**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to notify the resident's representative of a significant change in the resident's skin condition for one of two residents (Resident (R) 224) reviewed for pressure sores out of a total sample of 37. The facility failed to provide documentation that R224's representative was notified of a pressure area on the resident's heel when she returned to the facility after a recent hospitalization. Findings include: Review of the facility's Notification of Changes policy, dated 11/2022 and 06/2023, revealed, . The facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances may be . Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status . Review of R224's Face Sheet, provided by the facility, revealed an initial admission date of 02/26/21 and a readmission date of 11/24/22 with diagnoses of atherosclerotic heart disease, cardiomyopathy, atrial fibrillation, severe aortic stenosis, congestive heart failure, peripheral vascular disease, and dementia. Review of R224's Resident Exit-Skin/Wound Assessment, located under the Miscellaneous tab of the EMR and dated 11/20/22, revealed the resident was discharged to the hospital with only one pressure area, an unstageable pressure sore on the sacrum. Review of R224's Admit/Readmit Screener form, dated 11/24/22 and completed when the resident returned to the facility, revealed the presence of one Stage III pressure area on the sacrum, one Stage III pressure area on the right lower buttock, and one unstageable pressure area on the left heel. During an interview on 09/17/23 at 1:00 PM, R224's Family Member (1) stated that she was not aware of the pressure area on the resident's left heel. Review of R224's Progress Notes and Miscellaneous tabs of the EMR revealed no documentation Family Member 1 was notified of the left heel pressure area. During an interview with the MDS/Care Plan Coordinator on 09/19/24 at 3:00 PM, she stated that they held an IDT meeting after R224 returned from the hospital on [DATE], and Family Member 1 was in attendance. She stated that she remembered discussing the wound on the resident's left heel with the family, but did not remember what meeting that was. After reviewing the IDT meeting notes, she confirmed that the note did not include documentation of the unstageable pressure sore on the left heel. NJAC 8:39-13.1(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to conduct a thorough investigation of an alleged incident of staff neglect for one resident (R375) of four residents reviewed for abuse out of a total sample of 37 after the family stated the resident told them staff dropped him during a transfer, and the resident was found to have a right femur fracture. This has the potential to affect all residents receiving care by staff who may put residents at risk for neglect during care. Findings include: Review of R375's admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R375 was admitted to the facility on [DATE]. R375, who required staff assistance for transfers, was transferred by staff at various times on the morning of 04/17/23 prior to a podiatrist appointment at 1:00 PM. After R375 returned from the appointment, he complained of pain in his right leg and was sent to the hospital for further evaluation. Xrays revealed a right femur fracture, and R375 was admitted to the hospital. On 04/20/23 family members reported to the facility that R375 told them he fell and hurt his leg during a transfer by staff before leaving for his 1:00 pm appointment on 04/17/23. Review of the Facility's Investigation, dated 04/20/23, revealed that there were no interviews with the physical therapy aides or other staff that assisted with transfers on the morning of 04/17/23 before he was transferred to his wheelchair to go to his appointment at 1 PM. The staff that assisted with these transfers were not identified. Staff only identified, interviewed, and obtained statements from the two certified nurse aides that assisted with the transfer prior to the resident leaving for his 1:00 PM appointment. Review of R375's Discharge Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/05/23 revealed a Brief Interview for Mental Status (BIMS) score was not determined. During an interview on 09/19/24 at 11:56 AM, the Administrator stated the former Director of Nursing (DON) completed the investigation but that she now works for the state now. She said she contacted her and was told she would need to talk with her supervisor before answering any questions. The Administrator stated she felt like the fracture for R375 was likely the result of the braces the resident wore due to the weight, and she felt they did a thorough investigation. She stated she was unaware that all staff involved with transfers on the morning of 04/17/23 were not identified or interviewed. The Administrator confirmed all staff that assisted with any transfers on 04/17/23 should have been interviewed. She said she was going to have to reread the investigation. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I Assessment was completed accurately for two of three sampled residents (Resident (R) 108 and R79) reviewed for PASARRs out of a total sample of 45 residents. This had the potential to prevent or delay additional services to a resident that might qualify for a Level II PASARR. Findings include: 1. Review of R108's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, generalized anxiety disorder, and hallucinations. Review of R108's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 08/07/24, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R108 had no cognitive impairment. Further review revealed R108 had active diagnoses of major depressive disorder and anxiety disorder. Review of R108's Level One Nursing Facility Preadmission Screening for Mental Illness, Intellectual Disability, or Related Condition (PASARR), located under the Resident Documents tab in the EMR and dated and submitted on 08/02/23, indicated no mental illness diagnosis and was marked negative for a Level II assessment. During an interview on 09/19/24 at 10:42 AM, the Social Services Director (SSD) stated after a resident was admitted to the facility, they ensured the PASARR was completed. She stated they did not admit a resident without a PASARR. The SSD stated she was the one who was responsible for reviewing the PASARRs to make sure they were completed accurately. She stated a former employee was the person who completed R108's PASARR level I but agreed it should have been completed accurately. The SSD stated she would review the R108's PASARR and have it corrected. During an interview on 09/19/24 at 11:56 AM, the Administrator stated staff should be reviewing the PASARR Level I and making sure it was correct and if it was not correct, staff needed to revise and correct it. 2. Review of R79's Profile tab of the EMR revealed R79 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent and unspecified, and schizoaffective disorder, unspecified. Review of R79's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 06/11/24, revealed R79 had a BIMS score of 11 out of 15, which indicated R79 was moderately cognitively impaired. Review of R79's PASRR (Level 1 Screen), dated 05/13/23 and located under the Misc tab of the EMR, indicated a negative screening. Further review of the PASRR revealed that in Section II, there was no response to the question related to mental illness. It was recorded R79 had not been hospitalized related to mental illness within the last 2 years. Review of R79's psychiatry Progress Notes, dated 12/21/23 and located under the Misc tab of the EMR, revealed R79 was seen by the psychiatric group for schizophrenia and depression. The progress note revealed, . resident with a history of Depression . Patient has a history of inpatient hospitalizations at [hospital name withheld] 2 years ago for depression . During an interview on 09/17/24 at 4:00 PM, the SSD stated that residents come from the hospital or another facility with their PASARRs already completed. When asked to review R79's PASARR, the SSD acknowledged the PASARR was not complete. The SSD stated, Unfortunately, the questions were not answered, so it is not a complete PASARR. During an interview on 09/19/24 at 10:43 AM, the SSD stated that no one had reviewed R79's PASARR. She stated it was the facility's responsibility to review the PASARRs to make sure they