICCP as an intervention. On 1/21/25 at 12:05 PM, the surveyor interviewed LPN #2, who stated that Resident #71 used oxygen as needed during the night. LPN #2 further stated that she thought oxygen should be on the care plan as an intervention. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, stated that floor mats and oxygen should be on the ICCP listed as interventions. A review of the facility's Care Plans, Comprehensive Person-Centered policy last reviewed 12/17/24, included . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change . A review of the facility's Policy and Procedure for the Prevention of Fall policy reviewed 12/17/24, included . It is the policy of the facility to identify specific risk factors that may indicate the resident is at risk for falls upon admission, readmission, quarterly annually, and with any significant change. Based upon the assessment the residents will have a preventative plan of care initiated as well as be revised, monitored, and evaluated throughout their stay at the facility. The interdisciplinary team will collaborate in developing, evaluating, and revising fall prevention plan of care to prevent falls/injury, or to minimize injury and/or complications if a fall prevention plan of care to prevent falls/injury, or to minimize injury and/or complications if a fall should occur .5. The preventative measures will be identified on risk assessment and will assist with the development of an individualized care plan by the assigned nurse upon admission/readmission. Preventative measures: Beds: Utilize a floor mattress as indicated and needed. Communication of risk: Residents at risk for falls will be communicated to the interdisciplinary team via the care plan . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/17/25 at 11:55 AM, the surveyor observed the resident in the room sitting in a wheelchair waiting for lunch. The surveyor interviewed Resident #77 and asked the resident if they were receiving intravenous antibiotics and the resident stated, not for a couple days. At that time, the resident showed the surveyor an intravenous (IV) access site in the left upper extremity. The IV access site had a clear plastic dressing in place and under the dressing was a small gauze dressing over the insertion site of the catheter (where the catheter goes into the resident's skin) so that site could not be assessed. There was an illegible date on the dressing. The surveyor asked the resident if the facility had changed the IV access dressing and the resident stated that it was the dressing that the company put on, when they put it in. The surveyor asked the resident when they the IV was placed and they told the surveyor that they could not remember what day it was. On 1/17/25 at 12:00 PM, the surveyor reviewed the medical record for Resident #77. A review of the Resident Face Sheet reflected the resident was admitted to the facility with the diagnoses which included but was not limited to; chronic respiratory failure, opened wound on the buttocks and methicillin staphylococcus aureus (MRSA) infection. A review of the most recent comprehensive MDS dated [DATE], indicated that Resident #77 had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the physician's orders included a PO dated 1/4/25, to insert midline catheter for antibiotic infusion. A review of the Progress Notes included a Nurse's Noted dated 1/4/25 at 1:27 PM, which indicated that a new midline (PICC) was placed on left arm with measurements of 15 centimeters (cm); vitals were stable; and the resident was resting in bed with no distress or discomfort noted. On 1/17/25 at 12:17 PM, the surveyor reviewed the Medication Administration Record (MAR) which included a PO dated 12/19/24, to change dressing weekly for right upper arm midline with one lumen and as needed (PRN). On the day of observation, the resident had a PICC line in the left arm, not the right. There were no physician's orders to change the dressing for the left upper extremity PICC line site. On 1/21/25 at 11:03 AM, the surveyor interviewed the Registered Nurse (RN) who was providing care for Resident #77. The surveyor asked the RN if the resident had a peripherally inserted catheter (PICC) and where it was located. The RN told the surveyor the resident had one in the left arm. The surveyor asked about dressing changes and what the policy was at the facility. The RN explained that the dressings were changed weekly and as needed. The surveyor asked if the staff used a gauze dressing under the transparent dressing and the RN said no just the transparent dressing. The surveyor asked the RN to show the surveyor where the staff signed for dressing changes and the RN showed the surveyor the MAR that had an order for right arm PICC dressing changes weekly and as needed. The RN told the surveyor that the dressing should have been changed on the 12th of January and the 19th of January, but there were no nursing signatures on the MAR to indicate that it was done. At that time, the surveyor asked the RN to enter the resident's room and expose the PICC line site. The RN showed the surveyor the PICC dressing which had a date of 1/4/25, the date the left arm PICC line was inserted. The nurse stated, this has to be changed. The surveyor asked about the gauze under the dressing, and the RN said they put it there when they inserted the PICC line, and the facility did not use gauze. On 1/21/25 at 12:18 PM, the surveyor interviewed the Infection Preventionist (IP) regarding PICC line dressing changes. The IP stated that a new PICC line dressing was changed within 24 hours and then weekly. The IP stated the nurse was responsible to date and initial the dressing and sign the treatment record that it was completed. The IP also stated that physician's orders were required for PICC line dressing changes. On 1/23/25, the Regional Nurse, in the presence of the Assistant Administrator, DON, and the survey team acknowledged that Resident #77's PICC line should have been changed within twenty-four hours of admission. A review of the facility's undated Catheter Dressing Changes policy included that the facility was to change transparent semi-permeable membrane dressings as per regulation and as needed (when wet, soiled or not intact). The transparent dressing must be labeled with initials, date and time . NJAC 8:39-25.2 (c)5; 29.4(h) Based on observation, interview, and record review, it was determined that the facility failed to: a) properly secure medication being administered during medication pass and b) ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. The deficient practice was identified for 2 of 29 residents reviewed for medication administration (Resident #77 and Resident #127) . Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On 1/17/25 at 10:10 AM, Surveyor #1 and Surveyor #2 observed the Licensed Practical Nurse (LPN #3) prepare medications for Resident #127. The nurse removed a lidocaine patch (pain medication patch) from a locked drawer on the medication cart and placed it on top of the cart. LPN #3 then removed Miralax (a powdered laxative) and poured a measured amount into a plastic cup, then poured an additional measured amount into a second cup and placed both cups on the medication cart. LPN #3, with the cup containing the medication pills and one cup of Miralax powder, accompanied by Surveyor #1 proceeded into Resident #127's room to administer the medication to the resident who was in bed two by the window. Surveyor #2 stayed in the hallway next to LPN #3's unsecured cart that had the lidocaine patch and Miralax unsecured on top. There were no residents present by the cart at that time. The surveyors observed Resident #127 take their oral medications, and LPN #3 returned to the cart to retrieve the lidocaine patch and administered it on the resident. LPN #3 then returned to the cart and discarded the second Miralax cup that was left on the cart in the drug buster. On 1/17/25 at 10:35 AM, Surveyor #1 interviewed LPN #3 in the presence of the LPN/Unit Manager (LPN/UM #2), who stated that she poured two doses of Miralax because the first dose, the cap touched the powder so she felt it was an infection control concern. Surveyor #1 asked LPN #3 if it was okay to leave the lidocaine patch and Miralax on the medication cart unattended, and UM/LPN #2 responded no because there were residents that wandered and could potentially grab it off the cart. On 1/17/25 at 11:35 AM, Surveyor #1 interviewed the Director of Nursing (DON), who confirmed that the nurse should not have left the lidocaine patch and Miralax unattended because it was a safety hazard for other residents that may be in the hallway. On 1/17/25 at 1:03 PM, the surveyor reviewed the medical record for Resident #127. A review of the Resident Face Sheet (an admission summary) reflected Resident #127 was admitted to the facility with medical diagnoses which included but was not limited to; spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), spondylosis without myelopathy or radiculopathy lumbar sacral region (a radiographic diagnosis referring to degenerative changes in the disc), difficulty walking, and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/5/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a cognitively intact cognition. A review of the Order Summary Report included physician's orders (PO) dated 12/10/24, for lidocaine 4% topical patch; apply once daily to lower back and a PO dated 12/23/24, for Miralax 17 grams per dose oral powder; mix in 4-8 ounces of juice or water. On 1/23/25 at 10:34 AM, the survey team met with the DON, the Assistant Administrator, and the Regional Nurse, who all acknowledged the surveyor's concerns. A review of the facility's undated Medications policy included policy statement; medications are administered in a safe and timely manner and as prescribed .

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately document the administration of controlled medications. This deficient practice was identified on 2 of 4 medication carts reviewed for medication storage, and was evidenced by the following: During medication storage review on 1/22/25 at 11:15 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the D Wing medication cart #2's November 2024, December 2024 and January 2025 Change of Shift Controlled Medication Accountability Record (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the outgoing and incoming nurses each shift) which revealed the following: The nurses' signatures were blank for the outgoing nurse for the following shifts: For the day shift (7:00 AM to 3:00 PM) on: 11/26/24, 12/30/24, 1/6/25, and 1/17/25. For the evening shift (3:00 PM to 11:00 PM) on: 11/3/24, 11/11/24, 11/14/24, 11/19/24, 11/25/24, 12/1/24, 12/3/24, 12/9/24, 12/10/24, 12/18/24, 12/19/24, 12/25/24, 1/2/25, 1/5/25, 1/13/25, and 1/17/25. For the overnight shift (11:00 PM to 7:00 AM) on: 11/3/24 and 11/23/24. The nurses' signatures were blank for the incoming nurse for the following shifts: For the day shift on: 12/30/24 and 1/6/25. For the evening shift on: 12/5/24, 1/2/25, and 1/17/25. For the overnight shift on: 11/2/24, 11/23/24, and 11/25/24. A further review of the cart revealed the Individual Patient Controlled Substance Administration Record log (declining inventory) indicated the 1/11/25 6:00 PM (6 PM), dose of oxycodone apap 10-325 milligram (mg) tablet (a controlled medication used to treat pain) for unsampled Resident #1 was not signed out by the nurse administering the medication. At the time of observation, the surveyor interviewed LPN #1, who stated there should be no missing signatures on the change of shift accountability sheets or the narcotic inventory logs. LPN #1 further acknowledged that there were missing signatures on the narcotic declining inventory log and the change of shift accountability sheets; that the incoming and outgoing nurses should be counting the narcotics together and signing the log together to acknowledge the count was correct and accurate. On 1/22/25 at 11:45 AM, the surveyor in the presence of LPN #2, reviewed the D Wing medication cart #1's January 2025 Change of Shift Controlled Medication Accountability Record (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the outgoing and incoming nurses each shift) which revealed the following: The nurses' signatures were blank for the outgoing nurse for the following shifts: For the overnight shift on: 1/12/25 and 1/13/25. The nurses' signatures were blank for the incoming nurse for the following shifts: For the overnight shift on: 1/12/25. At the time of observation, LPN #2 stated that the change of shift accountability sheets should be completed at the time of the shift change and the count was done by the incoming and outgoing nurses. She further acknowledged that there should be no missing documentation on the change of shift accountability sheets. On 1/22/25 at 12:10 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM #1), who stated narcotic change of shift accountability logs should be completed by the outgoing and incoming nurses and should have no missing signatures. LPN/UM #1 stated that individual declining inventory sheets should be completed at the time the controlled medication was removed from inventory, and there should be no missing documentation. On 1/22/25 at 12:55 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the narcotic change of shift accountability logs were completed at shift change by the outgoing and incoming nurses. The DON further stated there should be no missing documentation or signatures on the narcotic change of shift accountability logs. The DON acknowledged that the individual declining inventory sheets should be completed and filled out for each narcotic dose dispensed immediately at the time the medication was removed from inventory. The DON acknowledged that if it was not documented it's not done. A review of the facility's undated Schedule II Controlled Substance Medication policy included .5. When a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. 6. An inventory count of all CDS medications stored on each nursing unit shall be performed at each change of shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form . A review of the facility's Medication Storage policy with a revision date of 9/6/19, included .A. With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy .C. Medications will be stored in an orderly, organized manner in a clean area . NJAC 8:39-29.4, 29.7(c)

