**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 32 residents, (Residents #41, #56, and #107), observed during environmental tour and medication administration. This deficient practice was evidenced by the following: 1. During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, Surveyor #1 (S#1) observed Resident #107's room with no privacy curtain and the ankle-foot orthosis (AFO, is a hard brace worn on the lower leg that improves overall walking safety and efficiency for people with certain medical conditions) in the windowsill. At that same time, the surveyor observed the resident lying on the bed and informed S#1 that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. S#1 reviewed the medical records of Resident #107 and revealed: A review of the admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral infarction (stroke) and hemiplegia (is a condition characterized by paralysis on one side of the body) and hemiparesis (is a condition characterized by one-sided muscle weakness, often caused by disruptions in the brain, spinal cord, or nerves connecting to the affected muscles) following cerebral infarction affecting left non-dominant side. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 2/7/25, with a brief interview for mental status (BIMS) score of 9 out of 15, which reflected that the resident's cognitive status was moderately impaired. On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), and S#1 notified them of the concern regarding the privacy curtain. On 3/3/25 at 10:19 AM, the survey team met with the LNHA, DON, ADON, and MDS Coordinator. The LNHA stated that all residents have privacy curtains now. S#1 asked if there was additional information that the LNHA, DON, and ADON wanted to add, and the LNHA responded nothing to add. 2. On 3/3/25 at 8:35 AM, during medication (med) administration pass observation, S#1 observed Licensed Practical Nurse #1 (LPN#1) administered medications to Resident #41 in room [ROOM NUMBER]. S#1 also observed LPN#1 performed hand washing inside the toilet room of Resident #41. At that time, S#1 observed water on the floor and LPN#1 stated that maybe there was a leak in the sink. S#1 reviewed the medical records of Resident #41 and revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation) unspecified and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent comprehensive MDS, with an ARD of 1/6/25, with a BIMS score of 8 out of 15, reflected that the resident's cognitive status was moderately impaired. On 3/4/25 at 8:21 AM, S#1 went to the 3rd-floor unit and met with the Registered Nurse (RN) who informed S#1 that the Unit Manager (UM) was not in yet, and will be the assigned nurse for room [ROOM NUMBER]. On that same date and time, S#1 notified the RN of the concern regarding a leak in room [ROOM NUMBER]'s toilet room yesterday (3/3/25) during med administration pass. Inside the toilet room, the RN opened the faucet in the sink and both S#1 and RN observed the leak. In the nursing station, S#1 interviewed the RN, who stated that as a practice, when there was a problem that need to be fixed, we call the reception desk and notify them, and the receptionist will call the maintenance department. The RN further explained that there was no accountability log that the facility utilized to report the work that needed to be done. On 3/4/25 at 8:25 AM, S#1 interviewed the Receptionist in the 1st floor reception desk. The Receptionist informed S#1 that she had worked yesterday and she did not recall that someone notified her that there was concern with room [ROOM NUMBER]'s toilet. The Receptionist also confirmed that there was no log when the unit calls for any repairs and the practice was when the unit call or anyone reported repairs needed, she will call and notify the Maintenance person. She also stated that 3rd floor called today prior to the surveyor talking to the surveyor and notified her and then she called maintenance to go to the 302 to look at the leak. The surveyor asked the reception to have the Director of Maintenance (DM) to go to the conference room for an interview. On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. S#1 notified the concern regarding room [ROOM NUMBER]'s toilet sink leak from yesterday's med administration pass observation and today. On 3/4/25 at 12:03 PM, the survey team met with the LNHA, DON, and ADON, and the LNHA stated that the team can proceed with the decision making and that the facility did not have any additional information to provide. A review of the facility's Homelike Environment Policy, with revision date of February 2021, that was provided by the LNHA revealed that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment . On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for an exit conference. The DM did not meet with the surveyor for an interview. 