Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 3/6/24, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 25 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 12%. This deficient practice was identified for two (2) of six (6) residents, (Resident #26 and an unsampled resident), that were administered medications by two (2) of four (4) nurses that were observed. The deficient practice was evidenced by the following: 1. On 3/6/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) preparing to administer medications to an unsampled resident which included a tablet of Glipizide 5 milligrams (mg) (a medication used to treat diabetes). The surveyor observed LPN #1 administer the medication to the resident and observed there was no meal tray at the resident's bedside. At 8:04 AM, the surveyor observed LPN #1 preparing to administer remaining medications with an administration time of 9:00 AM to the same unsampled resident. Upon re-entering the resident's room in the presence of LPN #1, the surveyor observed the resident with a meal tray and consuming food. The surveyor reviewed the electronic Medication Administration Record (eMAR) which reflected the physician's order as Glipizide 5mg 1 tablet by mouth one time a day for DM Give before meals, 30mins before meals, with an administration time of 7:00 AM. The surveyor asked LPN #1 if the Glipizide was given thirty (30) minutes before the residents AM meal as reflected in the physician's order. LPN #1 stated the Glipizide was not given thirty (30) minutes before the meal as stated in the physician's order. 2. On 3/6/24 at 8:39 AM, during the medication administration observation, the surveyor observed LPN #2 preparing to administer medications to resident #26. The surveyor observed the resident's eMAR which reflected an order for Colace oral capsule (a medication used to soften the stool), give 2 capsules by mouth one time a day for constipation. The order did not indicate a strength or dosage. The surveyor observed LPN #2 prepare two (2) capsules of Docusate (the generic equivalent to Colace) 100mg. The surveyor asked LPN #2 how they knew that was the correct dose. LPN #2 stated that those were the standard ones the facility always uses. 3. The surveyor continued to observe LPN #2 prepare medications for Resident #26. The surveyor observed the resident's eMAR which reflected an order for Lidocaine External Patch 5% (a topical anesthetic medication used to treat pain). The surveyor observed LPN #2 remove and prepare a Lidospot patch 4%/1% for administration. The surveyor asked LPN #2 if that was the correct item and strength. LPN #2 stated was since 4% plus 1% equals 5%. The surveyor observed the packaging for the Lidospot patch which indicated active ingredients of lidocaine 4% and menthol 1% (a topical analgesic used to treat pain). The surveyor asked LPN #2 if the Lidospot patch contained 5% lidocaine. LPN #2 stated the package label says it contains 4% lidocaine. The surveyor did not observe any lidocaine 5% external patches present in the medication cart. On 03/6/24 at 12:13 PM, the surveyor interviewed the Consultant Pharmacist (CP) by phone and asked if a Lidospot 4%/1% patch was equivalent to a lidocaine 5% patch. The CP stated they are not equivalent. They are different products. The surveyor asked the CP what the appropriate administration timing for Glipizide would be in relation to meals. The CP stated that Glipizide should be given at least 30 minutes before the meal. The surveyor reviewed the medication information sheet for Colace capsules (docusate sodium). The information indicated Colace capsules are available in multiple strengths, including 50mg, 100mg and 250mg. The information also indicated the daily dose can be from 50mg to 300mg per day. The surveyor reviewed the packaging and ingredient list for Lidospot patch and the medication information sheet for lidocaine 5% patch. The surveyor observed the Lidospot patch contains 4% lidocaine and 1% menthol as active ingredients, while the lidocaine 5% patch contains only lidocaine 5% as the active ingredient. On 3/6/24 at 12:30 PM, the Director of Nursing (DON) provided the surveyor with the facility policy on Administering Medications, revised April 2019, edited 5/21/19. The policy indicated at line 4. Medications are administered in accordance with prescriber orders, including any required time frame. It also indicated at line 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). And line 10. indicated The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. N.J.A.C 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 3/7/24 at 10:39 AM, the surveyor reviewed the electronic medical record for Resident #48. The medical record reflected the resident was admitted to the facility on [DATE] and was discharged home with a family member on 11/30/24. The surveyor reviewed the resident's electronic MDS records. The records reflected Entry/MDS 3.0 accepted 11/17/23, admission - None PPS/MDS 3.0 accepted 11/24/23, Medicare-5 day/MDS 3.0 Completed 11/24/23. The record did not reflect a discharge MDS. On 3/11/24 at 11:26 AM, the surveyor interviewed the Regional MDSC/RN by phone and stated she is accessed the record now and agreed that there was no discharge MDS present. She stated that she would open a discharge MDS right away. On 3/11/24 at 01:35 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing, and the facility management provided no additional information. According to the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After the transition of the MDS, a quality measure will be transmitted to enable a facility to monitor the resident's decline or progress. page 2-11 Discharge refers to the date a resident leaves the facility . There are two types of OBRA (Omnibus Budget Reconciliation Act) required discharges: return anticipated and return not anticipated. A Discharge assessment is required with all types of discharges. The manual on Pages 2-17, A Discharge Assessment - return not anticipated MDS must be completed not later than discharge date + 14 days. The assessment must also be transmitted to the QIES (Quality Improvement and Evaluation System) ASAP (Assessment Submission and Processing) system not later than the MDS completion + 14 days. NJAC 8:39 - 11.1 Based on the interview and record review, it was determined that the facility failed to a.) electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 3 of 24 residents (Resident #25, 26, and #39), and b.) complete the discharge assessment for 1 of 24 residents (Resident #48) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 3/4/24 at 10:30 AM, the surveyor observed Resident #25 out of bed in a wheelchair, alert and oriented, sitting in the activity room. The surveyor reviewed Resident #25's medical record. A review of the admission Record (an admission summary) (AR) documented that Resident #25 was admitted to the facility with diagnoses that included but were not limited to dementia (loss of memory). The resident's most recent Quarterly MDS (QMDS) assessment, dated 12/11/23, reflected that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognition impairment. Resident #25 was observed to have a QMDS with an Assessment Reference Date (ARD) on 12/11/23. The assessment was completed and will be transmitted no later than 12/25/23. However, the QMDS was not submitted until 1/9/24. A review of the undated Final Validation Report for Resident #25, provided by the MDS Coordinator/RN (MDSC/RN), revealed that Warning Assessment Completed Late: is more than 14 days after ARD. 2. On 3/4/24 at 11:42 AM, the surveyor observed Resident #26 sitting in a wheelchair inside the room beside the spouse. The surveyor reviewed Resident #26's medical record. A review of the AR documented that Resident #26 was admitted to the facility with diagnoses that included but were not limited to pneumonia (infection of the lungs). The resident's admission MDS (AMDS) assessment, dated 2/13/24, reflected that Resident #26 had a BIMS score of 12 out of 15, indicating moderate cognition impairment. A review of AMDS with an ARD on 2/13/24. The assessment was completed and will be transmitted no later than 2/26/24. However, the AMDS was not submitted until 2/29/24. A review of the undated Final Validation Report for Resident #26, provided by the MDSC/RN, revealed Warning Assessment Completed Late: for this admission assessment is more than 13 days after the entry date. 3. On 3/4/24 at 10:00 AM, the surveyor observed Resident #39 standing beside the bed fixing the bedsheet. The resident declined to speak with the surveyor. The surveyor reviewed Resident #39's medical record. A review of the AR documented that Resident #39 was admitted to the facility with diagnoses which included but was not limited to unspecified dementia (loss of memory). The resident's most recent QMDS assessment, dated 12/11/23, reflected that Resident #39 had a BIMS score of 3 out of 15, indicating severe cognition impairment. Resident #39 was observed to have an Annual MDS with an ARD on 10/21/23. The assessment was completed and will be transmitted no later than 11/3/23. However, the Annual MDS was not submitted until 11/16/23. A review of the undated Final Validation Report for Resident #39, provided by the MDSC/RN, revealed that Warning Assessment Completed Late: is more than 14 days after ARD. Resident #39 was observed to have a QMDS with an ARD on 1/21/24. The assessment was completed and will be transmitted no later than 2/3/24. However, the QMDS was not submitted until 2/8/24. A review of the undated Final Validation Report for Resident #39, provided by the MDSC/RN, revealed Warning Assessment Completed Late: is more than 14 days after ARD. On 3/8/24 at 11:20 AM, the surveyor interviewed the MDSC/RN, who stated that he is working part-time. The MDSC/RN stated that they had not had a full time MDS Coordinator since December 2023 and added that the position is still not filled. On 3/11/24 at 11:24 AM, the surveyor interviewed the Regional MDSC/RN over the phone and stated she was aware that the assessments were all late. She is the one who pulled out the final validated reports, and they showed late. They haven't had a full MDS Coordinator since December 2023. There's one part-time MDS coordinator who is doing remote work. The full-time regionals look at the assessments and check if there are some due.