2. On 1/16/25 at 11:23 AM, during initial tour of the facility, the surveyor observed Resident #8 in their room resting in bed. During a brief interview with the resident, the surveyor observed two 10 milliliter (ml) prefilled normal saline solution syringes unsecured and stored in a plastic cup at the resident's bedside on top of the nightstand. On 1/22/25 at 12:55 PM, the surveyor interviewed the DON, who stated that medications, including prefilled normal saline syringes should be secured in a medication storage compartment, accessible only to nurses. The DON confirmed that the observed 10 ml syringes in Resident #8's room should have been secured or with the nurse. A review of the facility's Medication Storage policy with revision date 9/6/19, included medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with NJ Department of Health guidelines. A. with the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy .C. Medications will be stored in an orderly, organized manner in a clean area . NJAC 8:39-29.4(a)(h) Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a) properly label opened multidose medications and b) properly secure prefilled normal saline syringes. This deficient practice was identified in 2 of 4 medication carts reviewed for medication storage and labeling and 1 of 4 nursing units (D Wing) and was evidenced by the following: 1. On 1/22/25 at 11:15 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #1), observed the D Wing nursing unit's medication cart #2. The following was observed: Two (2) opened foil pouches of ipratropium bromide 0.5 milligram (mg)/albuterol sulfate 3 mg inhalation solution (medication used to treat symptoms of lung disease), which were not dated with an opened date. One (1) prescription artificial tears bottle (medication used to treat dry eyes), which was not dated with an opened date or labeled with the resident's identifying information on the medication bottle. One (1) prescription fluticasone propionate and salmeterol inhalation powder 113 microgram (mcg)/14 mcg inhaler (medication used to treat asthma), which was not dated with an opened date or labeled with the resident's identifying information on the medication container. At that time, LPN #1 stated that once multi-dose medications were opened, the nurses dated the medication container and ensured the resident's name was on it as well as on the outside box or bag it came in to ensure proper identification of when the medication was opened and the resident it was prescribed to. On 1/22/25 at 11:45 AM, the surveyor, in the presence of LPN #2, observed the D Wing nursing unit's medication cart #1. The following was observed: One (1) opened foil pouch of ipratropium bromide 0.5 mg/albuterol sulfate 3 mg inhalation solution which was not dated with an opened date. One (1) opened prescription ipratropium bromide 0.03% nasal spray bottle (medication used to treat runny nose caused by allergies), which was not dated with an opened date or labeled with the resident's identifying information on the medication container. At that time, LPN #2 stated that multi-dose medications should be dated when the medication was opened and labeled with the resident's name on the medication container. LPN #2 acknowledged that the ipratropium bromide 0.5 mg/albuterol sulfate 3 mg inhalation solution and ipratropium bromide 0.03% nasal spray should have had a date and resident's information on the medication container. On 1/22/25 at 12:10 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that once multi-dose medications were opened, expectation was to date it with the opened date. LPN/UM #1 further stated that the medication containers should also be labeled with the resident's identifying information to ensure the correct resident was receiving the correct medication. On 1/22/25 at 12:55 PM, the surveyor interviewed the Director of Nursing (DON), who stated that multi-dose medications should be dated when opened and have the resident's name on the medication container. The DON further stated that the resident's identifying information should be on the medication container in case it got separated from the box. A review of the facility's Medication Storage policy with a revision date of 9/6/19, included .Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with NJ Department of Health guidelines .C. Medications will be stored in an orderly, organized manner in a clean area .E. Medications will be stored in the original, labeled containers received from the pharmacy .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that food brought in to residents by family and visitors were stored and handled in a safe and sanitary condition. This deficient practice was identified for 1 of 2 facility freezers reviewed during kitchen tour, and was evidenced by the following: On 1/16/25 at 9:23 AM, during initial tour of the facility kitchen, the surveyor, in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD), observed a one and a half (1.5) quart container of black raspberry ice cream which was approximately three quarters (3/4) empty dated opened 9/23/24, stored in the ice cream freezer. On 1/16/25 at 9:24 AM, the RFSD informed the surveyor that this was a specific resident's personal ice cream that was being stored by the facility. The container was not labeled with a resident's name, and the RFSD stated the resident was no longer at the facility and the ice cream should have been labeled with the resident's name. The surveyor reviewed the facility's Resident Food from Outside Sources with a last reviewed date of November 2023, included food and beverages brought in from outside sources will be labeled with the resident's name and date for storage in the pantry refrigerator. The uneaten portion will be discarded after 72 hours . On 1/23/25 10:45 AM, the Regional Nurse, in the presence of the Director of Nursing (DON), Assistant Administrator, and survey team, acknowledged the ice cream should have been disposed of. NJAC 8:39-17.2(g)

2. On 1/16/25 at 11:23 AM, during initial tour of the facility, the surveyor observed on the D Wing nursing unit the following: The wallpaper behind the resident's bed in Resident Room #D-4, bed two, had an approximated two and a half (2.5) inch wide by approximately four and a half (4.5) feet long section ripped off exposing the wall behind. The wall/wallpaper and vinyl baseboard along the base of the wall in the hallway next to the Shower Room by Resident Room #D-5 appeared to be wrinkled and coming off the wall. A portion of the vinyl baseboard next to the bathroom door in Resident Room #D-28 was missing and the drywall appeared to be damaged with a rust-like discoloration. On 1/23/25 at 1:31 PM, the surveyor interviewed the RMD, who stated that the facility utilized an electronic work order request system that all staff members had access to in order to notify maintenance of repairs needing to be completed. The RMD further stated that the facility was responsible to ensure that the building was in good repair to maintain a comfortable, homelike environment for all residents. On 1/23/25 at 10:45 AM, the Regional Nurse, in the presence of the Director of Nursing (DON), Assistant Administrator, and survey team acknowledged the surveyor's environmental concerns. A review of the facility's Quality of Life - Homelike Environment policy dated reviewed 12/20/24, included .residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment . NJAC 8:39-31.4(a) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 2 of 4 nursing units (A Wing and D Wing) reviewed for environmental concerns, and was evidenced by the following: 1. On 1/16/24 at 9:24 AM, the surveyor observed the A-wing nursing unit and identified the following concerns: The Shower Room was a large room with two shower stalls, three windows, and three metal wall heaters. The left shower stall had copious amount of standing water with a white milky coloring that filled half of the shower floor. Two of the three metal wall heaters had a red/orange discoloration on the heaters and on the tile under the heaters. The three window units' coverings were made of a thin paper-like material that contained holes throughout which did allow for privacy making the shower room visible from the outside. Resident Room #A-30 had a damaged window screen that did not fit into the window frame. On 1/16/25 at 11:18 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2), who stated that facility management was aware of the standing water in A-wing's Shower Room; that the water pooled every time the water was used. LPN/UM #2 acknowledged that the water had been stagnant for two hours since the surveyor's last observation. On 1/16/25 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON), who stated that LPN/UM #2 made her aware of the surveyor's concern. At that time, the surveyor and the DON toured the Shower Room together, and the DON acknowledged the shower water, the decolonization on the two heaters, and the window coverings in disrepair. The DON agreed and verbalized it was not a homelike environment for the residents. On 1/21/25 at 10:05 AM, the surveyor interviewed the Maintenance Staff (MS), who stated that there was an electronic maintenance system that all staff entered a problem or concern. The MS stated that the turn around time for maintenance work was same day or within twenty-four hours if no parts needed to be ordered. On 1/21/25 at 10:13 AM, the surveyor interviewed the Regional Maintenance Director (RMD), who acknowledged the surveyor's concerns with the Shower Room and the window screen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/16/25 at 10:15 AM, the surveyor observed Resident #73 lying in bed with a nebulizer machine (a small breathing machine that turns liquid medication into a mist that can be inhaled, a nebulizer allows medication to enter the lungs directly) on the bedside table with the tubing and mask undated and uncovered lying on the resident's personal belonging. The resident stated that they used the nebulizer machine at times to help them breathe better. On 1/17/25 at 11:25 AM, the surveyor observed a nebulizer machine on the bedside table with the nebulizer tubing undated and uncovered lying in the resident's drawer on the resident's personal belonging. 1/17/25 at 11:45 AM, the surveyor reviewed the medical record for Resident #73. A review of the Resident Face Sheet indicated that Resident #73 was admitted to the facility with the diagnoses which included but was not limited to; Parkinson's Disease and chronic obstructive pulmonary disease. A review of the most recent comprehensive MDS dated [DATE], indicated that the resident was cognitively intact and required moderate assistance with activities of daily living. A review of the physician's order (PO) dated 12/30/24, for a bronchodilator ipratropium 0.5 milligram (mg) and albuterol 3 mg (2.5 mg base) per 3 milliliters (ml) nebulization solution to be administered by inhalation route every six hours as needed for fifteen minutes. The PO instructed the nurse to obtain pre and post lungs sounds, pre and post vital signs (VS), oxygen saturation (measures oxygen levels in the blood), and enter the number of minutes that it took the nurse to administer the medication and document in the comment section of the Medication Administration Record (MAR). On 1/17/25 at 11:45 AM, the surveyor reviewed the MAR which revealed that on 1/5/25 at 9:36 AM, the resident received the nebulizer treatment ipratropium nebulization solution which required the nurse to document in the comment section of the MAR the resident's pre and post lung sounds, blood pressure, oxygen saturation, pre and post VS, and the number of minutes it to to administer the medication. In the comment section, the nurse documented that these vital signs were not collected and there were no documented pre or post lung sounds, or minutes that it took to administer the medication. On 1/17/25 at 11:55 AM, the surveyor reviewed the Progress Notes (PR) and there were no Progress Notes documented on 1/5/25, regarding why the resident received the nebulizer treatment, pre and post lung sounds, pre or post VS, or how many minutes it took to administer the medication. On 1/21/25 11:13 AM, the surveyor interviewed the LPN #5, who stated that nebulizer tubing should be labeled and dated and put into a designated respiratory storage bag to protect the tubing from contamination. LPN #5 explained that a PO was required to change and date the nebulizer tubing and the facility's process was that all respiratory tubing was changed on Thursday by the nurses on the 11:00 PM to 7:00 AM shift. LPN #5 added that if the resident's tubing had been left unbagged and lying on the resident's table or anywhere else that it should not be, it was because the resident and the resident's responsible party (RP) were constantly moving stuff in the resident's room and they were probably removing the tubing from the bag and placing it on the resident's bedside table or in the resident's bedside drawer. LPN #5 stated that Resident #73 and their RP required education on the importance of keeping the tubing free from contaminates by not placing the tubing on top or under the resident's personal belongings. At that time, LPN #5 accompanied the surveyor to the resident's room and confirmed that the resident's tubing was not labeled or dated and was laying on the bedside table with personal belongings piled on top the tubing and nebulizer machine. On 1/21/25 at 11:30 AM, LPN #5 reviewed with the surveyor Resident #73's medical record. A review of the physician's orders and Treatment Administration Record (TAR) confirmed there was not a physician's order to change the resident's nebulizer tubing. LPN #5 confirmed that it was not included on the individualized comprehensive care plan (ICCP) that the resident removed the nebulizer tubing from the respiratory bag and placed it on top of and under personal belongings and it should have been documented the resident was educated on the importance of keeping their nebulizer tubing bagged. LPN #5 reviewed Resident #73's MAR and confirmed that the resident received a nebulizer treatment on 1/5/25 at 9:36 AM, and there was no documentation in the comment section of the MAR that Resident #73's blood pressure (B/P), oxygen saturation, pulse, or respiration were obtained pre and post nebulizer treatment. There was also no documentation of pre or post lung sounds or documentation regarding how many minutes it took to administer the medication. On 1/21/25 at 12:07 PM, the surveyor interviewed the LPN Infection Preventionist (IP), who stated that all oxygen tubing and nebulizer tubing were required to be changed on the night shift once a week and documented on the TAR. