Deficiency Text Not Available

Based on observation, interviews, record review, and facility documents it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate a resident's dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for 1 of 1 resident, Resident #62, reviewed for dialysis. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/12/2025 at 10:36 AM, during the initial tour, the surveyor observed Resident #62 in their room with the lights off. The resident was in bed and their eyes were closed. On 1/12/2025 during entrance conference with the surveyor, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) from 11:17 AM to 11:42 AM, the LNHA verified that the facility did not have an onsite dialysis unit. The surveyor reviewed the electronic medical record (EMR) for Resident #62. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 diabetes Mellitus without complications, Hypertensive heart (complications of high blood pressure that affect the heart), essential primary hypertension (htn-high blood pressure) and chronic kidney disease with heart failure and with stage 5 chronic kidney disease or end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood). A review of the admission Minimum Data Set (MDS), an assessment tool, dated 11/2/24 revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, indicating the resident's cognition was not able to be assessed. Further review of the MDS, revealed the resident was receiving dialysis. A review of the individual comprehensive care plan (ICCP) revealed: Resident needs dialysis hemo (treatment that filters waste from the blood) r/t (related to) renal (kidney) failure goes to dialysis tues (Tuesday)-thurs (Thursday) and Saturday (Sat) Date Initiated: 10/28/2024. Intervention: May schedule time of medication to accommodate dialysis schedule. A review of physician orders (PO) revealed a PO: ESRD on dialysis Tues Thurs and Saturday pick up 5:15 am chair time 6:15 am return 9:15 am every shift every Tue, Thu, Sat; Start date 10/28/24. A review of the October 2024 Medication Administration Records (MAR) revealed on 10/29/24 (Tues) code 9 was entered for the administration times of 0900 and 1000; and on 10/31/24 (Thurs) a code 1 was entered for the administration times of 0900 and 1000 ;and the November 2024 MAR revealed 11/2/24 Sat and11/12/24 Tues, a code 9 was entered for the administration times of 0900 and 1000; 11/5/24 Tues, 11/9/24 Sat, 11/14/24 Thurs, 11/23/24 Sat, 11/26/24 Tues, code 1 was entered for the administration times for 0900 and 1000 for following medications: -AmLODIPine Besylate Oral Tablet 10 MG (miligrams) (Amlodipine Besylate) Give 10 mg by mouth one time a day for HTN. HOLD if SBP is BELOW 100, start date 10/27/24. -Aspirin 81 Oral Tablet Chewable (Aspirin) Give 81 milligrams by mouth one time a day for CAD (coronary artery disease-disease in the heart's major blood vessels) start date 10/27/24 -Calcitriol Oral Capsule 0.25 MCG (micrograms) (Calcitriol) Give 1 capsule by mouth one time a day every Tue, Thu, Sat (Saturday) for CKD (chronic kidney disease) Start date 10/29/2024 -FLUoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day every Tue, Thu, Sat for depression, start date 10/29/2024. - SITagliptin Oral Tablet 25 MG (Sitagliptin) Give 1 tablet by mouth one time a day for DM (diabetes mellitus), start date 10/27/2024. -Triphrocaps Oral Capsule 1 MG (B-Complex w/ (with) C & Folic Acid) Give 1 capsule by mouth one time a day for Supplement, start date 10/27/2024. -Calcium Acetate Oral Tablet 667 MG (Calcium Acetate (Phosphate Binder) Give 2 tablet by mouth three times a day for CKD 2 caps (capsules)=1334 mg, start date 10/29/2024. A review of the MARs chart code revealed a 1= out on med pass with meds and a 9=other/See nurses notes. A review of the nursing progress notes revealed the following progress notes: -10/29/2024 at 10:05 Note Text: out on pass-dialysis; author LPN#1. -10/31/2024 at 10:10 Note Text: out on pass-dialysis; author LPN#1. -11/2/2024 at 15:57 Narrative: Resident was out at dialysis the whole shift, did not return on 7/3 shift. Author RN/LPN (registered nurse/licensed practical nurse) -11/5/2024 at 12:44 Narrative: Resident is back to facility this morning following their dialysis treatment earlier. Author LPN #1. -11/9/2024 at 10:58 Narrative: Resident returned to facility at 1050 following their dialysis treatment. Author LPN #1. -11/12/2024 at 13:09 Narrative: Came back to facility at 1050 after dialysis treatment. Author LPN #1. -11/14/2024 at 14:58 Narrative: Came back to facility at 1050 after dialysis treatment. Author: LPN #1. -11/23/2024 at 05:15 AM Narrative: Resident OOF to dialysis. Author: LPN#2 -11/26/2024 at 06:52 Narrative: Left Facility to HD (hemodialysis) at 6:40am with ambulance. Author RN #1. Further review of the progress notes for the above mentioned dates and medications did not reveal documentation that the physician was notified or that the medications were given. On 1/15/25 at 10:36 AM, the surveyor interviewed License Practical Nurse (LPN) #1, who stated Resident #62 receives dialysis Tuesday, Thursday and Saturday; they get picked up at 5 AM and come back around 10 AM or 11 AM on those days. LPN #1 stated we (the nurses) change medication times according to the dialysis schedule. He then stated, if for some reason the resident came back after 10 AM, he would use the code for out on pass and let the doctor know. LPN #1 accessed the eMAR in the presence of the surveyor. He verified a 1= out on pass, and stated the medication was not given because the patient was not there. He stated if a 9 was entered it meant there would be a progress note explaining why the medication was not given. LPN #1 could not show the surveyor a note the physician was notified or that the medications were given for the above mentioned dates. On 1/15/25 at 10:53 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated the resident received dialysis Tuesday, Thursday, and Saturday, leaves at 5 am and comes back around 10 AM or 11 AM. She further stated if a resident was not in the building, medications should not be schedule at that time. They (the medications) should be scheduled for the time the resident was in the building. The LPN/UM stated the doctor should be called after one occurrence to make them aware and to change the time of the medications. At that time, the LPN/UM accessed the electronic MAR in the presence of the surveyor. She reviewed Resident #62's November MARs. She acknowledged the codes on the above mentioned dates and was unable to verify if the physician was notified or that the medications were given for the above mentioned dates. The LPN/UM could not speak to why the medications were scheduled for the times when the resident was not in the building on Tuesday, Thursday, or Saturday. She stated the doctor should have been called and the times changed. She stated it was important for residents to get their medications to keep them therapeutic. On 1/15/25 at 11:08 AM, the surveyor interviewed the DON, who stated residents, who were receiving dialysis, medications should not be timed for when the resident was not in the building. She stated the doctor should definitely be called if the medications were unable to given. Medicines. The DON further stated after one time, the doctor should be called and medication times changed. At that time, the DON reviewed Resident #62's November MARs in the presence of the surveyor. She acknowledged the above mention codes for a above mentioned dates and medications. She reviewed the EMR and verified the medications were not given or that the doctor was not called. She was unable to speak to why the medications were not given. The DON stated it was important for residents to receive their medications because of imbalance, they need to be given on a regular basis. On 1/15/25 at 2:25 PM, the surveyor made with the LNHA, the DON, the Infection Preventionist, Operations staff member, and the Regional Nurse of the above concerns. No additional information was provided. A review of the facility policy, Dialysis Medication revised 10/2024, revealed: Policy: It is the policy and procedure of this facility to ensure that residents underdoing dialysis receive the appropriated medications to manage their condition. Procedure: 1. The facility may adjust all medications according to the dialysis schedule. 2. Any changes to dialysis schedule, the facility will notify the MD and adjust medication schedule accordingly. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined the facility failed to ensure a.) a physician's order (PO) was in place for a resident who used a machine that helps you breathe for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), which the resident brought from home, b.) a PO was in place for the proper settings, c.) a PO was in place to maintain the cleanliness of the machine and it's parts in accordance to the manufacturer's instructions. This deficient practice was identified for 1 of 3 residents (Resident #9) reviewed for respiratory care; and d.) respiratory masks were stored properly after use to prevent contamination. This was identified for 2 of 3 residents (Resident #9 and #238) that were reviewed for respiratory care. This deficient practice was evidenced by the follows: 1. On 1/12/25 at 11:07 AM, the surveyor observed Resident #9 in bed covered with a sheet. The surveyor observed a nasal pillow mask (a type of mask that delivers air pressure directly into the nostrils through small, flexible pillows) lying directly on the bed. The mask was connected to a breathing machine which the resident identified as a CPAP (Continuous Positive Airway Pressure machine, which is one of the most common treatments for sleep apnea.) The resident stated the machine was brought from home and they have used it since admission. The resident stated they self applied and removed the nasal pillow mask. The resident acknowledged the mask was not bagged. The resident stated the staff do not bag the nasal pillow mask. In addition, the resident stated their granddaughter cleaned the mask the night before. The resident further stated that nursing staff stated that a PO was required for them to clean the machine and its parts. The surveyor reviewed the electronic medical record (EMR) for Resident #9. A review of Resident #9's admission Record (an admission summary) reflected the resident had diagnoses which included but were not limited to; Chronic Obstructive Pulmonary Disease (COPD) [lung disease that blocks airflow and make it difficult to breathe], morbid (severe) obesity, chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues), and obstructive sleep apnea. A review of a quarterly Minimum Data Set, a tool to facilitate the management of care dated 10/8/24, reflected the resident had a Brief Interview for Mental Status score of 15 out of 15, which reflected the resident had an intact cognition. It also reflected the resident had the diagnoses indicated above. A review of the individualized comprehensive care plan (ICCP) reflected a focus area for altered respiratory status and difficulty breathing related to sleep apnea with an initiation date of 1/9/23. Further review, reflected the resident used a BIPAP (Bilevel Positive Airway Pressure machine, which helps you breathe.) It did not reflect the proper settings, nor care instructions until 1/14/25, which was after surveyor inquiry. A review of the Order Summary Report (OSR) did not reflect a PO for the use of a BIPAP or CPAP machine, the proper settings, or the instructions to maintain the cleanliness for a CPAP or a BIPAP machine and its parts. A review of the electronic Medication Administration Record's (eMAR) and the electronic Treatment Administration Record's (eTAR) for Resident #9 from October 2024 through January 2025, did not reflect any treatments or care for a BIPAP or CPAP machine. A review of the Vitals Summary Oxygen Saturation report from 10/1/24 through 1/14/25, reflected the resident's oxygen saturation was checked on the following dates while the resident's machine for sleep apnea was in use: 10/14/24 used BIPAP machine, oxygen saturation at 96% 11/3/24 used BIPAP machine, oxygen saturation at 97% 11/21/24 used CPAP machine, oxygen saturation at 98% 12/5/24 used CPAP machine, oxygen saturation at 97% 12/7/24 used BIPAP machine, oxygen saturation at 98% 12/9/24 used CPAP machine, oxygen saturation at 100 % 12/10/24 used CPAP machine, oxygen saturation at 97% 12/12/24 used CPAP machine, oxygen saturation at 97% 12/13/24 used CPAP machine, oxygen saturation at 98% 12/16/24 used CPAP machine, oxygen saturation at 98% 1/12/25 used BIPAP machine, oxygen saturation at 99% A review of progress notes from 10/1/24 through 1/15/25, did not include any documented evidence that the resident used a BIPAP or CPAP, breathing machine. On 1/13/25 at 12:25 PM, the surveyor interviewed the resident in their room. The resident stated the company that provided the breathing machine for sleep apnea sent replacement tubing, nasal pillow masks and filters to their family's home. On 1/14/25 at 11:05 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) / Unit Manager (UM) [LPN/UM #1]. She acknowledged