3. On 2/25/25 at 10:54 AM, the Surveyor #2 (S#2) observed the Resident #56 sitting on the wheelchair in the resident's room [ROOM NUMBER]-W, and the resident was non-verbal. S#2 also observed the resident's room with no privacy curtain. On that's same date and time, S#2 interviewed LPN#2 who stated, They probably took it down to wash it. I cannot say how long. I have not been here for weeks. The resident should have a privacy curtain. The RN/UM stated and confirmed, I cannot tell you when they had it down, I did not know that there was no privacy curtain there, but the resident should have one, a privacy curtain. I will check with maintenance. The RN/UM further stated that the process for any work to be done, we call the receptionist downstairs on our work phone or text maintenance. The RN/UM also stated that the front desk will then notify maintenance on what needs to be done, there was no logbook on the unit, and the receptionist should have records of it when we call them. On 2/25/25 at 11:52 AM, S#2 interviewed the DM, who stated, They call through the lobby or the cell phone. Everything is tracked on the cell phone. I could just pull the records out through my data on the phone. I was not aware that room [ROOM NUMBER]-W had no privacy curtain but we are doing it now. I do rounds each morning on some rooms, to see if anything needs to be done, call bells, pillows, etc. On 2/25/25 at 12:10 PM, S#2 requested from the DON for the facility Policy and Procedure for maintenance work orders. On 2/25/25 at 1:02 PM, the LNHA stated, We have no Policy and Procedure for maintenance work orders, no tracking, we have phones to call if there are issues. If it can be fixed, we will fix it, if not, we will get the part and fix it. We also discussed this at morning meeting. A review of the facility's Homelike Environment Policy, revealed, Staff provides residents' comfort, independence and personal needs and preferences. On 2/27/25 at 12:24 PM, S#2 notified the LNHA, DON and DON on the concern regarding room [ROOM NUMBER]-W without a privacy curtain and that one was installed after the surveyor's inquiry. On 3/3/25 at 10:45 AM, the LNHA stated, We checked all the rooms, and we put in curtains. They all have privacy curtains now. NJAC 8:39-31.2(b), 31.4(a)(c), 31.8(c)5

Complaint NJ#166361 Complaint NJ#173486 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and the Ombudsman's office when a resident eloped from the facility in a timely manner and submit the facility's investigation within 5 days for 1 of 1 resident reviewed for elopement (Resident #123). This deficient practice was evidenced by the following: Refer to F689 On 2/25/25 at 8:43 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #123. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility that included diagnoses but were not limited to; unspecified dementia, low back pain, and chronic pain related to neoplasm (abnormal growth of tissue). A review of comprehensive Minimum Data Set (MDS), an assessment a tool, with an assessment reference date of 7/21/23, reflected a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. Additionally, the resident was documented as needing supervision (oversight, encouragement or cueing) with activities of daily living (ADLs) which included walking and did not require an assistive device. A review of hospital medical records, dated 7/10/23, indicated the resident had a history of elopement and had required staff supervision while under their care. A nursing progress note (NPP) dated 7/29/23 at 9:53 PM written by Registered Nurse (RN) revealed the following: At 5:00 PM, the RN served the meal tray to the resident. At approximately 6:00 PM, the RN searched for Resident #123, the resident was not found on the unit and the Licensed Practical Nurse/Supervisor (LPN/S) was notified. At approximately 7:00 PM, the police came to the unit and the RN provided information regarding the resident. The Resident Representative (RR) and the Physician were made aware of the resident's elopement. A NPP dated 7/29/23 at 10:01 PM written by the Assistant Director of Nursing (ADON) indicated the resident was returned to the facility, a body check was completed, there were no visible injuries, and a wanderguard was applied to the resident. There was no documentation in the facility's investigation that indicated notification of the elopement event to the NJDOH and the Ombudsman's office. A review of the submitted AAS-45 (Reportable Event Record/Report) submitted to the NJDOH was dated 8/4/23. The date of event was documented 7/29/23 at 5:30 PM. The AAS-45 further revealed the significant event was called in to the NJDOH on 7/31/23 at 11:05 AM and that the Ombudsman's office was notified 7/29/23. There was no exact time indicated for when the Ombudsman's office was notified by the facility. A review of a police report dated 7/29/23 for the incident, indicated that the police notified the Ombudsman's office regarding the resident's elopement. Ombudsman's office documentation indicated that the police informed them of the resident's elopement and not the facility. A review of the fax cover sheet sent with the facility's investigation to NJDOH revealed the summary and conclusion for the elopement incident was faxed on 8/8/23, 10 days after the event. On 2/27/25 at 11:48 AM, the surveyor interviewed the Director of Nursing (DON) and the DON about reporting facility reported events (FRE). The DON stated that any allegations of abuse, whether substantiated or not, were to be reported within two hours to the NJDOH and the ombudsman's office. The surveyor asked about other significant events, such as resident elopement. The DON did not provide a verbal response at this time and stated that she would review the facility's policy to provide an answer. On 2/27/25 at 12:16 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the DON, and the ADON of the concern with the delayed reporting of Resident #123's