Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of an unsampled resident on the 3rd floor. This deficient practice was found with 1 of 2 Certified Nursing Aides (CNA) observed on the 3rd floor during the survey. The deficient practice was evidenced by the following: On 4/8/25 at 12:14 PM, the surveyor observed an unsampled resident who self-propelled in their wheelchair down the hallway, the surveyor then overheard the CNA say to the unsampled resident, you can't be moving around in the hallway because people are eating in their room, and then the CNA went behind the resident's wheelchair and push their wheelchair down the hallway toward the unsampled resident's room. At 1:00 PM, the surveyor interviewed the CNA, who stated that he was not regularly on the unit and was concerned that the resident might try to enter other resident's rooms while they ate their lunch. At 1:35 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the unsampled resident was allowed to self propel around the unit freely, as the staff would observe the resident to ensure their safety. The LPN stated that the unsampled resident had never attempted to elope or go into other resident's rooms. A review of the facility's policy titled Dignity, dated reviewed January 2025, revealed that resident are to be treated with dignity and respect at all times. On 4/9/25 at 2:40 PM, the surveyor discussed the above concerns with the Administrator. The Administrator stated that the resident should be allowed to roam the unit freely and will investigate the situation. NJAC 8:39-4.1(a)12

Based on observation, interview and record review, it was determined that the facility failed to ensure the resident's executed living will and durable power of attorney for health care was maintained in the same section of the resident's medical record readily retrievable by any facility staff, follow up on a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, and determine the code status. This deficient practice was identified for 1 of 3 residents reviewed for advanced directives (Resident #52), and was evidenced by the following: On 4/3/25 at 10:18 AM, the surveyor observed Resident #52 asleep wearing a short sleeve shirt, the right upper arm had a small bandage near the arteriovenous (AV) fistula (surgically created connection between the artery and the vein primarily used for hemodialysis). On 4/4/25 at 9:10 AM, the surveyor observed Resident #52 laying on their side, asleep. The surveyor reviewed the medical record for Resident #52. A review of the Resident admission Record (admission summary) reflected that Resident #52 was admitted , with diagnoses which included end stage renal disease, dependence on dialysis and heart failure. The category to indicate Advance Directive (a living will/health care proxy) status was blank on the face sheet. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/5/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired. A review of the electronic Medical Record (eMR) did not reflect a code status for the resident and had a link for for advanced directives. The link showed the resident had a general durable power of attorney that did not include an advanced directive. A review of the resident's medical chart did not reflect evidence of an Advance Directive on file and did not reflect a POLST form (an end-of-life medical treatment order based on known preferences.) A review of the Social Services admission Evaluation (SSAE) with an effective date of 2/27/25, under Advanced Directives reflected that the resident had a durable power of attorney for healthcare decisions, a health care proxy and was interested in completing a POLST. Further review of the SSAE, revealed documentation made by the Social Worker (SW) that the resident was alert to person and place but had periods of forgetfulness and wanted to be a full code. On 4/4/25 at 10:31 AM, during an interview with the surveyor, the Social Services Director (SSD) stated that Resident #52 had a power or attorney (POA) on file and could not show that a living will, and health care proxy was on file (Advanced Directive). The SSD confirmed that a POA was not the same as the Advanced Directive. The SSD stated that the documentation was incorrect since the living will, and health proxy was not in file. On 4/4/25 at 11:12 AM, the surveyor and the MDS-Nurse reviewed the physical chart and the eMR together. The MDS-Nurse confirmed that the living will, health care proxy, POLST, code status, and an order from the physician were not found in both medical records. On 4/4/25 at 11:31 AM, during a follow-up interview with the surveyor, the SSD stated that the resident had been residing in the facility for over one (1) month and that the record of advanced directive and POLST should have been updated within three (3) days of admission. On 4/4/25 during an interview with the surveyor, the SW stated that the family representative had provided her with the living will and the health care proxy which she forgot to upload into the eMR. The SW acknowledged that she should have followed up with the POLST since family representative expressed interest in formulating a POLST upon admission. At that time the SW acknowledged and confirmed that the advanced directive was not on file, the POLST was not followed-up to completion which resulted in the missing code status for Resident #52. On 4/7/26 at 2:46 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concern with the missing living will, health care proxy, the POLST and the code status for Resident #52 who had been in the facility for over one (1) month. On 4/8/25 at 10:22 AM, during a meeting with the survey team, and the DON, the LNHA stated that the facility obtained the POLST after surveyor inquiry and that it was assumed that the resident was a full code. A review of the provided facility policy, Advanced Directives, dated/revised September 2022, included that resident or the residents' representatives executed Advanced Directive, upon admission, copies of these documents were obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. No further information was provided. NJAC 8:39-4.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility failed to maintain the residents' living environment and the outside of the facility in a clean, sanitary, and homelike manner for 1 unsampled resident (room [ROOM NUMBER]) and the area on the 2nd floor outside of the elevator doors. The deficient practice was evidenced by the following: 1. On 4/3/25 at 11:10 AM, on the 2nd floor, outside of the elevator the floor, the surveyor observed 2 broken pieces in the floorboards, where double doors closed. 2. At 11:35 AM, the surveyor observed the garbage area outside of the facility and observed 1 pair of plastic gloves, a plastic knife, a few pieces of paper napkins, and a few clear pieces of plastic on the ground around the garbage dumpsters. 3. On 4/8/25 at 12:08 PM, the surveyor observed an unsampled resident inside of room [ROOM NUMBER]. The surveyor observed that the latch at the top of the door was broken and twisted. The door was unable to close completely when the surveyor pulled it closed. At 12:10 PM, the surveyor interviewed the unsampled resident who resided in room [ROOM NUMBER], and the unsampled resident stated that the door does not always close and the staff know about it. The unsampled resident stated that the door latch had been broken since last month, and that they told a nurse about the door a while ago. At 1:20 PM the surveyor interviewed the Licensed Practical Nurse (LPN) on the floor, and the LPN stated that he was not aware of the door latch being broken. At 1:30 PM, the surveyor interviewed Maintenance Employee (ME) # 1 and ME # 2, who stated that they were just made aware of the door latch being broken and had not known about it or observed it prior to today. The ME # 1 and # 2 both stated that they will be fixing the door latch today and were not sure what happened. On 4/9/25 at 2:40 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing. No further information was provided. NJAC 8:39-31.2(e), 31.4(a)

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 1 of 5 residents, Resident #29, reviewed for immunization status. The deficient practice was evidenced by the following. Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of Pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. The surveyor observed Resident #29 on 4/3/25 at 10:47 AM awake in bed. A review of the 1/20/25 Quarterly MDS Section O0300, indicated the resident's pneumococcal vaccination was up to date. A review of the resident's immunization schedule revealed the resident received the pneumococcal polysaccharide vaccine (PPSV23) on 10/18/21. The surveyor interviewed the Infection Preventionist (IP) on 4/8/25 at 9:09 AM. At that time the IP stated the current pneumococcal vaccine offered to residents was the PPSV23. On 4/10/25 at 1:00 PM, the surveyor and the IP reviewed the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults (www.cdc.gov/pneumococcal/index.html) dated 10/2024. The IP stated the current pneumococcal vaccines are the pneumococcal conjugate vaccine (PCV) 20 and PCV 21. The facility policy titled Certifying Accuracy of the Resident Assessment, revised 11/2009, indicated the person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. NJAC 8:39-33.2(d)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #1) reviewed for care and services for pressure ulcers. