**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure two residents (Resident (R) 51 and R306) of 36 residents observed in Initial Pool had medications unattended at the bedside only with an assessment for safety and the ability to self-administer medications. These failures placed both residents at risk for overdose, missed medication doses, or misappropriation of medication. Findings include: 1. Review of R36's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed she admitted on [DATE] with diagnoses including post-polio syndrome and hemiplegia affecting the left dominant side. Review or R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/25, located under the MDS tab of the EMR, revealed she scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. R36 did not exhibit mood or behavioral symptoms. During an observation on 03/04/25 at 3:54 PM in R36's room, R36 was lying in bed with an over-bed table over her lap. There was a tube of Cortisone 10 (hydrocortisone anti-itch cream) on the over-bed table. R36 stated her skin, especially her right arm, was itching so she started applying cortisone cream. R36 stated the staff did not apply the cream for her; she applied it herself. Review of R36's Orders tab of the EMR revealed a physician's order, dated 09/26/24, for diphenhydramine (antihistamine) tablets as needed for itching and a physician's order, dated 12/31/24, for hydroxyzine (antihistamine) tablets as needed for itching. There was no order for hydrocortisone cream, nor was there an order to indicate R36 could self-administer medications. Review of R36's EMR under the Assessments tab revealed there was no assessment of the resident's safety with medications unattended at her bedside or ability to self-administer medications. Review of R36's EMR under the Care Plan tab revealed there was no plan of care addressing medications kept at the resident's bedside or self-administration of medications. During an observation on 03/07/25 at 10:34 AM in R36's room, R36 was again lying in bed with the tube of Cortisone 10 cream on the over-bed table in front of her. During a concurrent observation and interview on 03/07/25 10:37 AM in R36's room, Unit Nurse 2 verified the Cortisone 10 cream was left in R36's room unattended and R36 did not have an order for the cream and should not be self-administering medication. R36 stated her husband had brought in the cream. Unit Nurse 2 stated the staff should have reported the cream in R36's room for follow up, but she was not aware R36 was using the cream. 2. Observation and interview on 03/04/25 at 2:48 PM in R306's room revealed two open lidocaine patches laying on her overbed table. R36 stated she would be having a shower soon so the patches would be put on after her shower. She said the nurse had brought them into her room approximately one-half hour prior. Since she was having a shower soon, she left them on her overbed table and said she would put them on after her shower. During an interview on 03/0425 at 4:15 PM, Licensed Practical Nurse (LPN) 1 revealed she did not think there was any problem with leaving the lidocaine patches with R306 LPN1 stated she was sure R306 was safe to have medications left with her. Review of R306's admission date found under the Clinical Census tab of the EMR revealed she had been admitted on [DATE]. Review of R306's diagnoses found under the Medical Diagnosis tab of the EMR revealed she had diagnoses that included generalized osteoarthritis, low back pain and other chronic pain. Review of R306's admission MDS with an ARD of 02/27/25, located under the MDS tab of the EMR, revealed she had BIMS score of 15 which indicated she was cognitively intact. Review of R306's physician orders found under the Orders tab of the EMR revealed she had a 02/24/25 order for Lidocaine External Patch 4 % Apply to neck topically one time a day for pain and remove per schedule. Apply Lidocaine Pain Relief Max St [strength] 4 % Patch. Apply to back topically one time a day for pain. There was no physician's order for the self-administration of those medications. Review of R306's 02/21/25 Care Plan, located under the Care Plan tab in the EMR, revealed there was no plan of care addressing medications kept at the resident's bedside or self-administration of medications. Review of R306's Assessments tab of the EMR revealed there was no assessment for the self-administration of medications. During an interview on 03/05/25 at 3:00 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed R306 did not have an order or assessment to self-administer medications. LPN1 should not have left the Lidocaine Patches on the overbed table while she waited for R306 to have her shower. LPN1 should have kept the patches in the medication cart until she was ready to apply them. Review of the facility policy titled, Medication Administration - Self Administration, dated 02/07/25, revealed, Before a resident may exercise the right to self-administer medications: The assigned nurse must assess the resident's' cognitive, physical, and visual ability to carry out this responsibility . The assigned nurse/team must determine who will be responsible (resident or nursing) for the following: a. Storage of medications. b. Documentation of the administration of medications. c. Location of the medications administration (e.g. resident's room, nurse's station, activity room, etc.). The resident's Physician must be notified and orders obtained for self-administered Medications. Storage of medication will be monitored by nursing to ensure that medication is located in designated area. NJAC 8:39-29.2(c)6(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure the call bell was accessible for one of 36 residents (Resident (R) 32) observed in the Initial Pool. This failure placed R32 at risk of injury or distress when he could not access the call bell to alert staff of an emergency or unmet needs. Findings include: Review of R32's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he admitted on [DATE] with diagnoses including dementia and heart disease. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/25, located under the MDS tab of the EMR, revealed he scored eight out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Per the MDS, R32 did not exhibit mood or behavioral symptoms. R32 had no impairment of his functional range-of-motion in his upper extremities. Review of R32's Care Plan, dated 11/03/23 and located under the Care Plan tab of the EMR, revealed, I am at risk for falls because I am on a psychoactive medication, I am weak, I have unsteady gait. The goals included, I will verbalize understanding of the need to call for assistance through review date. The approaches included: Call bell within reach and Please remind me or encourage me to use my call bell. During an observation in R32's room on 03/04/25 at 1:58 PM, R32 was lying in bed in his room and the call bell was on the nightstand, approximately five feet away to his left side. R32 stated he sometimes used the call bell but could not reach where it was located. During an observation on 03/05/25 11:45 AM in R32's room, R32 was lying in bed and the call bell was again on top of the nightstand, approximately five feet away from him. R32 stated, I'd like to have it over here; I should have it. R32 stated he could not reach the call bell and needed to have it closer to his right side. During an observation in R32's room and concurrent interview on 03/05/25 at 11:54 AM, Certified Nursing Assistant (CNA) 2 confirmed the call bell was not within R32's reach and was on the wrong side for him to be able to use it. CNA2 stated R32 could use his call bell but needed it closer to his right side so he could use his right hand. CNA2 stated the call bell should be within his reach at all times. During an interview on 03/07/25 at 10:45 AM, Unit Nurse 2 stated R32's call light should be in his reach at all times, and she would ensure staff were educated to place call lights within reach of the residents. Review of the facility policy titled, Call Bells, dated 01/23/25, revealed, Policy: All residents will have a call bell within reach . Procedure: When getting a resident in a chair or in bed it is imperative that the call bell is in reach and functioning. NJAC 8:39-4.1(a)11

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R) 142 and R28) out of 34 sample residents had an accurately coded Minimum Data Set (MDS) assessment. This failure increased the risk of inappropriate care provision to R142 and R28. Findings include: 1. Review of R142's admission Record from the electronic medical record (EMR) Profile tab showed a facility admission date of 11/27/24 with medical diagnoses that included unspecified dementia without behavioral or psychotic disturbance and depression. Review of R142's admission MDS, located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/04/24 showed R142 was coded for having depression, dementia, and psychotic disorder (other than bipolar). During an interview on 03/06/25 at 9:55 AM regarding the psychotic disorder diagnosis, the MDS Coordinator (MDSC) stated, There was a psych follow progress note in [EMR] on 12/04/24 that did show an active diagnosis of anxiety treated with prn [as needed] Xanax, however, I must have mistaken 'disruptive mood dysregulation disorder' and coded psychosis in error. The MDSC confirmed R142 had no diagnosis of psychosis. The MDSC stated she used the RAI Manual (Resident Assessment Instrument) and not a policy regarding MDS accuracy. During an interview on 03/07/25 at 4:35 PM regarding MDS accuracy, the Director of Nursing (DON) stated an expectation that MDS coding would be reviewed for accuracy and would follow the RAI guidelines. Review of the October 2024 Resident Assessment Instrument (RAI) Manual stated on page I-1 stated: Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status. On Page I-7 showed: Steps for Assessment There are two look-back periods for this section: o Diagnosis identification (Step 1) is a 60-day look-back period. -Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period . 1. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days. -Diagnostic information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up. 2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. 2. Per R28's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease, Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. During an observation on 03/04/25 at 4:29 PM, R28 was sitting on his bed with a tab alarm hanging on his right side of the bedrail with a string pinned on his grey shirt on his right chest. On 03/06/25 at 9:05 AM and 03/07/25 8:50 AM, R28 was observed sitting on the bed again with the tab alarm pinned on his right chest. Review of R28's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for The resident is Moderate risk for falls. The care plan included the intervention of Pad alarm in bed and chair. Initiated 05/11/21. Revised 07/18/22. R28's Care Plan Report included a care plan for actual falls, initiated 01/05/22, revised 02/18/25, documented R28's fall events with the alarms used and interventions as follows: - A fall on 06/10/21 at 12:40AM, the intervention was bed alarm bed at night, tab alarm to wheelchair. Initiated: 06/10/21. - A fall on 11/02/21 at 4:55 PM, the intervention was replacing the broken tab alarms. - A fall on 01/4/22 at 11:30 AM, the intervention was continuing the tab alarms. - A fall on 01/4/22 at 11:30 AM, the intervention was continuing the tab alarms. - A fall on 02/17/25 at 10:55 PM, the intervention was replacing the broken bed alarms. Initiated 02/18/25. Review of R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 was in use of tab alarms for bed and chair as follows: - TAB ALARM TO WHEEL CHAIR, check for functioning and placement q [every] shift for safety hx [history] falls. Start date 06/10/21. - CHANGE PAD ALARM BATTERY MONTHLY ON THE 15TH every day shift every 1 month(s) starting on the 15th for 1 day(s). Start date 08/15/22. - TAB ALARM TO BED - CHECK PLACEMENT AND FUNCTIONING every shift. Start date 02/20/25. Review of R28's annual MDS with an ARD of 05/07/24, quarterly MDS with an ARD of 08/06/24, and quarterly MDS with an ARD of 02/04/25, located under the MDS tab of the EMR, revealed staff documented R28 did not use a bed alarm or chair alarm. During an interview on 03/07/25 at 11:15 AM, the MDSC reviewed R28's records and stated she would correct the three wrong MDS assessments immediately. Review of the October 2024 RAI Manual, under Chapter three, section P: RESTRAINTS AND ALARM, documented the following: - An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident's clothing, motion sensors, door alarms, or elopement/wandering devices. - Adverse consequences of alarm use include, but not limited to, fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy. - When the use of an alarm was considered as an intervention in the resident's safety strategy, use must be based on the assessment of the resident and monitored for efficacy on an ongoing basis, including the assessment of unintended consequences of the alarm use and alternative interventions NJAC 8:39-33.2(d)