the resident's breathing machine was used for sleep apnea and was the resident's personal machine from home. She stated it was the responsibility of the facility to maintain the machine (cleanliness, apparatus changes, etc.) LPN/UM #1 could not speak to how often the machine or mask needed to be cleaned or the frequency of which parts needed to be changed. She reviewed the POs in the EMR in the presence of the surveyor and acknowledged there were no POs for the machine or for its maintenance. On 1/15/25 at 10:02 AM, LPN/UM #1, in the presence of the survey team, stated she was aware of the resident using their personal BIPAP machine but she remained unaware of what and how often the family brought in replacement equipment. On 1/15/25 at 11:07 AM, the surveyor interviewed the resident about the sleep apnea machine in the presence of a second surveyor. The resident stated it was a CPAP machine. The resident stated the machine was provided and monitored by [name redacted] sleep center. The resident stated a telehealth appointment was conducted every six months. The resident stated the company provided replacement equipment and that the nasal pillow mask needed to be cleaned daily and changed weekly and the filter needed to be changed weekly as well, which the resident's family took care of. The resident stated the staff stated they were unable to complete these tasks since there were no PO's to do so. On 1/15/25 at 11:47 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the survey team. She was unsure if a PO was required to clean a CPAP or BIPAP machine, or if the staff needed to clean it periodically. She stated the machine settings required a PO. The IP stated the machine would not work properly if it was not cleaned properly. In addition, she stated the nasal pillow mask should be stored in a bag when it was not in use to avoid contamination which could cause infection. She stated the UM was responsible to ensure POs were in place for the breathing machine, and how to clean and store equipment. On 1/15/25 at 2:26 PM, the survey team met with administrative team: Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the IP, the Operations staff, and the Regional Nurse. The Regional Nurse informed the survey team that LPN/UM #1 verified the breathing machine was a BIPAP machine and the setting should be 15/5. She and the DON acknowledged that there should have been POs for the BIPAP machine use, settings, and it's care according to manufacturer's instructions. She also stated a PO was placed for a pulmonary (lung) consultation. The LNHA acknowledged that it was the facility's responsibility to clean the machine. The Regional Nurse stated it was nursing's responsibility to ensure these POs were in place. The administrative team acknowledged this information should have been included in the resident's ICCP. On 1/15/25 at 2:50 PM in the presence of the survey team, the Regional Nurse stated the nurse called [name redacted] the sleep study group to confirm which type of machine (BIPAP or CPAP) the resident had, the settings, and how to care for it (the machine) and to coordinate care going forward with the sleep study group. On 1/16/25 at 11:24 AM, the survey team met with the LNHA and DON. The DON stated that respiratory masks should be bagged and kept in the nightstand table drawer when not in use. In addition, she stated nursing obtained the manufacturer's instructions for Resident #9's BIPAP machine. The LNHA stated if there was an outside piece of equipment in a resident's room, staff should report this to the DON to ensure it was addressed properly. 2. On 1/12/25 at 10:00 AM, during initial tour, the surveyor observed Resident # 238 in their bed. The surveyor observed a nebulizer machine with a nebulizer mask on the resident's nightstand. The mask was lying directly on the facility provided newsletter with a facility provided gown resting on top of the mask. The resident stated, the nurse gives me the mask with the medicine in it and then comes back and takes the mask and puts it on the nightstand. The surveyor observed the resident was unable to reach the nightstand. The surveyor reviewed the EMR for Resident #238. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Type 2 Diabetes Mellitus with Diabetic neuropathy, unspecified (nerve damage usually in hands and feet) and COPD, unspecified. A review of the ICCP revealed: a Focus of oxygen therapy Date Initiated: 01/09/2025. Interventions: monitor for s/sx (signs/symptoms) of respiratory distress. A review of Resident #238's OSR revealed a PO for Ipratropium-Albuterol Solution 0.5-2.5 (3) Mg/3 ML (milligram/milliliter) 3 ml inhale orally via nebulizer four times a day for asthma .order date: 1/9/2025. A review of the eMAR for January 2025 revealed the above medication was administered at 0600 AM on 1/12/25. On 1/15/25 at 10:36 AM the surveyor interviewed the LPN #1, who stated a nebulizer mask should be rinsed and dried after use and stored in a bag. On 1/15/25 at 10:50 AM, the surveyor interviewed the LPN/Unit Manager (UM) #1, who stated a nebulizer mask should be rinsed and dried after a treatment was given and stored in bag to be keep it free from germs. On 1/15/25 at 11:19 AM, the surveyor interviewed the DON, who stated a nebulizer mask should be stored in a bag when it was not being used. On 1/15/25 at 11:50 AM, the surveyor interviewed the IP, who stated a nebulizer mask should be stored in bag, you don't want to leave it all over the place because it is going on the face. On 1/15/25 at 2:25 PM, the surveyor made with the LHNA, the DON, the IP, the Operations staff, and the Regional Nurse aware of the above concerns. A review of the facility's policy Oxygen Tubing and Respiratory Products revised 6/2024, revealed Policy: It is the policy and procedure of this facility that all oxygen tubing is of single use for a single resident, clean and properly stored and dated to prevent the transmission of infection 7. All nebulizer tubing shall be dated and stored in a bag when not in use and replaced every 7 days. NJAC 8:39-29.2(d).

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to provide privacy and promote dignity during resident assessment and medication administration. This deficient practice was identified for 2 of 2 residents (#20 and #52) reviewed for dignity and was evidenced by the following: 1. During the initial tour of the facility on 10/24/23 at 10:45 AM, the surveyor observed Resident #20 seated in the wheelchair in the hallway outside of their room. When interviewed, the resident reported a positive cough last evening. Review of Resident #20's admission Record revealed that the resident was readmitted to the facility in October of 2023 with diagnosis which included but were not limited to: muscle weakness, difficulty in walking, chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort breathing), heart failure, end-stage renal (kidney) disease and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). Review of Resident #20's Quarterly Minimum Data Set (MDS), an assessment tool dated 09/14/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. On 10/26/23 at 11:48 AM, the surveyor observed Resident #20 seated in a wheelchair at the bedside with their lunch tray on the bedside table in front of them. The resident reported a positive cough and stated that they did not feel well and did not feel hungry, but the food was good. The resident lifted the lid that covered their plate which revealed that the resident had only eaten rice and beans and pudding for lunch. At 12:15 PM, the surveyor observed Resident #20 seated in the wheelchair in the hallway outside of their room. The resident was accompanied by Licensed Practical Nurse (LPN) #3 and their attending physician. The physician used a stethoscope and listened to the resident's lung sounds in the hallway with both residents and staff nearby. The surveyor observed that the Director of Nursing (DON) was present in the nurse's station. The surveyor motioned to the DON to view the physician as he assessed the resident's lung sounds in the hallway. The DON approached the physician and told him that he should not have listened to the resident's lung sounds in the hallway. The physician stated that the residents moved around a lot and sometimes it was hard to find them when they were in the dining room. When the surveyor asked the physician if he examined residents in the dining room previously, he stated, I will document that the resident refused to go into their room because he/she wanted to eat in the dining room. The surveyor informed the physician that the resident had already eaten lunch in their room. At that time, the resident was observed seated in the dining area with friends, but was not eating. On 10/27/23 at 9:57 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that Resident #20 was set in their ways. LPN/UM #1 further stated that she assumed that the resident should have been brought back to their room to do whatever needed to be done for privacy. On 10/30/23 at 11:11 AM, the surveyor interviewed the DON who stated that Resident #20 was sometimes difficult, but she would not make excuses and maintained that she had spoken with the physician after the surveyor's observation. The DON stated that if the resident had given the physician a hard time, he should have asked a staff member for assistance. 2. On 10/26/23 at 9:02 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 as she administered four oral medications to Resident #52 in the hallway in plain view of multiple staff members who were nearby. LPN #1 then wheeled the resident back to their room and knocked on the door before she entered. The resident's room mate answered the door and denied the resident access to the room as they were not dressed. LPN #1 then proceeded to administer the resident's eye drops in the hallway in the presence of staff. At 9:23 AM, in a later interview with LPN #1, she stated that she should have administered Resident #52's medications and eye drops in their room to ensure privacy. LPN #1 further stated that she did not think about it at the time. On 10/30/23 at 11:06 AM, the surveyor interviewed the DON who stated that when LPN #1 administered medications and eye drops to Resident #52 in the hallway it was a privacy issue. Review of the facility policy Privacy and Dignity (Reviewed 06/23) revealed the following: Residents have the right to be treated with courtesy, consideration, and respect for the resident's dignity and individuality. Residents have the right to have physical privacy. The resident shall be allowed, for example, to maintain the privacy of his or her body during medical treatment and personal hygiene activities, such as bathing and using the toilet, unless the resident needs assistance for his or her own safety. NJAC 8:39-4.1(a) 12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to transfer discharged or expired resident's personal needs account (PNA) funds back to the appropriate jurisdiction within 30 days of death or discharge and ensure that the total amount in the PNA account did not exceed the Supplemental Security Income (SSI) resource limit. This deficient practice was identified for 7 of 7 residents reviewed for PNA accounting (Resident #7, #9, #298, #299, #300, #301, and #302). This deficient practice was evidenced by the following: The surveyor reviewed the Clover Meadows Healthcare and Rehabilitation Center Funds Balance Report - Resident Trust Liability (RTL) dated [DATE]. The RTL indicated the following balances: Resident #7 had $3,243.35, Resident #9 had $2,129.42, Resident #298 had $2.912.53, Resident #299 had $2,670.82, Resident #300 had $3,589.39, Resident #301 had $2,302.49, and Resident #302 had $2,729.20. Further review of these resident's medical records indicated that Resident #298 expired on [DATE], Resident #299 was discharged on [DATE], Resident #300 was discharged on [DATE], Resident #301 expired on [DATE], and Resident #302 was discharged on [DATE]. Resident #7 and Resident #9 still resided at the facility. On [DATE] at 11:05 AM, the surveyor interviewed the Director of Social Services (DSS) who informed that she is currently responsible for monitoring the resident's PNA accounts and ensures that the resident's PNA balance does not exceed the SSI limit of $2,000, confirmed that Resident #7 and Resident #9 should not have balances above that amount, and was unaware that they had exceeded that amount. The DSS could not speak to why the other residents still had a balance as they were no longer residing in the facility, and informed the surveyor that the business office is responsible for ensuring the accounts for those residents are handled appropriately. On [DATE] at 11:58 AM, the surveyor interviewed the Accounts Receivable Manager (ARM) in the business office by phone. The ARM stated that when residents are discharged or expire, their remaining balances are released to the appropriate jurisdiction or responsible party and are not kept by the facility. The ARM stated he would have to review these files. On [DATE] at 1:29 PM, the surveyor had a follow up call with the ARM, who acknowledged that these funds were behind and did not get to them as quickly as we should have, and that they should not have been in the fund balance at the facility this long. On [DATE] at 10:29 AM, the Licensed Nursing Home Administrator (LNHA) acknowledged that these funds were overlooked and late in being sent out. Review of the facility's Personal Fund policy with review date 6/2023 included any resident who is receiving benefits under any assistance program that has an asset level limit will be informed by the social worker or designee whenever the personal account balance is within $2,000 of the allowable limit. NJAC 8:39-4.1 (a) 8-10