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/3/25 at 10:47 AM, the surveyor observed Resident #1 in bed on a specialty mattress positioned on the right side in a supine position. The surveyor observed signage on the door, which indicated the resident was on Enhanced Barrier Precautions. The surveyor reviewed the medical record for Resident # 1. A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; quadriplegia, right hip abscess, cognitive communication deficit, stage 4 pressure ulcer of the sacrum (a wound that involves severe tissue damage), left hip osteomyelitis (bone infection) and sepsis (illness which causes a severe inflammatory response to bacteria.) A review of the quarterly Minimum Data Set, an assessment tool dated 1/2/25, reflected Resident #1 had a Brief Interview for Mental Status score of 12 of 15, which indicated the Resident had a moderate cognitive impairment. The 4/3/25 Weekly Wound Assessment Report included documentation regarding the stage 4 left hip pressure ulcer, which was currently unchanged. A review of the Physician Order (PO) dated 11/20/24 included: clean wound bed with Vashe Wound Solution (wound cleaning solution), pack with Calcium Silver Alginate Rope (used to absorb wound exudate), and cover with border foam dressing. On 4/9/25 at 11:05 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform the treatment to the resident's left hip stage 4 pressure ulcer and observed the following: The Registered Nurse/Unit Manager sanitized the over bed table and covered it with a barrier sheet. The LPN gathered the supplies, which included a package of calcium alginate rope, an Opti foam dressing, 4x4 gauze pads and scissors. The LPN donned (put on) a disposable gown, gloves, and placed all supplies on the over bed table. The LPN removed the soiled foam dressing, which had a moderate amount of brownish-red purulent drainage. The LPN discarded the soiled dressing, removed her gloves, and without sanitizing her hands, donned a new pair of gloves. The LPN cleansed the wound with Vashe-soaked gauze 3 times. Each time she cleaned the wound, she removed her gloves and, without sanitizing her hands, donned new gloves. The LPN opened the Sterile Alginate Rope and packed the wound with her gloved hands without using an applicator or Sterile Q tip. The LPN removed her gloves and donned a new pair, with no observed hand hygiene. The LPN dated, initialed, and timed the dressing and then applied it to the wound. The LPN positioned the resident for comfort, discarded all supplies, removed trash from the room, and washed her hands. The LPN did not sanitize the over bed table after the wound treatment was completed. On 4/9/25 at 11:30 AM, the surveyor discussed the infection control breaches with the LPN, who confirmed that she should have sanitized her hands between glove changes and should not have touched the sterile calcium alginate rope with her gloved hands. The IPN confirmed that the LPN should have disinfected the over bed table after the treatment was completed. On 4/9/25 at 11:50 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN) in the presence of the Licensed Nursing Home Administrator (LNHA). The IPN stated that hand hygiene should be performed before and after glove changes, the LPN should not be touching the sterile CA Alginate rope but should have used an applicator to pack the wound, and should have disinfected the over bed table when the treatment was completed. On 4/9/25 at 12:00 PM, the survey team met with the LNHA, Director Of Nursing and VP of Special Clinical Projects to discuss the above observations and concerns. A review of the facility's Pressure Ulcer/Skin Breakdown policy revised 3/2014 did not include performing hand hygiene between glove changes, using an applicator to pack wounds, or disinfecting the over-bed table after the wound treatment was completed. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations from February 2025 until surveyor inquiry for 1 of 5 residents (Resident #71) reviewed for medication management. The deficient practice was evidenced by the following. The surveyor observed Resident #71 on 4/03/25 at 10:43 AM laying in a low bed to the floor with cushioned mats on each side of the bed. The resident was calling out in a foreign language and appeared confused. A review of the medical record revealed the following information. The admission Record included the diagnosis of dementia with mood disturbance. The resident was receiving Hospice services. The April 2025 Medication Administration Record (MAR) included the following pain-related physician orders: Pain score every shift; 0=no pain; 1,2,3,4=mild pain, 5,6,7=moderate pain; 8,9,10=severe pain. Acetaminophen (Tylenol) 325 mg. Give 2 tablets by mouth every 6 hours as needed for mild pain (1-4). Morphine Sulfate Solution 20 mg./ml. Give 0.25 ml (5 mg.) by mouth every 3 hours as needed for severe pain (8-10). The surveyor interviewed the resident's medication nurse on 4/8/25 at 12:52 PM. The nurse stated she was unsure what the resident would receive if the pain was measured at 5, 6, or 7 on the pain scale. She stated she would have to call the physician to get an order. The CP documented on the 2/12/25 Consultant Pharmacist Evaluation (monthly medication recommendations by the CP) *pain 5-7 [illegible]. The surveyor discussed the concern with the Administrator and the Director of Nursing (DON) on 4/10/25. The DON stated she would obtain an updated physician's order to include orders for pain rated at 5 - 7 on the pain scale. A review of the facility policies titled Pharmacy Services-Role of the Consultant Pharmacist (4/2019) and Medication Regime Reviews (5/2019) indicated the CP documents a review of the medication regime at least monthly communicating potential or actual problems related to medications and medication irregularities. The physician provides a timely and adequate response to the recommendation. The Medical Director will provide a response, if no action is taken by the physician. NJAC-29.3

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 4/7/25 and 4/8/25, the surveyor observed five (5) nurses administer medications to five (5) residents. There were 27 opportunities, and two (2) errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for two (2) of five (5) residents (Resident #37 and 64), that was administered by two (2) of five (5) nurses. This deficient practice was evidenced by the following: 1. On 4/7/25 at 8:38 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who was assigned to the second-floor low side medication cart, knocked on Resident #37's door. The greeted the resident who was seated on the edge of their bed facing their breakfast tray on the bedside table. At 8:44 AM, the surveyor observed LPN #1 prepare medications for Resident #37. The medications prepared included a physician's order of Voltaren Gel 1% apply to the right knee 4 grams (gm) topically four times a day for pain. The order was started on 3/18/25. At 8:55 AM, the surveyor observed LPN #1 enter the threshold to administer the medications to Resident #37 that included the Voltaren gel. The LPN #1 administered the oral medications and before the LPN could administer the Voltaren gel, the surveyor asked the LPN to step outside the resident's room. At 8:57 AM, in front of the medication cart, LPN #1 informed the surveyor, that she would place the cream in front of Resident #37's knee and that she would squeeze the gel into the cap to measure 4 gm. At that time, the surveyor and LPN #1 reviewed the Voltaren Gel manufacturer's package. The LPN found inside a ruler that she described as stuck inside the packaging. The LPN confirmed that the ruler appeared unused. LPN #1 continued to inspect the ruler, and the measurement was defined on the ruler in inches to equal 4 gm. At that time, LPN #1 confirmed and acknowledged that she should have used the ruler to apply Resident #37's Voltaren gel. 2.) On 4/7/25 at 9:14 AM, the surveyor observed LPN #2 who was assigned to the lower-level high side, used the electronic Medication administration Record (eMAR) to review the medications for Resident #64. The medications reviewed included a physician's order of Midodrine 5 milligram (mg), give 1 tablet by mouth three times a day for hypotension (low blood pressure); hold for systolic blood pressure greater than 130. Do not administer after the evening meal or 4 hours from bedtime to avoid supine hypertension. The order was started on 3/25/25. At 9:24 AM, LPN #2 went inside Resident #64's room and took the resident's blood pressure measurement which resulted to a reading of 127/81 mmHg (systolic/diastolic; millimeters of mercury). LPN #2 stated because of the reading result he would administer Midodrine. At 9:34 AM, LPN #2 stated that the automatic dispensing machine (ADS) packaged Resident #64's medications but did not include the Midodrine. LPN #2 stated he would retrieve the Midodrine after administering the other medications he had prepared. At 10:03 AM, after returning from retrieving the Midodrine from the ADS machine, located on the first floor, LPN #2 began to prepare to administer the Midodrine. The LPN stated that he had previously taken the BP and recorded 127/77 mmHg on the eMAR. At 10:07 AM, LPN #2 locked the cart, and knocked on Resident #64's door to administer the medications that included the Midodrine. At 10:08 AM, the surveyor stopped the medication pass and asked to speak with LPN #2 in the hallway. The surveyor asked what the professional standard of practice for an order with blood pressure parameters was. At that time, LPN #2 acknowledged that the pressure had to be taken before administration of the Midodrine. At 10:14 AM, the surveyor observed LPN #2 take Resident #64's blood pressure (BP) that resulted in a reading of 121/60 mmHg. LPN #2 administered the Midodrine and updated the blood pressure recording. At 10:23 AM, during an interview with the surveyor, the LPN/Unit Manager stated that the BP for Resident #64 should have been retaken prior to administration. On 4/7/26 at 2:46 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concerns with the medication pass wherein the LPN #1 prepared to administer Voltaren gel without measurement of the correct dose, and LPN #2 who prepared to administer Midodrine utilizing a blood pressure reading from more than 30 minutes from the administration time and initially recorded the wrong BP reading. On 4/8/25 at 10:22 AM, during a meeting with the survey team, and the DON, the LNHA stated that the nurses were educated on the use the Voltaren dose card to measure the dosage prior to administration and were educated to obtain the vital signs within half hour of medication administration. A review of the provided facility policy, dated/revised April 2019 included that medications are administered in accordance with prescriber orders. Medications administration times are determined by resident need and benefit .Factors considered are enhancing optimal therapeutic effect if the medication .The policy and procedure did not include to obtain the vital signs within half hour of medication administration when the medication has a hold parameter. that was provided during the education after surveyor inquiry of the Midodrine. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Resident #29. This deficient practice was identified for 1 of 5 residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; Capvaxive), PCV20 (pneumococcal 20-valent conjugate vaccine), or PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to 1 year after the last PPSV23 (pneumococcal 23-valent polysaccharide vaccine; Pneumovax23) dose. Reference [previous guidelines] A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 3/15/23, included the following: The CDC recommends a single dose of PCV20 or PCV15 greater than or equal to 1 year after PPSV23. The surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) on 4/8/25 at 909 AM. The RN/IP stated that the current pneumococcal vaccine offered at the facility was the PPSV23. On 4/10/25 at 1:00 PM, the surveyor and the IP reviewed the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults (www.cdc.gov/pneumococcal/index.html) dated 10/2024. The IP stated she should have been offering residents the current pneumococcal vaccines, PCV20 and PCV21. The surveyor observed Resident #29 on 4/3/25 at 10:47 AM awake in bed. A review of the 1/20/25 Quarterly MDS Section O0300, indicated the resident's pneumococcal vaccination was up to date. A review of the resident's immunization schedule revealed the resident received the pneumococcal polysaccharide vaccine (PPSV23) on 10/18/21. The facility policy titled Pneumococcal Vaccine, revised 3/2022, indicated administration of the pneumococcal vaccines are made in accordance with current CDC recommendations at the time of the vaccination. NJAC 8:39-19.4(i)

Complaint #NJ 00174418 Based on interview and record review it was determined that the facility failed to respond to residents' requests for assistance in a timely manner for 5 of 5 residents in attendance at the resident group meeting (Resident #8, 37, 51,60, 97) and 1 of 20 Residents (Resident #254) observed during a tour of the first floor Nursing Unit. This deficient practice was evidenced by the following: The surveyor conducted the resident group meeting on 4/7/25 at 10:30 AM. All 5 of 5 residents stated that the call bell response was slow on all shifts. The residents stated they wait between 30 minutes to an hour. The surveyor interviewed resident # 254 on 4/7/25 at 12:50 PM. The resident stated that on 4/6/25, they waited from 9:00 PM to 10:30 PM for their call bell to be answered. The resident stated that they were incontinent and were dependent on staff for personal care. A review of minutes from past resident council meetings included a 2/10/25 comment from residents stating that they would like to see faster call bell responses. On 4/7/35 at 2:45 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing, who confirmed that all residents should have their call bells answered in a timely manner. NJAC 8:39 -27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ 00174418 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for a.) 1 of 20 residents reviewed for Activities of Daily Living (ADL) care (Resident #254) and b.) 4 of 4 residents (Resident #17, 90, 255 and 256) observed for incontinence care on 1 of 3 Units (1st-floor Nursing Unit). This deficient practice was evidenced by the following: 1. On 4/7/25 at 12:50 PM, during a tour of the 1st floor Nursing Unit, Resident #254 stated that on 4/6/25 at 9:00 PM, the resident was incontinent of his/her bowels and used the call bell to summon staff for assistance. The Certified Nursing Assistant (CNA #1) did not respond until 10:30 PM. The Resident was in a soiled brief for 1.5 hours. A review of Resident #254's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hypertension and compression fracture of the thoracic vertebra. A review of Resident #254's admission Minimum Data Set (MDS), an assessment tool dated 4/9/25, revealed Resident #254 had a brief Interview for mental status (BIMS) score of 14 out of 15 which indicated the resident's cognition was intact. The MDS further revealed the resident required staff assistance for toileting hygiene and was always incontinent of bowel and bladder. A review of Resident #254's Individualized Care Plan (CP) revealed there was no care plan that addressed the resident's incontinence care. 2. On 4/8/25 at 7:25 AM, the surveyor completed an incontinence tour on the First-floor Nursing Unit and observed the following: a. On 4/8/25 at 7:30 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #2) observed Resident #17 in bed. CNA #2 exposed Resident #17's incontinence brief, and the surveyor observed a second incontinence brief, which was saturated with urine. CNA #2 confirmed that the brief was saturated with urine. A review of Resident #17's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; Alzheimer's disease and chronic kidney disease. A review of Resident #17's quarterly MDS dated [DATE] revealed Resident #17 had a BIMS score of 3 out of 15, which indicated Resident #17 had a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident #17's Individualized Care Plan (CP), undated, had a focus area that included Urinary incontinence related to disease process with interventions that included but were not limited to providing incontinent care as needed. b. On 4/8/25 at 7:35 AM, the surveyor, accompanied by CNA #2 observed Resident #90 in bed. CNA #2 exposed Resident #90's incontinence brief, and the surveyor observed a second incontinence brief, which was saturated with urine. CNA #2 confirmed that the brief was saturated with urine. A review of Resident #90's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection and cognitive communication deficit. A review of Resident #90's admission MDS dated [DATE] revealed Resident #90 had a BIMS score of 10 out of 15, which indicated Resident #90 had a moderate cognitive impairment. The MDS further revealed that the resident required the assistance of staff for toileting hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident #90's CP, undated, had a focus area that included Urinary Incontinence related to disease process with interventions that included but were not limited to providing incontinent care as needed. c. On 4/8/25 at 7:38 AM, the surveyor, accompanied by CNA #2 observed Resident #255 in bed. CNA #2 exposed Resident #255's incontinence brief, and the surveyor observed a bladder absorbency pad inserted inside the brief, which was saturated with urine. CNA #2 confirmed that the brief and absorbency pad were both saturated with urine. A review of Resident #255's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; malignant neoplasm of the breast and hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body). A review of Resident #255's admission MDS dated [DATE] revealed that Resident #255 had a BIMS score of 14 out of 15, which indicated that Resident #255's cognition was intact. The MDS further revealed that the resident required staff assistance for toileting hygiene, and he/she was frequently incontinent of bladder and occasionally incontinent of bowel. A review of Resident #255's CP, undated, had a focus area that included Urinary incontinence related to disease process with interventions that included but were not limited to providing incontinent care as needed. d. On 4/8/25 at 7:40 AM, the surveyor, accompanied by CNA #2 observed Resident #256 in bed. CNA #2 exposed Resident #256's incontinence brief, and the surveyor observed a bladder absorbency pad inserted inside the brief, which was saturated with urine. CNA #2 confirmed that the brief and absorbency pad were both saturated with urine. A review of Resident #256's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; dementia and congestive heart failure. A review of Resident #256's admission MDS dated [DATE] revealed that Resident #256 had a BIMS score of 3 out of 15, which indicated that Resident #256 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident #256's CP, dated 4/5/25, had a focus area that included Urinary Incontinence related to impaired mobility/dementia with interventions that included but were not limited to; providing incontinent care as needed. On 4/8/25 at 7:41 AM, during an interview with the surveyor, CNA #2, stated that the residents should not have double briefs or bladder pads in place and that residents should receive incontinence care every two hours. On 4/8/25 at 7:43 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that it was the facility policy to apply only one adult brief and further stated that the facility did not use bladder pads. On 4/8/25 at 7:45 AM, during an interview with the surveyor, the 11:00 PM-7:00 AM, Licensed Practical Nurse (LPN) stated that the residents should not have two briefs and should not have bladder pads inserted within the briefs. The LPN further stated the CNAs should provide incontinence care every two hours. On 4/8/25 at 8:10 AM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA confirmed that the residents should not have two adult briefs in place and that the facility does not use bladder absorbency pads. On 4/10/25 at 6:30 AM, the surveyor conducted a phone interview with the 11:00 PM-7:00 AM shift CNA (CNA #3) assigned to Resident #90 and Resident #255 stated that she used two briefs and bladder inserts for residents who requested them. The surveyor asked the CNA if she had informed the nurses about the requests and if the resident's were care planned for two adult briefs and/or bladder pads. The CNA replied that she had not informed any of the nurses, and the requests were not in the residents care plans. On 4/10/25, the surveyor attempted a phone interview with the 3:00 PM-11:00 PM, CNA assigned to Resident #254 on 4/6/25. The CNA did not return the call. A review of the facility's Activities of Daily Living (ADL), Supporting policy dated as revised March 2018 reflected that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. NJAC 8:39-27.1 (a), 27.2 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The surveyor interviewed Resident #13 on 4/3/25 at 11:07 AM and on 4/7/25 at 10:25 AM in their room. The resident discussed their long term pain management for 3 herniated discs. The resident stated there was a time in October 2024 when a newly prescribed physician's order of oxycodone was not administered to the resident for 2 days. A review of the resident's medical record revealed the following information. The resident's admission Record included diagnoses of cervical disc degeneration, polyneuropathy, peripheral vascular disease, chronic pain, and Parkinson's disease. The 2/19/25 Annual Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits, utilized a manual wheelchair, experienced pain in the previous 5 days occasionally limiting day to day activities. The worst pain the resident experienced on a 0-10 scale (no pain to worst pain) in the previous pain was 3. The resident was coded to have taken opioid medicatons during the previous 7 days. The care plan for pain, initiated 2/26/21 and revised 8/21/24, identified pain related to arthritis, polyneuropathy, lower back pain, and chronic pain syndrome. Interventions included for nursing to administer pain medications according to physician orders; notify physician if pain frequency or intensity worsens or become ineffective; and obtain pain management consult if needed. The October 2024 Medication Administration Record (MAR) included the following order, Oxycodone Hcl tablet 10 mg. Give 1 tablet by [NAME] in the morning for pain management for 4 weeks. Start Date 10/24/24. The medication was not given on 10/24/24 or 10/25/24 as evidenced by a code of 9 defined in the MAR as other/see nurse note. A 10/24/24 (6:46 AM) Administration Note confirmed the handwritten prescription was faxed to the pharmacy by the nurse. A 10/25/24 (7:19 AM) Administration Note indicated the medication was not available to administer. The nurse left a message for the physician. The resident was noted to be upset. The surveyor interviewed the Nurse Manager on 4/07/25 at 10:33 AM. She stated that although the prescription was faxed to the pharmacy, the medication was not available in the facility's electronic medication dispensing machine on the mornings of 10/24/24 and 10/25/24. On 4/07/25 at 3:04 PM the surveyor discussed the concern with the Administrator and the Director of Nursing. The Administrator stated the first dose of the medication was administered on 10/26/24. The facility policy and procedure titled Pain Assessment and Management, revised October 2022, indicated nursing staff is to assess the resident's pain using a consistent approach and standardized pain assessment instrument. Additionally, nursing staff is to monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. NJAC 8:39-27.1(a) Complaint #'s : NJ 183721, 179025 Based on observation, interview, and record review it was determined that the facility failed to provide pain management that is consistent with professional standards of practice, the resident's goal and preference, and ensure a.) an assessment of Resident #150's pain was conducted prior to discontinuation of a pain medication, b) a narcotic medication was available for administration (for 2 doses) in accordance with the physician's order. This deficient practice was identified for 2 of 4 residents investigated for pain management and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #150. 1. A review of the Resident admission Record (admission summary) reflected that Resident #150 was admitted , with diagnoses which included displaced fracture of medial malleolus of the right tibia (displacement of the inner side of the ankle bone of the right lower leg), intraductal carcinoma in situ of the left breast (cancer in the milk ducts of the breast that can occur in both genders) and adjustment disorder. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/13/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It showed that the resident received scheduled pain medication and had not experienced pain in the last 5 days. A review of the Nurse's Progress Notes, written by the Nurse on Duty (NOD) on 2/22/25 at 1:01 AM, included the following documentation: -The nurse was informed by the resident that they did not receive their bedtime dose of Gabapentin (Neurontin; medication indicated for neuropathic pain (nerve pain)). -The nurse informed the resident that there was no active order, and the physician would be called for a new order to administer Gabapentin. -The nurse received a new order for Gabapentin. -The nurse was informed by the resident that they had taken a Gabapentin from their bag, after receiving the new order, then the resident continued to ask for the medication. A review of the hospital discharge medications included Gabapentin 100 mg, 1 capsule by mouth nightly for 14 days and was transcribed into the facility eMAR with the same duration. A review of the Order Review Report for February 2025 included the following orders: -Gabapentin 100 milligram (mg), give 1 capsule by mouth at bedtime for neuropathic pain for 14 days. The order was started on 2/7/25 and discontinued on 2/11/25. -Gabapentin 100 mg, give 1 capsule by mouth at bedtime for neuropathic pain. The order was started on 2/22/25 and discontinued on 3/4/25. A review of the electronic Medication Administration Record (eMAR) for February 2025, included a physician's order for Gabapentin 100 milligram (mg), give 1 capsule by mouth at bedtime for neuropathic pain for 14 days. The administration was scheduled nightly at 9:00 PM, and the order was started on 2/7/25 and ended on 2/11/25. A subsequent order for Gabapentin was started on 2/11/25 and ended on 2/20/25. Additionally, the eMAR reflected that Gabapentin was administered nightly from 2/7/25 to 2/20/25. On 2/21/25,the eMAR did not reflect an active order for the Resident's Gabapentin. The order was resumed on 2/22/25 and the resident continued to receive the medication nightly until discharge. A review of the resident's care plan reflected a focus on somatic pain related to cancer, lumbar radiculopathy, that was initiated on 3/11/25. The interventions included: administer pain medication per physician orders, notify physician of frequent/intensity and worsening or when current pain analgesia became ineffective and report nonverbal expression of pain. A review of the physician progress notes (PPN) did not show that the Resident #150 was assessed and informed prior to the discontinuation of the Gabapentin on 2/21/25. On 4/9/25 at 8:00 AM and on 4/10/25 at 9:10 AM, the surveyor attempted to call the NOD on 2/22/25, the voicemail box was full and was unable to leave a message on both times. On 4/9/25 at 12:08 PM, during a meeting with the surveyors, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concerns with Resident #150's Gabapentin that ended on 2/21/25 because of the 14-day duration, followed by the resident self- administration of their own supply of Gabapentin. On 4/10/25 at 11:28 AM, during a meeting with the survey team and the LNHA, the DON stated that she telephonically interviewed the NOD on 2/22/25, regarding Resident #150. The DON provided her signed statement of the interview to the surveyor. The DON stated that from the interview, she learned that the NOD did not witness the resident take their Gabapentin and was prohibited by the resident from entering their room, and from searching their bag. The DON stated that more information would be provided regarding the assessment of the resident's pain prior to the discontinuation of the pain regimen (Gabapentin) for neuropathic pain. The new order for Gabapentin was received on 2/22/25 at 12:45 AM and was scheduled for 9:00 PM that evening. An earlier administration was not reflected on the provided documentation and the medical record reviewed, On 4/10/25 at 1:00 PM, during a follow up interview with the survey team, the DON stated that the physician should have informed the staff when they wanted the Gabapentin order to be continued. At that time, the DON was unable to provide evidence that the Resident #150 was assessed by the physician prior to the discontinuation of the Gabapentin on 2/21/25. A review of the facility provided policy, Pain Assessment and Management dated/revised on 10/22 included that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. A review of the facility provided policy, Medications Brought to the Facility by the Resident/Family dated/revised on 4/2007 included the following: Medications brought into the facility by a resident or responsible party are used only upon written order by the resident's attending physician, once the contents are verified, and when appropriately packaged and labeled. Unauthorized medications are not accepted. The facility discourages the use of medications brought in from outside and will inform residents and families of that policy as well as applicable laws and regulations. Medications brought into the facility that are not approved for the resident's use shall be returned to the family. If the family does not pick up those medications within 30 days the facility made destroy them in accordance with established policies. No further information was provided.

