Complaint NJ#175244 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to notify the resident's representative and physician of a change in condition in a timely manner for one (1) of three (3) residents, (Resident #209), reviewed for accidents. This deficient practice was evidenced by the following: A review of the closed medical record for Resident #209 revealed the resident was admitted to the facility in 2023 and discharged from the facility in 2024. A review of the admission Record (an admission summary) revealed that Resident #209 was admitted to the facility with diagnoses which included but were not limited to: lower back pain, hypertension (high blood pressure), and metabolic encephalopathy (change in how your brain works due to an underlying condition). A review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/16/24, reflected the resident had a Brief Interview for Mental Status (BIMS) of 7 out of 15, which indicated the resident had moderate cognitive impairment. A review of the individualized Care Plan (CP) created 9/11/23, reflected a focus area: resident had impaired cognitive function or impaired thought processes impaired decision making and the interventions included but not limited to: Communicate with the resident/family/caregivers regarding resident's capabilities and needs. A review of the nursing Progress Note (PN) reflected the following: -6/24/24 at 23:48 [11:48 PM], at around 11 PM, pt (patient; also known as resident) came to nurses' station stating, my leg hurts, remember I told you earlier I fell yesterday, pt did not tell writer that the resident had sustained a fall yesterday, nor are there any reports of fall. Pt had noted confusion at times, Writer asked pt where specifically it hurts and pt pointed to right thigh, no noted bruising, medicated as ordered for pain. Further review of the PN dated 6/24/24 revealed that the resident's representative (RR) and the physician were not notified of the incident immediately after the incident. -6/25/24 at 16:20 [4:20 PM], Pt noted crying in pain, when asked what happened, patient stated she fell couple days ago and now their right leg hurts, MD [physician] notified, new orders received for right leg and hip x ray ordered STAT (with no delay or immediately), waiting for results, RR called, no answer, left msg. (message) endorsed to oncoming shift to follow up. A review of the June 2024 Grievance log that was provided by Licensed Nursing Home Administrator (LNHA) did not have a Grievance for Resident #209. During an interview with the surveyor on 9/19/24 at 12:54 PM, in the presence of the survey team, the Licensed Practical Nurse (LPN) stated she did not remember if she had notified the RR of resident's fall on 6/24/24 during her shift and had to read her notes to verify if the RR was notified or not. The LPN further stated, I would typically document when I notify the family of any incidents in PN or in incident report. On 9/19/24 at 01:27 PM, the survey team met with Director of Nursing (DON), LNHA, Assistant Director of Nursing /Infection Preventionist (ADON/IP), and Regional Nurse Consultant Nurse #1 (RNC #1). The surveyor notified the facility management of the above findings and concerns. The DON and LNHA acknowledged that the RR and the physician would be notified immediately of incidents or accidents once the residents were assessed. They further stated, Usually that's our process. A review of the facility's Accidents and Incidents- Investigating and Reporting policy dated 4/2024 revealed: Policy Interpretation and Implementation section: 2g.) The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; h.) The date/time the injured person's family was notified and by whom. On 9/20/24 at 01:15 PM, the survey team met with DON, LNHA, RNC#1, RNC#2, Regional LNHA for an exit conference. There was no additional information was provided. NJAC 8:39-13.1(c)

3. On 9/17/24 at 9:54 AM, the surveyor observed medication (med) administration for Resident #260. The surveyor observed the resident's electronic Medication Administration Record (eMAR) which contained a list of medications (meds) ordered by the resident's attending physician for administration at that time. The eMAR reflected an order for Colace Oral Capsule 100 MG (milligram) (Docusate Sodium), a med used to soften the stool, give 1 capsule by mouth two times a day for constipation. The surveyor observed the Registered Nurse (RN) prepare seven (7) of the resident's meds that were scheduled for administration. The surveyor observed the RN prepare and crush a med obtained from a bottle labeled Docusate Sodium 100 mg Tablets. The surveyor questioned the RN if that med was the correct med and what the physician ordered. The surveyor asked the RN to compare the order on the eMAR to the bottle where the med was obtained. The RN agreed that the order was for capsules and the med she obtained was a tablet. The RN stated that the resident gets their meds crushed in applesauce. The surveyor asked the RN what the procedure is if an order on the eMAR was for a med that cannot be given appropriately to a resident such as not to be crushed. The RN stated that she would call the physician to get the order changed. The surveyor inspected the med cart and observed a bottle that was labeled Docusate Sodium 100 MG Capusles. The surveyor interviewed the 3rd floor Unit Manager (UM) who was present during the observation. The surveyor asked the UM if it was appropriate to give a different dosage form of a med than what was listed on the order. The UM stated no, it should be what was ordered, or the order should be changed. The surveyor reviewed the hybrid medical record for Resident #260 which revealed a PO for Colace Oral Capsule 100 MG (Docusate Sodium) give 1 capsule by mouth two times a day for constipation. On 9/18/24 at 10:15 AM, the surveyor interviewed the Consultant Pharmacist (CP). The surveyor asked the CP if they do med pass observations. The CP stated yes, they do regular med pass observations. The surveyor asked the CP if it is appropriate for a nurse to administer a tablet form of a drug if the capsule form is ordered. The CP stated no, the correct dose form should be given, or the order should be changed. On 9/18/24 at 11:38 AM, the surveyor received a policy from the facility LNHA dated 4/2024 titled Administering Medications. The surveyor reviewed the policy. The policy reflected under Policy heading, Meds are administered in a safe and timely manner, and as prescribed. Under Line 4, Meds are administered in accordance with prescriber orders, including any required time frame. On 9/18/24 at 11:39 AM, the surveyor, in the presence of the survey team, met with the facility administrative team which included the LNHA, DON, RNC#1, and ADON/IP. The surveyor notified the facility management of the med pass results and the concern with the med error. The surveyor requested a recent invoice or packing list for the facility specifically for Colace or Docusate Sodium. On 9/19/24 at 9:54 AM, the DON provided Shipment Pack Lists for the facility with a ship date of 9/09/24. The lists reflected two (2) lines that show Colace Softgels or the generic equivalent (Docusate Sodium capsules) were shipped to the facility. No further pertinent information was provided by the facility. NJAC 8:39-11.2(a)(b); 19.4(a); 27.1(a) 2. On 9/16/24 at 11:50 AM, Resident #78 was observed lying in bed, alert, oriented, and verbally responsive. The resident had an indwelling urinary catheter (a flexible tube left in the bladder used to empty the bladder and collect urine in a drainage bag). The resident verbalized no concerns with their care. The surveyor reviewed the medical record of Resident #358 which revealed the following: The AR documented that the resident had diagnoses that included but were not limited to, urinary tract infection (UTI) and obstructive and reflux uropathy (a disease that affects the urinary and urogenital organs). A CMDS with an ARD of 7/15/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #358 scored a 14 out of 15, which indicated the resident was cognitively intact. A physician's order (PO) dated 8/28/24 read, catheter care every shift. A PO dated 7/08/24 read, foley catheter output every shift. A review of the September 2024 electronic Treatment Administration Record (eTAR) revealed no recorded urine output and low urine output as follows: 9/01/24 on 3-11 shift, the urine output recorded was 100 ml (milliliters). 9/05/24 on 3-11 shift, there was no urine output recorded and the entry was left blank. 9/05/24 on 11-7 shift, the urine output recorded was 150 ml. 9/06/24 on 3-11 shift, there was no urine output recorded and the entry was left blank. 9/07/24 on 7-3 shift, the urine output recorded was 100 ml. 9/09/24 on 3-11 shift, there was no urine output recorded and the entry was left blank. 9/10/24 on 7-3 shift, the urine output recorded was 100 ml. 9/10/24 on 3-11 shift, the urine output recorded was 100 ml. 9/12/24 on 3-11 shift, there was no urine output recorded and the entry was left blank. 9/13/24 on 3-11 shift, the urine output recorded was 150 ml. 9/14/24 on 3-11 shift, the urine output recorded was 100 ml. A review of September 2024 PN revealed there was no documentation of the physician or NP being notified of the resident's episodes of low urine output. Additionally, there was no documentation of what actions were taken for when the resident had low urine output. A care plan (CP) with a focus that read, [Resident #358] has a catheter for obstructive uropathy, renal calculi [kidney stone], status post urethral stent. The CP had an initiation date of 8/28/24. Interventions of the CP included: to monitor and document intake and output as per facility policy; Monitor/record/report to MD for s/sx[signs/symptoms] UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 9/19/24 at 9:45 AM, the surveyor interviewed the ADON/IP about facility protocol for monitoring and documenting urine output. The ADON/IP stated urine output was recorded by the nurses every shift and if urine output less than 30 ml per hour (240 ml per shift) it was considered a low urine output. The ADON/IP further explained if the urine output was low the nurse should assess the resident for abdominal distension, pain and appropriate placement of the urinary catheter; the nurses were to notify the physician; and possibly do a bladder scan if ordered by the physician. The surveyor reviewed with the ADON/IP the concerns found on the September 2024 eTAR. The ADON/IP stated it was expected for nurses to document on the eTAR and not leave entries blank. The ADON/IP stated it would be expected to notify the physician of low urine output and for it to be documented in a note. The ADON/IP could not speak to why there was no nurses PN found by the surveyor. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. The surveyor notified the facility management of the above concerns. The surveyor asked if it would be expected for the nurses to complete their documentation on the eTAR on their scheduled shift and for there to be a nurse PN to indicate actions taken for a resident with low urine output, including notifying the physician. The DON and ADON/IP acknowledged it was expected for nurses to complete their documentation on their shift and a nurses' note to be documented for the resident's low urine output including physician notification. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, RNC#1, and the Regional LNHA. There was no additional information provided by the facility. The surveyor reviewed the undated facility policy titled, Management of the Patient with an Indwelling Catheter. Under Purpose it read: To prevent complications associated with indwelling catheterization. Under Procedure it read, .5. Monitor patient and catheter every 8 hours or more frequently for drainage, grit, color, odor and pain . The policy did not further address the documentation of the resident's urinary output by the nurses or protocol for residents with low urine output. REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that staff monitor and document resident's condition status post (s/p) fall and clarify the neurocheck documentation according to standards of clinical practice for one (1) of three (3) residents, Resident #148, reviewed for accidents, b.) follow the physician's written order and appropriately document urinary catheter output for one (1) of two (2) residents, Resident #358, reviewed for urinary catheters. c.) ensure staff follow the physician's order for one (1) of three (3) nurses, (Registered Nurse), observed during medication administration according to the facility's policies and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey 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. 1. On 9/16/24 at 10:27 AM, the surveyor observed Resident #148 seated on the bed with breakfast in front of the resident. The resident informed the surveyor that they had a previous fall at the facility because the resident forgot to lock the wheelchair (w/c) when they transferred themselves from w/c to bed. The resident further stated that it was the resident's fault, and the resident was unsure if they sustained any injury when the resident fell. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #148 and revealed: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), anemia (low blood count) in chronic kidney disease, unspecified fall subsequent encounter, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The most recent Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 8/29/24, under Section C Cognitive Patterns, reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which reflected that resident was cognitively intact. Section J Health Conditions revealed that the resident had one fall incident with a minor injury. A review of the provided fall incident reports showed the following: -#1848 Fall 8/29/24 incident at around 3:22 PM, the resident hit their head a little bit, skin tear to right and left forearm and elbows, and was sent out to ER (emergency room) for CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) scan of head and evaluation. -#1856 Fall 9/04/24 incident, the resident slid out the w/c and w/c were unlocked. The resident sustained three open areas on the right inner forearm. A review of the Progress Notes (PN) of the Nurse Practitioner (NP) with an effective date of 9/04/24 at 12:26 PM included Seen and examined in room, awake, alert. Pt (patient) is s/p fall this morning. denies any trauma to the head, denies any hip pain. Remains on neurochecks. Further review of the PN revealed that there was no documented evidence from the nurses that the resident was monitored s/p fall from 8/29/24 and 9/4/24 except for the date of the fall. A review of the above fall incidents and hybrid medical records showed that there was no documented evidence that neurocheck (a tool used immediately s/p fall, Neuro check frequency is usually every four hours afterward) was done according to the notes of the NP. On 9/18/24 at 11:39 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the concerns regarding the two fall incidents. On that same date and time, the surveyor asked the facility management what the expectations for the nurses about any fall incidents with regard to documentation and monitoring post-incidents were. The DON stated that it was an expectation to monitor and document in the PN every shift for three days. The surveyor then notified the facility management of the concerns that for Resident #148 two fall incidents that there was no documentation from nurses routinely every shift for three days. On 9/19/24 at 01:26 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. The LNHA stated that when the resident went to the hospital and came back, the doctor did not order the neurocheck. The surveyor then asked the facility management, if the physician did not order neurocheck, and why it was documented in the NP's PN that the resident remained on neurochecks. RNC#1 stated that it should have been clarified. At that same time, the DON stated that we needed to re-educate the nurses with regard to documentation protocol every shift for three days when the resident had an incident or accident. The DON further stated that this concern will also be added to their QAPI (quality assurance performance improvement). A review of the facility's Falls-Clinical Protocol with an updated date of 4/2024 that was provided by the DON showed: Monitoring and Follow-up: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented . On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management.

Complaint #NJ 174669 Based on interview, record review and review of other documents provided by the facility, it was determined that the facility failed to obtain a physician's order for discharge and document the response of an approval or acceptance for the referral of home care/visiting nurse services post discharge to ensure a safe discharge for one (1) of two (2) residents reviewed for discharge (Resident #308). The deficient practice was evidenced by the following: On 9/17/24 at 12:55 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical record for Resident #308 which revealed the following: Resident #308's admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to pressure ulcer of sacral region (a wound that forms when prolonged pressure is applied to the sacrum, tailbone, or lower back), abnormal posture (rigid body movements and chronic abnormal positions of the body) and cognitive communication deficit (a difficulty with communication caused by a disruption in cognitive processes, such as memory, attention, or problem solving). A review of Resident #308's individualized care plan included a focus area that was related to discharge (d/c) planning and included but were not limited to the following interventions: Make arrangements with required community resources to support independence post-d/c (specify: homes care, PT (Physical therapy), OT (Occupational therapy), MD (Medical Doctor or physician), Wound Nurse) [homecare services] will be arranged prior to d/c RX (Prescription) will be obtained from MD Rehab will order recommended equipment A review of Resident #308's Discharge assessment-return not anticipated Minimum Data Set (DRNAMDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated that Resident #308 cognition was severely impaired. Further review reflected that Resident #308 had a planned d/c to home/community and that a referral was not made to the Local Contact Agency and the reason was the referral was not wanted. A review of Resident #308's Progress Note (PN) included the following note written by SWD (Social Worker Director) on 5/19/2024: Resident #308 was dc yesterday per [resident's representative or RR] request. SS (Social Services) visited [resident] routinely to monitor adjustment. Resident #308 appeared comfortable and participated in care and services. RR updated on Resident #308's wellbeing throughout stay. RR was aware of need for 24 hour care. Community resources/options reiterated and info was provided on pvt (private) help, LTC (long term care), respite stay, Medicaid. RR plans on hiring pvt help to assist upon dc home. Wound vac was ordered via [name redacted] and referral was made to [name redacted of HCSA #1] for continuum of care. Transportation arranged per request. There was no documentation that HCSA #1 (Home Care Service Agency #1) approved or accepted the referral. A review of Resident #308's Physician's Order (PO) Recap Report did not include a PO for d/c. There was no documentation in Resident #308's of an acceptance or approval from the home care service agency or a PO for d/c. On 9/17/24 at 01:23 PM, in the presence of a Social Worker, the surveyor interviewed the SWD regarding the process for d/c and d/c planning. The SWD stated that the process started at admission with the resident and their family and then the facility had a weekly internal meeting and the family was updated. The SWD stated that the insurance company would notify the facility of the d/c date. She added dependent on the type of the insurance, the notification could be three days to twenty four hours before the date. The SWD stated that when the d/c date was known, the facility would call the physician, rehab would order equipment and she would set up the home care services. She added that she would send a referral to the home care services agency (HCSA) and they would say yes we can take it. The SWD stated that sometimes the HCSA may have staffing issues and then the HCSA would communicate to me that they could not take the referral and then she would refer to a different agency. The SWD stated that the HCSA would text her and that she would document the referral in the medical record. On that same date and time, the surveyor asked the SWD about Resident #308's d/c planning. The SWD stated that if she remembered that she sent the referral to HCSA#1 and that they accepted the referral. She stated that after the resident went home, HCSA #1 called her a few days later and told her the agency could not take the resident and that HCSA #1 referred the resident to HCSA #2. The SWD stated that they would have kept Resident #308 at the facility longer or referred the resident to a different HCSA if she had known. The SWD stated that she called RR when she found out and that the RR told her that when HCSA #2 had reached out to RR to set up the home care visit that RR had already taken Resident #308 to the hospital. The surveyor asked the SWD if she received an email from the HCSA or documented the acceptance or approval from the HCSA. The SWD stated that she only received an email if the HCSA refused the referral. The surveyor asked the SWD to provide any documented evidence that the HCSA accepted or approved the referral. On 9/17/24 at 02:15 PM, the SWD provided the surveyor a screen shot of test message conversation between her and HCSA #1 which revealed the following: Mon, May 13 SWD-Resident #308 dc Saturday 5/18 Has wound vac from [company name redacted] 4:18 PM Fri, May 17 HCSA #1-we need order for .Resident #308 .asked our nurses to try for a verbal. Are you able to get an order for either? 5:26 PM SWD-On Sunday as I'm home now. 5:53 PM SWD-Resident has a vac!! 5:53 PM SWD-Mon wed Friday 5:54 PM Sun, May 19 SWD-a picture of a physician's RX which included the following: [name of homecare agency] RN(Registered Nurse)/PT/OT eval (evaluate) and TX (treat); wound mgmt (management) There was no documented evidence that HCSA#1 accepted or approved the referral. On 9/18/24 at 10:55 AM, the SWD stated that HCSA#1 had confirmed and needed a RX. The SWD stated that Resident #308 had commercial insurance and they gave a d/c date for the next day which she thought they found out on 5/13/24. She added that the RR wanted the resident to stay out the facility for a week as respite (planned or emergency temporary care that is not paid for by the insurance company). The SWD stated that she sent the referral to HCSA#1 on 5/13/24 and the resident was d/c on 5/18/24. On 9/18/24 at 12:02 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse Consultant #1 (RNC #1) and Assistant DON/Infection Preventionist (ADON/IP) the concerns that Resident #308 did not have any documentation that the referral for home care services was accepted or approved by the agency prior to the resident's d/c to home and that there was no PO for d/c. On 9/20/24 at 10:14 AM, the surveyor interviewed, via telephone, the Business Development Coordinator (BDC) for HCSA #1 regarding the process for referrals. The BDC stated that he would call and talk to SWD to get an update of the residents that were being d/c and that he would follow up with the branch of the HCSA#1 to see if there was availability. The surveyor asked the BDC if he sent any documentation that the resident's referral was accepted. The BDC stated not really. The surveyor asked the BDC if he had any documentation regarding Resident #308's referral. The BDC stated that he would check if he had any emails. He added that the communication was mostly verbal and by phone. The BDC stated that he submitted everything for the resident on a Thursday and that over the weekend he was notified that the branch of HCSA#1 could not take the resident. He added that he was not sure if the reason was a nurse callout or not. The BDC stated that he then contacted HCSA#2 to take the resident but that in the meantime the resident went to the hospital. The BDC added that moving forward he may do a specific email regarding the referral. On 9/20/24 at 11:26 AM, in the presence of the survey team, DON, RNC #1, Regional LNHA (RLNHA), the LNHA stated that the facility documented that a home care referral was made. She added that unless otherwise noted the staff only write a note if the referral was not accepted. The LNHA stated that the resident referral was accepted. She added that it was always an approval unless there was specific documentation of not being approved. The facility did not provide any additional information. A review of the undated facility provided policy titled, Discharge Summary and Plan included the following: Policy Statement When a resident's d/c is anticipated, a d/c summary and post-d/c plan will be developed to assist the resident to adjust to their new living environment. Policy Interpretation and Implementation 1. When the facility anticipates a resident's d/c to a private residence, another nursing care facility ., a d/c summary and a post-d/c plan will be developed which will assist the resident to adjust to their new living environment. 4. The resident will be evaluated for their d/c needs and will have an individualized post-d/c plan. 5. The post-d/c plan will be developed by the care planning/interdisciplinary team (IDT) with the assistance of the resident and their family and will include: . b. arrangements that have been made for follow-up care and services; . 8. Residents will be asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, they will be referred to local agencies and support services that can assist in accommodating the resident's post-d/c preferences. A review of the facility provided policy titled, Discharge Procedures with an adopted date of February 2023, included the following: Purpose To ensure that each patient d/c proceeds in an orderly fashion and that appropriate preparation and/or referral to community resources has been accomplished . Procedure 2. When the Interdisciplinary patient care team determines that the patient has reached their maximum potential appropriate for an inpatient stay, a projected d/c date will be established. 3. The Social Worker will discuss the patient's d/c date with the patient/family including community resource involvement 6. The IDT will maintain communication with the patient and family relative to the d/c planning . 8. Prior to d/c the nurse will check that the physician has written the d/c order and has completed the RX, if any. N.J.A.C. 39.4 (f)(h)

Complaint # NJ174669 Based on the interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for one (1) of two (2) residents reviewed for discharge (Resident #308). This deficient practice was evidenced by the following: On 9/17/24 at 12:55 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical record for Resident #308 which revealed the following: Resident #308's admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to pressure ulcer of sacral region (a wound that forms when prolonged pressure is applied to the sacrum, tailbone, or lower back), abnormal posture (rigid body movements and chronic abnormal positions of the body) and cognitive communication deficit (a difficulty with communication caused by a disruption in cognitive processes, such as memory, attention, or problem solving). A review of Resident #308's Discharge assessment-return not anticipated Minimum Data Set (DRNAMDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, which indicated that Resident #308 cognition was severely impaired. Further review reflected that Resident #308 had a planned discharge (d/c) to home/community. A review of Resident #308's Progress Notes reflected that the resident was d/c home. A review of Resident #308's hybrid medical record did not include a d/c summary. On 9/20/24 at 11:33 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse Consultant (RNC#1) and Regional LNHA (RLNHA) the concern that Resident #308 did not have a d/c summary in their hybrid medical record. The LNHA confirmed that the paper medical record did not contain a d/c summary. The DON stated that she was looking in the electronic medical record and that she observed a d/c instructions and d/c planning review. The surveyor asked if the facility could confirm that there was no d/c summary in the electronic medical record. The facility administration did not respond. The facility did not provide any additional information. A review of the undated facility provided policy titled, Discharge Summary and Plan included the following: Policy Statement When a resident's d/c is anticipated, a d/c summary and post-d/c plan will be developed to assist the resident to adjust to their new living environment. Policy Interpretation and Implementation 1. When the facility anticipates a resident's d/c to a private residence, another nursing care facility ., a d/c summary and a post-d/c plan will be developed which will assist the resident to adjust to their new living environment. 2. The d/c summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the d/c in accordance with established regulations governing release of resident information and as permitted by the resident. The d/c summary shall include a description of the resident's: a. current diagnosis; b. medical history . c. course of illness, treatment and/or therapy since entering the facility . o. cognitive status and p. medication therapy . 13. A copy of the following will be provided to the resident .and a copy will be filed in the resident's medical records: . c. The d/c summary. N.J.A.C. 8:39-35.2(d)(16)