Complaint # NJ00167863 Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of resident to resident abuse for 2 of 2 residents (Residents #52 and #64) reviewed for resident to resident abuse. This deficient practice was evidenced by the following: The surveyor reviewed Resident #64's electronic health record (EHR) and noted a Behavior Note within the Progress Notes (PN) that was documented on 09/23/23 at 6:38 PM, that was written by the Registered Nurse (RN) and revealed that the resident was observed taking food off of the food cart. Certified Nursing Assistant (CNA) covered the food cart and the resident became argumentative, cursed at another resident and a confrontation occurred with the same resident. No injuries were noted. CNA intervened, removed resident from the area and resident was taken back to his/her room. The RN indicated that both the resident's physician and responsible party were notified and psychiatry was reconsulted. On 10/25/23 at 10:44 AM, the surveyor interviewed CNA #3 who stated that while not assigned to Resident #64 today, she was familiar with the resident. CNA #3 stated that the resident cursed her out and hollered at her when she offered the resident a shower. CNA #3 further stated that awhile ago, she heard a noise and came out of a room and saw Resident #64 who kicked another resident who was seated in a wheelchair. CNA #3 was unable to recall who the resident had kicked. On 10/25/23 at 10:55 AM, the surveyor interviewed CNA #4 who stated that Resident #64 tried to get into the food cart every other day and cussed and swung at staff who tried to redirect the resident away from the food cart. CNA #4 stated that the staff tried to pass out food as fast as they could to ensure that the resident did not access the food cart. CNA #4 further stated that Resident #64 once kicked Resident #52 and the incident was reported. Review of Resident #52's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: dementia, anxiety, difficulty in walking and unspecified sequela (consequence of previous disease or injury) of cerebral infarction (stroke). Review of Resident #52's Quarterly Minimum Data Set (MDS), an assessment tool dated 08/26/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed that the resident required extensive assistance of one person for transfers to the wheelchair. The surveyor reviewed a Nursing Note written by a RN within the Progress Notes (PN) in the EHR dated 09/23/23 at 6:43 PM, which revealed that another resident was observed taking food off of the food cart. CNA covered the food cart and the same resident became argumentative, cursed at this resident and a confrontation occurred with the same resident. CNA intervened and separated both residents. Supervisor assessed resident. No injuries or redness were noted. The RN indicated that the resident's physician and responsible party were notified. Further review of the PN revealed that there was no further documentation written within the PNs until 10/05/23 at 3:37 PM, when a Monthly Nursing Comprehensive Summary was documented. At that time, the resident's skin was described as intact. On 10/25/23 at 12:44 PM, the surveyor observed Resident #52 seated in a wheelchair at the nurse's station. The resident was pleasant, but was confused to situation when interviewed. On 10/27/23 at 9:55 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that when a resident to resident altercation occurred she spoke with the residents involved and made a mitigation plan to prevent recurrence. DSS stated that she had not spoken with Resident #52 because the resident did not recall after three minutes due to their cognitive status and had no recollection and it may have been traumatic for the resident. DSS stated that she had spoken with Resident #64 who denied the incident. DSS stated that the incident may have been over a sandwich. DSS stated that interventions to prevent recurrence would be in the care plan. Review of Resident #52's Care Plan (CP) revealed that there was no entry that corresponded to the resident to resident altercation that was documented within the resident's PN on 09/23/23, until after surveyor inquiry on 10/30/23. Review of the CP entry revealed that the resident was involved in a resident to resident on 09/23/23, in which another resident kicked him/her per statement. The goal indicated that the resident would not be involved in future altercations involving injury. Interventions included: (09/23/23) Resident was immediately separated and assessed for injury with no injuries apparent. (09/24/23) Reassessed for any injuries-none apparent, resident does not recall event. (09/25/23) Resident reassessed by Unit Manager/Director of Nursing (UM/DON) with no injuries or ill effects . On 10/30/23 at 10:50 AM, the surveyor requested and reviewed the investigation that pertained to the resident to resident altercation that occurred on 09/23/23. Review of the Incident/Accident Report that was completed by the RN indicated that Resident became belligerent after CNA covered food tray and started cursing and kicked another resident in the right let. No injury obtained by resident. A statement was obtained from CNA #4 on 09/23/23, who also confirmed that Resident #64 got upset when the cover was pulled down on the food cart and started to yell. Resident #64 backed up and Resident #52 was behind him/her. Resident #64 told Resident #52 to move and called the resident a B word and a whore and kicked him/her on the right side of their leg. Review of the Reportable Event Record/Report dated 09/25/23 at 5:30 PM, revealed that the DON indicated that the following interventions were implemented after the incident/event: Resident #52's leg was reassessed the next day with no injuries, bruising and/or redness noted. The same upon assessment for Monday 09/25/23. The surveyor reviewed both the PN and the Skin Assessments within Resident #52's EHR and did not find documented evidence that Resident #52's right leg was assessed as described. Review of the weekly Skin Assessments indicated that a Weekly Skin Assessment was completed by a Licensed Practical Nurse (LPN ) on 09/27/23, and no skin abnormalities were noted at that time. On 10/30/23 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) who maintained that Resident #52 was assessed for several days with skin assessments and no injury was noted. The DON further stated that she was unsure if it actually happened because there was no bruise. On 10/30/23 at 1:14 PM, in a later interview with the DON, she stated that she did not have skin assessment documentation to validate that Resident #52's lower extremity was assessed daily after the resident was kicked by Resident #64 as previously described and reported to the New Jersey Department of Health. The DON stated that the skin assessments should have been documented within the resident's EHR. Review of the facility policy, Nursing Documentation (Reviewed 06/23) revealed: It is the policy of the facility to document by exception. All documentation confirms that care was provided. It assists in communication to other team members; it also identifies resident's status and clinical findings and interventions. Your responsibility in documentation acts as proof care was provided. All documentation is done in EHR. .Documenting your assessment post event includes interactions and any resulting actions taken to care for the resident. NJAC 8:39-13.4(c)2 i-vi

Complaint #NJ00151166 Based on interviews, medical records review, and review of other pertinent facility documentation on 10/30/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #243) left the facility against medical advice (AMA) and ended up at the hospital. The hospital reached out to the facility when the resident was ready for discharge from the hospital and the facility would not permit Resident #243 to return back to the facility. The deficient practice was identified for Resident #243, 1 of 1 residents reviewed for transfer/discharge and was evidenced by the following: According to the admission Record, Resident #243 was admitted to the facility with diagnoses which included but were not limited to bell's palsy (weakness of the facial muscles on one side of the face), hypotension (low blood pressure), and essential hypertension (high blood pressure). Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/13/21, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #243 was cognitively intact. On 12/13/2021, Resident #243 was examined by a psychiatrist who determined that the resident was competent to make their own decisions. The Progress Note (PN) revealed the initial incident occurred on 12/14/2021 when Resident #243 left against medical advice (AMA) and presented back to the facility on the same day and was permitted to return to the facility. The urinalysis for Resident #243 came back positive for amphetamines. Another PN written by the Social Worker (SW) dated for 12/15/2021 revealed there was an Interdisciplinary Team (IDT) care conference note which stated the purpose of the meeting with sister, the Power of Attorney (POA) to discuss future sign-outs and inability to potentially readmit moving forward. Zoloft was increased from 50 mg to 100 mg, the POA indicated that Resident #243's judgement was lacking and the SW noted that Resident #243 demonstrated recent inappropriate behaviors due to frustrations and ultimately resulted in Resident #243 signing out of the facility AMA. Care plan interventions included an additional meeting with psychiatrist in order to change medication, increase effective ways in coping with frustrations, and the next review would include following meeting with psychiatrist, medication change, allowing time for it to take effect, and review ability to process frustrations. The timeline received from the facility revealed that the POA was not in agreeance and asked the facility for specific areas of care to be implemented, asked the facility to retrieve the medical records, and asked for Resident #243 to be seen by his/her neurologist and asked that Resident #243 not get discharged without placement since the facility helped Resident #243 get out of their apartment lease so the resident had nowhere else to go and further noted that Resident #243 was not compliant with medications. The PN revealed the second incident occurred on 12/30/2021 when Resident #243 left the facility AMA again and refused to sign the release form. The surveyor reviewed the files and could not find any incident reports for Resident #243. The surveyor requested a copy of the incident reports from the facility for the first incident which occurred on 12/14/2021 which was documented in the progress note by the SW and the second incident which occurred on 12/30/2021 which was documented in the PN by the Case Manager. The facility was unable to provide any incident reports regarding the resident leaving AMA and in addition, was unable to provide notification to the Department of Health. The Case Manager confirmed with the surveyor that she followed up with the hospital and the hospital asked if the facility would take the resident back. The Case Manager stated that after speaking with the Director of Nursing (DON), who is currently the Regional DON (RDON), the Case Manager was advised by the former DON that the facility would not take Resident #243 back to the facility because they could no longer accommodate Resident #243's needs. Review of the Physician's orders did not reveal an order for a discharge and there was no written 30-day notification available to the surveyor that was sent to the POA and/or Resident #243 whom the psychiatrist deemed competent to make their own decisions. The policy updated for 01/2023, titled Discharge/Transfer Out of the Building revealed the objective was to facilitate safe, effective transfer of residents for provision of services not available in this facility. 1. Nursing will notify MD, DON/ADON and Social Services with the request for a transfer. 2. The nurse will document physician orders in PCC. NJAC 8:39 5.1(d)