Based on observation, interview, and record review it was determined that the facility failed to clarify a physician's order for peritoneal site care and the assessment for sign and symptoms of infection for precaution. The deficient practice was identified for 1 of 1 resident reviewed for Peritoneal Dialysis (PD) and was evidenced by the following: The surveyor reviewed the closed record for Resident #26. 1. A review of the Resident admission Record (admission summary) reflected that Resident #26 was admitted , with diagnoses which included end stage renal disease, and peritonitis. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/27/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact and on admission, the resident was received PD. A review of the electronic Treatment Administration Record (eTAR) included a physician's order for Peritoneal Catheter (PC) site care every shift. Assess for signs and symptoms of infection every shift for precaution schedule at 7:00 AM to 7:00PM and 7:00 PM to 7:00 AM. The order was started on 2/20/25. The required a documentation of Yes (Y) or No (No). The eTAR documentation for March 2025 reflected the following: 36 of the 62 shifts were documented No. 22 of the 62 shifts were documented Yes. 4 of the 62 shifts were documented as not applicable (NA). The eTAR documentation for April 2025 reflected the following: 3 of the 3 shifts were documented Yes. On 4/8/25 at 9:54 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN #1) stated he recalled the resident and was one of the nurses that signed the eTAR for the resident. LPN #1 stated that the nurses monitored the PD site, dressing change, fluid retention and was documented in the eTAR. At that time surveyor and, the LPN reviewed Resident #26's physician's order for PC site care and assessment for signs and symptoms of infection, together. LPN #2 stated that Y meant the dressing was changed, N meant that a dressing change may have been already done which did not required a dressing change and NA meant it was not done. The surveyor reviewed the list of staff qualified for PD treatment which included LPN #2. On 4/8/25 at 11:00 AM, during an interview with LPN #2 who was on the first-floor high side stated that the PD vendors gave her education on how to properly care for a PD resident. LPN #2 and the surveyor reviewed Resident #26's physician's order for PC site care and assessment for sign and symptoms of infection, together. LPN #2 stated that Y meant the resident was assessed for sign and symptom of infection and N meant the resident was not assessed for sign and symptoms of infection. LPN #2 also stated that there was no reason a No should be there in the documentation. On 4/8/25 at 11:41 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that Y meant it was done, N meant the patient refused, or it was not cleaned, or the resident cleaned it themselves but that required an order which Resident #26 did not have. The PD clinic advises us what care is needed for the resident; ultimately, we are responsible to ensure the PC site is cleaned. On 4/9/25 at 12:08 PM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concerns with Resident #26's physician's order that required a documentation for PC site care and assessment of sign and symptoms of infection wherein the nurses document No 36 times and Yes 22 times which could have indicated signs and symptoms of infection. On 4/10/25 at 11:28 AM, during a meeting with the survey team and the LNHA, the DON stated that N meant there were no signs and symptoms of infection, and the dressing was changed. The DON provided progress notes (PN) documentations of a bandage change for 1 of 2 shifts on 3/31/25, and 1of 2 shift on 3/30/25 and the PN did not indicate if signs and symptoms of an infection was present. At that time, the DON acknowledged the order should have been clarified to ensure the resident received proper care and assessment of the PC site. A review of the provided facility policy, Peritoneal Dialysis, dated/revised in October 2010, under Catheter and Site Observation included that if there were signs/symptoms of infection the catheter is cracked or torn, contact the physician for further instructions. No further information was provided. NJAC 8:39 - 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) disposition (destruction), reconciliation, and accountability of the returned controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for 1 of 1 automatic dispensing system (ADS), b.) opened saline solution bottle was dated, to indicate expiration, which was identified during an observation of a resident on enhanced barrier precautions (EBP), and c.) a medication was stored in accordance with manufacturer's specifications identified in 1 of 4 medication carts inspected. On [DATE] at 11:24 AM, during an interview with the surveyor, the Director of Nursing stated that she had access to the website to review different types of reports. The DON stated she compared the reports and destroyed the returned narcotic medication with another nurse. On [DATE] at 12:58 PM, during the inspection of the ADS, in the presence of the DON, and the Registered Nurse, the surveyor began the inspection of the ADS and the back-up supply of the facility. At that time the surveyor observed keys hanging on the outside of the ADS. The ADS required a biometric log or a password specific that was required to be typed into the screen of the machine prior to access. A review of the facility provided pharmacy provider's returned medication log (RML) against the facility's ADS narcotic destruction log (NDL)for the last quarter ([DATE], [DATE], February 2025, and [DATE]) revealed the following: [DATE] There were 14 narcotics on the RML and the ADS NDL had 7 narcotics listed, did not reflect the quantity destroyed per logged item, 5 out of 7 had the date of when the item was returned, and 1 out of 7 had the date of the destruction. There were 6 narcotics returned that were unaccounted. [DATE] There were 9 narcotics on the RML and the ADS NDL had 3 narcotics listed, did not reflect the quantity destroyed per logged item, the date of the item was returned and the date of the destruction. There were 6 narcotics returned that were unaccounted. February 2025 There were 4 narcotics on the RML and the ADS NDL had 1 narcotic listed, did not reflect the quantity destroyed per logged item, the date of the item was returned, and the date of the destruction. There were 3 narcotics returned that were unaccounted. [DATE] There were 8 narcotics on the RML and the ADS NDL had 7 narcotics listed, and did not reflect the quantity destroyed per logged item. There were 3 narcotics returned that were unaccounted. 2.) On [DATE] at 10:45 AM, during the inspection of the medication cart on the First-floor high side, the surveyor and the Licensed Practical Nurse (LPN #1) observed an opened bottle of Acidophilus in the medication cart. The surveyor and the LPN reviewed the bottle together which reflected manufacturer's recommendation: Refrigerate after opening. At that time, the Director of Nursing walked over to the medication cart and confirmed the Acidophilus should not have been in the cart and should have been refrigerated. 3.) On [DATE] at 1:32 PM, from the hallway the surveyor walked into Resident #95's room and found an opened, and undated sodium chloride bottle on the resident's bedside nightstand On [DATE] at 1:37 PM, during an interview with the surveyor, LPN #2 confirmed observing the opened and undated bottle of sodium chloride on the resident's bedside nightstand and stated that it should have been dated. LPN #2 stated he did not know who left it there. On [DATE] at 12:08 PM, during a meeting with the surveyors, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concerns regarding the concern with the facility's failure to ensure reconciliation and accountability of the disposition of narcotic medication from the ADS, the acidophilus found on the cart while the manufacture specifications indicated the item had to be refrigerated and the opened and undated bottle of sodium chloride in Resident # 95 bedside nightstand. At that time, the VPoSCP informed the surveyors that the ADS was owned by the pharmacy provider and not the facility and that the Chief Operating Officer wanted to meet with the survey team. On [DATE] at 11:28 AM, during a meeting with the survey team and the LNHA, the DON acknowledged that the tracking for the disposition could be better and would be better tracked moving forward. At that time, the LNHA acknowledged that the Acidophilus should have been refrigerated and the opened and undated bottle of sodium chloride should have been dated. At that time the DON confirmed that the bottle of sodium chloride expired after 24 hours. On [DATE] at 11:52 AM, during a meeting with the survey team, the COO of the provider pharmacy stated that the destruction and the tracking of the disposed narcotics, that required two (2) nurses' signatures was the responsibility of the facility's nursing staff. On [DATE] at 12:17 PM, the surveyor conducted a follow-up inspection of the ADS with the DON and the RN and found that one the keys hanging on the door was to open the non-controlled narcotic bin. At that time, the DON stated that a camera was in the medication room of the ADS and could review the camera to observe when a diversion occurred. A review of the provided facility policy, Controlled Substances, dated/revised [DATE], included: The system of reconciling receipt, dispensing and disposition of controlled substances includes . declining inventory record and destruction, waste and return to pharmacy records. Waste and/or disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet. A review of the provided facility policy, Medication Labeling and Storage dated/revised February 2023, included that the nursing staff is responsible for maintaining medication storage .Medications requiring refrigeration are stored in the refrigerator stored in the medication room at the nurses' station .Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices; The medication label includes, at minimum .expiration date, when applicable . NJAC 8:39-29.4(g)(h)(k),29.7(c)

2. On 4/7/25 at 12:20 PM, on the lower level (LL), the surveyor observed that in the bathroom of 2 unsampled residents in rooms #17, and #21, the emergency calling device's pull cords were wrapped around the grab bars. At 12:38 PM, the surveyor showed the concerns to the Registered Nurse (RN). The RN stated that the pull cords should not be wrapped around the grab bars and the paper product should not be placed inside the call device. The RN stated that the resident's on the LL mostly require assistance with toileting and showering and would not be in the bathroom without a staff member. 3. On 04/07/25 at 12:45 PM, on the first floor, the surveyor observed that in the bathroom of an unsampled resident's room, (room116), the emergency calling device cord above the toilet was missing. At 3:15 PM, the surveyor showed the CNA the concern. The CNA stated that the cord should be there. At 3:20 PM, the surveyor showed the concern to the Registered Nurse/ Unit Manager (RN/UM). The RN/UM confirmed that the cord should be there so that the residents could use it to summon help. NJAC 8:39-31.8 Based on observation, interview, and record review, it was determined that the facility failed to ensure that call devices were maintained in proper working order for rooms located in 2 of the 4 floors in the facility. 1. On 4/7/25 at 9:20 AM, during the medication pass observation of the Licensed Practical Nurse #1 (LPN #1) assigned to the medication cart on the lower-level high side, the surveyor observed LPN #1 walk into Resident #64's bathroom to wash his hands. At that time, the surveyor observed the emergency calling device near the shower, had a white paper type of product placed underneath the switch that prevented activation when the cord was pulled during an emergency. Across the way in the same bathroom, adjacent to the toilet bowl, the surveyor observed the call bell cord was wrapped around the grab bar. On 4/7/26 at 2:46 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concern with the observed condition of the emergency calling device that was seen in Resident #64's room which would not allow for the resident to call staff for assistance. On 4/8/25 at 10:22 AM, during a meeting with the survey team, the DON, the LNHA stated that Environmental Services department staff completed an inspection of all the resident bathrooms to ensure proper placement and function of the call bells, and that the cords were unwrapped from the grab bar.