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. The IP confirmed that if the tubing was not stored correctly and the tubing was not covered and protected, it could become contaminated. On 1/21/25 at 12:54 PM, the surveyor interviewed LPN/UM #3, who stated that if a resident was on a nebulizer treatment, the nurse was required to document pre and post VS to include oxygen saturation, pre and post lung sounds, and how many minutes the treatment was administered which was usually approximately 15 minutes. At that time, LPN/UM #3 reviewed Resident #73's MAR and confirmed that the nurse did not follow the PO for documentation of pre and post VS, oxygen saturations, pre and post lung sounds, or how many minutes it took to administer the medication. LPN/UM #3 stated that the nurse also did not document in the Progress Notes and confirmed that there was no order to change the nebulizer tubing weekly. LPN/UM #3 stated that the nebulizer tubing should be stored in designated respiratory bag dated with the resident's name, and if the resident had a history of removing the respiratory tubing from the bag or moving the tubing around the room, it should be included in their ICCP. On 1/23/25 at 10:54 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that the nurses should be documenting pre and post VS to include oxygen saturation, pre and post lung sounds, and how many minutes the treatment was administered in the supplemental (comment) section of the MAR. The RDON also added that all respiratory tubing should be dated and stored in a bag to prevent contamination of the tubing. A review of the facility's Administering medications through a small volume Nebulizer policy dated 12/20/24, included the purpose of this procedure was to safely and aseptically (free from microorganisms) administer aerosolized particles of medication into the resident's airway .staff were to obtain and document the resident's pulse, respiratory rate and lung sounds, date and time the length of the treatment and to obtain VS pre and post treatment . A review of the facility's Care Plans, Comprehensive Person-Centered policy dated 12/17/24, included a comprehensive person-centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs . A review of the facility's Respiratory Tubing policy dated 12/17/24, included respiratory equipment (oxygen cannula, tubing reservoir and distilled water) would be marked with date and initials and that oxygen cannula and tubing would be stored in a plastic bag when not in use . 4. On 1/16/25 at 11:30 AM, the surveyor observed Resident #115 lying in bed with a tracheostomy (trach; a surgically created opening in the neck that allows air to reach the lungs) and tracheostomy collar (are used to hold tracheostomy tubes in place; they wrap around the neck and secure with either Velcro or ties) connected to an oxygen (O2) concentrator at four liter per minute (4 lpm) providing O2 therapy. On 1/21/25 at 10:40 AM, the surveyor reviewed the medical record for Resident #115. A review of the Resident Face Sheet reflected the resident was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and tracheostomy care. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/17/24, reflected that the resident had a BIMS score of a 15 out 15, which indicated a fully intact cognition. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated 8/9/24, for enhanced barrier precautions (a set of infection control practices that use personal protective equipment (PPE) to reduce the spread of multidrug resistant organisms (MDRO's). Interventions included to provide trach care per physician's order. An additional focus area dated 8/9/24, for tracheostomy with interventions to provide trach care and maintenance per physician's order. A review of the Physician's Orders (PO) included the following: A PO dated 8/26/24, to administer oxygen at 4 lpm via trach collar continuous for 35% trach collar. A PO dated 8/8/24, to perform trach care every shift. On 1/21/25 at 11:27 AM, the surveyor observed LPN #4 perform trach care on Resident #115 and observed the following: LPN #4 performed hand hygiene using alcohol-based hand rub (ABHR) and donned PPE of a gown and gloves. LPN #4 removed the gauze dressing from the resident's trach and discarded it into the trash receptacle. Then without performing hand hygiene or changing his gloves, LPN #4 proceeded to walk across the room and [NAME] through supplies to obtain clean gauze and normal saline solution (NSS). With the same contaminated gloves, LPN #4 opened the sterile trach care kit, which he held in his left hand, and then proceeded to clean the surface of the bedside table with a germicidal wipe in his right hand. LPN #4, with the same gloves since removing the resident's trach gauze, placed a protective sheet on the bedside table and placed the trach kit on top. With no observed hand hygiene or glove change, LPN #4 proceeded to touch the sterile gauze from the trach care kit to begin cleaning the resident's trach stoma. At that time, the surveyor asked LPN #4 to stop the treatment. LPN #4 then removed his gloves, performed hand hygiene using soap and water, donned new gloves, and placed clean gauze on the resident's trach stoma. On 1/21/25 at 11:44 AM, the surveyor interviewed LPN #4, who acknowledged he did not perform hand hygiene and aseptic technique according to facility policy and regulatory standards while attempting to perform tracheostomy care. On 1/21/25 at 11:44 AM, the surveyor met with the LPN/UM #2 in the presence of LPN #4, who acknowledged the concerns the surveyor observed during trach care. On 1/21/25 at 12:00 PM, the surveyor interviewed the Infection Preventionist (IP), who stated she conducted education and performed competencies with all staff. The IP stated if they were an Agency Nurse, the unit manager went over special competencies that directly related to the resident's care. The IP acknowledged the surveyors concerns for infection control and hand hygiene during trach care. On 1/22/25 at 1:04 PM, the surveyor interviewed the DON, who stated that facility staff or agency should be able to perform trach care under their scope of practice and competencies were reviewed with upon entering the facility. On 1/23/25 at 10:44 AM, the survey team met with the Assistant Administrator, Regional Nurse, and DON, who all acknowledged the surveyor's concerns for trach care and infection prevention. No other documents were provided. A review of the facility's Tracheostomy Care/Tracheal Suctioning policy dated revised 12/17/24, included policy: to ensure the timely removal of secretions on the inner cannula to maintain a patent airway and help prevent infection, coupled with close monitoring of the stoma site. Procedure .tracheostomy care will be ordered & performed with aseptic technique .both tracheostomy care and tracheal suctioning will be performed with aseptic technique . A review of the facility's Infection Control Policy, Procedure, and Information policy dated revised 12/10/24, included Policy: handwashing, performed effectively by all personnel is essential for the prevention and control of infection. Procedure: Hands should be washed .before and after donning and doffing PPE when handling residents on transmission-based precautions .and after handling soiled dressing . NJAC 8:39-11.2(b); 19.4(a) Based on observation, interview, and reviewed of pertinent facility documents, it was determined that the facility failed to a) label, date, and store respiratory equipment in a manner to prevent contamination for infection control; b) obtain a physician's order for the administration of oxygen; c.) document the assessment of vital signs as ordered for a nebulizer treatment; and d) perform tracheotomy care with aseptic (sterile) technique to prevent infection. This deficient practice was identified for 3 of 4 residents reviewed for respiratory care (Resident #71, #73, and #85) and 1 of 1 resident reviewed for tracheostomy care (Resident #115), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that delivers additional oxygen through the nose) at 2 liters per minute (lpm). On 1/16/25 at 11:18 AM, the surveyor observed the nasal cannula tubing placed on the oxygen concentrator (device that delivers oxygen) unbagged and exposed to the air. On 1/17/25 at 11:20 AM, the surveyor reviewed the medical record for Resident #85. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; obstructive sleep apnea (sleep disorder that affects your breathing while you sleep), shortness of breath, Alzheimer's disease (brain disorder that causes memory loss), difficulty in walking, unspecified abnormalities of gait and mobility (abnormal walking pattern). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/3/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating a severely impaired cognition. A review of the Order Summary Report included a physician's order (PO) dated 1/8/25, for oxygen at 2 lpm via nasal cannula as needed if oxygen saturation (SPO2; percent of oxygen in a persons blood) was less than 92%. On 1/21/25 at 10:07 AM, the surveyor observed the nasal cannula tubing draped over the resident's nightstand, not bagged and exposed to the air. On 1/21/25 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #3), who stated that oxygen tubing should be stored in a bag when not in use. LPN/UM #3 further stated that the tubing should be stored in a bag for infection control purposes. At that time, LPN/UM #3 accompanied the surveyor to the resident's room and confirmed that the resident's tubing was draped over the resident's nightstand, not bagged and exposed to the air. LPN/UM #3 then replaced Resident #85's oxygen tubing, dated it, and placed it in a bag. On 1/21/25 at 10:47 AM, the surveyor interviewed the Director of Nursing (DON), who stated that oxygen tubing was changed once a week on the night shift. The DON further stated that oxygen tubing should be stored in a bag when not in use for infection control purposes. On 1/21/25 at 12:11 PM, the surveyor interviewed the LPN Infection Preventionist (IP), who stated that all oxygen tubing was required to be changed on the night shift once a week. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. She confirmed that if the tubing was not stored correctly in a bag and exposed to air, it could become contaminated. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, confirmed that oxygen tubing should be stored in a bag when not in use to ensure it did not touch any surfaces and become contaminated. 2. On 1/17/25 at 12:04 PM, the surveyor observed Resident #71 in their bedroom sitting on the side of the bed. The surveyor observed an oxygen concentrator near the resident's bed. Resident #71 stated that they put on their own oxygen at night and removed it in the morning. The resident stated that the facility did not provide a bag to store the oxygen tubing in when not in use. The oxygen tubing was observed lying on the resident's bed, not bagged, and exposed to air. The surveyor did not observe any bag to store the oxygen tubing. On 1/17/25 at 11:44 AM, the surveyor reviewed the medical record for Resident #71. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe), shortness of breath, wheezing (high pitched sound that occurs when the airways in the lungs become narrow), and seasonal allergic rhinitis (allergic reaction that causes sneezing). A review of the most recent comprehensive MDS dated [DATE], indicated the resident had a BIMS score of 15 out of 15, indicating a cognitively intact cognition. A review of the Order Summary Report did not include a physician's order for oxygen. On 1/21/25 at 10:31 AM, the surveyor interviewed LPN/UM #3, who stated that oxygen tubing should be stored in a bag when not in use. LPN/UM #3 further stated that the tubing should be stored in a bag for infection control purposes. On 1/21/25 at 10:47 AM, the surveyor interviewed the DON, who stated that oxygen tubing was changed once a week on the night shift. The DON further stated that oxygen tubing should be stored in a bag when not in use for infection control purposes. On 1/21/25 at 12:03 PM, the surveyor interviewed LPN #2, who stated Resident #71 used oxygen at night as needed. The surveyor asked LPN #2 to confirm the physician's order for the oxygen, and LPN #2 stated that there was no physicians order for the oxygen and acknowledged that there should have been. LPN #2 further stated that she would submit a physician's order for the oxygen at that time. On 1/21/25 at 12:11 PM, the surveyor interviewed the IP, who stated that all oxygen tubing was required to be changed on the night shift once a week. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. She confirmed that if the tubing was not stored correctly in a bag and exposed to air, it could become contaminated. The IP further stated that any resident that required oxygen should have a physician's order. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, stated that oxygen tubing should be stored in a bag when not in use to ensure it did not touch any surfaces and become contaminated. The Regional Nurse further stated that there should be a physician's order for any resident that required oxygen, and she acknowledged that there was no physician's order for Resident #71's oxygen until surveyor inquiry. A review of the facility's Respiratory Tubing policy dated reviewed 12/17/24, included . Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and residents name, between uses . A review of the facility's Oxygen Administration policy dated reviewed 12/17/24, included .Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration (for new admission check hospital discharge summary for oxygen orders and verify with admitting MD.) 2. Review the residents care plan to assess for any special needs of the resident . A review of the facility's Physicians Orders policy dated reviewed 12/17/24, included .Policy: It is the policy of our center to write physicians orders to establish a plan of care to follow for the care of the patient. Physician's orders are grouped into types of orders. Treatment Medications and Treatment orders: All treatments should include the treatment to be used and location of where the treatment should be placed, frequency and if appropriate, how the area should be cleaned and how it should be covered. Reason for the treatment required (diagnosis). This will be reflected on the Treatment Administration Record (TAR) .