Based on interview and record review, it was determined that the facility failed to complete the Comprehensive Assessment in accordance with the Resident Assessment Instrument (RAI) for 2 of 19 residents reviewed for comprehensive assessments (Residents #29 and #143). This deficient practice was evidenced by the following: Reference: The Centers For Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. At a minimum, facilities are required to complete a comprehensive assessment for each resident within 14 calendar days after admission to the facility and not less than once every 12 months while a resident, where 12 months refers to a period within 366 days. The MDS completion date for an annual assessment must be no later than 14 days after the ARD (ARD + 14 calendar days). 1) According to the Face Sheet, Resident #29 was admitted to the facility with diagnoses including but not limited to type 2 diabetes (high blood sugar) and end stage renal (kidney) disease. A review of the most recent Annual Minimum Data Set (MDS), an assessment tool, for Resident #29 revealed an ARD of 9/15/23 with a completion date of 10/16/23. A review of the medical record on 10/24/23 reflected that the annual MDS assessment for Resident #29 had not been completed according to the RAI manual (ARD + 14 days would be 9/29/23). On 10/30/23 during surveyor interview with the Regional MDS Coordinator and facility MDS Coordinator, they stated a comprehensive MDS should be completed within 14 days of the Assessment Reference Date and acknowledged that the annual assessment for Resident #29 was completed late. 2. According to the Face Sheet, Resident #143 was admitted to the facility with diagnoses including but not limited to: acute kidney failure and kidney transplant status. A review of the Minimum Data Set (MDS) admission Assessment for Resident #143 revealed an ARD of 10/15/23 with a completion date of 10/26/23. A review of the medical record on 10/31/23 reflected that the MDS for Resident #143 had not been completed in accordance with RAI manual. During an interview on 10/31/23 at 10:17 AM, the Registered Nurse/MDS Coordinator (RN/MDS) confirmed the admission assessment had not been completed by 10/24/23 as required. She confirmed that the admission assessment was completed on 10/26/23 two days past due. A review of the facility provided MDS policy reviewed 10/2023 reflected that it is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements. NJAC-11.2(e)

Based on observations, interviews, and review of medical records and other facility documention, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 1 resident reviewed for hospice (Resident #9). This deficient practice was evidenced by the following: During the initial tour of the facility on 10/24/23 at 10:31 AM, the surveyor observed Resdient #9 lying in bed with the bed positioned up against the wall and a fall mat was placed on the left side of the resident's bed. The resident smiled but did not respond when spoken to. Review of Resident #9's admission Record revealed that the resident was readmitted to the facility in June of 2023, with diagnosis which included age-related osteoporosis with current pathological fracture (bone fracture which occurs without adequate trauma), right femur (bone of the thigh), subsequent encounter for fracture with routine healing, mild intellectual disabilities, and schizophrenia (mental condition). Review of Resident #9's Order Summary Report revealed an order dated 09/21/23, admit to hospice. Further review of the resident's Minimum Data Set (MDS) 3.0 Assessment History, an assessment tool contained within the resident's Electronic Health Record (EHR), revealed that a SCSA was not completed for the resident within 14 calendar days from the residents hospice election as required. Review of an Addendum To Initial Certification contained within the Resident #9's hospice binder revealed that the resident's Date of Initial Certification for hospice services was 09/21/23, with a primary hospice diagnosis of right hip fracture. On 10/23/23 at 10:23 AM, the surveyor observed the Hospice Licensed Practical Nurse (HLPN) at Resident #9's bedside. When interviewed, HLPN confirmed that the resident received hospice services from an outside hospice provider and all of the documentation related to the resident's hospice care was kept current within the resident's hospice binder. On 10/30/23 at 9:52 AM, the surveyor interviewed the MDS Coordinator (MDSC) in the presence of the survey team. The MDSC stated that if a resident elected to go on hospice a Significant Change Assessment was completed. MDSC explained that she was new to the position and did not have a lot of experience with it and relied on nursing to keep her informed. On 10/30/23 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she would have imagined that the MDSC should have completed the SCSA for Resident #9 within the required time frame. The DON further stated that the MDSC was new to the position. On 10/30/23 at 11:25 AM, the Regional MDSC clarified that the SCSA was required to be completed within 14 days of a significant change in resident condition, such as hospice election. On 10/30/23 at 12:51 PM, in a later interview with the MDSC, she stated that a SCSA MDS was not completed for Resident #9 until today after surveyor inquiry. MDSC further stated that there was some confusion as to when the resident went on hospice. Review of the facility policy, Significant Change in MDS Policy (Updated 09/23) revealed the following: Policy: It is the policy and procedure of the facility to ensure that each resident who experiences a significant change in status is comprehensively assessed during he CMS(Centers Medicare/Medicaid Services)-specified Resident Assessment Instrument (RAI) process. .A significant Change in Status MDS is required when: A resident enrolls in a hospice program . Review of the facility policy, MDS Policy (Reviewed 10/23) revealed the following: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements. Purpose: .To provide information on the resident's condition. To facilitate development of a comprehensive care plan. To ensure care delivery that enhances the resident's quality of life. To help achieve the highest and practical level of self sufficiency. Procedure: .Assures the completeness and accuracy of the information in the MDS . NJAC 8:39-11.2(i)

**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 accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 19 residents reviewed (Resident #40 and #56). This deficient practice was evidenced by the following: 1.On 10/24/23 at 12:21 PM, the surveyor observed Resident #40 in the room sitting on the bedside. Resident #40 stated he/she had been at the facility for five years and had no concerns. Resident #40 told the surveyor they were pleased that they could smoke at the facility. Resident # 40 was admitted to the facility in 2019. Medical diagnoses included but were not limited to acute kidney failure, alcohol dependence, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Review of the annual Minimum Data Set (MDS), an assessment tool, dated 08/03/23 indicated that the resident had a Brief Interview of Mental Status score of 14, meaning the resident was cognitively intact. On 10/24/23 the surveyor reviewed Resident #40 care plan which showed the focus of the resident being a smoker. The care plan was initiated on 12/17/19. On 10/27/23 at 11:50 AM, the surveyor reviewed Resident #40 MDS list. The resident's entry MDS dated [DATE] section J, titled health conditions was marked no for tobacco use. Review of the annual MDS dated [DATE], 08/13/22, and 08/13/23 section J was marked no for tobacco use. On 11/01//23 at 11:15 AM, the surveyor reviewed the resident smoking Safety Evaluation. The evaluation had an effective date of 08/28/2019 and indicated at that time the resident was an independent smoker and did not require assistance. 2.On 10/24/23 at 10:33 AM, during the initial tour of the facility the surveyor observed Resident #56 was out of bed in a wheelchair. The resident told the surveyor they were going outside to Take care of things. The surveyor asked if the resident was a smoker and they replied, yes. Review of the admission Record revealed that Resident #56 was admitted to the facility in 2020. Medical diagnoses included but were not limited to diabetes (high blood sugar), anemia, alcohol abuse, and tobacco abuse. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 06/21/23 indicated the resident had a Brief Interview of Mental Status score of 15, meaning the resident was cognitively intact. On 10/25/23 at 01:21 PM, the surveyor reviewed Resident #56 care plan which showed a focus that the resident had a potential alteration in safety related to smoking. The care plan was initiated on 8/19/2021. On 10/25/23 at 01:51 PM, the surveyor reviewed Resident #56 entry MDS dated [DATE], section J titled Health Conditions was marked no for tobacco use. The surveyor then reviewed the annual MDS dated [DATE], 06/20/22, and 06/21/23. All three annual MDS were marked as no for tobacco use under section J. On 10/26/23 at 12:10 PM, the surveyor reviewed Resident #56 smoking assessment dated [DATE] which revealed the resident was an independent smoker and did not need assistance. On 10/30/23 at 09:52 AM, the surveyor interviewed the MDS Coordinator (MDSC) regarding Resident #40 and Resident #56 MDS. The surveyor asked the MDSC how new admission smokers were communicated to her department. The MDSC stated that nursing, activities, and the MDS department all do resident assessments. The surveyor then asked who was responsible for section J of the MDS which included tobacco use and she said, Section J is done by MDS department, that could have been an oversight. On 11/01/23 at 12:20 PM, the surveyor reviewed the MDS policy with a revision date of 10/2023. Under the procedure section, number three stated that the facility assures the completeness and accuracy of the information in the MDS. NJAC 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASARR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASARRs (Resident #56) and was evidenced by the following: On 10/24/23 at 10:33 AM, during the initial tour of the facility the resident was out of bed in a wheelchair. The resident told the surveyor they were going outside to Take care of things. The surveyor asked if the resident was a smoker and Resident #56 replied, Yes. On 10/24/23 at 12:18 PM, during resident record review the surveyor reviewed Resident #56 Pre-admission Screening and Resident Review (PASARR) one which was completed prior to admission to the facility on [DATE]. Under the section of Mental Illness screening, it was marked no, meaning the resident did not have a diagnosis or evidence of a major mental illness. Review of the admission Record revealed that Resident #56 was admitted to the facility in 2020. Medical diagnoses included but were not limited to diabetes (high blood sugar), anemia, alcohol abuse, and tobacco abuse. Review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 06/21/23 indicated the resident had a Brief Interview of Mental Status score of 15, meaning the resident was cognitively intact. The surveyor then reviewed Resident #56 entry MDS dated [DATE] section I, titled active diagnoses. The section for the diagnosis of schizophrenia was marked no, review of the annual MDS dated [DATE] was marked no for schizophrenia. The surveyor then reviewed the annual MDS dated [DATE] which was marked as yes for a diagnosis of schizophrenia. On 10/25/23 at12:03 PM, the surveyor requested to view the residents PASARR two. The facility provided surveyor with the PASARR one. Review of the PASARR one indicated that Resident #56, on admission to the facility on [DATE], did not have a diagnosis of or evidence of a major mental illness limited to the following disorders: schizophrenia, schizoaffective, mood, panic, anxiety, or another mental disorder that may lead to chronic disability. On 10/27/23 at 10:50 AM, the surveyor interviewed the Director of Social Services (DSS) who had been with the facility since 05/2021 regarding PASARRs. The DDS said, new admissions come in with a PASARR one and if not, I will complete one. The surveyor then asked the process if a resident had a new diagnosis after admission to the facility. The DDS told the surveyor, I would complete a new PASARR one in that event and if positive I would alert mental health, I access all diagnoses on the residents face sheets. The surveyor asked the DDS how she would be alerted to a new psychiatric diagnosis on an admitted resident, and she stated that she would be told in the morning meeting. The DDS could not speak to why a new PASARR one was not completed again at the time of Resident #56 new diagnosis. On 11/01/2023 at 10:10 AM, the surveyor reviewed the policy titled PASRR with a revised date of 06/2023. Number five, under the procedure section of the policy read that if a resident is admitted and the team identifies a PASRR needs revision a new PASRR will be initiated. NJAC 8:39-27.1 (a)

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to properly assess and monitor a resident that was previously identified as a high risk for falls after a fall occurred in accordance with professional standards and the facility policy for 1 of 1 resident (Resident #9) reviewed for falls. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During the initial tour of the facility on 10/24/23 at 10:31 AM, the surveyor observed Resident #9 lying in bed with the bed positioned up against the wall and a fall mat was placed on the left side of the resident's bed. The resident smiled when spoken to but did not speak when spoken to. On 10/25/23 at 10:23 AM, the surveyor observed the Hospice Licensed Practical Nurse (HLPN) #1 at Resident #9's bedside. When interviewed, HLPN #1 stated that the resident had fallen at the facility which resulted in a right shoulder fracture. HLPN #1 explained that the resident was deemed not to be a surgical candidate and was admitted to hospice services with uncontrolled pain. HLPN #1 was unable to state when the fall occurred. The surveyor reviewed an Initial Certification to Hospice form that was noted within the resident's hospice binder which indicated that the resident was admitted to hospice services in September of 2023 with a primary diagnosis of right hip fracture. On 10/25/23 at 12:34 PM, the surveyor interviewed CNA #2 who stated that she worked at the facility for seven years. CNA #2 stated that Resident #9 was dependent for all aspects of care and required assistance to turn and reposition for a couple of years now. CNA #2 stated that the resident and was unable to roll or attempt to get out of bed and required a mechanical lift for transfers. CNA #2 further stated that she was not at the facility when the resident had fallen and did not know how the fall occurred. Review of Resident #9's admission Record (an admission summary) revealed that the resident was readmitted to the facility in June of 2023 with diagnosis which included age-related osteoporosis (deterioration in bone mass with increasing risk to fragility fractures) with current pathological fracture (bone fracture that occurs without adequate trauma and is caused by a preexistent pathological bone lesion), right femur (the thigh bone), subsequent encounter for fracture with routine healing, mild intellectual disabilities, and schizophrenia (mental disorder). Review of Resident #9's Annual Minimum Data Set (MDS), an assessment tool dated 09/07/23, revealed that the resident's Brief Interview for Mental Status (BIMS) score was unable to be completed as the resident was rarely/never understood. Further review of the assessment revealed that the resident required extensive assistance of two persons for bed mobility and transfers and required supervision of one person for locomotion (how resident moves between locations) on the unit. Review of Section I of the MDS revealed active diagnosis which included but was not limited to: dislocation of the unspecified parts of the right shoulder girdle. Review of Section J of the MDS revealed that the resident had not had any falls since admission /entry or reentry or the prior assessment. The surveyor then reviewed Resident #9's Quarterly MDS Assessment, dated 06/08/23, under Section J which revealed that the resident had a fall within the last month which did not result in fracture. Review of Resident #9's Fall Risk Assessment effective 03/19/23, revealed that Resident #9 had a score of 20 on the assessment which indicated that the resident was a high risk for falls and a second Fall Risk assessment dated [DATE], had a score of 18 which indicted that the resident as a high risk for falls. Review of Resident #9's Progress Notes (PN) revealed an entry dated 05/10/23 at 10:29 PM written by Licensed Practical Nurse (LPN) #4, indicated that LPN #4 was notified by the Certified Nursing Assistant (CNA) that Resident #9 had an unwitnessed fall and fell out of their wheelchair at the base of the door. LPN #4 documented that he assessed the resident for any visible injuries and there were none as the resident did not verbalize or gesture to indicate the presence of pain. LPN #4 documented that both he and the CNA assisted the resident back into their chair and two CNAs then used a mechanical lift to assist the resident into bed for further full head to toe assessment. LPN #4 documented that both the MD (Medical Doctor) and family were contacted with no response. There was no documented evidence within the resident's medical record to indicate that the resident was assessed by a Registered Nurse (RN) immediately post-fall prior to transfer back into the chair or bed for the presence of injuries. Further review of the PNs revealed that the next PN was a Behavior Note, was written on 05/11/23 at 3:58 PM, by a RN which failed to contain documentation to indicate that post-fall monitoring was in place. The RN documented that the resident was awake, alert and oriented x 2-3 (self, place, time) with screaming behavior noted. A second Behavior Note dated 05/11/23 at 9:53 PM, was written by an LPN and indicated that it was shift 4/9 post fall, and no visible injuries were noted, and the resident was medicated for pain as ordered. There was no documented evidence within the PNs that were reviwed in the twenty-four hour period that followed the resident's fall to indicate that the resident's neurological status was assessed post-fall with neurological checks (looks at how appropriately the resident responds in three key areas, eye opening, verbal and motor skills) to rule out head trauma for an unwitnessed fall and post-fall notes for shifts 2/9 and 3/9 were not found. Review of the Resident #9's Care Plan (CP) revealed an entry that was initiated on 02/03/21 and revised on 10/30/23, which revealed that the resident had potential for falls related to poor safety awareness, impulsivity, vision problems, bilateral conductive hearing loss, and gait/balance problems. Further review of the CP revealed an entry dated 01/26/23 and revised 03/20/23, which revealed that the resident slid off the bed intentionally, witnessed by nurse. Staff will assist him/her out of bed during the morning rounds into his/her wheelchair. The goal was revised on 06/18/23 by the former Unit Manager, for the resident to be free from injuries related to fall accidents through the next review date. Review of Interventions included an entry dated 08/19/21, Staff to check on Resident #9 frequently and offer him/her to go back to bed around mealtimes. On 05/10/23, an intervention was added to the CP which indicated that prior to the end of 7-3 pm shift assess for any immediate needs such as: hunger, toileting, pain etc. and assist with the same. Review of Resident #9's Order Summary Report (OSR) revealed an order dated 07/15/23, for floor mat to left side of bed every hour of sleep at bedtime for preventative measures. Further review of the OSR revealed that the resident was admitted to hospice on 09/21/23. On 10/26/23 at 1:20 PM, the surveyor phoned LPN #4 who identified as an agency nurse via speaker phone in the presence of the survey team with his permission. LPN #4 denied any recollection of Resident #9's fall. LPN #4 stated that as an LPN, he was permitted under his scope of nursing practice to assess residents' post-fall. When the surveyor asked what a post-fall assessment entailed, LPN #4 stated that he was busy, and it was not a good time to talk. LPN #4 failed to provide the surveyor with a more convenient time to be interviewed when offered. On 10/27/23 at 9:50 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that she began working at the facility on 10/12/23. LPN/UM #1 stated that when a resident fell the nurse was required to perform an assessment and complete an incident report. LPN/UM #1 stated that while she was unsure of what the facility policy indicated, under the scope of practice of an LPN an RN was required to perform a resident assessment post-fall. On 10/30/23 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #9 was admitted to hospice due to natural progression, there was no fall. The DON stated that the resident's fall that occurred on 05/10/23 was addressed with an x-ray company who stated that the fracture was more acute. The DON stated that she probably documented the conversation that she had with the radiologist (a doctor who specialized in radiology and used x-rays) somewhere. The DON stated that technically, an LPN could not perform a resident assessment under their scope of practice. The DON stated that the Registered Nurse Unit Manager who was here the next day would have assessed the resident. The DON further stated that there also would have been a supervisor here as well. The surveyor informed the DON that there was no documented evidence contained within the resident's medical record to indicate that the resident was immediately assessed by an RN after the fall that was sustained on 05/10/23, nor was there documented evidence that neurological checks were performed to rule out head trauma. The DON agreed to provide the surveyor with all investigations related to Resident #9. The surveyor reviewed an Incident/Accident Report (I/AR) dated 05/10/23 at 3:45 PM, that was initiated by LPN #4 which indicated that Resident #9 slid out of their wheelchair during an unwitnessed fall. No injury occurred. Resident able to move all extremities without difficulty. No internal or external injury and rotation noted. Denies pain or discomfort, neuro checks in progress. Further review of the I/AR revealed that the physician was notified at 4:30 PM and the resident's responsible party was notified at 7:30 PM. The surveyor reviewed an Investigation of Incident/Accident Statement dated 05/10/23 that was written by a CNA, which indicated that Resident #9 was up in the wheelchair after she changed the resident around 2:30 PM. The CNA documented that when she left at the end of her shift the resident was in the chair in the day room. There were no further statements attached to the investigation other than the CNA's and LPN #4's. There was no neurological check sheet attached to the investigation or contained within the resident's medical record to demonstrate that neurological checks were performed for a 24-hour period post-fall. On 10/30/23 at 1:14 PM, the DON presented the surveyor with an X-ray report dated 05/30/23, which had a note written at the bottom of it which she stated proved that Resident #9's fall on 5/10/23, had nothing to do with the resident's diagnosis of femoral fracture as it was an acute injury. The hand written entry dated 05/10/23, revealed No injury, stated this was an acute occurrence. The DON stated that the interview should have been documented within the resident's medical record but was not. The DON further stated that she received a statement today from the RN Charge Nurse (RN/CN) who worked on 05/10/23, who stated that LPN #4 did not let the supervisor know about the resident's fall until a few hours later and she assessed the resident at that time. The DON stated that the RN/CN also should have documented the resident assessment in the resident's medical record and the RN Unit Manager should have also documented that she assessed the resident the following day. There was no documented evidence within the resident's medical record to confirm that the resident was assessed by a RN as described by the DON. On 10/30/23 at 3:57 PM, the surveyor attempted to phone the RN/CN for clarification, but was unable to reach her. On 10/30/23 at 8:15 PM, the surveyor interviewed the Radiologist who stated that on 05/30/23, the facility requested that he read Resident #9's x-ray and his impression was an unhealed recent longitudinal fracture (fracture extends along length of bone) extending from the medial femoral metaphyseal cortex (neck portion of long bone) to the intercondylar notch (a groove at the distal end of the femur) and recommended that the facility correlate the impression with a trauma history. The Radiologist explained that in the elderly with severe osteoporosis you do not know the exact time frame of the injury. The Radiologist further stated that the injury was recent and unhealed up to one month and the fracture could have been up to a month old. On 10/31/23 at 8:49 AM, the surveyor interviewed the DON who stated that perhaps she did not speak with the same Radiologist as the surveyor, though the DON provided the surveyor with the Radiologists contact information. The DON further stated that LPN #4 should have immediately called for the RN Supervisor to assess Resident #9 for injury and prevent further injury, as she was not called to assess the resident until after the resident had already been placed back in bed. When the surveyor asked how the RN Supervisor assessment and post-fall neurological checks could be verified? The DON stated that if it was not documented, then it was not done. On 10/31/23 at 10:24 AM, the surveyor interviewed the Speech Language Pathologist/Director of Rehabilitation (SLP/DOR) who stated that Resident #9 was seen by Occupational Therapy on 05/11/23 and an assessment was done to look at positioning after the resident fell from the wheelchair. The SLP/DOR reviewed the therapy notes in the presence of the surveyor and stated that the resident did not exhibit any pain during the assessment. The SLP/DOR explained that pain was assessed through nonverbal methods such as gestures and grimacing and there was nothing. The SLP/DOR stated that the resident was very loud, so she would have imagined there would have been yelling if the resident had pain. The SLP/DOR explained that the resident self-propelled backward in their wheelchair and used their feet to do so at the time of the assessment. The SLP/DOR further stated that whenever the