Based on record reviews and interviews with residents and staff, the facility failed to ensure one of 34 sample residents (Resident (R) 68) was provided with the opportunity to review her care plan, medication list and express her concerns and needs during a quarterly care conference. This failure has resulted in care not being tailored to R68's needs, as the care plan was not updated accordingly. Findings include: Review of the facility's policy titled Interdisciplinary (IDT) Care Plans, revised 03/08/23, outlined the care planning guidelines for the IDT team. These guidelines aim to address the individual physical, mental, emotional, psychological, social, spiritual, and medical needs of each resident. The policy details the following procedures: - An interdisciplinary approach will be followed during the formulation of the comprehensive care plan. The resident and/or family and, /or significant other and the whole interdisciplinary team will meet to discuss problems identified, formulate goals that are measurable and attainable and identify approach to be followed in attaining the goals set forth for the resident during an interdisciplinary care plan meeting. - The care plan will be individualized and will include problems, goals, and approaches that reflect the resident's uniqueness and idiosyncrasies. - IDT meeting is then scheduled with resident and or/family member per their preference, plan of care is reviewed; quarterly meetings will be scheduled thereafter or as requested/needed. - Care plans will be viewed and adjusted as needed and on a quarterly basis by any member of the IDT to ensure that the most current and comprehensive plan of care is followed. Per R68's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/20/21. Review of R68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25, located in the resident's EMR under the MDS tab, revealed the facility assessed R68 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also revealed R68 did not present behavior symptoms, was always incontinent with bowel and bladder did not walk, required set up or clean up assistance (helper sets up or cleans up, resident completes activity) for oral hygiene, substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) for sit to lying on bed, chair to bed transfer, dressing and toileting. Review of R68's Care Plan Report, located in the resident's EMR under the Care Plan tab, revealed The resident has an ADL [Activities of Daily Living] self-care performance deficits as evidenced by requiring: (including bed mob, transfer, toileting, eating, dressing, personal hygiene and ambulation,) initiated 05/02/22, included the following interventions: - Provide/Encourage assist in ADL's with (specify: 2 person). Hoyer lift for transfers. Initiated 05/02/22. - Resident prefers to be washed/showered and changed/toileted at 10 am at times refuses to be changed at this time despite encouragement. Staff will reattempt until resident ready to perform morning ADLs. Initiated 05/02/22. - Resident refuses to be toileted/changed during the night shift. Prefers door closed at all times, does not want staff in her room at night. Initiated 05/02/22. R68's Care Plan Report included a care plan for Personalized Care, Initiated 08/02/22, the care plan included all the following interventions: - Choosing bedtime: Very important to Resident. Initiated 08/05/22. - Resident prefers to not be changed/refuses care between the hours of 9pm /bedtime & 9am/after breakfast. Initiated 08/05/22. - Resident prefers/refuses to not have anyone enter her room between the hours 9pm/bedtime and 8am. Initiated 08/05/22. - Resident requests that anyone who wishes to enter her room knocks first, state their name, and wait for the resident to say it is ok to enter the room. Initiated 08/05/22. - Resident wishes for the Nursing Aides to schedule and coordinate times with the resident when care can be provided. Initiated 08/05/22. - Resident would like to be part of the discussion and decision making regarding her care and her mediations. Initiated 08/05/22. R68's records included an IDT -Team Conference note, dated 01/13/25 at 10:03 AM, under the EMR Assessment tab. The quarterly IDT- Team conference note documented the participants included R68, Unit Nurse 3, Social Service Assistant (SSA,) Activity Director, and a therapist from the rehabilitation department, included the following: - The conference note under nursing, documented Resident remains stable this quarter. Full code with POLST [Physician Orders for Life-Sustaining Treatment] in place. No recent hospitalizations, no change in medications. Skin remains intact, no falls. Lorazepam available as needed when resident request it during anxiety episodes. Does not report pain in the past 5 days. Resident requires extensive assistance for ADLS. Resident is currently taking Bactrim DS 800-160mg for UTI [urinary tract infection] for 3days. - The conference note under family/patient concerns documented No concerns at this time. On 03/06/25 from 3:32 PM to 4:00 PM, during the interview with the unit manager (Unit Nurse 3) and R68 in R68's room: Unit Nurse 3 reminded R68 about her quarterly care conference on 01/13/25. R68 stated that she thought the conference was meant to address her concerns, she was not aware it was her quarterly care conference, and she felt that the entire conference was full of arguments about her concerns. R68 stated she would like all the opportunities to discuss her care and goals, including the care conference. R68 would like to know what medication she was taking and why. R68 stated, for example, a few weeks ago, she was on three different kinds of bowel regimen medication, which caused her to have lots of diarrhea. R68 said if someone explained to her what medication she was taking, her diarrhea would be prevented. R68 reviewed her Personalized Care care plan and stated she did not know there was a care plan for her; she stated the care plan was accurate, that she wanted to have a good night's sleep, and did not want her brief changed after 9:00 PM and before 9:00 AM because of her personal preference. However, she said the Certified Nursing Assistant (CNA) usually set her up to self-clean her upper body after breakfast, but by the time they came back to change her briefs and clean her bottom, it usually was around noon or sometimes not until 2:00 PM. R68 said she did not want to be in a wet diaper the whole night until the next day noon or 2PM each day. R68 stated she would like to add to her care plan the following: - Get her brief change after breakfast first before setting up for her to self-clean her upper body. - Have a nurse to go through her medication list to explain to her what she is taking. - Change her social service from Social Service Assistant (SSA) to Social Service Director (SSD). - Have a counsel for her life trauma about once or twice a week for longer time. Unit Nurse 3 stated during each care conference the medication list and care plans should be reviewed, and the resident's care, goals, special needs or if any issues or changes should be discussed, and the care plan should be updated based on the changes after care conference. Unit Nurse 3 apologized to R68, that they did not go through the medication list and care plan review include updating her care plan for Personalized Care during the last quarterly care conference on 01/13/25. Unit Nurse 3 reviewed R68's personalized care plan and confirmed it had not been revised since it started on 08/05/22. She stated the care plan would be revised at least quarterly during the care conference to meet R68's needs. Unit Nurse 3 stated she would revise it to address R68's needs. NJAC 8:39-11.2(e)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of manufacturer's instructions, the facility failed to ensure that one of one Licensed Practical Nurse (LPN) (LPN1) observed for insulin administration had primed an insulin pen prior to dialing the ordered dose for Resident (R) 41. This failure had the potential to reduce the insulin dose which could have affected R41's blood glucose. Findings include: Review of the manufacturer's INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) KwikPen® (insulin lispro) revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Observation and interview with LPN1 on 03/06/25 at 12:45 PM during insulin administration for R41 revealed LPN1 retrieved a new Humalog insulin pen from the medication storage room. LPN1 put a new needle on the pen and dialed the pen to six units of insulin. Just prior to her administering the insulin, the surveyor asked if she had to prime the pen prior to dialing the ordered insulin dose. LPN1 stated she was not sure and then dialed the pen to ten units and asked if that was the correct amount. When the surveyor asked her if that was the recommended dose to prime the insulin pen needle she answered, is it one unit? The surveyor said No, it is two units. LPN1 then primed the insulin pen with two units, dialed the amount of six units, and administered R41 her insulin. Review of R41's Clinical Census tab found in her electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Review of R41's diagnoses found under the Clinical Diagnosis tab in her EMR revealed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified. During an interview on 03/06/25 at 1:20 PM, the Director of Nursing (DON) stated that the nurses have all been educated on using insulin pens and about priming the insulin pen first. NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

Based on observations, record reviews, and interviews, the facility failed to ensure one of five residents (Resident (R) 68) reviewed for Activities of Daily Living (ADL) out of 34 sampled residents received timely incontinence care. This failure placed the resident at an increased risk for skin breakdown, urinary tract infections, or an undignified existence. Findings include: Review of the facility's policy titled, ADL [activity daily living] policy, revised 09/01/13, reviewed 01/23/25, instructs care givers refer to the nurses' instructions on resident's electronic record for ADL needs and assistance required. Per R68's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/20/21. Review of R68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25, located in the resident's EMR under the MDS tab, revealed the facility assessed R68 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated the resident was assessed to not have any behaviors, was always incontinent with bowel and bladder, did not walk, required set up or clean up assistance (helper sets up or cleans up, resident completes activity) for oral hygiene, substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) for sit to lying on bed, chair to bed transfer, dressing and toileting. Review of R68's Care Plan Report located in the resident's EMR under the Care Plan tab revealed The resident has an ADL self-care performance deficits as evidenced by requiring: (including bed mob [mobility], transfer, toileting, eating, dressing, personal hygiene and ambulation,) initiated 05/02/22, included the following interventions: - Provide / Encourage assist in ADL's with (specify: 2 person). Hoyer lift for transfers. - Resident prefers to be washed/showered and changed/toileted at 10 am. at times refuses to be changed at this time despite encouragement. Staff will reattempt until resident ready to perform morning ADLs. - Resident refuses to be toileted/changed during the night shift. Prefers door closed at all times, does not want staff in her room at night. R68's Care Plan Report included a care plan for Personalized Care, Initiated 08/02/22, the care plan included all the following interventions: - Choosing bed time: Very important to Resident. - Resident prefers to not be changed/refuses care between the hours of 9pm /bedtime & 9am/after breakfast. - Resident prefers/refuses to not have anyone enter her room between the hours 9pm/bedtime and 8am. - Resident wishes for the Nursing Aides to schedule and coordinate times with the resident when care can be provided. Observation and interview on 03/04/25 at 12:29 PM, R68 was observed sitting on bed with a facility gown on, and she had face make up on. R68's tray table in front of her had a pink square plastic container