Based on observation, interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. This deficient practice was identified in one (1) of two (2) residents (Resident #36), reviewed for pressure ulcer care and prevention. The deficient practice was evidenced by the following: On 9/16/24 at 9:36 AM, the surveyor observed Resident #36 lying in their bed with the head of the bed elevated. The resident was alert and verbally responsive. Resident #36 stated they had a right heel wound which they were receiving treatment (tx) for. The resident added the wound was new, and they did not have it prior to being admitted to the facility. On 9/18/24 at 11:17 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) any skin investigations for Resident #36. On 9/19/24 at 9:00 AM, the surveyor asked the LNHA and Director of Nursing (DON) if there were any skin investigations for Resident #36. The DON stated the Assistant Director of Nursing (ADON) had the investigation and it would be provided to the surveyor. The provided skin investigation dated 9/09/24 revealed that the resident was found with an opening to the right heel. The right heel was cleansed with normal saline and medihoney applied and covered with dressing. A wound consult was also recommended. The investigation indicated the physician was made aware and an order for medihoney tx was to begin. The resident's representative was also made aware. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #36. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, chronic kidney disease, heart failure, hypertension (high blood pressure), diabetes mellitus, and osteoarthritis (a disease in which the tissues in the joint break down over time). A comprehensive Minimum Data Set (MDS) assessment tool used to facilitate the management of care, dated 8/20/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #36 scored a 14 out of 15, which indicated the resident was cognitively intact. Under Section M-Skin Conditions of the MDS assessment, it was documented that the resident was at risk for pressure ulcer/injury and it was determined by clinical assessment. A review of physician's orders (PO) included the following: A PO dated 9/11/24 with a start date of 9/12/24 read, Cleanse right heel with NSS [normal saline solution] and pat dry. Apply Medihoney and cover with dry dressing every day shift for wound care. A PO dated 9/09/24 read Wound consult as needed. A review of the September 2024 electronic Treatment Administration Record (eTAR) revealed: An entry dated 8/16/24 that read Skin evaluation with Bi-weekly shower schedule every day shift every Tues (Tuesday), Fri (Friday) for skin evaluation. Additionally, it read, Document using the following: 0- no skin impairment .1-previous skin impairment .2- newly identified skin impairment .If you respond with 2 further documentation in progress note (PN) and physician notification and Braden Scale . For the following dates of the skin evaluation the nurse documented the following. On 9/10/24 the nurse documented 0. On 9/13/24 the nurse documented n and on 9/17/24 the nurse document 1. The eTAR included the entry for the medihoney wound tx to the right heel that started on 9/12/24. There were no other wound tx entries for the right heel documented in the September 2024 eTAR. The resident had a care plan (CP) with a focus that read, [Resident #36] has potential/actual impairment to skin integrity fragile skin r/t [related to] Incontinence The CP was initiated on 8/14/24 and last revised on 8/28/24. Interventions listed were: Administer meds (medications)/vitamins as ordered and Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. The resident had a CP with a focus that read, [Resident #36] has a self-care performance deficit impaired imbalance. The CP was initiated on 8/14/24 and last revised on 8/14/24. The interventions indicated the resident was a one person assist with bathing/showering, dressing, personal hygiene, and oral care. The resident had a CP with a focus that read, [Resident #36] has limited physical mobility. The CP was initiated on 8/14/24 and last revised on 8/14/24. The interventions indicated the resident was a one person assist with ambulation/locomotion, bed mobility, and transfer. A review of nurse PN in September 2024 revealed there was no documentation about the resident being found with a new wound to the right heel. A review of the wound consultant note dated 9/11/24 revealed the resident was seen for a new wound to the right heel that was diagnosed as a full thickness diabetic wound and included the wound's assessment. The wound consultant physician recommended leptospermum honey (medihoney) tx to the right heel wound once daily. Additionally, the wound consultant recommended to offload the wound, reposition per facility policy, and a pressure off-loading boot. On 9/19/24 at 10:03 AM, the surveyor interviewed the DON. The surveyor reviewed the September 2024 eTAR's bi-weekly skin assessment entry. The surveyor asked what the documented n meant which was electronically signed by the nurse. The DON stated she was not sure why the nurse documented n since the entry indicated 0, 1 or 2 should be used when completing the entry. The DON stated she would follow up with the nurse for the meaning of the n documented. On 9/19/24 at 11: 54 AM, the DON stated it was clarified with the nurse that the n indicated there was no wound/change. On 9/19/24 at 02:00 PM, the policy titled Wound Care was provided to the survey team. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON), and Regional Nurse Consultant (RNC). The surveyor informed the facility about the concerns for Resident #36's wound care including: there was no wound tx order found between 9/09/24 and 9/11/24, there was no documentation of the resident's wound in the nurse PN, and the coding of the bi-weekly skin assessments in the eTAR were not accurate. There was no verbal response by the facility at this time. On 9/20/24 at 8:50 AM, the surveyor requested from the LNHA any additional policies related to wound care and skin assessments besides the Wound Care policy provided. On 9/20/24 at 11:21 AM, the survey team met with LNHA, DON, RNC, and Regional LNHA. There was no additional information and no additional policies provided by the facility. The surveyor reviewed the provided undated facility's policy titled, Wound Care, under documentation, it read: The following information should be recorded in the resident's medical record .4. Any change in the resident's condition . Further review of the above Wound Care Policy revealed that the policy did not further address wound assessments and its documentation. NJAC 8:39-27.1 (a)(e)

Based on observation, interview, review of the medical record, and other facility documentation, it was determined that the facility failed to ensure that residents admitted with decreased range of motion and mobility received appropriate treatment, device, appropriate services, and assistance to maintain and prevent further decline. This deficient practice was identified for one (1) of two (2) residents, Resident #67, reviewed for a limited range of motion (ROM). This deficient practice was evidenced by the following: On 9/16/24 at 10:25 AM, the surveyor observed Resident #67's room closed. Licensed Practical Nurse #1 (LPN#1) came out from the resident's room and informed the surveyor that the surveyor had to come back later. The LPN further stated that there were two aides providing care. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #67 and revealed: The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), unspecified sequelae of cerebral infarction (also known as an ischemic stroke, the pathologic process that results in an area of necrotic tissue in the brain), atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung), altered mental status, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction, and gastrostomy (surgical opening into the stomach for nutritional support or gastric decompression) status. The most recent quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/29/24, under Section C Cognitive Patterns, reflected cognitive skills for daily decision-making made regarding tasks of daily life score of 03 out of 15 which indicated that the resident's cognition was severely impaired. Section GG Functional Status showed that Resident #67 had both upper and lower extremities impairment. Further review of the MDS revealed that on admission MDS ARD 9/28/23, modified on 11/01/23, reflected that Section GG was coded for both upper and lower extremities impairment. A review of the personalized care plan (CP) showed that the impairments to both upper and lower extremities were not addressed. There was no documented evidence that services were provided or attempted to include interventions, care, and equipment to address the impairments. A review of the Progress Notes (PN) dated 11/08/23 by the Nurse Practitioner (NP) included that the resident was seen for follow-up and resident had no facial grimaces. The NP further documented that the resident was on Skilled OT (Occupational Therapy) for bilateral (Bil) upper extremities (UE) therapeutic exercises (Exs) and passive ROM (PROM) and tolerated movements fairly. A review of the provided OT Treatment Encounter Note(s) dated 11/14/23 revealed in the Summary of Daily Skilled Services that was electronically signed by OT: Contraindications: no contraindications present. 97530: Bil UE PROM Exs; as tolerated for both hands; at all joints as tolerated; to improve UE functioning and prevent further contracture . Patient's (Resident) family was updated that the patient is not candidate for skilled OT services at this time; to be dc (discontinued) from rehab at present; will be re evaluated if any significant change in functional status noted. Response to Tx (treatment): response to session interventions: actively participates with skilled interventions. Complexities: Barriers impacting treatment?=No There was no documented evidence in hybrid medical records that the PROM to Bil UE was followed through, documented in CP, and addressed to tasks. A review of the Task List Report of the Certified Nursing Aide did not include tasks that the aide performed from 10/05/23 to the current date that address the impairments to both upper and lower extremities. On 9/18/24 at 9:49 AM, the surveyor and LPN#2 went to the resident's room and observed the resident on the bed at approximately 45 degrees sitting position with gastrostomy tube feeding being infused via a machine. Afterward, LPN#2 asked the Unit Manager/Licensed Practical Nurse (UM/LPN) to help her reposition the resident. Both the LPN and UM/LPN confirmed that the resident had bilateral upper and lower extremities contractures. The UM/LPN stated that the contractures of the resident were not something new. The UM/LPN further stated that the resident was non-ambulatory, and the resident did not have an assistive device or splints since she started (UM/LPN claimed she had been working in the facility for a year and nine months) at the facility. The UM/LPN also stated that come to think of it the resident should at least have a carrot splint (an innovative device that offers painless positioning of severely contracted hands for better resident comfort, better hygiene, and easier caregiving). On 9/18/24 at 10:05 AM, the surveyor interviewed the Director of Rehabilitation (DoR) OT (Occupational Therapist). The DoR/OT informed the surveyor that she had been working in the facility since October 2023. The surveyor asked what the facility's process was, with regard to LTC (Long Term Care) residents about residents' maintenance and rehabilitation (rehab) for their functional status, specifically residents who came in with impairments. The DoR/OT stated that LTC residents were being seen by Therapists under Medicare B, we screened them quarterly and the screen was placed in a binder in my office. She further stated that when residents have contracture or limitations, we do ROM and splint as appropriate during therapy and then transition them to nursing. On that same date and time, the DoR/OT informed the surveyor that at times nursing will refer residents to rehab if needed, and if the resident was very contracted rehab would provide splint as appropriate. The surveyor asked the DoR/OT to show the surveyor the binder where compilations of rehab screen was, and the DoR/OT stated she would get back to the surveyor to bring the binder. On 9/18/24 at 10:23 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) regarding the rehab screen binder that the surveyor asked the DoR/OT to show to the surveyor. The Director of Nursing (DON) stated that she would get the DoR/OT and the binder. Afterward, the DoR/OT came and informed the surveyor in the presence of the survey team that she was unable to find the rehab screen binder because the one who had the binder resigned in July 2024. The DoR/OT further stated that she was unable to find right now the August rehab screen as well. The surveyor then asked the DoR/OT how she knew that the rehab screens were all done and who needed the rehab screens. The DoR/OT stated that she knew it was done and would get back again to the surveyor. On 9/18/24 at 11:33 AM, the DoR/OT provided a copy of the September 2024 Therapy Screen Forms. The surveyor notified the DoR/OT about the above concerns and findings that Resident #67 with limitations in both upper and lower extremities had no CP to address the limitations and impairments and had no care and services attempted to address the impairments. The surveyor also notified the DoR/OT that there was no documented evidence that the resident had a rehab screen quarterly and addressed the impairments. The DoR/OT stated that she would get back to the surveyor. A review of the August and September 2024 Therapy Screen Form that was provided by the DoR/OT revealed: August 2024: -14 out of 17 residents that were screened did not include the name(s) of the OT Staff that performed the therapy screen. -3 out of 17 residents had no name(s) and title(s) of Rehab staff who screened the residents. -8 out of 17 residents did not specify if the evaluation was recommended or not (yes or no was not encircled). September 2024: -5 out of 5 residents that were screened did not include the name(s) of the OT Staff that performed the therapy screen. -3 out of 5 residents did not specify if the evaluation was recommended or not. Further review of the above August and September 2024 Therapy Screen Form revealed that Resident #67 was not included on the list. The facility management was unable to provide documented evidence that the resident was screened quarterly by rehab according to the previous statement of the DoR/OT as part of the facility's process and practice. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the above concerns with Resident#67. On 9/18/24 at 01:51 PM, the surveyor in the presence of the survey team informed RNC#1 about the concern that Resident #67's tasks and CP did not address the resident's impairments. The surveyor asked RNC#1 why there was no CP for the resident's bilateral extremities impairments, and RNC#1 had no response. On 9/19/24 at 01:26 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. The LNHA stated for Resident #67, I did the digging, the resident was contracted prior to admission and was unable to move, the resident was on skilled therapy two different times, and dc therapy. The LNHA acknowledged that the Physiatrist documented in the PN that the resident will not benefit from ROM and splints due to wounds after the surveyor's inquiry. On 9/20/24 at 9:20 AM, the surveyor asked the DoR/OT in the presence of the DON about the OT who did the notes of the resident during OT txs. The DoR/OT stated that the OT was out of the country and the surveyor would not be able to interview the OT. The surveyor then asked DoR/OT why the provided copies for Physical Therapy and OT had no physician signatures. The DoR/OT stated that for rehab tx notes from 10/06/23 through 11/14/23, the physician should have signed them off. The facility management did not respond to why the physician did not sign the documents. On 9/20/24 at 10:33 AM, the surveyor in the presence of the survey team interviewed the Physiatrist via a phone interview. The Physiatrist informed the surveyor that she had been working in the facility for a year now but was unable to state the exact date. The Physiatrist also confirmed that it was yesterday only that she was able to see and evaluate Resident #67. The Physiatrist informed the surveyor that as a standard of practice, she and her team when assessing or evaluating the residents with high risk or presented with limitations, impairments, or contractures, it will be expected to initiate and attempt to treat residents with ROM and appropriate splints or other adaptive devices to prevent or further prevent contractures or impairments and document. On that same date and time, the surveyor notified the Physiatrist of the above findings and concerns. The surveyor asked the Physiatrist would a hand roll or carrot splint would be beneficial for residents with impairments to their hands, or will it harm the resident. The Physiatrist stated that we do that for prevention. She further stated that we can use a soft rolled-up washcloth, very easy to clean and will not hurt the resident. The surveyor then asked the Physiatrist, after seeing the resident yesterday if the soft hand roll or carrot splint would be appropriate or will it harm the resident. The Physiatrist responded that the soft hand roll or carrot splint would not hurt the resident and would probably be appropriate to the resident. A review of the facility's Range of Motion Devices with an updated date of 4/2024 that was provided by the DON showed: Policy: Residents with limited ROM may be candidates for the use of orthotic devices such as splints and braces. When used, these devices will be maintained to increase and/or prevent a further decrease in ROM and to reduce the risk of complications. Procedure: 1. Physical and occupational therapists may make recommendations for the use of ROM devices within their scope of practice . 5. The licensed nurse will document in the medical record the completion of monitoring for potential complications as ordered by the physician. a. In the event that a complication or potential complications is observed, the nurse will document details of the observation in the medical record . 6. The resident's CP will include measurable goals and objectives as well as resident-specific interventions for the use of ROM devices. The above policy did not contain any information about PROM. The facility did not provide any policy with regard to PROM. On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. The facility management was unable to show resident's quarterly rehab screens for Resident #67. N.J.A.C. 8:39-27.1(a), 27.2(m)

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure that a.) the monthly weight and re-weighs were done, documented, and monitored for two (2) of two (2) residents, Residents #2 and #67, b.) the physician was notified the significant weight loss for one (1) of two (2) residents, Resident #2, reviewed for nutrition, and c.) the duplicate physician orders for gastrostomy tube flushes were clarified for one (1) of one (1) resident, Resident #67, reviewed for hydration. This deficient practice was evidenced by the following: 1. On 9/16/24 at 10:40 AM, the surveyor observed Resident #2 seated on the bed with a breakfast tray in front of the resident with the Certified Nursing Aide (CNA) at the bedside. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #2 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to other low back pain, essential hypertension (elevated blood pressure), paroxysmal atrial fibrillation (AFIB; an irregular, often rapid heart rate that commonly causes poor blood flow), type 2 diabetes mellitus with diabetic chronic kidney disease, PVD (peripheral vascular disease), COPD (chronic obstructive pulmonary disease), UTI (urinary tract infection), PAD (peripheral arterial disease), heart failure unspecified, and chronic kidney disease stage 3A (mild to moderate loss of kidney function). The most recent admission (modified) Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/21/24, under Section C Cognitive Patterns, showed a brief interview for mental status (BIMS) score of 15 out of 15 which reflected that the resident's cognitive status was intact. A review of the personalized care plan (CP) showed a focus CP that the resident had a nutritional problem or potential nutritional problem r/t (related to) GERD (a digestive disease in which stomach acid or bile irritates the food pipe lining), CKD3 (chronic kidney disease stage 3), PVD, PAD, UTI, HTN (hypertension), and AFIB that was initiated on 6/14/24. The CP goal included but was not limited to the resident will maintain adequate nutritional status as evidenced by weight (wt) maintenance +/- 5% that was initiated on 6/14/24. According to the September 2024 Order Summary Report (OSR), there was an active physician's order (PO) with an order date of 6/14/24 to obtain wt one time a day starting on the 1st and ending on the 7th every month for monthly wt, enter wt in MAR (Medication Administration Record) and wts (weights)/vitals. A review of the Weights and Vitals Summary revealed the following: Date Value Warnings 9/06/24 165 lbs (pounds) 8/06/24 184.8 lbs +10% change [comparison wt 6/28/24, 160.2 lbs, +15.4%, +24.6 lbs] MDS: +5% change over 30 day(s) 8/01/24 184.6 lbs +10% change [comparison wt 6/28/24, 160.2 lbs, +15.2%, +24.4 lbs] -3% change from last wt [comparison wt 7/9/24, 190.8 lbs, -3.2%, -6.2 lbs] 7/09/24 190.8 lbs +10% change [comparison wt 6/28/24, 160.2 lbs, +19.1 lbs, +30.6 lbs] +3% change from last wt [comparison wt 6/28/24, 160.2 lbs, +19.1%, +30.6 lbs] 6/28/24 160.2 lbs -10% change [comparison wt 4/30/24, 184.8 lbs, -13.3%, -24.6 lbs] MDS: -5% change over 30 day(s) [comparison wt 5/30/24, 193 lbs,-17.1%, 33 lbs] A review of the Progress Notes (PN) dated 7/01/24 at 8:52 AM by the Dietitian revealed that Resident #2 was triggered for significant wt loss of -32.8 lbs/16.9% x 1 month. The PN showed that wt loss was possible prior to admission due to diuretics (water pill medication), which was fluid wt loss. The plan was to monitor labs (laboratory), wts, and skin integrity, and intervene as appropriate. Further review of the hybrid medical records showed that there was no documented evidence that the physician was notified of the significant wt loss. On 9/17/24 at 10:56 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) in the nursing station on the 3rd floor. The LPN informed the surveyor that Resident #2 was cognitively intact. The LPN stated that she was unsure if the resident had wt loss because it was the aide who was responsible for obtaining wts of the resident, and it was the Unit Manager/Licensed Practical Nurse (UM/LPN) who entered the wts in the resident's electronic medical records (EMR). On 9/17/24 at 11:22 AM, the surveyor interviewed the Dietician. The Dietician stated that in the facility's process about wts, the staff takes residents' wts the first seven days of the month, if there will -/+ 5 lbs wt changes, reweigh must be done on or before the 1 of the month. She further stated that she documents every month, every after wts were done, and as needed for significant changes. On that same date and time, the Dietitian informed the surveyor that the nursing department was responsible for obtaining the residents' wts and the staff documented it in a wt book. The Dietitian stated that it was the UM's responsibility to enter the wt in the EMR. She further stated that there was no other documentation of wts except for those two areas, the wt binder and the EMR. At that same time, the surveyor asked the Dietitian if she notified the doctor about the significant wt loss or wt changes, and if she documented the communication between the Dietitian and physicians about wt changes. The Dietitian stated that she did not call a doctor, she documented her assessment and notes in EMR. She further stated that when she started at the facility on 6/11/24, there was no wt meeting, and this would be the plan to have wt meetings. Afterward, the surveyor asked the Dietitian why there were no reweighs in September 2024 and July 2024 when the Weights and Vitals Summary indicated a wt change of -/+ 5 lbs or more. The Dietician stated, I can't answer that question. The Dietitian stated that the UM was aware that the resident should have a reweigh for September 2024 because she verbally notified the UM about it. Furthermore, the surveyor asked the Dietitian should there be a note that the physician was notified of the significant wt loss identified on 7/01/24 PN of the Dietician. The Dietitian stated Yes. The surveyor notified the Dietician of the above concern. On 9/17/24 at 11:45 AM, the surveyor interviewed the UM/LPN. The UM/LPN informed the surveyor that monthly wt should be done within the 1st seven days of the month and reweigh done on or before the 1 of the month. The UM/LPN stated that it was the aide's responsibility to take the residents' wt and log it in the binder, and it was her responsibility as UM to enter the wts in the EMR. On that same date and time, the surveyor notified the UM/LPN of the above findings and concerns. The UM/LPN stated that the reweigh of Resident#2 was obtained and she forgot to enter them into the EMR. The UM/LPN further stated that the physician should be notified of significant wt loss and documented in the EMR. The surveyor asked the UM/LPN why there was no documented evidence that the physician was notified of the significant wt loss (7/01/24 PN), and the UM/LPN did not respond. On 9/18/24 at 11:39 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the above concerns and findings with Resident#2. The surveyor also notified the facility management that Nurse Practitioner #1 (NP#1) did not call back when the surveyor called the NP today at 8:37 AM. On 9/18/24 at 02:00 PM, the surveyor interviewed NP#2 in the presence of the survey team via phone conference. NP#2 informed the surveyor that she called back on behalf of NP#1 and the Primary Care Physician (PCP). The surveyor notified NP#2 of the above findings and concerns regarding significant wt loss documented by the Dietitian on 7/01/24. The surveyor asked NP#1 if she or the PCP and the other NP were made aware by the facility about the significant wt loss. NP#2 stated that they were not made aware of the significant wt loss. She further stated that they were made aware today of the September 2024 monthly wt changes. On that same date and time, NP#2 stated that the wt change was possibly a problem with the scale. She further stated that according to the facility, the reweigh was done yesterday and it was 182 lbs. NP#2 also stated that it was probably not a true wt loss and that she would make sure to follow up on it. 2. On 9/16/24 at 10:25 AM, the surveyor observed Resident # 67's room closed. LPN#2 came out from the resident's room and informed the surveyor that the surveyor had to come back later. The LPN further stated that there were two aides providing care. The LPN also stated that the resident was NPO (nothing by mouth), with TF (tube feeding or gastrostomy tube). The surveyor reviewed the hybrid medical records of Resident #67 and revealed: The AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), unspecified sequelae of cerebral infarction (also known as an ischemic stroke, the pathologic process that results in an area of necrotic tissue in the brain), atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung), altered mental status, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction, and gastrostomy (surgical opening into the stomach for nutritional support or gastric decompression) status. The most recent quarterly MDS with an ARD of 6/29/24, under Section C, reflected cognitive skills for daily decision-making made regarding tasks of daily life score of 3 out of 15 which indicated that the resident's cognition was severely impaired. Section K Swallowing/Nutritional Status showed that the resident had TF. A review of the personalized CP showed a focus that the resident had a nutritional problem or potential nutritional problem NPO status, dependent on TF as the primary source of nutrition/hydration, altered nutrition r/t underweight BMI (body mass index is a value derived from the mass and height of a person), and severe protein-calorie malnutrition, date initiated 9/27/23. The goal was to maintain wt within 5% CBW (calculated body wt) or have gradual wt gain to a BMI of more than 18.5. Interventions included but were not limited to record wt (per facility protocol or MD (Medical Doctor) order that was initiated on 9/27/23. A review of the September 2024 OSR revealed: -an active PO with an order date of 10/05/23 to obtain wt everyday shift starting on the 6th and ending on the 6th of every month for monthly wt enter wt in MAR and Wts/Vitals. - Flush g tube (GT; gastrostomy tube) with 30 ml (milliliters) of water before and after medication (med) pass. every shift for G-Tube Patency-Start Date 10/06/2023. -Flush GT with 30 ml of water before and after med pass. Flush GT with 5 ml between each med every shift for Monitoring-Start Date 7/02/2024. The above duplicate orders for flushes of GT were transcribed to the July, August, and September 2024 electronic Medication Administration Record (eMAR) and signed by nurses as administered. The above order for monthly wt was transcribed to the March, May, and August 2024 electronic Treatment Administration Record (eTAR) and revealed: March 2024=3/06/24, wt coded as NA (not applicable), by LPN#1 May 2024=5/06/24, wt coded as NA, by LPN#1 August 2024=8/06/24, wt was blank A review of the Weights and Vitals Summary showed the following: Weight Summary: 9/06/24=125.6 lbs 8/05/24=125 lbs 7/06/24=125 lbs 6/10/24=125 lbs 4/12/24=124 lbs 02/09/24=126.1 lbs 01/25/24=126.8 lbs 12/13/23=128.6 lbs Further review of the above wt summary revealed that there were no wts obtained in May 2024 and March 2024. In addition, the PO for monthly wts to be done on 6th of the month was not followed. A review of the PN by the Dietitian dated 8/16/24 revealed the following: -Resident #67 remained dependent on TF as the primary source of nutrition and hydration and tolerated the TF well. - Weights: August wt pending; (7/6) 125 lbs, May wts missing, (2/9) 126.4 lbs, Ht: 68 BMI 19 (Low) -wt trend reviewed, August wt pending- unable to assess for any significant change. Otherwise, wts appear stable. -PLAN: Continue TF Regimen as ordered. Continue Protein modular and water flush Continue monthly wts, and monitor TF tolerance, labs, wts, and skin integrity. F/u (follow up) monthly. On 9/17/24 at 11:13 AM, the surveyor interviewed LPN#1. The LPN acknowledged that she worked on 3/06/24 and 5/06/24 whose initial appeared in the eTAR. The LPN stated that the code NA meant not applicable and the reason she documented NA on 3/06/24 and 5/06/24 was that the aides did not enter the wts in the binder. She further stated that it was the UM's responsibility to enter the wts in the EMR. At that same time, the surveyor notified LPN#1 of the above findings and concerns regarding the duplicate order for GT flushes. The LPN stated that the order on 10/6/23 for flushing 30 mls of water before and after meds should have been discontinued (d/c) and acknowledged that it was a duplicate order for 7/02/24. On 9/17/24 at 11:35 AM, the surveyor asked the Dietician why she documented that the May wt was missing and if she followed up on the missing wt. The Dietician stated, I can't answer that question. On 9/17/24 at 11:38 AM, the surveyor interviewed the UM/LPN. The UM/LPN stated that the nurses in the unit only enter wt upon admission and readmission which was why the nurses documented NAs in the eTAR for wts. The surveyor notified the UM/LPN of the above findings and concerns and asked the UM/LPN why there was no wt for May and March 2024 for the resident. The UM/LPN stated that the aide did not get the wt, and it should have been taken even though it was late and documented in the EMR. Furthermore, the UM/LPN further stated that the order for flushing 30 mls of water on 10/06/23 should have been d/c when the new order on 7/02/24 was entered. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor notified the facility management of the above concerns and findings with Resident#67. A review of the facility's Weight Assessment and Intervention Policy with an updated date of 4/2024 that was provided by the Dietitian showed: Policy Statement: Resident wts are monitored for undesirable or unintended wt loss or gain. Weight Assessment: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Wts are recorded in each unit's wt record chart and in the individual's medical record. 3. Any wt change of 5% or more since the last wt assessment is retaken the next day for confirmation. 1. If the wt is verified, nursing will immediately notify the dietitian in writing 5. The threshold for significant unplanned and undesired wt loss will be based on the following criteria: a. 1 month-5% wt loss is significant; greater than 5% is severe. b. 3 months-7.5% wt loss is significant; greater than 7.5% is severe. c. 6 months-10% wt loss is significant; greater than 10% is severe . Evaluation: 2. The physician and the multidisciplinary team identify conditions and meds that may be causing anorexia, wt loss or increasing the risk of wt loss. For example: a. cognitive or functional decline; . On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, IP/ADON, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. NJAC 8:39-27.2(a)