resident was up in the wheelchair it was in the dayroom in a supervised area with a back cushion in place for fall prevention. On 10/31/23 at 10:53 AM in a later interview with the DON, she stated that a three-day post fall documentation was required to be documented within Resident #9's electronic health record every shift for three days. The surveyor conveyed that the documentation contained within the resident's medical record did not reflect that the documentation was completed as described. The DON stated, It is not there? The DON stated that the neurological checks were documented on the 24-hour report. The DON provided the surveyor with the 24-hour report dated 05/10/23, which revealed the following: Resident #9 fell at 3:45 PM. MD notified; Family contacted with no answer. Follow up. Neuro checks. There was no documented evidence contained within the resident's medical record to suggest that the recommendation for neurological assessment checks and follow-up with the resident's responsible party or physician was completed. On 10/31/23 at 12:03 PM, the DON stated that she did not find a neurological check sheet within the investigation or within Resident #9's medical record. The DON further stated that the purpose of the neurological checks was to rule out a brain bleed or injury after a fall. Review of the facility policy, Incident/Accident Reporting Policy And Procedure (Reviewed 03/2023) revealed the following: It is the policy of this facility to provide a system whereby residents' incidents/accidents are reported, their causes identified when possible, and timely interventions are established to reduce the probability of repeated incidents. Procedure: It is the responsibility of the Lisenses [Sic.] Nurse who first witnessed the incident/accident to initiate and complete the Incident/Accident Report in its entirety utilizing input form the staff present at the time of the incident/accident. The Nurse assesses the residents' condition, renders appropriate treatment, i.e., first aid or calls the Physician who orders specific treatment or decides if the resident is to be transferred to the Emergency Room. The nurse also informs the responsible party immediately of any injury that may require residents to be transferred from the facility. In case of a fall, a Fall Risk Assessment and a Post Fall Inspection Tool is completed. In case of an actual or suspected neurological involvement, a 24-hour Neurological Assessment is completed. .A 3-day post fall monitoring and documentation will be done by all shift nurses assigned to residents who sustained a fall. A 3-day post incident monitoring and documentation will be done by all shift nurses for residents with a reported incident or injury of unknown etiology. Review of the facility policy, Nursing Documentation (Reviewed 06/23) revealed the following: It is the policy of this facility to document by exception. All documentation confirms that care was provided. It assists in communication to other team members; It also identifies resident's status and clinical findings and interventions. Your responsibility acts as proof care was provided . Gather information and prepare to chart, it is your responsibility as the professional or long term care staff member to document what you found, what you did or did not do for the resident. .Proper nursing documentation provides evidence that the nurse has acted as required or ordered. .Document all Events including falls, skin tears, any skin abnormalities etc.tell the whole story, be concise, stay limited to the facts. Review of the facility policy, Injury of Unknown Origin Policy and Procedure (Revised 04/23) revealed the following: .A 3-day post fall monitoring and documentation will be done by all shift nurses assigned to residents who sustained a fall . Review of the facility Position Summary (Job Description) for Position Title, Licensed Practical Nurse revealed the following: In conjunction with the RN/Unit Director, the Licensed Practical Nurse utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of individualized nursing care plans to ensure that the needs of residents are met. He/she assists in the orientation of and supervision of nursing personnel, attends to the daily operations of the unit per shift, unit level, and assumes responsibilities of a leadership role. Responsibilities/Accountabilities: .Communicates pertinent data to charge nurse, superior and/or physician; Review of the facility Position Summary (Job Description) for Position Title, Registered Nurse revealed the following: Takes an active role in direct resident assessment and care; .Assesses each resident daily and implements a change in the course of action as needed; .Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process; NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to properly document the correct amount of Oxygen administered in the progress notes. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for respiratory care, and was evidenced by the following: On 10/26/23 at 11:50 AM, the surveyor observed Resident #2 receiving Oxygen via nasal cannula with a setting of 2 liters/minute. A review of the face sheet revealed that Resident #2 was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease ( a respiratory disease), and congestive heart failure (a disease where the heart does not pump blood as well as it should), and pneumonia (an infection of the lungs) with a history of home Oxygen use. The admission Minimum Data Set, an assessment tool, dated 9/19/23 indicates a Brief Interview of Mental Status score of 5 (indicating severe cognitive impairment) and utilized oxygen both while a resident and while not a resident (prior to admission to facility). The physician orders included an order for Oxygen via nasal cannula with at 2 liters/minute dated 9/13/23 and review of Medication Administration Records (MARs) for September 2023 and October 2023, indicated Oxygen via nasal cannula at 2 liters/minute was administered on each day. A review of the progress notes with dates of 9/13/23, 9/16/23, 9/18/23, 9/26/23, 10/14/23, 10/15/23, 10/17/23, and 10/18/23 indicated that Resident #2 received Oxygen via nasal cannula at 3 liters/minute. On 10/27/23 at 06:55 PM, the surveyor interviewed Licensed Practical Nurse # 2 (LPN #2) via telphone, who wrote the progress notes indicating Resident #2 received Oxygen via nasal cannula at 3 liters/minute. She stated that she believed Resident #2 utilized 3 liters/minute of Oxygen at one point. She also stated that the notes with Oxygen via nasal cannula at 3 liters were written in error. On 10/30/23 at 10:31 AM, the surveyor interviewed the Director of Nursing, who stated that if the order is for Oxygen at 2 liters/minute and the MAR is signed for 2 liters/minute, then the progress notes should state 2 liters / minute. A review of the facility provided policy titled Nursing Documentation revised 6/23, indicated proper nursing documentation provides evidence that the nurse has acted as required or ordered. and use accurate information. NJAC-29.2 (d)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to a.) properly label, date, and store potentially hazardous foods in a manner that was intended to prevent the spread of food borne illnesses, and b.) maintain equipment and dishware in a manner to prevent microbial growth and cross contamination and c.) discarding food items. This deficient practice was observed and evidenced by the following: On 10/24/2023 at 09:43 AM, the surveyor toured the kitchen in the presence of the Director of Culinary Services (DCS) and observed there were no hair nets available at the entrance of the kitchen. The DCS stated no hair nets were kept at the entrance because it was the only way to deter staff from entering the kitchen, staff must ask for a hair net first. The surveyor asked if this was the policy and the DCS confirmed it was. In the walk-in freezer the surveyor observed four long hoagie rolls that were in a plastic bag unlabeled and three boxes of ice cream unlabeled. The DCS confirmed the items were unlabeled but stated the label tends to fall off because it is cold and showed the surveyor one label which was laying on the shelf but could not produce the other two. On that same day at 9:47 AM, in the dry storage area there were two packs of muffins that did not have labels to include the date received or an expiration date. There was also a 20 pound (lb) box of fettuccine, a box of mandarin oranges, and two boxes of decaffeinated tea with no labels on any of the items. On the dry storage rack there were three plate lids that were pulled off the rack. The surveyor asked if this was the clean rack and the DCS confirmed the items on the rack were clean but upon review, the three plate lids removed from the clean rack had a white flaky substance on each of them. The surveyor showed the substance to the DCS and upon swiping the finger the substance moved. This was observed by the DCS at the time of observation. On 10/24/2023 at 10:08 AM, the surveyor observed a shelf with a container of basil leaves that was labeled from June to December 2023. The DCS stated items are labeled for three months and then discarded. The curry powder was labeled from February to August 2023. The DCS confirmed the basil leaves and the curry powder should have been labeled for only three months and the curry powder should have been discarded. There was also a pan located under the serving table which had five containers of cereal. The DCS confirmed the cereal should have been labeled or returned to the box back in the dry storage. On 10/24/2023 at 10:15 AM, in the walk-in refrigerator, the surveyor observed a pack of romaine lettuce in a plastic bag that was unlabeled and a container of fresh garlic with an expiration date of 10/18/2023. The DCS confirmed the romaine lettuce should have been labeled with a receipt and an expiration date and the fresh garlic should have been discarded on 10/18/2023. On 10/24/2023 at 10:21 AM, the surveyor observed a tray of bananas sitting on the kitchen counter, several with brown coloring on them that were all unlabeled. The DSC confirmed the tray of bananas should have included a received and an expiration date. A review of a facility's undated policy titled, Food Service Employee Hygiene included that good personal hygiene and a neat appearances are essential for the food service employees. The following practices and procedures should be observed to prevent the spread of microorganisms to residents, staff and visitors. A review of the facility's policy dated for 06/2023 titled, Air Drying Policy and Procedures revealed to ensure that all dishes, utensils, pans and pots are dried after being cleaned and sanitized. The surveyor reviewed the facility's policy dated 07/2023 titled, Labeling and Dating Policy which revealed all food items must be labeled and dated to ensure foods are being used in a proper time frame. 1. All food products upon receiving, must be dated with the receiving date. 2. All food items must be labeled with either a manufacturer label or handwritten label. C. once prepared or portioned (individually wrapped) food items will be dated with compliance of the 72-hour rule and labeled with a use on or by date. Examples: Applesauce, pudding, and sandwiches. An additional policy dated 11/12/2019 titled, Labeling and Dating System Protocol revealed that opened Mayo, dressings, garlic, sauces must be dated with the date it was received in the kitchen with day one as the first day of labeling and discarded 30 days from the open date. NJAC 8:39-17.2(g)

Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to: 1) maintain proper infection control practices identified during the: a) medication administration observation and 2) follow their policy for Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that may cause serious illnesses and injuries) usage and hand hygiene to prevent the possible spread of infection. This deficient practice was identified during the: a) medication administration observation on 2 of 2 nursing units (North and East) for 2 of 2 nurses (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1) observed during the medication pass and b) for 1 staff member on 1 of 2 nursing units (North) and for 1 of 1 resident reviewed for Transmission-Base Precautions (TBP, infection control precautions in healthcare applied to residents who are suspected to be infected or colonized (germs on the body that do not produce symptoms) (Resident #31), and was evidenced by the following: 1. On 10/26/23 at 8:33 AM, the surveyor observed RN #1 who performed hand hygiene with the use of alcohol-based hand rub (ABHR) before she proceeded to obtain vital signs (blood pressure, and pulse oximetry, a noninvasive measure of measuring the saturation of oxygen in a person's blood using a probe placed on the finger) from an unsampled resident. RN #1 donned (put on) gloves and used disinfectant wipes to clean the blood pressure machine, cuff and pulse oximetry probe when finished. RN #1 then doffed (removed) the gloves and failed to perform hand hygiene before she accessed the medication cart, poured water into a cup from a water pitcher that was on top of the medication cart, accessed the medication cart and prepared and administered eight oral medications to the unsampled resident. RN #1 then donned gloves without first performing hand hygiene and applied a Lidocaine (used to help relieve pain) 4% patch to the resident's lower back. RN #1 then doffed the gloves and used ABHR to perform hang hygiene when she returned to the medication cart. When interviewed at that time, RN #1 did not recall that she had not performed hand hygiene before she donned gloves, cleaned the blood pressure and pulse oximetry device and doffed her gloves prior to medication administration and stated, I am sorry, I thought that I did. RN #1 stated that if hand hygiene were not performed after she cleaned the blood pressure machine and pulse oximetry probe when she doffed her gloves prior to medication preparation and administration it could result in contamination. On 10/26/23 at 9:02 AM, the surveyor observed LPN #1 as she prepared medications for Resident #52, which included Refresh eye drops one drop in each eye, (an eye lubricant, which was dispensed in a disposable, single use vial) that LPN #1 dropped on the floor. LPN #1 then proceeded to pick up the eye drop vial and placed it on top of the medication cart. LPN #1 then proceeded to return bingo cards (medication contained in blister packs) to the medication cart, used a pill crusher to crush the resident's medications, prepared apple sauce, poured water from the water pitcher that was on the medication cart and opened a straw and placed it in the cup of water before she administered the oral medications to the resident without first performing hand hygiene. LPN #1 then picked up the vial of eye drops from the medication cart and carried them into the food pantry while she washed her hands. LPN #1 then proceeded to donn gloves, picked up the vial of eye drops from the counter and administered the eye drops to Resident #52. At 9:23 AM, in a post-medication pass observation interview, LPN #1 stated that if she dropped Resident #52's eye drops on the floor and placed the vial on top of the medication cart and did not perform hand hygiene before she returned medications to the cart and administered medications to the resident without first performing hand hygiene it could result in contamination. LPN #1 further stated that if she administered eye drops from a vial that was dropped on the floor to the resident it could also result in contamination. On 10/27/23 at 9:59 AM, the surveyor interviewed LPN/UM (Licensed Practical Nurse/Unit Manager) #1, who stated that if eye drops were dropped on the floor, they should have been tossed for infection prevention. LPN/UM #1 further stated that hand hygiene should have been performed after handling eye drops that were dropped on the floor before medications were prepared for infection prevention. On 10/27/23 at 10:17 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated that hand washing was required when gloves were doffed after equipment was cleaned and before handling medications. ADON/IP explained that when gloves were doffed it was important to wash your hands to avoid moving infection or bacteria from one area to another. ADON/IP stated that if an eye drop vial were dropped on the floor nursing was required to throw it out, wash their hands, and get a new one as failure to do so was, a big no, no. ADON/IP stated that the eye drop vial should not have been placed on top of the medication cart or in the pantry due to infection control. ADON/IP further stated that nursing should not have administered those eye drops to the resident because it was wrong to do and could have posed a risk to the resident. On 10/30/23 at 11:06 AM, the surveyor interviewed the Director of Nursing (DON) who stated that once gloves were doffed after cleaning a blood pressure machine if hand hygiene were not performed there was a chance of contamination from surface to surface. The DON further stated that if an eye drop vial were dropped on the floor, she would have thrown it out for sure. 2. During the initial tour of the facility on 10/24/23 at 10:40 AM, the surveyor observed Resident #31 lying in bed asleep with signage outside of the room which cautioned to stop, contact precautions (intended to prevent transmission of infectious agents spread by direct or indirect contact with the patient or patient's environment) that was hung above a three-drawer plastic storage unit which contained PPE. At that time, the surveyor interviewed LPN #3 who stated that the resident was bed bound and incontinent and had bacteria in the urine. A Physical Therapist (PT) presented to the room and LPN #3 advised the PT to donn PPE as a precaution. The PT then proceeded to donn a gown, gloves and mask before she entered the resident's room as directed. Review of Resident #31's admission Record revealed that the resident was readmitted to the facility in May of 2022, with diagnosis which included but were not limited to: hemiplegia (paralysis on one side of the body) and hemiparesis (one sided weakness) following cerebral infarction (stroke) affecting right dominant side, weakness and unspecified dementia. Review of Resident #31's Quarterly Minimum Data Set (MDS), an assessment tool dated 09/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated that the resident's cognition was severely impaired. Review of Resident #31's Order Summary Report revealed an order dated 10/24/23, for Contact Isolation Precautions/ESBL urine (colonized). On 10/26/23 at 11:53 AM, the surveyor observed Certified Nursing Assistant (CNA) #1 as she entered Resident #31's room without first donning PPE and proceeded to move the resident's bedside table and fed the resident. CNA #1 then placed her hands on her hips over top of her uniform. CNA #1 then picked up the tray and carried it out of the room and placed it on a food cart in the hall. CNA #1 then proceeded to push the food cart to the other end of the hall before she performed hand hygiene with ABHR. At 11:56 AM, the surveyor interviewed CNA #1 who stated that Resident #31 had a urinary tract infection and was on isolation. CNA #1 stated that she did not think that she was required to wear gloves when she fed the resident. CNA #1 further stated that she did clean her hands after she moved the food cart. On 10/26/23 at 12:04 PM, the surveyor interviewed LPN #3 who stated that Resident #31 was on contact precautions and staff should wear PPE when they fed the resident. LPN #3 stated that she would have performed hand hygiene after feeding the resident, but the spread of infection was limited to contact with the resident's urine. LPN #3 further stated that if you touched the resident, then PPE should have been worn. On 10/27/23 at 10:03 AM, the surveyor interviewed LPN/UM #1 who stated that Resident #31 had ESBL (Extended-spectrum beta-lactamases (enzymes that are resistance to most beta-lactam antibiotics, including penicillin). LPN/UM #1 stated that she would expect hand hygiene to be performed before and after feeding the resident. LPN/UM #1 further stated it was an infection risk if hand washing were not done after feeding the resident and before handling the food cart. On 10/27/23 at 10:17 AM, the surveyor interviewed the ADON/IP who confirmed that Resident #31 was on contact precautions for ESBL in the urine. ADON/IP stated that staff were supposed to wash their hands when they fed the resident so that they did not transfer whatever the resident had to someone else. ADON/IP stated that the resident's lab culture was positive, and an Infectious Disease Consultant only recommended to continue the antibiotic that was previously ordered and did not specify whether the resident had an active infection or was colonized with the organism. On 10/30/23 at 11:02 AM, the surveyor interviewed the DON who stated that staff were required to donn gloves when they fed a resident who was on contact precautions. DON stated that staff were also required to wash their hands before they left the resident's room so that things were not passed along from their hands to other surfaces. Review of the facility policy, Medication Administration (Reviewed 03/23) revealed the following: .Hand Washing: .Hands must be disinfected immediately before and after eye drops .and patch administration. Miscellaneous: Medication disposal: If medication is dropped on top of the cart, dropped on the floor, or is refused-disposal should be in such a way as to avoid resident or others usable access . Review of the facility policy, Infection Control/Standard Precautions/Transmission-Based Precautions (Revised 07/23) revealed the following: Purpose: To control the spread of infection. Procedure: Contact Precautions: Transmission of disease can occur through direct and indirect contact .Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object. .Wear gloves when coming in direct contact with a patient .Wash hands immediately after removing . Review of the facility policy Standard and Transmission-Based Precautions, Handwashing/Hand Hygiene (Reviewed (08/29/23) revealed the following: The purpose of this procedure is to provide guidelines for effective handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections. Appropriate twenty (20) seconds hand washing with antimicrobial soap and water must be performed under the following conditions: .Before and after direct contact with residents . Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .After touching a patient or the patient's immediate environment .After glove removal NJAC 8:39-19.4

Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 10/26/23 at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the narcotic logbook for the North Wing Back Hall medication cart. The Controlled Drugs Accountability/Count Sheet for August, September, and October 2023 shift logs revealed the following incomplete or blank sections: 8/5/23 - 11 PM -7 AM total incoming count section containing counts for Bingo, Boxes, Bottle, and Sheet. 8/6/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/19/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/22/23 - 7 AM - 3 PM outgoing nurse signature 8/27/23 - 3 - 11 PM outgoing nurse signature 8/31/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet, and incoming and outgoing 11-7 nurse signature. 10/1/23 - 7 AM - 3 PM total incoming and outgoing bottle count, 3 - 11 PM total incoming and outgoing sheet count, 11 PM - 7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 10/7/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 10/9 - 10/17, 10/21 - 10/22/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 10/9, 10/13, 10/14, 10/17/23 - 11 PM -7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. At this time, the surveyor interviewed LPN #3 who stated that both the incoming and outgoing nurses on the shift were to complete the narcotic count and the narcotic count log together at the time of the count. On 10/26/23 at 11:19 AM, the surveyor in the presence of the Registered Nurse #1 (RN #1) reviewed narcotic logbook for the East Wing Front Hall medication cart. The Controlled Drugs Accountability/Count Sheet for August, September, and October 2023 shift log revealed the following incomplete or blank sections: 8/20/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. Incoming and outgoing nurse signatures for 7 AM - 3PM and 11 PM - 7 AM. 8/21/23 - 11 PM -7 AM total incoming and 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/23/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/26/23 - 11 PM - 7 AM outgoing nurse signature 8/27/23 - 3 - 11 PM, 11 PM - 7 AM total incoming and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/28 - 8/29/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 8/29/23 - 11 PM - 7 AM incoming and outgoing nurse signatures 8/30/23 - 7 AM - 3 PM and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 8/30/23 - 7 AM - 3 PM outgoing nurse signature 8/31/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 9/8/23 - 3 - 11 PM total incoming and 7 AM - 3PM and 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM, and 3 - 11 PM outgoing nurse signatures 9/9/23 - 3 - 11 PM and 11 PM - 7 AM outgoing nurse signatures 9/10/23 - 3 - 11 PM, 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 3 - 11 PM incoming and outgoing nurse signatures 9/11/23 - 11 PM -7 AM total incoming, 7 AM - 3PM, 3 - 11 PM, and 11 PM - 7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM, and 11 PM - 7 AM incoming and outgoing nurse signatures 9/12/23 - 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/19/23 - 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/20/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/23/23 - 3 - 11 PM, 11 PM -7 AM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM outgoing nurse signature 9/24/23 - 11 PM -7 AM total incoming, 3 - 11 PM, and 11 PM - 7 AM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 11 PM - 7 AM incoming and outgoing nurse signatures 9/25/23 - 7 AM - 3 PM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/27/23 - 11 PM -7 AM total incoming and total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 9/29/23 - 3 - 11 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. 