elopement. The facility was still looking at policy to provide response for the appropriate notification to the NJDOH and the Ombudsman's office. On 3/3/25 at 10:20 AM, the LNHA, the DON, and the ADON met with the survey team. The LNHA stated the facility followed state and federal regulations on notifying state agencies regarding reportable event. The surveyor asked for Resident #123's elopement when should it be reported to the NJDOH and the Ombudsman's office. The LNHA stated that the incident should have been reported within two hours. There was no additional information provided by the facility. A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a last revised date 6/4/24, did not address notification of an incident to the NJDOH and the Ombudsman's office. A review of the facility's Wandering and Elopements Policy, with a last revised date of March 2019, did not address notification of an incident to the NJDOH and the Ombudsman's office. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy, with a last revised date of September 2022 revealed under Policy Statement: All reports of abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. NJAC 8:39-9.4(f)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents (Resident #72 and #110), reviewed for MDS accuracy. This deficient practice was evidenced by the following: Reference: A review of the latest version of the MDS 3.0 Manual (updated October 2024), Chapter 3-page K-4, under steps for assessment revealed: This item compares the resident's weight in the current observation period with their weight at two snapshots in time: -At a point closest to 30-days preceding the current weight. -At a point closest to 180-days preceding the current weight. 1. On 3/3/25 at 9:17 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #72. A review of the admission Record (AR; an admission summary) revealed that Resident #72 had diagnoses that included, but were not limited to; Parkinson's disease, cerebral infarction (stroke), and type 2 diabetes mellitus. A review of the quarterly MDS, with an Assessment Reference date (ARD) of 1/11/25 revealed under section K (Swallowing/Nutritional Status), the resident was coded as having a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The resident weight was documented as 158 pounds (lbs.). A review of the resident's documented weights revealed the following: 7/5/24- 171.8 lbs. 8/5/24- 175 lbs 9/5/24- 172 lbs. 9/24/24- 179.4 lbs 9/25/24- 179.4 lbs 9/26/24-180.0 lbs. 10/4/24- 180 lbs. 10/21/24- 178.2 lbs. 11/12/24- 160.4 lbs. 12/2/24- 162.8 lbs. 1/3/25- 158.4 lbs. 2/18/25- 160.2 lbs. 3/1/25- 159.6 lbs. On 7/5/24, the resident weighed 171.8 lbs. On 1/3/25, the resident weighed 158.4 pounds which is a -7.80 % Loss. On 12/2/24, the resident weighed 162.8 lbs. On 1/3/25, the resident weighed 158.4 pounds which is a -2.70 % Loss. 2. On 3/3/25 at 10:15 AM, the surveyor reviewed the EMR of Resident #110. The AR revealed that Resident #110 had diagnoses that included, but were not limited to; chronic kidney disease, dementia, adult failure to thrive, and anemia. A review of the Significant Change MDS, with an ARD of 1/21/25 revealed under section K, the resident was coded as having a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Additionally, the resident was coded as having a significant weight gain if 5% or more in the last month or gain iof 10% or more in the last six months on a physician-prescribed regimen. The resident weight was documented as 110 lbs. A review of the resident's documented weights revealed the following: 7/2/24- 113.6 lbs. 7/4/24- 112 lbs. 8/5/24- 117 lbs. 9/4/24- 117 lbs. 9/5/24- 118 lbs. 10/2/24- 123.8 lbs. 11/4/24- 118 lbs. 11/5/24-118 lbs. 11/6/24-116 lbs. 12/2/24- 108 lbs. 12/4/24- 108 lbs. 1/14/25- 110.3 lbs. 1/31/25- 113.6 lbs. 2/1/25- 113.6 lbs. 2/6/25- 114.4 lbs. On 12/424, the resident weighed 108 lbs. On 1/14/25, the resident weighed 110.3 pounds which is a 2.13 % Gain. On 7/4/24, the resident weighed 112 lbs. On 1/14/25, the resident weighed 110.3 pounds which is a -1.52 % Loss. On 3/3/25 at 11:03 AM, the surveyor interviewed Registered Dietician #1 (RD#1) at the facility. RD#1 stated there were two RDs in the facility and were responsible for completing section K. RD#1 stated that the closest weight to the ARD would be used to determine if the resident had significant weight gain or loss (5% in 1 month and 10% in 6 months). RD#1 stated that RD #2 completed Section K for Resident #72's MDS assessment, RD #2 was not working today, and would be back tomorrow. The surveyor reviewed concerns regarding the accuracy of coding in the MDS assessments for Resident #72 and Resident #110, and RD #1 stated she would review and provide a response to the surveyor. On 3/3/25 at 11:45 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) about the concern for the MDS coding accuracy for Resident #72 and Resident #110. On 3/3/25 at 12:37 PM, RD #1 informed the surveyor that Resident #72 did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last six months during the look back period from the ARD of the MDS assessments. RD#1 stated Resident #110 did not have a weight loss or weight gain of 5% or more in one month or 10% or more in the last six months during the look back period from the ARD of the MDS assessment. RD #1 acknowledged that the MDS assessments were not accurately coded and stated it could be a data entry error by RD #2. On 3/4/25 at 9:17 AM, the surveyor interviewed RD #2 about completion of Section K in the MDS assessment. RD#2 stated the weight closest to the ARD date was used to determine significant weight changes in one month and six months. The surveyor notified RD #2 of the concerns found with the MDS assessments. RD #2 stated she believed it was human error when reviewing and coding the data. On 3/4/25 at 11:33 AM, the LNHA, DON, and ADON met with the survey team. There was no additional information provided by the facility. NJAC 8:39-33.