were correct. She stated, [R79] should have had another PASARR completed. During an interview on 09/19/24 at 3:00 PM, the Psychiatric Doctor (PD) stated R79 had been in an in-patient psychiatric facility, but he was unsure of the specific dates. NJAC 8:39-5.1(a)

Based on interview, record review, and facility policy review, the facility failed to provide food that accommodated resident allergies for one of seven sampled residents (Resident (R) 81) reviewed for food concerns out of a total sample of 37. This failure had the potential to cause residents harm due to allergic reactions. Findings include: Review of R81's undated admission Record, located in R81's electronic medical record (EMR) under the profile tab, showed a facility admission date of 05/10/24 and a re-admission date of 07/24/24 with medical diagnoses that included cerebrovascular disease, hemiplegia and hemiparesis, major depressive disorder. Review of R81's Food Preferences, dated 05/14/24 revealed, Dislikes fish. The form did not provide an entry for any type of food allergies. Review of R81's Care Plan dated 05/14/24 reveals, R81 has an allergy related to fish and powder eggs. Review of R81's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/16/24, revealed the facility assessed R81 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R81 was cognitively intact. During an interview on 09/16/24 at 10:36 AM, R81 stated, Last Friday [09/13/24] I was given fish for lunch. My meal ticket has that I am allergic to fish written on it. During an interview on 09/19/24 at 5:00 PM, the Assistant Director of Nursing (ADON) stated R81 had been served fish for lunch, and he ate some of it. The ADON stated he was provided Benadryl and had no signs or symptoms of an allergic reaction but requested to go to the hospital. The ADON stated R81 was sent to the hospital as requested and later took prednisone (a steroid medication that can be used to treat allergic reactions). During an interview on 09/19/24 at 5:15 PM, Registered Nurse (RN) 1 stated, [R81] informed me about fish on his lunch tray. I checked the tray, and he had been served fish and he had eaten some of it. I informed the NP [Nurse Practitioner] of the situation. The NP approved Benadryl for the resident. [R81] requested to go to the hospital. He had some redness on his face and was given prednisone before going to the hospital. During an interview on 09/19/24 at 5:20 PM, the Dietary Manager (DM) stated, When I went to check his lunch tray, [R81] had been served fish by accident. His meal ticket identified a food allergy to fish. The DM stated R81 refused to return the tray and was later observed in the smoking area scratching at his face. The DM stated, Since the incident, his meal ticket has been modified to verify the meal prior to serving. The meal ticket system automatically changes the meal due to allergy and dislikes. During an interview on 09/19/24 at 5:45 PM, the Assistant Dietary Manager (ADM) stated, We do not have a policy and procedure related to the accuracy of the plating of food and ensuring that the resident gets the proper meal. On 09/19/24 at 6:05 PM, a review of R81's meal ticket, dated 09/13/24, with the DM for the noon meal revealed R81 was allergic to fish, and he should have been given the alternate meal consisting of stuffed shells, tomato sauce, mixed vegetables, dinner roll, ice cream, apple juice, whole milk, ginger ale, coffee, and a small, tossed salad. The DM confirmed, The meal ticket system worked as indicated by the alternate meal being identified. However, [R81] was served the incorrect meal. NJAC 8:39-17.4(c)(e)

Based on observation interview and review of facility documentation, it was determined that the facility failed to maintain resident call bells that were accessible and within reach of all residents. This deficient practice occurred for 2 of 26 residents reviewed (Resident #130 and Resident #11). This deficient practice was evidenced by the following: 1. On 9/1/22 at 11:44 AM, two surveyors observed Resident #130 lying in bed. Resident #130 did not respond to surveyor questions. The resident's call bell (a bell used to summon staff) was observed on the floor behind the resident's bed. On 9/2/22 at 11:03 AM, two surveyors observed Resident #130 lying in bed. The surveyors observed the resident's call bell on the floor behind the resident's bed. The surveyors interviewed Resident #130 at this time. The surveyor asked Resident #130 how they call for staff to come help them. The resident stated that they, yell. The surveyor asked if there was a button for them to press to call for staff. The resident stated that they cannot find the button. On 9/6/22 at 10:56 AM, two surveyors observed Resident #130 lying in bed. The surveyors observed that the resident's call bell was on the floor behind the bed, not within the resident's reach. On 9/6/22 at 11:06 AM, two surveyors requested that the Certified Nursing Assistant (CNA) for Resident #130 accompany them into the resident's room. The surveyors interviewed the CNA and asked where the resident's call bell should be. The CNA stated that the resident does not like having their call bell near them and that they yell out for help to get staff's attention. On 9/6/22 at 12:26 PM, the surveyor interviewed the Registered Nurse/ Unit Manager (RN/UM). The surveyor stated that Resident #130's call bell was observed on the floor three times on three different days. The surveyor asked the RN/UM where the resident's call bell should be. The RN/UM stated that the call bell should not be on the ground and stated that it should be clipped onto the bed or attached the resident's siderail and within the resident's reach. A review of resident's hybrid medical record revealed the following: The admission Record indicated that the resident had diagnoses which included but were not limited to Heart Failure, Acute Kidney Failure, Legal Blindness, Major Depressive Disorder, and Anxiety Disorder. The 7/6/22 quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that Resident #130 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. The MDS further reflected that the resident required extensive to total assistance from one staff member in most areas of activities of daily living including bed mobility, dressing, toilet use, and personal hygiene. The fall risk care plan indicated that Resident #130 needed a working and reachable call light. 2.) On 9/1/22 at 10:38 AM, two surveyors observed Resident #11 in bed. The resident was non-interviewable and was observed with a tracheostomy in place attached to a tracheostomy collar connected to an oxygen concentrator at 6 liters per minute. The call bell was observed to be far from resident's reach. On 9/2/22 at 11:14 AM, Resident #11 was observed in bed with eyes closed. The call bell was observed to be clipped on to the pull cord close to the wall and was not within resident's reach. On 9/6/22 at 11:16 AM, Resident #11 was observed in bed with eyes open. The surveyor introduced self to the resident. The resident was non-interviewable. The call bell was clipped on to the pull cord close to the wall and was not within resident's reach. The surveyor brought the CNA assigned to Resident #11 inside the room. The CNA confirmed to the surveyor that the resident's call bell was supposed to be placed within resident's reach. The CNA further stated that the call bell was not in the right place and was not within resident's reach. A review of the admission record for Resident #11 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Respiratory Failure, Dysphagia and Seizure disorder. The resident's most recent Annual MDS, an assessment tool used to facilitate the management of care dated 8/1/22, reflected that Resident #11 had a BIMS score of 00, indicating severe cognitive impairment. The MDS further reflected that the resident requires total assistance with one to two staff assist in most areas of Activities of daily living including transfers, bed mobility, eating and bathing. A review of the care plan titled, Resident #11 is at risk for falls r/t gait/balance problems; Alzheimer's, CVA with an intervention that included, call bell within reach. On 9/6/22 at 12:46 PM, the surveyors expressed their concerns to the Licensed Nursing Home Administrator (LNHA), Director of Nursing, and RN Regional Coordinator. The surveyor asked if administration would expect that residents would be unable to reach their call bells. The LNHA stated, of course not. The facility policy, Call Bell Policy and Procedure with a revised date of 7/10/22 indicated that, call bells shall be placed within reach of resident at all times, including but not limited to after care is provided/ repositioning, toileting, bed mobility, and or meals. NJAC 8:39-4.1(a)11; 31.1(b)