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to ensure that the dish machine logs were completed and failed to ensure the dish machine was properly functioning and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/25 at 11:14 AM, in the presence of the Food Services Director (FSD) and the Culinary Director (CD), the surveyor observed the following: 1. The surveyor observed the low temperature dish machine and the FSD used a test strip to measure the Parts Per Million (PPM) for the sanitizer portion of the machine. The FSD attempted to use the test strip and he was unable to use the test strip correctly, then the CD instructed the FSD with how to measure the PPM for the dish machine. The FSD stated that he should have known how to perform this test on the machine and he was covering today for his food service worker who normally performed this task. 2. The surveyor reviewed the dish machine log, which revealed that the PPM was not recorded for the dates of 4/1, 4/2, or 4/3/25. The log indicated the month of February at the top of the log sheet, and the FSD stated that they just re-use the same February log each month to record the PPM measurements daily. The FSD stated that the log was not filled out and it should have been. The FSD stated that he did not know if the PPMs were checked on any of the dates which were blank up. The FSD stated that he was going to re-wash all the dishware. 3. The surveyor observed the following cleanliness concerns in the kitchen environment: -On the tiled wall, near the hand washing sink, the surveyor observed that the walls were soiled with brown colored substance, -The surveyor bserved orange colored food debris on the wall behind the food preparation area, -The surveyor observed that 2 of 4 of the convection oven handles soiled with thick black grease-like substance, which was easily lifted with the tip of the FSD pen and, -The surveyor observed brown debris on the outlet on the wall near food prep. 4. The surveyor observed the flat top grill, which was on wheels, was not completely underneath the vent hood, it stuck out about 3 inches into the food preparation area. The FSD stated that they were not currently using the flat top grill but it should have been under the vent hood. 5. On a shelf in the food preparation area, the surveyor observed one 1/4 sized steam table pan with white colored debris on the surface of the pan, the surveyor observed 1 of 2 quart sized steam table pans stacked on top of each other and when separated, they were soiled with white colored debris. The FSD stated that these pans should been completely cleaned before stacking. 6. The surveyor observed a low shelf with clean and ready use dishware and cutting boards stored on it. There was no barrier between the floor and the clean dishware and cutting boards, in the high traffic area. The FSD stated that there should be a barrier between those clean items and where foot traffic occured. 7. On 4/8/25 at 11:14 AM, the surveyor observed the Lead [NAME] (LC), who was wearing gloves, taking the lunch tray line temperatures. The LC removed her soiled gloves and immediately put on a new pair of gloves, without hand hygiene in between. The surveyor interviewed the LC, who stated that she should have washed her hands in before putting on new gloves. On 4/9/25 at 2:40 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing. No further information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene for 2 of 2 Certified Nursing Assistants (CNA), b.) failed to dispose of waste appropriately in 1 of 3 residents rooms reviewed for Transmission Based Precautions (TBP) (Resident # 95) and, c.) failed to have signage for 1 of 3 residents reviewed for TBP (Resident # 95). Reference: According to the U.S. CDC guidelines for Transmission-Based Precautions dated 4/13/24, included the following recommendation details: -Contact Precaution; Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. -Droplet Precaution; Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. -Airborne Precaution; Use personal protective equipment (PPE) appropriately. [NAME] mask upon entry into the patient room or patient space. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html#toc According to the Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions (EBP) in Nursing Homes dated 6/28/24 included the following: -Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html This deficient practice was evidenced by the following: 1. On 4/8/25 at 12:04 PM, the surveyor observed CNA # 1, remove a resident's tray from the food truck, on the 3rd floor. The CNA # 1 did perform hand hygiene prior to removing the tray and then, she assisted an unsampled resident with their meal set up. The surveyor then observed the CNA # 1 remove another tray from the food truck and again, did not perform hand hygiene prior to assisting another unsampled resident with their meal set up. At 12:15 PM, the surveyor interviewed the CNA # 1, who stated that she should clean her hands between assisting residents with meal set up and she stated that she did not realize that she did not perform hand hygiene. 3. On 04/08/25 at 7:25 AM, the surveyor accompanied the Certified Nursing Assistant (CNA) during their incontinence care tour and observed the following: The CNA entered Resident #17's room, donned a pair of gloves and exposed their incontinence brief. The CNA removed and discarded her gloves with no observed hand hygiene. The CNA entered Resident #90's room, donned a new pair of gloves and exposed the resident's incontinence brief. The CNA removed and discarded her gloves, with no observed hand hygiene. The CNA entered Resident #255's room, donned a new pair of gloves and exposed the incontinence brief. The CNA removed and discarded her gloves with no observed hand hygiene. The CNA entered Resident #256's room, donned a new pair of gloves and exposed the resident's incontinence brief. The CNA removed and discarded her gloves with no observed hand hygiene. The surveyor observed that the CNA opened four incontinence briefs without performing hand hygiene between the residents or between glove changes. On 4/8/25 at 7:41AM, the surveyor interviewed the CNA who acknowledged that she did not perform hand hygiene between residents or glove changes but confirmed that she should have for infection control prevention. On 4/8/25 at 7:43 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) confirmed that the CNA should wash her hands for at least 20 seconds if she touches the resident and that all staff should perform hand hygiene between residents and between glove changes. On 4/8/25 at 8:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and Drector of Nursing (DON), who confirmed that staff should perform hand hygiene between residents and before donning and after doffing gloves. A review of the facility-provided Handwashing/Hand Hygiene policy revised 10/2023, included .The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated immediately before touching a resident .after contact with body fluids . immediately after removing gloves . NJAC 8:39 - 19.4(a)(n); 27.1 (a) 2. On 4/3/25 at 11:00 AM, during the initial tour, the surveyor observed Resident 95's door stocked with Personal Protective Equipment (PPE; specialized clothing and equipment used to create a barrier between healthcare workers and hazards like infectious material, bodily fluid and airborne particles to prevent exposure and spread of infection). There was no signage on the door to indicate whether the resident was on contact precaution (recommendations include use of gloves and gown that involved contact with the resident or the resident's environment), droplet precaution (recommendations include use of donning a mask upon entry into the resident's room or space), airborne precaution (recommendation include use of fit-tested NIOSH-approved N95 or higher level respirator for healthcare personnel), and enhanced barrier precautions (gloves and gown during high contact activities with the resident). At that time, from the hallway, the surveyor observed the resident was asleep, had fall mats on both side of the bed. On 4/3/25 at 12:31 AM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) stated that the resident had Clostridioides (Clostridium) difficile (C.diff), and knew to wear gown and gloves. On 4/3/25 at 12:37 PM, during an interview with the Licensed Practical Nurse (LPN) stated that the sign for type of precaution should have been posted and stated that the staff knew to use the gown and gloves when providing care for the resident. At that time, the Licensed Practical Nurse (LPN)/Infection Preventionist (LPN/IP) arrived at the nurses' station and stated that the EBP sign was there and fell behind the PPE gown that was hanging on the door. The LPN/IP stated that she replaced the EBP sign on the door and added a picture that showed which PPE was required for the room. 3. On 4/8/25 at 1:32 PM, the surveyor observed Resident #95's room from the hallway and saw used PPE gowns overflowing from the trash bin and a used glove on the floor. The resident was asleep and unable to be aroused with the surveyor's voice. On 4/8/25 at 1:37 PM, the surveyor and the LPN walked towards the Resident's room and confirmed observing the overflowing PPE, the glove on the floor. The LPN also stated that there should have been a trash bag in the bin for sanitary removal of the PPE. On 4/9/25 at 10:49 AM, during an interview with the surveyor, the LPN/IP stated that the overflowing used gowns and the used glove on the floor was unacceptable because it was unsanitary. On 4/9/25 at 12:08 PM, during a meeting with the surveyor, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Special Clinical Project, the surveyor discussed the concerns with the infection control processes that were breached. On 4/10/25 at 11:28 AM, during a meeting with the survey team and the DON, the LNHA stated that the EBP sign fell, and the facility was looking into other types of reinforcements to prevent reoccurrence. The LNHA also stated that the housekeeping department was educated to check the EBP rooms more often to avoid reoccurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to complete and transmit Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) 3.0 Manual guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Residents #23, and #65). This deficient practice was evidenced by the following: 1. On 4/04/2023 at 1:03 PM, the surveyor reviewed the admission Record (AR) for Resident #23 which revealed that Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to noninfective gastroenteritis and colitis (inflammation of the intestine). The admission MDS assessment, Assessment Reference Date (ARD) dated 3/27/23 was completed on 4/03/23 and was due for submission by 4/02/23. The MDS was not submitted until 4/06/23. 