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 1 of 35 residents reviewed (Resident #63). This deficient practice was evidenced by the following: On 2/24/25 at 10:59 AM, the surveyor observed Resident # 63 was seated in a wheelchair (w/c) in front of their room, repeatedly stated, why, I am here, come here. The resident was able to self propel their w/c in short distance. The surveyor reviewed Resident #63's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/10/25, with a brief interview for mental status (BIMS) score of 5 out of 15, reflected that the resident's cognition was severely impaired. A review of the current Resident #63's [NAME] (is a documentation system used in nursing that allows nursing to write, organize, and easily reference key resident information for their CP) Report revealed that the resident required one to two persons assist with ADLs (activities of daily living), two persons assist with bed mobility and on FMP (functional maintenance program) for ambulation in the room with supervision as tolerated. A review of the Rehabilitation (rehab) Screen that was signed by the Physical Therapist (PT) on 7/12/24, reflected that the resident's current status was supervision with bed mobility, transfers, ambulation, eating, and toilet use. The PT also documented that there was no change in functional status since last seen in rehab. A review of the Rehab Screen that was signed by the PT on 1/10/25 reflected that there were no changes with the resident and no indication for skilled therapy at this time. On 2/27/25 at 1:23 PM, the surveyor notified the MDS Coordinator (MDSC) and the Assistant Director of Nursing (ADON) the above concerns that the current [NAME] Report and the Rehab Screen did not match. On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, and MDSC. The surveyor asked should the CP be updated and revised to reflect the current condition of the resident if the MDS and [NAME] Report were accurate, and the ADON stated that the CP should have been revised for Resident#63. NJAC 8:39-11.2(f)(i)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to ensure that the recommendations of the Consultant were followed and reviewed by the Primary Care Physician for 1 of 6 residents, (Resident #32), reviewed for use of psychoactive medications according to the standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/24/25 at 11:06 AM, the surveyor observed Resident #32 seated in a wheelchair in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide, who informed the surveyor that the resident will be going down for lunch. The surveyor reviewed the medical records for Resident #32. A review of the admission Record (an admission summary) reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 12/23/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive medications (meds). A review of the electronic Medication Administration Record (eMAR) revealed that the resident was on the following psychotropic meds: A physician's order (PO) dated 3/21/24, and was discontinued (d/c) on 2/18/25, Risperidone (antipsychotic medication) 1 mg (milligram) give 3 tablets (tabs) by mouth two times a day for bipolar disorder, 3 tabs=3 mg. A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for bipolar disorder to be given with 4 mg to equal a total of 5 mg. A PO dated 3/18/24, Mirtazapine Oral tab 15 mg give 1 tab by mouth at HS for depression. A PO dated 3/19/24, Sertraline HCL (hydrochloride) Oral tab 100 mg give 1 tab by mouth one time a day for depression. A PO dated 3/19/24, Benztropine Mesylate Oral Tab 10 mg give one tab by mouth one time a day for tremors. A PO dated 4/26/24, Divalproex Sodium tab delayed release 500 mg give 3 tabs by mouth at HS for bipolar disorder, 3 tabs=1500 mg. A review of the Progress Notes dated 2/18/25, Psych (Psychiatric) Follow Up, that was electronically signed by the Advanced Practice Nurse (APN) had an assessment and plan that included but were not limited to; d/c Benztropine, add Venlbenazine 40 mg at HS for tardive dyskinesia if approved by PCP (Primary Care Physician), add psychology consult and psychotherapy. Further review of the medical records revealed that there was no documented evidence that the Psychology and Psychotherapy was initiated, and if the PCP was made aware of the recommendations to d/c Benzotropine and to add Venlbenazine (or Ingrezza, is used to treat tardive dyskinesia). There was no documented evidence that the recommendations of the APN were relayed to the PCP and if the PCP approved or declined the recommendations. On 3/3/25 at 12:58 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), and the surveyor notified of the concerns about the 2/18/25 psyche recommendations that were not followed. On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for surveyor's concern about APN's recommendations that were not