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring administration of a medication, (Procrit)(an injectable medication used to stimulate bone marrow to produce more red blood cells), according to a physician's order. This occurred for one (1) of five (5) residents, (Resident #21), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 3/4/24 at 11:53 AM, the surveyor observed Resident #21 in the facility lobby area self-propelling him/herself and talking with the receptionist. At that time, the surveyor interviewed Resident #21 at a nearby private area in the lobby. The resident stated that he/she was very happy with the care at the facility. The surveyor reviewed the medical record for Resident #21. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/21/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the admission Record revealed diagnoses which included anemia and chronic kidney disease. A review of the Order Summary Report (OSR) revealed a physician's order (PO) with a start date of 11/8/23 for Procrit solution 20000 unit/milliliter (ML), (Epoetin Alfa), Inject 1 ML subcutaneously in the evening every Wednesday for anemia of chronic disease hold for hemoglobin (Hgb) 10 or greater. A review of the February electronic Medication Administration Record (eMAR) revealed the corresponding above PO for Procrit scheduled for administration at 6 PM on Wednesdays. The administration documentation on the dates of 2/7/24, 2/14/24, 2/21/24 and 2/28/24 indicated the number nine (9) which correlated with the Chart Codes for Other/See Nurses Notes. There was no indication on the eMAR as to the Hgb laboratory results that corresponded to the PO. A review of the electronic nursing Progress Notes (ePN) for Procrit administration for the dates of 2/7/24 and 2/14/24 revealed Held HGB 10.5. In addition, the ePN for Procrit administration for the dates of 2/21/24 and 2/28/24 indicated Waiting for supply. A review of the resident's February laboratory results for the following dates revealed: - a collection dated of 2/14/24 and received date of 2/15/24 had a Hgb result of 8.6. - a collection date of 2/21/24 and a received date of 2/21/24 had at Hgb result of 9.4. - a collection date of 2/26/24 and a received date of 2/26/24 had a Hgb result of 8.5. There were no Hgb laboratory results found corresponding to the 2/7/24 Procrit administration day which was contradictory to the ePN for 2/7/24. In addition, the 2/14/24 collection date with a received date of 2/15/24 Hgb results had not correlated with the 2/14/24 ePN. A review of the March eMAR revealed the corresponding above PO for Procrit scheduled for administration at 6 PM. The administration documentation on 3/6/24 indicated that the Procrit was administered at 6 PM. There were no corresponding Hgb laboratory results indicated on the eMAR. A review of the resident's March laboratory results collected on 3/6/24 indicated that the Hgb was 8.1. On 3/7/24 at 1:21 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The surveyor requested that the DON provide documentation of the Hgb laboratory results and nurses notes that correlated with the administration documentation of Procrit for the month of February. On 3/13/24 at 12:50 PM, the survey team met with the LNHA and DON. The DON stated that the Hgb lab results would usually be obtained the day before or day of the date of administration of Procrit to fulfill the PO. The DON explained that on 2/6/24 there were no lab results obtained because Resident #21 had gone to the hospital and had returned the next day so there were no results to base whether the Procrit should have been administered according to the PO. The DON added that she would have expected the nurse to call the physician for follow up orders. The DON also explained that the lab results for the administration of Procrit on 2/14/24 were obtained on 2/14/24 but were not posted until 2/15/24. The DON added that she would have expected the nurse to call the physician and move the PO to 2/15 for administration. The DON further explained that the LPN had indicated in the EPN that the Procrit was held for a Hgb greater than 10 because the LPN was using the Hgb results from 1/30/24. The DON acknowledged that the LPN had made an error. The DON also stated that there were Hgb lab results that were less than 10 for 2/21 and 2/28 which indicated according to the PO that the Procrit should be administered. The DON also stated that according to the EPN the LPN had documented that there was no supply of the medication and therefore the medication was not administered. The DON added that she would have expected the LPN to follow up with the pharmacy to obtain the Procrit or call the physician for follow up orders. The DON was unable to speak to what the issue was with obtaining the Procrit from the provider pharmacy because the LPN had not documented the reason the medication was not available or followed up with the pharmacy or gave a report to the next shift to follow up. The DON stated that the LPN was the same LPN for all the dates in February for the Procrit administration. The DON acknowledged that the LPN had not followed proper procedure for making sure the lab results were obtained according to the PO and ensuring the Procrit was administered according to the PO. In addition, the DON stated that on 2/12/24 there was an inservice explaining the procedure to follow when a medication was not available that the LPN had attended but had not followed the procedure. The DON and LNHA stated that moving forward any medication that was not available from the provider pharmacy was to be reported by the nurses to administration so that additional follow up would be able to be completed to ensure either obtaining the medication or follow up by a physician. A review of the current facility policy for Administering Medications with an edited date of 5/21/19 provided by the DON reflected that Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation included; Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. In addition, Medications are administered in accordance with prescriber orders, including time frame. Also, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: .Any results achieved and when those results were observed. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.3(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C: #NJ00166633 Based on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to implement the facility's policy titled, admission Agreement (AG). This deficient practice was identified for 1 of 6 (Resident #3) residents reviewed as evidenced by the following: According to the facility admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Spinal Stenosis, Dementia, Type 2 Diabetes. Resident was discharged on 8/11/2023. The facility was unable to provide Resident #3's AG. On 11/9/23 at 11:59 a.m., the surveyors interviewed the facility's admission Director (AD) who stated, AG for Resident # 3 can't be found. On 11/9/23 at 1:23 p.m., the surveyors interviewed the Administrator (LNHA) and AD. LNHA stated, I'm unable to locate Resident # 3's AG. The AD stated, there should be an AG done, but I can't to find it. A review of the facility's policy titled, admission Agreement, revised on 8/2018, indicated all residents have a signed and dated admission Agreement on file. Further review of the policy under Policy Interpretation and Implementation .4. A copy of the admission Agreement is provided to the resident .and a copy is placed in the resident's permanent file. NJAC 8:39-4.1(a)8

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT # NJ00166633 Based on interviews, and review of medical records (MR) and other facility documentation on 11/8/23, 11/9/23, and 11/13/23, it was determined that the facility failed to provide the resident's representative (RR) a 30-day written notice in advance of an impending discharge prior to the facility-initiated discharge. In addition, the facility failed to follow their policy on Discharging the Resident and admission Agreement who was discharged on 8/10/23 and 8/14/23 for 2 of 6 residents (Residents #3 and #4) reviewed for discharge. This deficient practice is evidenced by the following: The surveyor reviewed facility 8/1/23 to 11/8/23 Discharges on 11/8/23. The 8/2023 Discharges revealed that Residents #3 was discharged from the facility (F1) to another facility (F2) on 8/10/23 and Residents #4 was discharged from the facility (F1) to another facility (F3) on 8/14/23. Review of the facility policy titled Discharging the Resident, edited on 4/28/17, reflected Purpose The purpose of this procedure is to provide guidelines for the discharge process .4. F. Why the discharge is necessary . 1. According to the admission record (AR), Resident #3 was admitted to the facility on [DATE] and was discharged on 8/10/23 to F2. Diagnoses included but were not limited to: Dementia and Difficulty in Walking. The Minimum Data Set (MDS), an assessment tool dated 7/23/23, revealed a Brief Interview for Mental Status (BIMS) score of 3/15, which indicated that her/his cognition was severely impaired needed help with Activities of Daily Living (ADL). The quarterly assessment MDS, dated [DATE], revealed in Section Q, the Resident, RP, and the Power of Attorney (POA) did not participate, however, the discharge plan under Q0400, the discharge plan was active and already occurring for the resident to return to the community. During the surveyor's interview on 11/13/23 at 11:43 with Social Worker (SW #1), who completed 7/23/23 Section Q MDS, revealed that he made a mistake of coding Q0400, he stated that he should have had coded to 0 to indicated that the discharge plan was not active. A care plan (CP), initiated on 4/29/21, indicated that Resident #3 was a Long-Term Care Resident. Interventions included but were not limited to; Provide referrals to area centers upon request., reassess care needs and potential for discharge as needed, and support patient, family and/or representative as needed. The facility was unable to provide Resident #3's AG. The facility was unable to provide a Physician order to indicated that the Physician was notified and agreed for the Resident's discharge to F1 prior to 8/10/23. A review of Resident #3's progress notes (PN), documented by SW #2, on 4/28/21 at 10:46 p.m., documented that Resident #3 was recently approved for Medicaid and planned to remain for Long-Term Care (LTC), on 7/20/21 at 11:32 a.m. Resident #3 continued to be a LTC resident, on 10/11/21 at 10:52 a.m. documented Plan remains to be LTC and 10/28/21 at 9:33 pm, documented Plan remains for LTC placement. Further review of the PN, SW #3 documented that Resident #3 remained appropriate for LTC on 3/2/22 at 2:45 p.m., 11/10/22 at 12:56 p.m., 5/1/23 at 3:25 p.m., and 5/4/23 at 3:45 p.m. The PN revealed that on 8/11/23 at 5:13 p.m., documented by registered nurse (RN) wrote Resident transferred F2 at 4 p.m. The Resident's PN and MR revealed no documented evidence that facility-initiated discharge requirements were given to the RR. The PN further revealed there was no documentation indicating the plans for discharge to F2. The General Notes Report (GNR), provided by the facility on 11/9/23, according to the Administrator the GNR was an internal staff communication and was not part of the resident's MR. The GNR, dated 8/11/23 at 10:16, documented by the facility's Regional Marketing and Business Development (RMBD), indicated that she spoke to the Resident's family member (RP) and left a message and texted the Resident's Power of Attorney with message. The RMBD further documented Told [RP] due to issue at the facility we have to transfer [Resident #3] to [F2]. RP asked if this will be permanent and let her know that we do not have a date as to when she can return. We do not know if the issue will ever be fixed, but we'll keep her posted. patient transferring today. The RMBD further documented at 10:46 [POA], called me and [she/he] was concerned about [Resident #3's] transfer, but after I spoke to [her/him] [she/he] understands. [she/he] know that we do not have a transfer back dated, and I explained that I could not disclose the maintenance issue. At 4:20 p.m., RP further documented, Spoke to [POA] and [RP], they both expressed concern about the transfer . The surveyor conducted a telephone interview with Resident #3's POA on 11/13/23 at 9:13 a.m. The POA stated that she/he received a call from the facility (unable to recall exact time and date) on the same day to inform her/him that Resident #3 was being discharged to F2. POA stated that when she/he arrived at the facility, Resident #3's was about to leave, Resident's belongings were already packed, and the transportation was already outside the building waiting for the Resident. The POA explained that the facility did not give her/him a chance to say no or to check other facility that was closer to his/her home. The POA further stated that the facility was unable to explain a reason for the discharge, according to the POA the facility stated, maintenance issue. 