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) that a physician's ordered pain medication specified a pain level and b.) appropriate monitoring of pain with adequate assessment and re-assessment was consistently completed for a resident who exhibited pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #133), and was evidenced by the following: On 1/16/25 at 9:39 AM, the surveyor interviewed Resident #133 who was sitting at the side of the bed. The resident was cognitively intact and stated that they were admitted to the facility with a right below knee amputee (BKA). The surveyor observed that the resident had a dressing intact to the right stump area and that was wrapped in a bandage. The resident reported that they had frequent pain in the surgical area of the right stump. On 1/17/25 at 10:20 AM, the surveyor reviewed the medical record for Resident #133. A review of the Resident Face Sheet reflected the resident was admitted to the facility with the diagnoses which included but was not limited to; heart failure and right BKA. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/30/24, indicated that Resident #133 was cognitively intact and required partial to moderate assistance with activities of daily living (ADLs). The MDS also reflected that the resident occasionally had pain at a level of five on the numeric pain scale 0-10. A review of the Physician Order Activity Report (POAR) included a physician's order (PO) dated 12/23/24, for the pain medication acetaminophen (Tylenol) 325 milligram (mg) tablets; give two tablets (650 mg) by oral route every six hours as needed for pain and to monitor pain and follow up in 60 minutes. There was no documentation in the PO as to what the resident's pain level should be before the administration of the pain medication. A review of the corresponding Medication Administration Record (MAR) reflected that the resident received Tylenol on 12/24/24 at 5:52 AM. There was no documentation that there was follow-up regarding the effectiveness of the medication in 60 minutes as ordered. An additional review of the POAR included a PO dated 12/24/24, for the narcotic pain medication oxycodone acetaminophen (Percocet) 5 mg-325 mg; give one tablet by oral route every four hours as needed for moderate to severe pain (4-10). A review of the corresponding January 2025 MAR from 1/1/25 to 1/16/25, Resident #133 received pain medication on 15 out of 16 days. The MAR revealed that the facility had no documentation that the resident was assessed for a pain level, location of pain, description of pain, or if the pain medication was effective at controlling the resident's pain on the following dates: 1/1/25, 1/2/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25 and 1/16/25. A review of the Nursing Progress Notes reflected that there was no consistent documentation that indicated where the resident had complaints of pain, what the level the pain was, or if the pain medication that the resident received was effective at controlling the resident's pain from 1/1/25 until 1/16/25. The surveyor reviewed the POAR which reflected a PO dated 12/23/24, to monitor the resident's pain every shift according to the following pain scale: 0 = no pain, 1-4 = mild pain, 5-6 = moderate pain, 7-8 = severe pain, 9-10 = very severe horrible pain. A review of the corresponding January 2025 MAR from the dates of 1/1/25 to 1/16/25, the resident only had documented complaints of pain on 1/3/25, 1/10/25, 1/12/25, 1/15/25 and 1/16/25, however the resident was administered pain medication on the following dates: 1/1/25, 1/2/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, and 1/16/25. A review of the individualized comprehensive care plan (ICCP) included a focus area for the resident's pain. Interventions included that the resident would be assessed for pain and a baseline through pain assessment. On 1/17/25 at 9:45 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that Resident #133 only required supervision for all aspects of ADLs, and that the resident complained of severe pain in their surgical amputation site and would request to see the nurse for pain medications. On 1/17/25 at 10:11 AM, the surveyor interviewed the resident's Physical Therapist (PT), who stated that the resident had a new right knee BKA and was working on strengthening so that the resident would eventually receive a prosthetic. The PT stated that the resident complained of phantom pain in the right lower extremity and the nurse usually provided pain medication prior to attending PT. The PT stated that the resident also complained of right shoulder pain, and they complained to the PT that they had not received their pain medication prior to participating in PT. The PT stated that he was not sure if the pain medication was administered as needed (PRN) or routine. On 1/17/25 10:36 AM, the surveyor interviewed LPN #5, who explained that if a resident had complaints of pain, she tried non-pharmalogical approach to pain management, and if that was ineffective, she asked the resident what their pain level was to administer the proper as needed (PRN) medication. LPN #5 stated that pain medications were administered according to what the resident's pain level was, and the nurse was responsible to document location of pain, level of pain and type of pain. LPN #5 stated this documentation was located in the Progress Notes as well as the MAR in the comment section. LPN #5 stated the nurse was also responsible to monitor and document the effectiveness of pain medication. At that time, LPN #5 reviewed Resident #133's MAR and Progress Notes with the surveyor and confirmed there was no consistent documentation regarding the pain level the resident had, location of the pain, or if the pain medication was effective at managing the resident's pain. LPN #5 stated that the nurses were sometimes busy and forgot to document. On 1/17/25 at 11:56 AM, the surveyor interviewed LPN/Unit Manager (LPN/UM #3), who stated that the resident's Tylenol order should have a numeric number level for when the pain medication should be administered to the resident. LPN/UM #3 stated that when a nurse administered a pain medication, the nurse was responsible to document where the pain location was, pain level, when the pain started, and a description of the pain. LPN/UM #3 stated the nurse documented in the Progress Note and the comment section of the MAR because it was important to follow-up with the resident to assure continuity of care and to monitor the effectiveness of the pain medication given. LPN/UM #3 stated that the nurses were not documenting, it could mean lack of education. On 1/23/25 at 10:48 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated a physician's order should contain a pain level for pain medications; all assessments of resident's complaints of pain should be documented in the supplemental documentation (comment section) located in the MAR which included the resident's pain level, description of the pain, location of the pain, and follow- up to assure the effectiveness of the pain medication administered. A review of the facility's Pain Management and Documentation policy dated 12/23/24, indicated that the facility utilized the electronic medical record (EMR) to monitor pain and pain response using the pain rating score, assess resident's pain level and monitors the resident's response to pain interventions including side effects and documents response. A review of the facility's Physician's Orders policy dated 12/17/24, included that the policy of the center was to write physician's orders to establish a plan of care to follow for the patient. The orders were to include monitoring should include height, weight, vital signs, blood sugar, pulse [oximetry]. This included entering a value for the monitoring . NJAC: 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/16/25 at 9:23 AM, during the initial tour of the facility kitchen in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: The FSD performed hand hygiene at the hand washing station and was timed by the surveyor using a digital stopwatch to lather her hands with soap for 16 seconds prior to rinsing. The trash receptacle by the hand wash station was positioned under a stainless-steel shelf which had a tray of clean plastic cups stacked. When the FSD used the foot pedal to open the receptacle lid, it hit against the tray of clean cups. Paper towels at the hand washing station were not stored in the paper towel dispenser, they were stored on the stainless-steel shelf above the trash receptacle, with the first few paper towels of the stack appeared to be wet. The exhaust hood spanning above the stove and cooking area had areas where the surface was showing paint chipping. The FSD acknowledged the hood needed to be resurfaced/painted. The food preparation area by the bread toaster, there were one brown and one white cutting boards, both had extensive discoloration, stained, and pitted. The drying rack had two yellow and one red discolored, stained, and pitted cutting boards. The FSD acknowledged the cutting boards were in use and should have been discarded. The walk-in freezer contained two opened boxes of corn on the cob dated opened 12/2/24, and one opened box of croissants with an opened date 1/12/25. The plastic bags inside the boxes were opened exposing the contents to air. The corn showed signs of what the RFSD stated was freezer burn and acknowledged it should not be that way. On 1/16/25 at 10:32 AM, the surveyor interviewed the FSD, who stated that hand washing should be 30 seconds of lathering outside the flow of water; the trash bin should not be able to come in contact with clean kitchen supplies; and the paper towels should be stored in the dispenser and not on the shelf. On 1/21/25 at 11:59 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the Director of Nursing (DON) and the survey team, who stated that the current Centers for Disease Control and Prevention (CDC) guidelines for hand washing was a minimum of 20 seconds of soap lathering prior to rinsing. The IP further stated that having a trash receptacle in the kitchen in a position where it can come in contact with clean kitchen supplies was not appropriate for infection control. A review of the facility's Hand Washing/Waterless Hand Washing policy with a last reviewed date of 12/10/24, included under the section labeled procedure, .b. wet your hands with water. c. apply enough soap to cover your hands. d. apply friction to all wetted surfaces, including between the fingers, for a period of 20 seconds. e. if a nail stick is used, clean the nails under running water. f. rinse hands under running water from wrist to fingers . A review of the facility's Dietary Sanitation Policy with an effective date of 2/2/21, included employees must wash hands for at least 20 seconds when they come in before they start their assignment, when they walk out of the kitchen and/or as needed . A review of the facility's food service Equipment in Use policy included all kitchen equipment are either fixed or replaced as they get damaged, small ware, pots, pans, dishes, cutting boards, can opener, and so on. It is up to the dietary department head to keep replacing them and maintained cleaned, sanitized before it is in use . A review of the facility's food service Environmental policy with an effective date of 3/1/24, included environmental rounds are done daily, this include dumpsters, patios, loading dock, kitchen, building in general .housekeeping is responsible for providing soap and hand sanitizer plus drying towels for the building . A review of the facility's food service Cold Food policy with an effective date 1/7/24, included all boxes must be checked, date manufactured, date which will be expired, they must be closed, unopened, once they are in the refrigerators or freezers, they must have a received date and always closed to avoid freezer burn, they must be rotated . NJAC 8:39-17.2(g)

Deficiency Text Not Available

Complaint #NJ 161020 Based on interviews, record review, and review of pertinent documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 5 residents reviewed for investigations and was evidenced by the following: On 12/4/23 at 12:30 PM, the surveyor interviewed Resident #93, who stated that while at the facility, they had broken their arm. The resident further said a resident had pushed them at the nurse's station and caused the broken arm. A review of Resident #93 Face Sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included hypertension, open-angle glaucoma, and left eye cataract. A review of Resident #93's Annual Minimum Data Set (MDS), an assessment tool, dated 9/8/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A review of a nursing progress note dated 12/5/22 at 12:24 AM, revealed at 5:00 PM on 12/4/22, the Registered Nurse Night-Shift Supervisor (RNS#2) was summoned from down the hall, and noted Resident #93 lying on their left arm against the nurse's station. The resident stated that they were assisting another resident from falling, and both had fallen. Resident #93 injured their left arm and was sent to the hospital. Further review revealed a progress note on 12/5/22 at 4:19 PM indicating the resident sustained a closed nondisplaced fracture of the surgical neck of the left humerus. A review of the nursing progress note from the time of the incident dated 12/6/22 at 7:28 AM, revealed that RNS#2 had asked the resident how they felt. The resident responded, Not good at all. I broke my arm; I'm gonna get that another resident because they pushed me, and I fell down. On 12/5/23 at 10:00 AM, the surveyor reviewed a facility document titled Incident/Accident Report for Resident #93. The report revealed that on 12/4/22 at 5:00 PM, the resident fell while attempting to help another resident from falling from their wheelchair, and Resident #93 fell onto their left arm. The attached fall review dated 12/5/22 revealed the fall was an isolated incident. A review of a facility's document titled Incident/Accident Report for Resident #237 revealed that on 12/4/22 at 5:00 PM, the resident was trying to get up from their wheelchair and fell. A review of the attached Employee Statement dated 12/4/22, revealed that the Licensed Practical Nurse (LPN) heard a loud voice yelling help , help . The LPN then rushed to the nurses station and saw the resident on the floor. The resident stated that Resident #93 held their hand. Resident #93 stated that they were trying to stop Resident #237 from falling. Further review of the employee statement revealed that it appeared both residents lost their balance and fell and there was no further documentation that would indicate that the fall was witnessed. Attached to Resident #237's Incident Accident Report revealed an attached document with an investigation date of 12/6/22 completed by the previous DON, titled, Summary of Investigation dated 12/4/22. The summary indicated Resident #93 stated that they attempted to hold Resident #237 to prevent Resident #237 from standing up. Resident #237 landed on top of Resident #93, and Resident #93 sustained a fractured arm. Further review revealed that Resident #93 later referenced to being pushed by Resident #237. The DON determined that both residents lost their balance based on how both residents were found on the floor. There were no statements from staff included with the investigation regarding Resident #93's allegation that they were pushed by Resident #237. On 12/4/23 at 1:42 PM, the surveyor interviewed the Interim Director of Nursing (DON), who stated when an incident occured, the nurses would evaluate the residents and start an incident report, they would gather statements from witnesses, notify the physician and the family and send the resident out to the hospital if they needed. On 12/8/23 at 7:00 AM, the surveyor interviewed the RNS#2 who stated if there were an allegation of the resident-to-resident incident or staff-to-resident incident, she would start an investigation. The RNS#2 said that in Resident #93's incident, she witnessed the resident fall with another resident. The RNS#2 stated she did not know who the other resident was. She stated that she was aware that Resident #93 did change their story and said they were pushed, but the RNS#2 stated that was not what happened. The RNS#2 stated that the administration were aware the resident had changed the story. On 12/8/23 at 9:30 AM, the surveyor interviewed the Interim DON, who stated that she thought the nursing supervisor witnessed the fall and that the claim was not investigated further. She said that she was not the DON at the time but was the Assistant Director of Nursing (ADON). During a follow up interview on 12/8/23 at 11:30 AM, the Interim DON stated RNS#2's documentation was conflicting and that she would investigate further since she became aware that the fall was not witnessed. On 12/14/23 at 10:25 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Regional Nurse, and the Interim DON. The Regional nurse stated that a summary and reinvestigation were done yesterday (12/13/23). The LNHA stated that if this incident had happened today, 100% an investigation would have been done. A review of the facility's policy labeled Abuse, Mistreatment, Neglect, exploitation, and Misappropriation of Residents Property dated 1/20/23, Included under the Section V Investigation: The Director of Nursing/Designee's responsibilities are to coordinate the investigation of alleged violations and, upon receipt of the resident's accident/incident report, will continue the investigation . the investigation shall include statements from all parties involved . and findings from the investigation shall be documented and collected for a formal and comprehensive review. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 27 residents reviewed (Resident #116 and #97). This deficient practice was evidenced by the following: 1. On 11/30/2023 at 9:40 AM, the surveyor observed Resident #116 in bed eating lunch. The surveyor reviewed the medical record for Resident #116. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic congestive heart failure and essential hypertension. A review of Resident #116's August 2023 Nursing Progress Notes included an entry dated 8/14/2023 at 12:37 PM, which indicated the resident was admitted to the facility for longterm care and was receiving Hospice services. A further review of the resident's medical record revealed hospital records dated 8/11/23 at 4:31 PM, which indicated the hospital case manager had requested the Hospice team forward a copy of the resident's signed contract for Hospice services be forwarded to the facility. A review of the admission Minimum Data Set (MDS), dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 99, which meant that the resident was not able to complete the interview. Section O of the MDS did not identify the resident was receiving Hospice special services. 2.) On 11/29/2023 at 1:02 PM, the surveyor observed Resident #97 sitting on their bed eating lunch. The surveyor observed the resident was wearing oxygen. The surveyor reviewed the medical record for Resident #97. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease with (acute) exacerbation. A review of the most recent Quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which demonstrated an intact cognition. Section O of the MDS did not identify the resident was receiving oxygen therapy services. During an interview with the surveyor on 12/13/23 at 11:36 AM, Regional Minimum Data Set Coordinator (RMDS) stated that the current MDS Coordinator was not available, and she was currently overseeing the MDS process in the facility. The RMDS confirmed that coding of the MDS was based upon the CMS RAI Manual. The surveyor reviewed Resident #116 and Resident #97's MDS with the RMDS. The RMDS responded that she would have to review the clinical information and return with a response. During an interview with the surveyor on 12/14/23 at 10:27 AM, the Regional MDS Coordinator (RMDS), in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Nurse (RN), and Director of Nursing (DON), acknowledged that Section O of the MDS should have identified hospice for Resident #116 and oxygen therapy for Resident #97. A review of the facility provided undated MDS policy documented with Subject: RAI Process/MDS, last revised 10/11/2023, revealed . Nursing and Rehabilitation is responsible for completing Section O. NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a) properly transcribe a physician's order for 2 of 27 residents reviewed for medications (Resident #59 and #388); b) failed to follow physician's order to obtain blood sugar and administer insulin for 1 of 27 residents reviewed for medications (Resident #388). These deficient practices were evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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. A.) On 11/29/2023 at 12:47 PM, the surveyor observed Resident #59 seated in reclining chair as the Certified Nursing Assistant (CNA) provided feeding support for lunch. The surveyor reviewed the medical record for Resident #59. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnosis that included Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain) and Atherosclerotic heart disease of native coronary artery without angina pectoris (reduced blood flow to the heart that can cause chest pain). A review of the admission MDS, dated [DATE], reflected a BIMS score of 13 out of 15, which demonstrated an intact cognition. The MDS also identified that the resident had a feeding tube (a flexible plastic tube placed into the stomach or bowel to help receive nutrition) upon admission. A review of Resident #59's December 2023 Resident Medication Administration Record (MAR) established that the nurse's initials under the corresponding date established that the physician's order had been completed. Upon further review, the MAR revealed the following single order: Tube Feeding-continuous using feeding pump; Formula: Jevity 1.5; At: 60cc/hr (cubic centimeters per hour) for 20 hours/day; Start at: 2p; Remove at:10a or until total; volume of 120cc (cubic centimeters) infused; Total volume:1200ml. Position: High Fowlers (head elevated 60-90 degrees) in chair/semi-Fowlers (head elevated 30-45 degrees) in bed; Check for patency of tube by aspirating back stomach contents. Check for residual prior to each feeding and indicate amount of resident noted in comment section. If residual less than 100cc.continue with feeding. If residual is 100cc or more, hold feeding x1 hour and recheck. If residual still 100cc or more, hold feeding and contact MD/NP (doctor of medicine/nurse practitioner) for additional instructions/orders. Water with Meds: 30cc Before & After Meds/5cc of water BETWEEN each med Protocol: Medication Pass: Check for placement prior to and flush per protocol Start Date: 11/20/2023 The surveyor identified that the facility failed to properly transcribe the physician's order into separate individual orders so that each seperate order could be carried out and documented as administered. B.) On 11/29/2023 at 12:42 PM, the surveyor observed Resident #388 in bed. The resident did not respond to the surveyor presence or inquiry. The surveyor reviewed the medical record for Resident #388. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnoses that included encephalopathy (change in brain function), sepsis (condition in which the body responds improperly to an infection), diabetes, and epilepsy (seizure disorder). A review of the MDS, with an Assessment Reference Date of 12/5/23, reflected a brief interview for mental status (BIMS) of 99, which meant that the resident was not able to complete the interview. The MDS also identified that the resident had a feeding tube. A review of Resident #388's December 2023 Medication Administration Record (MAR) revealed a nurse's initials under a corresponding date established the nurse had carried out the physician's order. Upon further review the MAR revealed the following single order for: G-tube feeding: Jevity 1.4 at 70cc/hr to start at 2pm and finish at 10pm. Add flush every shift 350mL Q4H (every 4 hours) total volume form and flush 2500cc TOT Fluid/24H: 3164cc. Position: High Fowlers (head elevated 60-90 degrees) in chair/semi-Fowlers (head elevated 30-45 degrees) in bed; Check for patency (openness) of tube by aspirating (drawing) back stomach contents. Check for residual (remaining g-tube feeding) prior to each feeding and indicate amount of resident noted in comment section Check for patency of tube by aspirating back stomach contents. Check for residual prior to each feeding and indicate amount of resident noted in comment section. If residual less than 100cc.continue with feeding. If residual is 100cc or more, hold feeding x1 hour and recheck. If residual still 100cc or more, hold feeding and contact MD/NP for additional instructions/orders. Further review of the resident's MAR revealed the following order: Insulin Lispro (U-100) 100 unit/mililiter (mL) subcutaneous solution: inject by subcutaneous route every 8 hours BS every 8 hours- 150=0, 151-200=2units, 201-250=4units, 251-300=6 units, 301-350=8 units, 351-400= 10 units, greater than 401 give 12 units and call MD. Start Date: 11/29/2023 02:57 am Upon review of the December 2023 MAR revealed that the following dates included nurse's initials under the ordered date and times, but did not document the resident's blood sugar results and/or if insulin was administered: 12/1/23 at 4:30pm, 12/3/23 at 7:30am, 12/4/23 at 11:30am, 12/4/23 at 4:30pm, 12/5/23 at 7:30am, 12/5/23 at 11:30am, 12/7/23 at 7:30am, 12/7/23 at 11:30am (8 units of insulin administered but no blood sugar result documented), 12/7/23 at 4:30pm, 12/9/23 at 7:30am, 12/9/12 at 11:30 am, 12/10/23 at 7:30 am 11:30am (8 units of insulin administered but no blood sugar result documented), and 12/11/23 at 4:30pm. During an interview with the surveyor on 12/11/23 at 12:30 PM, LPN#1 confirmed that nurses were responsible for documenting everything they said and did for the resident. When asked about physician's orders, LPN#1 confirmed that nursing was responsible for inputting new orders into the EMR. During an interview with the surveyor on 12/12/23 at 11:13 AM, Registered Nurse (RN #1) reviewed the resident's EMR and confirmed that the way the feeding orders had been entered did not provide the ability to document that each step of the multi-step process had been completed and individually accounted for. During an interview with the surveyor on 12/13/23 at 12:11 PM, the Director of Nursing (DON), in the presence of the Registered Nurse Unit Manager (RNUM#1), confirmed that the enteral order should not be bundled together, but rather separated into individual orders. The DON also confirmed that nurse's initials on the blood glucose and insulin order accounts that the blood sugar was obtained, but due to numerous documenting areas in the MAR they will have to closely review the administration record to determine if there were missed documentation. During an interview with the surveyor on 12/14/23 at 10:27 AM, the Regional Nurse (RN) in the presence of the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and MDS Coordinator, acknowleged that each section of the order should have been entered separately to allow the nurses to sign for each order independently. A review of the facility provided undated Licensed Practical Nurse Job Description document, included: [ .] Review medication cards for completeness of information, accuracy in the transcription of the physician's order [ .]. A review of the facility provided Medication Administration and Documentation Policies, Procedures, & Information, with an Effective Date of 7/1/22 and Last Reviewed on 6/22/23 included under the heading Licensed Nurse: .16. Documents administration of medication in the [MAR] immediately following administration. Notes in [MAR] medications not administered (i.e. refused, etc) and identifies reason . 21. Upon completion of the medication pass and prior to end of the shift the medication nurse will check dash board to ensure all medications and monitoring is completed as per assignment time. A review of the facility provided Physician's Orders policy, with an Effective Date of 1/21/22 and Last Reviewed on 6/20/23, included: .monitoring: orders including monitoring of height, weight, vital signs, blood sugars, pulse ox, etc. This including entering a value for the monitoring NJAC 8:39-27.1(a)-29.2(d)

Complaint # NJ166083 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a dispensed and administered controlled substance medication was accurately accounted for 1 of 1 residents reviewed, Resident #187. 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. On 12/13/23 at 11:54 AM, the surveyor reviewed the closed medical record for Resident #187. A review of the admission Record revealed that Resident #187 was admitted to the facility in June 2023 with diagnoses that included Parkinson's disease, pain, diabetes mellitus, agitation, and neoplasm (abnormal or excessive growth of tissue) of the kidney. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 6/21/23, reflected the resident had short-term memory problems and further assessed that Resident #187's cognitive skills for daily decision-making were severely impaired. A review of the June 2023 Order Summary Report reflected a physician's order (PO) with a start date of 6/19/23 for lorazepam (a medication used to treat anxiety and agitation) 1 mg (milligram) one tablet by mouth every 8 hours as needed for restlessness or agitation. A review of the June 2023 Medication Administration Record (MAR) revealed a PO dated 6/19/23 for lorazepam 1 mg take one tablet by mouth every 8 hours for 14 days as needed. The MAR was signed on 6/19/23 and 6/21/23 which indicated that Resident #187 had received one dose of the lorazepam on each of those days. A review of the Individual Patient Controlled Substance Administration Record (declining inventory log) reflected that the facility received #42 lorazepam 1 mg tablets for Resident #187 on 6/19/23. On 6/21/23 the declining inventory record revealed that #42 lorazepam 1 mg tablets were unused and disposed of by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). A review of the Controlled Substance Transaction Report obtained from the pharmacy reflected no documentation indicating that the lorazepam 1 mg tablet doses were obtained from the facility's medication dispensing machine. On 12/12/23 at 6:44 AM, during a telephone interview with the surveyor, the Registered Nurse Night Supervisor (RNS#2), who signed the MAR indicating that she had administered the medication on 6/21/23 stated that she could not recall where she got the lorazepam from or why she had not signed the declining inventory record. RNS#2 further stated that sometimes a narcotic was taken out and the nurse forgets to sign for it. The surveyor asked RNS#2 supervisor if she counted the narcotics with the incoming nurse. RNS#2 replied it was her regular practice to count the controlled medications with the incoming nurse. On 12/12/23 at 11:00 AM, during an interview with the surveyor, the Interim DON stated that following the facility policy, she and the former DON destroyed #42 lorazepam 1mg tablets in the facility drug buster. She further stated that they were not aware that there were any discrepancies which was why they had not conducted an investigation. At that time, the surveyor requested a copy of the Change of Shift Controlled Medication Accountability Record for the month of June 2023. The Interim DON stated that she was not able to locate it. On 12/12/23 at 11:30 AM, the surveyor left a voicemail for the previous DON requesting a call back. The DON did not return the surveyor's phone call. On 12/13/23 at 11:41 AM, the surveyor attempted to contact the RN who had signed the MAR indicating she had administered one of the doses of lorazepam on 6/19/23. The RN did not return the surveyor's call. On 12/13/23 at 11:46 AM, the surveyor placed a second call to the previous DON and left a voice message. The DON did not return the surveyor's call. On 12/13/23 at 1:35 PM, the survey team met with the administration to discuss the above observations and concerns. On 12/14/23 at 10:26 AM, the Interim DON stated that there was no further information. Review of the Facility's policy entitled, NARCOTICS: ENSURING THE SECURITY OF NARCOTICS dated 11/28/16 and reviewed on 10/25/23 reflected, .It is the policy of this facility to ensure that narcotics are maintained in a manner that ensures the safekeeping and integrity of the narcotics: All nurses must ensure that the narcotic count is accurate at the time they receive the keys and at the time they are handing over the keys to the oncoming shift. At no time should any nurse perform narcotic count alone. Each nurse is responsible for ensuring that the count is correct by standing side by side during the narcotic count. NJAC 8:3929.7(C)