Based on observation and interview it was determined that the facility failed to provide a homelike environment during meal service as evidenced by the following: On 9/6/22 at 11:59 AM, during the lunch meal service in the 5th floor dining room, the surveyor observed that all the meals in the dining room (DR) were served on meal trays and was left on the trays in front of the residents. Further observation revealed that the trays used to serve the resident's meals were observed to be warped. The surveyor also observed the Certified Nursing Assisntant (CNA's) who were providing assistance with set-up to the residents in the DR left the lid from the food plate on the table and placed all the empty packet of milk carton, straw papers and other trash in front of the resident. On 9/9/22 at 12:48 PM, the surveyor discussed the above concern to the Administrator, Director of Nursing and Regional Nurse. No further information was provided. N.J.A.C. 8:39-4.1(a)12

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 3 of 26 residents reviewed for resident assessment (Resident #3, Resident #11 and Resident #32). This deficient practice was evidenced by: On 9/6/22 at 12:45 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. 1.) Resident #3 was observed to have an Annual MDS with an Assessment Reference Date (ARD) of 7/11/22 and was due to be transmitted no later than 8/15/22. The MDS was not transmitted until 9/8/22. 2.) Resident #11 was observed to have an Annual MDS with an ARD of 8/1/22 and was due to be transmitted no later than 8/29/22. The MDS was not transmitted until 9/8/22. 3.) Resident #32 was observed to have a Quarterly MDS with an ARD of 8/9/22 and was due to be transmitted no later than 9/6/22. The MDS was not transmitted until 9/8/22. On 9/8/22 at 11:10 AM, two surveyors interviewed the MDS Coordinator about the late transmission of Resident #3's Annual Assessment. The MDS Coordinator stated that she did not transmit the Annual Assessment and that it is the responsibility of the Regional MDS Coordinator to transmit the assessments. On 9/8/22 at 1:00 PM, the survey team interviewed the Licensed Nursing Home Administrator (LNHA) about the facility's process for MDS transmission and expressed their concern about the late Annual Assessment. The LNHA confirmed that the Regional MDS Coordinator transmits the facility's MDS assessments but could not speak to why this assessment was not transmitted timely. On 9/9/22 at 10:58 AM, two surveyors interviewed the Regional MDS Coordinator over the phone. The surveyor asked why the Annual MDS was not completed timely. The Regional MDS Coordinator stated, I don't know how that happened. The surveyor asked when the Annual Assessment should have been completed. The Regional MDS Coordinator stated, within 14 days of the completion date. According to the latest version of the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2019) page 2-21 The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis. The manual revealed on page 2-16 An Annual (Comprehensive) Assessment must be completed no later than care plan completion date + 14 days. The also manual reflected on Page 2-20, The MDS must be transmitted (submitted and accepted into the QIES ASAP system) electronically no later than 14 calendar days after the care plan completion date. NJAC 8:39-11.2

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 1 of 3 residents reviewed, Resident #103 as evidenced by the following: On 9/01/22 at 10:20 AM, the surveyor observed Resident #103 lying in bed watching TV. The surveyor also observed a nebulizer machine on the nightstand, labeled with the resident's name. The resident stated, he/she receives nebulizer treatments three times a day. The surveyor reviewed Resident #103's hybrid medical record. The admission Record reflected that Resident #103 was admitted with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), Emphysema, and Rhabdomyolysis. The surveyor reviewed the September 2022 Physician's Order (PO) form, which showed that Resident #103 had a PO for Xopenex Nebulization Solution 1.25 MG/3ML (Levalbuterol HCl) 3ml inhale orally via nebulizer every 8 hours related to COPD. The surveyor reviewed Resident #103's Interdisciplinary Care Plans, which showed that the facility did not develop a care plan that included the use of a Nebulizer and COPD. On 9/12/22 at 10:00 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated, anyone who has a respiratory diagnosis like COPD and/or is receiving a respiratory treatment like a nebulizer, should have that addressed in their care plan. The DON was unable to explain why Resident #103 does not have a care plan addressing this. The surveyor reviewed policy titled, Optima Care Harbor View Comprehensive Care Plans Policy & Procedures, revised on 1/5/22. The policy reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident. Policy and Interpretation and Implementation: 8. The comprehensive, person-centered care plan will: g. Incorporate identified problems areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables, and objectives in measurable outcomes; 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The surveyor reviewed an additional policy titled, Administering Medication through a Small Volume (Handheld) Nebulizer, approved on 3/20/22. The policy reflected, Policy statement: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Policy Interpretation and Implementation: 1. Review the resident's care plan, current orders, and diagnoses to determine resident needs. 2. If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the Chronic Obstructive Pulmonary Disease (COPD), Clinical Protocol in addition to this procedure. The DON was unable to provide the surveyor with any COPD Clinical Protocol information. NJAC 8:39- 11.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to review and revise a care plan to reflect changes to a resident's nutritional care for 1 of 3 residents (Resident # 58) reviewed. The deficient practice was evidenced by the following: On 9/1/22 at 10:10 AM, the surveyor observed Resident #58 lying in the bed and observed Glucerna 1.5 tube feeding running at 50ml/hr. The resident was pleasant during the interview process. A review of the admission Record for Resident #58 revealed that he/she was initially admitted with diagnoses that included but not limited to: Encounter for surgical aftercare following surgery on the digestive system, Cerebral infarction, Adult failure to thrive, and Dysphagia, Gastrostomy status (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support.) A review of an Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/7/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS further indicated that the resident has a feeding tube which was the sole source of nutrition and hydration delivery. A review of the Order Summary Reports reflected the following Enteral Feed Order's which provide the residents nutrition: An order for Glucerna 1.5 liquid via PEG to run at 50 ml/hr via PUMP dated 6/8/22. Total volume to be infused: 1000 ml/24hrs. Up at 17:00 and down when total volume is infused, remember to set specific hang time below AND every shift Check and ensure accurate rate and feeding. An order for water flushes via PEG tube with 300 ml of H2O every 6 hours dated 6/8/22. Total volume of flush = 1200 ml/day. On 9/1/22 at 12:30 PM, the surveyor reviewed Resident #58 care plan dated 6/7-6/14/22 for, NPO (nothing by mouth) status, tube feeding to meet nutrition and fluid needs. Under the intervention portion of that care plan states Flush with 200ml H2O q 6 hours. On 9/12/22 at 9:40 AM, the surveyor interviewed Registered Dietitian (RD#1). RD#1 acknowledged, he/she is responsible for updating the resident's care plans for enteral feedings and anything dietary related, but was unable to state how the Resident #58 care plan was not updated with the change to the water flushes. The surveyor reviewed policy titled, Optima Care Harbor View Comprehensive Care Plans Policy & Procedures, revised on 1/5/22. The policy reflected, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident. Policy and Interpretation and Implementation: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change. 