2. According to AR, Resident #4 was admitted to the facility on [DATE] and was discharged on 8/14/23 to F3. Diagnoses included but were not limited to: Pervasive Developmental Disorder, Schizophrenia, and Need for Assistance. The MDS, dated [DATE], revealed that Residents BIMS was not performed because the Resident was unable to complete the interview. Section Q of the MDS revealed the Resident #4 participated and under Q0400 that an active discharge planning was not occurring for the resident to return to the community. A CP, initiated on 11/21/2020, indicated that Resident #4 was planning to remain in LTC. There was no indication on the CP that the resident was to be discharged to F3. Review of the Resident #4's admission AGREEMENT (AG), signed on 2/10/22 at 1:33 p.m. indicated that the Resident was acknowledging the involuntary and voluntary discharge requirement. The AG under ARTICLE X1 TERMINATION OF AGREEMENT, TRANSFER AND DISCHARGE 1. Involuntary Discharge. Facility may transfer or discharge Resident upon thirty (30) days advance written notice for one or more of the following reasons: (a) the transfer or discharge is necessary for Resident's welfare and Resident's needs cannot be met in the facility; (b) Resident's medical condition no longer requires Facility's care or services; (c) the safety of individuals in the Facility is endangered; (d) the health of individuals in the Facility would otherwise be endangered; (e) Resident Parties have not paid (or made arrangements to have paid) the fees Resident Parties are obligated to pay for items and services Resident received; (f) Resident has been terminated to be mentally ill, in accordance with Federal or State law, and Resident requires specialized services for mental illness; (g) Facility ceases to operate; or (h) Facility ceases to participate in the Medicare or Medicaid programs, for any reason, and Resident's stay at the Facility is being paid for by Medicare or Medicaid .4. Voluntary Discharge. Resident Parties may transfer or discharge Resident from the Facility upon the provision of thirty (30) days written notice to terminate this Agreement. All payments to the Facility for care and services to the Resident shall become immediately due and owing as of the Resident's final day at the Facility . The facility was unable to provide a Physician order to indicated that the Physician was notified and agreed for the Resident's discharge to F3 prior to 8/14/23. A review of Resident #4's PN, documented by SW #2, on 11/22/20 at 10:21 p.m. indicated that Resident #4's plan was to remain in LTC. On 11/22/20 at 10:43 p.m. indicated Anticipated length of stay: LTC, on 3/5/21 at 6:07 p.m. indicated that Resident #4's legal guardian plans was for her/him to remain a LTC resident, on 5/27/21 at 10:44 a.m. documented, :Plan remains for LTC at this time as [Resident #4] requires total care, on 11/23/21 at 11:07 a.m., 10/11/22 at 12:38 p.m., and 2/24/23 at 9:19 indicated that Resident #4 remained LTC. Further review of Resident #4's PN, dated 8/11/2023 at 12:32 p.m. documented by the former Administrator indicated that she had spoken to Resident #4's Guardian and agreed for the transfer to F3. Resident #4 was discharge to F3 on 8/14/23. The Resident's PN and MR revealed no documented evidence that facility-initiated discharge requirements were given to the RR. The PN further revealed there was no documentation indicating the plans for discharge to F2. The surveyors conducted an interview with Maintenance Director (MD) on 11/9/23 at 9:15 a.m., the MD stated there was no maintenance issues between 8/2023 through 11/9/23. The review of facility's maintenance log sheet (MLS) from 7/23/23 to 10/3/23, the MLS revealed there was no indication in the MLS that the facility was having a maintenance issue in room [ROOM NUMBER] and 143. The surveyor conducted an interview with SW #1 on 11/8/23 at 1:20 p.m., the SW stated that the residents were discharged to another facility in 8/2023 because the facility was transitioning from Long-term care to Subacute Rehabilitation. The SW further stated that he did not call or arranged the resident's discharges in August because he was new. The surveyor conducted an interview with RMBD on 11/9/23 at 11:31 p.m. RMBD stated that the [NAME] President of Operation (VPO) had provided her list of family members (FMs) to call for possible transfer to another facility because of a maintenance issue, the RMBD was unable to explain what was the maintenance issue and to provide the list of residents who was discharged to another facility. The RMBD further stated that when the 4 FMs agreed, the former Administrator and Director of Nursing (DON #1) were informed and arranged for the transfer. The surveyor conducted a telephone interview with DON #1 on 11/9/23 at 1:25 p.m. DON #1 stated that she received a notification from the RMBD and VPO that Resident #3 and Resident #4 were moving to another facility. DON #1 further stated that she instructed the Unit Clerk to set up the transportation on the same day when she received the instruction from the Corporate. DON #1 revealed that the 30-day notice was not provided to the Residents or to their FMs and she was not aware that there was a maintenance issue. The former Administrator was not available for interview on 11/8/23, 11/9/23, and 11/13/23. The surveyor conducted an interview with the VPO on 11/13/23 at 10:01 a.m. The VPO confirmed the transfers occurred on 8/2023. VPO explained that the discharges were voluntary discharge because when the facility offered the FMs agreed for the residents to be discharged to another facility. The VPO further explained due maintenance issue such as sprinkler issues, trying to repair and remodel the F1 was trying to condense to opening up the rooms to repair of what was happening, we barely have short term patient to cycle out, so we offered LTC patient to be transferred to another facility or a room change. The VPO further stated that a 30-day notice was not necessary because they were ready to go home and agreed. The surveyor conducted an interview with Resident #4's Guardian on 11/13/23 at 3:26 pm. The Guardian revealed that F1 provided a list of facilities to choose from on 8/11/23 and Resident 4 was discharge to F3 on 8/14/23. The Guardian stated that there was no clear understanding or explanation of why [Resident #4] was being transferred and there was no 30-day discharge notice given. The Guardian further stated that I didn't have the choice, the discharge process was not there, and I wish more time was given. The surveyor conducted an interview with Resident #3 and Resident #4 primary physician on 11/13/23 at 4:03 p.m. The residents Primary Physician (PCP) stated that she/he was not aware that the residents were transferred to another facility. The PCP further stated that she/he was made aware when the residents was not in their rooms. NJAC 8:39- 4.1(a)31 NJAC 8:39- 4.1(a)32

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 6 (Resident #3) residents reviewed. This deficient practice was evidenced by the following: According to the admission record (AR), Resident #3 was admitted to the facility on [DATE] and was discharged on 8/10/23, with diagnoses that included but were not limited to: Dementia and Difficulty in Walking. A review of Resident #3's care plan documented Resident #3 is a long-term care (LTC) resident, initiated on 4/29/21. A review of the Progress Notes (PN) dated 5/3/23 at 11:08 a.m. documented under Care Conference Note, Resident #3 remains appropriate for LTC. Review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care dated 7/23/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident had a severely impaired cognition. Further review of the MDS Section Q0400 Discharge Plan was coded 1, indicating an active discharge planning is already occurring for the resident to return to the community. During the surveyor's interview on 11/13/23 at 11:43 with Social Worker (SW), who completed 7/23/23 Section Q MDS, revealed that he made a mistake of coding Q0400, he stated that he should have had coded to 0 to indicated that the discharge plan was not active. NJAC 8:39-33.2(d)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain accountability for oxygen therapy for 1 of 1 resident reviewed for respiratory care, Resident # 32. The deficient practice was evidenced by the following: On 12/13/21 at 10:39 AM, the surveyor observed Resident #32 sitting in the hallway in a wheelchair by the window looking out. The resident was wearing oxygen via a nasal cannula (a tube in the opening of the nostrils that delivers oxygen). The surveyor was unable to see the setting on the portable oxygen concentrator. On 12/14/21 at 10:04 AM, the surveyor observed Resident #32 in the doorway of their room, seated in a wheelchair, without the nasal cannula on, it was hanging off one ear. The surveyor asked the resident if they needed help putting it on. The resident said no, I can do it, it just takes time. On 12/14/21 at 10:19 AM, the surveyor observed the resident sitting in their wheelchair at the end of the hall looking out the French doors to the outside field. The resident was wearing the nasal cannula at that time that was attached to the oxygen concentrator. The surveyor asked the Unit Manager/Registered Nurse (UM/RN) to confirm the oxygen setting on the oxygen concentrator on the back of the resident's wheelchair. The UM/RN checked it and stated it was set at 2 liters per minute (lpm). On 12/14/21 at 10:30 AM, the surveyor reviewed the residents electronic medical record which revealed the following: A current physician's order sheet (POS) that read Oxygen 2 liters via N/C as needed for SOB (Shortness of Breath). The start date was 8/20/21. The December 2022 Electronic Medication Administration Record (EMAR) read Oxygen 2 liters via N/C as needed for SOB. There were no signatures on the EMAR that accounted for the resident's oxygen usage. On 12/14/21 at 11:39 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) about the oxygen for Resident #32 and where they accounted for its use. The LPN showed the surveyor the EMAR and stated that it was a PRN (used as needed). The LPN confirmed that she should have signed for it there. She then proceeded to sign for the oxygen as being used on 12/14/21 at 7:30 AM. The LPN said the resident usually wore it when out of bed, and when in bed. She further stated [The resident] has had it on all morning since I came in. The surveyor asked the LPN if they should have been signing for the oxygen use. She said yes. She didn't know why it hadn't been signed for. She said it was used for comfort. On 12/14/21 at 12:11 PM, the surveyor asked the UM/RN if the nurse should have been accounting for the use of the oxygen by signing the EMAR. She said she wasn't sure if they were supposed to be signing for the oxygen when used. The UM/RN further stated that the resident usually used the oxygen when out of bed, not usually when in bed. The surveyor told the UM/RN that the LPN just said the resident wore the oxygen when in bed and when out of bed. The surveyor asked her how often the resident wore the oxygen when out of bed. She said she didn't know. On 12/16/21 at 2:00 PM, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the concern with the facility not accounting for the use of the oxygen for Resident #32. On 12/20/21 at 10:38 AM, the LNHA said the facility clarified the oxygen order for Resident #32 with the doctor. He then stated the doctor changed the order to continuous instead of as needed. On 12/20/21 at 11:00 AM the surveyor reviewed the facilities Policy and Procedure titled Oxygen Administration. Under Purpose it read The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Documentation it read; After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. NJAC 8:39-27.1 (a)

Based on observation and interview, it was determined that the facility failed to store medication at the appropriate temperature and failed to store controlled substances in a manner that would prevent loss or diversion. This was found with 1 of 2 medication refrigerators inspected. The deficient practice was evidenced by the following: On 12/14/21 at 11:31 AM, the surveyor inspected the Medication refrigerator in the med room on the Sub Acute unit with Licensed Practical Nurse #1 (LPN #1). There was an unopened box that contained one single dose pre-filled syringe of Invega Sustenna (an extended-release injection used to treat schizophrenia). On the box the storage instructions read: Store at room temperature 77 degrees Fahrenheit. The temperature in the refrigerator was 42 degrees. LPN #1 confirmed that the Invega should not have been stored in the refrigerator. Further inspection found a locked narcotic box attached to a shelf that was removable. LPN #1 did not have the key to the narcotic box. LPN # 2 opened the narcotic box. Inside of the box was an unopened 30 ml bottle of Ativan Concentrate (A schedule IV-controlled liquid antianxiety medication). On 12/14/21 at 2:27 PM, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the Invega which was improperly stored. The DON said the Invega that was in the refrigerator was discarded and there was another box of Invega in the medication cart they would use. On 12/20/21 at 2:15 PM, the surveyor reviewed the facility's policy and procedure titled Storage of Medications. Under Policy Interpretation and Implementation it read; 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls and 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. NJAC 8:39-29.4 (h)