Complaint NJ#175244 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a moderately impaired resident received care and services with regard to pain management for one (1) of one (1) resident, Resident #209, reviewed for pain according to standards of clinical practice and facility's policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey 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. A review of the closed medical record for Resident #209 revealed: The admission Record (an admission summary) showed that Resident #209 was admitted to the facility with diagnoses which included but were not limited to: lower back pain, hypertension (high blood pressure), and metabolic encephalopathy (change in brain works due to an underlying condition). According to the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/16/24, reflected the resident had a Brief Interview for Mental Status (BIMS) of 07 out of 15, which indicated the resident had moderate cognitive impairment. A review of the Physician Order (PO) Recap Report dated 6/01/24 - 9/30/24 indicated that Resident #209 had the following orders: -A PO with a start date of 10/13/23 - Acetaminophen Tablet (tab(s) 325 mg (milligram), give 2 tabs by mouth every 6 hours (hrs) as needed (PRN) for Temp greater than 100 . and give 2 tabs by mouth every 6 hrs PRN for pain. -A PO with a start date of 6/25/24 - Tylenol Extra Strength oral tab 500 mg (Acetaminophen)- give 500 mg by mouth every 6 hrs as PRN for pain on right leg. -A PO with a start date of 7/02/24 - Tylenol Extra Strength oral tab 500 mg (Acetaminophen)- give 1 tab by mouth three times a day for pain. A review of the electronic Medication Administration Record (eMAR) revealed that pain assessment was done every shift not until June 2024 when pain assessment was stopped. Further review of the above PO revealed that there was no documented evidence that routine pain assessment was done from June through July 2024. In addition, there was no documented evidence as to why the every shift pain assessment was discontinued. A review of the individualized Care Plan (CP) did not reflect a CP for pain. During an interview with the surveyor on 9/19/24 at 9:54 AM, in the presence of the survey team, the Director of Nursing (DON) stated that pain was assessed upon admission, every shift by the nurse. The DON also stated that the nurses would assess for pain as part of their vital signs (are group of the four to six most crucial medical signs that indicate the status of the body's functions) and minimum quarterly or PRN. She further stated that if the resident was in pain, then they (nurse) would administer pain medication (med(s) and an hour later they would re-assess for effectiveness. If the pain med was effective, then they (nurse) would document and if the pain med was not effective then they would notify the doctor. The DON further stated that the Unit manager (UM) did the quarterly assessment in Electronic Medical Record (EMR). The DON stated that the nurses verbally ask the residents about pain and did not have to document. The DON also stated that for resident with cognitive impairment, the nurses would use facial expressions. On 9/19/24 at 10:49 AM, in the presence of second surveyor, the Unit Manager/Licensed Practical Nurse (UM/LPN) stated as standards of practice, the pain assessment should be done and documented in the EMR every shift. The UM/LPN further stated that we verbally ask them. The UM/LPN acknowledged that pain should be included in the CP. On 9/19/24 at 10:56 AM, in the presence of second surveyor and Licensed Practical Nurse #1 (LPN#1), the LPN#2 stated she would assess her residents for pain during daily rounds. LPN#2 showed the surveyors a pain assessment for an unsampled resident in the eMAR, completed for every shift. The eMAR reflected Pain Level and D (7 AM-3 PM), Pain Level and E (3 PM-11 PM) and Pain Level and N (11 PM-7 AM) and the nurses entered the pain level in numbers and signed off with their initials in the blank boxes for their shift. LPN#2 further stated if the residents were not able to voice pain, then she would see the resident's facial expressions for pain assessment. LPN#1 agreed with LPN#2's statements and stated she assessed the pain for her residents as described by LPN#2. On 9/19/24 at 01:27 PM, the survey team met with the DON, Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing /Infection Preventionist (ADON/IP), and Regional Nurse Consultant Nurse #1 (RNC#1). The surveyor notified the facility management of the above findings and concerns. The DON confirmed that the pain assessment fell off from their orders and it would be reinstated. A review of the facility's Pain Assessment and Management policy dated 4/2024 revealed: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Under General Guidelines: 1.) The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive CP, and the resident's choices related to pain management. 5.) Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. 6.) For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. In section under Assessing Pain: 2.) Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. In section under Defining Goals and Appropriate Interventions: 4.) For those situations where the cause of the resident's pain has not been or cannot be determined, follow current standards of practice for managing pain to help determine appropriate options. In section under Monitoring and Modifying Approaches: 1.) Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. A review of the facility's policy Care Plans, Comprehensive Person-Centered with a last updated date of 4/2024, revealed: Policy statement: A comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1.) The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered CP for each resident. 2.) The comprehensive, person-centered CP is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3.) The CP interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. On 9/20/24 at 01:15 PM, the survey team met with DON, LNHA, RNC#1, RNC#2, Regional LNHA for an exit conference. There was no additional information was provided. NJAC 8:39-11.2(b); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ167713 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a) maintain the dialysis communication record between the facility and the dialysis center for one (1) of two (2) residents (Resident #458) and b.) provide care and services in accordance with professional standards clinical practice and facility policy for two (2) of two (2) residents (Resident #98, 458), reviewed for dialysis services. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as 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. 1. On 9/16/24 at 8:48 AM, the surveyor observed Resident #98 in their room sitting in bed, watching television. The resident had no concern with care. The surveyor reviewed the electronic medical record (EMR) for Resident #98. A review of the admission Record (AR; or face sheet; admission summary) reflected that Resident #98 was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and hyperkalemia (high potassium in the blood). A review of the comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care dated 8/25/24 showed that the resident's Brief Interview for Mental Status (BIMS) score was 13 out of 15, which indicated that Resident #98's cognitive status was intact. Section O - Special Treatment and Procedures, reflected that the resident received dialysis services (a process of purifying the blood due to impaired kidney function). A review of the resident's individualized Care Plan (CP) revised 9/19/23, reflected that Resident #98 needed dialysis (hemo) r/t [related to] renal failure. The CP interventions included: to assess dialysis access graft/fistula each shift for bruit and thrill. The September 2024 Order Summary Report (OSR) revealed an active physician orders (PO) for the following: -Start date 01/15/24: Assess dialysis site for signs and symptoms of infection, every shift for monitoring access dialysis site and indicate yes/no, if yes please indicate in progress notes (PN). -Start date 01/15/24: Fistula/AV Graft site: Located Left arm. Thrill and Bruit present? (Y/N) every shift for dialysis access site evaluation access site every shift for thrill & bruit if not present notify MD (Medical Doctor) immediately. -Start date 01/15/24: Dialysis Treatment Center: [name redacted] every: M-W-F (Monday-Wednesday-Friday) pick up time: 9:00 AM Chair time 10:00 AM Transportation: [name of transportation company]. On 9/18/24 at 01:45 PM, the surveyor reviewed the Dialysis Center Communication Record (DCCR, also referred as CR) (a binder on the unit which contains a resident's status on hemodialysis treatment days between the facility and the dialysis center) contained three separate areas to be filled out; the top section was to be completed by the facility nurse prior to the resident leaving the facility for the dialysis treatment (tx), the middle section was to be completed by the Dialysis center staff after tx and in the bottom section, was post dialysis vitals and site assessment to be completed by the facility nurse immediately upon the resident's return to the facility. A review of the DCCR from 9/02/2024 to 9/16/2024 revealed that CR were not consistently filled out for the following dates: September 2,4, 6, 11,13 and 16, 2024. The surveyor observed the DCCR's top and bottom sections were completely blank on 9/11/24. A review of the PN from September 2024 did not reflect assessment of the dialysis access site post hemodialysis tx for the following dates: September 2,4,6,11,13 and 16, 2024. Further review of the PN for September 2024 did not reflect if the left arm access site were evaluated for thrill (buzzing sensation can be felt) and bruit (is an important sound and indicator of how well your dialysis access is functioning) for the above mentioned dates. During an interview with the surveyor on 9/18/24 at 01:51 PM, Licensed Practical Nurse #1 (LPN#1) stated that the nurses were responsible for filling out the pre-tx and post-tx vital signs on the DCCR. She further stated that nurses were responsible for checking and documenting access site for any signs of bleeding or drainage at the AV fistula site (AV fistulas are created surgically for patients who require dialysis. These are used as an access point to connect the patient to a dialysis machine). LPN #1 confirmed that the expectation was that the communication record would be completely filled out once resident returned from their hemodialysis session. On 9/19/24 at 01:27 PM, the survey team met with Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing/Infection Preventionist (ADON/IP) and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the above findings and concerns regarding the Resident #98's DCCR. The ADON/IP confirmed that the communication form should be completed upon the residents return to the facility. A review of the facility's policy, Dialysis Communication, updated 4/2024 did not address the protocol for the nurses to complete Communication form for the residents who receive hemodialysis services. On 9/20/24 at 01:15 PM, the survey team met with DON, LNHA, RNC#1, RNC#2, Regional LNHA for an exit conference. The facility management did not provide additional information and did not refute findings. 2. The surveyor reviewed the EMR of Resident #458 and revealed: The AR documented that the resident had diagnoses that included but were not limited to, Stage 4 (severe) chronic kidney disease (CKD), dependence of renal (kidney) dialysis, type 2 diabetes mellitus (DM2) with diabetic chronic kidney disease, unspecified dementia, and peripheral vascular disease. The cMDS dated [DATE] indicated the facility assessed the resident's cognition using a BIMS test. Resident #458 scored a 02 out of 15, which indicated the resident had severe cognitive impairment. A PO dated 9/28/23 read, Dialysis on Tuesday, Thursday, and Saturday with a chair time at 9:30 AM and a pickup time of 8:30 AM. A review of PN from September 2023 revealed there were no PN for when the resident was to be sent for dialysis on the following days: 9/16/23, 9/21/23 and 9/30/23. Further review of the PN from September 2023 revealed there were no PN for when the resident returned from dialysis on the following days: 9/02/23, 9/05/23, 9/07/23, 9/12/23, 9/16/23, 9/21/23, 9/23/23, and 9/28/23. A review of a CP with a focus that read [Resident #458] has a nutritional problem or potential nutritional problem r/t therapeutic diet, BMI > 40, meets criteria for morbid obesity, 1:1 feeder, food-drug nutrient interactions. PMH [primary medical history] includes DM2, CKD, ESRD [End Stage Renal Disease] on HD [hemodialysis] . The CP had an initiation date of 9/01/23 and a last revised date of 9/20/23. An intervention of the CP read, Provide, serve diet as ordered. Monitor intake and record q [every] meal. On 9/18/24 at 12:56 PM, the surveyor interviewed LPN#1 who had cared for the resident. LPN#1 had recalled Resident #458 was visually impaired, with confusion, frequently refused care, and had poor appetite. LPN#1 further recalled that the resident needed to be fed, staff would attempt to feed resident and would make the resident's family aware when the resident refused. On 9/18/24 at 01:51 PM, the surveyor interviewed LPN#2 about nursing responsibilities for dialysis residents. LPN#2 stated when sending a resident to dialysis the nurse would assess the dialysis access site, check vital signs (blood pressure, pulse, temperature, respiratory rate, oxygen saturation), and complete the pre-tx section of the DCCR including any changes with the resident. LPN#2 further explained upon a resident's return to the facility from dialysis, the DCCR would be reviewed for documentation by dialysis nurse regarding the status of the resident and the post-tx assessment section would be completed by the nurse on the form. The surveyor asked LPN #2 about any food/snack provided for dialysis residents. LPN#2 replied that a resident would receive a bagged lunch or snack, if the resident was unable to eat meal prior to their pick up for dialysis. On 9/19/24 at 9:00 AM, the surveyor requested from the LNHA and DON the paper medical records for Resident #458. On 9/19/24 at 9:30 AM, the LNHA provided the paper medical record for Resident #458. A review of the provided medical record revealed there were no DCCRs, or dialysis communication forms for the resident. On 9/19/24 at 9:31 AM, the surveyor informed the LNHA and the DON that there were no dialysis communication forms found in the resident's closed medical records. The LNHA stated they would have medical records recheck the files for them. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor notified the facility management of the concern that there were no dialysis communication forms found for the resident. The LNHA stated they have not found and would continue to look for to provide to the surveyor. The surveyor requested the printout of the Certified Nurse Aide (CNA) tasks documentation for Resident #458 in September 2023. On 9/19/24 at 3:00 PM, the LNHA provided the CNA tasks documentation titled Documentation Survey Report for September 2023. On 9/20/24 at 10:00 AM, the surveyor reviewed the provided September 2023 Documentation Survey report for Resident #458. An entry of the form read ADL- Eating and percentage consumed with scheduled entry times of 9 AM, 1 PM, and 6 PM. There were 84 of 90 entries that were not signed and left blank. The unsigned entries did not indicate how the resident ate their meals (independent, limited assistance, extensive assistance or total dependence) and the percentage of meals consumed. On 9/20/24 at 8:29 AM, the surveyor interviewed a CNA about CNA task documentation. The CNA stated CNA documentation was completed in the EMR and completed what applied to the specific resident. The surveyor asked the CNA how often the eating and percentage consumed entry was completed for the residents. The CNA replied that for each resident it should be completed every shift. The CNA confirmed entries should not be left blank. On 9/20/24 at 8:38 AM, the surveyor interviewed the ADON/IP and the Registered Nurse Unit Manager (RN/UM) about CNA documentation. The ADON/IP stated CNA tasks were triggered upon resident's admission based on the nurse's evaluation in the EMR. The surveyor asked about the eating and percentage consumed entry for residents. The ADON/IP stated it was expected to be completed by the CNAs every shift for the residents and entries should not be left blank. On 9/20/24 at 8:50 AM, The surveyor requested from the LNHA any additional policies for dialysis other than the dialysis communication policy already provided to the survey team by the facility. On 9/20/24 at 10:30 AM, the surveyor interviewed the DON about Resident #458 and CNA task documentation. The DON did not recall the resident. The surveyor discussed the concern for Resident #458 that there was no documentation of percentage consumed at mealtime. The DON stated eating and percentage consumed by the resident should be documented by the CNA every shift. The surveyor asked about meals and snacks for dialysis residents. The DON stated the residents depending on their pick-up time would receive their scheduled meals prior to leaving the facility. If the dialysis pick-up time was at an off hour or between mealtimes, the resident would be provided a snack. If the resident did not want to eat their meal before going to dialysis it would be held until they returned from dialysis. At time if resident refuses meal will be held for resident until they return from dialysis. On 9/20/24 at 10:36 AM, the surveyor interviewed the ADON/IP about Resident #458. The ADON that she did recall Resident #458, who had visual impairment, resistive to care, and at times difficult to redirect. The ADON/IP added that she recalled the resident's family had to be called as the resident would refuse care or refuse to go to dialysis. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, RNC#1, and the Regional LNHA. The surveyor informed the facility about the concerns that no dialysis communication forms were provided for the resident and 6 of the 90 eating and percentage consumed entries were completed on the Documentation Survey Report. There was no additional information provided by the facility. The surveyor reviewed the facility's policy titled Dialysis Communication with a last updated date of 4/2024. Under Policy Interpretation and Implementation, it read, .3. The facility and dialysis center will determine a method to exchange written information between the centers on dialysis days. Examples of communication methods may include but are not limited to: forms, binders, books and copies of medical records .4. Examples of information that may be communicated between the facilities include .b. Hemodialysis Communication Form (or equivalent) .j. dietary needs . The policy did not address record keeping of the dialysis communication form and it did not address meals/snacks for residents going to dialysis. The surveyor reviewed the facility policy titled, Activities of Daily Living (ADLs), Supporting with an updated date of 4/2024. Under Policy Interpretation and Implementation, it read, .3. The resident's ability to participate in ADLs and the support provided during ADL care and resident-specific tasks will be documented each shift by CNAs in the medical record . NJAC 8:39 - 27.1(a); 2.9

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on two (2) of five (5) days during the survey. This deficient practice was evidenced by the following: On Monday, 9/16/24 at 7:45 AM, upon entry into the facility, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted in the reception area of the lobby. The NHRCSR posted for day shift was dated 9/15/24. There was no NHRSCR posted for 9/16/24 day shift. On Tuesday, 9/17/24 at 8:45 AM, the surveyor observed the NHRCSR posted in the lobby. The NHRCSR posted for day shift was dated 9/16/24. There was no NHRSCR posted for the 9/17/24 day shift. On 9/18/24 at 11:39 AM, in the presence of the survey team, the surveyor notified the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), Assistance Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1(RNC#1) about the concern that the NHRSCR was not posted daily for two out of the five days during the survey. The DON stated that the Staffing Coordinator (SC) was responsible for posting the NHRSCR and acknowledged that staffing should be posted prior to beginning of each shift. During an interview with the surveyor, on 9/20/24 at 9:45 AM, SC confirmed that she was responsible to post the NHRCSR at the front desk. The SC further explained that it was important to post NHRSCR everyday to let the residents and their families know that we had right number of staff to care for their loved ones. The SC acknowledged that it was not acceptable that the staffing was not posted for each shift as the shift changed. A review of a facility's Staffing, Sufficient and Competent Nursing Policy with an updated date of 4/2024, revealed: 6.) Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift. On 9/20/24 at 01:15 PM, the survey team met for Exit conference with LNHA, DON, ADON/IP, RNC#1, RNC#2 and the Regional LNHA. The facility management did not provide an additional information and did not refute the findings. NJAC 8:39-41.2