2. On 4/06/2023 at 11:21 AM, the surveyor reviewed the AR for Resident #65 which revealed that Resident #65 was admitted to the facility with a diagnosis that included but was not limited to fracture of the right femur and was discharged to home on [DATE]. The Discharge Assessment-return not anticipated (DRNA-MDS) assessment ARD dated 12/07/22 was completed on 4/06/23 and was due for submission by 12/20/22. The MDS was not submitted until 4/9/23. On 4/05/23 at 10:49 AM, the surveyor interviewed the Registered Nurse (RN) MDS Coordinator responsible for the submission of MDS assessments. The RN/MDS Coordinator stated that she worked on a full-time basis and was responsible for submitting, reviewing, and batching the MDS assessments. The MDS Coordinator indicated that their electronic system did not alert her when an MDS assessment was due. The RN/MDS Coordinator stated that she was aware that the MDS assessments were submitted late. On 4/12/23 at 1:48 PM, the surveyor discussed concerns with the Licensed Nursing Home Administrator (LNHA), and Director of Nursing (DON). No further information was provided by Administration. The facility's Comprehensive Assessment Policy dated 3/22 reflected under Policy Interpretation and Implementation: 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. 2. admission Assessment - The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: a. this is the resident's first time in this facility, OR b. the resident has been admitted to this facility and was discharged return not anticipated, OR c. the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. NJAC 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, in accordance with the federal guidelines. This deficient practice was identified for 2 of 24 residents reviewed for resident assessment (Resident #14, and Resident #68). This deficient practice was evidenced by the following: 1. During the initial facility tour on 3/30/23 at 12:25 PM, the surveyor observed Resident #14 watching tv wearing a hearing aid to her left ear. The surveyor reviewed the medical records of Resident #14 which revealed the following: The admission MDS (AMDS) dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated that the resident's cognition was intact. The AMDS Section B Hearing, Speech, Vision of Resident #14 Hearing aid was coded 0 (zero) or No, which did not reflect the resident's current use of a hearing aid. The Care Plan initiated on 2/27/23 reflected Focus: Difficulty communicating related to hard of hearing at times, wears left hearing aid (sometimes cannot hear, was provided with pen and paper). Deaf on the right ear. The Resident Evaluation with COVID-19 Screen initiated on 2/26/23 under section E Oral/Dental and Hearing/Speech/Vision/Diet reveals 10. Does the patient have a hearing aid or hearing appliance? Yes, 10a. Hearing aid placement (select one) Left ear. On 04/12/23 at 08:55 AM, the surveyor interviewed the Registered Nurse (RN) Unit Manager (UM) RN/UM who stated that the resident was wearing a hearing aid to the left ear since the day of admission in the facility. On 04/12/23 at 09:10 AM, the surveyor interviewed the RN/MDS Coordinator who stated that it was the other full-time MDS Coordinator who made the assessment. She stated that she should review all initial assessments from other departments to make sure that everything will be captured in the assessment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 reflected under Section B: Hearing, Speech, and Vision under Coding instructions Code 1, yes: if the resident did use a hearing aid (or other hearing appliance) for the hearing assessment coded in B0200, Hearing. 2. On 03/30/23 at 11:10 AM, during the initial facility tour, the surveyor observed the resident with a permacath (a flexible tube inserted into the vein for dialysis treatment) in place to the right upper chest. Resident # 68 stated that they go to dialysis on Tuesday, Thursday, and Saturday at 4:00 PM. The surveyor reviewed the medical records of Resident #68 which revealed the following: The admission Record showed that Resident #68 was admitted to the facility with a diagnosis that included but was not limited to end stage renal (kidney) disease (ESRD). The AMDS dated [DATE] showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that the resident's cognition was intact. The AMDS Section O Special Treatments, Procedures, and Programs did not reflect that Resident #68 received dialysis while a resident was in the facility. The Order Summary Report (OSR) which reflected active physician orders as of 12/20/22 revealed that the resident received hemodialysis on Tuesday, Thursday, and Saturday at 4:00 PM. On 04/10/23 at 10:07, the surveyor interviewed MDS Coordinator who stated that she is aware that the resident was getting dialysis three times a week. She stated that it was not coded in the MDS assessment. NJAC 8:39 - 11.2 (e)

Complaint #NJ00149914 Based on observation, interview, review of facility records, and other pertinent facility documents on 4/4/23, it was determined that the facility failed to follow a Professional Standards of Practice by not transcribing an order for medication appropriately. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: A review of the admission Record for the Resident # 103 reflected that the resident was admitted to the facility with diagnoses which included but were not limited to cellulitis of unspecified part of limb, acute embolism and thrombosis of unspecified deep veins of lower extremity, and congestive heart failure. A review of the October 2021 electronic Medication Administration Record (eMAR) showed a Physician's Order (PO) dated 10/20/21 for Torsemide (a medication to treat fluid retention) 20mg 3 tablets by mouth twice daily for edema 20mg give 2 tablets= 40mg total dose. The medication dosage was adjusted on the October 2021 eMAR on 10/29/21 with a new PO for Torsemide 20mg prescribed for 3 tabs by mouth twice daily for edema 3 tabs= 60mg total dose. A review of the Progress Notes revealed that during the dates of 10/20/21 to 10/29/21, the resident did not have worsening edema. On 4/4/2023 at 1:20 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who received the original order for Torsemide. The LPN stated that she does not remember the order for this resident and did write what the Physician stated over phone. She said that she was not sure how the order transcribed into the October 2021 eMAR for 3 tablet PO BID for edema give 2 tablets=40mg. On 4/4/23 at 1:45 PM, the surveyor discussed concerns with Administrator and Director of Nursing (DON). The DON stated that there was no harm to the resident as there was no worsening edema and that the error on the transcription of this medication was noted to be in the additional directions section of the order. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) wear the appropriate personal protective equipment (PPE) inside a resident's room on Transmission Based Precautions (TBP) and, b.) conduct hand hygiene between tasks and after the removal of gloves for 1 of 6 residents (Resident #135) reviewed on TBP. This deficient practice was evidenced by the following: On 4/16/21 beginning at 10:21 AM, the surveyor conducted the Entrance Conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) when the Cohort Plan for the building was revealed as follows: Green Zone - Naïve, negative, recovered, and vaccinated. Staff were to wear goggles or face shield and surgical mask at minimum. Yellow Zone - Unknown or potentially incubating, New Admission/re-admission and not COVID-19 recovered. Staff were to wear a N95 or KN95, no need to cover with surgical mask, face shield or goggles and a gown and gloves with high contact activity. If only going in to give medication or water, no gown was required. Red Zone - Person Under Investigation (PUI) in house and having symptoms and point of care (POC) positive, awaiting PCR result. Staff were to wear a N95 covered by a surgical mask, face shield or goggles, gown, and gloves and optional hair covering. On 4/20/21 at 11:08 AM, the surveyor observed Resident #135's room in the area identified by signs as the Yellow Zone and there was a sign with STOP by the door to the room and an overdoor bin with PPE that contained reusable gowns and gloves. The surveyor observed a staff member in the room wearing an N95 mask and gloves removing a garbage bag from the can in the room. The staff member then placed the garbage bag into the can on his cart which was in the hallway, outside the resident's room. With the same gloved hands, the staff member grabbed a roll of paper towels from his cart and re-entered Resident #135's room. The staff member then returned to his cart, grabbed the mop and proceeded to mop the resident's floor. He then returned the mop to the cart, removed his gloves, and without conducting hand hygiene, pushed the cart down the hallway of the Yellow Zone, stopped outside room [ROOM NUMBER], and reached into the room without fully entering and removed a cardboard box that was by the door and placed it on the top his cart. The staff member then began to push his cart down the hallway again. At 11:14 AM, the surveyor interviewed the staff member who identified themselves as a Housekeeper and he confirmed that he was wearing an N95 mask and no eye protection. He also confirmed that he did not have a gown or eye protection on when he was in Resident #135's room. The Housekeeper confirmed that he should have worn a gown when he was in a resident room in the yellow zone. The Housekeeper then removed a face shield from his cart when asked if he should have been wearing eye protection in Resident #135's room. The Housekeeper then proceeded to put the face shield on over his N95 mask and then conducted hand hygiene using alcohol-based hand rub (ABHR). At 11:20 AM, the surveyor interviewed the Second Floor Unit Manager (UM) who was made aware of the observation with the housekeeper. The UM confirmed an N95/KN95, face shield and gown should be worn with high contact patient care like changing the garbage and mopping the floor. She also confirmed that the Housekeeper should have conducted hand hygiene by stating, Wash