Based on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for hospice/end of life care and was evidenced by the following. On 12/13/21 at 11:47 AM, the surveyor observed Resident #136 awake and alert in bed. A review of the resident's hybrid medical record revealed the following information: According to the admission Record the resident was admitted with diagnoses including but not limited to esophageal cancer and status post feeding tube insertion. The 11/30/21 admission Minimum Data Set assessment tool indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 and was enrolled in a hospice program. The 12/4/21 facility hospice care plan included interventions to provide comfort and supportive care and hospice staff visitation to provide care, assistance, and evaluations. The resident's paper chart contained a tab for hospice documentation. The Hospice Care Face Sheet indicated the resident was admitted to the hospice program on 11/29/21 for diagnoses of malignant neoplasm of the lower third of the esophagus and surgical aftercare following surgery on the digestive system. A review of the paperwork failed to reveal a hospice agency nursing care plan or hospice nurse progress notes. A staff sign in sheet located on the resident record indicated hospice nurse visits occurred on 11/29/21, 12/1/21, 12/8/21, and 12/13/21. On 12/16/21 at 10:09 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM). When asked where the hospice nursing progress notes and hospice care plan were filed, the RNUM replied, they usually leave their notes, but I don't see them. I'll get back to you. The RNUM did not provide the notes to the surveyor. On 12/16/21 at 12:09 PM, the facility Administrator provided the surveyor with hospice agency progress notes and care plan which had been sent to the facility by the hospice agency several minutes earlier. On 12/21/21 the surveyor reviewed the facility policy for the Hospice Program, revised 7/2017, provided by the Administrator. The policy indicated the facility will communicate and collaborate with the hospice representatives and coordinate care between the facility and the hospice agency. The most recent hospice plan of care specific to each resident must be obtained by the facility. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed with 1 of 1 Lab Technician and 1 of 1 dietary aide and was as evidenced by the following: On 12/14/21 at 9:10 AM, the surveyor observed a Lab Technician (LT) enter a resident's room wearing two surgical masks and no eye protection. The LT placed a large bag which contained her supplies on the bed next to the resident. The LT put gloves on her hands with no hand hygiene first and then drew the resident's blood. The LT then took her cell phone out of her pocket with her gloved hand and put it to her face to answer a phone call. The LT placed the phone back into her pocket and removed her gloves. The LT did not perform hand hygiene when she removed her gloves. The LT took the bag of supplies and walked down the hallway to another resident's room. At 9:15 AM, the surveyor observed the LT enter another resident's room, still wearing two surgical masks and no eye protection. The LT put on new gloves without any hand hygiene, grabbed supplies, the LT drew the resident's blood. The LT removed her gloves, and this time did perform hand hygiene with alcohol-based hand rub (ABHR). At 9:22 AM, the surveyor interviewed the LT who stated, I don't work here, I work with the hospital and I have one more resident's blood to draw. The surveyor asked about hand hygiene before and after wearing gloves, the LT stated that she should have performed hand hygiene before and after wearing gloves and that she forgot. The LT stated that she should not have grabbed her phone with her soiled gloved hands. At 9:50 AM, the surveyor observed the LT enter another resident's room, who was on droplet precautions which was identified with a sign outside the resident's door indicating Quarantine droplet/contact precautions. There was also Personal Protective Equipment (PPE) outside of the resident's room. The droplet/contact precautions sign indicated that a person entering the room must wear a gown, gloves, N95 respirator mask and eye protection. The surveyor observed the LT put on gloves, gown, a face shield and did not put on a N95, she only had two surgical masks on. The LT entered the resident's room and closed the door and prior to exiting the room the LT removed the gown, gloves and face shield and performed hand hygiene with ABHR. At 10:00 AM, the surveyor interviewed the LT who stated that she is fit tested for a N95 mask but that she did not have the N95 mask with her. The LT stated that she had two surgical masks on and that should be enough to wear into the resident's room who is on droplet/contact precautions. At 10:06 AM, the surveyor discussed the above concerns with Administrator, Director of Nursing (DON) and the Infection Preventionist (IP), who stated that the LT should have performed proper hand hygiene before and after wearing gloves, the LT should not have touched her phone with gloved hands and the LT should have worn a N95 mask when entering a resident's room who is on droplet/contact precautions. At 1:05 PM, the surveyor observed a Dietary Aide (DA) bring a tray of food to a resident's room who was droplet/contact precautions. The DA knocked on the door and entered room with only a surgical mask on, no eye protection, no gown and no gloves. The DA placed the tray on bedside next to resident and asked the resident if there was anything else needed, the DA then exited the room and closed door. There was no observed hand hygiene. At 1:07 PM, the surveyor interviewed the DA, who stated that she does only brings trays into the resident's room when a tray is ordered between mealtimes. The DA stated that she did not think that PPE should have been worn since there is no COVID positive resident in the building. The surveyor pointed out the sign on the resident's door which read droplet/contact precaution wear gown, gloves, eye protection and N95 respirator when entering the room. The DA said that she should have worn all the proper PPE, including eye protection, N95, gown and gloves. The DA also state that she should have cleaned her hands after leaving the room as well. At 1:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the DA should not have been passing out trays and that the nursing staff are the ones who pass out the trays, the LPN stated that the DA should have worn a N95, gown, gloves and eye protection if entering a resident's room who is on quarantine with droplet/contact precautions. At 12/14/21 on 2:15 PM, the surveyor discussed above concerns with Administrator and DON, who stated that the DA should not be passing trays out to residents and that if she had to enter the resident's room, she needed to wear proper PPE. The surveyor reviewed the policy and procedure titled Handwashing/ Hand Hygiene which was reviewed 1/20/21. The policy and procedure indicated that hand hygiene is to be performed before and after applying gloves. The surveyor reviewed the stop sign placed on resident's door which was titled Quarantine Droplet/Contact Precautions. The sign indicated that personnel entering the room must clean hands when entering and exiting, wear gown, N95 respirator, eye protection and gloves. N.J.A.C. 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to investigate a full thickness tissue-loss pressure ulcer identified three days after admission to the facility. This deficient practice was identified for 1 of 5 resident's reviewed with pressure ulcers (Resident #40), and the evidence was as follows: On 1/27/2020 at 10:42 AM, the surveyor observed Resident #40 in bed and lying on a low air-loss mattress with the head of the bed slightly elevated. The resident would not speak specifically to the surveyor's inquiry. The resident was unsure if he/she had any wounds that the nurse was treating. On 1/28/20 at 9:54 AM, the surveyor observed the Certified Nursing Aide (CNA) in the resident's room preparing to provide morning care to Resident #40. At that time in the presence of the CNA, the surveyor asked the resident's permission to observe morning care with the CNA, and the resident refused. The surveyor then exited the resident's room to allow the CNA to continue with the care. The surveyor reviewed the medical record for Resident #40. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses which included sepsis (a systemic infection), morbid obesity, and necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/31/19 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating a moderate to severe cognitive impairment. The assessment further included that the resident was admitted with two stage III (full thickness tissue loss) pressure ulcers. A review of the Universal Transfer Form (UTF), a communication tool to summarize transfer information, dated 12/24/19 indicated that the resident had a right groin wound (necrotizing fasciitis) but no other pressure ulcers or ulcerations. A review of the electronic Progress Notes (ePN) dated upon admission on [DATE] at 11:38 PM included that the resident was admitted with current skin breakdown/skin conditions: refer to the completed evaluation and physician orders for type and location. A review of the Resident Evaluation/initial nursing admission assessment dated [DATE] included that the resident had an indwelling urinary catheter for the contamination of a stage 3 or 4 pressure ulcer with urine, and that the resident had a front right thigh stage III wound that was 20 centimeters (cm) long and extended to the right inner thigh. Under the Skin Evaluation section, the space to record additional observations/comments was blank. There was no documented evidence of additional pressure ulcers or ulcerations present upon admission. A review of the physician's orders sheet with a start date of 12/25/19 included a physician order (PO) to cleanse the right leg wound with normal saline solution, pack with gauze and cover with a dry dressing every shift. There was no documented evidence of a physician order for any other ulcerations or skin conditions. A review of the electronic Treatment Administration Record (eTAR) for December 2019 included the PO dated 12/25/19 for the right leg wound, but there was no documented evidence upon admission for the accountability for a wound dressing to any other non-intact skin areas for the dates of 12/24/19, 12/25/19 or 12/26/19. A review of the subsequent ePN's dated 12/25/19 and 12/26/19 did not reflect documented evidence of an open wound or treatment to an open wound other than the right thigh wound. A review of a ePN dated three days after admission on [DATE] at 4:30 PM, reflected that the Registered Nurse/Unit Manager documented that Resident #40 was admitted on [DATE] with wounds to right buttock, left buttock, and right leg with wound care treatment orders as follows: cleanse right buttock with NSS [normal saline solution], pat dry, and apply a wet to dry dressing daily; cleanse left buttock with NSS, pat dry, apply xeroform, and cover with a dry dressing daily . The RN/UM then documented at 5:10 PM that day that the left buttock wound was a stage II (partial thickness tissue loss) pressure ulcer measuring 1.5 cm x 1.5 cm x 0.2 cm with moderate serous drainage. She documented the right buttock was a stage II ulcer that measured 2.0 cm x 1.5 cm x 0.2 cm with moderate serous drainage. This did not correspond with the UTF, the Resident Evaluation nursing assessment upon admission on [DATE], or subsequent ePN's dated 12/25/19 and 12/26/19 that the resident had been admitted with the pressure ulcers to the left and right buttocks. There was no documented evidence for the identification or a treatment order for the buttock wounds on 12/24/19, 12/25/19 and 12/26/19. A review of the wound consultant initial Visit Report dated 12/31/19 reflected that the resident had a right thigh wound, in addition to a right and left gluteal fold stage III (full thickness tissue loss) pressure ulcers. The right gluteal fold measured 1 cm x 1 cm x 0.2 cm and had moderate serous (clear) drainage and the left gluteal fold measured 1.5 cm x 2 cm x 0.2 cm and also had moderate serous drainage. The wound consultant/Nurse Practitioner (NP) indicated that the stage III pressure ulcers had 100% granulation tissue (indicating signs of healing) and recommended to apply medihoney (a debriding ointment), calcium alginate (an absorbent dressing), and cover the wounds with a foam dressing daily. On 1/28/20 at 11:20 AM, the surveyor interviewed the RN/UM who documented three days after admission that the resident was admitted with two stage II pressure ulcers on the right and left gluteal folds. The surveyor asked the RN/UM about the note she wrote on 12/27/19. The RN/UM stated that the resident was admitted on [DATE] and that usually she does a skin check on new admissions. She stated that she did a skin check on 12/27/19 and saw the wounds, and she reviewed the hospital records and saw that the resident had skin breakdown. She was not sure where within the hospital documents it established that the resident had stageable wounds, or if the wounds had healed prior to discharge from the hospital. The RN/UM confirmed that the UTF reflected that the resident did not have a stageable pressure ulcer, and the admission Resident Evaluation assessment dated [DATE] did not address the gluteal pressure ulcers or behaviors that would have limited staff ability to inspect the skin. The RN/UM stated that upon admission, the LPN's are expected to perform a head to toe skin assessment and document the findings with in the resident's medical record. The RN/UM stated that she documented that the resident was admitted with the wounds. The surveyor asked if she spoke to the Licensed Practical Nurse (LPN) who performed the admission assessment, or if the CNA's who had performed incontinence care had observed the presence of the wounds, and the RN/UM stated that she had not spoken to those staff prior to writing her note, and that she had just assumed that it had been there. She confirmed the hospital records were vague in the assessment of the skin/pressure ulcers and did not document evidence of what stage the stageable wounds were to the buttocks. She acknowledged that the wound consultant/NP documented the wounds as stage III pressure ulcers on 12/31/19. The RN/UM stated that she had brought this situation up to the the Director of Nursing (DON) on 12/27/19. The RN/UM confirmed there was no physician order for the treatment to the stage II or stage III gluteal fold wounds on 12/25/19 and 12/26/19. The RN/UM could not speak to if the wounds had healed and reopened. The RN/UM stated that she did not perform an investigation but that the surveyor could ask the DON. On 1/28/20 at 11:46 AM, the surveyor interviewed the CNA who stated that she was