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents (Resident #62) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 9/16/24 at 9:06 AM, the surveyor observed Resident #62 in their room, lying in bed with the head of the bed elevated. The resident was alert, verbally responsive, and could not recall how long the resident was at the facility. Resident #62 verbalized no concerns with their care. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #62. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, unspecified dementia with psychotic disturbance, and hypertension. A comprehensive Minimum Data Set (MDS) assessment, dated 6/08/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #36 scored a 11 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order dated 4/15/24 read, Lorazepam Oral Concentrate 2MG/ML (milligrams/milliliters) give 1 ml by mouth every 4 hours as needed (PRN) for Agitation and anxiety. A care plan with a focus that read, [Resident #62] uses antipsychotic medication (med) (Seroquel) r/t [related to] agitation not resolved by lorazepam use. The care plan was dated 02/08/24 and last revised on 8/30/24. An intervention for the care plan read Gradual dose reduction as directed by physician with an initiation date of 02/08/24. A review of the psychiatry consultant notes revealed there were no notes found after February 2024. On 9/18/24 at 02:00 PM, the surveyor requested the CP recommendations from the last three months and psychiatry consultant notes. On 9/19/24 at 9:00 AM, the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) provided documentation that indicated the resident representative wanted the primary physician to be responsible for the resident's med regimen and not the psychiatry consultant after February 2024. The LNHA stated they would provide the CP recommendations to the surveyor. On 9/19/24 at 9:30 AM, the LNHA provided the CP recommendations for Resident #62. A review of the CP reports for June 2024, July 2024 and August 2024 revealed there were recommendations to specify a duration for the PRN psychoactive medications (meds) (lorazepam), unless clinical rationale documented by physician. The June 2024 report, dated 6/27/24, handwritten by the entry indicated the physician was informed and hospice to communicate. The July 2024 report dated 7/31/24, handwritten by the entry read awaiting hospice recommendation. The August 2024 report dated 8/30/24, handwritten by the entry indicated the resident had not taken the med since ordered. Additional review of progress notes revealed there was no documentation of follow up with physicians or hospice regarding CP recommendations. There was also no documentation by the primary physician and nurse practitioner (NP) about review of the resident's psychotropic med regimen. On 9/19/24 at 10:12 AM, the surveyor interviewed and reviewed the CP recommendation reports with the DON. The DON stated she had reviewed the August 2024 CP report on 9/2/24 and reviewed the Medication Administration Record (MAR) for Resident #62. The DON further explained that the resident had not received any PRN lorazepam and she was going to follow up with the physician and hospice. The DON acknowledged that she had not followed up with the physician or hospice yet. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON), and the Regional Nurse Consultant (RNC). The surveyor informed the facility of the concern that the CP recommendations were not followed up and there was no documentation by the primary physician that indicated follow up about the resident's psychotropic med regimen. The surveyor asked who was responsible for reviewing the CP recommendation reports. The DON replied that the ADONs were responsible and that she assisted with them when needed. The surveyor asked when it was expected for the CP recommendations to be followed up. The DON responded within two weeks after the report was received. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, the RNC, and the Regional LNHA. There was no additional information provided by the facility. The surveyor reviewed the provided facility policy titled Psychotropic Medication Use with a last updated date of 4/2024. Under Policy Interpretation and Implementation it read, .12. Psychotropic meds are not prescribed or given on a PRN basis unless that med is necessary to treat a diagnoses specific condition that is documented in the clinical record .PRN orders for psychotropic meds are limited to 14 days .For psychotropic meds that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . Under Resident Evaluation of the policy, it read, .3. When determining whether to initiate, modify, or discontinue med therapy, the IDT [Interdisciplinary Team] conducts an evaluation of the resident . The surveyor reviewed the provided facility policy titled Medication Regimen Reviews with a last updated date of 4/2024. Under Policy Interpretation and Implementation it read, .11. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or (if the medical director is the physician of record) the administrator .12. Documentation will be placed in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .14. The CP provides the director of nursing services and medical director with a written, signed and dated copy of all med regimen reports. Follow up will be completed within 30 days . NJAC 8:39-27.1 (a); 29.3

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored securely and appropriately. This deficient practice was identified in one (1) of two (2) medication carts observed on the third floor during the surveyor's initial tour of the facility. This deficient practice was evidenced by the following: On 9/16/24 at 11:49 AM, the surveyor observed the medication (med) cart located on the 3rd floor, side three. The surveyor observed two vials of med located on the top of the med cart. The vials were observed to be opened for use and had a manufacturer label that reflected they contained the drug Acetylcysteine (a med used to decrease mucous in some lung conditions). The surveyor did not observe a nurse or other authorized person at the med cart. As the surveyor was attempting to locate the nurse assigned to the med cart, a nurse approached the cart and placed the vials in her pocket. The surveyor asked the nurse if she was the nurse assigned and she stated that she was. The surveyor asked the nurse if any medications (meds) should be left on top of the cart unattended. The nurse stated no, but I went to check on a resident and was going to put them back in the refrigerator. On 9/18/24 at 10:15 AM, the surveyor interviewed the Consultant Pharmacist (CP). The surveyor asked the CP if any meds should be left unattended and unsecured on top of a med cart. The CP stated, no, there should never be any meds left unattended or unsecured. The surveyor requested a policy for Med Storage from the Licensed Nursing Home Administrator (LNHA). On 9/18/24 at 11:39 AM, the surveyor, in the presence of the survey team, met with the Director of Nursing (DON), the LNHA, the Regional Nurse Consultant (RNC), and the Infection Preventionist (IP). The LNHA provided the surveyor with a policy titled Storage of Meds with a date last updated of 4/2024. The surveyor discussed the concern with meds being left unattended and unsecured on top of a med cart. The surveyor asked the DON if meds should be left on top of the med cart unattended. The DON stated no they should not be. The surveyor reviewed the policy Storage of Medications. The policy reflected under item 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer meds have access to locked meds. The policy heading also reflected The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The facility did not provide any further pertinent information. NJAC 8:39-29.4(h)