Based on interview and record review and review of other facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #116), and was evidenced by the following: On 11/29/2023 at 1:02 PM, the surveyor observed Resident #97 sitting on the bed eating lunch. The surveyor observed the resident wearing oxygen. The surveyor reviewed the medical record for Resident #97. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Chronic Obstructive Pulmonary Disease with (acute) exacerbation. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 9/29/23, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which demonstrated an intact cognition. On 12/12/2023 at 12:56 PM, the surveyor reviewed the facility's Medication Regime Review (MRR) for Resident #97. The surveyor observed that the resident had a review completed on 11/14/23 by the Consultant Pharmacist which stated, currently receiving Diltiazem 120mg (milligrams) tablet once daily which is not long acting and not recommended for once daily dosing. Please evaluate and switch to Diltiazem CD 120mg once daily, if appropriate. The box next to the recommendation which identified Physician/Prescriber Response: Agree; Will do or Disagree/State Reason, was not filled out and a signature was not present on the MRR form. During an interview with the surveyor on 12/13/23 at 12:11 PM, the Interim Director of Nursing (DON), in the presence of the Registered Nurse Unit Manager (RNUM#1), stated that the unit managers were responsible for ensuring all MRR were completed. When asked what the turn around time frame for the MRR was, the DON responded that the facility tries to give them one week, but up to 2. The surveyor inquired about the role of the consultant pharmacist and the DON indicated that they were in the building weekly to complete different tasks, but would review all the recommendations monthly. The DON reported that this resident was on a different wing of the building at the time of this MRR and it would have to have been reviewed with the previous unit manager. The DON stated that the MRR should have been addressed. During an interview with the surveyor on 12/14/23 at 10:27 AM, the Regional Nurse (RN), in the presence of the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional MDS Coordinator (RMDS), acknowledged that the unit manager was responsible and that the MRR was not completed and should have been addressed within 14 days. A review of the facility provided undated Pharmacy Consultant Services Policy, with Effective Date of 1/10/20 and Last Review Date: 2/10/23, documents that under the Heading of Nurse Manager/Designee: [ .] 8. Review consultant recommendations and contacts MD/NP to address as soon as possible [ .] 13. Reviews all pharmacy recommendations and ensures that MD/NP see the recommendations, address the recommendations, signs, responds, and acts on the recommendations as appropriate and returns all recommendations within 2 weeks of receipts [ .]. NJAC 8:39-29.3 (a)

Based on observation, interview, record review, and review of other documentation, it was determined that the facility failed to maintain infection control standards and procedures when performing a wound care treatment for 1 of 1 residents (Resident #4) performed by 1 of 1 nurses observed providing a wound care treatment. This deficient practice was evidenced by the following: On 11/29/23 at 11:41 am, the surveyor observed Resident #4 sitting in bed eating lunch. A review of the Resident Face Sheet, Resident #4 was admitted to the facility in 9/2021 with diagnoses that included cerebral infarction (damage to the brain due to loss of oxygen), hemiplegia (one-sided paralysis of the body) and stage 4 pressure ulcer to the sacrum. A review of Resident #4's Annual Minimum Data Set (MDS), an assessment tool dated 8/16/23, revealed that the resident's Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicated that the resident had severe cognitive impairment. Further review revealed the resident required extensive to total dependency for activities of daily living (ADL) and review of the skin portion of the MDS indicated that the resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A review of the Physician's Order Sheet revealed an order dated 12/6/23 to cleanse the sacral wound with normal saline solution (NSS), pat dry, apply Collagen powder mixed with NSS to the wound bed and undermining, lightly pack the wound cavity with calcium aligate, apply zinc ointment to the periwound and cover with a silicon-bordered dressing daily and when needed. On 12/6/23 at 10:30 am, the surveyor observed the Licensed Practical Nurse (LPN) in the presence of the Infection Preventionist LPN perform a wound care treatment on Resident #4 and observed the following: The LPN used alcohol-based hand rub (ABHR) and donned gloves. She poured NSS onto 4x4 gauze and cleansed the sacral wound. The LPN, without removing her gloves and performing hand hygiene, opened and mixed the triple helix powder with NSS in a plastic medication cup, using a tongue depressor, and applied the mixture to the wound. She then cut a piece of calcium alginate and packed the wound with a cotton-tipped applicator. The LPN then covered the wound with a border gauze. During an interview with the surveyor on 12/6/23 after the wound treatment was completed, the LPN stated that after cleansing the wound, she should have changed her gloves and used ABHR before continuing. The LPN stated that she thought she had changed her gloves because thats what she would usually have done. During an interview with the surveyor on 12/6/23 at 11:00 am, the Interim Director of Nursing (DON) stated that gloves should have been changed after cleansing the wound, and hand hygiene should have been performed. She would have expected the nurse to have changed her gloves because the nurse's gloved hands would have been dirty. During an interview with the surveyor on 12/13/23 at 11:51 am, the IP/LPN stated that after cleansing the wound, the nurse should have changed gloves and sanitized her hands to prevent contamination and infection. On 12/13/23 at 1:37 pm, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the findings. The surveyor reviewed the facility's policy titled, Infection Control: Wound Management, with a review date of 6/12/23, which revealed the facility would apply clean gloves during an aseptic dressings procedure. NJAC 8:39-19.4(a)

Complaint # NJ166916 Based on interview, medical record review and other pertinent documentation, it was determined that the facility failed to a.) ensure skin conditions were addressed in accordance with professional standards by failing to obtain physician's orders and treatments for a surgical site dressing, leg wound, and skin tear; assess and document monitoring of a surgical site, leg wound and heel blister b.) ensure a care plan was in place which addressed actual skin impairment c.) complete an incident report for a skin tear and d.) ensure timely physician notification and timely transfer of a resident to the hospital. This deficient practice was identified for 1 of 28 residents (Resident #287) reviewed for quality of care and was evidenced by the following: 1. According to the Resident Face Sheet, Resident #287 was admitted to the facility with diagnoses which included but were not limited to; postprocedural hematoma (collection of blood under the skin) of skin and subcutaneous tissue following other procedure, and lymphedema (swelling). According to the resident's admission Minimum Data Set, (MDS) an assessment tool dated, 1/12/23, included that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. The MDS further included that the resident had a surgical wound. The care plan decision was signed as completed on 1/16/23. A review of the resident's Universal Transfer Sheet from the hospital dated 1/9/23 revealed that the resident had a deep tissue injury to their right lower extremity. A review of Resident #287's hospital records included a podiatry consult dated 1/9/23. The consult indicated the physician was requested for lymphedema dressing evaluation. The podiatry plan of care revealed that local wound care was rendered with Allevyn (a foam dressing) to the right leg wound and elastic strechable bandage wraps to bilateral lower extremities. A review of the hospital's After Visit Summary included instructions for bacitracin 1 gram daily topically for leg wound to be started on 1/10/23. Additional instructions included to change dressing to leg wound every other day with Allevyn. According to the facility's Nursing- Admission/readmission Assessment form dated, 1/9/23, the general skin condition revealed that the resident had no wounds, had occlusive dressings to both breasts where drains were removed, and had lymphedema to bilateral legs with intact elastic stretchable bandage wraps. There was no documentation regarding the resident's right leg wound. A review of Resident #287's Progress Notes (PN) revealed that on 1/9/23 at 11:10 PM, the resident was newly admitted at 6:00 PM. The PN included that the resident had lymphedema, occlusive dressings to both breasts and that the resident's drains (to the breasts) were removed on that day. There was no futher documentation regarding the elastic stretchable bandage wraps to the resident's legs, or the right leg wound. A review of the History and Physical completed by the resident's physician dated 1/10/23, included the plan was to continue all treatment and wound care. A review of the Physical Medicine and Rehab Consult, dated 1/11/23, indicated that the resident was hospitalized , had thoracic surgery, pectoral muscle hematoma and right lower extremity cellulitis. The resident had pleural effusion and underwent thoracentesis ( a procedure to remove fluid or air from around the lungs), and bilateral hematoma drainage. A review of a PN dated, 1/25/23 at 8:29 AM revealed, Dressings removed from bilateral breasts. No open areas or drainage noted. Dressing to right posterior leg changed. It is a skin tear. Slowly healing. A review of Resident #287's January 2023 Treatment Administration Record (TAR), included the following physicians orders: An order dated 1/21/23 at 2:15 PM, for Opsite to left heel blister monitor every shift. (discontinued on 1/24/23); An order dated 1/26/23 at 9:59 AM, to clean left posterior open purpura (bursting of small blood vessels ) with normal saline, apply bacitracin and cover with border gauze. Further review of Resident #287's January 2023 TAR revealed that there were no orders for the resident's surgical dressings to the breasts, elastic stretchable bandage wraps documented on admission, the leg wound (from the discharge paperwork) or the skin tear to the resident's right posterior leg. A review of the medical record revealed that there were no other progress notes between 1/9/23 and 1/25/23 that addressed the resident's dressings to the breasts. In addition, there were no progress notes that addressed the elastic stretchable bandage wraps that were documented on the admission assessment, or the left heel blister. A review of the resident's Baseline Care Plan, created on 1/9/23, indicated that the resident recently had surgery and was at risk for developing pressure ulcers. The goal was to keep the resident's skin intact. An intervention was that the resident required an air mattress. A review of the resident's Care Plan Activity Report included a focus of Skin: Prevention dated 1/9/23, that the resident will have no skin breakdown. Interventions included to monitor the skin surfaces for changes every shift, be provided with regular skin care, daily bed bath and shower twice weekly, turn and reposition every two hours, and to toilet every two to four hours. There was no indication on the resident's care plans that addressed the resident's surgical site, elastic stretchable bandage wraps, leg wound, skin tear to the right posterior leg or left heel blister. Review of a PN dated, 1/26/23 at 4:02 PM written by Licensed Practical Nurse Unit Manager #1 (LPNUM #1), revealed that the resident's family member alerted LPNUM #1 that the resident was in distress and needed immediate attention. The LPNUM #1 entered the room and the resident stated that their breasts hurt and they wanted to go to the hospital. The resident's vital signs were stable, the resident was not in respiratory distress, was offered acetaminophen but declined. LPNUM #1 further documented that the resident's breasts were firm, and the resident voiced that their breasts were painful. There was no documentation that the physician was notified that the resident requested to go to the hospital. On the same day at 6:19 PM, two hours later, a PN written by the Registered Nurse (RN) Supervisor revealed that the resident's family member requested to send the resident to the hospital. The resident was complaining of chest tightness. The physician was notified, and transportation was made to send the resident to the hospital. The resident was transported to the hospital at 6:48 PM. Review of a PN dated 1/26/23 at 10:43 PM, indicated the resident was admitted with a diagnosis of COVID-19. An additional PN dated, 1/27/23 at 3:34 AM, indicated that the resident was admitted with congestive heart failure. During an interview with the surveyor on 12/06/23 at 10:54 AM, LPNUM#1 stated when there was a new admission, the nurse would complete a full body assessment and review the hospital orders with the physician. LPNUM#1 stated that the assessments would be documented in the computer. If a resident was admitted with dressings, the nurse would check if the dressings were intact and if there was any drainage. There would be a physician's order (PO) for a treatment, and to monitor the site which would then be transcribed on the TAR. If the physician did not want the dressing to be touched, there would be an order and it would documented in the PN. If the resident had elastic stretchable bandage wraps or a wound, the nurse would assess the skin and get an order for the physician for a treatment. LPNUM#1 further stated that Baseline Care plans were started on admission, and areas such as skin would be completed and updated. If a resident developed a skin tear, the nurse would complete an incident report (IR) with statements from the CNAs and nurses, call the physician and obtain a treatment order. Any skin change would be documented. If a resident wanted to go to the hospital, the nurse would assess the resident, take vital signs, and notify the physician. On 12/06/23 at 11:08 the surveyor reviewed Resident #187's medical record with LPNUM #1. LPNUM #1 confirmed that there was no order or treatment for the dressings to the resident's breast, elastic stretchable bandage wraps, and skin tear. She stated that there should have been an order. Additionally, there should have been documentation for the heel blister. LPNUM #1 stated that the care plan should have included the breast dressings, elastic stretchable bandage wraps, right leg skin tear, heel blister, and right leg purpura. LPNUM#1 reviewed the PN she wrote when the resident requested to be sent to the hospital on 1/26/23. LPNUM#1 stated she was waiting on the RN to assess the resident, and confirmed she did not notify the physician at that time. During an interview with the surveyor on 12/06/23 at 12:28 PM, the Interim Director of Nursing (DON) stated the process for new admissions included an admission head to toe assessment, baseline care plan , and verifying and obtaining physicians orders. If a resident had skin issues, dressings, or wounds on admission, the nurse would remove the dressing unless there was an order not to touch the dressing. The nurse would assess the skin, measure, and check if there was any drainage, notify the physician and initiate an order. The DON stated orders would be checked for wounds and they would be monitored. If a resident developed a skin tear, an IR with statements would be completed, the physician would be notified, and a treatment would be on the TAR. If a resident requested to go to the hospital, the physician would be notified and the resident would be sent to the hospital. On 12/06/23 at 12:40 PM, the surveyor reviewed Resident #187's medical record with the Interim DON. The DON stated that the surgical site to the resident's breast and ace wraps to the residents legs should have had an order and should have been on the TAR, unless it was a do not touch order. The blister to the resident's heel should have been documented in the PN, the skin tear should have had an order and IR completed. In addition, the DON stated the skin concerns should have been the resident's care plan. The DON further stated that LPNUM#1 should have notified the physician that the resident wanted to go to the hospital at that time. During a telephone interview with the surveyor on 12/11/23 at 4:39 PM, the Registered Nurse Supervisor (RNS) stated residents arrive with orders from the hospital. If the resident arrived with a dressing with no order, the nurse would call the hospital for the order, and it would go on the facility PO and TAR. If there was any skin impairment, the nurse would document, get an order and put on the TAR. An IR would be completed for a skin tear. If a resident wanted to go to the hospital, the physician would be notified and the resident would be sent at that time. During a follow up interview with the surveyor on 12/12/23 at 10:41 AM, LPNUM#1 confirmed she did not notify the MD when Resident #287 initially requested to go to the hospital and that the protocol was to have the supervisor assess the resident. She stated she had then left for that day and didn't know how long it was before the RNS came. She stated if the resident had a follow up appointment a PO for a consult would be entered or it would be in the PN. The surveyor reviewed #287's discharge orders and universal transfer sheet with LPNUM#1. She stated there should have been a PO for the dressings, and leg wound and it should have been on the TAR. If the physician did not want that