in/Wash out. She added that the residents in the Yellow Zone were New Admissions and on TBP for 14 days because of a potential unknown exposure. The UM also confirmed that the facility staff have been educated on the needed PPE when entering a resident's room in the Yellow Zone. The surveyor then reviewed the facility Cohort Plan, with a revised date of 3/25/2021, that read under Yellow: Unknown or potentially incubating: *Admits & readmits who are unknown, negative, or long recovered per above guidelines, *asymptomatic with known exposure; and, * symptomatic PUI not yet confirmed. Under isolation type: *TBP - sign on each door; separate gowns & gloves for each patient at point of use; extended use/reuse of masks and eye protection permitted. *Patients stay in room with door closed as much as possible. *May prioritize gowns for high contact care activities. Under PPE use: *Fit tested N95 or equivalent KN95, facemask if not available, eye protection, gown, gloves, per optimization of PPE & Yellow Zone PPE use *Mask on resident when staff enters Rm; mask resident if must leave Rm. On 4/26/21 at 3:39 PM, the surveyor interviewed the DON who confirmed that the Housekeeper should have had a gown and eye protection on in addition to the N95 and gloves he was wearing when he was in Resident #135's room, and that hand hygiene should have been conducted between tasks and after he removed the gloves. On 4/27/21 at 9:53 AM, the surveyor reviewed the facility policy titled, Handwashing/Hand Hygiene, with a review date of 4/12/2018, and read under Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. And; 7. Use of an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves; and; n. Before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. At 11:40 AM, the surveyor reviewed the admission Record for Resident #135 which revealed they were admitted to the facility in April of 2021 with diagnoses not limited to cerebral infarction, Hemiplegia and Hemiparesis, atrial fibrillation, ischemic cardiomyopathy, congestive heart failure and unstable angina. The surveyor then reviewed the facility Employee Education Attendance record for the Housekeeper which revealed that on 11/23/20 he was in attendance for training on proper handwashing technique, proper PPE usage, and proper cleaning of rooms. On that same day the Housekeeper satisfactorily completed a hand washing and PPE Competency Validation. On 4/14/21, the Housekeeper participated in a training on the Updated Cohort Plan, with the objective to know which patients are included in each cohort zone, what PPE to utilize, what activity they are allowed to do, i.e., showers, visits, gym use, dining. N.J.A.C. 8:39-19.4

Based on observation, interview, and record review, it was determined that the facility failed to hold the prescribed medication Midodrine (a medication to treat low blood pressure) for 2 of 2 Resident's reviewed (Resident #39 & #80). 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 4/16/21 at 1:05 PM, the surveyor observed Resident #80 in a Broda chair, a tilt-in-space positioning wheelchair, in the day room. The surveyor attempted to speak with the resident however the resident's speech was not organized. On 4/21/21 at 9:41 AM, the surveyor observed Resident #80 reclined in a Broda chair sleeping, in the hallway across from the nurse's station. The resident was dressed with their feet resting on the footrest. The resident had anti-slip gripper socks on their feet. The resident appeared to be resting comfortably. On 4/22/21 at 1:49 PM, the surveyor observed Resident #80 in the dayroom reclined in a Broda chair and dressed in sweat suit with gripper socks on their feet. The resident was watching television with activities staff who had put on a colored ball light and aroma therapy. On 4/26/21 at 9:31 AM, the surveyor reviewed the admission Record of Resident #80 which revealed they were admitted to the facility in July 2020 with diagnoses not limited to Parkinson's disease, Dementia with behavioral disturbances, orthostatic hypotension, hypertension, and anxiety disorder. Review of the active Order Summary Report revealed a physician's order for: Midodrine HCL tablet 10 milligrams (mgs), Give 1 tablet by mouth every 8 hours for orthostatic hypotension (low blood pressure). Hold for SBP (systolic blood pressure-maximum pressure during one heartbeat) greater than 120. The surveyor then reviewed the Medication Administration Record (MAR) for February 2021, March 2021 and April 2021 which revealed the following: The MAR for period 2/1/21-2/28/21 revealed the medication Midodrine was administered to Resident #80 when their BP was above prescribed hold parameter for SBP > 120 on the following days as indicated by a check mark: 0600 (6:00 AM): 2/5/21 (BP 135/79), 2/14/21 (BP 121/68), 2/20/21 (BP 131/65), 2/23/21 (BP 150/96). 1400 PM (2:00 PM): 2/7/21 (BP 124/78), 2/16/21 (BP 123/80), 2/22/21 (BP 125/65), 2/28/21 (150/84). 2200 (10:00 PM): 2/5/21 (BP 129/78), 2/20/21 (BP 144/67). The MAR for period 3/1/21-3/31/21 revealed the medication Midodrine was administered to Resident #80 when their BP was above the prescribed holdparameter hold for SBP > 120 on the following days: 0600: 3/3/21 (BP 135/78), 3/7/21 (BP 126/75). 1400: 3/1/21 (BP 123/74), 3/3/21 (BP 127/67), 3/20/21 (BP 127/66), 3/30/21 (BP 132/67). 2200: 3/17/21 (BP 121/87), 3/31/21 (BP 121/76). The MAR for period 4/1/21-4/30/21 revealed the medication Midodrine was administered to Resident #80 when their BP was above the prescribed hold parameter for SBP > 120 on the following days: 0600: 4/5/21 (BP 126/70), 4/10/21 (BP 125/76), 4/17/21 (BP 122/60). 1400: 4/17/21 (BP 126/68). 2200: 4/23/21 (BP 122/80). 2. On 4/19/21 at 12:51 PM, the surveyor observed Resident #39 in bed with a lunch tray on the overbed table and talking to a Certified Nursing Assistant (CNA). On 4/21/21 at 12:47 PM, the surveyor observed Resident #39 in bed with the head of the bed elevated. The resident offered no complaints and stated that they, feel good. On 4/24/21 at 9:56 AM, the surveyor reviewed the admission Record of Resident #39, which revealed they were originally admitted to the facility in May 2020, and then re-admitted in January 2021, with diagnoses not limited to diabetes mellitus, end stage renal disease, orthostatic hypotension, hypertension, and dependence on renal dialysis. Review of the active Order Summary Report revealed a physician's order for: Midodrine HCL tablet 10 milligrams (mgs), Give 1 tablet by mouth every 8 hours for hypotension (low blood pressure). Hold for SBP (systolic blood pressure-maximum pressure during one heartbeat) greater than 110 to prevent confusion. The surveyor then reviewed the Medication Administration Record (MAR) for February 2021, March 2021, and April 2021, which revealed the following: MAR for period 2/1/21-2/28/21 revealed the medication Midodrine was administered to Resident #39 when their BP was above the prescribed hold parameter for SBP > 110 on the following days, as indicated by a check mark: 0600 (6:00 AM): 2/9/21 (BP 111/76), 2/15/21 (BP 118/76), 2/17/21 (BP 131/76), 2/18/21 (BP 137/78), 2/20/21 (BP 111/72). 1400 PM (2:00 PM): 2/8/21 (BP 121/69), 2/18/21 (BP 137/78), 2/26/21 (BP 116/65). 2200 (10:00 PM): 2/11/21 (BP 114/71), 2/16/21 (BP 117/67), 2/19/21 (BP 112/74), 2/23/21 (BP 132/76), 2/27/21 (BP 112/65). The MAR for period 3/1/21 - 3/31/21 revealed the medication Midodrine was administered to Resident #39 when their BP was above the prescribed hold parameter for SBP > 110 on the following days: 0600: 3/5/21 (BP 122/72), 3/1/21 (BP 117/79), 3/15/21 (BP 113/69). 1400: 3/8/21 (BP 116/62), 3/9/21 (BP 118/68), 3/10/21 (BP 123/74), 3/13/21 (BP 119/78), 3/17/21 (BP 130/65), 3/18/21 (BP 127/21). 2200: 3/5/21 (BP 116/72). The MAR for period 4/1/21 - 4/30/21 revealed the medication Midodrine was administered to Resident #39 when their BP was above the prescribed hold parameter for SBP > 110 on the following days: 0600: 4/5/21 (BP 122/74), 4/22/21 (BP 133/82), 4/26/21 (BP 142/74). 1400: 4/2/21 (BP 122/64), 4/8/21 (BP 119/64), 4/12/21 (BP 133/67), 4/22/21 (BP 126/61). 2200: 4/23/21 (BP 146/62). On 4/26/21 at 3:26 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator and other surveyors; she stated that the medication Midodrine was used for a low heart rate and blood pressure. There were parameters for the medication depending on the order and it was not to be given if the blood pressure was at a certain level. She further stated it was a guideline of when to give and when to hold it. The DON confirmed that the check mark on the MAR meant that the medication was administered and the initials following the check mark indicated the nurse that administered the medication. On 4/27/21 at 9:35 AM, the DON confirmed that the medication Midodrine was administered in error and outside the parameters by different nurses, on different days, and on different shifts for Resident #39 and Resident #80. She also added that the facility Medication Administration policy did not contain information specific to parameters, but that the facility's pharmacy group had a policy that addressed parameters. The surveyor then reviewed the consultant pharmacy group form titled, Medication Administration Observation Quality Improvement Program, that revealed the following under the Medication Administration section: Appropriate vital signs are taken and recorded prior to preparing and administering medications. At 9:39 AM, the surveyor reviewed the facility policy titled, Documentation of Medication Administration, with a revised date of April 2007. It read as follows under the Policy Interpretation and Implementation section: 1. A Nurse of Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage; c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); f. Signature and title of the person administering the medication; and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.). The surveyor then reviewed the policy provided by [Provider Pharmacy], the facility's pharmacy, titled, General Guidelines for the Administration of Medications, with an effective date of January 2015, which read under Procedure, number 7: The nurse takes and records any necessary vital signs as indicated for the order on the Medication Administration Record (pulse, BP, etc.). If vital sign readings are outside the parameters established by the medication order and/or facility policy, the nurse will hold the medication and if necessary, contact the physician for further instruction. N.J.A.C. 8:39-11.2(b)