14. The Interdisciplinary Team must review and update the care plan. A review of the job description for the Dietitian under Responsibilities/Accountabilities states: 4. Ensures appropriate documentation of nutritional assessment to the MDS and recommended intervention in the resident chart and/or care plan; reviews the documentation of others regarding nutritional concerns and responds appropriately. 8. Review resident care plans . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to develop a plan of care and failed to perform a smoking assessment to determine the level of supervision required for 1 of 3 residents reviewed for smoking, Resident # 22. The deficient practice was evidenced by the following: On 9/1/22 at 11:05 AM, the surveyor spoke with Resident # 22 in the resident's room while the resident sat in a chair. The resident stated they smoked at the facility three times a day, at 9 am, 1 pm, and 7 pm. The resident said the cigarettes were locked up in the recreation department as well as the lighters. The resident said the staff supervised the smokers, distributed the cigarettes, and lit the cigarettes for the residents. On 9/8/22 at 12:51 PM, the surveyor reviewed the residents hybrid medical record which revealed the following: An admission Record with diagnoses which included, Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis, Hypokalemia, Major Depressive Disorder, Essential Hypertension. A Significant Change Minimum Data Set assessment dated [DATE] which indicated that the resident scored a 14 of 15 in the Brief Interview of Mental Status exam. This indicated that the resident was cognitively intact. A smoking assessment dated [DATE]. Question #1 read Is resident a smoker? the answer was yes. The rest of the assessment was not filled out. Additionally, there was no care plan for smoking. The surveyor confirmed with the Registered Nurse (RN) assigned to the resident that a smoking assessment should have been done and that there should have been a care plan for smoking. There were no other smoking assessments in the medical record. On 9/8/22 at 1:00 PM, the surveyor spoke with the Administrator and the Director of Nursing (DON) about the resident not being assessed to smoke and about there not being a care plan for smoking. They confirmed that they should have done a smoking assessment on admission and they should have had a care plan for smoking. On 9/9/22 at 10:10 AM, the Administrator and the DON provided the smoking contract from the resident that was signed by the resident on 5/17/22. The Administrator confirmed that there was no smoking assessment completed on admission, or since admission, and there was no care plan for smoking. The surveyor observed the resident in the smoking area multiple times throughout the survey. Observed that there was a smoking attendant present while the residents were smoking. The smoking area was on the second floor on the outside patio. On 9/9/22 at 11:00 AM, the surveyor reviewed the facility's policy and procedure titled Smoking Policy and Procedure with a revision date of 3/2022. Under Purpose number 1. read Upon admission to the facility all smokers will be assessed. The resident's level of safety and their level of smoking privilege will be determined, based on the smoking assessment. 2. read Residents will be assessed monthly to ensure that their current level has not changed. NJAC 8:39-11.2 (d) 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to perform post dialysis assessments for 1 of 1 residents reviewed for dialysis care and services, Resident # 127. The deficient practice was evidenced by the following: On 9/1/22 at 11:51 AM, the surveyor observed Resident # 127 laying in bed in the residents room. The resident didn't answer when spoken to. The resident was covered with a blanket. The Registered Nurse (RN) who was assigned to the resident confirmed that the resident went out for hemodialysis every Tuesday, Thursday, and Saturday. On 9/8/22 at 10:39 AM the surveyor reviewed the resident's record which revealed the following: An admission record with diagnoses that included Type 2 Diabetes, End Stage Renal Disease, Hypertensive Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis. A current Physician's Order Sheet (POS) with an order that read; Dialysis at [name redacted] every Tuesday, Thursday, and Saturday. The date of the order was 7/27/22. An admission Minimum Data Set assessment dated [DATE] that indicated the facility attempted to conduct a brief interview of mental status with the resident, however, the resident was unable to complete the interview. The staff completed the mental status assessment using observation. It was determined that the resident's cognitive skills for daily decision making were severely impaired. At that time the surveyor reviewed the dialysis communication book which the resident took to dialysis. On the sheets titled Dialysis Communication Sheet there was a section where the facility nurse would write an assesment as well as any relevant information prior to sending the resident to dialysis and a section where the dialysis nurse would write information during dialysis. There was no section where the nurse would document an assessment of the resident upon return to the facility from dialysis. The surveyor reviewed the communication sheet with the RN. The RN confirmed that there was no section for the nurse to document an assessment of the resident upon return from dialysis. The RN said she would let the Unit Manager (UM) know. The UM was covering for an absent UM on another floor throughout the survey. The surveyor asked the RN where the nurses documented the assessment of the resident when they returned from dialysis. The RN said she was not there when the resident returned to the facility from dialysis because it was on a different shift. The RN said the nursing staff documented their assessment of the resident in the nurses' progress notes. The surveyor reviewed the progress notes for August and September 2022. The August progress notes included ten return notes by the nurse on duty. The resident had thirteen dialysis visits in August. The nurse did not include an assessment of the resident upon return to the facility from dialysis in any of the ten nurses progress notes. None of the ten notes included the resident's vital signs and only one nurses' note included an assessment of the dialysis access site. The September progress notes included two return notes by the nurse on duty. The resident had three dialysis visits by that date in September. The nurse did not include an assessment of the resident upon return to the facility from dialysis in either of the two nurses' progress notes. The two notes did not include the resident's vital signs upon return to the facility or an assessment of the dialysis access site. On 9/13/22 at 1:30 PM the surveyor spoke with the Administrator and the Director of Nursing (DON) about the concern with the lack of assessment of the resident upon return from dialysis. There was no response from the Administrator of the DON, but they stated they would provide the policy for review. On 9/14/22 at 1:59 PM the surveyor reviewed the facility's Policy and Procedure titled Hemodialysis Policy & Procedure revised date 9/5/22. Under B. Post Dialysis it read: 1. Upon resident's return from hemodialysis the receiving nurse on the unit will check the communication notebook from the dialysis center for any relevant information/instruction and initial that it was noted. Notify the nursing supervisor for any recommendations that the primary physician should be aware of and follow through. 2. The nurse on the unit will inspect needle puncture sites for post dialysis bleeding, and palpate for thrill and auscultate for bruit every shift & notify MD of any abnormality. Observe and report indications of infection such as erythema, swelling, unusual tenderness at the graft, fistula or shunt site. 3. The dietitian will also check the notebook for any relevant information. The post dialysis procedure did not include obtaining the residents vital signs or address the need for the nurse to document the findings. The surveyor asked the DON if that should have been done upon the resident's return from dialysis. She said yes it should have been done by the facility nurse upon the resident's return. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility failed to a) accurately follow the facility documentation policy related to the inventory control wasting of opioids and benzodiazepam control substance classes of medications for 2 of 20 residents who were receiving controlled substance medications inspected on the 5th floor, Resident #61 and Resident #24, b) remove a discontinued control substance medication from stock, and c) keep an accurate physical inventory of back up narcotics stored in a CUBEX system (automated medication dispensing system). This deficient practice was evidenced by the following: a) On [DATE] at 11:59 AM, the surveyor conducted a unit inspection which included an inventory comparison of the Individual Patient Controlled Substance Administration Record (CSAR) and physical controlled substance inventory with the RN Nurse Manager(RNNM). When the RNNM presented the CSAR for Tramadol 50 mg belonging to Resident #61 there was an entry dated [DATE] at 9 AM and signed by RNNM, documented fell out. The RNNM stated that she found the Tramadol 50 mg falling out of the sealed foil pack. When asked if there was a witness to this, the RNNM stated she forgot to get another witnessing nurse's signature on the CSAR, but that she was the nurse who wasted the medication. The CSAR for Tramadol 50 mg contained documention of two entries on [DATE] and on [DATE] indicating, Wasted in the Time column. The [DATE] entry had one nurse's signature. Both entries on the CSAR failed to include a time that the 2 doses were wasted. A review of the CSAR revealed two entries on [DATE] and [DATE] indicating Wasted in the Time column. Both entries were signed by two nurses but failed to include a time that these 2 doses were wasted. b) The CSAR contained documention that there were 14 tablets of Tramadol 50 mg belonging to Resident #24, found in inventory and this was the correct amount that was physically present. The CSAR contained documention of 20 tablets of Tramadol 50 mg delivered by the Provider Pharmacy on [DATE] for Resident #24, had a documented expiration date on the medication seal of [DATE]. Review of the CSAR had entries for [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The original order for Tramadol 50 mg dated [DATE] was ordered with a discontinuation date of 7 days later for Resident #24. The Tramadol 50 mg was then discontinued on [DATE]. The medication remained in the locked narcotic section of the medication cart, despite the order being discontinued until [DATE], when the surveyor noted the medication. c) On [DATE] at 11:05 AM, the surveyor interviewed the 4th floor Registered Nurse Charge Nurse (RNCN) in reference to the CUBEX system. The CUBEX system was located in the locked medication room on the 4th floor. The surveyor discussed the inventory process of the control substance medications that were stored in the CUBEX system. The RNCN informed the surveyor no inventory was completed during her shift. The RNCN presented a bound book to the surveyor titled, Cubex Daily Inventory Check book. The surveyor reviewed the Cubex Daily Inventory Check which indicated that the last time inventory was performed was [DATE] with NO documented under the discrepancy column. On [DATE] at 9:49 AM, the surveyor in the presence of the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed a physical count of all controlled substance medications in the CUBEX system. Although the CUBEX system presented an automated inventory of 30 Clonazepam 0.25 mg (30 Clonazepam 0.5 mg cut in half and sealed), there were no physical tablets in the area designated for this medication. Clonazepam is a schedule IV (low potential for abuse and low risk of dependence) control substance medication. Further information obtained from the CUBEX system established that the last entry into the CUBEX system for this medication was on [DATE] at 6:02 PM. On [DATE] at 12:42 PM, the surveyor interviewed the Consultant Pharmacist (CRPh) who was not aware that the facility failed to perform daily inventory counts of back up narcotics stored in the CUBEX system. The CRPh informed the surveyor that she does not have access to the CUBEX system. On [DATE] at 10:20 AM, the surveyor interviewed the Provider Pharmacy Account Executive (PPAE), who explained the Cubex provides the ability to do a physical count of the narcotic inventory through an option Cycle Count. The PPAE stated that the facility should perform a physical control substance count of all medications stored in the CUBEX system at least once daily. The PPAE was able to review the past history for Clonazepam 0.25 mg and informed the surveyor that the medication was delivered on [DATE] with a documented expiration date in [DATE]. There was no evident information to show that the medication was removed or destroyed because it had expired. No documentation was available that the medication had been removed or destroyed due to expiring The PPAE informed the surveyor electronic inventory sheets which include all control substance medications are sent out by email daily. The PPAE also informed the surveyor that a technician comes to the facility monthly from the Pharmacy Provider to remove all expired non control substance medications. The technician does not have access to any control substances stored in the CUBEX system, this is the responsibility of the facility. The PPAE added that the electronic inventory is only as accurate as the CUBEX information updated by the facility. The surveyor reviewed the Controlled Dangerous Substance Inventory for Back Up Box and Emergency Kits policy. The policy stated, 4. In the event a controlled substance medication in the emergency supply box inventory expires, it must be immediately destroyed at the facility per facility policy and procedure. Attached to the policy was the CUBEX Daily Inventory Check that specified For the Month Of: and included columns for Incoming (RN#1) Outgoing (RN#2) Discrepancies Y or N and Resolution. This CUBEX Daily Inventory Check was provided to the surveyor by the DON who explained that this reporting paper should have been filled out daily. Review of the Controlled Substances policy indicated 9. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Review of the facility policy Discarding and Destroying Medications approved 1/2022 indicated 7. The medication disposition record must contain, as a minimum, the following information: i. Signature of witnesses. On [DATE] at 2:15 PM, the surveyor met with the DON and Licensed Nursing Home Administrator (LNHA) to discuss findings concerning the discrepancies with control substance management at the facility. On [DATE] at 1:26 PM, the surveyor met with the DON in the presence of LNHA and the RN Clinical Support Regional staff person to discuss further findings concerning the discrepancies with control substance management at the facility. No further information was provided to the survey team. On [DATE] at 10:04 AM the surveyor met with the DON in the presence of the ADON, PPAE and the LNHA to discuss further findings concerning the discrepancies with control substance management at the facility. The DON stated that inventory of controlled substance medication should be performed daily. The DON added that when medications are wasted, there needs to be two nurses' signatures on the inventory sheet. On [DATE] at 10:15 AM, the surveyor discussed the expired Tramadol 50 mg ([DATE]) found in the locked narcotic box of 5th floor the medication cart on [DATE]. The DON agreed that the Tramadol 50 mg should have been removed from stock and destroyed once the [DATE] order was discontinued on [DATE]. The Tramadol should not have remained in the medication cart. On [DATE] at 12:53 PM, the surveyor discussed all the controlled substance medication issues with the DON and LNHA during the survey exit via a phone call. No further information was provided by the facility to the survey team. NJAC 8:39- 29.4(b)2