with a small white towel and soapy water inside. R68 stated staff changed her brief last night at around 8:00 PM to 8:30 PM, and she had not been changed since. The resident stated she had a wet brief on (during the interview) and she had been sitting in the wet brief since last night. R68 further stated I was done with this basin from ten o'clock until now it is still sitting here.this is really typical every day and no one comes in to get me changed. I have to wear a diaper because I cannot walk, and I can't get to the bathroom. In the morning, I am sitting in a soaked diaper, I am on diuretics, so I urinate more. R68 looked and sounded upset and stated one activity staff came to invite her to join a lunch celebration on the second-floor activity room today. R68 stated Look at me, I cannot go like this. R68 stated it was a big problem to get ready in the morning and this was not the first time she missed activities, and she also had missed doctor's appointments in the past because no one assisted her to be ready on time. R68 stated she was always the last one the aides came to assist in cleaning up and to get dressed. R68 stated she had a small abrasion near her buttock, thigh area. When wet, sometimes she felt a bit of pain before. Staff gave her a pad to protect it from getting wet in the past. On 03/04/25 at 1:18 PM, Certified Nursing Assistant (CNA) 5 was observed to answer R68's call light, CNA5 and another CNA entered R68's room for a long time. On 03/04/25 at 4:49 PM, R68 was observed dressed and sitting in her wheelchair in her room near the window. When asked, R68 stated CNA5 came to respond to her call light and changed her when this surveyor left her room on 03/04/2025 at 1:17 PM. R68 stated however she did not get help to be dressed and transferred to her wheelchair until around 2:30 PM. R68 stated her day had just begun from then. When asked, R68 stated she did not press call light again after CNA5 left around 1:30 PM, she just waited, she thought the aides were busy. And when they have time, they would come and help her to get dressed. R68 was in her wet brief from the night before her bedtime until the next day on 03/04/25 at 1:17 PM. R68 did not get dressed until 2:30 PM. Observation was conducted on 03/05/25 from 9:25 AM to 12:20 PM outside of R68's room. At 9:35 AM, CNA6 knocked on R68's door and asked, are you done with your tray? CNA6 entered R68's room and brought out breakfast tray. At 11:03 AM, R68 had a female visitor. At 11:10 AM, R68's visitor left. At 11:44 AM, CNA5 knocked on R68's door to answer the call light instantly, and CNA5 was at R68's doorway and told R68 that she would be back in 15 minutes. At 11:46 AM, CNA5 and CNA6 knocked on R68's door and entered to change her. At 12:07 PM, CNA5 and CNA6 exited R68's room. During an immediate interview with both CNAs, CNA5 stated she delivered breakfast to R68 around 8:30 AM and she prepared a basin to set R68 up for oral and face hygiene at 10:30 AM. CNA5 stated she came back to change R68's brief and provide peri care around 11:15 AM to 11:30 AM. CNA 5 stated R68 usually likes to sit in her wheelchair after cleaning up, but she preferred to stay in bed that day. R68 was in her wet brief from the night before bedtime until the next day 03/05/25 at 11:46AM. During an interview on 03/06/25 at 10:00 AM, CNA4 confirmed R68 had not been changed since last night. CNA4 stated she delivered breakfast to R68 at 8:00 AM and R68 told her she had a doctor's appointment that day at 9:00 AM. When asked, it was already 10:00 AM now, did R68 miss her appointment? CNA4 said, Yes, that is what she said but she could still go. During an observation on 03/06/25 at 10:04 AM, CNA4 knocked on R68's door and entered to change her and CNA1 entered the room one minute later. At 10:19 AM, CNA1 and CNA4 came out of R68's room and talked to Licensed Practical Nurse (LPN) 6. During an observation in R68's room on 03/06/25 at 10:21 AM, LPN6 applied Dermaseptin Ointment (barrier cream) and formed patch to R68's left buttock to her inner thigh area. R68's skin had a patch of scattered redness and whiteness around 10 centimeters (cm) by 10 cm. It presented with a history of open and healed skin. LPN6 stated R68 currently had no skin opening, the care was for prevention. LPN6 stated R68 used to have scattered open rashes in that area about a month ago, because R68 had diarrhea related to her bowel regiment, and the physician already changed the order. During the observation when asked, R68 said her doctor's appointment was at 11:30 AM that day. On 03/06/25 at 10:37AM, CNA1 and CNA4 completed the care and left R68's room. Review of R68's Progress Note, under EMR Progress Note, included an APN [advance practice nurse] PROGRESSNOTES, dated 01/30/25 at 2:43 PM. The progress note documented the physicians - attending visited R68 to follow up chief complaint of blood on wash cloth. The after-visit progress note documented the following: . Patient was requesting to reevaluate her again for possible perineal bleed. She reports taking shower today and no bleeding noted. Upon eval [evaluation], noted small skin opening at her sacrum. Foam patch was applied by unit manager. She does have rash in her perineal, currently uses antifungal. No additional skin opening or discharge noted. Interventions: Sacral ulcer: noted small skin opening, foam patch applied, rx [prescription] wound team to follow, monitor sx [symptoms] Candidiasis: continue nystatin 100000 U/gm [units per gram] q [every] bid [two times a day], monitor sx [symptoms] During an interview on 03/06/25 from 3:32 PM to 4:00 PM with Unit Nurse 3 and R68 in R68's room, R68 stated that the CNAs usually set her up to self-clean her upper body after breakfast, but by the time they came back to change her briefs and clean her bottom, it was around noon or sometimes 2:00 PM. R68 stated she did not want to be in a wet diaper the whole night until the next day until noon or 2:00 PM each day. R68 stated she preferred to get changed after breakfast before setting up for upper body hygiene cleaning. Unit Nurse 3 stated she would revise R68's personalized care plan for the care for the next day. NJAC 8:39-4.1(a)22 NJAC 8:39-27.1(a) NJAC 8:39-27.2(h)

Based on observations, record reviews, and interviews, the facility failed to ensure one of one resident (Resident (R) 79) reviewed for pain out of 34 sampled residents was offered nonpharmacological interventions and documented and followed physician's order to administer pain medication. This failure placed the resident at risk of unmanaged pain and had the potential to negatively affect his quality of life. Findings include: The facility's Pain Management Policy and Procedure, reviewed 01/25/25 and outlined the procedures for assessing and managing pain. These assessments included evaluating pain intensity, location, and duration, as well as observing facial expressions, cries, and moans. Based on these assessments, appropriate care plans for pain management were developed. The pain interventions included the following: - Nursing treatments, for example, facilitating hygiene, initiating relaxation techniques. - Nursing observations, for example, correcting a resident's or family's misconceptions about pain and its treatment and teaching the concept of resident controlled analgesia when applicable. - Medication. The policy further instructed staff to document the details of the residents' pain in a progress note. This documentation included the following information: pain location, intensity, quality, frequency, duration, radiation, and any precipitating factors. Additionally, staff should note the treatments used to relieve the pain and assess their effectiveness. This included documenting the resident's response, such as whether the resident reported that the pain is relieved or controlled, appears relaxed, can rest or sleep appropriately, and is able to participate in activities. Per R79's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 01/17/24 with diagnoses which included peripheral vascular disease (condition of narrowed arteries reduce blood flow to the arms or legs) and stroke. Review of R78's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/25 and located in the resident's EMR under the MDS tab revealed the facility assessed R79 to have a Brief Interview for Mental Status (BIMS) score of 10 out 15 which indicated the resident was moderately cognitively impaired. The MDS also indicated the resident could follow instructions to answer questions, but needed cueing to recall words, had limited range of motion (ROM) upper and lower extremities on one side, did not walk, required substantial to maximal assistance (help does more than half of the effort) for roll left and right on bed, and dependent (helper does all the effort) on bed to chair transfer. R79 experienced moderate pain and did not receive non-medication interventions for pian. On 03/04/25 at 2:58 PM, R79 was sitting in a wheelchair and wearing bilateral green protection boots in his room. R79 expressed concerns regarding his pain. R79 reported experiencing chronic pain, often rating it between 8 and 9 out of 10 on his right heel after his pressure ulcer had healed. R79 stated that the nursing staff had only offered him pain medication as an intervention. R79 stated that he would be willing to try hot packing, leg circulation exercises, or ice packing if it would relief his pain. Review of R79's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for I am in pain/risk for pain r/t [related to] Chronic Physical disability, wounds, initiated 01/25/24. The care plan included the interventions as follows: - Administer pain medication per physician orders. Initiated 01/25/24. - Encourage / assist to reposition frequently for comfort as needed. - Implement non-drug therapies such as but are not limited to, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, ultrasound as tolerated and ordered to assist with pain and monitor for effectiveness. - Monitor side effects of pain medication (i.e. constipation, GI [gastrointestinal] upset, Nausea/vomiting.) - Report non-verbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing. R79's Care Plan Report included a care plan for The resident has Peripheral Vascular Disease (PVD), initiated 03/21/24, revised 04/22/24. The care plan included the interventions as follows: - Educate resident to use caution with heating pads, hot water bottles. - Elevate legs when sitting or sleeping. - Encourage resident to change position frequently, not sitting in one position for long periods of time. Review of R79's Medication Administration Record (MAR) report from 12/01/24 to 03/06/25 and located in the resident's EMR under the Orders tab revealed R79 received some pain medications; however, not all pain medications were administered according to the physician's orders: - Gabapentin Capsule 300 MG Give 1 capsule by mouth at bedtime for Neurotic Pain. Start date 03/29/24. - Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for [650mg] mild pain 1-3. Start date 01/17/24. a. December 2024, not given. b. January 2025, not given. c. February 2025, was given two times when pain level 3/10. d. March 1 to March 6, 2025, was given two times when pain level 3/10. - traMADol [opioid] HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for moderate pain 4-6. Start date 01/27/24. a. December 2024 not given. b. January 2025, was given eight times when the pain level was between 5/10 to 8/10. The Administration Report documented the staff did not follow physician's order administered Tramadol instead of Percocet on 01/05/25 at 8:55 AM, and 01/24/25 at 12:27AM when R79 had severe pain, pain level 8/10. c. February 2025, was given six times when the pain level was between 4/10 to 6/10. d. March 1 to March 6, 2025, was not given. - Percocet [opioid] Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for severe pain 7-10. Start date 04/04/24. a. December 2024, was given forty-three times when the pain level was between 5/10 to 9/10. The Administration Report documented that the staff did not follow physician's order administered Percocet instead of Tramadol on 12/16/24 at 05:50 AM and 12/18/24 at 08:08 PM when R79 had moderate pain, pain level of 5/10. b. January 2025, was given forty-seven times when the pain level was between 0/10 to 9/10. The Administration Report documented the staff did not follow physician's order: On 01/05/25 at 04:06 PM, administered Percocet when R79 had no pain (0/10) On 01/13/25 at 09:41 AM and 01/17/25 at 08:39 AM, administered Percocet instead of Tramadol when R79 had moderate pain, pain level 5/10. On 01/24/25 at 10:07 AM, Percocet instead of Tramadol when R79 had moderate pain, pain level 6/10. c. February 2025 gave twenty-three times for pain 7/10 to 9/10. d. March 1 to March 6, 2025, was not given. Review R79's record revealed, there was no documentation that what non-pharmacological interventions for pain were offered or refused and if the opioid medication's adverse side effects had been monitored. During an interview on 03/06/25 at 11:12 AM, Unit Nurse 3 reviewed R79's record and stated the nurses usually offered nonpharmacological interventions as per the care plan before administering pain medication to R79; however, it was not documented. Unit Nurse 3 stated the nonpharmacological interventions for pain should be documented what had been given or offered and refused. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure that residents were evaluated for the need and safety for use of bed rails prior to the installation/use of rails, documented alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident (R) 28, R74, and R124) reviewed for bed rail use. This failure had the potential for the resident or the RR to be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment. Findings include: 1. Review of R74's undated admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he admitted on [DATE] with diagnoses including Parkinson's disease, anxiety, dementia, and muscle weakness. Review of R74's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/26/24, located under the MDS tab of the EMR, revealed he scored two out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. Per the MDS, R74 exhibited physical behavioral symptoms directed toward others and was dependent on staff for bed mobility or transfers. Review of R74's Care Plan, dated 08/12/24 and located under the Care Plan tab of the EMR revealed, I am at risk for falls because I am on a psychoactive medication, I am on pain medication, I am weak, I have cognitive deficits, I have impulsive behavior, I have poor safety awareness, I have unsteady gait. The approaches included, I need 1/4 siderail up [on each side] when in bed to help with in turning and repositioning myself in bed and it is for my own safety. During an observation on 03/04/25 at 11:56 AM in R74's room, R74 was lying in bed with 1/4 bed rails in the up position on each side of the bed, in the middle of the bed. In a concurrent interview with R74's family member (F1), she stated the bedrails were used to keep him from falling out of bed, especially when he had spasms or was agitated. F1 stated she had signed a consent form for use of the bedrails and felt they were beneficial to keep R74 from falling out of bed. During observations on 03/06/25 at 9:11 AM, 10:03 AM, 11:31 AM, and 2:27 PM in R74's room, R74 was lying in bed with 1/4 bedrails up on both sides of the bed in the middle. Review of R74's Informed Consent for Use of Bed Rails, dated 03/03/24 and located in the hard chart at the nurses' station, revealed F1 consented to the use of bedrails. However, specific risks versus benefits of use were not documented on the form, nor was the type of rail or frequency of use specified. Review of R74's EMR under the Orders tab revealed an active physician's order, dated 05/17/24, for 1/4 siderails on each side of the bed every shift. Review of R74's EMR under the Assessment and Miscellaneous tabs and the hard chart at the nurses' station revealed there was no assessment of R74's need for, and safety with, bedrails. During an interview on 03/07/25 at 10:55 AM, Unit Nurse 2 stated R74 was not safe in bed without the rails, as he used them to aid in positioning as well as for fall prevention during muscle spasms. Unit Nurse 2 stated she was able to find the consent form for use and the initial Care Plan including bed rail use; however, she was unable to find an assessment for the use of bedrails. Unit Nurse 2 stated an assessment should be completed of the resident's need for, and safety with, bed rails before implementation. During an interview on 03/07/25 at 10:58 AM, Licensed Practical Nurse (LPN) 5 stated R74 preferred the bed rails up for safety and added R74 would hold on tight to the bed rails when he had spasms due to Parkinson's disease. LPN5 stated R74 should have been assessed upon admission for use of bed rails but was unsure if the assessment was completed. During an interview on 03/07/25 at 4:51 PM, the Director of Nursing (DON) stated R74 had not been assessed for the use of bed rails and would be assessed right away. The DON stated the trigger to complete the assessment was not updated in the EMR software, so R74's assessment was missed. 2. Per R28's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions,) Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. Review of R28's quarterly MDS with an ARD of 02/04/25, located in the resident's EMR under the MDS tab, revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R28 was cognitively impaired and received antipsychotic and antidepressant medication. On 03/04/25 at 4:29 PM, observed R28 was sitting on his bed with a upper side rail up on his right side and his bed was against the wall on his left side. On 03/06/25 at 9:05 AM, and 03/07/25 at 8:50 AM, R28 was observed sitting on bed again with a side rail up his right side of bed. Review of R28's Care Plan Report, located in the residents' EMR under the Care Plan tab, included a care plan for Resident is at high risk for skin breakdown incontinence, cognitive loss, decreased mobility. Initiated 05/06/21, revised 11/21/22, included intervention of Provide 1/4 side rails to assist with positioning and comfort. R28's Care Plan Report included a care plan for actual falls I fell on 6/6/22 @ 4:00 AM in my room from my bed, initiated 01/05/22, revised 02/18/25, documented the intervention of was given a mild rail. Start date 06/07/22. R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 was monitored for side rails use daily as follows: - Mid Side Rail every Shift. Start date 06/07/22. - MID SIDE RAILS X2 WHILE IN BED EVERY SHIFT. Start date 09/27/22. Review of R28's record revealed R28's did not have a device use assessment for the side rail use. There was no documentation that the risks and benefits education was provided to the legal representative and the consent were obtained. During an interview on 03/07/25 at 5:08 PM, the DON stated there was no consent for the siderail use. The DON stated the facility had changed from a diffident EMR software to the current one a while ago; she was not aware the new EMR software did not have a process to obtain consent and assessments for siderails use. The DON stated the device use assessment for siderails should be done upon admission, readmission, and quarterly. 3. Review of R124's admission Record from the EMR Profile tab revealed a facility admission date of 10/26/23 with medical diagnoses including dementia. Review of R124's annual and quarterly MDS with ARDs of 10/28/24 and 01/28/25 showed a BIMS score of 99, indicative of the inability to complete the scoring due to incomplete, nonsensical, or refusal to answer. Observation of R124's bed on 03/05/25 at 10:19 AM showed bilateral upper bed rails. The resident was not in bed at this time. Review of R124's EMR Assessments and Miscellaneous tabs did not show any documented evaluation for the need or safe use for bed rails. Review of R124's EMR Progress Notes did not reveal any documentation of bed rail evaluation or risk/benefit discussion with R124's RR. During an interview on 03/07/25 at 3:10 PM, LPN2 stated Whenever [R124] is in bed, she has the bed rails in place because she uses them for mobility and to get in and out of bed. She is able to do that independently. Also present, LPN4 stated, She [R124] rarely naps. The left side rail goes down [demonstrated by LPN2 to show it goes in the middle third of the mattress] but the right one stays up near her head. During an interview on 03/07/25 at 4:21 PM, the DON stated, The side rail evaluations are not done. During the switch [named former and current EMR systems] somehow the side rail evaluations aren't triggering. I believe the nurses are doing them, there is just no place to document it. Unable to find any consent form for [R124]. Review of the facility's policy titled, Use of Side Rails, dated 01/23/25, revealed: Policy: To Provide for the safe and appropriate utilization of side rails. Procedure 1. Side rail Evaluation template shall be completed for all Admissions, Re-admissions, and as needed. 2. Side Rail Evaluation template may be completed by a licensed nurse . 4. Appropriate type of side rail shall be indicated on the assessment form. 5. Informed consent shall be obtained from the resident/responsible party . 7. Re-evaluation for appropriateness of side rail shall be completed Quarterly 8. IDT shall determine if the use of side rail is considered a restraint. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure medications for return to the pharmacy were kept in a secure location. An inventory had not been completed for those medications to ensure what medications were to be returned to the pharmacy. This failure put residents at risk of accessing and taking those medications not prescribed to them by a physician. Findings include: Review of the facility's policy titled, Discarding, Destroying Medication revised 01/25/25, indicated, .individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: b. All such medications are identified as to lot or control number: and c. The receiving Pharmacist and a Registered Nurse (RN) employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned. Review of the facility's policy titled, Storage of Medication revised 01/25/25, indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Observation and interview on 03/05/25 at 11:25 AM revealed an approximately eight-gallon size bag of medications with four blister packs and a box of nebulizer medication on top of the bag under the nurse's desk. During an interview at this time, Licensed Practical Nurse (LPN) 3 stated, They were there for the pharmacy to pick up. When questioned about the process for disposal of those medications, LPN3 stated the night nurse had started the process by bringing them out, but did not finish as there was no Discontinued Medication Form which listed the medications and quantity completed. LPN3 agreed at times there were no staff at the nurses' station, and the medications would have been accessible for the residents, staff, and/or visitors. During an interview on 03/05/25 at 12:30 PM, the Infection Preventionist revealed the process for sending medications back to the pharmacy was to take the sticker off the medication label, the sticker contained the resident's name and the name of the medication. That would then be attached to the Discontinued Medication Form with the quantity of medications being returned to the pharmacy. That form would then be put with the medications. The medications should have been stored in the locked medication storage room. During an interview on 03/05/25 at 12:43 PM, the Director of Nursing and the Assistant Director of Nursing confirmed the medications left under the desk had not been secured as stated in the policy. They said the process had been started to get the medications ready to be sent back to the pharmacy, but had not been completed, and the medications had been left at the nurse's station. Review of the Discontinued Medication Form filled out after the observation revealed the bag contained the following medications: fluorocort (a corticosteroid) 0.1 milligram (mg) 15 tablets, amlodipine (treats high blood pressure) 2.5 mg 29 tablets, folic acid 800 micrograms (mcg) 36 tablets, midodrine (treats low blood pressure) 5 mg 116 tablets, sitaliiptin (medication to lower blood sugar) 25 mcg 2 tablets, pentoxifylli (treats poor circulation) 400 mg extended release (ER) 22 tablets, calcacetate 667 mg 53 capsules, furosemide (a diuretic) 20 mg 15 tablets, acyclovir (antiviral medication) 800 mg 1 tablet, atorvastatian (lowers cholesterol) 80 mg 8 tablets, gabapentin (an anticonvulsant) 100 mg 59 capsules, vitamin d-4 5000 units 12 tablets, Eliquis (a blood thinner) 5 mg 15 tablet, levothyroxine (a thyroid medication)100 mcg 6 tablets, benzonatate (cough medicine) 100 mg 19 capsules, omeprazole 40 mg 3 capsules, midodrine 10 mg 29 tablets, levothyroxine 137 mcg 10 tablets, sertraline (an antidepressant)100 mg 23 tablets, janumet (diabetes medication) 50-500mg 29 tablets, ipratropium/albuterol (used to treat symptoms of lung disease) 50 pre-filled single use vials, cephalexin (an antibiotic) 500 mg 1 capsule, metoprolol (blood pressure medication) 25 mg 29 tablets, lactulose solution (used to treat constipation)473 milliliters (ml), and ibuprofen 100mg/5ml 473 ml. NJAC 8:39-5.1(a) NJAC 8:39-29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain an effective infection control and prevention program for one of four residents (Resident (R) 67) observed for pressure ulcers out of 34 sampled residents. Licensed Practical Nurse (LPN) 7 failed to don the required personal protective equipment prior to providing care to R67 who was physician ordered Enhanced Barrier Precautions (EBP). The LPN also failed to perform hand hygiene when changing gloves during wound care. This failure placed the resident at an increased risk of developing a wound infection and/or place other residents at the risk for the transmission of infections. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions revised 03/28/24 revealed . Enhanced Barrier Precautions expanded the use of PPE beyond situations in which exposure to blood and bodily fluid is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing examples of high-contact resident care activities requiring gown gloves and use for Wounds: chronic wounds . Examples of chronic wounds include, but are not limited to, pressure ulcer, diabetic foot ulcer, unhealed surgical wounds and venous stasis ulcer . Review of R67's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab medical record revealed R67 was admitted to the facility on [DATE] with diagnoses which included paraplegia, chronic kidney disease, and pressure ulcer of the sacral region. Review of R67's Care Plan, dated 06/18/24 and located in the resident's EMR under the Care Plan tab revealed . Actual skin breakdown stage IV sacrum related to: impaired mobility, incontinence, pain . Review of R67's quarterly Minimum Dats Set (MDS) with an Assessment Reference Date (ARD) of 12/12/24 and located in the resident's ERM under the MDS tab showed R67 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Further revealed R67's assessment was captured for pressure ulcer stage 4 on admission. Review of R67's Physician Orders, dated 06/12/24 and located in the resident's EMR under the Orders tab revealed . Place patient on Enhanced Barrier Precautions due to stage IV sacral wound. every shift for precaution will remain on EBP until wound is healed . Further review showed an order for pack sacral wound with Dakins moist Gauze and cover with foam every day and evening shift . Wound care observation on 03/06/25 at 11:41 AM in R67's room, showed LPN7 placed the resident's wound dressing supplies on the resident's bed next to the resident's coccyx directly on the bed without a barrier between the bed and the wound care supplies. Additionally, LPN7 did not don the PPE of a gown which was required when provided care to R67 who was on EBP. Continued observation revealed LPN7 with gloved hands removed the soiled dressing from R67's wound. LPN7 then doffed her gloves which revealed the LPN had a second pair of gloves under the gloves she just doffed. The LPN then proceeded with the wound care without performing any type of hand hygiene in between the glove change. During an interview on 03/06/25 at 11:45 AM, LPN7 confirmed using double gloves to remove the dressing. LPN7 confirmed she did not use hand sanitizer after removing the dressing with the first pair of gloves and because her gloves were soiled, she did not remove the second pair of gloves to wash her hands. LPN7 confirmed she did not place a barrier on the bed before laying the supplies down because R67 just received peri-care. During a telephone interview on 03/07/25 at 3:10 PM, LPN7 stated when asked if she wore PPE when providing care to a resident on EBS she stated No. I did not wear PPE because we were in the rush of the moment. I just do the hand hygiene and come out. During an interview on 03/06/25 at 4:30 PM, Unit Nurse 3 stated it was her expectation LPN7 would have donned a gown when she provided wound care to R67 who was ordered EBP. Unit Nurse 3 also stated We are not taught to wear double gloves. We expect the nurses to use barriers when setting up equipment to provide wound care. The Unit Nurse stated it was her expectation LPN7 would not have used double gloves when she provided wound care, and she expected the LPN would have changed gloves and washed her hands in between the glove change. During an interview on 03/06/25 at 4:54 PM, the Director of Nursing (DON) stated she expected the nurses to wear PPE gowns when providing wound care to a resident on EBP precautions. NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care for one of 34 sample residents (Resident (R) 41) regarding a continuous blood glucose monitor; or measurable goals or objectives regarding behaviors for two of seven residents (Resident (R) 60 and R138) reviewed for psychotropic medications. These failures placed the residents at risk of unmet care needs pertaining to glucose management and behavior management. Findings include: 1. During an interview on 03/05/25 at 10:27 AM, R41 revealed she had diabetes. R41 stated she received insulin and the staff administered the insulin. R41 had a Freestyle Libre blood glucose monitor (a continuous blood glucose monitor) that staff used to monitor her blood glucose levels. During an observation of insulin administration for R41 and interview with Licensed Practical Nurse (LPN) 1 on 03/06/25 at 12:45 AM revealed R41's blood glucose had been checked earlier; she had a continuous blood glucose meter and used a special phone to check the blood glucose. LPN1 was not sure who applied and/or changed the continuous blood glucose meter. Review of R41's Clinical Census tab found in her electronic medical record (EMR) revealed she had been admitted to the facility on [DATE]. Review of R41's diagnoses found under the Clinical Diagnosis tab in her EMR revealed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified. Review of R41's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date of 01/09/25 revealed she had a Brief Interview for Mental Status of 15. That indicated her cognition was intact. Review of R41's March 2025 Medication and Treatment Administration Records (MAR/TAR), located under the EMR Physicians Orders tab, revealed PATIENT HAS BLOOD SUGAR SENSOR TO LEFT ARM FOR BLOOD SUGAR CHECKS every shift -Start Date-02/09/2025 2300 [11:00 PM]. There were no further orders on when to change the continuous glucose monitor. Review of R41's 01/15/25 Comprehensive Care Plan found under the Care Plan tab in the EMR revealed no focus area, goal, or interventions about the use of a continuous glucose monitor. Observation and interview on 03/07/25 at 12:45 PM with R41 revealed she had a Freesytle Blood Glucose monitor on her left upper arm. R41 said that her significant other changed it every two weeks. The staff did not do anything with the monitor. R41 would check her blood glucose and tell them the reading. During an interview on 03/07/25 at 1:21 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) agreed there had been no monitoring of R41's Free Style Libre glucose monitor. They were aware her significant other changed the monitor when it was needed. During an interview on 03/07/25 at 1:32 PM, the Minimum Data Set Coordinator (MDSC) confirmed there was no information regarding R41's care plan about her use of a continuous blood glucose monitor. 2. Review of R60's admission Record from the EMR Profile tab showed a facility admission date of 09/14/19 with medical diagnoses that included dementia, hemiplegia and hemiplegia following cerebral infarct (ischemic stroke, a condition where blood flow to the brain is blocked), atrial fibrillation, depression, psychosis, mood disorder, pseudobulbar affect (a neurological disorder characterized by uncontrollable episodes of laughing or crying that are often inappropriate or disproportionate to the situation), and pain. Review of R60's Care Plan from the EMR Care Plan plan tab showed a focus of Verbal/physical agitation/aggression/socially inappropriate/disruptive behavior related to [nothing was filled in] initiated on 01/31/22 with a goal of I will have fewer episode of behavioral symptoms through review date initiated: 01/31/22, revised on 07/13/22, with a target date of 05/27/25. Further review of R60's Care Plan showed no baseline of how many episodes occurred when initiated, or a quantitative amount for any of the reviews since 01/31/22 to enable a baseline to ensure the goal was achieved or required adjustments. 3. Review of R138's admission Record from the EMR Profile tab showed a facility admission date of 08/21/24 with medical diagnoses that included dementia / vascular dementia with other behavioral disturbance, glaucoma, hypertension, and high cholesterol. Review of R138's Care Plan from the EMR Profile tab showed a focus of Resistive care related to change in routine, cognitive impairment, unfamiliar environment/caregiver, dx [diagnosis] of Dementia initiated on 08/29/24; with a care plan goal of I will have fewer episode [sic] of behavioral symptoms through review date initiated on 08/29/24 with a target date of 04/22/25. Further review of R138's Care Plan showed no baseline of how many episodes occurred when initiated, or a quantitative amount for any of the reviews since initiation to enable a baseline to ensure the goal was achieved or required adjustment. During an interview on 03/07/25 at 4:29 PM, the Director of Nursing (DON) stated, The goals needed to be reassessed to ensure there was a baseline to ensure a goal is measurable. Review of the facility policy titled Interdisciplinary Care plans, reviewed 01/21/25, revealed, .4. The care plan will be individualized and will include problems, goals and approaches that reflect the resident's uniqueness and idiosyncrasies. .6. Care plans will be reviewed and adjusted as needed and on a quarterly basis by any member of the IDT [interdisciplinary team] to ensure that the most current and comprehensive plan of care is followed. Review of the October 2024 Resident Assessment Instrument (RAI) Manual stated on page 4-5: Begin to develop an individualized care plan with measurable objectives and timetables to meet a resident's medical, functional, mental and psychosocial needs as identified through the comprehensive assessment. Page 4-8 stated: . the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Page 4-10 stated: 1. Assisting the resident in achieving their goals. 2. Individualized interventions that honor the resident's preferences. 7. Evaluating treatment of measurable objectives, timetables and outcomes of care. Page 4-11 stated: The following key steps and considerations may help the IDT develop the care plan after completing the comprehensive assessment: 1) Care Plan goals should be measurable. The IDT may agree on intermediate goal(s) that will lead to outcome objectives. Intermediate goal(s) and objectives must be pertinent to the resident's goals, preferences, condition, and situation (i.e., not just automatically applied without regard for their individual relevance), measurable, and have a time frame for completion or evaluation. NJAC 8:39-11.2(e) thru (i) NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure psychotropic medication efficacy was monitored and failed to ensure PRN (as needed) antianxiety medications had a stop date including a rational for continuing the PRN medication beyond 14 days for eight of eight residents (Resident (R) 23, R28, R38, R42, R60, R61, R138, and R142) reviewed for unnecessary and/or psychotropic medications from a total survey sample of 34 residents. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of medication. Findings include: 1. Per R28's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 05/05/21 with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions,) Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves,) anxiety disorder, and depressive disorder. Review of R28's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/25 and located in the resident's EMR under the MDS tab revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R28 received antipsychotic, and antidepressant medication. Review of R28's Care Plan Report located in the residents' EMR under the Care Plan tab, included a care plan for Psychotropic drug use Detail: Potential adverse effects from psychotropic drug use secondary to the use of antidepressant and antipsychotic medications, initiated 05/07/21. The care plan included the interventions as follows: - Administer medication per order. - Always approach in a calm, unhurried manner. Attempt to build a trusting relationship. Provide reassurance that resident is safe. Allow to verbalize feelings/concerns. Assist with problem solving. - Assess for dehydration, dry mouth. -Attempt to identify any triggers or contributing factors to mood changes. Educate staff as able to avoid these triggers as much as possible. -Encourage to verbalize feeling. -Monitor for adverse effects of Med [medication]. -Monitor for any contributing factors to aggression (pain, changes in medical status, change in mental status). - Monitor for S/S [signs and symptoms] depression (self-isolation, crying, tearfulness, decreased appetite, irritability, change in sleep habits, lethargy. - Monitor for therapeutic effect of med. - Monitor for: Movement Disorders/Tardive Dyskinesia Decline in Mood/LOC [level of consciousness] Decline in ADL's [activity of daily living] Urinary retention Dizziness Constipation. - Prior to beginning, explain all TX [treatment] /or procedures in a calm manner. - Provide safety measures at all times. R28's Care Plan Report included a care plan for The resident uses antidepressant medication r/t [related to] Depression,, initiated 05/15/21. The care plan included the interventions as follows: - Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. - Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms anti-depressant drugs being given. - Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activity daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea and vomiting], dry mouth, dry eyes. R28's Care Plan did not include interventions to what target behaviors were treated for antipsychotic and antidepressant medication use. The Care Plan also did not include what nonpharmacological interventions the staff would offer if the target behaviors were observed. R28's Psychiatric Progress Note dated 02/05/25 and located in the residents' EMR under the Prog [Progress] Note tab, included a nurse practitioner's psych [psychotropic] follow up note, which revealed Clinical signs and target symptoms: forgetfulness/memory loss, confusion .ASSESSMENT/PLAN .Always consider supportive and individualized non-pharmacologic interventions, inc [including]: redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. R28's medication Administration Report for order range 01/01/25 to 03/06/25, documented R28 received phototropic medication and related monitoring by physician's order as follows: - ARIPiprazole (Antipsychotic) Tablet 5 MG [milligram] Give 1 tablet by mouth one time a day for schizophrenia identify and monitor the behavior exhibited for aripiprazole. Start date 10/23/21. - Sertraline HCl (Antidepressant) Tablet Give 75 milligram by mouth one time a day for Depression Sertraline 25 mg-give 3 tabs [tablets]= 75 mg. Start date 11/16/24. - Observe potential side effects of ANTIDEPRESSANTS: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. DOCUMENT IN PROGRESS NOTE IF OBSERVED. every shift. Start date 06/10/21. - Observe potential side effects of ANTIPSYCHOTIC MEDS: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. DOCUMENT IN PROGRESS NOTE IF OBSERVED. every shift DOCUMENT IN PROGRESS NOTE IF BEHAVIOR OBSERVED. Start date 06/10/21. - Target Behavior: Agitation and Yelling every shift Document behavior in progress notes every shift Start date 06/14/22. Review of R28's undated admission Record, located in the resident's EMR under the Profile tab revealed that the facility combined two behaviors, Agitation and Yelling, into one monitoring category for two different classes of medications: antipsychotics and antidepressants. It was unclear which target behaviors monitoring were associated with the use of antipsychotic, and which were linked to antidepressant. Additionally, the target behavior monitoring did not record the number of behavior episodes observed during each shift. There was no documentation indicating the nonpharmacological interventions as the nurse practitioner's ASSESSMENT/PLAN were offered to R28. During an interview on 03/07/25 at 10:46 AM, the Director of Nursing (DON) reviewed R28's records and stated that the facility had combined the monitoring of target behaviors for antipsychotic and antidepressant medications, and the nonpharmacological interventions had not been offered. The DON further stated the target behavior monitoring and nonpharmacological interventions would be separated by medication type and included in the care plan. 2. Per R23's undated admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 01/09/25 with diagnoses which included anxiety and depression disorder. Review of R23's admission MDS with ARD of 01/16/25 and located in the resident's EMR under the MDS tab revealed the facility assessed that the resident did not exhibit mood or behavioral symptoms. R23 received antidepressant medication. Review of R23's Care Plan Report located in the resident's EMR under the Care Plan tab, included a care plan for Psychotropic drug use Detail: Potential adverse effects from psychotropic drug use secondary to the use of x Antidepressant, initiated 01/17/25. The care plan included the interventions as follows: - Administer medication per order. - Always approach in a calm, unhurried manner. Attempt to build a trusting relationship. Provide reassurance that resident is safe. Allow to verbalize feelings/concerns. Assist with problem solving. - Assess for dehydration, dry mouth. - Attempt to anticipate needs to reduce anxiety. Attempt to keep daily routine as able. Attempt to identify triggers to anxiety, educate staff to avoid these areas. - Attempt to identify any triggers or contributing factors to mood changes. Educate staff as able to avoid these triggers as much as possible. - Dietary consult as needed. - Encourage to verbalize feeling. - 'Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. - Monitor for adverse effects of Med. - Monitor for any contributing factors to aggression (pain, changes in medical status, change in mental status.) - Monitor for S/S depression (self-isolation, crying, tearfulness, decreased appetite, irritability, change in sleep habits, lethargy. - Monitor for S/S of anxiety (fidgeting, easily annoyed, repetitive speech/behaviors. Intervention indicated with least restrictive measure that is effective. Keep MD [medical doctor] informed of concerns. - Monitor for therapeutic effect of med. - Notify physician of decline in ADL or mood/behavior related to dosage change. - Prior to beginning, explain all TX [treatment] /or procedures in a calm manner. - Provide patient education to risks and benefits of medications as needed. - Provide safety measures at all times. - Reduce environmental noise/distractions to facilitate sleep. - Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors. R23's Care Plan Report included a care plan for Impaired Coping, initiated 01/16/25, including the interventions as follows: - Monitor for signs / symptoms of depression. - Evaluate sleep pattern. R23's Care Plan did not include interventions to what target behaviors he was treating for antidepressant medication use. And what nonpharmacological interventions the staff would offer if the target behaviors were observed. R23's Psychiatric Progress Note located in the residents' EMR under the Prog Note tab, included a nurse practitioner's psych [psychotropic] follow up note, dated 03/05/25 of Clinical signs and target symptoms: forgetfulness/memory loss, confusion, anxiety, verbal aggression .ASSESSMENT/PLAN .Always consider supportive and individualized non-pharmacologic interventions, inc [include] redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. R23's medication Administration Report for order range 02/01/25 to 03/04/25, documented R23 received phototropic medication and related monitoring by physician's order as follows: - buPROPion HCl (antidepressant) Oral Tablet 75 MG (Bupropion HCl) Give 75 mg by mouth one time a day for depression. Start date 01/10/25. - Mirtazapine (antidepressant) Tablet 30 MG Give 1 tablet by mouth at bedtime for insomnia. Start date 01/10/25. - Observe potential side effects of ANTIANXIETY MEDS: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucination. DOCUMENT IN PROGRESS NOTE IF OBSERVED every shift. Start date 01/10/25. - Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others (screaming, yelling w/ no apparent reason), Rejection of care (medication, care, and treatment), wandering every shift Document behavior in progress notes every shift. Start date 01/10/25. - ALPRAZolam (antianxiety) Oral Tablet 0.25 MG (Alprazolam) Give 0.25 mg by mouth every 12 hours as needed for anxiety for 90 Days. Start date 01/10/25. The medication Administration Report documented R23 received on 2/14/25 at 10:17 PM. A review of R23's entire EMR revealed that the facility did not monitor hours of sleep for antidepressant use to treat insomnia. It was unclear which target behaviors monitoring were associated with the use of antianxiety and which were linked to antidepressant. Additionally, the target behavior monitoring did not record the number of behavior episodes observed during each shift. There was no documentation indicating the non-pharmacological interventions as the nurse practitioner's ASSESSMENT/PLAN was offered to R23. During an interview on 03/07/25 at 10:46 AM, the DON reviewed R23's records and stated that the facility had combined the monitoring of target behaviors for antidepressant and antianxiety medications, and the non-pharmacological interventions had not been offered. The DON stated if antidepressant medication were used to treat insomnia, the hours of sleep would be monitored. The DON further stated the target behavior monitoring and non-pharmacological interventions would be separated by medication type and included in the care plan. 3. Review of R60's undated admission Record from the electronic medical record (EMR) under the Profile tab showed a facility admission date of 09/14/19 with medical diagnoses that included dementia, hemiplegia/hemiparesis after cerebral infarct (stroke), atrial fibrillation, depression, psychosis, mood disorder, and pseudobulbar affect. Review of R60's Order Summary from the EMR under the Orders tab revealed physician orders for: -Depakote sprinkles (a mood stabilizer medication)125 milligrams (mg, generic name divalproex) each morning and bedtime for mood disorder, ordered 01/27/25 -Escitalopram (an antidepressant medication) 5mg daily for depression, start 12/21/22 -Quetiapine (an antipsychotic medication) 12.5mg three times a day for delusional disorder ordered 02/11/25 -Target Behavior: monitor for verbal behavior (yelling, crying), Rejection of care every shift and document if behavior observed in progress notes every shift, ordered 03/25/21. -Observe potential side effects of antidepressants: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Document in progress note if observed every shift -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress notes if observed every shift. Document in progress note if behavior observed. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed. Review of R60's Care Plan located in the EMR under the Care Plan tab revealed focus areas for: -Verbal/physical agitation/aggression/ socially inappropriate/disruptive behavior related to (nothing added); initiated on 01/31/22 -The resident uses psychotropic medications related to behavior management; initiated on 11/22/20 Further review of the Care Plan revealed interventions to monitor for psychotropic medication side effects, however, no target behaviors were identified for each psychotropic medication to enable efficacy monitoring. 4. Review of R138's undated admission Record from the EMR under the Profile tab showed a facility admission date of 08/21/24 with medical diagnoses that included unspecified dementia with other behavioral disturbances and vascular dementia with other behavioral disturbance. Review of R138's Order Summary from the EMR under the Orders tab revealed: -Divalproex sodium 125 mg twice a day for mood disorder, ordered 11/26/2024 -Risperidone Tablet (an antipsychotic medication) 0.5 mg twice a day for dementia with psychosis, ordered 11/15/2024 -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress note if observed every shift. Document in progress note if behavior observed, initiated 02/05/25. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed, initiated 08/21/24. -Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others(screaming, yelling w/ no apparent reason), Rejection of care (medication, care and treatment), wandering every shift Document behavior in progress notes every shift; ordered 02/05/25. Review of R138's Care Plan located in the resident's EMR under the Care Plan tab revealed no identified behaviors related to the use of the mood stabilizer or antipsychotic medications to enable monitoring for medication efficacy. 