**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #: 177087, 178121 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment by ensuring resident bathroom doors were in good repair. This deficient practice was observed in 1 of 2 nursing units and was evidenced by the following: On 1/6/25 at 12:27 PM, during initial tour of the facility, the surveyor observed the bathroom door of Resident room [ROOM NUMBER] to be deformed with a bow causing the top corner and the bottom corner of the handle side to be bowed out from the frame when the door was completely closed. Only the latch was able to fully be seated in the door frame with the top and bottom corners pulled away allowing the surveyor to see into the bathroom with the door closed. The door also had at least eight approximately half inch sized holes drilled into the door on the inside running half the length of the door from the top down. The door handle appeared to be coming off/loose from the door on the inside. On 1/9/25 at 12:08 PM, the surveyor interviewed the Director of Maintenance (DM), who stated that the facility utilized a system called TELS that all staff had access to put in work orders and inform the Maintenance Department of repairs that needed to be addressed. The DM acknowledged having knowledge of the bathroom door of Resident room [ROOM NUMBER] being in disrepair, but stated that the facility had not yet developed a plan to address it. The DM was unsure of how long it had been in its current state. The DM further stated that the facility was aware that some doors need to be replaced, specifically on the second floor, but stated we don't have anything in place for door orders. The DM acknowledged that the facility had a responsibility to ensure the building was in good repair and to look and function as good as it should in order to maintain a homelike environment for residents. On 1/9/25 at 12:52 PM, in the presence of the survey team, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed that all staff had access and knew how to use the TELS repair order system and that the Maintenance Department as well as the Regional Administration did monthly rounds of the facility to ensure all repairs were addressed. On 1/10/25 at 10:22 AM, in the presence of the survey team, the LNHA provided the surveyor with photos of the bathroom door for Resident room [ROOM NUMBER] and acknowledged it was in disrepair and he informed the surveyor that the door was replaced after surveyor inquiry. A review of the facility's Homelike Environment policy with revised February 2021, included .Residents are provided with a safe, clean, comfortable and homelike environments and encouraged to use their personal belongings to the extent possible .the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary, and orderly environment . A review of the facility's Maintenance Service policy revised December 2009, included .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . NJAC 8:39-31.4(a)

Complaint NJ #: 177087 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse within two hours to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documentation for Resident #145. This documentation included the following: An internal compliance hotline call from the resident dated 7/27/24. A fall accident report and investigation dated 9/26/24. A fall accident report and investigation dated 10/14/24. At that time, the surveyor asked the LNHA if that was all the reports for Resident #145, and the LNHA replied as far as she was aware, it was. On 1/9/25 at 9:04 AM, the LNHA and the Director of Nursing (DON) informed the surveyor that after the surveyor's multiple inquiries for reportable events, accidents, incidents, and grievances regarding Resident #145, they began to ask facility staff if they were aware of any other incidents that were not provided to the surveyor. The LNHA stated that the Social Worker (SW) looked through her emails and found two emails, both dated 8/7/24, one was from Resident #145 and the second from the Resident's Representative (RR). The emails both included grievances and an accusation of verbal abuse from an unnamed nurse at the facility towards the resident. The LNHA stated that the email was just found in the SW's spam/junk folder after surveyor inquiry. The LNHA acknowledged that the allegation was absolutely considered verbal abuse, and stated that the facility started an investigation into the matter which included attempting to reach out to the resident who no longer resided at the facility. On 1/9/25 at 9:58 AM, the surveyor reviewed Resident #145's medical record. A review of the resident's Transfer/Discharge Report indicated the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), need for assistance with personal care, and chronic pain. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/31/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. On 1/9/25 at 11:46 AM, the surveyor interviewed the LNHA, who stated that normally when an allegation of abuse or grievance was reported to the facility by a resident or the resident's representative, it was brought to the attention of the administration team. The LNHA continued if a particular person or staff member was named, then that staff member was suspended pending an investigation, and the facility reported the allegation to the NJDOH, the office of the Ombudsman, and if necessary to local law enforcement. The LNHA stated that investigations should be completed and closed out in five days or sooner. The LNHA stated she was unsure as to why or how Resident #145's emailed grievance/allegation of abuse was sent to the spam/junk folder and the facility's information technology (IT) department had to investigate it. The LNHA further acknowledged that it was the facility's responsibility to ensure all allegations of abuse and grievances were received timely and addressed including reported immediately. The LNHA stated that the abuse allegation was reported to the NJ DOH on 1/8/25. On 1/9/25 at 1:01 PM, the Regional Director of Operations (RDO), in the presence of the survey team, acknowledged the delay in investigating the accusation of abuse and stated, we agree that the system inhibited the ability to respond to the complaint/allegation. On 1/10/25 at 10:22 AM, the LNHA acknowledged to the surveyor, in the presence of the survey team, that the allegation of abuse which was sent on 8/7/24, was just being investigated and followed up with/reported after surveyor inquiry. A review of the facility provided policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated revised September 2022, included the following:All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting Allegations to the Administrator and Authorities 1. If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #: 173483 Based on interview, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to obtain admission diet orders for a resident identified as a nutritional risk. This deficient practice was identified for 1 of 19 residents reviewed for physician's orders (Resident #146), and was evidenced by the following: A review of the admission Record face sheet (an admission summary) indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to; malignant neoplasm of the urethra (cancer of the tube that carries urine out of the body), absence of the left upper arm limb (left upper arm (LUA) amputation), and right left below the knee amputation (BKA). A review of the admission Screener (AS) dated 4/24/24, reflected that Resident #146 required assistance with activities of daily living (ADLs) and was confined to the wheelchair. The AS also reflected that the resident had a pressure ulcer located on the coccyx area. A review of the Minimum Data Set (MDS), an assessment tool, was not required to be completed for the resident. The resident resided in the facility for eight days in 2024. A review of the Physician's Order Report (POR) revealed that Resident #146 did not have a diet order. A review of the admission Nutritional Risk Assessment (ANRA) dated 4/26/24 at 10:31 AM, reflected that the Registered Dietitian (RD) assessed Resident #146 as new admission to facility after a hospitalization related to percutaneous endoscopic gastrostomy (PEG; an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) removal, a wound infection of the left foot, right BKA and LUE amputation at elbow, and stage two pressure ulcer of the coccyx (tailbone). The ANRA reflected that Resident #146 was at risk for malnutrition related to altered skin integrity, underweight body mass index (BMI; calculation of weight to height), multiple amputations, with need for a therapeutic diet and supplementation. The ARNA dated 4/26/24, indicated that Resident #146 had a pressure injury noted to coccyx on admission (stage II per hospital records) and diet was to include double protein with meals. Recommendations included to: provide diet as ordered of regular, regular textures, thin liquids, double portions; provide Ensure Plus eight ounces (8 oz) every day and monitor future tolerance/acceptance; monitor future wound reports, update to resident skin integrity; monitor resident intake, weight trends, signs and symptoms of aspiration, gastrointestinal regularity, and glycemic control; monitor resident fluid/hydration status, updated lab values, updated food preferences; provide additional assistance with meals and supplements as needed. The ANRA revealed a discrepancy related to whether the resident was to have double protein diet or a double portion diet and a diet was not prescribed by a physician on admission to the facility. A review of Resident #146's individualized comprehensive care plan (ICCP) initiated on 4/26/24, reflected that the resident had the potential for nutritional problems related to hypertension, pancreatitis, PEG removal and amputations and had a need for a therapeutic diet with supplementation. Interventions included to provide a regular diet, regular textures, thin liquids with double protein. This diet was not ordered when the resident was admitted to the facility. On 1/9/25 at 9:06 AM, the surveyor interviewed the RD, who stated that she had been working in the facility for approximately five months and did not know the resident. At that time, the RD reviewed Resident #146's electronic medical record (EMR) and confirmed that a diet was not ordered for Resident #146 at the time the resident was admitted to the facility. The RD stated that the nursing department was responsible to obtain the physician's order for Resident #146's diet on admission and explained that the importance of obtaining a physician's order was so the resident received a food tray in accordance with their diet orders from the hospital records. The RD also stated that it was important to have admission diet orders to assure that the resident received a therapeutic diet with the right texture and consistency to ensure safety. The RD reviewed the ANRA dated 4/26/24, and confirmed that the resident should have received double portions of protein for wound healing, however the recommendation documented on the nutritional risk assessment dated [DATE], indicated Resident #146 was to receive double portions of the entire meal. The RD stated that the previous dietician must have made an error in documentation and that according to the resident's tray ticket, Resident #146 was provided with the correct double protein diet. The surveyor reviewed Resident #146's food tray ticket dated 4/24/24, which indicated that the resident received a double meat diet, however a diet was not prescribed for the resident on admission to the facility. On 1/9/25 at 10:37 AM, the surveyor interviewed the Licensed Practical/Nurse Unit Manager (LPN/UM), who explained the admission process to the surveyor and stated that admission orders were to include diagnoses, the correct diet with consistencies of diet, texture of diet or if the resident was on a therapeutic diet, allergies, medications, labs, and treatments. At that time, the LPN/UM reviewed Resident #146's admission orders and confirmed that a diet was not ordered for the resident on admission. On 1/9/25 at 10:50 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that admission orders included: weights, medications, treatments, diet, skin checks, bath, and shower orders. The ADON stated that it was important to put a diet order from the physician in the EMR to ensure the resident received the correct therapeutic diet with proper texture and consistency to ensure that the resident was safe. The ADON stated that when the diet was ordered, the nurse completed a diet slip and gave it to the kitchen but must have forgotten to write the diet in the physician's orders. The ADON stated that the kitchen had a different computer system and they inputted the diet into their system so that the resident received the tray with the correct diet even though there was not a physician's order for the resident's diet. The ADON confirmed that the staff did not obtain a diet order for Resident #146 on admission to the facility. On 1/10/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) who both confirmed that residents' diet orders were required at the time of admission. A review the facility's undated Diet Order Policy included that upon admission, the resident's diet will be updated by the nursing staff based on hospital recommendations .the dietician and speech pathologist may review the recommended diet order upon admission to ensure that it is appropriate and if adjustments were to be made, the physician would be notified to approve or disapprove of the recommendations and changes to the diet would be made to the diet order following documentation in the electronic medical record (EMR) . NJAC 8:39-11.2 (a), 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and review of pertinent facility documents it was determined that the facility failed to complete individual comprehensive care plans for three residents with urinary and bowel incontinence. This deficient practice was identified for 3 of 3 resident reviewed for incontinence (Resident #42, #47, and #52), and was evidenced by the following: 1. On 1/9/25 at 9:00 AM, the surveyor conducted incontinence rounds on the Second-Floor long term care nursing unit with the Certified Nursing Assistant (CNA #1). During the incontinence rounds, CNA #1 removed Resident #47's incontinence brief which was dry and the surveyor observed that the resident had a white towel within the incontinence brief. CNA #1 told the surveyor that the resident requested a towel within the incontinence brief. The surveyor interviewed the resident who confirmed that they wanted a towel in their incontinence brief. On 1/9/25 at 10:00 AM, the surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected Resident #47 was admitted to the facility with medical diagnoses that included but were not limited to; hemiplegia (left side paralysis), diabetes mellitus (high blood sugar), and muscle wasting. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/26/24, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of Section H for bowel and bladder, revealed the resident was always incontinent of bowel and bladder. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated on 11/1/23, for bowel incontinence. Interventions included to: check resident approximately every two hours and provide incontinence care as needed and to apply moisture barrier as needed. A further review of the ICCP included a focus area dated 11/1/23, for urinary incontinence. Interventions included to: establish voiding patterns; provide incontinence care as needed; and check resident approximately every two hours and provide incontinence care as needed. On 1/9/25 at 12:49 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the resident with a towel in their incontinence brief. The surveyor asked how staff would know that was a resident preferred that and the LNHA stated it should be included in the care plan. 2. On 1/9/25 at 9:10 AM, the surveyor conducted incontinence rounds with CNA #1 for Resident #52. CNA #1 removed the resident's incontinence brief which revealed another incontinence brief under the first brief, and the surveyor observed the resident was laying on a third incontinence brief opened and under the resident being used as a bed pad. CNA #1 told the surveyor that the resident requested the double briefs. The surveyor asked Resident #52 if it was a preference and the resident shook their head yes. On 1/9/25 at 10:30 AM, the surveyor reviewed the medical record for Resident #52. A review of the admission Record face sheet reflected Resident #52 was admitted to the facility with medical diagnoses which included but were not limited to; hemiplegia (right sided paralysis), cervical spine injury, anxiety disorder, and difficulty in walking. A review of the most recent comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 9 out of 15, meaning the resident had a moderately impaired cognition. A review of Section H, Bowel and Bladder, indicated the resident was always incontinent of bowel and bladder. A review of Resident #52's ICCP included a focus area dated 10/2/23, for bowel incontinence. Interventions included to provide incontinence care and apply moisture barrier as needed and to monitor the resident's bowel habits. The ICCP also included a focus area initiated 10/2/23, for urinary incontinence. Interventions included to offer toileting prior to bedtime and to check the resident approximately every two hours and provide incontinence care as needed. The ICCP did not include double briefing per the resident's request. On 1/9/25 at 12:49 PM, the surveyor interviewed the LNHA regarding Resident #52's double incontinence briefing. The surveyor asked how staff would know that was the resident's preference, and the LNHA stated it should be included in the ICCP. 3. On 1/9/25 at 9:00 AM, the surveyor conducted incontinence rounds on the Second-Floor long term care nursing unit with the Registered Nurse/Unit Manager (RN/UM). During the incontinence rounds, the RN/UM removed Resident #42's incontinence brief which was dry. The surveyor interviewed the resident, who stated, at nighttime it is my preference to have two diapers and a towel applied between my legs. It helps me not soak the bed and I feel safer and stay dry. On the day shift, the resident preferred to wear one incontinence brief when out of bed. The RN/UM acknowledged that the staff was aware of Resident #42's preferences for incontinence care at night. On 1/9/25 at 10:58 AM, the surveyor reviewed the medical record for Resident #42. A review of the admission Record face sheet reflected Resident #42 was admitted to the facility with medical diagnoses that included but were not limited to; muscle wasting and atrophy (thinning or loss of muscle tissue). A review of the most recent comprehensive MDS dated [DATE], revealed Resident #42 had a BIMS score of 15 out of 15, meaning the resident was cognitively intact. A review of Section H, Bowel and Bladder, revealed the resident was frequently incontinent of bowel and bladder. A review of the ICCP included a focus area dated 10/6/24, for bowel incontinence. Interventions included to: establish bowel elimination patterns, monitor bowel habits, and offer toileting assistance at the same time each day that the resident has an incontinence episode; provide incontinence care as needed; and to apply moisture barrier as needed. The ICCP also included a focus area dated 10/6/24, for urinary incontinence. Interventions included: to establish voiding patterns; offer/encourage toileting prior to bedtime; and check resident approximately every two hours and provide incontinence care as needed. The ICCP did not include double briefing or a towel between the resident's legs per the resident's request. On 1/9/25 at 12:49 PM, the surveyor interviewed the LNHA regarding resident's preferences for double incontinence briefing. The surveyor asked how staff would know that was the resident's preference, and the LNHA stated it should be included in the ICCP. A review of the facility's Care plans, Comprehensive Person-Centered policy with a revision date of March 2022, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident and includes residents stated goals . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #: 173135; 173483 Based on observation, interview, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for a replacement nutritional supplement after the facility identified that there was a national shortage of the resident's (Resident #146) current nutritional supplement; b.) consistently document the assessment and dressing changes to a resident's (Resident #195) peritoneal dialysis site (kidney treatment that filters waste and excess fluid from the blood using the lining of the abdomen); c.) appropriately administer intravenous (IV) antibiotic medication in accordance to the physician's order; and d.) document communication with the physician in accordance with professional standards of practice. This deficient practice was identified for 3 of 19 residents reviewed for professional standards of practice (Resident #146, #195, and #295). Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was identified by the following: 1. A review of the admission Record (AR) face sheet (an admission summary) indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to; malignant neoplasm of the urethra (cancer of the tube that carries urine out of the body), absence of the left upper arm limb (left upper arm (LUA) amputation), and right left below the knee amputation (BKA). A review of the admission Screener (AS) dated 4/24/24, reflected that Resident #146 required assistance with activities of daily living (ADLs) and was confined to the wheelchair. The AS also reflected that the resident had a pressure ulcer located on the coccyx (tailbone) area. A review of the Minimum Data Set (MDS), an assessment tool, was not required to be completed. The resident resided in the facility for eight days in 2024. A review of the admission Nutritional Risk Assessment (ANRA) dated 4/26/24 at 10:31 AM, reflected that the Registered Dietitian (RD) assessed Resident #146 as new admission to facility after a hospitalization related to percutaneous endoscopic gastrostomy (PEG) (an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) removal, a wound infection of the left foot, right BKA and LUE amputation at elbow, and stage two pressure ulcer of the coccyx. The ANRA reflected that Resident #146 was at risk for malnutrition related to altered skin integrity, underweight body mass index (BMI), multiple amputations, with need for a therapeutic diet and supplementation. Recommendations from the RD included to provide Ensure Plus (a nutritional supplement) eight ounces (8 oz) daily. A review of the Physician's Order Report (POR) included a physician's order dated 4/26/24, for Ensure Plus 8 oz daily by mouth. A review of the corresponding April 2024 Medication Administration Record (MAR) reflected that the nurses were documenting that Resident #146 received the Ensure Plus and consumed 100 percent of the supplement given on 4/27/24, 4/28/24, 4/29/24, and 4/30/24. A review of Resident #146's individualized comprehensive care plan (ICCP) initiated on 4/26/24, reflected that the resident had potential for nutritional problems related to hypertension, pancreatitis, PEG removal and amputations and had a need for a therapeutic diet with supplementation. Interventions included to provide and serve nutritional supplementation as ordered: Ensure Plus 8 oz daily. The RD provided the surveyor with Resident #146's meal tickets from 4/24/24 to 5/1/24, and the nutritional supplement documented on the meal ticket indicated that the resident received a Mighty Shake. The Mighty Shake was provided to the resident every meal according to the meal ticket. There was no physician's order for the resident to receive the Mighty Shake with every meal as was written on the meal ticket. On 1/9/25 at 9:06 AM, the surveyor interviewed the RD, who stated that she had been working in the facility for approximately five months and she was unfamiliar with the resident. At that time, the RD reviewed the physician's orders with the surveyor and confirmed that Resident #146 did not have a physician's order for the Mighty Shake; the resident had a physician's order for Ensure Plus 8 oz to be given once a day. The RD stated that at that time the Ensure Plus was ordered, there was a national shortage of Ensure Plus and that the equivalent nutritional supplement would have been the Mighty Shake to be given as a substitute. The RD confirmed that an order was not obtained for the Mighty Shake and that the nurse should have discontinued the Ensure Plus supplement and ordered the Mighty Shake as the substitute. The surveyor reviewed the MAR with the RD, and she stated that she did not know why the nurses signed that the resident received the Ensure Plus when it was not available to give to the resident. The RD provided the surveyor with a letter from the company that supplied the Ensure Plus dated 4/12/24, and according to the letter the company was experiencing temporary out of stock items and that the supplement would be expected to be back in stock by mid-June or July of 2024. The RD provided the surveyor with a form titled, Acceptable Supplement Substitution policy dated January 2024, and according to this policy a Mighty Shake/health shake would have been an acceptable substitute for Ensure Plus 8 oz. On 1/9/25 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that if nutritional supplements were needed, an order was obtained from the medical doctor (MD) and the supplement was documented on the MAR as well as how much the resident consumed. LPN/UM #1 stated that if there was a national shortage of the supplement during the time the supplement was ordered, the MD should have been notified and the original supplement should have been discontinued and the replacement supplement should have been ordered. LPN/UM #1 stated all nutritional supplements required a physician's order. LPN/UM #1 reviewed the MAR with the surveyor and confirmed that the nurses signed on the MAR that the resident received Ensure Plus as well as signed how much the resident consumed. LPN/UM #1 confirmed there was no physician's order for the Mighty Shake, and the nurses should not have documented the resident received the Ensure Plus when there was a national shortage. On 1/9/25 at 10:50 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who explained that nutritional supplements were considered medications and were ordered by the MD and signed on the MAR the amount the resident consumed. The ADON stated if there was a national shortage of a nutritional supplement at the time it was ordered for Resident #146, and the supplement was not available, the staff notified the RD who recommended to discontinue that supplement and recommended a substitution. The ADON confirmed a physician's order was required for a Mighty Shake, and that staff did not notify the RD or MD to discontinue the Ensure Plus and order the Mighty Shake. On 1/10/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), who both confirmed that the nurses should have changed Resident #146's supplement order, even though the supplements were interchangeable, they should have changed the order to specify the supplement that the resident was provided. 2. On 1/6/25 at 9:30 AM, during an interview with LPN/UM #1, the surveyor was told that Resident #195 was receiving peritoneal dialysis treatments while at the facility. The resident received treatments every evening. A review of the AR face sheet reflected that Resident #195 was admitted to the facility with medical diagnoses which included but were not limited to; end stage renal disease, hypertension (high blood pressure), heart failure, and depression. A review of the most recent comprehensive MDS dated [DATE], revealed Resident #195 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. A review of Section O, Special Procedure and Treatments, revealed the resident was a peritoneal dialysis resident. A review of the physician's orders included the following orders dated 8/1/24, for the resident: peritoneal dialysis (PD) solution 2.5% 6000 milliliter (ml) yellow bags in the evening for PD; dialysis instill two (2) 6000 ml green bags; peritoneal dialysis solution 1.5% purple bag in the evening for PD; dialysis instill one (1) purple bag solution; and peritoneal dialysis solution 2.5% dextrose (1.5%) 2,000 ml solution yellow in the evening for PD; dialysis instill 1 small yellow bag. A review of the resident's ICCP included a focus area dated 8/1/24, for peritoneal dialysis. Interventions included to: monitor dialysis access site for signs and symptoms of infection; report abnormal findings to physician or designee; and check and change dressing on dialysis access as ordered and per policy. A review of the MAR and the TAR did include the dialysis access site assessments or dressing changes as indicated in the ICCP. A review of the Progress Notes included two Nurse's Notes, one dated 10/25/24, and one dated 11/11/24, that included the dialysis access site assessments. There was no additional documentation regarding the assessment of the site. On 1/7/25 at 11:44 AM, the surveyor observed Resident #195 in the room who had just received morning care from the Certified Nursing Assistant (CNA #1). Resident #195 told surveyor they had been on dialysis for three years prior to admission to the facility. The resident then showed the surveyor the abdominal catheter (flexible tubing) used for the dialysis treatment. The catheter was secured with tape to prevent pulling. There was an undated white gauze dressing over the catheter site. On 1/8/25 at 1:49 PM, the surveyor interviewed the DON regarding care of the resident's dialysis catheter site. The surveyor asked if there should be a dressing over the site and she stated yes. The surveyor then asked if there would be a physician's order for a dressing change and the DON stated yes. On 1/10/25 at 12:30 PM, the DON showed the surveyor an order for an antibiotic ointment to the dialysis catheter site. The order did not include a dressing. The surveyor asked the DON if the order should have a dressing, and if the dressing should be dated when changed. The DON confirmed yes. A review of the facility's Peritoneal Dialysis (Continuous Ambulator) dated revised October 2010, included .catheter care and site observation .11. to apply sterile dressing of the catheter insertion site . 3. On 1/8/24 at 10:00 AM, the surveyor reviewed the medical record for Resident #295. A review of the AR face sheet reflected that Resident #295 was admitted to the facility with medical diagnoses which included but was not limited to; methicillin resistant staphylococcus aureus infection (MRSA; a type of bacteria that is resistant to many antibiotics). A review of the most recent MDS dated [DATE], reflected that Resident #295 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A further review of the MDS reflected the resident used antibiotics and received IV medications as a resident. A review of the resident's ICCP included a focus area initiated on 4/13/24, and revised on 4/23/24, that the resident received intravenous therapy of daptomycin- sodium chloride intravenous solution 700-0.9 milligram (mg) per 100 ml-% (700 mg); use 700 mg (an antibiotic). Interventions included to: monitor dressing at IV insertion site daily and change as ordered; monitor/document/report to physician as needed signs and symptoms of infection at the IV site; and report to nursing if IV comes out or site appears different. The ICCP did not include to administer the antibiotic as ordered. A review of the Order Summary Report (OSR) included a physician's order (PO) dated 4/13/24, and discontinued 4/14/24, for daptomycin 700 mg IV; to administer one time a day for MRSA and discontinuation date of 4/14/24. A review of the MAR indicated the antibiotic medication daptomycin 700 mg was to be administered intravenous (IV) with a start date of 4/14/24 at 6:00 AM. The nurse's initial signature on the MAR dated 4/14/24 at 11:00 AM, indicated NA, meaning the medication was not available and the resident did not receive their daily dose of physician ordered daptomycin on 4/14/24. A review of the Progress Notes did not reflect any nursing documentation regarding the missed medication dose, and that the nurse called the physician to notify them of the missed dose or the pharmacy was contacted. The facility was unable to provide any documentation regarding the unavailable antibiotic. On 1/9/24 at 11:00 AM, the surveyor interviewed the contracted Pharmaceutical Representative (PR) liaison, who stated the pharmacy to delivered medication to the facility on the weekend once daily to the facility between 7:30 PM and 10:00 PM. The PR stated facility could request an additional delivery if a stat (immediate) medication or a specific timed medication was needed for a resident. The PR reviewed the order sent to the company for daptomycin ordered on 4/13/24, for the dose on 4/14/24 at 6:00 AM, and the PR stated that the dose did not arrive at the facility until 4/14/24 at 9:51 PM. The PR confirmed that there were no stat requests or calls to the pharmaceutical company for a rushed delivery for the daptomycin. On 1/10/25 at 9:35 AM, the surveyor interviewed the DON, who explained that the staff should have placed a call to the physician to let them know that there was a delay in administration of the medication, and documented that call in the Progress Notes. The DON stated that the nurse should have either obtained a new order or called the pharmacy to ask for a stat dose or the estimated time of arrival (ETA) for the delivery of the medication based on the physician's recommendations. On 1/10/25 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who indicated that the staff should have notified the resident's physician. The LNHA acknowledged there was a delay in medication administration, and it prolonged the resident's care. On 1/10/25 at 10:30 AM, the surveyor team met with the LNHA and DON, who both acknowledged the surveyor's concerns and no additional information was provided. A review of the facility's Physician Orders policy dated February 2014, included that licensed nurses would obtain, document, and provide care and services in accordance with orders received from the physician. The provision of care and services in accordance with physician orders would be documented in accordance with professional standards of practice . A review of the facility's Administering Medications policy dated April 2019, included medications are administered in a safe and timely manner and as prescribed .medications are administered with in one (1) hour of their prescribed time, unless otherwise specified . NJAC 8:39-11.2(b)