Based on observation, interview, and record review, it was determined the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's needs. This deficient practice was identified for 1 of 29 residents, Resident #87, reviewed for hospice/end-of-life care. The deficient practice was evidenced by the following: On 9/6/22 at 10:56 AM, the surveyor observed Resident #87 in bed sleeping. On 9/7/22 at 11:53 AM, the Licensed Practical Nurse (LPN) informed the surveyor that Resident #87 was on hospice care. The LPN further stated that the hospice nurse came to the facility once or twice a week. The surveyor reviewed the resident's medical records which revealed the following: A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with a diagnosis that included but was not limited to Unspecified Dementia without Behavioral Disturbance and Hypertension. A recent quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management dated 6/17/22, revealed a Brief Interview for Mental Status score of 99, which indicated that the resident was unable to complete the interview. A Physician's Order which revealed the following: Hospice Care: Grace with an order date of 1/9/2020. A review of the resident's medical record revealed there were no hospice nurse visit notes after July 11, 2022. On 9/7/22 at 12:45 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) and asked her who was responsible for making sure that the hospice visit notes were in Resident #87's medical record. The RN/UM stated, nobody is really assigned to make sure these hospice notes are placed in the resident's chart. She further stated that the hospice nurse would give a verbal report to the nurse on duty and place the hospice visit note in the resident's medical record for every visit. The RN/UM acknowledged that the last hospice visit note titled Skilled Nursing Visit Note was dated 7/11/22. On 9/9/22 at 10:18 AM, the surveyor called the Hospice Nurse/HN. The HN stated that she documented her hospice visit notes on her laptop and gave verbal reports to the nurse on duty before she left the facility. She further stated that she printed her hospice visit notes titled Skilled Nursing Visit Note every 2 weeks and placed them in the resident's medical record. The HN acknowledged that she should have printed her hospice visit notes for every visit. On 9/12/22 at 1:30 PM, the surveyors met with the Licensed Nursing Home Administrator, Director of Nursing (DON), and Regional Clinical Nurse and discussed the above concern. No further information was provided. A review of the facility policy titled Hospice Services with an approved date of 7/5/22 did not include medical records information. A review of Grace Healthcare Services Agreement for Nursing Facility Services signed on 1/18/13 included 4.3 Communication. Hospice and Facility will communicate pertinent information with each other either verbally or in the patient's medical record at each hospice patient visit to ensure that the needs of each hospice patient are met 24 hours a day. Documentation of such communication shall be included in the patient's medical record. On 9/13/22 at 12:09 PM, the surveyor interviewed the DON in the presence of another surveyor and asked her who was responsible for making sure the hospice visitation notes were placed in the resident's medical record. She stated, The unit manager and the nurse on duty now and then. The surveyor asked the DON what would be done if the hospice visitation notes were not in the resident's medical record. The DON further stated, I would call the hospice agency to get a hold of the hospice visitation notes. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) On 9/02/22 at 8:20am, the surveyor observed Resident # 58 lying in bed asleep. Resident's enteral feeding machine was off and the enteral formula bottle was hanging with 50% of the formula remaining. Surveyor observed the enteral feeding bottle was not labeled with any information for the resident. A review of the admission Record for Resident #58 revealed that he/she was admitted with diagnoses that included but not limited to: Encounter for surgical aftercare following surgery on the digestive system, Cerebral infarction, Adult failure to thrive, and Dysphagia, Gastrostomy status (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support. A review of an Annual MDS, an assessment tool used to facilitate the management of care, dated 6/7/22, reflected that the resident had a BIMS score of 3 which indicated severe cognitive impairment. The MDS further indicated that the resident has a feeding tube which was the sole source of nutrition and hydration delivery. A review of the Order Summary Reports reflected the following Enteral Feed Order's which provide the residents nutrition: An order for Glucerna 1.5 liquid via PEG to run at 50 ml/hr via PUMP dated 6/8/22. Total volume to be infused: 1000 ml/24hrs. Up at 17:00 and down when total volume is infused, remember to set specific hang time below AND every shift Check and ensure accurate rate and feeding. An order for water flushes via PEG tube with 300 ml of H2O every 6 hours dated 6/8/22. Total volume of flush = 1200 ml/day. At 8:45am, during an interview with the RN # 2 in residents' room, the RN # 2 acknowledged the enteral feeding bottle was not labeled and should contain the resident's name, room number, date, time the feeding began, enteral feeding rate and total volume. The RN # 2 further explained the 3-11 shift nurse was the nurse who hung the enteral feeding, and it was their responsibility to label the enteral feeding bottle. On 9/07/22 at10:50am, the surveyor interviewed LPN # 1, who acknowledged they forgot to fill out the enteral feeding label. The LPN # 1 further stated, they know what needs to go onto the enteral feeding label and has been in-serviced on that procedure. A review of the facility policy and procedure, Enteral Feeding revised on 3/22/22, reflected as part of their Procedure: 7. Feedings given via pump will be routinely administered in a closed feeding system. Tube feedings have a hang time of 48 hours. When a new feeding bag in hung, product will be labeled with name of the resident, date, and time bag was hung, and also signed for by nurse. Based on observation, interview, and record review, it was determined that the facility failed to follow a Professional Standards of Practice by a.) not following a Physician's Order (PO) on application of hand rolls to maintain joint integrity for 1 of 4 residents reviewed with limited range of motion, Resident #71, b.) failed to label and date an Enteral feeding bottle for 1 of 2 residents reviewed for Enteral feeding, Resident # 58, c.) failed to assess a weight change for 1 of 5 residents reviewed for nutritional status which did not contribute to weight loss, Resident # 124 and, d.) Failed to have a valid physician's order and accurately document the administration of a controlled substance, Resident #61 and Resident #24. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: a.) On 9/6/22 at 11:14 AM, the surveyor observed Resident #71 inside the room, lying in bed with eyes open. The surveyor further observed hand rolls applied to both hands of the resident. Resident #71 stated to the surveyor that they wear hand rolls all day. On 9/7/22 at 11:52 AM, the surveyor observed Resident #71 in bed with eyes closed. The surveyor observed hand rolls applied to both hands of the resident. A review of the admission record for the Resident #71 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Osteoarthritis, Benign Prostatic Hyperplasia, and Glaucoma. The resident's most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/30/22, reflected that Resident #71 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. A review of the September 2022 Treatment Administration Record showed a PO dated 8/25/22 for Application of bilateral hand rolls applied daily from 3pm to 8pm. On 9/8/22 at 10:50 AM, the surveyor interviewed the registered Nurse (RN # 1) assigned to Resident #71 who stated that bilateral hand rolls were applied in the day time after morning care and would only be removed during care to check skin integrity. The surveyor interviewed the 7-3 Certified Nursing Assistant (CNA # 1) assigned to the resident who stated that when she reported for her shift in the morning, both the hand rolls were applied to the resident already. The RN acknowledged to the surveyor that the bilateral hand rolls were applied at a wrong time and was not according to the physician's order. On 9/8/22 at 12:47 PM, the surveyor discussed the above concern to the Administrator, Director of Nursing (DON) and the Regional RN # 1. There was no further information provided. c.) On 9/1/22 at 