followed, we do not have further documentation. A review of the facility's Psychopharmacologic Medication Policy, with revision date of 9/6/18, that was provided by the DON revealed: Policy: It is the policy of the facility to ensure that psychoactive meds are used only when appropriate indications are present and when the medication regimen helps to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being . Implementation: 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic meds . Other: 22. The physician shall respond appropriately by changing or stopping problematic doses or meds, or clearly documenting why the benefits of the med outweigh the risks or suspected or confirmed adverse consequences . On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) ensure that the fall and pain evaluations were done as part of fall investigation, b.) care plan (CP) intervention was followed, and c.) CP intervention was in place for each fall and revised to reflect current condition of the resident. This deficient practice was identified for 1 of 5 residents, (Resident #107), reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey 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 well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed. There was an ankle-foot orthosis (AFO, is a hard brace worn on the lower leg that improves overall walking safety and efficiency for people with certain medical conditions. AFOs provide gait stability, keep joints properly aligned, and help compensate for muscle weakness) in the windowsill. On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position. At that same time, Certified Nursing Aide #1 (CNA#1) entered the resident's room and confirmed that she was the aide of Resident #107. CNA#1 left the room afterward. The surveyor reviewed the medical records of Resident #107 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral infarction (stroke) and hemiplegia (is a condition characterized by paralysis on one side of the body) and hemiparesis (is a condition characterized by one-sided muscle weakness, often caused by disruptions in the brain, spinal cord, or nerves connecting to the affected muscles) following cerebral infarction affecting left non-dominant side. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/7/25, with a brief interview for mental status (BIMS) score of 9 of 15, which reflected that the resident's cognitive status was moderately impaired. Section GG Functional Abilities: Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair), toilet transfer, and ambulation were coded 3 (partial/moderate assistance). Section J Health Conditions reflected that the resident was coded 1 for number falls since admission or prior assessment with injury except major. A review of the two fall investigations that was provided by the Director of Nursing (DON) revealed: -12/30/24 fall investigation reflected that the resident was found lying on the floor with their head against the wall and the resident sustained a left forehead bump. The 12/30/24 fall investigation had an attached Progress Notes dated 12/31/24 that included Care Conference Note that was electronically signed by the DON, documented that the fall incident happened on 12/30/24 at 11:30 AM and the team believed that the resident's medical condition was the predisposing factor to the fall, and we will continue to monitor and encourage to take resident's medications. -1/15/25 fall investigation reflected that CNA#2 notified the Licensed Practical Nurse (LPN) that the resident was found sitting on the floor in resident's room with wheelchair behind the resident and cane on the right side lying on the ground. The resident did not have an injury at the time of incident. The 1/15/25 fall investigation had an attached Progress Notes dated 1/16/25 that included Nursing/Clinical note that was electronically signed by the Registered Nurse (RN), documented that the IDT (Interdisciplinary Team) reviewed the fall incident happened on 1/15/25 at approximately 11:30 AM, that Resident #107 was cognitively intact, ambulates independently with quad cane, resident reported they were walking with their cane and their legs became weak and fell. It was also documented that therapy to continue gait/balance/transfer training and will continue basic fall precautions per CP. Included in the attachment for 1/15/25 fall investigation were the Pain Evaluation and Fall Risk Evaluation both dated 1/15/25. Further review of the above two fall investigations revealed that on 12/30/24 fall incident, there were no fall and pain evaluations that were completed. A review of the current Resident #107's [NAME] (is a documentation system used in nursing that allows nursing to write, organize, and easily reference key resident information for their CP) Report revealed that the resident required supervision with ambulation and transfer. In addition, the CP reflected a focus CP for at risk for falls due to history of falls, impaired balance/poor coordination, left side paralysis, medication side effects, noncompliance with use of assistive devices that was initiated on 2/2/24 and revised on 2/6/24 with an interventions/task that included but were not limited to; raised toilet seat (initiated on 5/13/24), therapy evaluation and treatment as ordered, encourage to transfer and change positions slowly, have commonly used articles within reach, maintain bed in