3 - 11 PM, and 11 PM - 7 AM incoming and outgoing nurse signatures 9/30/23 - 7 AM - 3 PM total incoming counts for Bingo, Boxes, Bottle, and Sheet. 7 AM - 3 PM incoming and outgoing nurse signatures 10/12/23 - 11 PM - 7 AM incoming and outgoing nurse signatures 10/13/23 - 7 AM - 3 PM total outgoing counts for Bingo, Boxes, Bottle, and Sheet. At this time, the surveyor interviewed RN #1 who stated that both the incoming and outgoing nurses on the shift were to complete the narcotic count and the narcotic count log together at the time of the count, and there should not be any blanks on the logs. On 10/26/23 at 11:48 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager #2 (LPN/UM #2), who confirmed the incomplete sections of the logs, and stated they should not be blank and if not documented, then not done. On 9/6/23 at 12:47 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the narcotic shift log should be completed and signed by two nurses together, the incoming and the outgoing nurses, when the shift-to-shift narcotic count is completed. She confirmed that this process is in place to keep track of accountability, which is very important because you're dealing with narcotics. A review of the facility's Narcotic and Controlled Substance policy with a reviewed date of 1/2023, included, It is the policy and procedure of this facility to comply with the Controlled Substance Act. As well as to monitor narcotic administration and to ensure accountability for all narcotics. The section titled procedure included, a narcotic count will be completed by two licensed nurses prior to the end of each shift, opening of a unit and closing of a unit. NJAC 8:39-29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly store medications and properly label opened multidose medications. This deficient practice was observed in 1 of 1 medication storage rooms and 2 of 2 medication carts reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 10:27 AM, the surveyor, in the presence of the Licensed Practical Nurse #3 (LPN #3), reviewed the North Wing Back Hall medication cart. The following was observed: One (1) opened aluminum envelope of dorzolamide hydrochloride and timolol maleate ophthalmic solution, usp 2%/0.5% preservative free (a prescription eye drop medication used to treat glaucoma) labeled from the manufacturer to contain 15 single use containers, opened and contained 18 single use containers. The opened envelope had the date 10/24 written on it but was not labeled with a resident's name. One (1) opened bottle of artificial tears eye drops in its box with the opened date of 10/23 and no resident identifier or name. Two (2) vials of nitroglycerin (a prescription medication used to treat heart disease and chest pain) without a pharmacy label on the medication vials. At this time, the surveyor interviewed LPN #3, who acknowledged that these medications should have all been labeled with resident names. On [DATE] at 11:19 AM, the surveyor in the presence of the Registered Nurse #1 (RN #1), reviewed the East Wing Front Hall medication cart. The following was observed: Two (2) opened fluticasone propionate and salmeterol 250 micrograms (mcg) /50 mcg inhalation powder inhalers (a medication used to treat lung disease), each one inhaler was dated as being opened on [DATE] with no resident name on the inhaler device, and the second was in its opened box which was labeled as being opened on [DATE] with no opened date and no resident name on the inhaler device. At this point, RN #1 informed the surveyor that the inhalers themselves should be labeled with the date opened as well as resident name. On [DATE] at 12:25 PM, the surveyor, in the presence of Licensed Practical Nurse/Unit Manager #1 (LPN/UM #1) reviewed the North Wing medication storage room and the following was observed: One (1) box of budesonide inhalation susp 1 milligram (mg) /2 milliliter (ml) (a medication used to treat lung disease) containing one opened foil pouch which contained 3 single use vials. The pouch was labeled as being opened 10/5 with instructions on box from manufacturer to use within two weeks of opening. One (1) box albuterol sulfate inhalation solution 2.5 mg / 3 ml (a medication used to treat lung disease) with one opened foil pouch dated 10/5 containing two single use vials. LPN/UM #1 informed the surveyor this medication pouch should be only good for seven days after opening. On [DATE] at 12:47 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that all nursing staff are responsible to ensure medication storage are kept in good order, medications are labeled appropriately, and not expired. The DON confirmed that inhalers and other multiuse medication devices should be labeled with resident name and date opened so that they don't get mixed up if separated from the box. A review of the facility's Medication Storage policy with reviewed date 3/2023, included, medications are stored in the containers which they are received. Transfer between containers is performed only by the issuing pharmacy. Drug containers that are soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels, are returned to the pharmacy. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed. A review of the facility's Medication Labeling policy with reviewed date of 3/2023, included contents of one container may not be transferred to another container. N.J.A.C. 8:39-29.4

Based on observation, interview and record review, it was determined that the facility failed to follow acceptable standards of clinical practice to ensure that physician's orders and consultant's recommendations were accurately transcribed and implemented in accordance with their facility policy. This deficient practice was identified for 1 of 2 residents reviewed for Dialysis (Resident #21), and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: 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 well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 08/23/21 at 7:59 PM, during the initial tour of the facility, the surveyor observed Resident #21 who was seated in a wheelchair at the bedside. The resident stated, My eyes, my eyes. The resident stated they had not received his/her eye drops and were only administered once that day. According to the facility's admission Record, Resident #21 was admitted to the facility in 08/2020 and had diagnoses which included but were not limited to: end stage renal disease, dependence on renal dialysis, and hypertensive retinopathy (damage to the retina (the transparent, light-sensitive structure at the back of the eye) caused by high blood pressure. Review of the Minimum Data Set (MDS) (an assessment tool) dated 06/13/21, revealed that the resident was readmitted to the facility after hospitalization in 06/2021. Further review of the MDS revealed that the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated that the resident was cognitively intact. Review of Resident #21's Physician's Orders revealed that on 07/31/21 an order was placed for Artificial Tears eye qid x 5 day (to be administered four times per for 5 days) and a second order for an Eye Consult for irritation of the eye. The orders were noted as a 24-hour check by nursing on both 08/01/21 and 08/03/21. Further review of the medical record revealed that Resident #21's Eye Doctor Consult was completed on 08/03/21 and the consultant documented that the resident had mild dry eyes and recommended that the treatment plan was to continue Artificial Tears TID ou (three times daily in both eyes). Review of Resident #21's August 2021 Medication Administration Record (MAR) revealed the following entry: Artificial Tears Solution 1% (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes four times a day for dry eyes x 5 days start date 07/31/21 and the D/C (discontinue) date was noted to be on 08/23/21 at 9:59 AM. Review of the entry confirmed that the resident only received the eye drops once on 08/23/21 as the order was discontinued after the 9:00 AM dose was administered. The surveyor reviewed the physician's orders contained within the medical record which failed to contain an order to discontinue the order on 08/23/21 as it was transcribed onto the MAR. During an interview with the surveyor on 08/23/21 at 10:07 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated that the 11-7 Nurse was responsible to complete the chart check and flagged anything in question for the Unit Manager to follow-up on. She stated that Resident #21 moved to her unit recently and she was not aware of the eye doctor consult or recommendations. The LPN/UM reviewed both the Physician's Orders and the MAR with the surveyor and stated that she thought that the mistake occurred when the nurse who entered the order failed to ensure that the eye drops were only ordered for five days as indicated in the order. She further stated that the order should have been rewritten correctly. During an interview with the surveyor on 08/26/21 at 12:47 PM, the Registered Nurse (RN) stated when a consult was completed if a recommendation was made, she would notify the resident's primary physician. She stated that Resident #21 asked for his/her eye drops today. She stated that when she reviewed the Electronic Health Record (EHR) she saw that the order for eye drops was no longer active. She stated that she informed the resident that she would phone the physician and obtain a new order. During an interview with the surveyor on 08/26/21 at 12:55 PM, the Director of Nursing (DON) stated that the nurse who was assigned to Resident #21 on the day the eye consult was completed was responsible to notify the primary physician of the recommendations and obtain an order that was then placed on the electronic MAR (Medication Administration Record). She stated that if the physician were not in agreement with the recommendations then the nurse must document that in the Progress Notes. She further stated that the nurse who placed the order should have ensured that the initial order written by the primary physician on 07/31/21 was calculated so that the order only remained active for five days. She stated that the stop date must be included. The DON further stated that the night nurse should have flagged the consult and reported off on the consultant's recommendations on the 24-hour report for follow-through during the day shift. She stated that the order that was written on 07/31/21 for Artificial Tears to be administered for five days should not have remained active through 08/23/21. During a later interview the surveyor on 08/27/21 at 9:59 AM, the DON stated that it appeared as though the nurse incorrectly transcribed the physician's order for Artificial Tears Eye qid x 5 days and instead entered the order incorrectly onto the EMAR as: Artificial Tears Solution 1% instill 1 drop in both eyes four times a day for dry eyes. She stated that the nurse failed to include that the eye drops were ordered for five days and did not place a stop date on the order. The DON stated that the error was most likely picked up when the Recaps (medication reconciliation) were done and the nurse who did them realized that the order was only supposed to be active for five days and she discontinued the order. She stated that she would not have known to look for the Eye Doctor's Physician Consult which contained the recommendation to continue Artificial Tears three times daily in both eyes and the order was dropped. She stated that the physician shared some responsibility and failed to ensure that the consultant recommendations were reviewed. She further stated that the ultimate responsibility fell on nursing to ensure that they reviewed the consult and called the physician to tell them what the consultant recommended and obtained related orders if applicable. On 08/27/21 at 10:42 AM, the DON provided the surveyor with the facility 24 Hour Report dated 08/03/21, which failed to contain documented evidence that Resident #21's Eye Doctor's Physician Consult was completed and written recommendations were conveyed to facility staff. The surveyor reviewed the facility policies, Consult and Order Policy and Procedure (Revised 5/2021) and Medication Transcription (Revised 03/2021) which revealed the following: Policy: It is the policy of .to follow through and carry out all consults and orders as needed and deemed necessary by the residents [sic.] primary care physician.Orders- Once an order is received the nurse will contact the primary care physician to confirm the order. The order will be transcribed into the emar by the nurse. It is the responsibility of the 11-7 nurse to check all new orders. Policy: An accurate and current medication administration record (MAR) is critical for accurate medication administration and patient safety. All medication orders will be entered by nursing personnel into the patient's written POS in the chart and into the EMAR via the orders tab .Medication orders transcribed onto the MAR must have the following information: Date the medication was ordered.Name of the medication. Dose of the medication.Route of the administration.Administration times. Stop date, if appropriate . NJAC 8:39 11.2(b)