12:00 PM, the surveyor observed Resident # 124 in bed. The resident stated that he/she had weight loss and it was desired as he/she felt good now. Resident # 124 stated that the weight loss happened because he/she had a decreased appetite and illness in the recent past. The resident stated that the food tasted okay, and he/she had a good appetite at most meals. On 9/2/22 at 10:02 AM, the surveyor interviewed the CNA # 2 assigned to the resident who stated that the resident had been eating better at about 75% consumed at most meals and the resident says he/she felt good with his/her weight loss. On 9/2/22 at 10:50 AM, the surveyor interviewed the RN # 3 assigned to the resident who stated that Resident # 124 had been losing weight and had a history of many diagnoses which may have contributed to the weight loss. The resident was obese and was currently eating well but the resident said he/she was happy with his/her weight loss. The RN # 3 stated that the doctor and interdisciplinary team were following the resident closely with the weight changes. At 12:39 PM, the surveyor observed Resident # 124 in their room served their lunch meal. The resident consumed 50-75% of the meal served. On 9/13/22 at 10:42 AM, the surveyor observed Resident # 124 in their room served their lunch meal. The resident again consumed 50-75% of the meal served. A review of the admission Record revealed that Resident # 124 had diagnoses which included but were not limited to Chronic Systolic (Congestive) Heart Failure, Obesity, Pancreatitis, Type 2 Diabetes Mellitus, Nausea with Vomiting, Diarrhea, and Enterocolitis due to Clostridium Difficile (a bacteria that causes diarrhea and inflammation of the colon). A review of the quarterly MDS, an assessment tool used to facilitate care management dated 7/11/22, revealed a Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. A review of Resident # 124's weights revealed that on 7/13/22, the resident weighed 223 pounds (lbs) and on 8/1/22, the resident weighed 201 lbs, which indicated a significant weight loss of 9.8% weight loss in one month. The resident did not lose any further weight with a documented weight of 201 lbs on 9/1/22. A review of the resident's progress notes and assessments documented by the interdisciplinary team, which included nursing and the resident's physician, revealed that the resident's meal intake, snack intake and weight status were documented for the weight change documented on 8/1/22. Further review of the resident's progress notes and assessments revealed that there was a nutrition follow up note documented by the Registered Dietitian (RD), which was dated 7/27/22 that revealed that the resident weighed 223 lbs and had weight loss over the last 90 days with recommendations and rationale for this weight loss. There were no progress notes or assessments done by the RD to assess the weight change documented on 8/1/22. On 9/14/22 at 1:00 PM, the surveyor interviewed the RD who was assigned to Resident # 124 and he stated that the resident did have a weight change documented on 8/1/22 and there was no weight change note to assess the concern. He stated that there should have been an assessment/progress note written to address the weight change. He also stated that the resident's appetite had improved and the resident was happy with the weight changes plus the resident had not lost any further weight this month. On 9/14/22 at 1:42 PM, the surveyor discussed the above concern with the Administrator and DON. There was no further information provided. The surveyor reviewed the facility's Nursing and Dietary Policy and Procedure, dated 2/24/22, which revealed that residents with significant weight change shall be evaluated by the Dietitian and reviewed by the team, the monthly weight record is completed accurately, and the Dietitian makes nutrition notes every admission/readmission, quarterly and annual as well as nutrition notes if there are significant changes, e.g. weight loss/weight gain. d.) On 9/12/22 while reviewing the 5th floor facility control substance inventory system, the surveyor reviewed the Individual Patient Controlled Substance Administration Record (CSAR) for Resident #61. The CSAR documented a delivery from the Provider Pharmacy of #20 Tramadol 50 mg for Resident #61 on 7/16/21. The CSAR also indicated that a dose of Tramadol 50mg was administered to Resident #61 on 7/3/22. A review of the admission Record for the Resident #61 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Unspecified Schizophrenia, Dementia and idiopathic peripheral autonomic neuropathy. The resident's most recent MDS, dated [DATE], reflected that Resident #61 had a BIMS score of 8, indicating a moderately impaired cognition. A review of the Physician Orders (PO) for 7/2022 does not indicate that there was any physician order for Tramadol 50 mg for Resident #61. A review of the Electronic Medical Administration Record (EMAR) dated 7/2022, does not indicate that there was any entry documenting that the Tramadol was administered to Resident #61. A review of the EMAR dated 7/16/21, documented a physician order for Tramadol 50 mg 1 tablet every 8 hours prn for pain management for 7 days. The medication was not documented as administered to Resident #61 and expired on 7/24/21. A review of the EMAR dated 2/17/22, documented a physician order for Tramadol 50 mg 1 tablet every 12 hours prn for back pain moderate pain 4-6. The medication was documented as administered on 2/17/22 for a pain level of 4 and 2/22/22 for a pain level of 5. A review of the EMAR dated 3/2022, documented that the order expired on 3/11/22. Review of PO from 7/2021 to 7/2022 revealed that there were only two POs for Tramadol 50 mg. Review of the Documentation of Medication Administration policy states, A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). On 9/15/22 at 12:15 PM, the surveyor informed the DON and LNHA of this issue and no further information was supplied. e.) On 9/12/22 while reviewing the 5th floor facility control substance inventory system, the surveyor reviewed the CSAR for Resident #24. The CSAR documented that Oxycodone IR 5 mg #60 tablets were delivered from the Provider Pharmacy for Resident #24. The CSAR revealed #55 doses had been administered to Resident #24 from 8/4/22 to 8/31/22 with #2 documented doses Wasted on 8/29/22 and 9/1/22. A review of the admission record for the Resident #24 reflected that the resident was admitted to the facility with diagnoses which included but not limited to Dementia and Diabetic neuropathy. The resident's most recent MDS, dated [DATE], reflected that Resident #24 had a BIMS score of 00, indicating a severely impaired cognition. A review of Resident #24's 8/2022 EMAR, indicated a physician's order for Oxycodone 5 mg 1 tablet every 12 hours for pain management hold if patient lethargic or sleepy with a start date of 7/15/22, and hold dates of 8/26/22 to 8/29/22. The documented administration times for Oxycodone 5 mg was 9:00 AM and 9:00 PM. Review of the CSAR indicated that Oxycodone IR 5 mg was removed from inventory at 5:00 PM on 8/9/22, 8/10/22, 8/11/22, 8/12/22 and 8/31/22. Review of the documentation for the administration of Oxycodone IR 5 mg for 8/9/22, 8/10/22, 8/11/22, 8/12/22 and 8/31/22 indicates 9:00 PM. Review of the CSAR indicates that Oxycodone IR 5 mg was removed from inventory on 8/26/22 at 9:00 AM and 9:00 PM Review of the 8/2022 EMAR indicates that Oxycodone IR 5 mg was administered to Resident #24 at 9:00 AM and held at 9:00 PM. Review of the Documentation of Medication Administration policy indicated, Administration of medication must be documented after (never before) it is given. On 9/2/22 at 2:15 PM, the surveyor met with the DON and Licensed Nursing Home Administrator (LNHA) to discuss findings concerning the discrepancies with documentation involving administration. There was no further information provided during the survey. NJAC 8:39-11.2 (b); 27.1 (a); 29.2(d)