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for two (2) of the 28 residents reviewed (Residents #62 and #148). This deficient practice was evidenced by the following: 1. On 9/16/24 at 9:06 AM, the surveyor observed Resident #62 in their room, lying in bed with the head of the bed elevated. The resident was alert, verbally responsive, and could not recall how long they were at the facility. Resident #62 verbalized no concerns with their care. The surveyor reviewed the hybrid (paper and electronic) medical record of Resident #62. The admission Record (AR; a summary of important information about the resident) documented that the resident had diagnoses (Dx) that included but were not limited to, dementia, and hypertension. A comprehensive Minimum Data Set (MDS) assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/08/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #36 scored a 11 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated 01/05/24 read, DNR [do not resuscitate]. A PO dated 01/05/24 read, [agency name] hospice. A care plan (CP) with a focus that read, [Resident #62] has advance directives/wishes in place. Copy requested, POLST [Practitioner Orders for Life-Sustaining Treatment] on file. The intervention read CODE STATUS-DNR which was dated 6/04/22. The care plan was last revised 01/25/24. A completed POLST dated 8/15/22 documented the resident wished to have a DNR status. A Social Worker (SW) progress note (PN) dated 6/10/24 documented that the SW and interdisciplinary team [IDT] met with resident's representative previous week to discuss the resident's status and CP. The note indicated advance directives were reviewed and the resident had a DNR status. A review of physician PN revealed the primary nurse practitioner (NP) and the primary physician documented that the resident was a DNR/DNI [do not intubate]/DNH [do not hospitalize] status. There was no additional documentation found in the hybrid medical records that detailed the resident having a DNR/DNI/DNH status. On 9/18/24 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP) and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the concern that the physician PN by the primary NP and physician did not accurately reflect the resident's desired code status of DNR. The physician PN conflicted with all order medical record documentation. The facility stated they would review and provide further information. On 9/19/24 at 01:29 PM, the LNHA, DON, ADON/IP and RNC met with the survey team. The LNHA stated the DNR status of Resident #62 was the accurate and most up to date advance directive for the resident. The LNHA acknowledged the physician PN were not accurately documenting the resident's advance directives. There was no additional information provided by the facility. The surveyor reviewed the facility provided, undated policy titled Electronic Medical Records. The policy did not address medical record accuracy or documentation. On 9/20/24 at 8:50 AM, the surveyor requested from the LNHA any additional policies related to medical records, record keeping and physician documentation. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, the RNC, and the Regional LNHA. There was no additional information provided by the facility. 2. On 9/16/24 at 10:27 AM, the surveyor observed Resident #148 seated on the bed with breakfast in front of the resident. The nebulizer (neb) mask was hung on the oxygen (O2) regulator attached to the wall. The surveyor reviewed the hybrid medical records of Resident #148 and revealed: The AR reflected that the resident was admitted to the facility with Dx that included but were not limited to essential hypertension (elevated blood pressure), anemia (low blood count) in chronic kidney disease, unspecified fall subsequent encounter, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The most recent admission MDS with an ARD of 8/29/24, under Section C Cognitive Patterns had a BIMS score of 14 out of 15 which reflected that resident was cognitively intact. A review of the September 2024 Order Summary Report (OSR) revealed an active PO with an order date of 8/22/24 of Ipratropium Bromide (a bronchodilator medicine that dilates the airways of the lungs) Inhalation solution 0.02% 2.5 ml (milliliters) inhale orally every 6 hours (hrs) as needed (PRN) for SOB (shortness of breath) or wheezing, 2.5 ml=0.5 mg (milligrams) total. Not to exceed 6 doses/24 hrs. The personalized CP with focus was that the resident had a COPD r/t (related to) smoking with an intervention that included to give aerosol, or bronchodilators as ordered that was initiated on 8/28/24. A review of the Pulmonary (Pulmo) Consult notes dated 9/10/24 showed that the resident was referred to due to a Dx of COPD with Impression/Plan: Dx COPD, duoneb (combines ipratropium and albuterol to treat COPD) every 6 hrs, supplement O2 PRN, and monitor pulse oximeter (a noninvasive method for monitoring blood O2 saturation). A review of the PN revealed that the Physician who did the Pulmo consult on 9/10/24 documented in the PN that the resident was seen and examined, and to see documents for pulmo consultation. A review of the 9/04/24 and 9/13/24 PN of the NP showed that the NP documented on both PNs Respiratory: Good air entry, Nonlabored, Now wheezing, rhonchi or crackles. Further review of the PN showed that the plan for the resident that was documented on 9/10/24 by the Pulmo doctor was not followed. There was no documented evidence that the Primary Care Physician (PCP) nor the NP caring for the resident was notified of the plan. On 9/18/24 at 9:27 AM, the surveyor interviewed the ADON/IP. The surveyor notified the ADON/IP of the above findings and concerns regarding the 9/10/24 Pulmo consult. The ADON/IP stated that there should be documentation that the Pulmo consult was relayed to the PCP and if the PCP agreed or disagreed with the recommendations it should be in the PN. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor notified the facility management of the above concerns and findings. On 9/18/24 at 01:56 PM, the DON informed the surveyor in the presence of the survey team that according to the Unit Manager/Licensed Practical Nurse (UM/LPN), during their (Pulmo doctor and the UM/LPN) rounds on 9/10/24, the Pulmo doctor was made aware that the resident had an order for PRN Ipratropium, and the doctor verbally stated to the UM/LPN not to proceed with the plan of duoneb and the monitoring of O2 saturation. The DON further stated that according to the UM/LPN, she was unaware that the Pulmo consult paper was handed to someone (unsure who was the person) and it was uploaded to the electronic medical record. The DON also stated that per UM/LPN, if she knew it was uploaded, she should have questioned the recommendations. At that same time, the surveyor asked the DON who was responsible for reviewing the PN of the NP and should the notes had been clarified prior to the surveyor's inquiry. The DON acknowledged that the UM had written a note regarding the round with the Pulmo doctor after the surveyor's inquiry. The DON further stated that the NP's PN should have been clarified as well. Furthermore, the DON stated that the NP notes should not copy and paste notes. She further stated that the 9/04/24 and 9/13/24 PN of the NP about new wheezing should have been no wheezing. On 9/20/24 at 11:19 AM, the survey team met with the LNHA and DON, RNC#1, and Regional LNHA. The LNHA stated I think we provided everything, and nothing to add. A review of the facility's Electronic Medical Records Policy with an updated date of 4/2024 that was provided by the DON revealed: Policy Statement: Electronic medical records may be used in lieu of paper records when approved by the administrator. Policy Interpretation and Implementation: 1. Electronic records are an acceptable form of medical record management . On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. NJAC 8:39-23.2 (a)(b); 35.2 (d)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The surveyor reviewed the hybrid medical record of Resident #62 and revealed: The AR documented that the resident had Dx that included but were not limited to, dementia, and hypertension. A comprehensive MDS assessment, dated 6/08/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #36 scored a 11 out of 15, which indicated the resident had moderate cognitive impairment. Section O of the MDS indicated the pneumococcal vaccine was offered and decline. A review of immunizations listed in the EMR revealed there was no documentation to indicate administration or declination of the pneumococcal vaccine. Additional review of the EMR revealed no documentation of the resident's vaccination status being assessed or pneumococcal vaccine being offered. A review of the paper chart revealed there was no documentation indicate administration or declination of the pneumococcal vaccine. A review of physician orders revealed there was no physician orders for pneumococcal vaccine administration. On 9/19/24 at 9:45 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) about resident immunization. The ADON/IP stated all residents were offered vaccination unless contraindicated and the resident's immunization status was assessed upon admission by the nurses. The ADON/IP further explained if a vaccination was declined it should be documented in the EMR. The surveyor discussed with the ADON/IP that there was no documentation found in Resident #62's EMR regarding pneumococcal vaccination. The ADON/IP stated she would follow up to provide further information. On 9/19/24 at 12:05 PM, the ADON/IP stated she could not find documentation to indicate Resident #62 was a assessed or offered a pneumococcal vaccine. The ADON/IP stated there was no declination forms that the facility used and that it would be documented in the immunizations tab and progress note in the EMR. The surveyor asked who was responsible for resident's immunizations. The ADON/IP stated that she currently was and that previously it was former ADONs. The surveyor asked how often a resident's immunization would be reviewed to ensure their immunizations were up to date. The ADON/IP replied she would specifically for long term residents review every six months and that she could not speak to what happened with Resident #62's pneumococcal vaccination record. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The survey notified the facility management about the concern that there was no documentation of Resident #62 being assessed and offered the pneumococcal vaccine. There was no verbal response by the facility at this time. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, RNC#1, and the Regional LNHA. The regional LNHA stated that a resident/resident representative would be educated regarding pneumococcal vaccine upon admission and that it was included in the admission packet, which was signed by the resident/resident representative. The surveyor reviewed the facility provided admission packet for Resident #62. The document included an overall outline which included a page for pneumococcal vaccine. There was no documentation in the provided admission packet which indicated the pneumococcal vaccine was offered or declined. There was no additional information provided. Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a pneumococcal vaccine or document the reason for ineligibility for the pneumococcal vaccine for three (3) of five (5) residents reviewed for immunizations (Resident #43, #62 and #148). The deficient practice was evidenced by the following: Reference: Centers for Disease Control (CDC) recommends pneumococcal vaccination (PCV) for many adults based on age, having certain risk conditions, and pneumococcal vaccines already received . CDC recommends PCV15, PCV20, or PCV21 for adults who never received a PCV and are Ages 65 years or older Ages 19 through 64 years with certain risk conditions. Chronic conditions and other factors that increase someone's risk for pneumococcal disease include: Chronic heart, kidney, liver, or lung disease (Chronic lung disease includes chronic obstructive pulmonary disorder (COPD), emphysema, and asthma); Diabetes; Immunocompromising condition (having a weakened immune system). 1. On 9/18/24 at 12:39 PM, the surveyor reviewed Resident #43's hybrid (combination of paper and electronic) medical record and revealed: Resident #43's admission Record (AR; or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses (Dx) that included but were not limited to metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain), multiple myeloma (cancer that develops when abnormal plasma cells build up in the bone marrow and form tumors in the bones, which can lead to dysfunction of the immune system), type 2 diabetes mellitus (a chronic disease that occurs when the body is unable to produce enough insulin or use it properly, resulting in high blood sugar levels), hypertension (high blood pressure), morbid obesity (disorder that involves having too much body fat, which increases the risk of health problems), anemia (condition in which the body doesn't produce enough healthy red blood cells, which results in a lack of oxygen-rich blood) and asthma (chronic lung disease that causes inflammation in the airways, making it difficult to breathe). Further review of the above AR showed that the resident had comorbidities (simultaneous presence of two or more medical conditions in a patient). A review of Resident #43's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #43 was cognitively intact. Further review of the MDS indicated that the resident's pneumococcal vaccination was not up to date and that the reason was the resident was not eligible. A review of the immunizations tab in the electronic medical record (EMR) revealed there was no documentation to indicate administration, declination or not eligible status of the pneumococcal vaccine. Additional review of Resident #43's hybrid medical record revealed no documentation of the resident's vaccination status being assessed or pneumococcal vaccine being offered. On 9/18/24 at 12:58 PM, in the presence of another surveyor, the surveyor notified the Licensed Nursing Home Administrator (LNHA) the concern that there was no documentation of the reason why Resident #43 was ineligible for the pneumococcal vaccine. On 9/20/24 at 11:21 AM, in the presence of the survey team, Director of Nursing (DON), Regional Nurse Consultant #1 (RNC#1), and Regional LNHA, the LNHA stated that residents were offered the vaccination. The LNHA stated that Resident #43's age would typically be the reason why she was not eligible. The facility did not provide any documentation of the reason why Resident #43 was not offered or was ineligible for the pneumococcal vaccination. The facility did not provide any additional information. 3. On 9/16/24 at 10:27 AM, the surveyor observed Resident #148 seated on the bed with breakfast in front of the resident. The nebulizer (neb) mask was hung on the oxygen (O2) regulator attached to the wall. The surveyor reviewed the hybrid medical records of Resident #148 and revealed: The AR reflected that the resident was admitted to the facility with Dx that included but were not limited to essential hypertension (elevated blood pressure), anemia (low blood count) in chronic kidney disease, unspecified fall subsequent encounter, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The most recent admission MDS assessment dated [DATE], under Section C Cognitive Patterns had a BIMS score of 14 out of 15 which reflected that resident was cognitively intact. Section O Special Treatments, Procedures, and Programs showed that the pneumococcal vaccine was not offered. Further review of the hybrid medical records revealed that there was no documented evidence that the pneumococcal vaccine was offered and declined by the resident. There was no documented evidence that the resident received an education about the risks and benefits of the vaccine. On 9/18/24 at 9:27 AM, the surveyor interviewed the ADON/IP. The ADON/IP stated that immunization records should be found in the resident's medical records and everything should be entered either in the immunization tab or miscellaneous of the EMR. She further stated that it was usually done by the Admitting Nurse, once the resident was admitted to the facility the nurse would check the hospital or other facility records provided upon admission. She also stated that if the resident did not have records, all immunizations that included influenza, pneumococcal, and COVID-19 vaccines would be offered, and education provided to the resident. On that same date and time, the surveyor notified the ADON/IP of the above findings and concerns. The ADON/IP checked the EMR and stated that she did not find any immunization records on the computer. The ADON/IP also checked the paper chart of the resident and stated that she did not find any records for immunizations that the pneumococcal vaccine was offered, declined and education was provided. She stated she did not know what happened and why there was no documentation that the vaccine was offered. She also stated that there was no education and no consent found. She further stated that it should have been offered. On 9/18/24 at 10:32 AM, the surveyor interviewed the Registered Nurse MDS Coordinator (RNMDSC). The RNMDSC informed the surveyor that she thinks the facility had a policy for MDS and they also follow the RAI (Resident Assessment Instrument) Manual for doing MDS. She further stated that she gathered the information that was put in the MDS or to answer the MDS in the resident's chart, orders, nurses, and other IDT (interdisciplinary team) notes including doctors and consultants, eMAR (electronic Medication Administration Record), eTAR (electronic Treatment Administration Record), resident/representative's interviews. At that same time, the surveyor asked the RNMDSC about Section O was coded pneumococcal was not offered. The RNMDSC stated that during the lookback, there was no documentation that the vaccine was offered, and that was why it was coded as not offered. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor notified the facility management of the above concerns. On 9/19/24 at 01:26 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. The LNHA stated that as per concern with the pneumococcal vaccine, the facility utilized an outside company for doing their MDS, unlike now, the facility had an in-house MDS staff. A review of the facility's Pneumococcal Vaccine Policy with an updated date of 02/2024 revealed: Policy Statement: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident has already been vaccinated. 2.Provision of such education shall be documented in the resident's medical record. 3. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol. 4. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. 6. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC and Advisory Committee on Immunization Practices recommendations at the time of the vaccination. On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. NJAC 8:39-19.4 (a,4)(d)(h)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the closed medical record for Resident #209 revealed: The AR showed that Resident #209 was admitted to the facility with diagnoses which included but were not limited to: lower back pain, hypertension (high blood pressure), and metabolic encephalopathy (change in how brain works due to an underlying condition). A review of the resident's Quarterly MDS (QMDS) dated [DATE], reflected the resident had a BIMS of 7 out of 15, which indicated the resident had moderate cognitive impairment. The QMDS with an ARD (is the last day of that period of time that the MDS assessment coves for that particular assessment for that particular resident) of 6/16/24 Section J - Health Condition (J0100 - Pain Management), signed by RN/MDSC#2 on 6/24/24, revealed the assessment was done eight (8) days after the ARD of 6/16/24. This interview is conducted during the look-back period of the ARD. On 9/19/24 at 10:30 AM, in the presence of second surveyor, the surveyor interviewed RN/MDSC#1 about the process for completing section J- pain assessment. RN/ MDSC#1 stated that she would check eMARs/eTARs, interview the residents and the staff. She further explained the interview should be conducted during five (5) day look back period. The surveyor asked RN/MDSC #1 if the Section J- pain assessment interview should be conducted prior to or after the ARD date. The RN/MDSC did not provide verbal response to the question. On 9/19/24 at 01:27 PM, the survey team met with DON, LNHA, ADON/IP and RNC#1. The surveyor notified the facility management of the above findings and concerns. On 9/20/24 at 11:21 AM, the survey team met with DON, LNHA, RNC #1, Regional LNHA for responses. No responses were provided. On 9/20/24 at 01:15 PM, the survey team met with DON, LNHA, RNC #1, RNC #2, Regional LNHA for an exit conference. No additional information was provided by the facility. A review of the latest version of CMS- RAI 3.0 Manual (updated October 2023), Chapter 3, page J-5, Under tips and Special Populations, it read, Attempt to conduct the interview with all residents. This interview is conducted during the look-back period of the ARD and is not contingent upon item B0700, Makes self-Understood. NJAC 8:39-11.1; 11.2(e)(1); 33.2 (d) 2. On 9/16/24 at 9:06 AM, the surveyor observed Resident #62 in their room, lying in bed with the head of the bed elevated. The resident was alert, verbally responsive, and could not recall how long they were at the facility. Resident #62 verbalized no concerns with their care. The surveyor reviewed the hybrid medical record of Resident #62. The AR documented that the resident had diagnoses that included but were not limited to, dementia, and hypertension. A Significant Change in Status Assessment (SCSA) MDS assessment, dated 6/08/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #36 scored a 11 out of 15, which indicated the resident had moderate cognitive impairment. A review of a social services' note dated 6/10/24 read Annual review- SW[social worker] and IDT met with [resident representative] earlier last week .No significant changes noted cognitively, socially or physically. [Resident #62] appears to be adjusting well to facility and routine with no mood indicators There was no additional documentation found that the IDT reviewed and determined there was a significant change with the resident. Additionally, a review of the resident's care plan (CP) revealed there was no documentation to indicate a significant change in the resident's status. On 9/18/24 at 10:42 AM, the surveyor interviewed RN/MDSC#1, about the SCSA completed for Resident #62. The RN/MDSC stated she was not MDS coordinator at the time and would have to review why the SCSA was completed for the resident. On 9/19/24 at 9:10 AM, RN/MDSC#1 met with the surveyor and stated the SCSA was completed as the resident was on hospice and believed the IDT at the time assessed the resident who showed a decline in status for a significant change. The surveyor stated the notes from June 2024 do not reflect a significant change in resident and requested additional supportive documentation for the SCSA of Resident #62. On 9/19/24 at 02:15 PM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor informed the facility of the concern for the SCSA. The documentation did not reflect reason for SCSA was completed and the RN/MDSC did not provide any additional information. The LNHA stated they would follow up to provide additional information. Additional review of the SCSA dated 6/8/24 revealed: Under Section E, E1100, Change in Behavior or Other Symptoms, it was coded 3. N/A (not applicable) because no prior MDS assessment. A review of the resident's MDS assessments revealed there were previous MDS assessments. Under Section O, O0300, Pneumococcal Vaccine it was coded the resident had not received the vaccine because it was offered and declined. There was no documentation in the medical record found to indicate the resident was offered and declined a pneumococcal vaccine. On 9/20/24 at 9:54 AM, the surveyor interviewed RN/MDSC#1 about Section E, E1100 coding of the SCSA. The surveyor reviewed the entry with the RN/MDSC. She stated she believed the N/A coding would not be appropriate if the resident had a previous MDS. She further stated she would like to review Resident #62's medical record to verify if E1100 was coded inaccurately. On 9/20/24 at 11:21 AM, the survey team met with the LNHA, the DON, the RNC#1, and the Regional LNHA who were made aware of concern with coding of E1100 and O0300. There was no additional information provided by facility. A review of the latest version of the CMS - RAI 3.0 Manual (updated October 2023), Chapter 2-page 2-24, under SCSA (A0310A = 04) it read, The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline . 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'selflimiting'; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the CP. A review of the latest version of the CMS - RAI 3.0 Manual (updated October 2023), Chapter 3-page E-22, under E1100 Steps for Assessment read: 1. Review responses provided to items E0100-E1000 on the current MDS assessment. 2. Compare with responses provided on prior MDS assessment. 3. Taking all of these MDS items into consideration, make a global assessment of the change in behavior from the most recent to the current MDS. 4. Rate the overall behavior as same, improved, or worse. Under Coding Instructions, it read: .Code 0, same: if overall behavior is the same (unchanged) .Code 1, improved: if overall behavior is improved .Code 2, worse: if overall behavior is worse .Code 3, N/A: if there was no prior MDS assessment of this resident . A review of the latest version of the CMS - RAI 3.0 Manual (updated October 2023), Chapter 3-page O-17, under O0300B Coding Instructions it read: Code 2, Offered and declined: resident or responsible party/legal guardian has been informed of what is being offered and chooses not to accept the pneumococcal vaccine . REPEAT DEFICIENCY Complaint #NJ175244 Refer to F883 Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 28 residents, (Residents #62, #148, and #209), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI (Resident Assessment Instrument) Manual of October 2023, for definitions of the types of therapies listed in this section, please refer to the Glossary in Appendix A. O-23 Coding Instructions: Coding Instructions for Respiratory, Psychological, and Recreational Therapies. o Total Minutes-Enter the actual number of minutes (mins) therapy services were provided in the last 7 (seven) days. Enter 0 if none were provided. o Days-Enter the number of days therapy services were provided in the last 7 days. A day of therapy is defined as treatment (tx) for 15 min or more in the day. Enter 0 if therapy was provided but for less than 15 mins every day for the last 7 days. If the total number of mins during the last 7 days is 0, skip this item and leave blank. 1. On 9/16/24 at 10:27 AM, the surveyor observed Resident #148 seated on the bed with breakfast in front of the resident, the nebulizer (neb) mask was hung on the oxygen (O2) regulator attached to the wall. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #148 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), anemia (low blood count) in chronic kidney disease, unspecified fall subsequent encounter, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). A review of the September 2024 Order Summary Report (OSR) revealed an order for: -Cephalexin (an antibiotic that can treat infections) oral capsule 250 mg (milligrams) give 1 capsule by mouth one time a day for prosthetic joint ppx (prophylaxis) for 27 Administrations-Start Date 8/23/2024. - Incentive Spirometry: Assist resident (as needed) to place the mouthpiece in the mouth, sealing lips around it. Breathe in as slowly and deeply as possible. Try to raise the piston toward the top of the column. Hold breath as long as possible before exhaling for 5 repetitions and 3 sets. Cough between breaths. three times a day for 14 days- Start Date 8/22/2024. The above order for Cephalexin was transcribed to the August 2024 electronic Medication Administration Record (eMAR) and signed by nurses as administered. The above order for incentive spirometry (a handheld medical device used to help patients improve the functioning of their lungs, by training residents to take slow and deep breaths, this simplified spirometer facilitates lung expansion and strengthening) was transcribed to the August 2024 eMAR and signed by nurses from 8/23/24 through 8/29/24 for a total of seven days and 155 mins as follows: Date Minutes 8/23/24: AM none Noon 5 Evening 15 8/24/24: AM none Noon 5 Evening 15 8/25/24: AM 15 Noon 15 Evening 15 8/26/24: AM none Noon 15 Evening 15 8/27/24: AM 5 Noon 5 Evening 15 8/28/24: AM none Noon 5 Evening 5 8/29/24: AM none Noon 5 Evening blank Total minutes: 155 mins Total days: 7 days The most recent admission MDS with an assessment reference date (ARD) of 8/29/24, under Section C Cognitive Patterns, reflected a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which reflected that the resident was cognitively intact. Section N Medications showed that the resident was not coded for antibiotic (ABT) use. Section O Special Treatments, Procedures, and Programs reflected that the resident received respiratory therapy for 165 mins and six days during the lookback period (the time period over which the resident's condition or status is captured by the MDS assessment). On 9/18/24 at 10:32 AM, the surveyor interviewed Registered Nurse/MDS Coordinator #1 (RN/MDSC#1). The RN/MDSC informed the surveyor that the facility followed the RAI Manual for MDS. She further stated that she gathered the information that was put in the MDS or to answer the MDS from the resident's chart, orders, nurses, and other IDT (interdisciplinary team) notes including doctors and consultants, eMAR, eTAR (electronic Treatment Administration Record), and resident's interview. At that same date and time, the surveyor notified the RN/MDSC of the above findings and concerns that the MDS on 8/29/24 did not show that the resident received ABT even though the nurses signed the eMAR from 8/23/24 through 8/29/24 for Cephalexin. The surveyor also notified the RN/MDSC of the concern regarding Section O respiratory therapy. The surveyor asked why the 8/29/24 MDS was not coded for ABT, what happened why there was a discrepancy between what was coded in Section O of the MDS, and the RN/MDSC stated that she would get back to the surveyor. On 9/18/24 at 11:39 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the above concerns with the accuracy of MDS for ARD 8/29/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 9/16/24 at 10:33 AM, during the initial tour the surveyor observed Resident #124 eating breakfast in their chair. The surveyor observed undated O2 tubing connected to the wall O2 flowmeter. The tubing was open and placed on top of the nightstand. There was a signage posted outside the resident's room which indicated O2 in use. On 9/17/24 at 12:20 PM, the surveyor observed the resident in their bed, watching television. The surveyor did not observe O2 tubing in the room. O2 in use signage was observed at the door before entering in the room. The surveyor reviewed the medical record for Resident #124. The AR revealed that Resident #124 was admitted to the facility with Dx which included but were not limited to: Acute [characterized by sharpness or severity of sudden onset] respiratory failure with hypoxia (happens when you don't have enough oxygen in your blood), hypertension, and muscle weakness (generalized). A review of the cMDS dated [DATE] reflected a BIMS score of 11 out of 15, which indicated that the resident had a mildly impaired cognition. Section O of the MDS, indicating Special Treatments, Procedures, and Programs received by Resident #124 in the last 14 days documented, O2 Therapy. A review of Resident #124's PN which reflected that Resident #124 was on O2 therapy are as follow: A PN dated 7/17/24 at 7:56 AM - Patient received in bed O2 via NC in place. A Skilled Evaluation GG note dated 7/18/24 at 13:22 (01:22 PM) stated O2 sat: 97%, Method: O2 via NC. A Physician/NP/PA (physician assistant) PN dated 7/30/24 at 16:57 (4:57 PM) mentioned VS: 124/74, 83, 18, 98 F, 98% on 2L NC. A review of Resident #124's OSR did not reflect PO for O2 therapy. A review of Resident #124's electronic Medication Administration Record (eMAR) did not reflect an order to administer O2 therapy. A review of Resident #124's eTAR did not reflect an order to change Equipment (O2 tubing) as per PO or per facility policy/protocol. A review of Resident #124's CP did not reflect a CP for O2 therapy. On 9/19/24 at 01:27 PM, the survey team met with the DON, LNHA, ADON/IP and RNC#1. The surveyor notified the facility management of the above findings and concerns. The ADON/IP acknowledged that it was not an acceptable practice to place a resident on O2 without a PO. On 9/20/24 at 9:28 AM, the DON explained that O2 tubing would be dated once it was removed out of the packing. It would be stored in a small plastic bag when the equipment/O2 tubing was not in use. DON further stated that O2 tubing would be changed every 7 days. The nurses would document that in eTAR. A review of the facility's policy Oxygen Administration with a last updated date of 4/2024, revealed: Purpose of this procedure is to provide guidelines for safe O2 administration. Under Preparation: 1.) Verify that there is a PO for this procedure. Review the PO or facility protocol for O2 administration. 2.) Review the resident's CP to assess for any special needs of the resident. On 9/20/24 at 01:15 PM, the survey team met with DON, LNHA, RNC #1, RNC #2, Regional LNHA for an exit conference. No additional information was provided. N.J.A.C. 8:39-11.2 (a)(b)(e); 19.4(a); 27.1(a) 3. On 9/16/24 at 10:16 AM, the surveyor observed Resident #11 lying in a low to the floor bed with O2 being delivered via NC tubing from the O2 regulator connected to the wall. The surveyor observed that there was an additional NC tubing that was not dated that was attached to a portable O2 tank that was on the back of Resident #11's wheelchair (w/c). The NC tubing was hung over the portable tank and it was not contained in a bag. On 9/17/24 at 9:44 AM, the surveyor observed that Resident #11's additional NC tubing that was not dated that was attached to a portable O2 tank on the back of the w/c. The NC tubing was hung over the portable tank and it was not contained in a bag. A review of Resident #11's AR indicated that the resident was admitted to the facility with medical Dx that included but were not limited to acute respiratory failure (a condition where there's not enough O2 or too much carbon dioxide in your body), COPD, and hypertension (high blood pressure). A review of Resident #11's most recent Significant change in status MDS, reflected that the resident had a BIMS score of 06 out of 15, which indicated that Resident #11's cognition was severely impaired. Further review reflected that the resident received O2 therapy. On 9/17/24 at 10:19 AM, the surveyor interviewed LPN#1 regarding the process for O2. LPN#1 stated that O2 tubing was changed weekly and dated using tape. She added that when it was not in use that it should be placed in a bag. The surveyor asked LPN#1 to observe Resident #11's NC on the w/c. The LPN confirmed the NC was not dated and not in bag and that it should have been. On 9/17/24 at 12:31 PM, the surveyor interviewed the third UM/LPN regarding O2. The UM/LPN stated that O2 tubing was changed weekly on Sunday and dated. She added that if it was not in use that it should be placed in a bag. 4. On 9/16/24 at 9:55 AM, the surveyor observed Resident #103 seated in a w/c. The surveyor observed that on the back of the w/c was a portable O2 tank that had a NC tubing that was not dated and was hung over the tank. The NC tubing was not placed in a bag when not in use. The surveyor also observed a neb tx mask and tubing, dated 9/16/24, that was partially wrapped in a paper towel. The mask was not contained in a bag. Resident # 103 stated that they did not need O2 anymore and only received breathing tx. A review of Resident #103's AR indicated that the resident was admitted to the facility with medical Dx that included but were not limited to COPD, pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, making it difficult to breathe) and hypertension. A review of Resident #103's most recent qMDS reflected that the resident had a BIMS score of 12 out of 15, which indicated that Resident #11's cognition was moderately impaired. Further review reflected that the resident received O2 therapy. On 9/17/24 at 10:25 AM, the surveyor interviewed LPN#1 regarding the process for O2 and neb tx. The LPN stated that O2 tubing was changed weekly and dated using tape. The LPN further stated that the neb mask should be washed and dried and placed in a bag when not in use. She added that when the O2 tubing was not in use that it should be placed in a bag. The surveyor asked the LPN to observe Resident #103's NC on the w/c. LPN#1 confirmed the NC was not dated and not in bag and that it should have been. On 9/17/24 12:37 PM, the surveyor interviewed the UM/LPN regarding neb tx mask. The third floor UM/LPN stated that neb tx mask should be in a bag when not in use. On 9/18/24 at 12:00 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, RNC#1 and ADON/IP the concerns that Resident #11 and #103 had O2 tubing not dated and not contained in a bag when not in use and Resident #103 had the neb mask and tubing partially wrapped in paper towel and not contained in a bag when not in use. The facility did not provide any additional information. A review of the undated facility provided policy titled, Oxygen Administration included the following: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy did not contain information regarding dating the tubing or storage of respiratory equipment when not in use. Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order for one (1) of five (5) residents, Resident #67, b.) followed and clarified the plan for respiratory care of one (1) of five (5) residents, Resident #148), c.) ensure respiratory tubing, cannula, and masks were stored in accordance with infection control measures for four (4) of five (5) residents, Residents #11, #103, #124, and #148, and d.) obtain a physician order for oxygen therapy for one (1) of five (5) residents, Resident #124, reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 9/16/24 at 10:25 AM, the surveyor observed Resident #67's room closed with an oxygen (O2) sign outside the door. Licensed Practical Nurse #1 (LPN#1) came out from the resident's room and informed the surveyor that the surveyor had to return later. The LPN further stated that there were two aides providing care. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #67 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses (Dx) that included but were not limited to essential hypertension (elevated blood pressure), unspecified sequelae of cerebral infarction (also known as an ischemic stroke, the pathologic process that results in an area of necrotic tissue in the brain), atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung), altered mental status, hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction, and gastrostomy (surgical opening into the stomach for nutritional support or gastric decompression) status. The most recent quarterly Minimum Data Set (qMDS) with an assessment reference date (ARD) of 6/29/24, an assessment tool used to facilitate the management of care, under Section C Cognitive Patterns, reflected cognitive skills for daily decision-making made regarding tasks of daily life score of 3 out of 15 which indicated that the resident's cognition was severely impaired. Section O Section O Special Treatments, Procedures, and Programs reflected that the resident received O2 therapy during the last 14 days. A review of the personalized care plan (CP) with the focus that the resident had O2 therapy with an intervention that included O2 settings via nasal cannula (NC) at 2 L/M (liters/minute) that was initiated on 9/18/24. A review of the September 2024 Order Summary Report (OSR) revealed an active physician order (PO) with an order date of 02/21/24 for O2 at 2LPM (liters per minute) per NC for respiratory distress/SOB (shortness of breath) every shift. The above order for O2 was transcribed to the September 2024 electronic Treatment Administration Record (eTAR) and signed every shift by nurses as administered. On 9/18/24 at 9:49 AM, the surveyor and LPN#2 went to the resident's room, and both observed the resident on the bed at approximately 45 degrees sitting position with TF (tube feeding) running via a machine. The resident was on 4LPM via NC. LPN#2 confirmed it was at 4LPM and the date in the tubing wrapped around tape was 9/16/24 which she claimed was the date the tubing was changed. On that same date and time, LPN#2 asked the Unit Manager/Licensed Practical Nurse (UM/LPN) to help her reposition the resident. Both LPN#2 and UM/LPN confirmed the resident was on 4LPM via NC. On 9/18/24 at 9:53 AM, the UM/LPN checked the electronic medical record (EMR) for the resident's order for O2. The UM/LPN stated that the resident's PO was 2LPM, not 4LPM and she did not know who changed the O2 to 4LPM. She further stated that she would assess the resident, and she immediately went to the resident's room. On 9/19/24 at 01:26 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing/Infection Preventionist (ADON/IP), Director of Nursing (DON), and Regional Nurse Consultant #1 (RNC#1). The DON stated that the nurses should follow the PO for 2LPM and it was a human error when the O2 was observed at 4LPM. 2. On 9/16/24 at 10:27 AM, the surveyor observed Resident #148 seated on the bed with breakfast in front of the resident. The nebulizer (neb) mask was hung on the O2 regulator attached to the wall, undated, and not properly stored (exposed to environment). The surveyor reviewed the hybrid medical records of Resident #148 and revealed: The AR reflected that the resident was admitted to the facility with Dx that included but were not limited to essential hypertension (elevated blood pressure), anemia (low blood count) in chronic kidney disease, unspecified fall subsequent encounter, and chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The most recent comprehensive MDS (cMDS) with an ARD of 8/29/24, under Section C, a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which reflected that resident was cognitively intact. A review of the September 2024 OSR revealed an active PO with an order date of 8/22/24 of Ipratropium Bromide (a bronchodilator med that dilates the airways of the lungs) Inhalation solution 0.02% 2.5 ml (milliliter(s)) inhale orally every 6 hours (hrs) as needed (PRN) for SOB or wheezing, 2.5 ml=0.5 mg (milligram(s)) total. Not to exceed 6 doses/24 hrs. The personalized CP with focus was that the resident had a COPD r/t (related to) smoking with an intervention that included to give aerosol, or bronchodilators as ordered that was initiated on 8/28/24. Further review of the CP revealed that there was no documented evidence for care of respiratory equipment and supplies r/t on how to store neb mask when not in use or the proper storage. A review of the Pulmonary (Pulmo) Consult notes dated 9/10/24 showed that the resident was referred to due to a Dx of COPD with Impression/Plan: Dx COPD, duoneb (combines ipratropium and albuterol to treat COPD) every 6 hrs, supplement O2 PRN, and monitor pulse oximeter (a noninvasive method for monitoring blood O2 saturation). A review of the Progress Notes (PN) revealed that the Physician who did the Pulmo consult on 9/10/24 documented in the PN that the resident was seen and examined, and to see documents for pulmo consultation. A review of the 9/04/24 and 9/13/24 PN of the Nurse Practitioner (NP) showed that the NP documented on both PNs Respiratory: Good air entry, Nonlabored, Now wheezing, rhonchi or crackles. Further review of the PN showed that the plan for the resident that was documented on 9/10/24 by the Pulmo doctor was not followed. There was no documented evidence that the Primary Care Physician (PCP) nor the NP caring for the resident was notified of the plan. On 9/18/24 at 9:27 AM, the surveyor interviewed the ADON/IP. The surveyor notified the ADON/IP of the above findings and concerns regarding the 9/10/24 Pulmo consult. The ADON/IP stated that there should be documentation that the Pulmo consult was relayed to the PCP and if the PCP agreed or disagreed with the recommendations it should be in the PN. On that same date and time, the ADON /IP stated that the neb mask should have been stored in a bag when not in use and dated. She further stated that the reason for proper storage was for infection control and to protect from bacteria. On 9/18/24 at 9:40 AM, the surveyor and the ADON/IP went inside the resident's room, and both observed the neb mask was hung on the O2 regulator attached to the wall, not stored in a bag, and no date in the tubing. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, ADON/IP, and RNC#1. The surveyor notified the facility management of the above concerns and findings. On 9/18/24 at 01:56 PM, the DON informed the surveyor in the presence of the survey team that according to the UM/LPN, during their (Pulmo doctor and the UM/LPN) rounds on 9/10/24, the Pulmo doctor was made aware that the resident had an order for PRN Ipratropium, and the doctor verbally stated to the UM/LPN not to proceed with the plan of duoneb and the monitoring of O2 saturation. The DON further stated that according to the UM/LPN, she was unaware that the Pulmo consult paper was handed to someone (unsure who was the person) and it was uploaded to the EMR. The DON also stated that per UM/LPN, if she knew it was uploaded, she should have questioned the recommendations. At that same time, the surveyor asked the DON who was responsible for reviewing the PN of the NP and should the notes had been clarified prior to the surveyor's inquiry. The DON acknowledged that the UM had written a note regarding the round with the Pulmo doctor after the surveyor's inquiry. The DON further stated that the NP's PN should have been clarified as well. On 9/20/24 at 11:19 AM, the survey team met with the LNHA and DON, RNC#1, and Regional LNHA. The LNHA stated I think we provided everything, and nothing to add. A review of the facility's Care Plans, Comprehensive Person-Centered Policy with last updated date of 4/2024 that was provided by the DON showed: Policy Statement: a comprehensive, person-centered CP that included measurable objectives, and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 3. The CP interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment 7. The comprehensive, person-centered CP: e. reflects currently recognized standards of practice for problem areas and conditions . A review of the facility's Physician Orders Policy with an updated date of 4/2024 that was provided by the DON revealed: Policy: Medication (med) and treatment (tx) orders will be accepted only from authorized, credentialed physicians or from other authorized, credentialed practitioners in accordance with state regulations regarding prescriptive privileges. Process: Type of Order: 2. Must be recorded in the EMR . Consultant Recommendations/Orders: 1. Consultants may make recommendations for any med or tx, as necessary as long as in all cases, the attending physician must be notified of the order and approved per state regulations. 4. Findings and recommendations will be documented on the Consultation Form by the consultant; 5. The nurse will notify the attending physician of findings and recommendations. 6. The attending physician, if in agreement, will order the specific tx as outlined by the consultant. On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ175260 and NJ176352 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure sufficient nursing staff and ensure call bells were answered timely without waiting a long period of time for seven (7) of 28 residents (Residents # 36, 60, 83, 84, 100, 102, and 153). This deficient practice was evidenced by the following: 1. On 9/16/24 at 7:45 AM, the surveyor observed the posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 9/15/24 -Day shift 7:00 AM- 3:00 PM, which displayed Current Resident Census: 120 and the CNA (Certified Nursing Aide) to Resident ratio of 1:8.6. On 9/17/24 at 8:45 AM, the surveyor observed the posted NHRCSR dated 9/16/24 - Day shift 7:00 AM-3:00 PM, Current Resident Census: 126 and the CNA to Resident ratio of 1:9. On 9/20/24 at 9:45 AM, the surveyor interviewed the Staffing Coordinator (SC). The SC informed the surveyor that she was aware of the mandated New Jersey staffing law. The SC stated that on 7 AM to 3 PM, day shift, the CNA to Resident ratio should be 1:8. 2. On 9/16/24 at 10:18 AM, during the initial tour the surveyor observed Resident #83 resting in their bed. The resident stated that the night staff takes longer to answer the call light and was worried to sit for long periods when the resident was soiled with feces. On 9/17/24 at 11:11 AM, the surveyor observed the resident watching television in the bed and the resident stated that last night they had bad cough and used the call bell to get some help, and no one answered the call bell. The resident further stated that they had to call their family member and then the staff came to assist the resident after the family member called the facility and asked them to help the resident. At 11:50 AM, Resident #83's representative (RR) called the surveyor into the room. The RR confirmed that the resident had called the family member overnight to get some help after waiting for someone to answer the call bell. The staff came to assist the resident after the family member's phone call to the facility. The family member stated when they called the facility, they were told that the staff was on break. The surveyor reviewed the medical records of Resident #83 and revealed: A review of the admission Record (AR; admission summary) revealed that Resident #83 was admitted to the facility with diagnoses which included but were not limited to: autoimmune thyroiditis (occurs when your body makes antibodies that attack the cells in your thyroid), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and difficulty in walking. A review of the resident's comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, dated 7/27/24, reflected the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated the resident had intact cognition. Further review of MDS Section GG - Functional Abilities and Goals reflected that Resident was dependent, where the helper had to do all the effort, resident did none of the effort to complete the activity, for toileting hygiene. The resident had a care plan (CP) with a focus that read, [Resident #83] has a self-care performance deficit. The CP was initiated on 7/20/24 and last revised on 7/22/24. The interventions indicated the resident was a one person assist with bathing/showering, dressing, personal hygiene, and oral care. The resident had a CP with a focus that read, [Resident #83] has limited physical mobility Weakness. The CP was initiated on 7/22/24 and last revised on 7/22/24. The interventions indicated the resident was a one person assist with ambulation/locomotion, bed mobility and transfer. 3. On 9/16/24 at 9:26 AM, the surveyor observed Resident #100 lying in their bed, alert and verbally responsive. The resident stated there were long wait times when using the call bell for assistance and it could happen on any shift. The surveyor reviewed Resident #100's medical records which revealed the following: The AR documented that the resident had diagnoses that included but were not limited to, sacral pressure ulcer, peripheral vascular disease, and polyneuropathy (disease affecting multiple nerves throughout body, causing weakness, numbness and burning pain). A cMDS assessment dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #100 scored a 14 out of 15, which indicated the resident was cognitively intact. On 9/16/24 at 9:36 AM, the surveyor observed Resident #36 lying in their bed with the head of the bed elevated. Resident #36 was alert and verbally responsive. The resident reported a concern with long wait time for call bell response on a couple of night shifts. Resident #36 stated it most recently occurred the week prior and wait times were longer than twenty minutes (mins). 4. The surveyor reviewed Resident #36's medical records which revealed the following: The AR documented that the resident had diagnoses that included but were not limited to, chronic kidney disease, heart failure, hypertension (high blood pressure), and osteoarthritis (a disease in which the tissues in the joint break down over time). A cMDS assessment dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #100 scored a 14 out of 15, which indicated the resident was cognitively intact. On 9/18/24 at 11:17 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the facility's call bell system. The LNHA stated the call bell system does not have an automated report or keep record of call bell light response. The LNHA stated that call bell audits were conducted to assess the call bell response by staff and would provide call bell audits completed to the surveyor. On 9/19/24 at 9:00 AM, the surveyor requested the call bell audits that were to be provided by the LNHA. On 9/19/24 at 9:40 AM, the LNHA provided the call bell audits that were conducted. The surveyor reviewed the provided documents titled CALL BELL AUDIT FORMS. The call bell audits were completed on 02/12/24, 02/21/24, 5/29/24, 6/03/24, 7/05/24, and 8/28/24. The call bell audits each included from two to four rooms call bell response times and 01 of the 06 call bell audits were conducted during the 11-7 shift between 6-7 AM. The call bell audits revealed wait times ranged from 04 to 25 mins. Additionally, it was documented that the staff members were in-service or re-educated when longer wait times occurred. This occurred for wait times of 16 mins, 25 mins, 18 mins, 24 mins and 15 mins. On 9/19/24 at 10:00 AM, a review of call bell audits provided by LNHA revealed call bell audits completed in February, May, June, July, and August 2024 with wait times ranging from 04-25 mins. Additionally documented were in-service for the CNA when longer wait times found, 16 mins on 02/12/24, 25 mins on 6/03/24, 18 mins on 6/03/24, 24 mins PM 8/28/24, and 15 mins on 8/28/24. On 9/19/24 at 02:04 PM, the survey team met with the Director of Nursing (DON), LNHA, Assistant Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). The surveyors informed the facility regarding the concerns with call bell response. The surveyor asked the LNHA what the expected call bell response time by staff was. The LNHA stated will ask family and residents their expectation and it was a difficult number to quantify. The LNHA stated the goal was 15 mins. The LNHA acknowledged that in the case of something emergent or a resident needing immediate assistance it was important for staff to answer call bells as promptly as possible. The surveyor reviewed the provided facility policy titled, Call System, Resident with an updated date of 4/2024. Under Policy Interpretation and Implementation, it read: .6. Calls for assistance are answered as soon as possible . 5. On 9/18/24 at 11:03 AM, during the resident Council meeting, four (4) of four (4) residents (Resident #84, #153, #60, and #102) stated that the average call bell response time was at least 20 mins. A review of Resident #60's most recent MDS, dated [DATE], reflected the resident scored a 14 out of 15 on the BIMS which indicated the resident's cognition was intact. A review of Resident #84's most recent MDS, dated [DATE], reflected the resident scored a 12 out of 15 on the BIMS which indicated the resident had a moderate cognitive impairment. A review of Resident # 102's most recent MDS, dated [DATE], reflected the resident scored a 15 out of 15 on the BIMS which indicated the resident's cognition was intact. A review of Resident #153's most recent MDS, dated [DATE], reflected the resident scored a 14 out of 15 on the BIMS which indicated the resident's cognition was intact. On 9/19/24 at 9:44 AM, the surveyor observed the Registered Nurse entered room [ROOM NUMBER] and responded to the call bell after 14 minutes. A review of the provided facility policy titled, Call System, Resident with an updated date of 4/2024. Under Policy Interpretation and Implementation, it read: .6. Calls for assistance are answered as soon as possible . On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. NJAC 8:39-25.2(a,b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 9/17/24 at 9:54 AM, the surveyor observed medication (med) administration for Resident #260. The surveyor observed the resident's Electronic Medication Administration Record (eMAR) which contained a list of medications (meds) ordered by the resident's attending physician for administration at that time. The eMAR reflected an order for Bepreve Ophthalmic Solution 1.5% (Bepotastine Besilate), a med used to treat itchiness in the eye due to allergic conjunctivitis, instill one drop in both eyes two times a day for itches/allergies. The surveyor observed Registered Nurse #1 (RN#1) prepare seven (7) of the resident's meds that were scheduled for administration. The surveyor observed the RN select the eye med Bepotastine along with a tissue and administer the drops to the resident. The surveyor observed the RN use the same tissue to wipe both eyes after each drop was administered. The surveyor asked the RN if the same tissue should be used for different eyes. The RN agreed that she should have used two different tissues, one for each eye. The surveyor interviewed the 3rd floor UM who was present during the observation. The surveyor asked the UM if it was an acceptable practice to use the same tissue to wipe separate eyes. The UM stated no, it was an infection risk. On 9/18/24 at 10:15 AM, the surveyor interviewed the Consultant Pharmacist (CP). The surveyor asked the CP if they do med pass observations. The CP stated yes, they do regular med pass observations. The surveyor asked the CP if it is appropriate for a nurse to use the same tissue to wipe both eyes when administering eye drops. The CP stated no, it could be an infection control issue. The surveyor reviewed the hybrid medical record for Resident #260 which revealed a physician's order for Bepreve Ophthalmic Solution 1.5% (Bepotastine Besilate) instill one drop in both eyes two times a day for itches/allergies. On 9/18/24 at 11:38 AM, the surveyor received a policy from the LNHA dated 4/2024 titled Administering Medications. The surveyor reviewed the policy. The policy reflected under Policy heading, Meds are administered in a safe and timely manner, and as prescribed. Under Line 25, Staff follows established facility infection control procedures .for the administration of meds, as applicable. On 9/18/24 at 11:39 AM, the surveyor, in the presence of the survey team, met with the facility administrative team which included the LNHA, DON, RNC#1, and ADON/IP. The surveyor notified the facility management of the med pass results and the concern with infection control. No further pertinent information was provided by the facility. 5. On 9/16/24 at 10:22 AM, during a tour on a unit, the surveyor observed CNA#3 in Resident #33's room, talking with the resident who was seated in their wheelchair at the bedside. Resident #33's door had an EBP sign posted and a PPE supply bin at the door. The EBP signage indicated that PPE such as gloves and gown should be worn while providing high-contact care activities with a resident to reduce the spread of MDROs. High-contact care activities included but were not limited to, assisting with toileting, changing briefs, providing hygiene care, transferring, and dressing. On 9/16/24 at 10:26 AM, while passing Resident #33's room, the surveyor observed from the doorway of the room, the resident was no longer at the bedside in their wheelchair. The resident's bathroom door was open and it was not visible from the hallway. The surveyor heard Resident #33 and CNA#3 talking in the resident's bathroom. On 9/16/24 at 10:27 AM, the surveyor from the hallway, observed CNA#3 come out of the resident's bathroom wearing gloves and CNA#3 closed Resident #33's room door. CNA #3 was not wearing a PPE gown. On 9/16/24 at 10:36 AM, the surveyor observed CNA#3 came out of Resident #33's room, no longer wearing gloves, went to a cart and retrieved supplies which included an incontinent brief and gown. CNA#3 returned directly to the resident's room and did not retrieve any PPE supplies from the bin at the resident's door. On 9/16/24 at 10:50 AM, the surveyor interviewed CNA#3. CNA#3 stated she had assisted Resident #33 with toileting and hygiene care. The CNA confirmed she was only wearing gloves in the room and did not wear a PPE gown when assisting the resident. The surveyor reviewed EBP signage posted at the resident's door. CNA#3 acknowledged signage posted, explained that she missed it and should have worn a gown when providing care to the resident. On 9/16/24 at 10:56 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about EBP protocol. The RN/UM stated for residents who were on EBP, staff assisting with activities such as, hygiene care and toileting would be expected to wear PPE gown and gloves. The surveyor informed the RN/UM regarding observation of CNA#3. RN/UM stated she would follow up with CNA#3. On 9/18/24 at 12:08 PM, the survey team met with the DON, LNHA, ADON/IP, and RNC#1. The surveyor informed the facility of the above concerns. The DON acknowledged it would be expected for CNA#3 to wear gown and gloves when assisting a resident on EBP during high-contact activities. On 9/19/24 at 01:29 PM, the LNHA, ADON/IP, DON and RNC#1 met with the survey team. The LNHA stated the CNAs were re-educated about infection control and EBP protocol to prevent re-occurrence. A review of the facility's policy titled Enhanced Barrier Precautions with an edited date of 4/10/2024, under Policy Interpretation and Implementation, number 2 read: .a. Gloves and gowns are applied prior to performing the high contact resident care activity . Under number 3 it read, .Examples of high-contact resident care activities in which gown and gloves are used as part of EBPs include: d. dressing; e. bathing/showering; f. transferring; g. providing hygiene; h. changing linens; i. changing briefs or assisting with toileting . Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for four (4) of nine (9) staff (two Recreation Staff, one Certified Nursing Aide, and one Hospice Aide), b.) follow appropriate infection control practice during the medication pass observation when administering an eye drops for one (1) of three (3) nurses, c.) maintain infection control standards and procedures during wound care treatment for one (1) of one (1) nurse observed for wound treatment, and d.) follow appropriate infection control practices prevent the potential spread of infection for one (1) of two (2) linen carts observed during environmental tour in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. According to the CDC guidelines dated 4/02/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) included information for EBP (enhanced barrier precautions) when to use PPE (personal protective equipment) during high contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use for EBP include: Dressing . Providing hygiene Changing linens . Device care or use: central line, urinary catheter, . Implementation When implementing Contact Precautions or EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room . Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education Provide education to residents and visitors . 1. On 9/16/24 at 9:26 AM, during the Entrance Conference meeting with two surveyors with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the DON informed the surveyors that the facility was on a COVID outbreak. The DON further stated that the outbreak started on 8/28/24 with one resident. She also stated that the resident was discontinued (d/c) on isolation and there were no other residents in the facility that were on precaution except for residents on EBP (an infection control intervention designed to reduce transmission of MDROs in nursing homes). On 9/16/24 at 10:40 AM, during the initial tour of the 3rd-floor unit, the surveyor observed Certified Nursing Aide #1 (CNA#1) and assisted Resident #2 in their room for breakfast. CNA#1 had a pair of gloves in use during the meal setup. Afterward, the surveyor observed CNA#1 remove her used gloves, discard them into the garbage receptacle that was inside the resident's room, and immediately leave the resident's room without performing hand hygiene. Outside the resident's room, the surveyor interviewed the CNA. CNA#1 informed the surveyor that she wore gloves inside the resident's room because she assisted the resident repositioned on the bed and set up the resident's breakfast tray. The CNA stated that she should have performed hand hygiene inside the resident's room but was unable to because there was no ABHR inside the resident's room. She further stated that she could perform hand hygiene either inside or outside the resident's room because the resident was not on precaution. On that same date and time, the CNA informed the surveyor that she had previously received in-service and education about hand hygiene and PPE use but was unable to remember who the person was provided the education. The CNA acknowledged that she should have performed hand hygiene immediately after the removal of gloves. Afterward, the surveyor observed the CNA performed hand hygiene with ABHR outside room [ROOM NUMBER]. 2. On 9/16/24 at 10:40 AM, the surveyor observed CNA#2 inside room [ROOM NUMBER] with bilateral gloves and surgical mask in use while setting up the breakfast tray of Resident # 8. There was a posted sign outside the resident's door for EBP. The CNA surgical mask was in her bilateral earlobes, her nose and mouth were not covered, and it was below the chin. On 9/16/24 at 10:52 AM, the surveyor interviewed the CNA#2. The CNA acknowledged that her mask was not properly used when she was in Resident #8's room. The CNA stated that at times the surgical mask fell which was why it was below her nose. She further stated that the mask should be able to cover her nose and properly be worn. 3. On 9/16/24 at 10:50 AM, the surveyor observed a linen cart parked between rooms [ROOM NUMBERS]. Inside the linen cart were folded linens, towels, and gowns. In between the folded linen supplies was a styrofoam (styro) cup with cover, and there was a spoon and fork. At that time, the Social Worker (SW) was in the hallway, and the surveyor interviewed the SW regarding the linen cart. The SW informed the surveyor that the linen cart was considered clean. The SW then took the covered styro cup and removed the lid. The SW confirmed that there was cornbread inside the styro cup. The SW further stated that she did not know who put the cornbread inside the clean linen cart. The SW acknowledged that there should be no food inside the clean linen cart. A review of the Departmental (Environmental Services)-Laundry and Linen Policy with an updated date of 4/2024 that was provided by the LNHA showed: Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. General Guidelines: 11. Keep soiled and clean line, and their respective hampers and laundry carts, separate at all times. 12. Clean linen will remain hygienically clean (free from pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts . 4. On 9/16/24 at 10:54 AM, the surveyor observed the Licensed Practical Nurse (LPN) in the hallway near the nursing station with a surgical mask that was below her nose and mouth. The surveyor asked the LPN about the mask and the LPN stated that the mask in the facility was optional. The surveyor asked the LPN should the mask be worn below the nose and mouth and the LPN stated No. On 9/18/24 at 9:27 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The surveyor also notified the ADON/IP of the concern regarding the observations of CNA#1's use of gloves and did not perform hand hygiene after gloves removal, CNA#2 and the LPN's improper use of mask, and the clean linen cart with food and utensils. On 9/18/24 at 9:40 AM, both the surveyor and the ADON/IP observed the LPN in the 3rd-floor nursing station with a surgical mask in use that was below her nose and mouth. The surveyor asked the ADON/IP if that was appropriate how the LPN wore her mask. The ADON/IP stated that it was inappropriate, the mask should cover her nose and mouth. On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, ADON/IP, and Regional Nurse Consultant #1 (RNC#1). The surveyor notified the facility management of the above findings and concerns. On 9/19/24 at 01:26 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. The LNHA stated that with regard to infection control, the staff were previously educated about PPE and hand hygiene. The LNHA further stated that currently, the facility had no mask requirement, and masks were optional. On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, IP/ADON, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. 7. On 9/16/24 at 9:26 AM, the surveyor observed Resident #100 in bed with a specialty mattress in place. Resident #100 stated they had a chronic wound at the base of their spine. The Resident further stated that they had the wound prior to their admission to the facility. The surveyor reviewed the medical record for Resident #100 and revealed: The Resident's admission Record or face sheet (an admission summary) showed that Resident #100 was admitted to the facility with diagnoses that included diabetes mellitus, and a wound to the sacrum (lower portion of the spine near the pelvis). A review of the admission Minimum Data Set (MDS), an assessment tool dated 8/16/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Section M -Skin Conditions indicated the resident had one Stage 4 pressure ulcer (a bed sore with full-thickness tissue loss with exposed bone, tendon, or muscle). A review of the resident's September 2024 Order Summary Report reflected a physician's order (PO) dated 8/31/24, to cleanse the sacral wound with normal saline (NSS), pat the wound dry; apply Santyl ointment (used to aid in wound healing) and cover the wound with a border gauze daily. A review of Resident #100's Care Plan (CP) reflected a focus area that the resident had a stage 4 wound to the buttocks dated 7/18/24. The goal of the resident's CP was the resident's ulcer would remain free from complications r/t skin concerns. The interventions in the resident's CP included but was not limited to administer meds/vitamins as ordered. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Apply barrier cream to peri area with each episode of incontinence care. The surveyor observed outside of Resident #100's room a sign that indicated the resident was on EBP which instructed before entering and exiting the room, everyone must perform hand hygiene; wear (don) a gown for high contact resident care activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy; wound care including any skin opening requiring a dressing. On 9/19/24 at 11:00 AM, the surveyor observed RN#2 perform a wound care treatment to Resident #100's sacral wound and observed the following: RN#2 reviewed the PO with the surveyor, donned appropriate PPE, cleansed her hands, disinfected the over bed table (OBT), gathered supplies and brought the supplies into Resident #100's room which included: an open package of 4x4 gauze pads, a tube of Santyl ointment, 4 NSS bullets; sterile border gauze dressing, 2 cotton- tipped applicators and 2 plastic med cups. RN#2 performed the wound treatment according to the PO. The RN discarded the used supplies in the trash, and then brought the tube of Santyl ointment and package of 4x4 gauze pads into the bathroom and set them on the wet, unclean bathroom sink vanity. The RN washed her hands, then picked up the tube of Santyl and package of gauze pads and placed the tube of Santyl ointment and package of gauze pads back into the treatment cart without disinfecting the tube of Santyl. At this same time, the surveyor interviewed RN#2. RN#2 acknowledged that only supplies needed for the wound treatment were to be brought into the resident's room and any extra supplies should have been left in the cart. The RN further stated that once supplies were brought into the room, the supplies should not be brought back and placed into the cart as it would contaminate the cart, which is used for multiple resident's treatment and that the remaining 4x4 gauze should have been discarded. On 9/19/24 at 11:51 AM, the surveyor interviewed the ADON/IPN who confirmed that RN#2 should only bring in the amount of Santyl needed for the wound. The tube of Santyl should not have been brought into the room and further stated that putting the tube of Santyl and open package of gauze pads back into the treatment cart was unacceptable as it was an infection control concern. On 9/19/24 at 01:29 PM, the surveyor discussed the above observations and concerns with the facility administration. A review of the facility's Wound Care policy undated, included the purpose of this procedure is to provide guidelines for the care of wounds to promote healing disinfect reusable supplies as indicated i.e., outsides of containers . NJAC 8:39-19.4(a)(1,2),(m,n)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness and in accordance with professional standards for food service safety. The deficient practice was evidenced by the following: On 9/16/24 at 7:55 AM, the surveyor toured the facility kitchen with Dietary Aid (DA#1). DA#1 stated that the Food Service Director (FSD) was not at the facility. The surveyor observed the following concerns: 1. The surveyor observed a refrigerator next to the stove. The contents in the refrigerator included but were not limited to two (2) packages of waffles, one (1) bowl of substance that looked like a chicken salad or tuna salad covered with aluminum foil and one (1) silver pan with pasta and red sauce covered with aluminum foil. The items were not labeled or dated. There was debris on the bottom of the refrigerator. 2. The surveyor observed 2 wheeled carts positioned together with the following food items on the cart's three shelves: a box of bacon with 9/09/24 written on it; three (3) trays of chicken; two (2) metal containers with a pureed substance; one (1) container of macaroni; one (1) container of red sauce; one (1) container of mashed potatoes; one (1) container of rice; one (1 ) container of a whitish liquid; four (4) containers of sauces; a red lidded container with substance inside; a box of bacon with 9/09/24 written on it and a small square pan with chicken covered with aluminum foil with 9/17/24 written on it. The surveyor observed that only two of the items were labeled and dated. The surveyor asked DA#1 what the items on the cart were for and who had put them there. DA#1 stated that the Lead [NAME] (LC) had been here and had taken out the food and that the LC was on a break. 3. The surveyor observed DA#2 washing pans in the 3-compartment sink (a manual sink used in commercial kitchens to wash, rinse, and sanitize dishes). The surveyor asked DA#2 to test the solution that should have contained sanitizing solution that was in the third compartment. DA#2 took a test strip from a bottle that did not contain an expiration date. The test strip result was colored blue which indicated a measurement of 0 as compared to the color legend on the bottle. The surveyor observed the bottle of test strips which included the following: Match the center of the test strip pad to the color chart to determine antimicrobial fruit and vegetable treatment concentration. The surveyor asked DA#2 if he was trained to use the 3- compartment sink and what was the solution in each compartment. DA#2 stated that he was trained and that the first compartment had soap in the water, the second compartment had water and the third compartment had just water. The surveyor then asked DA #1 the process of the 3-compartment sink. DA #1 stated that the first compartment had soap and water to wash, the second compartment had clean water to rinse and the third compartment had sanitizing solution. The surveyor observed that there was sanitizing solution available and DA#1 showed the surveyor that the solution flowed through the tubing into the third compartment. The surveyor also observed that the facility dishwasher was working. 4. The surveyor observed a box fan on the container that was running and blowing air on a container of utensils. The box fan had an accumulation of dust on both sides of the fan. 5. The surveyor observed four air circulation vents in the ceiling that had brownish discoloration on them. 6. The surveyor observed eight ceiling tiles that had black debris or brownish black splattered stains. 7. The surveyor observed an accumulation of dust on the silver serving utensil rack. On 9/16/24 at 8:28 AM, in the presence of two other surveyors, the surveyor showed the Licensed Nursing Home Administrator (LNHA) the concerns that were observed in the kitchen during the initial tour with DA#1. At 8:29 AM, the surveyor asked DA#2 to test the solution in the third compartment of the 3-compartment sink. DA#2 tested the solution with a test strip and the result was a blue color. The surveyor asked the LNHA to confirm the result with the color legend on the bottle. The LNHA confirmed that the result indicated zero. The surveyor asked the LNHA what zero meant. The LNHA stated that zero meant that there were no chemicals in the solution and that there should be. The surveyor asked the LNHA to view the test strip bottle for an expiration date. The LNHA stated that she did not observe an expiration date on the bottle. The LNHA then stated that the FSD usually tested the 3-compartment sink and that there was a new FSD that was starting soon. She added that the facility just had a local kitchen inspection and that it was satisfactory. At 8:34 AM, the surveyor showed the LNHA the two carts of food that were not labeled or dated. The surveyor asked DA#2 if he knew when the food on the carts were placed there. DA#2 stated that when he came in at 6 AM the carts with the food were already out. The surveyor asked if the food that was out should be labeled or dated. The LNHA stated that the food should not be left out like that. She added that it should have been labeled and that if the food was for garbage that it should have been thrown out. The LNHA attempted to contact the LC that was at the facility earlier but was unable to reach the LC. The kitchen staff discarded the food on the carts. At 8:38 AM, the surveyor showed the LNHA the refrigerator and asked if the food should be labeled and dated. The LNHA stated that the refrigerator was not for resident food and that it should not be like it was. The dietary staff discarded the unlabeled and undated food. At 8:39 AM, the surveyor showed the LNHA the box fan. The LNHA stated that the box fan should not be there. The dietary staff removed the fan. At 8:40 AM, the surveyor showed the LNHA the air circulation vents, the ceiling tiles and the silver serving utensil rack. The LNHA did not say anything. At 8:47 AM, the surveyor asked the LNHA to view the log book for the three compartment sink that DA#1 stated earlier that was locked in the office. The LNHA looked for the log book in the office but was unable to find it in the office. The LNHA stated that the log book was normally out for staff but that the FSD was leaving the facility and that currently was out on an emergency. She added that she went over all the log books with the FSD on Friday before she left and everything was up to date. At 8:53 AM, the LNHA found the log book on a shelf in the kitchen. The surveyor viewed the log book which included the following: Three Compartment Sink Sanitation Test Procedure Sept. 2024 Date 2 through 15 indicated that QT-10 Quaternary Test Strip was at 200 PPM and initialed by DA#2. The surveyor asked DA#2 if he had worked on 9/14/24 and 9/15/24. DA#2 stated that he did not work on those two days and that he did not know who signed the log book with his initials. On 9/16/24 at 11:50 AM, in the presence of the survey team, the LNHA stated that in August, the FSD was placed on a PIP (performance improvement plan) with expectations and goals. The LNHA stated that the FSD refused to sign the PIP and that she resigned. The LNHA stated that they inserviced the FSD and wanted to correct the issue. The LNHA gave the surveyor a copy of the plan. A review of the PIP that the FSD refused to sign included the following areas of concern: Running out of food items, patients getting trays that are missing items and or not what they order. Consistent call outs, lack of staffing, lack of ability to recruit or retain appropriate staff. Lack of communication to LNHA and regional staff regarding issues in the building. Not holding staff accountable for their performance, insubordination, behavior. Not holding staff accountable to dress code. Labeling and dating all items. Log books all complete. Not coming to department meetings. Lack of consistent follow up with resident complaints and grievances. The FSD was not present during the survey. On 9/18/24 at 11:15 AM, the surveyor requested the training for DA#2. The LNHA stated that there were not competencies done for each individual task. The surveyor requested the time card for DA#2. The LNHA stated that DA#2 had told the surveyor that he was not working on the weekend and that the staff had told her that they were just copying the initials on the log book. The LNHA confirmed that no other dietary staff had the same initials as DA#2. On 9/18/24 at 11:57 AM, in the presence of the survey team, the surveyor notified the LNHA, Director of Nursing (DON), Regional Nurse Consultant#1 (RNC#1) and Assistant DON/Infection Preventionist (ADON/IP) the concerns observed in the kitchen: three compartment sink testing showed no sanitizing solution; sanitizer log book signed by staff not working; food left out unlabeled and undated; refrigerator had food unlabeled and undated; accumulation of dust on box fan and serving utensil rack; and discolored vents and ceiling tiles. On 9/20/24 at 11:29 AM, in the presence of the survey team, DON, RNC#1, Regional LNHA (RLNHA), the LNHA stated that education was done with dietary staff. The RLNHA stated that the LNHA had identified an issue with the FSD and followed the steps of identifying an issue, creating a PIP and doing followup on the PIP. The facility did not provide any additional information. A review of the facility provided policy titled, Food Receiving and Storage with a revised date of October 2017, included the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food services, or other designated staff, will maintain clean food storage areas at all times . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). A review of the facility provided policy titled, Sanitization with a revised date of October 2008, included the following: Policy Statement The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm chlorine solution; b. 150-200 ppm quaternary ammonium compound (QAC); or c. 12.5 ppm iodine solution. 5. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways: a. Contact for at least 30 seconds with an iodine solution (at approved concentration); b. Contact with QAC (at approved concentration) per manufacturer's instructions; c. Contact for at least 10 seconds with a chlorine (at approved concentration); or d. Immersion for thirty (30) seconds in hot (at least 171 degrees F) water . 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent; b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: (1) chlorine 50 ppm for 10 seconds; (2) iodine 12.5 ppm for 30 seconds; or (3) quaternary ammonium compound 150-200 ppm for time designated by the manufacturer . 14. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 15. The food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. N.J.A.C. 8:39-17.2(g)