5. Review of R142's undated admission Record from the EMR under the Profile tab showed a facility admission date of 11/27/24 with medical diagnoses that included unspecified dementia without behavioral or psychotic disturbance and depression. Review of R142's Order Summary from the EMR under the Orders tab revealed: -Clonazepam (an anxiolytic medication) 0.5 mg three times daily for anxiety, ordered 02/07/25 -Divalproex sodium 250 mg three times a day for mood disorder, ordered 01/08/25 -Mirtazapine (an antidepressant medication) 7.5 mg at bedtime for depression, ordered 02/04/25 -Risperidone 1 mg twice a day for psychosis, ordered 02/20/25 -Observe potential side effects of antidepressants: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Document in progress note if observed every shift. -Observe potential side effects of antipsychotic meds: Blurred vision, dry mouth, drowsiness, muscle spasms or tremors, weight gain, Tardive Dyskinesia. Document in progress note if observed every shift. Document in progress note if behavior observed. -Observe potential side effects of mood stabilizer meds: Abdominal pain, ataxia, frequent urination, nausea, vomiting, thirsts, tremors, weight loss/gain. Document in progress note if observed every shift. -Target Behavior: Hallucination, Delusion, physical behavior towards others, verbal behavior (screaming at others, cursing at others), behavior not directed towards others(screaming, yelling with no apparent reason), Rejection of care (medication, care and treatment), wandering every shift. Document behavior in progress notes every shift, ordered 02/05/25. During an interview on 03/07/25 at 10:35 AM regarding target behaviors for each psychotropic medication, the DON stated, Right now, we do not have target behaviors for each medication. Review of the facility policy titled Use of Psychotropic Medication, reviewed 01/23/25, revealed: .Procedure: 1. Psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety; and d. Hypnotic 2. Diagnoses which may require antipsychotic medication use and do not require daily monitoring of target behaviors: a. Schizophrenia b. Schizo-affective disorder c. Delusional disorder d. psychotic mood disorders, including mania and depression with psychotic features e. acute psychotic episodes f. brief reactive psychosis g. Schizophreniform disorder h. atypical psychosis i. Huntington's disease j. Tourette's disorder k. organic mental syndromes (i.e., delirium, de entia, and other cognitive disorders) with associated psychotic and/or agitated behaviors which are causing the resident to exhibit behavior such as screaming, yelling, pacing, or to experience psychotic symptoms (hallucinations, paranoia, delusions) which may or may not be danger us to him/herself or others but are causing the resident distress or impairment in functional capacity. 2. Diagnoses which may require anxiolytic/sedative se and do not require daily monitoring of targeted behaviors: a. Generalized anxiety disorder b. Panic disorder c. Symptomatic anxiety that occurs in resident with another diagnosed psychiatric disorder 3. Sample targeted behaviors for antipsychotic medication or anxiolytic/hypnotics use: Wringing of hands Hitting Grabbing and hurting self or others Throwing objects Making strange noises Biting Disrobing Kicking Scratching Repetitive statements Tension Cursing Pushing others Assaultiveness [sic] Screaming continuously Yelling continuously Crying continuously Negativism Hallucinations If the targeted behaviors being monitored for antipsychotic medication use do not indicate the resident is harmful to self or others, the physician should document in his progress notes that the medication is needed to increase the functional status of the resident. 6. Review R38's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and depression disorder. Review of R38's Care Plan, dated 08/08/24 and located in the resident's EMR under the Care Plan tab showed R38 was care planned for verbal and physical, aggression, and disruptive behavior such as screaming and yelling. Review of R38's quarterly MDS with and ARD of 12/16/24 and located in the resident's EMR under the MDS tab showed the facility assessed R38 to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The MDS also indicated the resident had other behavioral symptoms not directed towards. Review of R38's Physician Order, dated 02/27/25 and located in the resident's EMR under the Orders tab showed to administer lorazepam (benzodiazepine to treat anxiety) 0.5 mg (milligrams) by mouth every six hours as needed for anxiety. Further review showed no stop date along with rationale to continue as needed usage. 7. Review of R42's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and bipolar disorder. Review of R42's Care Plan, dated 05/10/24 and located in the resident's EMR under the Care Plan tab showed R42 was care planned with a problem of mood related to the usage or side effects of medication. Review of the R42's quarterly MDS with and ARD of 11/25/24 showed the facility assessed R42 to have a BIMS score of 12 out of 15 which indicated the resident was moderately cognitively impaired. Review of R42's Physician Order, dated 03/04/25 and located in the resident's EMR showed to give lorazepam 0.5 mg tablet by mouth every 12 hours as needed for anxiety. Further reviewed showed no stop date. 8. Review of R61's undated admission Record, located in the resident's EMR under the Profile tab showed R61 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and bipolar disorder. Review of R61's annual MDS with an ARD of 12/04/24 showed the facility assessed R61 to have a BIMS score of 99 which indicated R61 could not participate in the assessment and was severely cognitively impaired. R61 was assessed to have had behaviors towards others such as hitting, kicking, pushing, and scratching during the assessment period. Review of R61's Care Plan dated 12/12/23 and located in the resident's EMR under the Care Plan tab showed R61 had aggression both verbal and physical towards staff and others. Review of R61's Physician Orders, dated 02/11/25 and located in the resident's EMR under the Orders tab showed to administer lorazepam 1mg tablet by mouth every eight hours as needed for anxiety for 60 days. Further review of the electronic record revealed no rationale on why to continue lorazepam for 60 days. During an interview on 03/07/25 at 1:03 PM, when brought to the attention of the Nurse Practitioner of the missing stop dates for R38's and R42's PRN lorazepam, the Nurse Practitioner confirmed there were no stop dates for the PRN lorazepam. Further interview revealed the Nurse Practitioner confirmed there was no rationale to continue past 14 days for R61's PRN ordered lorazepam. Review of the facility's policy titled Use of Psychotropic Medication revised 03/2019 showed .Psychotropic PRN [as needed] or Excluding antipsychotics. Time Limitations: 14 days ii. Exception: Order may be extended beyond 14 days if the physician believes it is appropriate to extend the order. iii. Physician should document that rational of the extended time period in the medical record and indicate the specific condition . NJAC 8:39-5.1(a) NJAC 8:39-29.3

Based on observation, menu review, interview, and facility policy, the facility failed to ensure residents who ate in the second-floor dining room received adequate portion sizes according to the menu. This failure had potential to cause hunger, weight loss, or malnutrition for the 28 residents, out a census of 158, who ate their meals in the second-floor dining room and had orders for regular portions with chopped or regular texture. Findings include: Review of the undated Cedar Unit Assignment Sheet, provided on paper by the facility with the residents who ate in the second-floor dining room circled, revealed 15 residents ate in the second-floor dining room from the Cedar unit. Review of the undated Maple Unit Assignment Sheet, provided on paper by the facility with the residents who ate in the second-floor dining room circled, revealed 17 residents ate in the second-floor dining room from the Maple unit. Review of the facility's Diet Type Report, dated 03/07/25 and provided on paper by the Dietary Manager (DM), 31 of the 32 residents who ate in the second-floor dining room had orders for regular portions at meals. Of those 31 residents, 14 received a regular texture, 14 received a chopped texture. Additionally, two residents received a ground texture and one received a puree texture, and these meals were pre-plated in the kitchen. The 28 residents who received regular or chopped diets had their meals plated at the steam table in the second-floor dining room. Review of the facility's Fall/Winter Week 4 menu, provided on paper by the DM, revealed the following portion sizes for regular and chopped meals on Thursday lunch: -Mashed Potatoes: 1/2 cup (4 ounces (oz)) -California Blend Vegetables: 1/2 cup (4 oz) During an observation of lunch service at the steam table in the second-floor dining room on 03/06/25 beginning at 11:57 AM, Server (S) 1 served 2-oz. portions of mashed potatoes and 2-oz portions of California blend vegetables to 28 residents in the dining room. She did not use two scoops of each item to equal 4-oz. servings. In a concurrent interview, S1 confirmed her scoop sizes for the California vegetable blend and the mashed potatoes were both 2 oz. She stated she did not have any large scoops available on the second floor. Review of the facility's Fall/Winter Week 4 menu, provided on paper by the DM, revealed the following portion sizes for regular and chopped meals on Friday lunch: -Rice Pilaf: 1/2 cup (4 oz) -Italian [NAME] Beans: 1/2 cup (4 oz) During an observation of lunch service at the steam table in the second-floor dining room on 03/07/25 beginning at 12:16 PM, S1 confirmed her scoop sizes for the Italian green beans and rice pilaf were both 2 oz. She stated she tried serve a heaping scoop because she did not have any larger scoop sizes available. S1 did not use two scoops of each item to equal 4-oz servings. In a concurrent interview, S1 stated the portion sizes documented on the menu should have been 4 oz.; however, she did not have 4-oz. scoops available. During an interview on 03/07/25 at 12:37 PM, the DM stated the kitchen had new 4-oz scoops available and he would provide some to the second-floor dining room. The DM stated S1 should have served a 4-oz portion of each starch and vegetable by either using a 4-oz scoop or using two 2-oz scoops. The DM stated some of the residents in the second -floor dining room preferred smaller portions, as larger portions could be overwhelming, but their diet orders were for regular portions. The DM stated he discussed this issue with the Registered Dietitian (RD), who told him the portion size called for on the menu should be served unless there was an order for small portions. During an interview on 03/07/25 at 4:04 PM, the RD stated the issue of preferences of small portions had not been discussed with her and stated the portion size as documented on the menu should be served to meet calculated nutritional needs. Review of the facility's undated policy titled, Proper Portion Sizes revealed, All meals served in the dietary department shall adhere to standardized portion sizes to maintain consistency, meet dietary guidelines, and control food costs. Staff members responsible for meal preparation and service must use standardized measuring tools (such as portion scoops, ladles, etc.) to ensure accuracy . The following portion sizes shall be adhered to for all resident meals: . Starches (Potatoes, Rice, Pasta, Grains, etc.) - 4 oz at both lunch and dinner . Cooked or Marinated Vegetables - 4 oz per serving. NJAC 8:39-17.2

Based on observation, interview, and policy review, the facility failed to ensure nine cartons of milk were not expired. Though the milk was discarded prior to meal service, the potential receipt of expired milk by nine residents placed these residents at risk of foodborne illness. Findings include: During an initial tour of the kitchen on 03/04/25 at beginning at 10:42 AM, conducted along with the Dietary Manager (DM) and Regional Food Service Director (RFSD), the dairy refrigerator with ready-to-serve items prepared for lunch, located at the tray line in the meat kitchen, was observed. In the dairy refrigerator were eight cartons of milk with a sell by date of 02/17/25 and one carton of milk with a sell by date of 02/12/25. The FSD and DM pulled out the nine expired milks from the refrigerator and discarded them. In a concurrent interview, the FSD stated the milk cartons in the dairy refrigerator had been prepared for use during lunch service for residents who did not prefer a kosher diet. She stated a new shipment had just been received, so she was not aware any of the milks were expired and stated they should not be available on the tray line. The DM stated the milk shipment had just come in, so he did not understand why expired milks were being used, and stated the expired milks needed to be discarded. Review of the facility's undated policy titled, Receiving and Inspecting Guidelines, revealed, Rotation: Rotate stock to use older items first . Make a schedule to throw out food on a regular basis . FSD and Cooks check dates and leftovers daily. NJAC 8:39-17.2(g)