Based on observation, interview, review of facility medical records and other pertinent facility documents, it was determined that the facility failed to document the necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. This deficient practice was identified for 1 of 2 residents reviewed for pressure ulcers (Resident #4), and was evidenced by the following: A review of the admission Record face sheet (an admission summary) Resident #4 was admitted to the facility with the diagnoses that included but not limited to; dementia, diabetes mellitus and severe protein calorie malnutrition. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/19/24, indicated that Resident #4 had severe cognitive impairment and was dependent on staff for all aspects of activities of daily living (ADLs). A review of Section M reflected that Resident #4 was at risk for developing pressure ulcers and had a full thickness stage 3 pressure area. On 1/6/25 at 12:35 PM, the surveyor observed Resident #4 lying in bed on an air mattress. The resident was unable to be interviewed due to an impaired cognition and the resident had a non-verbal status. The nurse assigned to the resident indicated that Resident #4 had a pressure ulcer on the left foot. The surveyor observed the dressing on the left foot dated 1/6/24. A review of the Weekly Skin Check dated 12/28/24, indicated the resident had a pressure ulcer on the left foot bunion area. A review of the Treatment Administration Record (TAR) dated 1/1/25 until 1/31/25, reflected a physician's order dated 12/6/24, for Medi-honey wound/burn dressing external gel (wound dressings); apply to left bunion wound topically every day shift for wound care. Cleanse left bunion wound with normal saline solution (NSS); apply Medi honey and NSS moist gauze to the base of the wound and secure with dry gauze and rolled gauze once daily. According to the TAR, on 1/4/25 and 1/5/25, there were no nurses' signatures that indicated wound care was provided to Resident #4's left bunion wound. The surveyor reviewed Resident #4's individualized comprehensive care plan (ICCP) dated 5/14/19, which indicated that the resident had a wound to the left bunion area and had the potential for pressure ulcer development. Interventions included to provide treatments per physician's orders and the staff was to monitor for effectiveness of treatments rendered. A review of the Wound Assessment Report dated 1/7/25, indicated that Resident #4 had a left foot bunion pressure area stage three and that the wound measured three centimeters by three centimeters by nine centimeters (3 cm x 3 cm x 9 cm) with a 0.20 depth and was improving without complications. On 1/8/25 at 9:17 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the nurse assigned to the resident was responsible to complete wound care and then signed on the TAR the treatment was completed. The RN stated if the TAR was not signed by a nurse, it indicated that the wound care was not completed. The RN stated if for any reason the wound care was not completed, the nurse indicated no on the TAR and then documented in a progress note as to why it was not completed. At that time the RN reviewed Resident #4's TAR, in the presence of the surveyor, and agreed that the TAR dated 1/4/25 and 1/5/25, on day shift was blank and if there were no signatures from the nurse on those days, that indicated that wound care was not completed on those days. On 1/8/25 at 9:31 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that it was the responsibility of the nurse to complete the resident's wound care and document the completion on the TAR. The LPN/UM stated if signatures were missing on the TAR, it indicated that the wound care was not completed or that the nurse forgot to sign that the treatment was completed. The LPN/UM stated that it would be important to sign the TAR so that the facility could ensure the best care was rendered for the residents and documenting completion of a procedure was important to ensure that proper care was provided. On 1/8/25 at 11:48 AM, the surveyor interviewed the Director of Nursing (DON), who stated that wound care was completed per physician's orders and documented on the TAR for completion. The DON stated that it was important for the nurse to sign the TAR after wound care completion because if the nurse did not sign the TAR, it indicated that the treatment was not done as ordered by the physician. On 1/9/25 at 9:55 AM, the surveyor interviewed the LPN, who stated that she had worked on 1/4/25 and 1/5/25, and she confirmed that the TAR did not contain her signature for the resident's wound care on those days. The LPN stated that it was a crazy busy weekend and that she must have forgotten to sign out the TAR on those dates, but she remembered performing Resident #4's left bunion area treatments. The LPN acknowledged that based on standards of nursing practice, if you did not sign that a procedure was performed then it was not done. On 1/9/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that after a treatment was performed by the nurse, it was the nurse's responsibility to document that it was completed by putting a signature on the TAR. The ADON stated that if the TAR was blank and there was no signature that documented the treatment was performed, then the conclusion would be that the treatment was not provided to the resident. On 1/10/25 at 10:39 AM, the surveyor interviewed the DON, who stated that the nursing staff were required to sign the TAR when treatments were provided. She stated that when the nurse signed the TAR, it confirmed that the treatment was provided. A review of the facility's Wound Care policy dated 2001, included the following information should be recorded in the resident's medical record: the type of wound care given; the date and time the wound care was given; all assessment data; the signature and title of the person recording the data . NJAC 8:39-27.1 (e)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 1 of 3 residents reviewed for dialysis (Resident #68), and was evidenced by the following: On 1/6/25 at 12:25 PM, during initial tour of the facility, the surveyor observed Resident #68 in their bedroom sleeping. On 1/7/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #68. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but not limited to; end stage renal disease (kidneys have permanently lost their ability to function), chronic kidney disease (slow loss of kidney function over time), and type two diabetes mellitus (body does not use insulin properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/14/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a cognitively intact cognition. A further review included the resident received dialysis while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 12/7/24, for dialysis at [dialysis center name] on Tuesday, Thursday, and Saturday; pick up at 7:00 AM. A further review revealed a PO dated 12/7/24, to give book and bag lunch prior to leaving; check the book after arrival for communication in the morning every Tuesday, Thursday, and Saturday. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/18/24, that the resident needed hemodialysis related to renal failure at [dialysis center name] on Tuesday, Thursday, and Saturday. Interventions included but not limited to; monitor dialysis access site for signs and symptoms of infection, report abnormal findings to the physician or designee, monitor shunt sites for thrill and bruit (an assessment done by feeling their shunt for electric pulse that can be done with fingers or stethoscope done every shift to make sure functioning) every shift and as needed. On 1/8/25 at 10:22 AM, the surveyor reviewed Resident #68's dialysis communication book that was sent with the resident on dialysis treatment days. The communication forms were reviewed from October 2024 to January 2025. The following dialysis communication forms were not completed by the facility's nurse upon return from dialysis: 10/12/24, 10/15/24, and 10/17/24. The dialysis communication form was not completed by the dialysis center on 11/7/24. On 1/8/25 at 10:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated Resident #68 went out for dialysis on Tuesday, Thursday, and Saturday. LPN #1 further stated that prior to their departure, the nurse obtained vital signs, monitored the access site, and documented on the dialysis communication form that it was sent to dialysis with the resident. LPN #1 also stated that when the resident returned from dialysis, the nurse obtained vital signs, monitored the access site for drainage, checked the bruit and thrill and documented it in section three of the communication form. LPN #1 stated that if the dialysis center did not fill out their section, the facility called the center to see what they did at the dialysis center and if there were any new orders or changes. On 1/9/25 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of the dialysis communication form was to ensure communication between the facility and dialysis center. The DON further stated that when a resident went out to dialysis, the nurse was responsible to complete section one with vital signs, upon return the nurse reviewed the form and completed section three. The DON also stated that the dialysis center completed section two with weights, vital signs, labs, and new orders. The surveyor asked the DON if the dialysis center left section two blank, what should the nurse do. The DON replied, the nurse called the dialysis center to find out if there were any new orders or any concerns. The DON acknowledged that the dialysis