Based on the interview and review of facility documentation, it was determined that the facility failed to a.) ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plan to meet the requirements and needs of all residents in the facility and b.) meet the staffing plan as reflected in the Facility Assessment. These failures had the potential to affect all 126 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 9/16/24 at 7:54 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the Facility Assessment (FA). Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 126. 1. A review of the facility's Facility Assessment with a date of July 23, 2024. The FA submitted by the LNHA on 9/17/24 at 9:00 AM did not reflect, under Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, Section 3.2 Staffing Plan, Section 3.5 Policies and Procedures for provision of care, any contingency plan for staffing. The FA provided by the LNHA included a document titled Attachment 1. Attachment 1 reflected an excerpt from the Federal Register Volume 81, dated 10/4/16 titled Facility Assessment. On 9/19/24 at 12:53 PM, the surveyor interviewed the LNHA regarding the FA and showed the LNHA Attachment 1. The LNHA informed the surveyor that she was aware of the updates and new memo from CMS (Centers for Medicare and Medicaid Services) about the FA with an effective date of 8/08/24. The LNHA stated that Attachment 1 was just an attachment, and that the regulation was being followed. The LNHA stated that the FA was reviewed with the QAPI (Quality Assurance Performance Improvement) Committee on 8/08/24 as indicated on the FA. 2. A review of the facility's Facility Assessment with a date of July 23, 2024. The FA submitted by the LNHA on 9/17/24 at 9:00 AM reflected, under Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, Section 3.2 Staffing Plan, Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the resident at any given time. Under the section Nurse aides, the Total Number Needed or Average or Range was reflected as 16-18. A review of the facility's nurse staffing reports, provided by and signed by the LNHA, dated 9/16/24, for the weeks of 9/01/24-9/07/24 (week 1) and 9/08/24-9/14/24 (week 2) revealed the following: For week 1, Nurse Aide staffing on the day shift was less than 16 four (4) time, on the evening shift seven (7) times, on the night shift seven (7) times. For week 2, Nurse Aide staffing on the day shift was less than 16 two (2) times, on the evening shift seven (7) times, on the night shift seven (7) times. Further review of the facility provided Staffing Plan in the FA reflected the statement .sufficient staff to meet the needs of the residents at any given time, and a number range of 16-18 which was not met. On 9/19/24 at 02:04 PM, the surveyor in the presence of the survey team met with the LNHA, DON, Regional Nurse Consultant (RNC), and Infection Preventionist (IP). The surveyor notified the LNHA of the concern with the FA not containing a staffing contingency plan as per the CMS update published 5/10/24, effective 8/08/24 and the Quality Safety Oversight (QSO) memo dated 6/18/24. On 9/20/24 at 12:16 PM, the surveyor met with the LNHA and asked if there was any further information or documentation the facility wished to provide. The Facility did not provide any further pertinent information. NJAC 8:39-5.1(a)