Based on observation, interview and review of the facility's policy, the facility failed to ensure one of four soiled utility rooms (400 Unit) was maintained in a sanitary condition. This failure placed all residents on the 400 Unit at risk for not having a safe and clean homelike environment. Findings include: Observation on 03/04/25 at 11:55 AM of the 400 Unit's soiled utility room revealed the soiled utility room had a bag of trash on the floor next to the trash receptacle. Observation on 03/05/25 at 9:48 AM of the 400 Unit's soiled utility room revealed, Housekeeper (HK) 1 placed a bag of trash on the floor next to the trash receptacle because the trash receptacle appeared full. Observation on 03/05/25 at 9:53 AM of the 400 Unit's soiled utility room revealed two bags of soiled laundry on the floor. During an observation and interview on 03/05/25 at 9:55 AM, the Housekeeping Director (HD) stated there was not supposed to be anything on the floor, it was not acceptable. The HD observed the laundry bin and stated it was not full and picked up the bags of soiled laundry and placed them in the laundry bin. The HD stated anytime housekeeping staff went into the soiled utility room, it was her expectation they check for laundry and trash being on the floor. The HD confirmed the Review of the facility's policy titled, Basic Cleaning: Trash Removal revised 03/2020 showed .place bag (trash) in proper receptacle on utility cart or trash bin . NJAC 8:39-31.4(a)

Based on observation, interview, and policy review, the facility failed to ensure dumpster lids were kept closed and trash was not on the ground in the dumpster area. This failure had the potential to cause pest infestation or spread of infection affecting all 158 residents. Findings include: During an initial tour of the kitchen on 03/04/25 beginning at 10:42 AM, conducted along with the Dietary Manager (DM) and Regional Food Service Director (RFSD), the three trash and one recycling dumpster were observed. The recycling dumpster lid and the lid of the middle trash dumpster were open. The front trash dumpster was over-filled with trash preventing the lid from closing all the way. There was trash on the ground around all the dumpsters. The DM began picking up trash next to the recycling dumpster and disposing of it in the dumpster. During a concurrent interview, the RFSD stated the trash was due for pick up today and confirmed the lid did not close and two dumpsters were open. The DM and RFSD left the dumpster area without closing the open lids. During an observation of the dumpster area on 03/07/25 at 12:12 PM, conducted along with the RFSD, the three trash and one recycling dumpsters were open. There was a bag of cans on the ground next to the recycling dumpster. The RFSD stated the dumpsters were open and normally should be kept closed. The RFSD confirmed a bag of empty cans was on the ground and should have been placed inside the dumpster. During an interview on 03/07/25 at 12:37 PM, the DM stated some of the kitchen staff were too short to reach the dumpster lid, so they typically left the lid open during the day for easy access and would ensure the lids were closed at the end of the day. The DM stated he instructed the staff who could not reach to leave the bags of cans on the ground next to the dumpster to be put in at the end of the day. Review of the facility policy titled, Maintaining a Clean and Sanitary Dumpster Area, dated 02/12/25, revealed, No loose garbage or food waste should be left outside the dumpster . At the end of each kitchen shift, designated staff will inspect the dumpster area to ensure trash is properly contained [and] the area around the dumpster is free of debris and spills . Pest Control Measures: Keep the dumpster lids closed at all times to prevent pest entry. NJAC 8:39-19.7

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's use of supplemental oxygen was addressed in the comprehensive care plan for 1 (Resident #277) of 3 residents reviewed for respiratory care. Findings included: A review of an Interdisciplinary Care plans policy and procedure, last dated as reviewed in 01/2023, revealed, Policy: This facility believes that each resident is a unique individual with physical, mental, emotional, psychological, social, spiritual and medical needs. An individual who possesses strengths and has a potential for betterment of self, no matter what stage of life they are in. This facility also believes in ensuring quality of life and providing quality care to all its residents through the use of the interdisciplinary care planning process. The policy objectives included, 2. To provide a guideline for all staff to follow in their delivery of care. The policy procedure noted, in part, 4. The care plan will be individualized and will include problems, goals and approaches that reflect the resident's uniqueness and idiosyncrasies. A review of Resident #277's admission Record revealed the facility admitted the resident with diagnoses that included chronic obstructive pulmonary disease (COPD) and unspecified dementia. A review of Resident #277's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #277's Order Summary Report revealed an order dated 02/08/2023 that directed staff to administer continuous oxygen to the resident via nasal cannula at three liters per minute. A review of Resident #277's comprehensive care plan revealed the plan failed to address the resident's use of oxygen therapy or staff expectations surrounding such use. On 02/21/2023 at 10:36 AM, Resident #277 was observed sitting in bed, visiting with a family member. The surveyor noted Resident #277 had oxygen on by way of a nasal canula. During an interview on 02/22/2023 at 3:55 PM, Licensed Practical Nurse (LPN) #3 said if a resident received supplemental oxygen, it should be on their care plan. During an interview on 02/22/2023 at 4:10 PM, LPN #4 said if a resident received oxygen, it would be included on their care plan. New Jersey Administrative Code 8:39-11.2(e)(2)

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide services to a resident who was unable to carry out activities of daily living (ADLs) necessary to maintain good grooming and personal hygiene for 1 (Resident #328) of 1 sampled resident reviewed for ADLs. Specifically, Resident #328 had facial hair approximately ½-inch long on both sides of their face, jaw, chin, and neck. Findings included: Review of a facility policy titled, Supporting ADLs, issued 04/2016 and last reviewed by the facility in 01/2023, specified, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy further specified, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (bathing, dressing, grooming, and oral care). Furthermore, the policy indicated, 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. A review of an admission Record indicated the facility admitted Resident #328 with diagnoses of acute respiratory failure with hypoxia, cerebral infarction, and seizures. A review of a COMS [Communications] - ADL Only Evaluation - V2, dated 02/09/2023, revealed Resident #328 was totally dependent on staff for bed mobility, transfers, eating, toilet use, and personal hygiene. Review of Resident #328's care plan, initiated on 02/20/2023, revealed the resident had an ADL performance deficit as evidenced by the resident requiring extensive to total care related to medical conditions. The care plan interventions directed staff to assist/encourage the resident to participate in daily hygiene, grooming, dressing, oral care, and eating as needed. On 02/21/2023 at 9:57 AM, Resident #328 was observed in bed with a mustache and facial hair about ½-inch in length on both sides of the face, jaw, chin, and neck. On 02/22/2023 at 11:17 AM, Resident #328 was observed in bed with a mustache and facial hair about ½-inch in length on both sides of the face, jaw, chin, and neck. During an interview on 02/22/20233 at 11:21 AM, Certified Nurse Aide (CNA) #5 stated Resident #328 required total care and needed to be shaved. CNA #5 stated Resident #328 was not shaved because the staff were too busy, but noted Resident #328 would be shaved later. During an interview on 02/22/2023 at 11:26 AM, Licensed Practical Nurse (LPN) #6 revealed Resident #328 was totally dependent on staff for all care. LPN #6 indicated Resident #328 had facial hair about ½-inch in length and needed to be shaved. LPN #6 stated Resident #328 should be shaved daily and as needed. Per LPN #6, the unit managers were usually responsible for monitoring ADL care provided by CNAs, but if she noticed a resident needed care, she would tell the resident's CNA to perform the care. During an interview on 02/22/2023 at 11:41 AM, Unit Manager (UM) #7 stated Resident #328 required total care and should be shaved as needed, including when staff identified the resident had facial hair. UM #7 stated Resident #328 would be shaved that day. Per UM #7, CNAs were required to make rounds to monitor the resident's ADL needs but the CNA staff were busy and did not get a chance to shave Resident #328. During an interview on 02/23/2023 at 9:01 AM, the Director of Nursing (DON) revealed Resident #328 required total care for all ADLs and was not able to self-shave. The DON stated staff should ensure ADLs were completed daily for Resident #328 and anticipate the resident's needs. Per the DON, she expected good grooming and personal hygiene for the residents to be completed daily and as needed. The DON stated staff indicated Resident #328 had long facial hair and, when it was first found, the CNA should have notified the nurse. According to the DON, she made daily rounds to monitor care, but the unit manager and CNAs were responsible for ensuring residents received good grooming and personal hygiene. During an interview on 02/23/2023 at 10:51 AM, the Administrator revealed Resident #328 was totally dependent on staff for all care. The Administrator stated the CNAs were responsible for ensuring residents were shaved and groomed daily. The Administrator stated the resident's assigned nurse was responsible for monitoring ADL care. Per the Administrator, he expected residents to receive good grooming and for personal hygiene to be provided daily and as needed. New Jersey Administrative Code 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff administered oxygen at the rate ordered by the physician for 1 (Resident #277) of 3 residents reviewed for respiratory care. Findings included: A review of a facility policy titled, Administration of Oxygen, last reviewed by the facility in 01/2023, revealed, Purpose: To prevent hypoxia [absence of enough oxygen in the tissues to sustain bodily function]. Nurses and other certified/trained staff. Procedure: 1. Obtain orders from the primary care physician for: a. Oxygen therapy b. Flow rate or concentration in a cannula, mask, re-breather mask, etc. c. Respiratory therapy consultation, if indicated. d. Pulse oximetry reading if desired. A review of Resident #277's admission Record revealed the facility admitted the resident with diagnoses that included chronic obstructive pulmonary disease (COPD) and unspecified dementia. A review of Resident #277's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #277's comprehensive care plan revealed the plan failed to address the resident's use of oxygen therapy or staff expectations surrounding such use. A review of Resident #277's Order Summary Report revealed an order dated 02/08/2023 that directed staff to administer continuous oxygen to the resident via nasal cannula at 3 liters per minute (LPM). On 02/21/2023 at 10:36 AM, Resident #277 was observed sitting in bed. Resident #277 was receiving supplemental oxygen via nasal canula at a rate of 1.5 LPM in contrast to the order for staff to continuously administer 3 LPM of supplemental oxygen to the resident. During an interview on 02/22/2023 at 3:55 PM, Licensed Practical Nurse (LPN) #3 said physician orders should be followed. LPN #3 stated she checked a resident's oxygen flow rate setting each time she entered a resident's room. During an interview on 02/23/2023 at 4:10 PM, LPN #4 stated physician orders should always be followed. Per LPN #4, she checked a resident's oxygen flow rate setting each time she entered a resident's room. New Jersey Administrative Code 8:39-11.2(b)