always the CNA assigned to care for Resident #40 since admission, and that she worked full time during the day shift (7 AM to 3 PM). The CNA stated that the resident was always cooperative with care for her, and that he/she was incontinent of bowel and had a bowel movement this morning. The CNA stated that the resident came in to the facility with wounds to the buttocks, and that he/she always had a treatment over top of the buttock wounds that she could recall, even on Christmas day when she worked. The CNA stated that she did not have to write a statement regarding the resident's skin and that no one had asked her about the condition of the resident's skin upon admission. On 1/28/2020 at 1:16 PM in the presence of the survey team, the DON stated that there was no investigation conducted for the lack of documentation related to the buttocks pressure ulcers for the three days after admission to the facility. On 1/29/20 at 10:44 AM, the surveyor interviewed the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that she did not conduct an investigation at the time the wounds were first documented. She stated that she had since spoke to the admitting LPN who told her that the resident refused to turn and therefore the skin could not be adequately visualized. The DON stated that if a resident refuses to turn for the admission assessment, that the physician should be notified and it should get reported on the 24 hour report to check the skin at the next incontinence care change or at the next most convenient time when the resident was getting up, such as for physical therapy. The DON acknowledged that she did not get statements from the CNA's or nurses who cared for the resident on 12/24/19, 12/25/19 and 12/26/19 to see if wounds were identified during incontinence care, and if so, did they report the wounds to the nurse or the supervisor, because there had been no treatment order in place on those dates. The DON understood the surveyor's questions, and confirmed had she had obtained statements through an investigation, she would be able to demonstrate that the pressure ulcers to the buttocks were actually there or not there upon admission. She provided the surveyor hospital records that reflected the resident had gluteal and sacral wounds during a hospital stay, but she could not speak to if the wounds had healed and subsequently reopened or if the resident was admitted with the wounds. The DON stated that as of yesterday 1/28/2020, the right and left gluteal pressure ulcers wounds had healed. On 1/29/2020 at 12:02 PM, the surveyor attempted to conduct a phone interview with the LPN who admitted the resident on 12/24/19. The LPN did not answer the phone nor return the surveyor's request for a return call. On 1/30/2020 at 12:36 PM, the surveyor conducted a phone interview with the Registered Nurse/Supervisor (RN/S) for the evening shift of 12/24/19. The RN/S stated that she was went into the resident's room with the LPN that evening to assess the resident's skin but the resident was refusing to be turned to fully check the skin. The RN/S stated that she believed there were open areas to the buttocks due to the fact the resident had an indwelling urinary catheter from the hospital, and that the hospital records reflected evidence of a history of wounds to the buttocks and sacrum. She stated that she did not recall communicating with anyone (nurse or physician) that the resident's skin was not fully assessed due to his/her refusal to turn in bed in order for staff to adequately visualize the skin. The RN/S stated that she believed the resident was admitted on an air mattress due to the resident's condition and risk factors. The RN/S confirmed to the surveyor that there had been no investigation done prior to surveyor inquiry to evaluate if the wounds had been present upon admission and if they were determined to be not present on admission, to determine if they were avoidable or unavoidable. A review of the facility's Investigating Injuries revised December 2016 included that the Administrator will ensure that all injuries are investigated. It also included that if an incident/accident is suspected a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the Administrator and Director of Nursing Services. A review of the facility's Abuse Investigation and Reporting policy revised July 2017 included that the individual conducting the investigation will, at a minimum include a review of the the resident's medical record to determine events leading up to the incident; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; review all events leading up to the alleged incident. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/27/2020 at 11:24 AM, the surveyor observed Resident #53 sitting upright in a wheel chair in his/her room. The resident appeared well nourished. The resident told the surveyor that he/she was a diabetic and needed to follow a specific diet and could not eat foods that had a lot of sugar. The surveyor observed that the resident had snacks on his/her over bed table. The snacks included were a one ounce (oz) package of baked goldfish crackers, a peanut butter and jelly round snack pie in its original sealed packaging, four oz of cranberry juice, and a package of whole grain graham crackers. The resident stated that he/she liked the graham crackers the best and they were the healthiest food option to eat. The surveyor reviewed the medical record for Resident #53. A review of the resident's admission Record face sheet reflected that the resident had diagnoses which included, but were not limited to edema (swelling), type two diabetes mellitus without complications, hyperlipidemia (a high cholesterol), muscle weakness, and difficulty walking. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact with some forgetfulness. A review of the resident's January 2020 electronic Order Summary Report (OSR) reflected a physician's order (PO) dated 10/21/2020 for daily weights. The PO further specified to call for a weight gain greater than three pounds (lbs.) for two consecutive nights related to fluid retention. A review of the resident's January 2020 Weights and Vitals Summary reflected the following weights: On 1/6/2020 the resident's weight was 246 lbs On 1/7/2020 the resident's weight was 258 lbs On 1/8/2020 the resident's weight was 258 lbs. (This reflected a 12 lb, non-significant weight gain for two consecutive days.) A review of the resident's January 2020 ePN did not reflect that the physician was made aware of the residents 12 lb weight gain. A review of the resident's undated comprehensive care plan reflected a focus area for nutrition related to the fact the resident was noted with a trending weight gain. The goal specified that the resident would not experience a significant change in weight through the next review date and to consume appropriate foods and fluids to maintain nutritional status. The interventions included daily weights as ordered and to notify the physician and responsible party of significant weight changes. On 1/29/2020 at 11:39 AM, the surveyor interviewed the resident's Registered Dietician (RD) who stated that the resident had a PO for daily weights related to swelling and fluid retention of the resident's bilateral lower extremities. The RD further stated that the resident had a PO, and if there was a weight gain of three or more pounds, the nurse was to notify the resident's primary physician. The RD stated that she was aware that the resident had more than a three pound weight gain, so she made recommendations to notify the physician. The RD told the surveyor that she or the nursing staff would be responsible for notifying the physician of the resident's weight gain. The RD was unsure if the physician was notified when the resident had a weight gain. She stated that she would have to follow-up. On 1/29/2020 at 11:56 AM, the surveyor interviewed the resident's LPN who stated that the resident was weighed daily related to a history of fluid retention. The LPN stated that if there was a weight discrepancy of five lbs or more the physician should be notified. The LPN did not know if the physician was notified of the resident's 12 lbs weight gain. On 1/29/2020 at 12:41 PM, the surveyor interviewed the RN/UM who stated that if the staff noticed a discrepancy in a resident's weight, the resident would be re-weighed to determine the accuracy of the weight. The RN/UM stated that the physician would also be notified. On 1/30/2020 at 11:15 AM, the RD/Licensed Nursing Home Administrator (RD/LNHA) stated that there was no documentation that the resident's physician was notified of the resident's weight gain. The RD/LNHA stated that the staff failed to notify the physician, and that they should have in accordance with the physician's order. A review of the facility's Change in a Resident's Condition or Status Policy dated 5/2017 included, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an) i. specific instruction to notify the Physician of changes in the resident's condition. Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) address a recommendation made by a wound consultant, b.) notify a physician in accordance with a physician order for a resident who had a three pound weight gain in two days, and c.) ensure the treatment administration record was signed in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 18 residents reviewed for standards of practice (Resident #3, #6, and #53). 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 casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On 1/28/2020 at 9:32 AM, the surveyor observed Resident #6 sitting upright on a seat cushion in a wheelchair in the activity room. There was a private aide sitting with the resident. The surveyor observed that the resident was alert and oriented to name only, and was unable to answer the surveyors questions. The private aide stated to the surveyor that the resident had a history of dementia, and that she assisted in providing activities of daily living for the resident. The private aide told the surveyor that the resident's skin was intact. On 1/26/2020 at 11:54 AM, 1/27/2020 at 9:45 AM, and 1/29/2020 at 11:15 AM, the surveyor observed the resident's assigned room, which was vacant at the time. The surveyor observed that the resident had a pressure relieving mattress, that was not a low air-loss mattress. The surveyor reviewed the medical record for Resident #6. A review of the admission Record face sheet (an admission summary) reflected that the resident was recently admitted to the facility and had diagnoses which included dementia with behavioral disturbances, and presence of an artificial hip joint. The surveyor attempted to review the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, but the resident was admitted to the facility less than 14 days ago. A review of the resident's individualized care plan dated 1/11/2020, included that the resident had actual skin breakdown to the sacrum (the area near the tailbone) with interventions that included to consult the wound specialist as needed. The care plan did not address the resident's mattress. A review of wound consultant initial Visit Report dated 1/14/2020 indicated that the resident had was admitted to the facility with a stage III (full thickness tissue loss) pressure ulcer to the sacrum that measured 2.7 centimeters (cm) x 1 cm x 0.2 cm and had a moderate amount of serous (clear) drainage, and 10% slough (dead tissue). Recommendations included a new treatment order and a low air loss mattress needed. A review of a Skin Note written by the Registered Nurse/Unit Manager dated 1/14/2020 at 6:43 PM indicated that the resident was seen by the wound consultant/ Nurse Practitioner (NP) and the resident had a stage III sacral pressure ulcer. The note included that a new treatment order in place .Care plan and orders reviewed and updated accordingly. Will continue to monitor. The note did not address the recommendation regarding the low air loss mattress. A review of the physician's orders sheet for January 2020 did not reflect evidence for a physician's order for a low air loss mattress. A further review of the electronic Progress Notes (ePN) for January 2020 did not reflect documented evidence to address the wound consultant's recommendation dated 1/14/2020 for a low air-loss mattress. On 1/29/2020 at 11:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #6. The LPN stated that the resident was confused, dependent on staff for care, and was admitted to the facility with a stage III pressure ulcer to the sacrum. The LPN further added that the resident was admitted to the facility for rehabilitation following a new hip replacement. The LPN confirmed that the resident did not have a low air-loss mattress on the bed, and stated that the resident should have one, because a resident with a stage 3 or 4 pressure ulcer should have a low air loss mattress. The LPN added that air mattresses are usually received within a day or two of when they are ordered. The LPN further stated that she doesn't review the recommendations made by the wound consultant but that the Registered Nurse/Unit Manager (RN/UM) reviews them, and she calls the physician for the orders. On 1/29/2020 at 11:35 AM, the surveyor interviewed the RN/UM who confirmed that she does wound rounds with the wound consultant/NP. She added that she reviews all recommendations made by the NP and obtains a physician's order to implement them. The RN/UM stated that residents that have a stage 3 or 4 pressure ulcer should have a low air-loss mattress to aid in the healing of the pressure ulcer. The RN/UM confirmed the resident was admitted to the facility with a stage III pressure ulcer to the sacrum. The RN/UM was not sure if the resident had a low air loss mattress. The surveyor showed the RN/UM the recommendation by the wound consultant/NP that a low air loss mattress needed. The RN/UM stated that she didn't recall the recommendation and wasn't aware of it. The RN/UM indicated that the recommendation may have been missed, and she couldn't speak to it any further. On 1/29/20 at 12:47 PM, the surveyor interviewed the wound consultant/NP who stated that Resident #6 was admitted with a stage III pressure ulcer to the sacrum and acknowledged that she usually recommends low air loss mattresses for a stage III pressure ulcer, especially if a resident was cognitively impaired and wouldn't have the cognitive capacity to remember to turn. The NP could not recall if she had seen one in place for the resident during the most recent subsequent visit. The NP stated that usually when she recommends the air mattresses, they are implemented very quickly. She could not speak to why there would be no air mattress for the resident at that time. On 1/30/2020 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated that the resident's low air loss mattress was reviewed for appropriateness, but due to the fact the resident was status-post new hip replacement, an air mattress was contraindicated. The DON stated that this contraindication should have been documented within the electronic Progress Notes in accordance with professional standards of nursing practice. The DON acknowledged that the LPN, RN/UM, and the wound consultant/NP were not aware of the contraindication for the resident's recommended low air loss mattress. 