communication forms were not filled out completely on the following dates: 10/12/24, 10/15/24, 10/17/24, and 11/7/24. On 1/9/25 at 12:49 PM, the DON, in the presence of the Licensed Nursing Home Administer (LNHA), Assistant Director of Nursing (ADON), [NAME] President of Clinical Services, and the survey team, stated the importance of the dialysis communication forms were to ensure communication between the facility and the dialysis center. The DON also stated that the dialysis center completed section two with how the dialysis treatment went, vital signs, and any new orders. The DON further stated if section two was not completed by the dialysis center, the nurse contacted the dialysis center and documented any new orders. A review of the facility's Hemodialysis Catheters - Access and Care of policy dated revised February 2023, included the nurse should document in the resident's medical record every shift as follows: .3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis . NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 1 of 1 observed medication storage room, and was evidenced by the following: On 1/8/25 at 9:49 AM, the surveyor toured the medication room on the Subacute unit in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed the following: debris on the medication room floor and brown substance build up in the corners; debris (appeared to be a tea bag) in the drain of the sink, brown discoloration in the basin, along the edge of the sink, behind the sink, and around the faucet; in the cabinet housing the sink, the surveyor observed brown, black, and orange substance towards the back of the cabinet under pipes. On 1/9/24 at 10:00 AM, the surveyor reviewed the monthly cleaning schedule which revealed the medication room was to be cleaned on 1/24/25. The medication room had been scheduled for cleaning on 11/22/24 and 12/27/24. On 1/9/25 at 12:54 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who explained that the facility had an electronic request system in place that went directly to a beeper/cell phone of the maintenance staff. They continued it was reviewed in the morning and a text alert was sent throughout the day. The LNHA stated anybody in the building had access to the electronic reporting system, and the staff reached out to housekeeping staff by phone or on the unit if there were any concerns that needed immediate attention. On 1/10/25 at 9:19 AM, the surveyor interviewed the Maintenance Director (MD), who stated that the facility utilized an electronic system for reporting any maintenance issues that came up. The MD stated the all staff were able to make a service ticket and if there was an issue under the sink in the medication room, it should have been reported. The MD confirmed he did not have any request tickets for under the sink in the cabinet. On 1/10/25 at 9:29 AM, the surveyor interviewed the Director of Housekeeping (DH), who revealed that the medication rooms were cleaned monthly and on a schedule. The DH stated he expected his staff to follow the cleaning step, cleaning process. The DH stated if there was an issue that needed to be addressed all staff could report it, and then it would be properly cleaned as needed. On 1/10/25 at 9:35 AM, the surveyor interviewed the DON, who stated all the staff could report a need for cleaning or something to be fixed. The DON stated for housekeeping, they placed a call to the department, and for maintenance, the staff placed a request in the electronic maintenance system that was available on all the computers. The DON confirmed everyone should be accountable if they saw something to report it to keep the facility clean. A review of the facility's undated 5 Step Daily Room Cleaning policy included .3. Dust Mop Floor-you may use a broom to sweep in tight spaces, sweep up debris in dustpan; 4. Clean and sanitize sink: the sink includes: The sink, fixtures, pipes under sink. Use germicide to clean the sink to be sure it is disinfected. You may use glass cleaner on the faucets to shine them after germicide has been used .7. Damp Mop Floor - use proper mop and germicide solution to disinfect the floor. Be sure to run the mop along the edges. When damp mopping floors pay close attention to any possible buildup along the corners and edges. Use a scraper to remove any potential build up in these areas to maintain a clean and sanitary surface . NJAC 8:39 -31.2(e)

NJ Complaint NJ #: 177087 Based on interview and review of pertinent facility documents, it was determined that the facility failed to investigate allegations of verbal abuse emailed to the facility on 8/7/24, by both a resident (Resident #145) and their representative, that an unidentified nurse verbally abused the resident and it was not investigated until surveyor inquiry. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documents for Resident #145. The documentation included the following: An internal compliance hotline call from the resident dated 7/27/24. A fall accident report and investigation dated 9/26/24. A fall accident report and investigation dated 10/14/24. At that time, the surveyor asked the LNHA if those were all the reports for Resident #145 that the facility investigated, and the LNHA replied yes, as far as she was aware. On 1/9/25 at 9:04 AM, the LNHA and the Director of Nursing (DON) informed the surveyor that after the surveyor's multiple inquiries for reportable events, accidents, incidents, and grievances regarding Resident #145, they began to ask facility staff if they were aware of any other incidents that were not provided to the surveyor. The LNHA stated that the Social Worker (SW) looked through her emails and found two emails, both dated 8/7/24, one was from Resident #145 and the second from the Resident's Representative (RR). The emails both included grievances and an accusation of verbal abuse from an unnamed nurse at the facility towards the resident. The LNHA stated that the email was just found in the SW's spam/junk folder after surveyor inquiry. The LNHA acknowledged that the allegation was absolutely considered verbal abuse, and stated that the facility started an investigation into the matter which included attempting to reach out to the resident who no longer resided at the facility. On 1/9/25 at 9:58 AM, the surveyor reviewed Resident #145's medical record. A review of the resident's Transfer/Discharge Report indicated that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), need for assistance with personal care, and chronic pain. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. On 1/9/25 at 11:46 AM, the surveyor interviewed the LNHA, who stated when an allegation of abuse or grievance was reported to the facility by a resident or their representative, it was brought to the attention of the administration team. The LNHA continued if a particular person or staff member was named, then that staff member was suspended pending investigation. The LNHA stated that investigations should be completed and closed out in five days or sooner. The LNHA stated she was unsure as to why or how the emailed grievance/allegation was sent to the spam/junk folder and the facility's information technology (IT) department needed to investigate it. On 1/9/25 at 1:01 PM, the Regional Director of Operations (RDO), in the presence of the survey team, acknowledged the delay in investigating this accusation of abuse and stated, we agree that the system inhibited the ability to respond to the complaint/allegation. On 1/10/25 at 10:22 AM, the LNHA acknowledged to the surveyor, in the presence of the survey team, that the allegation of abuse that was emailed on 8/7/24, was just being investigated and followed up with now after surveyor inquiry. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated revised April 2021, included .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to; freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms .the facility would .develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents .identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property . NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00169890 Based on interviews, medical record review, and review of other pertinent facility documents on 12/28/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 2 of 3 residents (Resident #1 and Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted on [DATE], with diagnoses that included but were not limited to: Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), gout, and chronic kidney disease. The Minimum Data Set (MDS), an assessment tool, dated 12/2/23, revealed a Brief Interview of Mental Status (BIMS) of 15/15 which indicated the resident's cognition was intact and the resident needed assistance with ADLs including bed mobility (turning and positioning), toilet transfer, dressing, and transfers. Review of Resident #2's DSR (ADL Record) and the progress notes (PN) for the month of 12/2023, lack any documentation to indicate that the care for bed mobility (turn and positioning), toilet transfer, dressing, and transfers was provided and/or the resident refused care on the following dates and shifts; 7:00 am-3:00 pm shift on 12/5/23, 12/6/23, 12/9/23, 12/10/23, 12/12/23, 12/16/23, 12/17/23, 12/21/23 to 12/23/23, 12/25/23, and 12/27/23 to 12/31/23. 3:00 pm-11:00 pm shift on 12/5/23, 12/9/23 to 12/13/23, 12/15/23, 12/16/23, 12/20/23, 12/22/23 to 12/25/23, and 12/27/23 to 12/31/23. 11:00 pm-7:00 am shift on 12/4/23, 12/8/23, and 12/29/23 to 12/31/23. 2. According to the facility AR, Resident #1 was admitted on [DATE], with diagnoses that included but was not limited to: muscle wasting and atrophy, COPD, and abnormalities of gait and mobility The MDS, dated [DATE], revealed a BIMS of 14/15 which indicated the resident's cognition was intact and the resident needed assistance with dressing and supervision with other ADLs including bed mobility (turning and positioning), toilet transfer and transfers. Review of Resident #1's DSR (ADL Record) and the progress notes (PN) for the month of 12/2023, lack any documentation to indicate that the care for bed mobility (turn and positioning), toilet transfer, dressing, and transfers was provided and/or the resident refused care on the following dates and shifts; 7:00 am-3:00 pm shift on 12/5/23, 12/10/23, 12/11/23, 12/13/23, 12/15/23 to 12/17/23, 12/21/23 to 12/23/23, 12/25/23, and 12/29/23 to 12/31/23. 3:00 pm-11:00 pm shift on 12/5/23, 12/6/23, 12/8/23 to 12/14/23, 12/16/23, 12/20/23, 12/22/23 to 12/25/23, and 12/27/23 to 12/31/23. 