ordered, it should have been documented. During a follow up interview with the surveyor on 12/12/23 at 12:15 PM, the DON reviewed the MR for Resident #287 and stated it was messy and confirmed there was no order for the surgical site breast dressing, leg wound or documentation in the PNs. There was no IR provided for the resident's skin tear. The DON reviewed the hospital discharge instructions and stated she did not know why the treatment wasn't ordered for the leg wound on admission and that the physician should have been notified for treatments to the leg wound and the surgical site dressings. She stated, if it was not documented, I can't say it was done. During a telephone interview with the surveyor on 12/13/23 at 11:00 AM, Resident #287's physician stated he would expect to be notified if a resident had a surgical wound, or any wounds and he would give an order for a treatment. In addition, if a resident wanted to go to the hospital, he would want to know why, the nurse's assessment of the resident, and would give an order to send the resident to the hospital. The physician stated Resident #287's discharge orders and recommendations should have been addressed and due to the complex history of the resident, the resident could go to the hospital at any time. A review of a facility policy titled, admission: Nursing dated 1/3/23, included that it was the policy of the facility that a resident was received, assessment completed and orders written upon admission. The purpose was to ensure all needs were identified, medications/treatment ordered based on assessment and transfer documentation. Nursing instructions would be added based on the new admission assessment. A baseline care plan would be initiated and completed with in 48 hours of admission. A review of a facility policy titled, Resident's Baseline Care Plan, reviewed on 9/20/2023, revealed that it is the policy of the center to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Duties include to complete admission assessment, begin initial baseline care plan based on information obtained during the initial assessment, reviews all admission documents and documentation and meets with resident for initial assessment, initiate or updates applicable section of the baseline care plan based on review of documents/assessments. The facility may provide a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed with in 48 hours and includes: Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; any updated information based on the details of the comprehensive care plan as necessary. A review of a facility policy titled, Skin and Wound Management dated 1/17/23 included, Any new wound/skin breakdown must be addressed as soon as discovered: Steps to Follow: Assess/evaluate site, inform MD and obtain treatment order, complete investigation/incident report, write progress note, update care plan. A review of a facility policy titled, Change in Condition dated 6/7/23, included that it was the policy of the facility to identify and communicate changes in condition to the physician and other team members. A complete assessment will be conducted of all systems and the nurse would contact the physician or nurse practioner to discuss findings and formulate a plan. A review of a facility policy titled, Incident Report- Resident reviewed on 7/12/23, included an investigation will be initiated whenever an untoward event occurs which may or may not result in injury to a resident. Incidents may include skin tears. The procedure included to initiate an incident report. A review of a facility policy titled, Documentation in the EMR [electronic medical record] reviewed on 5/11/23, included that it was the policy of the center to document all information related to the patient's medical record in the EMR. NJAC- 8:39-27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to investigate the root cause of a facility-acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #6). The evidence was as follows: During the initial tour of the facility on 8/12/21 at 11:38 AM, the Unit Manager (UM) informed the surveyor that Resident #6 had a facility-acquired pressure ulcer to the left heel that was unstageable (full thickness tissue loss in which wound depth is not visible due to coverage of dead tissue and cannot be determined). The surveyor reviewed the medical records for Resident #6. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses which included end stage renal disease, heart failure, diabetes, edema (swelling), and weakness. A review of a comprehensive significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/10/21 reflected that the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating an intact cognition. The section used to assess the resident's skin indicated that the resident had no pressure ulcers or skin breakdown at that time. A review of the resident's individualized care plan initiated on 5/2021 reflected that the resident was at risk for skin breakdown. The care plan was updated on 5/20/21 which reflected that the resident developed a left heel Deep Tissue Injury (DTI; an injury to the underlying tissues of the skin produced by prolonged pressure and are likely to deteriorate). A review of the Pressure Sore Tracking System audit dated 5/19/21 reflected that Resident #6 developed a new left heel unstageable pressure ulcer to the outer aspect of the heel that measured 1.3 centimeters (cm) x 1.5 cm. Interventions included to suspend the heels with pillows and apply skin prep. A review of the Treatment Administration Record (TAR) for May 2021 reflected a physician's order dated 5/20/21 for skin prep to the left outer aspect of the left heel with an opsite dressing (transparent dressing) and check its placement every shift. If it falls off then reapply it. The TAR also reflected new orders to suspend the bilateral heels on pillows while in bed and apply skin prep to the bilateral heels every shift. On 8/17/21 at approximately 12:45 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) any investigations for Resident #6, including the investigation into the possible root cause for the left heel pressure ulcer that was facility-acquired. The LNHA stated that he would have to check with the DON. On the next day on 8/18/21 at 9:45 AM, the DON informed the surveyor that there were no formal investigations completed into the facility acquired pressure ulcer for Resident #6. She stated that they would do an investigation if a new wound formed to determine when and where it came from. She stated that while there was no investigation recorded, they believed it occurred when the resident returned from the dialysis center when it was found. She stated that the resident had multiple co-morbidities that placed the resident at increased risk. The DON confirmed a second time, that We didn't do a written investigation. We do wound rounds and we did it on a Thursday that week instead of a Wednesday. The DON acknowledged that the facility conducts investigations into injuries that occur at the facilities such as bruises or skin tears, and acknowledged that she should have had an investigation into the facility acquired pressure ulcer. On 8/18/21 at 10:04 AM, the surveyor observed Resident #8 in bed with his/her eyes closed. The surveyor observed that the resident had his knees bent with his/her feet resting directly on the mattress. The surveyor observed that when the Licensed Practical Nurse (LPN) told the resident to rest his/her legs straight on the mattress in the resident's primary language, the resident followed instructions. The LPN informed the surveyor that the resident did not speak English but was able to communicate his/her needs. The surveyor asked the LPN how the resident got the wound to the left heel, and the LPN stated that she believed that it happened at the dialysis center where he/she spends four hours a day sitting in one position three days a week. The surveyor, the LPN, and the Director of Nursing (DON) observed the resident's wound to the left heel, by removing the old dressing to the site. The DON stated that she performs wound rounds weekly and that the left heel wound was smaller than a dime, superficial, and healing well. She confirmed that the wound was found after the resident returned from the dialysis center in May 2021. On 8/19/21 at 11:24 AM, the Regional Nurse informed the survey team that they reached out to the dialysis center this morning regarding the wound that may have occurred at the center, and he stated that the dialysis center uses pressure-relieving chairs that are cushioned. The Regional Nurse confirmed that this information would be expected to be included in their investigation at the time the wound was identified to determine a root-cause. The Regional Nurse stated in the presence of the survey team that the wound was unavoidable due to his/her comorbidities and the resident's occasional non-compliance with elevation and offloading his/her heels. The LNHA, the DON, and the Regional Nurses were informed of the surveyors findings, and acknowledged that an investigation should be conducted into any facility-acquired pressure ulcer, including an ulcer or other injury that occurred while at a medical appointment. A review of the facility's Incident Reporting - Resident policy revised 3/1/2020 included that an investigation will be initiated whenever an untoward event occurs which may or may not result in injury to a resident. Incidents may include .skin tears, lacerations, fractures, known or unknown in origin; Bruising, including hematoma/known or unknown in origin . The policy did not address that facility-acquired pressure ulcers would warrant an investigation into the cause. A review of the facility's undated Abuse Prevention Policy and Procedure included that the statements from those allegedly involved in the mistreatment, neglect, abuse .will be obtained; Statements shall be obtained from the resident(s) involved if able. Any injury to the resident(s) shall be objectively documented in the narrative nurses notes . The facility must have procedures in place to investigate different types of incidents including incidents of unknown origin. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment tool for assessing pressure ulcer risk, behaviors of wandering, and a dental assessment. This deficient practice was identified for 2 of 22 residents reviewed for MDS accuracy (Resident #6 and #53). The evidence was as follows: 1. During the initial tour of the facility on 8/12/21 at 11:38 AM, the Unit Manager (UM) informed the surveyor that Resident #6 had a facility-acquired pressure ulcer to the left heel that was unstageable (full thickness tissue loss in which wound depth is not visible due to coverage of dead tissue and cannot be determined). The surveyor reviewed the medical records for Resident #6. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses which included end stage renal disease, heart failure, diabetes, edema (swelling), and weakness. A review of the Pressure Ulcer Injury Risk Evaluation dated 5/1/21 reflected that the resident was evaluated with a total score of 14. The form indicated that a Total score of 8 or above represents HIGH RISK and a prevention protocol should be initiated immediately. A review of a comprehensive significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/10/21 reflected that the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating an intact cognition. The section used to assess the resident's skin indicated that the resident was not at risk for skin breakdown and had no pressure ulcers or other skin breakdown. A review of the resident's individualized care plan initiated on 5/2021 reflected that the resident was at risk for skin breakdown. The care plan was updated on 5/20/21 which reflected that the resident was at such risk that nine days after the significant change MDS assessment, he/she developed a left heel Deep Tissue Injury (DTI; an injury to the underlying tissues of the skin produced by prolonged pressure and are likely to deteriorate). On 8/18/21 at 10:04 AM, the surveyor observed Resident #8 in bed with his/her eyes closed. The surveyor observed that the resident had his knees bent with his/her feet resting directly on the mattress. The surveyor observed that when the Licensed Practical Nurse (LPN) told the resident to rest his/her legs straight on the mattress in the resident's primary language, the resident followed instructions. The LPN informed the surveyor that the resident did not speak English but was able to communicate his/her needs. The surveyor asked the LPN how the resident got the wound to the left heel, and the LPN stated that she believed that it happened at the dialysis center where he/she spends four hours a day sitting in one position three days a week. The surveyor, the LPN, and the Director of Nursing (DON) observed the resident's wound to the left heel, by removing the old dressing to the site. The DON stated that she performs wound rounds weekly and that the left heel wound was smaller than a dime, superficial, and healing well. She confirmed that the wound was found after the resident returned from the dialysis center in May 2021. On 8/18/21 at 10:41 AM, the surveyor interviewed the certified-MDS Coordinator/Registered Nurse who stated that she worked at the facility full time as the MDS Coordinator for more than 10 years. The surveyor reviewed the significant change MDS assessment dated [DATE] for Resident #6 with the MDS Coordinator. The MDS Coordinator confirmed that the assessment reflected that the resident was not at risk for a pressure ulcer. She stated that she did not complete that section, but that the nurse may have put that the resident was not at risk because he/she was continent of urine and that the resident was not at risk for skin breakdown on the sacral area. She confirmed that pressure ulcers can develop on other areas of the skin other than sacrum and hip region. She acknowledged that the resident was at risk for skin breakdown because he/she had a decline in his/her participation in activities of daily living and developed a wound nine days after the assessment was completed. She confirmed that all residents in long term care have some form of risk for developing a pressure ulcer. She confirmed that it was inaccurate, and that she would modify it. On 8/19/21 at approximately 11:25 AM, the Regional Nurse stated in the presence of the survey team that the MDS dated [DATE] was inaccurately coded. He confirmed that it should have reflected that the resident was at risk for a pressure ulcer. He acknowledged that Resident #6 did have a care plan for pressure ulcer risk at that time, but that it should have still been documented accurately in the MDS. 2. On 8/17/21 at 10:30 AM, the surveyor observed Resident #53 independently ambulating by the nurses station. The surveyor greeted the resident and asked how he/she was doing and the resident did not verbally respond. The resident proceeded to walk down the hallway. The surveyor reviewed the medical record for Resident #53. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnoses which included Alzheimer's disease, anxiety disorder, and psychosis. A review of a dental exam performed in November 2020 which revealed that the resident was edentulous (without natural teeth), and at that time was not a candidate for dentures. A review of the annual MDS dated [DATE] reflected that a BIMS could not be obtained, so staff assessed the resident's cognition to have a short and long-term memory problem with a moderately impaired decision-making capacity. The MDS revealed that the resident was fully dependent on staff for eating and required one staff member to assist in feeding. It further indicated in the section used to assess the oral/dental status of the resident, that the staff performing the assessment was unable to examine. A review of any corresponding progress notes for the MDS did not indicate why the staff was unable to examine the oral/dental status of the resident when he/she was assisted in feeding by staff, and a previous dental exam indicated that the resident had no natural teeth. On 8/18/21 at approximately 10:45 AM, the surveyor interviewed the certified-MDS Coordinator/Registered Nurse who reviewed the annual MDS dated [DATE] with the surveyor. The MDS Coordinator confirmed that the resident had a dental exam done prior to the MDS which reflected that the resident was edentulous, and was dependent on staff during feeding. She stated that the resident likely did not open his/her mouth during the assessment. She confirmed that if the resident was fed by staff, they could examine the resident's oral/dental status during meals or interview the nursing department that assisted in feeding to determine if the resident had any oral/dental/gum concerns that could be accurately recorded in the annual MDS. She stated that she would go back and modify the MDS to reflect the change. She was unable to provide documented evidence regarding why the resident's oral/dental status was unable to be examined at the time of the MDS assessment. She confirmed that the resident had no dental issues or gum concerns that were addressed during that time frame. A review of the CMS RAI manual updated 10/2019 reflected that the intent of assessing the oral/dental status of the resident was to intended to record any dental problems present in the 7-day look-back period .Assessing dental status can help identify residents who may be at risk for aspiration, malnutrition, pneumonia, . It further included that If a resident is unable to self-report, then observe him or her while eating .to determine if chewing problems or mouth pain are present .Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents . On 8/19/21 at 11:24 AM, the surveyor interviewed the Regional Nurse in the presence of the survey team, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The Regional Nurse acknowledged that the MDS assessments were not accurate for Resident #6 and Resident #53 as presented in the findings. He stated that they were modified. No additional documentation was provided to refute the surveyor's findings and the DON stated that the facility did not have an MDS assessment policy, but that they used the CMS RAI Manual for how to code the MDS assessments. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by not accurately following a Physician's Order (PO) for the administration of one dose of insulin. The deficient practice was identified for 1 of 22 residents reviewed for professional standards of practice (Resident #81), 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 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 8/13/21 at 10:58 AM, the surveyor observed Resident #81 in a common room participating in an exercise program being televised. The surveyor attempted but was unable to interview the resident. The surveyor reviewed the medical record for Resident #81. A review of the Resident Face Sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included dementia (impairment of the brain function), diabetes (chronic condition that affects the way the body processes sugar causing a high blood sugar), diabetic neuropathy (nerve damage associated with high blood sugar), and dependence on renal dialysis (a process of removing excess fluids and toxins from the blood when the kidneys can no longer perform this function). A review of the significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/16/21 reflected the resident had a brief interview for mental status (BIMS) score of 99, indicating that the resident was unable to complete the interview. The assessment reflected that staff performed a cognitive assessment which revealed that the resident had a short and long-term memory problem and a moderately-impaired decision-making capacity. A review of the August 2021 Physician's Orders form revealed a physician's order (PO) dated 7/31/21 for Novolog Insulin, 100 units/milliliter solution, inject by subcutaneous route (under the skin) three times a day before breakfast, dinner and bedtime on dialysis days Tuesday, Thursday and Saturday using an insulin sliding scale. The sliding scale order was written as follows: if the blood sugar (BS) results are 150-200 administer two (2) units, 201-250 administer four (4) units, 251-300 administer six (6) units, 301-350 administer eight (8) units, 351-400 administer ten (10) units and if BS greater than 400 or below 60 then call the physician. The form also revealed that there was a standing routine order for Novolog insulin dated 7/9/21. The PO specified to administer Novolog Flexpen Insulin, 100 units/ml (3 ml), inject 4 units subcutaneously twice a day before a meal routinely. A review of the current August 2021 Medication Administration Record (MAR) reflected the PO dated 7/31/21 for the Novolog Insulin sliding scale. The order specified if the blood sugar (BS) results are 150-200 administer two (2) units, 201-250 administer four (4) units, 251-300 administer six (6) units, 301-350 administer eight (8) units, 351-400 administer ten (10) units and if BS greater than 400 or below 60 then call the physician. The MAR for August 2021 indicated that on 8/12/21 (Thursday/a dialysis day) at 7:30 AM the resident's BS result was 141. The MAR was signed by the Licensed Practical Nurse that she administered two (2) units of insulin. (This did not correspond with the physician's order to administer two (2) units if the blood sugar was between 150 - 200). Further review of the August 2021 MAR for Resident #81 revealed that the Licensed Practical Nurse also signed for the administration of the routine dose of four (4) units of Novolog Insulin at 7:30 AM on 8/12/21 in accordance with the PO dated 7/9/21 to total six units of Novolog insulin at breakfast, When resident should have only received the four units of Novolog insulin in accordance with the resident's blood sugar and sliding scale parameters ordered by the physician. A further review of the MAR did not reveal any other improperly administered doses of Novolog insulin in accordance with the hold parameters. A review of the progress notes for 8/12/21 did not reveal a nurses note that corresponded with the two units of Novolog insulin given outside the BS parameter. On 8/18/21 at 08:37 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she had administered the insulin dose at 7:30 AM to Resident #81 on 8/12/21 (Thursday/dialysis day). The LPN stated that the insulin dosage was based on the PO and should be followed as ordered. The LPN added that according to the PO she should not have administered any insulin based on the sliding scale order. The LPN also stated that she was unsure why she had administered 2 units of insulin for a BS of 141 and thought maybe the two (2) units was a routine PO for the resident, and not on a sliding scale. A review of the MAR for August 2021 did not reveal a standing routine order for Novolog insulin 2 units. On 8/19/21 at 11:41 AM the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), two (2) Regional Nurses (RN1 and RN2), the Assistant Director of Nursing and Infection Preventionist. The RN 1 stated that a Medication Error Report was generated regarding the incorrect dose of insulin being administered by the LPN. The RN1 also stated that the LPN was in-serviced and a medication pass competency was going to be completed. The RN1 acknowledged that the nurse gave two units of insulin when she should not have. He stated that the resident had no adverse outcome as it was given with the resident's breakfast. The subsequent blood sugar taken was within the resident's normal acceptable parameters. He acknowledged that the LPN was not following the physician's order. A review of the facility policy dated 2/21/21 for Medication Administration and Documentation provided by the DON reflected that medication administration would occur in an accurate manner. In addition, the policy reflected that the nurse would assure the five rights and compare the medication dosage on the medication administration record with the physician's order and would check at least three times prior to the administration of a medication for accuracy. NJAC 8:39- 11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a.) the appropriate storage of a urinary leg bag to prevent catheter-associated urinary tract infections in accordance with nationally accepted guidelines for infection prevention and control, b.) a care plan for the use of a urinary leg bag, and c.) the policy addressed storage of urinary leg bags to prevent urinary tract infection. This deficient practice was identified for 1 of 2 residents reviewed with an indwelling urinary catheter (Resident #74). The evidence was as follows: On 8/17/21 at 9:25 AM, the surveyor observed Resident #74 in bed, awake and watching TV. The surveyor observed an indwelling urinary catheter bag secured to the bed frame in a dignity bag. The urine in the tubing was pale yellow with a small amount of sediment in it. The resident agreed to be interviewed at that time. The resident stated that he/she has had several urinary tract infections and that he/she had them even prior to admission to the facility due to multiple co-morbidities. He/She stated that it was a supra-pubic catheter (indwelling catheter that is surgically placed directly into the bladder through the abdominal wall). The resident stated that he/she had some discomfort at the site, but that the nurses were aware, and denied that he/she was currently on an antibiotic for a urinary tract infection (UTI) . The surveyor observed the resident's bathroom at that time, and observed a clear plastic bag wrapped around the hand rail. Inside the clear plastic bag was a used urinary leg bag that was uncapped and was stored with a moderate amount of yellowish-orange colored liquid within the clear plastic bag. Between 9:30 AM and 9:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to care for Resident #74. The LPN stated that the resident had an indwelling urinary catheter due Neutrogena bladder caused by Multiple Sclerosis (MS) (a progressive autoimmune disease that eats away at the protective covering of the nerves and leads to impaired functional mobility). She stated that the resident has had UTI's in the past due to multiple co-morbidities that make him/her more prone to them. She stated that the resident was alert and oriented and very involved in treatment and care decisions. At 9:41 AM, the surveyor and the LPN entered the resident's bathroom and observed the storage of the urinary drainage bag. The surveyor asked the LPN what she was seeing in regards to how the bag was stored, and the LPN replied, it looks dirty. She stated that there was an orange-colored liquid in the bag and that she didn't know what that substances was. She stated that she could guess what it was but that she did not want to guess. She also acknowledged that there was no cap on the end of indwelling urinary drainage bag. She stated that if a bag was being stored it should be cleaned and clear of any liquids before storing, the urinary drainage spout should be capped, and the drainage bag should be stored in a clean plastic bag in the bathroom. She stated that she did not personally store the leg bag in the improper manner, but the 3 PM to 11 PM shift removes the leg bags and applies a large drainage bag in during evening care. She stated that she would not use that leg bag, but that if she had to apply one, she would get a new one. She stated that the Certified Nursing Aides (CNA) apply the leg bags, and that the surveyor could speak to the CNA assigned to the resident today. At 10:00 AM, the surveyor interviewed the resident's assigned CNA, who stated that she worked at the facility full time, but would float between units. The CNA stated that she was responsible to empty the indwelling urinary drainage bag at least twice a shift and inform the nurse of the total volume at the end of the shift. She stated that she would let the nurse know if the resident had any signs or symptoms of a UTI, including pain or discomfort and changes in urine color, consistency, smell. She stated that she also applies a urinary leg bag when the resident gets out of bed so as to conceal the bag. At that time, the surveyor and the CNA looked at the storage of the leg bag in the resident's bathroom, and the surveyor asked what the CNA was seeing. The CNA stated that firstly there was no cap on the catheter bag, but stated that they are so small, they easily get lost. She stated that they are blue and they disappear. She also stated that the yellowish-orange liquid in the bag was pee that that she would get a brand new leg bag to apply on the resident. She stated that there should never be urine left in the leg bag when it was being stored overnight. She stated it may have been the evening or night shift that did that. She stated that she usually gets a new leg bag for resident's anyway, but acknowledged that the bag should not be stored in this manner. She stated that if it wasn't cleaned and there was no cap, the CNA should have just thrown out the bag instead of storing it improperly. On 8/17/21 at 10:58 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that he had been working as the IP since September 2020, and they were currently working on a quality improvement project in regards to indwelling urinary catheters. The surveyor asked if the facility's leg bags were single-use or can be used multiple times, and he stated that he wasn't sure and would follow up with the surveyor. At that time, the surveyor and the IP entered the bathroom of Resident #74 to observe the storage of the leg bag. The IP immediately looked at it and repeated, No, No, No, The surveyor asked what was wrong with what he was seeing and he stated that the bag was dirty, there is no cap and that it was supposed to be cleaned out before being placed in the clear plastic bag. He stated that it appeared as though there was urine in the bag where the leg bag was being stored. He stated that the 3 PM to 11 PM shift stored it improperly and that he would ensure the resident got a brand new leg bag. He then confirmed that the leg bags were re-usable, but that staff had to clean them properly before storage and ensure there was a cap on the drainage spout to prevent the possibility of infection. The IP acknowledged the surveyor's findings and stated that he would look up any in-service education done and determine who improperly stored the leg bag in this manner. The IP stated that the resident did not currently have a UTI, but that he/she had a history of recurrent chronic UTI's in the past due to multiple co-morbidities including recent stents in the kidney's and bladder dysfunctions. He stated that due to the resident's history of UTI's, they would consider using brand new leg bags each time one had to be applied. The surveyor reviewed the medical record for Resident #74. A review of the resident's active Physician's Orders sheet for August 2021 and generated on 8/17/21, reflected that the resident was recently admitted to the facility with diagnoses which included sepsis (a life-threatening complication from an infection), neuromuscular dysfunction of the bladder, kidney stones, urinary tract infection with hematuria (blood in the urine), and anxiety disorder. The Physician's Order sheet revealed a physician's order (PO) dated 7/2/21 to change the urinary drainage bag on the first and third Monday of the month during the 11 PM to 7 AM shift. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/6/21 reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had a fully intact cognition. It further included that the resident had an indwelling urinary catheter. A review of the resident's individualized, comprehensive care plan dated 4/14/21 reflected that Resident #74 had an indwelling urinary catheter due to a Neutrogena bladder. Interventions included to monitor for changes in output, signs of bladder distension, and to increase oral fluids. The care plan did not address interventions to apply a leg bag and the frequency of when a new one would need to be applied. In addition there was a care plan focus that the resident had a history of UTI's initiated on 7/7/21. Interventions included to monitor for signs and symptoms of urological dysfunction, and We will provide your (sic) with catheter care q [every] shift and PRN [as needed]. It did not address the use or storage of the urinary leg bag. On 8/19/21 at 11:21 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team and the Regional Nurses and the Licensed Nursing Home Administrator (LNHA). The DON acknowledged the surveyor's findings and stated that they were currently working on revamping the urinary leg bag uses. The Regional Nurse confirmed that the resident had a history of UTI's and that storing an indwelling urinary catheter bag improperly could place the resident at risk for a UTI, but confirmed that the CNA or LPN would not have applied the leg bag had it been seen stored in that manner. A review of an Inservice Education Attendance Sheet dated 11/29/2020 reflected that Certified Nursing Aides, Licensed Nurses, Recreation and Housekeeping departments attended an in-service education training on preventing UTI's in residents with indwelling urinary catheters with a method of instruction that was presented orally, by video, and with accompanying hand-outs. A review of the facility's indwelling urinary catheter policy revised 11/2020 included that the drainage bag is changed when the catheter is changed, but the policy did not specify if the drainage bags were for single-use, or if they were for multi-use how they were to be cleaned prior to storage. A review of the Centers for Disease Control (CDC) Summary of Recommendations for the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), included to, .Prevent contact of the drainage spigot with the non-sterile collecting container .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. NJAC 8:39-9.4 (a); 27.1 (f)