low position, and provide assistant to transfer and ambulate as needed that were initiated on 2/2/24. Further review of the CP revealed that the CP did not include new interventions for fall incidents that happened on 12/30/24 and 1/15/25. Also, there was a discrepancy on what was resident was coded for in MDS (partial and moderate assistance) and what was reflected on resident's CP (supervision) with regard to ADLs. On 2/27/25 at 11:10 AM, the surveyor interviewed the MDS Coordinator (MDSC), who informed the surveyor that the facility followed the RAI (Resident Assessment Instrument) manual when doing MDS and there was no separate policy for MDS. The surveyor notified the MDSC of the above concerns, and the MDSC responded that she would get back to the surveyor to review the [NAME] Report and MDS Section GG for accuracy. On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant Director of Nursing (ADON), and the surveyor notified them of the above concerns. On 2/27/25 at 1:23 PM, the MDSC in the presence of the ADON with the provided documents informed the surveyor that the MDS was coded accurately. The surveyor asked the MDSC if the MDS was coded accurately, why the CP did not reflect the current condition of the resident, and both ADON and the MDSC did not respond. A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a revision date of July 2017, that was provided by the ADON revealed: Policy Interpretation and Implementation: 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: k. any corrective action taken; l. follow up information; m. other pertinent data as necessary or required; and . A review of the facility's Fall Risk Assessment, with a revision date of March 2018 revealed: Policy Interpretation and Implementation: 1. Upon admission, the nursing staff and the physician will review resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time . 6. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls . A review of the facility's Pain Assessment and Management Policy, with a revision date of October 2022, that was provided by the ADON revealed: General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive CP, and the resident's choices related to pain management . On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for the surveyor's concerns, no further information to provide. NJAC 8:39-3.2(a,b); 11.2(b);27.1(a)

Complaint NJ #176146 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to; a.) determine the cause, implement a new intervention, and start treatment to prevent further pressure injury/pressure ulcer (PI/PU) for a facility acquired PI/PU for 1 of 2 residents reviewed for PU, (Resident #102), b.) follow the recommendations of the wound care consultant physician for 1 of 2 residents reviewed for PU, (Resident #102), c.) follow a physician order for Braden Scale assessment for 2 of 2 residents reviewed for PU, (Resident #102 and #302), and d.) clarify multiple physician orders for 1 of 2 residents reviewed for PU, (Resident #302). This deficient practice was evidenced by the following: 1. On 2/24/25 at 10:19 AM, Surveyor #1 (S#1) observed Resident #102 seated in a wheelchair and the resident's legs were wrapped with ace bandages. S#1 interviewed Resident #102 who stated that they did not think they had any wounds or PI/PU. On 2/25/25 at 10:25 AM, S#1 interviewed Resident #102's Certified Nurse Assistant (CNA) who stated that Resident #102 had a PU on the heel. On 2/25/25 at 10:28 AM, S#1 interviewed Resident #102's Licensed Practical Nurse #1 (LPN#1) regarding the process for a new PI/PU. LPN#1 stated that when a resident had a new PI/PU that it would be reported to the wound team. She added that an incident report and investigation would be done. She added that a Braden Scale was in the computer. On 2/25/25 at 11:13 AM, S#1 requested from the Licensed Nursing Home Administrator (LNHA) any incident report and/or investigation for Resident #102 that was related to (r/t) the resident's skin. On 2/25/25 at 12:42 PM, S#1 reviewed the facility provided incident report and investigation for Resident #102 which was dated 1/16/25, and included the following: Incident Report: Incident description: The patient (also known as the resident) was seen today by Wound Consultant Physician (WCP), the wound team and the undersigned. The patient noted with a P2 collapsed blister to right lateral heel 6.5 x 6.0 x 0 P2, left lateral heel P2 collapsed blister 4.5 x 3 x 0. There was no conclusion listed on the incident report. WC Multi Wound Chart Details with 2 PU listed and 1 wound listed as blanchable redness to the right, dorsal second toe. Facility Acquired PU Investigation Form which under summary indicated patient has CKD4 (chronic kidney disease stage 4), liver transplant status, recently admitted to hospice Dx (diagnosis) pulmonary fibrosis. Although skin care and turning/positioning provided, wound developed. Unavoidable PU Physician Documentation which indicated that despite preventive measures outlined above and in consideration of the underlying clinical conditions identified, this PU is an unavoidable outcome . Care Plan (CP) Report which did not contain the date(s) the actual skin breakdown CP was initiated or the interventions that were placed. A review of Resident #102's admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to lung transplant status, congestive heart failure and anemia. A