11:00 pm-7:00 am shift on 12/4/23 and 12/29/23 to 12/31/23. During an interview with the surveyor on 12/28/23 at 2:50 pm, the Director of Nursing (DON) said that the ADL tasks are completed by the CNA and there should be no blanks. The DON further stated that there is no way of knowing if the task was done if it was not documented. Review of a facility policy titled Activities of Daily Living (ADLs), Supporting, with a revised date of March 2018, reflected The resident's ability to participate in ADLs and the support provided during ADL care and resident-specific tasks will be documented each shift by Certified Nursing Assistants in the medical record . NJAC 8:39-35.2(d)(9)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of the transfer to the hospital for three of three residents (Resident (R) 15, R35, R66) reviewed for hospital transfers, out of a total sample of 28 residents. Findings include: Review of the facility's policy titled, Transfer or Discharge, Facility-Initiated, dated 10/22 (sic), revealed, Policy Statement: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Notice of Transfer or Discharge (Emergent or Therapeutic Leave): 1. When resident who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT (sic) discharges, because the resident's return is generally expected .4. Notice of Transfer is provided to the resident and representative as soon as possible as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements. 1. Review of R15's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R15 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R15's EMR Progress Notes, located under the Notes tab, revealed a Health Status Note, dated 01/23/23, indicated, Resident not feeling well this morning .MD [Medical Doctor] notified .Resident sent out to [local hospital] for evaluation . Review of the facility report Admission/Discharge To/From Report, . Discharges 01/01/23 to 01/31/23 [sic], dated 02/02/23, revealed, R15 was not listed on the report. 2. Review of R35's undated admission Record, located in the EMR under the Profile tab revealed R35 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R35's EMR Progress Notes, located under the Notes tab, revealed a Health Status Note, dated 09/01/23, indicated, During breakfast resident became lethargic refuse her breakfast. Resident respond to verbal command and respond to her name .MD [name] was contacted and made aware of resident status receive order for resident to be sent out for evaluation to [local hospital] . Review of the facility report Admission/Discharge To/From Report . Discharges 09/01/23 to 09/33/23 [sic] dated 10/09/23, revealed, R35 was not listed on the report. 3. Review of R66's undated admission Record, located in the EMR under the Profile tab revealed R66 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R66's EMR Progress Notes, located under the Notes tab, revealed a Health Status Note, dated 06/08/23, indicated, Resident transferred to [local hospital] after he appeared lethargic, unable to respond to verbal stimuli. Supervisor called and informed about resident's condition . Review of the facility report Admission/Discharge To/From Report, . Discharges 06/01/23 to 06/30/23 dated 07/28/23, revealed, R66 was not listed on the report. In an interview on 11/08/23 at 1:21 PM, the Administrator stated, The report I ran to provide notice to the Ombudsman of discharges did not include anyone on a bed hold; they were only included on the report when/if the bed hold ended before they returned . there was no notice sent to the Ombudsman. NJAC 8:39-4.1(a)32 NJAC 8:39-5.3(b) NJAC 8:39-5.4(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for two of 44 sampled residents (Resident (R) 19 and 68). Staff failed to accurately code dialysis for R19 and hospice for R68. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning of the resident. Findings include: Review of the Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised October 2023, revealed the intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods. 1. Review of R19's Face Sheet, under the electronic medical record (EMR) Profile tab, revealed that R19 was re-admitted to the facility on [DATE] with a diagnosis including end stage renal disease (ESRD). Review of R19's Physician Order dated 03/14/16, under the EMR Orders tab, revealed Discontinue dialysis, son's preference. Review of the Care Plan dated 02/28/16, under the EMR Care Plan tab, revealed The resident has a terminal prognosis related to end stage diabetic with end stage renal disease family does not want any aggressive treatment done. Review of the Quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/29/23, under the EMR ''MDS'' tab, revealed dialysis coded while a resident. 2. Review of R68's Face Sheet, under the EMR Profile tab, revealed that R68 was re-admitted to the facility on [DATE] with diagnosis including toxic encephalopathy, and anxiety. Review of the Quarterly MDS assessment with ARD 09/11/23, under the EMR MDS tab, revealed hospice coded as no. However, review of the Quarterly MDS assessment with ARD 06/11/23 revealed hospice coded as yes. Review of R68's Physician Order dated 12/09/22, under the EMR Orders tab, revealed Admit to hospice [name of hospice]. Interview with MDS Regional Coordinator on 11/09/23 at 11:55 AM, she indicated that R19's assessment was miscoded for dialysis and indicated that R68's assessment was miscoded for hospice. Said that she would except staff to look through care plans, medication administration record (MAR), treatment administration record (TAR), physician orders, and nursing notes to get the information to code the assessments correctly. Indicated that there is no facility policy regarding coding, codes according to the RAI manual. NJAC 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to properly maintain clean filters on oxygen concentrators for three of four residents sampled for respiratory care (Resident (R) 15, R21, and R35). The facility failed to ensure residents had active orders for oxygen use for one resident R353. Findings include: Review of the facility's policy titled, Oxygen Administration, dated 10/10 [sic], revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Further review of the policy reveals it fails to address the proper maintenance and cleaning of the oxygen concentrators. 1. Observation on 11/06/23 at 11:28 AM revealed R15's concentrator located next to his bed to have a dirty air intake filter and the unit was dirty. Review of R15's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pulmonary fibrosis, chronic respiratory failure, and chronic obstructive pulmonary disease. Review of R15's Physician Order, dated 03/30/23, located in the resident's EMR under the Orders tab, revealed an order for O2 [oxygen] at 2 lpm [liters per minute] via nasal cannula. Further review of physician orders revealed no orders for the cleaning of the concentrator filter. Observation on 11/08/23 at 2:35 PM with Registered Nurse (RN) 1 revealed R15's oxygen concentrator located next to his bed to have a dirty air intake filter. During an interview at the time of the observation, RN1 stated, the filter is dirty, and the machine is dirty, the machine and the filter should be clean. RN1 did not know who was responsible for cleaning the filters. 2. Observation on 11/07/23 at 8:43 AM revealed R21's concentrator located next to her bed to have a dirty air intake filter. Review of R21's undated admission Record, located in the EMR under the Profile tab revealed R21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, primary pulmonary hypertension, obstructive sleep apnea. Review of R21's Physician Order, dated 04/20/23 located in the resident's EMR under the Orders tab revealed an order for O2 at 3 lpm via nasal cannula continuously to keep oxygen levels greater than 90%. Further review of physician orders revealed no orders for the cleaning of the concentrator filter. Observation on 11/08/23 at 2:50 PM with RN1 revealed R21's oxygen concentrator located next to her bed to have a dirty air intake filter. During an interview at the time of the observation, RN1 stated, the filter is dirty, and it should be clean. 3. Observation on 11/07/23 at 10:37 AM revealed R35's concentrator located next to her bed to have a dirty air intake filter. Review of R35's undated admission Record, located in the EMR under the Profile tab revealed R35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease. Review of R35's Physician Order, dated 09/29/22 located in the resident's EMR under the Orders tab revealed an order for O2 at 2 lpm via nasal cannula. Further review of physician orders revealed no orders for the cleaning of the concentrator filter. Observation on 11/08/23 at 2:45 PM with RN1 revealed R35's oxygen concentrator located next to her bed to have a dirty air intake filter. During an interview at the time of the observation, RN1 stated, the filter is dirty, and it should be clean. 4. Review of R353's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, hypokalemia, fatigue, muscle wasting and atrophy, unspecified asthma with exacerbation, adult failure to thrive, and recurrent depressive disorders. Review of R353's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 09/19/23, revealed she scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. It did not indicate that R353 received oxygen therapy as a resident. Review of R353's Care Plan, located under the Care Plan tab of the EMR and dated 11/03/23, revealed the R353 did not have interventions related to receiving oxygen therapy. Review of R353's Orders tab of the EMR revealed no order for PRN or continuous oxygen During an observation on 11/06/23 at 10:51 AM ,R353 was observed sitting in bed with the head of bed upright and nasal cannula laying on bed. R353 said she took off the nasal cannula earlier to receive a breathing treatment, but she forgot to put it back on. Oxygen setting noted to be at two liters per minute (LPM) but R353 said it should be on three LPM. During an observation on 11/07/2023 at 2:08 PM R353 was observed sitting in bed with head of bed upright wearing nasal cannula. Oxygen setting noted to be at 2 liters per minute (LPM). During an observation on 11/08/2023 at 10:53 AM R353 was observed sitting in bed with head of bed upright wearing nasal cannula. R353 stated she needed a clean nasal cannula because she was still using the one from the hospital because staff had not changed it. R353 said her nasal passage was dry because the oxygen cannister did not have a humidifier bottle and she stated she supposed to have cool air. During an interview on 11/08/23 at 10:55 AM Licensed Practical Nurse (LPN) 5 said she checks residents' oxygen every shift to ensure the oxygen was on the correct liters per minute (LPM). And if a resident was receiving oxygen therapy there would be an order for it, and she reviewed orders daily. It also comes up on the medication administration review (MAR) and she reviewed that daily, but she has not documented anything about oxygen on R353 MAR yet, but she thought the LPM were 2-3. She said she was unaware R353 had no order for oxygen but there should have been one. She did not check for an order when she checked his/her oxygen and provided inhalation medications. She said she should have checked for an order when she observed R353 with a nasal cannula receiving continuous oxygen, but she had a lot of patients. During an interview on 11/09/23 at 5:20 PM the DON said there would be an order for continuous or PRN [as needed] oxygen and residents receiving oxygen therapy were signed into the pulmonary program during the admission process. The DON stated R353 should not have been receiving oxygen without a physician's order. During an