3. On 1/26/2020 at 9:41 AM, the surveyor interviewed the RN/Supervisor who stated that he was not sure of residents on the unit with pressure ulcers and would have to check with the DON. At that time, the DON stated that Resident #3 had a facility-acquired pressure ulcer. On 1/27/2020 at 9:57 AM, the surveyor observed Resident #3 lying in bed in an upright position on a low air loss mattress. The surveyor interviewed the resident who stated that the nursing staff came into his/her room all the time and provided the care needed. The resident could not elaborate further concerning his/her skin condition or treatments. On 1/28/2020 at 10:32 AM, the surveyor interviewed the CNA who stated that she had provided care to Resident #3 and the resident had a wound on the buttock area. The CNA added that the nurses took care of the wound area. On 1/29/2020 at 9:20 AM, the surveyor interviewed the LPN who stated that Resident #3 had a pressure ulcer on the sacral (tailbone) area and had provided treatments to the pressure ulcer according to the physician's orders signed on the electronic treatment administration record (eTAR). The LPN could not speak to the stage (phase of the wound healing process) of the pressure ulcer but knew that the wound consultant had seen the resident on 1/28/20. The LPN added that the RN/UM had a wound book which outlined the stage and treatment of each resident who had a wound or a pressure ulcer. On 1/29/20 at 9:42 AM, the surveyor with the RN/UM reviewed the pressure ulcer records regarding Resident #3. The RN/UM stated that the resident had several hospitalizations and the pressure ulcer was improving. The RN/UM added that the wound consultant had seen the resident on 1/28/2020 and the treatment that was ordered by the physician on 1/7/20 was going to continue. The surveyor reviewed the medical record for Resident #3. A review of the admission Record face sheet reflected that the resident was recently admitted to the facility with diagnoses which included a pressure ulcer of the left buttock, stage two (2), traumatic brain injury and somnolence (excess sleepiness). A review of the quarterly MDS dated [DATE], reflected the resident had a BIMS score of 10 out of 15, indicating that the resident had a moderately impaired cognition. In addition, the section M for Skin Conditions reflected that the resident's skin condition had an unhealed pressure ulcer at a stage three (3). A review of the current Order Summary Report reflected a physician's order (PO) dated 1/7/20 to Cleanse coccyx (bony portion at the base of the spine) wound with normal saline, pat dry, apply collagen powder (a medication that promotes wound healing) then calcium alginate (an absorbent dressing that promotes wound healing) and cover with a foam dressing every day shift. A review of the current electronic medication treatment record (eTAR) reflected the administration of the PO wound treatment to the resident from 1/7/20 to 1/29/20. According to the eTAR, there was no documentation that the treatment was administered on 1/8/20, 1/9/20, 1/14/20 and 1/22/20. On 1/29/2020 at 10:23 AM, the surveyor with the LPN reviewed the eTAR for January 2020 for the resident. The LPN stated that when she does the treatment she then signs the eTAR after completing the treatment. The LPN added that there were days that an extra nurse worked and that nurse would complete the wound treatments for the floor. The LPN also stated that whoever does the treatment should sign the eTAR when the treatment was completed. The LPN could not speak to the blanks for the administration of the wound treatment on 1/8, 1/9, 1/14 and 1/22. On 1/30/2020 at 10:34 AM, the survey team met with the LNHA and the DON. The DON stated that she had checked with the nurses responsible for administering the wound treatment to Resident #3 and the wound treatment was completed but the nurses had not signed the eTAR for 1/8, 1/9, 1/14 and 1/22. The DON stated that the nurse who administers the treatment must sign the eTAR after the treatment was completed in accordance with professional standards of nursing practice. NJAC 8:39- 11.2(b), 35.2(g)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident who was dependent on staff for activities of daily living was provided nail care consistent with his/her needs and preferences. This deficient practice was identified for 1 of 5 residents reviewed for activities of daily living (Resident #51), and was evidenced by the following: On 1/26/2020 at 10:04 AM, the surveyor observed Resident #51 in an upright position in bed. The resident's breakfast tray was located on the tray table to the right of the resident's bed. The resident pointed at the surveyor and stated that he/she had spilled his/her coffee and needed a new cup. The surveyor observed a white thick food-like substance on the resident's thumb. The surveyor observed that all 10 of the resident's fingernails were long with a black colored substance underneath the nails. On 1/28/2020 at 9:38 AM, the surveyor observed the resident in bed. The resident's fingernails were long with a blackish substance underneath the nails. The surveyor asked the resident about the length of his/her nails. The resident stated that his/her fingernails were cut. The surveyor asked how often his/her nails got cut and the resident stated his/her age incorrectly, and that his/her fingernails no longer grew. The surveyor reviewed the medical record for Resident #51. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included unspecified psychosis, delusional disorder, abnormal posture, and generalized muscle weakness. A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/31/19 reflected that the resident had a brief interview for mental status (BIMS) score of 12 out of 15 which indicated a moderately impaired cognition. A further review of the MDS, Section G for Functional Status reflected that the resident required a one-person extensive physical assist for personal hygiene. A review of the resident's individualized care plan dated 10/15/18 included that the resident had an activities of daily living (ADL) self-care performance deficit related to physical limitations. Interventions included for one person assist with ADL's and to assist with daily hygiene, grooming, dressing, oral care, and eating as needed. The care plan did not specifically address nail care. A review of the resident's electronic Certified Nursing Aide (CNA) [NAME], a communication tool used by CNA's with specific resident care needs and preferences, included under eating/nutrition to check hands/nails and offer to wash if visibly soiled. There was no evidence of when that intervention was initiated. On 1/29/2020 at 9:20 AM, the surveyor interviewed the resident's CNA who stated that nail care was done when she had time or the resident's fingernails were too long. The CNA continued that if the fingernail was passed the nail bed, then the fingernail would be cut or filed down. The CNA stated that she soaked the resident's hands in water and cleaned under the fingernails usually one to two times a week, only if she had time to do it. The CNA stated that there was no tracking or accountability for nail care. The CNA stated that the resident had not refused nail care in the past. At 10:19 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the CNA performed care on the resident. The LPN stated that she was not aware that the resident refused showers or personal hygiene care. The LPN stated at times, the resident became angry and would demand staff get out of his/her room. When the resident calmed down, staff would be able to return to the room and continue with that task. At 11:39 AM, the surveyor observed the CNA and the resident in the resident's room. The CNA assisted the resident with the lunch meal setup. The surveyor observed the resident pick up a piece of bread and observed the resident's fingernails were long and beyond the nail bed, with a blackish substance underneath. At this time, the surveyor stepped out of the room with the CNA. The CNA confirmed that the resident's fingernails were long and had a blackish substance underneath the nails. The CNA stated that the fingernails should be cut and cleaned and she would do that today. The CNA was unable to recall the last time she performed nail care on the resident. On 1/30/2020, the Director of Nursing (DON) stated, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, that cleaning underneath the fingernails should be performed daily with care. The LNHA stated that staff were in-serviced yesterday on nail care. The DON acknowledged that there was no accountability system for nail care. A review of the facility's Fingernails/Toenails, Care of policy dated revised February 2018, included that nail care includes daily cleaning and regular trimming. NJ 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/27/2020 at 11:24 AM, the surveyor observed Resident #53 sitting upright in a wheelchair in his/her room. The surveyor observed that the resident had a low-air loss mattress. The resident told the surveyor that he/she had a sore on his/her bottom that occurred at the facility and the nurses performed a treatment to it every day. On 1/29/2020 at 10:50 AM to 11:35 AM, the surveyor observed a LPN with the assistance of the RN/UM, perform a wound treatment to Resident #53's right buttock wound. Prior to performing the wound dressing change to the resident's right buttock area, the LPN reviewed the Physician's Order (PO) with the surveyor. The LPN told the surveyor that she was going to cleanse the Moisture Associated Skin Damage (MASD) (moisture rash) with normal saline, apply a Xeroform petroleum gauze (a sterile wound dressing that does not stick to the area and is comfortable and soothing to the skin), and then cover with a foam dressing. The surveyor observed the resident positioned on his/her right side. The surveyor observed a white border dressing attached to the resident's right buttocks. The dressing was observed to be smaller than the affected area on the resident's right buttocks and did not completely cover the MASD on the resident's right buttocks. The surveyor further observed that the dressing was not dated, timed, and there were no initials on it. At 11:20 AM, the LPN removed the dressing attached to the resident's right buttocks. The surveyor observed that when the LPN removed the white border dressing, there was no Xeroform petroleum gauze attached to the resident's right buttocks or the white border dressing. The surveyor asked the LPN to describe what the wound looked like to the surveyor. The LPN stated that the wound was MASD, had irregular borders, was linear in length and consisted of granulation (new connective tissue) tissue. The surveyor asked the LPN to look at the dressing she had just removed from the resident's right buttocks and describe what the drainage looked like. The LPN stated that there was a moderate amount of serous (clear) drainage on the dressing. The surveyor reviewed the medical records for Resident #53. A review of the resident's admission Record record face sheet reflected that the resident had diagnoses which included, but were not limited to edema (swelling), type two diabetes mellitus without complications, peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), muscle weakness, and difficulty walking. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact with some forgetfulness. A review of the resident's January 2020 Order Summary Report (OSR) reflected a PO dated 1/14/2020 to cleanse the right buttocks with normal saline, pat dry, apply Xeroform Petroleum 4 x 4 pad, and cover with a foam dressing daily for MASD. A review of the resident's undated comprehensive care plan reflected a focus area that the resident had actual skin breakdown on the right buttocks related to MASD. The goal reflected that that resident's right buttocks would heal without complications. The interventions included to administer a treatment in accordance with physician's orders and provide follow-up care with the physician as ordered. On 1/29/2020 at 11:56 AM, the surveyor interviewed the resident's LPN who stated that the resident was alert and oriented and could make their needs known. The LPN stated that the resident was incontinent of urine at times and needed assistance with repositioning in bed. The surveyor explained to the LPN the observations made during the wound care treatment. The surveyor asked about the dressing she removed from the resident's right buttock which was small, didn't cover the affected area, was undated/timed, and there was no Xeroform petroleum gauze to the resident's right buttocks or on the border dressing when removed. The LPN responded, You're right. I noticed that too when I took off the dressing. The LPN stated that the wound care nurse came to the facility on 1/28/2020 so she wasn't sure who performed the treatment to the resident's right buttocks the day before because she did not. She could not speak to if the dressing was changed during an incontinence episode either. On 1/29/2020 at 12:41 PM, the surveyor interviewed the RN/UM who stated that she noticed when the LPN removed the dressing to the resident's right buttocks it was the incorrect wound treatment and did not correspond with the physician's order. The RN/UM further stated that she was the nurse who performed the correct wound treatment to the resident's right buttocks with the wound care physician the day before at approximately 5:00 PM. The RN/UM further stated that a nurse working the 3:00 PM to 11:00 PM or the 11:00 PM to 7:00 AM nurse must have incorrectly applied the treatment to the resident during incontinence care and she would have to conduct an investigation as to what exactly happened. On 1/30/20 at 11:39 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident was provided incontinence care during the 11:00 PM to 7:00 AM shift at which time the resident's dressing became soiled and the nurse applied an incorrect treatment to the resident's right buttocks. This was not reflected in the eTAR or the progress notes. A review of the facility's policy for Skin Tears, Abrasions and Minor Breaks in the skin revised September 2013 included to Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record .assemble the equipment and supplies as needed. 4. On 1/27/2020 between 10:30 AM and 12:00 PM during tour of the building in the presence of the Maintenance Director, the surveyor observed 2 of 5 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with air mattresses. The residents were observed to be in bed on top of their respective air mattresses. The surveyor observed that the air mattresses were making a slight hissing sound. Upon closer inspection, the PSI gaskets in the respective rooms had an air leak producing a continuous air flow in an attempt to keep the mattress inflated to their settings. The surveyor could palpate the air. The Maintenance Director confirmed to the surveyor that the air mattresses needed a new O-ring to prevent leaking and hissing of the air. The surveyor observed that despite the air leaking from the site of the O-ring, the resident's air mattresses were not currently deflated. NJAC 8:39-27.1(a) Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) accurately assess the skin and obtain a physician order for wound treatments for a newly admitted resident with pressure ulcers for two days, b.) appropriately apply a moisture barrier cream to prevent skin breakdown during an incontinence care observation, c.) apply a wound treatment in accordance with a physician's order, and d.) maintain the proper functioning of two low-air loss mattresses used for skin protection. This deficient practice was identified for 3 of 5 residents reviewed with pressure ulcers (Resident #40, #53, and #166). The evidence was as followed: 1. On 1/27/2020 at 10:42 AM, the surveyor observed Resident #40 in bed and lying on a low air-loss mattress with the head of the bed slightly elevated. There was an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) secured to the resident's bed frame with the collection bag in a blue privacy cover. The catheter was draining clear yellow urine. At that time, the resident wouldn't speak specifically to the surveyor's inquiry. The resident was unsure if he/she had any wounds that the nurse was treating. On 1/28/20 at 9:54 AM, the surveyor observed the Certified Nursing Aide (CNA) in the resident's room preparing to provide morning care to Resident #40. At that time in the presence of the CNA, the surveyor asked the resident's permission to observe morning care with the CNA, and the resident refused. The surveyor then exited the resident's room to allow the CNA to continue with the care. The surveyor reviewed the medical record for Resident #40. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses which included sepsis (a systemic infection), morbid obesity, and necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin). A review of the hospital records printed on 12/18/19 reflected that the resident had an extended hospitalization for acute respiratory failure, sepsis, and necrotizing fasciitis with complications including a right lower leg blood clot. The hospital records reflected that the resident had a right gluteal fold ulcerating wound which was proximal to the posterior thigh and measured 3.5 centimeters (cm) x 4 cm, and that there was another small ulceration to the inferior aspect of this ulceration. The hospital records reflected that the resident had multiple wounds to the right gluteal fold/sacral (tailbone) area, and that the resident had an indwelling urinary catheter to promote wound healing due to the multiple wounds and bowel incontinence. The hospital records did not include documented evidence of wound staging (used to determine depth and severity). A review of the Universal Transfer Form (UTF) (a communication tool to summarize transfer information) dated 12/24/19 indicated that the resident had a right groin wound (necrotizing fasciitis) but no other pressure ulcers or ulcerations. A review of the electronic Progress Notes (ePN) dated upon admission on [DATE] at 11:38 PM included that the resident was admitted with current skin breakdown/skin conditions: refer to the completed evaluation and physician orders for type and location. A review of the Resident Evaluation/initial nursing admission assessment dated [DATE] included that the resident had an indwelling urinary catheter for the contamination of a stage 3 or 4 pressure ulcer with urine, and that the resident had a front right thigh stage III wound that was 20 centimeters (cm) long and extended in the right inner thigh. Under the Skin Evaluation section, the space to record additional observations/comments was blank. There was no documented evidence of additional pressure ulcers or gluteal ulcerations present upon admission. A review of the physician's orders sheet with a start date of 12/25/19 included a physician order (PO) to cleanse the right leg thigh wound with normal saline solution, pack with gauze and cover with a dry dressing every shift. There was no documented evidence of a physician order for a treatment to wounds to the gluteal region. A review of the electronic Treatment Administration Record (eTAR) for December 2019 included the PO dated 12/25/19 for the right leg wound, but there was no documented evidence upon admission for the accountability for a wound dressing or treatment to gluteal ulcerations for the dates of 12/24/19, 12/25/19 or 12/26/19. A review of the subsequent ePN's dated 12/25/19 and 12/26/19 did not reflect documented evidence to address the gluteal ulcerations or a treatment to those areas. A review of a ePN dated three days after admission on [DATE] at 4:30 PM, reflected that the Registered Nurse/Unit Manager documented that Resident #40 was admitted on [DATE] with wounds to right buttock, left buttock, and right leg with wound care treatment orders as follows: cleanse right buttock with NSS [normal saline solution], pat dry, and apply a wet to dry dressing daily; cleanse left buttock with NSS, pat dry, apply xeroform, and cover with a dry dressing daily . The RN/UM then documented at 5:10 PM that day that the left buttock wound was a stage II (partial thickness tissue loss) pressure ulcer measuring 1.5 cm x 1.5 cm x 0.2 cm with moderate serous drainage. She documented the right buttock was a stage II ulcer that measured 2.0 cm x 1.5 cm x 0.2 cm with moderate serous drainage. (This was the first time the gluteal ulcerations were addressed). There was no documented evidence for the identification or a treatment order for the buttock wounds on 12/24/19, 12/25/19 and 12/26/19 upon admission to the facility. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/31/19 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating a moderate to severe cognitive impairment. The assessment further included that the resident was admitted with two stage III (full thickness tissue loss) pressure ulcers. A review of the wound consultant initial Visit Report dated 12/31/19 reflected that the resident had a right thigh wound, in addition to a right and left gluteal fold stage III (full thickness tissue loss) pressure ulcers. The right gluteal fold measured 1 cm x 1 cm x 0.2 cm and had moderate serous (clear) drainage and the left gluteal fold measured 1.5 cm x 2 cm x 0.2 cm and also had moderate serous drainage. The wound consultant/Nurse Practitioner (NP) indicated that the stage III pressure ulcers had 100% granulation tissue (indicating signs of healing) and recommended to apply medihoney (a debriding ointment), calcium alginate (an absorbent dressing), and cover the wounds with a foam dressing daily. On 1/28/20 at 11:20 AM, the surveyor interviewed the RN/UM who had documented three days after admission that the resident was admitted with two stage II pressure ulcers on the right and left gluteal folds. The surveyor asked the RN/UM about the note she wrote on 12/27/19, and the RN/UM stated that the resident was admitted on [DATE] and that usually she does a skin check on new admissions. She stated that she did a skin check on 12/27/19 and saw the wounds, and she reviewed the hospital records and saw that the resident had skin breakdown while at the hospital. She confirmed the hospital records did not include what stage the gluteal wounds were, so she could not speak to if the gluteal wounds had improved, stayed the same, or worsened since admission. The RN/UM confirmed that the UTF reflected that the resident did not have a stageable pressure ulcer, and she suggested maybe it was an error by the transferring hospital. The RN/UM acknowledged that the admission Resident Evaluation assessment dated [DATE] did not address the gluteal pressure ulcers or that Resident #40 had any behaviors that would have limited staff's ability to inspect the resident's skin. The RN/UM stated that upon admission, the LPN's are expected to perform a head-to-toe skin assessment and document the findings within the resident's medical record. The RN/UM stated that she documented that the resident came to the facility with the wounds. The surveyor asked if she spoke to the Licensed Practical Nurse (LPN) who performed the admission assessment, or if the CNA's who had performed incontinence care had observed the presence of the wounds, and the RN/UM stated that she had not spoken to those staff prior to writing her note, and that she had just assumed that it had been there based solely on the hospital record. She confirmed the hospital records were vague in the assessment stage of the gluteal ulcerations. She acknowledged that the wound consultant/NP documented the wounds as stage III pressure ulcers on 12/31/19. The RN/UM stated that she had brought this situation up to the the Director of Nursing (DON) on 12/27/19. The RN/UM confirmed there was no physician order for the treatment to the stage II or stage III gluteal fold wounds on 12/25/19 and 12/26/19. The RN/UM could not speak to if the wounds had reopened. The RN/UM stated that she did not perform an investigation but that the surveyor could ask the DON. On 1/28/20 at 11:46 AM, the surveyor interviewed the CNA who stated that she was always the CNA assigned to care for Resident #40 since admission, and that she worked full time during the day shift (7 AM to 3 PM). The CNA stated that the resident was always cooperative with care for her, and that he/she was incontinent of bowel and had a bowel movement this morning. The CNA stated that the resident came in to the facility with wounds to the buttocks, and that he/she always had a treatment over top of the buttock wounds that she could recall, even on Christmas day when she worked. On 1/28/20 at 12:04 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse who stated her primary full time role was to complete the MDS assessments for each resident in the building. The MDS Coordinator stated that she does not directly observe skin during her assessments, but that she relies on the initial nursing Resident Evaluation assessment done on admission and the wound flow sheets which reflect if the wounds were present upon admission. At that time, the MDS Coordinator/RN provided the surveyor a copy of the Pressure Injury Record for the right and left buttock gluteal fold ulcerations with dates of origin identified as 12/24/19. The boxes were checked that the resident was admitted with these wounds. The MDS Coordinator stated that she relies on the accuracy of the wound flow sheets when completing the MDS assessments, to determine if the resident was admitted with the wounds or if a wound was facility-acquired. She stated that since the flow sheet indicated that the resident was admitted with the gluteal pressure ulcers, then she documented in the MDS dated [DATE] that the resident came with the wounds. On 1/28/2020 at 2:27 PM, the surveyor interviewed the full time Registered Dietician (RD), who stated that Resident #40 had some dementia, keeps snacks in the room, and that the resident gets added protein with medication pass due to multiple wounds. The RD stated that she completed an initial assessment on 12/27/19 and when a resident is forgetful or an