review of Resident #102's most recent comprehensive Minimum Data Set (cMDS), an assessment tool, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #102 was cognitively intact. Further review under Section M Skin Conditions indicated the resident had 2 Stage 2 PU which were not present upon admission/entry or reentry. A review of Resident #102's comprehensive CP included the following focus areas: At risk for alteration in skin integrity r/t impaired mobility with an initiated date of 1/10/2025, with the following interventions: Encourage and assist to reposition; use assistive devices as needed; Observe skin condition with ADL (activities of daily living) care daily; report abnormalities; Obtain labs as ordered and report results to physician. Actual skin breakdown r/t right lateral heel P2 with an initiated date of 1/13/2025, with the following intervention that was initiated the same date: Administer treatment (tx) per physician orders (PO). The following interventions were initiated on 1/27/25: Encourage and assist as needed to turn and reposition; use assistive devices as needed; Specialty low air loss mattress/wheelchair; Suspend/float heels as able; Use pillows and/or positioning devices as needed; WC as needed. The CP indicated that Resident #102 had developed a PU on 1/13/25. The incident report for the development of the PU was dated 1/16/25 when the WCP saw the resident. There were no added interventions in addition to wound treatment to prevent further PI/PU until 1/27/25. A review of Resident #102's progress notes (PN) did not include any description of skin breakdown prior to 1/16/25. A review of Resident #102's January 2025 electronic Treatment Administration Record (eTAR) included a PO for Braden Scale on admission x three weeks post admission in the evening every Mon (Monday) for three Weeks with a start date of 1/13/2025, which was not administered or signed by the nurse as being done for 1/13/25, 1/20/25 and 1/27/25. Further review of the eTAR included a PO for Braden Scale on admission x three weeks post admission on e time only for one Day with a start date of 1/10/2025, which was signed by a nurse as administered on 1/10/25. A review of Resident #102's electronic medical record under the Forms tab (assessments and evaluations section) revealed that the only Braden Scale assessment that was done was on admission and it was included in the Resident Evaluation. The PO was not followed. On 2/26/25 at 10:28 AM, S#1 interviewed the Registered Nurse (RN) regarding the process for assessing skin and new PI/PU. The RN stated that upon admission, the skin was assessed and a Braden Scale assessment was done. She added that a second day skin check was also ordered but that one was in the PN. The RN stated that there was an order for a weekly skin observation and it would note no skin breakdown, a previously identified wound or a new wound. S#1 asked the RN what the process was if a new skin issue was seen between the weekly observation, and the RN stated that for every new opening a risk management/skin incident report would be done. She added that it would be reported to the wound team that came to the facility on Monday and Thursday. The RN further stated that there would be a PN that would document the location and size. She added that the CP would be updated by unit manager (UM). The RN stated that the wound team also saw residents when they first came to the facility. On 2/26/25 at 10:37 AM, S#1 interviewed the first floor UM regarding the process for a new skin issue. The first floor UM stated that when a staff saw a new opening that the staff would report it to the nurse or herself and that they would notify the wound team. She added that they would put an air mattress and skin prep before the wound team saw them. The first floor UM stated that the new skin issue would be documented in a PN and an incident report would be done. She added that the CP would be updated usually by the Infection Preventionist (IP) or that she herself could also do it. S#1 asked the first floor UM about Resident #102's incident report. The first floor UM stated that the wound team would visit all new admits and also if a referral was done. She added that maybe the wound team saw the PI/PU when they assessed the resident and in that case there would not have been a note before. S#1 then asked the first floor UM for more information regarding the CP that was initiated on 1/13/25 for an actual skin breakdown to the right lateral heel. The first floor UM stated she would get back to S#1. On 2/26/25 at 10:58 AM, S#1 interviewed the Assistant Director of Nursing (ADON) regarding the process of a new skin issue. The ADON stated that an assessment was done and would be documented in the PN and an incident report would also be done. She added the regular doctor would be notified and they would refer to wound healing. The ADON stated that usually there would be some documentation about the issue prior to the wound consultant. The ADON stated that when there was an actual opening a CP would be initiated. The ADON stated that Resident #102 was transferred from a sister facility. The ADON stated that Resident #102's PU was facility acquired. S#1 asked the ADON the reason there was no documentation regarding the PU when there was a CP initiated. The ADON stated she would have to look into it. On 2/26/25 at 12:37 PM, the ADON stated that CP