interview on 11/09/23 at 6:06 PM the Regional Director of Operations said any treatment or medication a resident received should have a physician's order and staff should have followed that order. NJAC 8:39-19.4(a)(k) NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure that one of the 24 sampled residents (Resident (R)23) medical records from a sample of 24 residents were maintained in a complete, and accurately documented manner. Specifically, R23 Suprapubic Catheter was observed to have bright red blood in the line and urine specimen bag with no documentation identified in the electronic medical record (EMR). Findings include: A review of the undated Catheter Care, Urinary policy provided by the facility, .The following should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual (s) giving the catheter care. 3. Any problems noted at the catheter-urethra junction during perineal care such as .redness, bleeding . Record review of the admission Record found under the Profile tab of the EMR revealed R23 was admitted to the facility on [DATE] with diagnoses including dementia, acute kidney failure, urinary tract infection, major depressive disorder, and heart failure. A review of Progress Notes, located in the electronic medical record (EMR) under the Progress Note tab for the month of November 2023 indicated no communication related to blood being in R23 urine specimen bag. During an observation and interview on 11/07/23 at 2:12 PM with the Licensed Practical Nurse (LPN)5,. LPN5 stated R23 suprapubic catheter was changed on 11/06/23 which caused some trauma and resulted in bleeding. During an observation and interview on 11/08/23 at 8:46 AM with a Registered Nurse (RN)1 revealed that R23 line was clear of blood, however, blood was observed in the urine specimen bag. According to RN1, the blood was dark in color indicating old blood. When asked why there was blood in R23 bag. RN1 stated, due to trauma from being changed or when R23 tugs on his catheter line. The survey further asked RN1 what is the facility procedure if blood is observed in the resident's line or bag. RN1 stated the information is documented in the EMR, and the physician is notified. RN1 was asked to provide the progress report indicating the change in condition. RN1 was unable to locate the report. During an interview on 11/08/23 at 9:16 AM with the facility Director of Nursing (DON) revealed that R23 suprapubic catheter was changed on 11/06/23 due to not flowing correctly she was able to locate the information in the 24-hour report log. The DON further expressed that the 24-hour log is not a legal document and is used to communicate between shifts. DON continued to share that her expectation is that treatments are documented in the treatment authorization request (TAR) and a progress note written. The DON further stated, I have informed all nursing staff that the 24-hour report is not a binding document, all information should be put into the EMR. I have counseled the nurse, and she will enter a late entry note. During an interview on 11/09/23 at 6:09 PM with the facility's Regional Director revealed that his expectations are that all staff follow policy and procedures related to documenting all treatment and procedures in the EMR. NJAC 8:39-35.2(d)6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) accurately obtain resident weights and b.) accurately assess the nutritional status for a resident with a significant weight loss in accordance with professional standards to accurately determine nutritional needs for the same resident. This deficient practice was identified for 1 of 3 residents reviewed for nutrition (Resident #55), and was evidenced by the following: On 06/16/21 at 9:55 AM during initial tour, Resident #55 was observed standing at the foot of his/her bed. The resident appeared thin and was unable to be interviewed. The surveyor reviewed the medical record for Resident #55. A review of the electronic Progress Notes reflected that the resident was admitted to the facility in October of 2020, with diagnoses which included muscle wasting, history of traumatic brain injury, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), malnutrition, congestive heart failure (CHF; chronic condition in which the heart does not pump blood as well), hypertension (high blood pressure), and alcohol abuse. A review of the the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/7/21, reflected a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severely impaired cognition. Further review reflected in Section K, Swallowing/Nutritional Status, that the resident did not have a weight loss of 5% or more in the last month or 10% or more in the last six months. A review of the Weights and Vitals Summary reflected the following weights: 11/12/2020 153.0 pounds (lbs.) 12/30/2020 150.0 lbs. 1/13/20/21 150.0 lbs. 3/10/21 129.4 lbs.; reweigh 136.4 lbs. 4/8/21 130.2 lbs. 4/9/21 reweigh 125.2 lbs. 5/5/21 128.0 lbs. 6/6/21 133.0 lbs. This reflected a significant weight loss of 11.33% in six months. A review of the hospital records reflected on 10/3/2020, the resident weighed 150.0 lbs. A review of the admission Nutritional Risk assessment dated [DATE], reflected that the resident weighed 153.0 lbs. with a body mass index (measure of body fat based on height and weight) of 24 which indicated normal body weight. The evaluation included that hospital weight noted on 10/3/2020 at 150.0 lbs. and weights appears to be stable, will monitor weekly trend and reassess as needed. It also included that the resident's intake was above the estimated needs using the current body weight with a plan to maintain the current body weight without significant change. The assessment did not include the resident's usual body weight. A review of the Nutritional Risk assessment dated [DATE], reflected that the resident weighed 136.4 lbs. with significant 9% or 13.6 lbs. weight loss in three months that was unplanned and not desired. The evaluation included that the weight loss was likely due to variable intake and CHF with possible fluid fluctuations likely contributing to some weight loss. The plan was to continue current diet at this time; provide snacks and preferences as able; encourage adequate intake; and continue to monitor intake, weight, skin and labs as available. The assessment did not include the resident's usual body weight. A review of the resident's individualized care plan included a focus initiated 10/31/2020 and last revised 11/19/2020, for: I have a nutritional problem or potential nutritional problem with regards to the need for a therapeutic diet and variable oral intake with a history of hypertension, CHF, COPD, anemia (a condition in which the blood does not have enough red blood cells), and alcohol abuse. Interventions included; to provide and serve diet as ordered, heart healthy regular diet with double portions; monitor intake and record every meal; weighed monthly/weekly as ordered; obtain and monitor laboratory/diagnostic work as ordered; Registered Dietitian (RD) to evaluate and make diet change recommendations as needed; and monitor/record/report to the physician as needed any signs and symptoms of malnutrition: emaciation (abnormally thin), muscle wasting, significant weight loss of three pounds (3.0 lbs.) in one week, greater than 5% in one month, greater than 7.5% in three months, or 10% in six months. The care plan did not address the significant weight loss from the Nutritional assessment dated [DATE]. An additional review of the electronic Progress Notes did not reflect that the physician was made aware of the resident's significant weight loss or the weight loss of three pounds (3.0 lbs.) or more in one week in March, April, or May. A further review of the electronic Progress Notes included a Nutrition Note dated 5/5/21, which reflected that the resident's current body weight was 128.0 lbs. with weights of 130.2 lbs. on 4/21/21 and 129.4 lbs. on 3/21/21. The RD noted that the resident's weights fluctuate and that the weight is on the lower end of the acceptable weight range and that weight gain can be beneficial. There was no documentation that the RD addressed the significant weight loss at this time. On 6/23/21 at 10:13 AM, the surveyor interviewed RD #1 who stated that Resident #55 was admitted to the facility with a feeding tube that was never used at the facility to provide nutrition since the resident's oral intake was stable. When questioned about the resident's weight loss, RD #1 replied that he/she was never 150.0 lbs. At this time, the surveyor requested additional information regarding the resident's weight status upon admission and weight loss. On 6/23/21 at 1:09 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that RD #1 was on a leave of absence from the facility from 10/30/2020 until 4/1/21, and that the facility used a contracted nutrition company to provide RDs for nutrition consultations and would provide the survey team with the contact information. On 6/23/21 at 1:11 PM, the surveyor interviewed Certified Nursing Aide (CNA #1) who stated that the CNAs obtained residents' weights according the residents' scheduled weighing time. CNA #1 continued that if there was a discrepancy in the weight, the aide would remove the resident from the scale, reset the scale, then re-weigh the resident. If there was still a weight discrepancy after that, CNA #1 would inform the nurse. On 6/23/21 at 1:22 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that weekly weight and nutritional supplements were ordered by the RD if the resident was losing weight. If there was a suspected weight discrepancy, the resident was re-weighed with both the nurse and RD present to ensure the accuracy of the weight. The LPN stated that the Unit Manager or the RD would inform the physician of any significant weight changes. On 6/23/21 at 1:43 PM, the surveyor conducted a telephone interview with the Consultant RD #2 who stated that she was the [NAME] President of Clinical Services for the company and her primary role was to train the RDs of the company. The Consultant RD #2 stated that RD #3 was the primary consultant assigned to the facility, but she had covered RD #3's time off. The Consultant RD #2 stated that she had covered for RD #3 in March and completed the Nutritional Assessment from 3/12/21 in which she addressed the significant weight loss of the resident possibly being attributed to a gradual loss of fluids since his/her hospitalization in October 2020. On 6/24/21 at 8:37 AM, the Director of Nursing (DON), in the presence of the LNHA, LNHA in training, Regional Director of Clinical Services (RDCS), Regional Director of Operations (RDO) and the survey team stated that after surveyor inquiry, the facility contacted the resident's family member who informed the facility that the resident's weight was usually around 120.0-130.0 lbs. The DON continued that resident at the time was refusing weights so the nurse entered the resident's weight from the hospital record as the weight for 11/12/2020, which was not standard practice and she should not have done. The DON confirmed that there was no documentation of