unreliable historian, she relies on the admission nursing assessment/Resident Evaluation to be accurate when reviewing skin conditions to determine if she should make recommendations for vitamins or supplements to aid in wound healing. She acknowledged that her initial evaluation on 12/27/19 did not reflect the gluteal pressure ulcers because it was not in the Resident Evaluation dated 12/24/19. She stated that she knew the resident had a right thigh wound and had made recommendations based on that wound to promote wound healing through nutritional means. She added that she also recommended labs to determine nutritional status which were done. The RD stated she adjusted the resident's nutritional plan after the pre-albumin lab (lab used to determine recent nutrition status) came back slightly low 14 (normal is 17-34) collected on 12/31/19. On 1/28/2020 at 1:16 PM in the presence of the survey team, the DON stated that there was no investigation conducted for the gluteal pressure ulcers. On 1/29/20 at 10:44 AM, the surveyor interviewed the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that she spoke to the admitting LPN who told her that the resident refused to turn on the side to do a full skin inspection, and therefore the skin could not be adequately visualized. The DON stated that if a resident refuses to turn for the admission assessment, that the physician should be notified when obtaining orders, and it should get reported on the 24 hour report to check the skin at the next incontinence care change or at the next most convenient time when the resident was getting up, such as for physical therapy. The DON acknowledged that she did not get statements from the CNA's or nurses who cared for the resident on 12/24/19, 12/25/19 and 12/26/19 to see if wounds were identified during incontinence care, and if so, did they report the wounds to the nurse or the supervisor, because there had been no treatment order in place one those dates. The DON acknowledged that there was no treatment order in place on 12/25/19 and 12/26/19 to the two gluteal stage III pressure ulcers. The DON stated that the resident was admitted with the wounds and that as of yesterday 1/28/2020, the right and left gluteal pressure ulcers wounds had both healed. The DON and LNHA were unable to provide documented evidence from the hospital as to what stage the gluteal pressure ulcers were upon admission to the facility. On 1/29/2020 at 12:32 PM, the surveyor conducted a phone interview with the wound consultant/Nurse Practitioner (NP) who stated that she started consulting with the facility in April or May of 2019. The NP stated that she makes wound rounds every Tuesday. The NP added that Resident #40 had a large surgical right thigh wound with necrotizing fasciitis and two pressure ulcers to the gluteal region that she believed were present on admission. The NP stated that the resident had been on an air mattress every since she started seeing the resident (12/31/19), otherwise she would have recommended one. The NP stated that she doesn't document where the wounds are acquired but that the RN/UM tells her, and that she makes recommendations based on that information provided. The NP stated that when she made rounds yesterday on 1/28/2020, both gluteal ulcers were healed, and that she just recommended a barrier cream to the buttocks for skin protection. On 1/29/2020 at 12:02 PM, the surveyor attempted to conduct a phone interview with the LPN who admitted the resident on 12/24/19. The LPN did not answer the phone nor return the surveyor's request for a return call. On 1/30/2020 at 12:36 PM, the surveyor conducted a phone interview with the Registered Nurse/Supervisor (RN/S) for the evening shift of 12/24/19. The RN/S stated that she went into the resident's room with the LPN that evening to assess the resident's skin but the resident was refusing to be turned to fully check the skin, even with family attempting to encourage the resident to turn. The RN/S stated that she believed there were open areas to the buttocks due to the fact the resident had an indwelling urinary catheter from the hospital, and that the hospital records reflected evidence of a history of wounds to the buttocks and sacrum. She stated that she did not recall communicating with anyone (nurse or physician) that the resident's skin was not fully assessed due to his/her refusal to turn in bed to adequately visualize the skin. The RN/S stated that she believed the resident was admitted on an air mattress due to the resident's condition and risk factors. The RN/S confirmed to the surveyor that there had been no investigation done prior to surveyor inquiry to evaluate why there had been no treatment in place to the gluteal ulcerations for two full days when the resident allegedly was admitted with two stage III pressure ulcers. 2. On 1/27/20 at 10:58 AM, the surveyor observed Resident #166 in bed with the resident's family representative at the bedside. A CNA (CNA #1) and Occupational Therapist (OT) were in the resident's room, and CNA #1 was preparing to turn the resident to the left side to perform incontinence care. At that time, the surveyor observed CNA #1 and OT turn the resident and remove an incontinent brief soiled with a moderately sized loose bowel movement (BM). CNA #1 removed the BM from the resident's skin using a terry cloth towel and with each long motion of the cloth against the raw reddened skin, the resident flinched forward, saying It hurts. The surveyor and CNA #1 observed the resident's peri-rectal area which was bright pink and raw in appearance, but the skin was intact. The sacral (tailbone) area had a large bright reddened area about the size of a softball. There was no evidence of residual barrier cream or zinc oxide ointment observed on the skin. At that time, CNA #1 stated to the surveyor that this was the first time that she has worked with Resident #166. The resident was not assigned to her, she was just covering for the resident's assigned CNA #2 who was assisting with another resident at that time. CNA #1 stated that the resident's skin was very reddened and didn't know what the redness was from. At that time, the CNA #1 removed personal protective equipment (PPE), washed her hands and told the surveyor that she wanted to get a nurse to assess the resident's raw, reddened skin. At 11:09 AM, the surveyor observed the resident's assigned CNA #2 apply PPE and enter the resident's room with LPN #1. LPN #1 introduced herself stating that she was not the resident's assigned LPN today, but that she would assess the resident's skin. At that time CNA #2 stated to the surveyor that she performed morning care for Resident #166 before 8:00 AM. She stated that the resident had a formed bowel movement this morning and that she hadn't yet been back until now. CNA #2 confirmed it had been three hours since she was last checked for an incontinence episode. At that time, the CNA #2 secured the new incontinent brief and pulled up the resident's pants without applying a barrier cream, and before the LPN #1 could inspect the skin. At 11:14 AM, LPN #1 stated she needed to assess the resident's skin. At that time, LPN #1 and CNA #2 removed the incontinence brief to inspect the skin. LPN #1 just looked at the area without touching and stated, it's reddened so [Resident #166] needs to get barrier cream to the area. LPN #1 stated that the resident was not assigned to her but that she believed the resident had an order for a barrier cream to protect the skin. At that time, the LPN #1 removed the PPE and washed her hands and exited the room to get barrier cream. LPN #1 stated there was no barrier cream in the room and that barrier cream was not kept in individual resident rooms, only the treatment cart. The LPN #1 returned to the resident's room with LPN #2 who was assigned to care for the resident. Wearing a gown and gloves, LPN #2 came into the room with a medicine cup filled with barrier cream and handed it to LPN #1 to apply. LPN #2 stood by the doorway while LPN #1 and CNA #2 went over to the resident to apply the barrier cream. LPN #1 then applied a thick layer of barrier cream to the bright reddened area on the sacrum using a tongue blade. She did not apply barrier cream to any other areas of the resident's perineal area or pinkened raw areas of the peri-rectal region. She then secured the resident's incontinent brief and CNA #2 assisted in adjusting the resident's pants and repositioning the resident. The facility staff then obtained a mechanical lift to transfer the resident into a chair. At 11:30 AM, the surveyor interviewed LPN #1 who stated that she just applied the barrier cream only to the reddened area. The surveyor asked what the reddened area was, and she stated stated it is a non-blanchable redness and thinks it might be from pressure. The surveyor asked LPN #1 how she knew it was non-blanchable (a condition of the skin that remains red when pressed, typically indicative of a stage I pressure ulcer) and LPN #1 could not speak to it, as the surveyor did not observe LPN #1 press or palpate the area. LPN #1 stated that the wound team came every Tuesday (tomorrow) to evaluate wounds, and that they would be able to better evaluate what the redness was. She stated that in the mean time, the barrier cream would protect the area. She didn't speak about protecting the rest of the perineal area from incontinence episodes when asked. At approximately 11:32 AM, the surveyor interviewed LPN #2 who stated that Resident #166 was on transmission based precautions for infectious diarrhea and was currently only on an antibiotic to treat it since admission to the facility. LPN #2 stated the resident had a bowel movement this morning when the CNA #2 changed her. LPN #2 acknowledged that she had not done an incontinence check between when CNA #2 had last been in the room at the beginning of the shift until now at 11:00 AM. LPN #2 confirmed it was approximately three hours since the resident had last been checked. She couldn't speak to how often a resident with infectious diarrhea should be checked for incontinence episodes for the purpose of protection of the skin. At approximately 11:35 AM, the surveyor interviewed CNA #2 who stated that she keeps the residents skin protected by applying a moisturizing lotions to her body when she does care, including the buttocks area. She stated she applied lotion to the resident this morning. The surveyor asked where the lotion was kept, the CNA #2 stated that it was kept at the bedside. The CNA #2 acknowledged that barrier cream that the nurse applied today was not kept at the bedside, and that nurses apply the barrier cream. The surveyor reviewed the medical record for Resident #166. A review of the admission Record reflected that the resident was recently admitted to the facility with diagnoses which included dementia, hemiplegia and hemiparesis (weakness to one side of the body) due to a stroke, and Clostridioides Difficile infection (CDI, formerly called Clostridium Difficile) (infectious diarrhea). The surveyor attempted to review the admission MDS, but the resident was admitted less than 14 days ago. A review of the resident's individualized care plan initiated on 1/22/2020 included that the resident was admitted with a risk for alteration in skin integrity related to impaired mobility. The goal specified, will decrease/minimize skin breakdown risks. Interventions included, to apply Barrier cream to perianal/buttocks as needed. Provide preventative skin care routinely and as needed. (The care plan did not address the resident's bowel incontinence or how often incontinent checks should be performed with a CDI). A review of the CNA kardex (communication tool for CNA's addressing resident-specific needs and preferences) with a print date of 1/23/2020 included toileting and elimination needs. The kardex indicated, Apply barrier cream after incontinence/peri care and as needed (FYI) [For Your Information]. A review of the nursing admission assessment/Resident Evaluation dated 1/21/2020 included that the resident was admitted with excoriation noted to groin and perineal area A review of a physician's order dated 1/22/2020 included to apply a barrier cream to the sacrum after routine cleansing every shift for wound. A review of the electronic Treatment Administration Record (eTAR) for January 2020 revealed that nurses were signing every shift for applying barrier cream to the sacrum every shift (day, evening and night shift) A review of the wound consultant/NP initial Visit Report dated 1/28/2020 included that the resident had a 7 cm x 7 cm stage I pressure injury to the sacral region with non-blanchable redness. The NP recommended zinc oxide barrier cream to continue to the region with each shift change and maintain a turning and repositioning program as per facility protocol. On 1/29/20 at 10:22 AM, the surveyor interviewed a third LPN (LPN #3) who stated that We apply barrier cream every shift and with each incontinence care. LPN #3 stated it should be applied to the sacrum and the entire buttocks area, and not just the reddened area. At approximately 10:30 AM, the surveyor interviewed the RN/UM who stated that barrier cream was to be applied to the peri-area with each incontinent episode and not just on reddened areas. The RN/UM added that the residents are checked every 2-3 hours for incontinence. On 01/29/2020 at 10:34 AM, the surveyor interviewed the DON who stated that incontinence care checks should be done every every 2-3 hours routinely. The surveyor asked if incontinence checks get performed any more frequently for a resident with a CDI, and the DON stated it was dependent on how often the resident was having a bowel movement. The DON could not speak to how often the resident was having BM or if they were loose. The DON stated that the barrier cream w[TRUNCATED]