Based on observation, interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that residents provided one or more rooms designated for residents dining and dining activities according to the federal regulation, approved floor plan, and facility policy. This failure had the potential to affect all 126 residents who currently live in the facility. This deficient practice was evidenced by the following: On 9/16/24 at 9:26 AM, Surveyor #1 (S#1) and Surveyor #2 (S#2) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) for an Entrance Conference. The LNHA informed the surveyors that the facility census (the current total number of residents in the facility) was 126. On that same date and time, the LNHA stated that since she started at the facility, there was no physical dining area which was why there were no dining services offered to the residents. The LNHA further stated that we have room tray services. Both the LNHA and DON stated that they were present during the last recertification survey (8/15/23). On 9/18/24 at 11:39 AM, the survey team met with the LNHA, DON, Assistant Director of Nursing/Infection Preventionist (ADON/IP), and Regional Nurse Consultant #1 (RNC#1). S#1 notified the facility management of the concerns with the facility not having dining services even though the facility was approved for communal dining on the 1st floor according to the floor plan submitted by the facility. The surveyor asked for the facility's policy regarding dining services. On 9/19/24 at 01:26 PM, the survey team met with the LNHA, ADON/IP, DON, and RNC#1. Surveyor #3 (S#3) notified the facility management of the resident council meeting concerns that four (4) of four (4) residents wanted to have dining activity and that they were not offered communal dining. The four residents claimed that would be nice to have communal dining. At that same time, the LNHA stated that will be corrected and we will offer communal dining on 10/15/24 because the new Food Service Director will start on 9/30/24 who will be responsible for dining activities and services. A review of the facility's Accommodation of Needs Policy with an updated date of 4/2024 that was provided by the LNHA revealed: Policy Interpretation and Implementation: 1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered . 4. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the resident's wishes. For example: d. Making accommodations for the resident to be able to consume meals in their preferred environment. For example: If the resident wishes to dine in their rooms, the food is brought to the and set up, feeding assistance is provided as needed. If the resident chooses to attend communal dining, their food is delivered in the communal dining area, resident is assisted to the dining area and assisted with set-up feeding as needed. On 9/20/24 at 01:14 PM, the survey team met with the LNHA, DON, ADON/IP, Regional LNHA, RNC#1, and RNC#2 for an exit conference. There was no additional information provided by the facility management. NJAC 8:39-18.4(c); 27.3(a)

C# NJ00169866 Based on interview, medical records (MR) review, and review of pertinent facility documents on 02/08/24 and 02/12/24, it was determined that the facility failed to complete the residents care plan (CP) that was initiated on 11/22/23 for a Resident who was at risk for falls for 1 of 4 residents (Resident #2). The deficient practice was evidenced by the following: According to the admission Record (AR), Resident #2 was admitted with diagnoses which included but were not limited to: Metabolic Encephalopathy, Alzheimer's Disease, Adult Failure to Thrive, Difficulty in Walking, and Muscle Weakness. The Minimum Data Set (MDS), an assessment tool dated 11/28/23, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 6 which indicated cognition was severely impaired and the resident needed help in Activities of Daily Living (ADLs). Review of the progress notes (PN), dated 12/02/2023 at 2:21 p.m., documented by Licensed Practical Nurse (LPN #1), indicated Patient [Resident #2] received walking around, stable, verbally responsive. Medication given as prescribed. Eat 40% of breakfast. At 11:30 [a.m.] patient had a fall while walking on the hallway. Fall was witnessed. Doctor notified; family notified. Dr. ordered to send the patient out to the ER. for scan. A Care Plan (CP), initiated on 11/22/23 and revised on 12/21/23 did not reflect interventions related to the Resident's fall on 12/2/23. During the interview with the ADON on 02/08/24 at 3:23 p.m., the ADON stated that when a fall occurred, the Interdisciplinary Team (IDT), DON, ADON, UM, Social Service, and the Director of Rehab, would review the incident report and would revise and or update the CP on the day it was being reviewed. The ADON was unable to explain why Resident #2's CP did not include interventions to reflect the Resident's fall on 12/02/23. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered last updated 5/2023, under Policy Interpretation and Implementation 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source (s) of the problem areas, not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay. N.J.A.C: 8:39-11.2 (e)2 (i)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Entry Reporting Assessment in accordance with federal guidelines. This deficient practice was identified for 2 of 38 residents reviewed for resident assessment (Resident #90, #133). This deficient practice was evidenced by: On 8/10/23 at 10:26 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. A MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. 1. Resident #90 was observed to have an Entry MDS of 6/19/23 and was due to be transmitted no later than 7/3/23. The Entry MDS was not transmitted until 7/4/23. 2. Resident #133 was observed to have an Entry MDS of 7/22/23 and was due to be transmitted no later than 8/5/23. The Entry MDS was not transmitted until 8/10/23. According to the latest version of the Center for Medicare/Medicaid Services (CMS)- Resident Assessment Instrument 3.0 Manual (updated October 2019) page 2-11 MDS used to track residents and gather important quality data at transition points, such as when they enter a nursing home. The manual revealed on Page 2-18 Entry tracking record must be completed not later than entry date +7 calendar days. The assessment must also be transmitted to the QIES ASAP system not later than entry date + 14 calendar days. On 8/15/23 at 11:44 AM, the surveyor interviewed the facility's Registered Nurse (RN) MDS Coordinator who was responsible for completing and transmitting the MDS assessments who agreed that the above MDS assessments were transmitted late. No further information was provided. On 8/15/23 at 12:30 PM, the surveyor discussed the above concern to the facility's RN [NAME] President of Clinical Services. No further information was provided. NJAC 8:39-11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On [DATE] at 1:56 PM, the surveyor reviewed the medical records for Resident #86. A review of the Resident #86's FS revealed that the resident was admitted to the facility in [DATE] with diagnoses that included but were not limited to Chronic Ischemic Heart Disease (heart problems caused by narrowed heart arteries that supply blood to the heart muscle), and Chronic Kidney Disease, Stage 4 (Severe). A review of the Quarterly MDS, dated [DATE], documented in Section K under nutrition that the resident had a weight of 258 lbs., and had no significant weight loss. A review of the weights in the electronic health record documented the following weights: [DATE] 222.6 lbs. [pounds] [DATE]- 224 lbs. [DATE]- 207 lbs. [DATE]- 191.2 lbs. [DATE]-192.6 lbs. [DATE]- 190.5 lbs. [DATE]- 258.6 lbs. [DATE] 184.5 lbs. [DATE] 185.4 lbs. A review of the dietician's nutrition note dated [DATE], indicated the weights on [DATE] were likely not accurate, compared to the resident's weight trend. On [DATE] at 9:57 AM, the surveyor interviewed the MDS Coordinator #2 who completed the nutrition section of the Quarterly MDS for Resident #86. MDS coordinator #2 stated that she checked the resident's weight history in the electronic medical record for any significant weight loss prior to completing the Quarterly MDS. The surveyor reviewed Resident #86's weights and Quarterly MDS with MDS Coordinator #2. She acknowledged that the documented weight of 258 lbs. was not an accurate weight in comparison with the resident's weight trends at the time. The MDS Coordinator #2 also acknowledged that the assessment should have been coded to indicate the resident had a 5% weight loss in 1 month, based on the resident's weight at the time of the assessment. A review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, updated [DATE], indicated in Chapter 3 MDS Items [A] section A2100: OBRA Discharge Status under Coding Instructions: Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home and Code 03, Acute hospital. A review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, updated [DATE], indicated in Chapter 3 MDS Items [K] section K0200B, Weight indicates: 1. Base weight on the most recent measure in the last 30 days. 2. Measure weight consistently over time in accordance with facility policy and procedure, which should reflect current standards of practice (shoes off, etc.). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days of the Assessment Reference Date (ARD) of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. 5. If the resident's weight was taken more than once during the preceding month, record the most recent weight . Review of the CMS RAI Version 3.0 Manual Section K0300 indicates, Weight Loss, indicated the definition of 5% weight loss in 30 days as: Start with the resident's weight closest to 30 days ago and multiply it by .95 (or 95%). The resulting figure represents a 5% loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5% body weight . On [DATE] at 2:13 PM, the surveyor met with the [NAME] President of Clinical Services and the Acting Licensed Nursing Home Administrator who could not explain why the MDS was coded incorrectly for Resident #138, #140 and #86. No further information was provided. NJAC 8:39-11.1, 11.2(e)(1) Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 3 of 22 residents (Resident # 138, #140, and #86) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On [DATE] at 12:13 PM the surveyor reviewed the closed medical chart for Resident #138 who was MDS coded for hospitalization. The surveyor reviewed the Progress Notes (PN) created on [DATE] by the Social Worker (SW) for Resident #138. The PN documented that Resident #138 was discharged home per their family's request. Review of the [DATE] Nursing PN documented that Resident #138 was discharged at 11:30 with the family via a wheelchair, without any distress or discomfort, all discharge papers ready and signed by the resident. Review of Resident #138's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to generalized muscle weakness, unspecified fall, unspecified fracture of lower end of left Humerus, difficulty walking, malignant neoplasm of prostate and bladder. Review of the A section of the [DATE] MDS for Resident #138 revealed that section A2100 Discharge Status documented 03. Acute hospital. There was another option 01. Community (private home/apt., board/care, assisted living, group home) which identified the correct discharge for Resident #138. On [DATE] at 1:17 PM, the surveyor met with both MDS Coordinators #1 and #2. MDS Coordinator #1 explained, the wrong button was chosen when the MDS was completed for Resident #138. 2. On [DATE] at 2:05 PM, the surveyor reviewed the closed medical chart for Resident #140 who was MDS coded for being discharged home, to the Community. a. Review of Resident #140's [DATE] Nursing PN documented, patient admitted to SBMC with diagnosis of cardiac arrest as per emergency room (E.R.) nurse. Continued review of the Nursing PN documented: b. On [DATE] at 19:15 the documented Nursing PN read, Nursing Note Narrative: Writer went to check on patient and administer night meds, when writer went in patient was laying on his side, unresponsive, unarousable. Writer called for help. c. 19:15- CPR was initiated. d. 19:17 - Code was called, 911 called. e. 19:26 - EMS on scene, writer continued compression. f. 19:30 - EMS took over compressions, placed patient on Lucas, patient intubated. g. Family and MD aware h. 20:05 - Patient regain pulse, EMT transferred to patient to hospital. Family made aware, left message for doctor, awaiting return call. i. Nursing supervisor in room during code. Review of Resident #140's FS reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to Acute Kidney Failure, Sepsis, presence of Aortocoronary Bypass Graft, HIV, Heart Failure, Chronic Kidney Disease, Stage 3 Unspecified, Muscle Weakness and Difficulty Walking. Review of the A section of the [DATE] MDS for Resident #140 revealed that section A2100 Discharge Status documented 01. Community (private home/apt., board/care, assisted living, group home). Acute hospital. There was another option 03. Acute hospital. which identified the correct discharge for Resident #140. On [DATE] at 1:21 PM, the surveyor met with both MDS Coordinators #1 and #2. MDS Coordinator #2 explained, the wrong button was chosen when the MDS was completed for Resident #140.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to properly administer a medication used to treat hypotension in accordance with the physician's order (PO) in accordance with professional standards of nursing practice, for 1 of 22 residents, Resident #97. The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the electronic medical record (EMR) of Resident #97 which revealed the following: The admission Record revealed that Resident #97 was admitted [DATE] with diagnoses that included but were not limited to, Pneumonitis (inflammation in your lung tissues), Sepsis (the body's life threatening response to infection that can lead to tissue damage, organ failure, and death), Acute Respiratory Failure (serious condition that makes it difficult to breathe on your own), permanent chest pacemaker, and cerebral infarction (a condition that occurs when there is a lack of adequate blood supply to the brain). The admission Minimum Data Set (MDS) assessment, dated 6/23/23, indicated that Resident #97 was rarely understood, had unclear speech. A Brief Interview for Mental Status (BIMS) could not be completed, indicating that Resident #97 was cognitively impaired. A PO, dated 6/28/23 read, Midodrine HCl Oral Tablet 5 mg Give 1 tablet via G-tube (gastrostomy tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) every 8 hours for hypotension related to SEPSIS, UNSPECIFIED ORGANISM .Hold for BP [Blood Pressure] more than 120/80. A review of the electronic Medication Administration Record (eMAR) for July 2023 revealed the nurses signed the Midodrine 5 mg was administered 7/1 at 0600, 7/3 at 2200, 7/4 at 0600, 7/5 at 0600 and 1400, 7/6 0600 and 2200, 7/7 at 0600, 7/13 at 2200, 7/15 at 1400, 7/18 at 2200, 7/20 at 0600, 7/27 at 0600 and 2200, 7/29 at 2200, 7/31 at 1400. All of the July 2023 listed nursing administration times had documented BPs that exceeded 120/80. All of the documented nursing administration times with the BPs that exceeded 120/80, should not have been administered to Resident #97 as per the PO. A review of August 2023 eMAR revealed that the nurses signed for the administration of the Midodrine 5 mg on 8/2 at 1400, 8/3 at 2200, 8/4 at 0600 and 2200, 8/6 at 1400 and 2200, 8/9 at 0600. All of the August 2023 listed nursing administration times had documented BPs that exceeded 120/80. All of the documented nursing administration times with the BPs that exceeded 120/80, should not have been administered to Resident #97 as per the PO. On 8/10/23 at 10:54 AM, the surveyor interviewed a Licensed Practice Nurse (LPN) assigned to care for Resident #97. The LPN stated that the vital signs for a medication with specific BP parameters would be checked first, the PO reviewed, and followed to hold a medication based on the parameters ordered. On 8/10/23 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated it was expected for the nurses to follow the PO as ordered. The surveyor reviewed the August 2023 eMAR regarding the administration of Midodrine 5 mg with the LPN/UM. The LPN/UM acknowledged that the Midodrine 5 mg was administered many times when it should have been held according to BP parameters of the PO. On 8/10/23 at 2:05 PM, the surveyor informed the Acting Licensed Nursing Home Administrator and Regional VP of Clinical Services of the above concerns with Resident #97's midodrine medication order not being followed. The surveyor reviewed the facility provided policy titled, Administering Medications, with a date of 4/2023. Under Policy heading it read: Medications are administered in a safe and timely manner, as prescribed. Under Policy Interpretation and Implementation it read: 4. Medications are administered in accordance with prescriber orders, including any requires time frame .10. 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 .11. The following information is checked/verified for each resident prior to administering medications: .b. Vital signs, if necessary . On 8/14/23 at 2:53 PM, the surveyor informed the Director of Nursing, and the two Acting Directors of Nursing of the above concerns. No further information was provided by the facility. NJAC 8:39-11.2 (b); 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain weekly weights for a resident according to the physician's order (PO) and facility policy for 1 of 5 residents, Resident #97 reviewed for nutrition. This deficient practice was evidenced by the following: On 8/7/23 at 9:10 AM, the surveyor reviewed Resident #97's electronic medical record (EMR) which revealed the following: A review of the Resident #97's face sheet (FS) (an admission summary) revealed that they were admitted on [DATE] with diagnoses that included but were not limited to Pneumonitis (inflammation in your lung tissues), Sepsis (the body's life threatening response to infection that can lead to tissue damage, organ failure, and death), Acute Respiratory Failure (serious condition that makes it difficult to breathe on your own), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), dysphagia (difficulty swallowing), and adult failure to thrive. The admission Minimum Data Set (MDS) assessment, dated 6/23/23, indicated that Resident #97 was rarely understood, and a Brief Interview for Mental Status (BIMS) could not be completed, indicating that Resident #97 was cognitively impaired. The admission MDS assessment further indicated that Resident #97 received nutrition via a G-tube (gastrostomy tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) with no known weight loss. A PO dated 6/16/23 documented, Weight upon admission, weekly x 4 weeks, then monthly thereafter. A review of the resident's nutritional care plan (CP) included an intervention Record weight per protocol. The start date of the CP was 6/16/23 and the intervention start date was 6/17/23. A review of the weights documented in the EMR for Resident #97 revealed 137 pounds (lbs.) on 6/16/2023 and 116 lbs. on 8/4/2023. A nutrition note written by the Registered Dietician (RD), dated 7/13/23, indicated that the RD was unable to assess the resident's current weight and once feasible would get an updated weight for the resident. On 8/9/23 at 10:55 AM, the surveyor interviewed the certified nursing assistant (CNA) who was assigned to care for Resident #97. The CNA stated at the start of the shift after receiving report, the unit clerk would provide the list of residents to be weighed for the day. The CNA stated the weight results would be provided to the nurse or unit clerk to be documented on the weight list at the nurses' station. The CNA stated she was not sure of the schedule for when Resident #97 needed to be weighed. On 8/9/23 at 11:03 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) on the unit. The LPN informed the surveyor that admission and daily weights would be documented in the EMR by the nurses. Weekly and monthly weights to be obtained were on a list which was provided by the RD. The LPN explained that the list was kept in a weight binder on the unit. The CNA would let the unit clerk know the weight results for it to be documented on the list, which the dietician would review. On 8/9/23 at 11:20 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that located in the EMR there would be a Physician's Order (PO) and the CNAs would be directed to obtain the resident's weight. The LPN/UM stated that the unit clerk would create a weight list for residents who would have to be weighed that would be directed by the RD. The weight list includes residents for weekly weights, monthly weights and those who needed to be re-weighed. The LPN/UM specified that daily weights were documented by the nurses in the EMR. The LPN/UM added that weekly and monthly weight results were entered by the RD in the EMR. The LPN/UM informed the surveyor that the nurses were responsible for reviewing the weights of residents and ensuring weights were done. The LPN/UM added that the RD should review the resident's weights. On 8/9/23 at 11:45 AM, the surveyor interviewed the RD in the presence of the Regional Registered Dietician (RRD). The RD stated the facility protocol was for residents to be weighed upon admission, then weekly weights for four weeks, followed by monthly weights. The RD stated she provided the list of residents to be weighed on a weekly basis to the nursing unit. The RD revealed that she would then review the results and if there were weight differences or missing weights, she would request a re-weigh. The RD further stated that she would request that the nurse, unit clerk and unit manager would re-weigh of a resident. The RD stated that she was responsible for reviewing residents' weights, as well as nurses monitoring that resident's weights are done. The surveyor discussed the discrepancy of Resident #97 with the RD, missing weekly weights for a total of four weeks in the months of June and July. On 8/10/23 at 1:32 PM, the RD informed the surveyor that she reviewed the weights in the weight binder and did not find any weights for Resident #97. The RD could not provide information as to why there were no other weights obtained for the resident between 6/16/23 and 8/4/23. On 8/10/23 at 2:05 PM, the surveyor informed the Acting Licensed Nursing Home Administrator (LNHA) and the Regional VP of Clinical Services of the above concerns. On 8/14/23 at 9:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON acknowledged that weights should be obtained and documented according to the facility's policy and the PO. On 8/14/23 at 9:55 AM, Resident #97 was observed lying in bed with the head of the bed elevated. The resident was alert, responsive with gestures and unclear speech. The resident was receiving a tube feeding through their G-tube. A review of the facility provided policy titled Weight Policy with a revised date of 12/2022, under Policy, it read: It is the policy of this facility to weigh each resident on admission, then weekly for (4) four weeks, then monthly thereafter, unless otherwise ordered by physician/IDT team. The facility will utilize a consistent procedure for monitoring weights and prevent unnecessary weight loss/gain in our residents. A review of the facility provided policy titled Weight Assessment and Intervention with a date of 4/3/2023, under Weight Assessment it read: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team and/or as ordered by the physician . 2. Weights are recorded in each unit's weight record chart and in the individual's medical record . On 8/14/23 at 2:53 PM, the surveyor discussed the above concerns related to Resident #97's missing weights with the Director of Nursing (DON), and the two ADONs. There was no further information provided by the facility. NJAC 8:39-27.2(a)