this at the time in the resident's medical record. At this time, the surveyor questioned the DON if the resident's weight was 150.0 lbs. in the hospital, why the facility had the resident's weight documented as 153.0 lbs on 11/12/220 and 150.0 lbs. on 12/30/2020 and 1/13/21? The DON responded that he would need to investigate this further. At this time, the LNHA in training stated that if he had to speculate, that the nurses were going off the hospital weights to make it look more real. On 6/24/21 at 9:21 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that she was the nurse who inputted the the weight in the computer on 11/12/21 of 153.0 lbs. She stated that the resident was refusing weights so she used the weight of 153.0 lbs. that was from the New Jersey Universal Transfer Form dated 10/29/2020, as the resident's current weight. The ADON stated that it was not facility practice to do this, and she had not documented in the medical record that this was the weight upon transfer to the facility. The ADON stated that the weight of 150.0 lbs. from 12/20/2020 and 1/13/21, were inputted by a nurse who no longer worked at the facility, but she used the weights from the hospital record for the resident. The ADON confirmed that this was not documented in the medical record. At this time, the surveyor and the ADON reviewed the New Jersey Universal Transfer Form dated 10/29/2020 and confirmed that the weight upon transfer was 153.0 lbs. The surveyor and the ADON also reviewed the resident's medical record, and the ADON confirmed that the resident received no laboratory/bloodwork since residing at the facility. On 6/24/21 at 11:19 AM, the surveyor re-interviewed the RD #1 in the presence of the LNHA and survey team, who stated that she assessed residents upon admission, quarterly, annually, and any significant changes or as needed to make sure that residents maintained good nutritional status through monitoring weights and intakes. RD #1 stated that she was on leave from the facility when the resident was admitted to the facility so she had not completed the initial assessment, but she completed the resident's quarterly assessment on 5/5/21. RD #1 acknowledged that she did not address and should have the significant weight change of 10% or more at this time in either her assessment or on the MDS because she felt that the resident did not have an actual weight loss, and that she thought the Consultant RD #2 addressed this previously. On 6/25/21 at 9:30 AM, the LNHA in the presence of the LNHA in training, RDCS, RDO, DON, ADON, and survey team stated that the resident was not accurately assessed at the facility and acknowledged there was missing documentation that the resident had not lost weight at the facility. A review of the facility's undated Weight Assessment and Intervention policy included that any weight change of five pounds (5.0 lbs.) or more since the last weight assessment will be retaken for confirmation and the RD will review weights on a routine basis to address changes. The RD will review weights monthly to follow individual weight trends to determine if there is a significant weight change of 5% in one month; 7.5% in three months; or 10% in six months. The policy also included that care planning for weight changes shall address to the extent possible the identified causes of weight change; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment. N.J.A.C. 8:39-27.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and review of facility documentation it was determined that the facility failed to follow facility policy by documenting communication with the dialysis center on resident dialysis days. This deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #57 and Resident #38), and was evidenced by the following: 1. On 6/17/21 at 9:31 AM, during the initial tour of the facility the surveyor observed Resident #38 lying in bed. Resident #38 stated he/she goes in the morning for dialysis on Monday, Wednesday and Friday. The surveyor reviewed the medical record for Resident #38. A review of the admission Summary reflected that the resident was admitted to the facility in October of 2019 with a diagnosis which included end stage renal disease (kidney failure), chronic kidney disease, diabetes mellitus, hypertension (high blood pressure), and muscle wasting. A review of the most recent significant change Minimum Data Set (MDS), an assessment tool dated 4/16/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. A review of Section O, Special Treatments and Procedures, reflected that the resident received hemodialysis services (a process of purifying the blood due to impaired kidney function. A review of the physician's orders (PO) which reflected the following: 1. A PO dated 10/23/19 for LEFT ARM: NO B/P (blood pressure), IVs (intravenous) OR BLOOD DRAWS every shift. 2. A PO dated 2/24/21 and discontinued 6/22/21 for: Dialysis on Monday, Wednesday, and Friday at 6:45 AM. Give book and bag lunch prior to leaving; check book after arrival for communication. 3. A PO dated 6/22/21 for Dialysis on Monday, Wednesday, and Friday, Pick up 4:45 AM. Every night shift every Monday/Wednesday/Friday for HD send Dialysis communication log with Patient. On 6/17/21 at 10:49 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #1) who stated that Resident #38 was on dialysis. At that time UM/LPN #1 provided the dialysis communication logbook (a book on the unit which contains the resident's healthcare records: HCR) for Resident #38. The surveyor and UM/LPN #1 reviewed the communication logbook together. The book contained two dates 4/15/21 and 6/7/21 with pre and post vital signs written by the dialysis facility. UM/LPN #1 stated that the reason for the missing dates was because the resident had been in the hospital and was not here for dialysis. On 6/22/21 at 10:59 AM, UM/LPN #1 stated that the night shift (11:00 PM- 7:00 AM) nurses were responsible for sending the communication logbook with the resident to dialysis. She further stated that if there was nothing in the book, she would call the dialysis facility and ask for the information that would be in the communication logbook. On 6/22/21 at 11:05 AM, the surveyor interviewed the Registered Nurse (RN) who stated that he started at the facility three weeks ago and was not sure of Resident #38 having a communication logbook. He acknowledged the resident was on dialysis and stated he would take the resident's vital signs upon return. On 6/22/21 at 12:33 PM, in the presence of the survey team the Director of Nursing (DON) stated they had to replace the communication logbook several times because Resident #38 would be hospitalized , and the hospital never returned the book. On 6/23/21 at 9:52 AM, the surveyor interviewed the LPN regarding the communication logbook who stated that she had been at the facility for eight months and when Resident #38 returned for dialysis, there was a notebook that had his/her vital signs, any abnormalities, and weights. She further stated if the book was blank then she would call the dialysis facility. The LPN stated, she usually took the resident's vital signs as soon as he/she returned from dialysis but does not always document that the resident returned and the vital signs in the progress notes. The LPN acknowledged she was supposed to document every time that the resident returned from dialysis and was still learning all the things she was supposed to do. On 6/23/21 at 1:11 PM, UM/LPN #1 informed the surveyor that the communication logbook was now in a binder. At that time the surveyor reviewed the updated dialysis communication binder that included the Dialysis Progress Note (a form used to communicate the resident's status on dialysis treatment days between the facility and the dialysis center); which contained two separate areas to be filled out; the top section was to be completed by the facility nurse prior to the resident leaving the facility for the dialysis treatment and the bottom section was to be completed by the dialysis center after treatment. The Dialysis Progress Note reflected the top section not filled out by the facility's nurse. On 6/23/21 at approximately 1:13 PM, the DON stated the night shift nurse should have filled out the form prior to the resident leaving for dialysis. He acknowledged it was missing Resident #38's name, the date, time of transport, pre vital signs and signature. 2. On 06/16/21 at 09:43 AM, during the initial tour of the facility the surveyor observed Resident #57 in the room sitting in a wheelchair. Resident #57 told the surveyor he/she goes to dialysis in the morning. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that the resident was admitted to the facility in November of 2020 and had diagnosis which included end stage renal disease, diabetes mellitus, anxiety, legal blindness, and hypertension. A review of the most recent quarterly MDS dated [DATE], reflected that Resident #57 had a BIMS score of 7 out of 15 which indicated the resident had moderately impaired cognition. A further review reflected in Section O, Special Treatments and Procedures, that the resident was receiving hemodialysis while at the facility. On 06/22/21 at 09:28 AM, the surveyor reviewed the active PO which reflected the following: 1. A PO dated 11/2/2020 for Dialysis: Emergency Care of Dialysis Site, Apply Pressure if bleeding, Notify Physician every shift. 2. A PO dated 11/2/2020 for LEFT ARM: NO B/P, IVs OR BLOOD DRAWS every shift. 3. A PO dated 11/3/2020 for Dialysis on Tuesday/Thursday/Saturday at 6 am. Give Book and bag lunch prior to leaving. Check book after arrival for communication. On 06/23/21 01:45 PM, the surveyor reviewed the dialysis communication book in the presence of the UM/LPN #2. A review of March 2021 through June 2021 reflected that the resident attended dialysis on Tuesdays, Thursdays, and Saturdays. A further review revealed that in March 2021 the communication booklet was completed four days of the twelve dialysis days. In April 2021 the communication book was completed eight days of the thirteen dialysis days. In May 2021 the communication book was completed seven days of the thirteen dialysis days. June 1, 2021 through June 23, 2021, the communication book was completed nine days of the twelve dialysis days. The surveyor interviewed UM/LPN #2 regarding the incomplete communication forms and she informed the surveyor that, it wasn't being done at all so this is better. A review of the facility's undated Dialysis Communication policy included that routine communication of relevant information will be provided by the facility to the dialysis center on the treatment days and more frequently as necessary. The facility and dialysis center will determine a method to exchange written information between the centers on dialysis days. Examples of communication methods may include, but not limited to forms, binders, books and copies of medical records. The hemodialysis communication form will be completed by the facility prior to going to hemodialysis. The Hemodialysis center will complete prior to sending resident back to the facility. N.J.A.C 8:39-2.9; 27.1(a)