16. The hybrid medical records of Resident #37 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 17. The hybrid medical records of Resident #54 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 18. The hybrid medical records of Resident #38 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. On 09/12/22 at 10:38 am, the surveyor interviewed a Registered Nurse (RN) regarding where the physicians sign the orders for residents. The RN stated the physicians usually sign in the resident's paper chart and the physicians may sometimes sign in the EHR. The RN stated the monthly POS are usually kept in a binder for the physicians to sign. The RN clarified the monthly POS were kept in the binder and once signed were to be returned to the resident's chart. On 09/12/12 at 11:50 am, the surveyor asked the RN/Unit Manager (RN/UM) about the monthly POS for residents. The RN/UM stated there were binders on the unit for the physician to sign orders. The surveyor observed that the binders on the unit consisted only of monthly physician orders from 2020. The RN/UM stated the Director of Nursing (DON) had the current binders and would provide to the surveyor. On 09/12/22 at 01:19 pm, the surveyor informed the Administrator, DON, and RN regional coordinator of the concerns with the monthly physician orders not found in the chart and the signing of the monthly POS by physicians. The DON stated there was a binder with monthly physician orders for the physicians to sign. The DON stated when the physicians visit, the staff have the physicians sign the POS and place it back in the resident's chart. The DON and Administrator stated they would provide further information to the surveyor. On 09/14/22 at 1:42 PM, the surveyor discussed with the Administrator and the DON the signing of the POS by the physicians. The Administrator stated the physicians will be coming in to complete the signing of the June, July, and August 2022 POSs. The Administrator and DON did not provide a response as to why POSs were not signed. The surveyor asked who was responsible for ensuring the physician's signed orders for the residents. The Administrator replied the medical records staff was responsible. On 9/15/22 at 9:49 am, the surveyor interviewed the Medical Records staff person (MR) about physicians signing orders and the monthly POS. The MR stated she was responsible for getting the POS together in the binders and getting the physician to sign them. The MR further stated she would call the physicians' office to see when they would be coming in and told the offices she could fax orders to be signed by the physicians. The MR stated she printed out the POS every month to prepare for physicians to sign. On 9/15/22 at 12:07 pm, the DON provided surveyor reviewed the facility's policy and procedure titled, Electronic Medical Records, reviewed 01/2022, did not address physicians signing orders. No further information was provided by the facility. NJAC 8:39- 23.2 (b) 4. Resident #63's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. 5. Resident #87's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 18 of 29 residents (Resident #3, #118, #130, #63, #87, #84, #32, #71, #11, #70, #147, #117, #22, #7, #127, #38, #54, #37) reviewed and occurred over several months. This deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above which revealed the resident's primary physician had not hand signed the Order Summary Reports (monthly physician's orders) located in the residents' chart. In addition, there were no electronic signatures under the physician's orders for the following residents: 1. Resident #3's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 2. Resident #118's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 3. Resident #130's hybrid medical records revealed that the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, and August 2022. 6. Resident #84's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. 7. Resident #32's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. 8.) Resident #71's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. 9.) Resident #11's hybrid medical records revealed that the resident's physician had not hand-signed or electronically signed the monthly physician orders for June, July, and August 2022. 12.Resident #117's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, or August 2022. 13. Resident #22's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, and July 2022. 14. Resident #7's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, or August 2022. 15. Resident #41's hybrid medical record revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for June 2022, July 2022, or August 2022. 10. The surveyor reviewed the closed record of Resident #70 who resided at the facility for one month for sub-acute rehabilitation. A review of the hybrid medical record failed to reveal signed physician orders for the resident's stay during June 2022 and July 2022. 11. The surveyor reviewed the closed record of Resident #147 who resided at the facility for over 6 years as a long term care resident. A review of the hybrid medical record revealed the physician did not sign orders for June 2022, July 2022, and August 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that contracting agents who provided services to residents were familiar and adhered to infection practice guidelines according to the facility's policy, Contracting Agents Policy, and Center for Disease Control (CDC ). This deficient practice was identified for 2 of 2 residents observed for X-ray procedures, Resident #213 and #1, as evidenced by the following: On 9/24/20 at 11:08 AM, the surveyor observed the Portable X-ray Technologist (PXT), wearing Personal Protective Equipment (PPE) (gown, face shield, gloves, and surgical mask) completing Resident #213's chest X-ray. Resident #213 was observed lying in bed. The X-ray cassette was removed from under the resident's bedsheet with Resident #213 observed lying on top of the bedsheet. On 9/24/20 at 11:10 AM, the surveyor observed the PXT remove his PPE inside the resident's room. The PXT used a hand sanitizer to clean his hands and pushed the X-ray machine (cassette in place) to Resident #1's room. On 9/24/20 at 11:15 AM, the surveyor observed the PXT put on PPE (gown, surgical mask, gloves, and face shield) and carry the X-ray cassette (which was not sanitized) towards Resident #1. The surveyor interrupted the PXT as he was about to place the cassette behind Resident #1, seated in a wheelchair. On 9/24/20 at 11:20 AM, the surveyor interviewed the PXT, who informed the surveyor that the X-ray cassette and the X-ray machine should have been sanitized prior to utilizing it. The PXT stated that he forgot to sanitize the X-ray cassette and machine between Resident #213 and Resident #1. The PXT said that he wiped down the cassette and machine before entering the facility. Resident #213 was admitted to the facility on [DATE] from the hospital with a diagnosis that included but were not limited to Parkinson's Disease, Diabetes Mellitus (DM), Hypertension (HTN), Difficulty walking with muscle weakness. Resident #213's room was located in an Observation Quarantine Unit to rule out COVID-19 infection. Resident #1 was admitted to the facility on [DATE] and readmitted from the hospital on 9/22/20 with the diagnosis that included but were not limited to Alzheimer's Disease, DM, Cerebral Infarction, Amputation of left leg below the knee, and HTN. Resident #1's room was located in the Observation Quarantine Unit as well to rule out COVID-19 infection. On 9/24/20 at 2:30 PM, the surveyor met with the facility Administrator and Director of Nursing, who stated that the PXT should be wiping down all the equipment entering the facility and then between each resident. On 9/25/20 at 9:30 AM, the Administrator presented the facility Policy and Procedure for Outside Vendors-COVID 19, which documented, The outside vendors who are Essential will be identified by the Administrator and will be required to follow their protocol on using PPE and cleaning equipment as long as it is in compliance with the facility policies and procedures. The Administrator also presented the surveyor with the supporting COVID-19 Response Policy and Procedure from the Contracting Agent, Before entering a patient room, you are to wipe down equipment, change your isolation gown, put new gloves, clean the cassette and use a panel cover if necessary. You are required to keep your equipment clean. You will need to clean the equipment before and after each use (before entering and upon leaving a resident's room) and, Under no circumstances are you to enter a patient's room following an exam in another room without taking the proper precautions to ensure the safety of not only yourself but the residents and staff of facilities. NJAC 8:39-19.4 (a)