Based on observation, interview, and record, it was determined that the facility failed to monitor an enteral tube feeding administration pump to assure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 3 residents reviewed for enteral tube feeding, (Resident #391), and was evidenced by the following: On 8/2/23 at 10:24 AM, the surveyor observed Resident #391 in bed awake, alert, and verbal. Communication board on table at bed side. observed with an enteral tube feeding pump (TF; a tube feeding surgically inserted to the stomach) administering Glucerna 1.2 (nutritional formula) at a rate of 65 milliliters (ml) an hour. On 8/3/23 at 9:13 AM, the surveyor observed the resident in bed on specialized mattress awake, alert, and responded appropriately to surveyor. The surveyor observed Glucerna 1.2 being administered at a rate of 80 ml per hour. The surveyor reviewed the Electronic Medical Record for Resident #391. Review of the Face Sheet (FS) (a one-page summary of information about a resident that documents pertinent information), which included but was not limited to Metabolic Encephalopathy, UTI, Sepsis, Acute respiratory failure with hypoxia, COPD, DM 2 without complication, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Pneumonitis due to inhalation of food and vomit, and gastrostomy status. A review of the Brief Interview for Mental Status (BIMS) dated 7/24/23 expressed a score of 12 out of 15, indicating that Resident #391 had moderate impairment cognition. A review of the August 2023 Physician Orders (PO), which revealed an order initiated on 7/24/23 for Enteral Feed Order every shift for nutrition support Enteral Nutrition via pump Glucerna 1.2 at 65 ml per hour for 24 hours via pump per Percutaneous Endoscopic gastrostomy (PEG), total volume infused (TVI): 1560 mL, which was discontinued on 8/2/23. The surveyor reviewed the July and August 2023 Electronic Administration Medication Administration Record (eMAR) which documented a physician order for Resident #391, Glucerna 1.2 at 65 ml per hour (hr.) for 24 hours via pump per Percutaneous Endoscopic gastrostomy (peg) total volume infused of 1560 ml. Review of the TVI infused in 24 hours documented for the 7 to 3 shift on the July and August 2023 eMAR included, 7/25/23 900 ml TVI, 7/26/23 1560 ml TVI, 7/27/23 eMAR documented a 9 indicating to see progress notes, which documented, every shift for nutrition support Enteral Nutrition via Pump- Glucerna 1.2 @ 65 ml per hour for 24 hours via pump per PEG. TVI: 1560 mL, Feeding still running, and 7/28/23-8/1/23 documented 1560 ml TVI. The TVI documentation did not consider any pauses for resident care throughout the day. The directions for the infusion of the Glucerna 1.2 at 65 ml per hour would have to be infused without any pausing to completely infuse 1560 ml in a 24 hour period. On 8/3/23 at 9:48 AM, the surveyor interviewed the Registered Nurse (RN) assigned to Resident #391. The RN stated that Resident #391 was fed with Glucerna 1.2 at 65 ml/hr. continuous over 24 hrs. The RN further stated that if facility staff are providing care for Resident #391, the feeding would be held, once care is completed the feed would be resumed. The RN added that there is no total volume ordered that needs to be infused. On 8/3/23 at 9:57 AM, the surveyor interviewed the RN/Unit Manager (UM), who verified that there was a previous order for continuous 65 ml/hr. The feeding is held when Resident #391 is receiving physical therapy that requires the resident to lay flat on a bed. The RN/UM verified that the resident's feed is also held during care. The RN/UM stated that there was no total volume ordered with the feeding of 65 ml/hr. continuous. On 8/3/23 at 10:49 AM, the surveyor reviewed the August 2023 eMAR with the RN/UM. The RN/UM agreed that the 7/24/23 PO dictated the feed for Glucerna 1.2 was ordered at 65 ml/hr. for 24 hour with a total volume of 1560 ml. The RN/UM admitted that she was not aware of a total volume to be infused of 1560 ml ordered by the physician. The RN/UM added that she was only aware of a 24-hour continuous feeding ordered by the Physician. On 8/7/23 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who could not explain the accountability for the difference between the total amount of feed ordered by the physician for the day and the amount that was actually infused when the feed was held during daily care and rehabilitation. The DON and ADON could not verify the exact amount of feeding received by Resident #391 daily. A review of the facility's policy titled Enteral Nutrition under Policy Interpretation and Implementation number 10 presents, Enteral feedings are scheduled to try and optimize resident independence whenever possible . Further review of the policy numbered section 11 establishes, The nurse confirms that the orders for enteral nutrition are complete. Complete orders include e. volume and rate administration. On 8/10/23 at 2:07 PM, the surveyor met with the covering Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services to discuss the discrepancy with Resident #391's peg feed. The [NAME] President of Clinical Services acknowledged that there was a discrepancy, and that Resident #391 was not receiving the full 1560 ml of Glucerna 1.2 ordered. No further information was provided. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to act upon recommendations reported to the facility by the Pharmacy Consultant (PC) within an acceptable timeframe. This deficient practice was observed for 1 of 38 residents (Resident #105) reviewed. On 8/7/23 at 12:24 PM, the surveyor observed Resident #105 lying in bed, awake and alert. The resident was placed under contact isolation due to diagnosis of Clostridium Difficile (Infection of the large intestine (colon) caused by the bacteria Clostridium difficile). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care Brief Interview for Mental Status (BIMS) section, dated 6/21/23 reflected that Resident #105 was cognitively intact. A review of the resident's face sheet (FS) (an admission summary) indicated that Resident #105 was admitted to the facility on [DATE] and had diagnosis which included but not limited to, Acute Respiratory Failure, Sepsis, Congestive Heart Failure and Atrial Fibrillation. On 8/8/23 at 10:22 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) on the unit who provided forms dated 6/15/23 and 7/26/23 titled, Nursing Summary Report (NSR). The NSR documented the recommendations by the PC. The surveyor did not find any recommendations made for Resident #105. The RN/UM confirmed that she could not locate any NSR for Resident #105 from June 2023 through August 2023. A review of the progress notes dated 6/15/23 and documented by the pharmacist indicating, IMRR (independent medical record review) complete. On 8/10/23 at 9:30 AM, the Registered Nurse/Vice President of Clinical Services (RN/VP CS) provided a copy of Resident #105's Nursing Summary Report (NSR) which documented the PC review from 6/15/23 and 7/26/23. The surveyor reviewed the NSR with the RN/UM who confirmed to the surveyor that the NSR had not been reviewed, as the form was not initialed nor dated as completed. There was no documentation on the form to indicate that the PC's recommendations were reviewed or addressed. The RN/UM further stated that she was responsible to review all the recommendations from the PC and to discuss the recommendations with the Physician. A review of the NSR form dated 6/15/23, included PC recommendations, 1.) Metamucil (psyllium) should be mixed in eight (8) ounces of water prior to administration. Include the volume needed for mixing in the order. ; 2.) Prevacid should be administered on an empty stomach, at least 30 minutes before eating. Evaluate 1800 (6:00 PM) dose. A review of the NSR form dated 7/26/23, included PC recommendations, 1.) Metamucil (psyllium) should be mixed in eight (8) ounces of water prior to administration. Include the volume needed for mixing in the order. ; 2.) Prevacid should be administered on an empty stomach, at least 30 minutes before eating. Evaluate 1800 (6:00 PM) dose. A review of the electronic Medication Administration Record (eMAR) from June 2023 through August 2023 did not reflect that the above PC recommendations were handled based on the PC's recommendation. On 8/10/23 at 2:45 PM, the surveyor requested the facility's policy for the Pharmacy Consultant. A review of the facility's policy titled; Medication Regimen Reviews revealed the following: #14. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Follow up will be completed within 30 days. On 8/15/23 at 10:54 AM, the RN/VP CS confirmed that the 6/15/23 and 7/26/23 NSR which was provided by the PC were never reviewed or handled. NJAC 8:39-29.3 (a)

Based on observation, interview, and record review it was determined that the facility failed to consistently implement interventions to prevent falls. The deficient practice was observed for 1 of 1 residents (Resident #30) reviewed for falls and was evidenced as follows: On 6/14/21 at 10:28 AM, the surveyor observed Resident #30 in a wheelchair transported by a Certified Nursing Assistant (CNA#1) in the unit hallway. CNA #1 stated the resident is a fall risk and receives 1:1 care. The surveyor reviewed the medical record of Resident #30 which revealed the following: An admission Record which indicated the resident was admitted to the facility with diagnoses which included Sepsis and Dementia with Behavioral Disturbance. The 5/29/21 admission Minimum Data Set an assessment tool, indicated the resident had short-term and long-term memory impairment and severely impaired decision-making skills. The resident required extensive assistance of one caregiver for bed mobility and was totally dependent upon staff for moving in and out of bed. The resident was noted to have had one fall without injury since admission to the facility. A Fall Risk care plan was initiated on the day of admission. The resident was noted to be at risk for falls due to deconditioning, confusion, poor safety awareness, and a history of actual falls. The care plan was revised on 6/1/21 due to an actual fall on 5/28/21. The resident had been placed at the nurses' station for close supervision. The Unit Clerk reported to the nurse that the resident was on the floor. The resident sustained a mid forehead bruise and a skin tear to the right and left elbows. The revised Care Plan included the intervention to place patient on line of sight for closer monitoring. On 6/15/21 at 09:18 AM, the surveyor knocked on the resident's closed door twice without receiving an answer. The surveyor opened the door a crack and called out asking permission to enter the room. There was no answer. The surveyor opened the door wider and observed the resident with eyes closed in bed and CNA #2 was seated at the bedside in a stationary chair with her eyes closed and head tilted to the side. CNA #2 did not awaken to the sound of the surveyor's voice. The surveyor left the resident's room and summoned the Registered Nurse Unit Manager (RNUM), requesting that she accompany the surveyor to the resident's room. As the surveyor and the RNUM approached the door to the resident's room, CNA#1 referring to CNA #2 in the resident's room stated she is out cold. Upon entering the room, CNA #2 was observed standing in the room holding the resident's finished breakfast tray. The surveyor interviewed CNA #2 at that time. CNA #2 stated she had worked the previous night shift and was now doing a 1:1 with this resident for the day shift. She stated the resident was on monitoring for fall prevention. The surveyor interviewed the RNUM immediately after interviewing CNA #2. The RNUM stated she would give CNA #2 a break from her assignment on the unit since she may be tired from working the night shift. The RNUM returned to the surveyor several minutes later stating the Administrative team is interviewing CNA #2 and CNA #2 will probably be suspended pending an investigation. On 6/21/21 at 11:00 AM, the Regional Registered Nurse provided the surveyor with a copy of the facility investigation which revealed the following: On 6/15/21 CNA #2 was asked to provide 1:1 care to Resident #30 after she completed working the 11 p.m. to 7 a.m. shift. At approximately 8:30 a.m. the RNUM stated she spoke with CNA #2 to ask if she was alright to work. CNA #2 stated she was alright to work. CNA #2 stated after the resident ate breakfast, she felt her eyes get heavy and closed them for relief. She told the RNUM that she did not hear a knock on the door. When the surveyor and RNUM approached the resident's room, CNA #1 stated, she is out cold. Upon entering, the CNA was observed awake and walking in the room. On 6/16/21 the Director of Nursing (DON) provided the surveyor with the facility's policy and procedure for Falls and Fall Risk Managing, last revised 8/17/20. The policy indicated staff will identify and implement interventions to try to minimize serious consequences of falling. NJAC 8:39-27.1 (a) (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documents it was determined that the facility failed to properly label and date medications in 3 of 6 medication carts inspected. The deficient practice was evidenced by the following: 1. On 6/14/21 at 11:30 AM, the surveyor inspected the Post 2 medication cart on the third floor with the Licensed Practical Nurse (LPN#1) who was assigned to the cart. Inside of the medication cart was a Lantus Insulin pen (A device used to inject insulin. It contains a cartridge, a dial to measure dosage, and a disposable needle) that had an open date of 5/10/21 and an expiration date of 6/6/21 written on a label attached to the pen. There was a printed pharmacy label on the bag that contained the insulin pen. The printed pharmacy label had a resident's name on it, Resident #27. There was no pharmacy label on the insulin pen and no resident name. 2. On 6/14/21 at 12:56 PM, the surveyor inspected the Post 1 medication cart on the third floor with LPN #2 who was assigned to that cart. Inside of the medication cart was an Insulin Lispro Kwikpen with no resident label on the Insulin Lispro Kwikpen or on the bag that contained the Insulin Lispro Kwikpen. The surveyor asked LPN #2 if she noticed the Insulin pen or the bag that contained it did not have a pharmacy label with a resident name. LPN #2 stated she did not notice it. She said if she had noticed that the pen or the bag did not have a pharmacy label she would have thrown them away. On 6/14/21 at 1:30 PM, the survey team spoke with the Administrator, the Director of Nursing (DON), and the Regional Nurse, and made them aware of the concerns with the labeling and dating of medications that were stored in three of six medication carts. On 6/15/21 at 8:45 AM, the Regional Registered Nurse (RRN) informed the surveyor that Resident #27 was admitted on [DATE], so she didn't understand why the Insulin pen was dated 5/10/21. She also provided a packing slip which showed the Lantus Insulin pen for Resident #27 was delivered on 5/21/21. She said she could not verify any of the dates because the nurse threw the pen in the sharps container (a puncture proof container for disposing needles and devices that are sharp) and the bag in the garbage which was taken to the dumpster. The Regional Nurse also provided the Packing Slip that showed the Lantus insulin was delivered to the facility on 5/21/21 and the Face Sheet for Resident # 27 that showed the resident was admitted to the facility on [DATE]. She didn't know why the nurse dated the pen incorrectly. The surveyor reviewed the Pharmacy Consultant's Unit Inspection dated 5/26/21 for the 3rd floor. Under Comments it read Identified the following medication without a labeled date of expiration: Insulin Lispro (1). Identified the following improperly stored medication/s: Kwik Pen (1); Insulin Aspa (1). Identified the following medication without a labeled date of expiration: Insulin Lispro (1) and Insulin Aspa (1). Identified the following mislabeled item: Unlabeled Insulin Lispro Pen inside bag labeled with Sevelamer (a prescription medication that lowers the amount of phosphorus in the blood) for a resident. 3. On 6/14/21 at 1:39 PM, the surveyor inspected the third floor medication cart #4 in the presence of LPN #3. Two medications were marked by nursing when opened on outer box, but not marked on the medication bottle on the inside of the box. The details are as follows: a) Olopatadine Hcl 665 mcg. 240 metered doses - nursing had marked that the box was opened on 5/2/21. The bottle inside the box was not marked when opened. The manufacturer specifications for this product indicated the medication should be discarded 4 weeks after opening. b) Propionate nasal spray 50 mcg. 120 metered sprays - nursing had marked that the box was opened on 5/2/21. The bottle inside was not marked when opened. The manufacturer specifications for this product indicated the medication should be discarded 30 days after opening. LPN #3 stated she was aware the inside containers should have been dated when opened. She stated she did not notice they were not dated or that the medications were beyond their discard date. On 6/15/21 at 8:48 AM, the RRN stated the resident was admitted on [DATE] and the medications were delivered on 6/3/21, therefore, the boxes were misdated. However, no explanation was offered as to why the medications bottles were not labeled with the open date. On 6/15/21 at 9:30 AM, the surveyor reviewed the facility's policy and procedure which was titled Storage of Medication with a review date, 3/18/17. Under Policy Interpretation and Implementation number 3 read: Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Medications that are stored in more than one layer of packaging will have both the medication container as well as the outer medication box/wrapper labeled with appropriate date opened on all layers of storage. NJAC 8:39-29.4 (h)