was initiated by accident. She added that the resident was admitted to the facility and three days later when the CP was being reviewed the staff clicked on wound and then revised it on 1/16/25 when they saw the fluid filled blister. The ADON stated that according to the Nurse Practitioner note the resident was seen and noted no pressure wound on 1/13/25. A review of Resident #102's wound consultant notes (WCN) dated 1/16/25, included the following orders: Wound #2 Right, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. Foam Dressing Every Mon and Thursdays (Thur). Offload. Monitor for changes. Wound #3 Left, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes. Wound #4 Right, Dorsal Second Toe Other Orders Wound Dressing Apply: - Skin Prep BID (twice a day) with Hygiene. Offload. Monitor for change A review of Resident #102's WCN dated 1/23/25, included the following orders: Wound #2 Right, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes. Wound #3 Left, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes. Wound #4 Right, Dorsal Second Toe Other Orders Wound Dressing Apply: - Skin Prep BID with Hygiene. Offload. Monitor for changes. A review of Resident #102's January 2025 eTAR included the following orders that were not the recommended orders that were written by the WCP: Skin prep to bilateral heels, and second toe (blanchable redness) every day shift for collapsed blister with an order date of 1/18/25, and a start date of 1/19/25. The order was not started until three days after the resident was seen by the WCP. The WCP order was for bilateral heels to have skin prep applied and a foam dressing on Mon and Thur and not be done daily. The WCP order was for the second toe to have skin prep applied two times a day and not only once a day. A review of Resident #102's WCN dated 1/27/25, included the following orders: Wound #2 Right, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. BID Leave open to air. Offload. Monitor for changes. D/C Treatment - Foam Dressing Wound #3 Left, Lateral Heel Other Orders Wound Dressing Apply: - Skin Prep. BID Leave open to air. Offload. Monitor for changes. D/C Treatment - Foam Dressing Wound #4 Right, Dorsal Second Toe was resolved. A review of Resident #102's eTAR included the following order that was not the recommended order that was written by the WCP: Skin prep to bilateral heels (blanchable redness) every day shift for collapsed blister with a start date of 1/29/25. The WCP recommended that the skin prep was to be applied to bilateral heels two times a day. On 2/27/25 at 11:01 AM, S#1 interviewed the LPN regarding WCP. The LPN stated that the WCP after the assessment would pass the note to the UM and she put the notes in. She added that usually the tx was put in place the same day. On 2/27/25 at 12:42 PM, S#1 notified the LNHA, Director of Nursing (DON) and ADON the concerns that Resident #102 did not have any documentation of a PI/PU when a CP for actual skin breakdown was initiated on 1/13/25 and the only description and measurement of the PI/PU was not until the incident report on 1/16/25 that the WCP did; there was no conclusion for the investigation related to the cause of the PI/PU and an added intervention to prevent further PI/PU until 1/27/25; the recommended initial tx and subsequent tx for Resident #102 from the WCP was not followed and an initial tx was not started until three days after the initial wound consult (WC) visit; and the order for Braden Scale was not followed. On 3/3/25 at 10:20 AM, the survey team met with the LNHA, DON, ADON and MDS Coordinator for their responses to the concerns that they were notified of from the previous day. At 10:41 AM, the ADON stated that there was no additional information for Resident #102. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol Policy, with a revised date of March 2014, included the following: Assessment and Recognition 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history or pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; d. Current tx, including support surfaces: . Cause Identification 1. The physician will help identify factors contributing or predisposing resident to skin breakdown; . 2. The physician will help clarify relevant medical issues; . Tx/Management 1. The physician will authorize pertinent orders related to wound tx, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration 2. The physician will help identify medical interventions r/t wound management; . Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a revised date of July 2017, included the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendor, etc. occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation 1. The nurse supervisor/charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); . k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and . 2. On 2/26/25 at 9:48 AM, Surveyor #2 (S#2) reviewed the electronic medical record (EMR) of Resident #302. A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; left and right knee contracture (a fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement of the associated body part), left and right hip contracture, left and right ankle contracture, muscle wasting atrophy (loss of muscle mass and strength), osteoporosis (condition in which bones become weak and brittle), dysphagia (difficulty swallowing foods or liquids), malnutrition, failure to thrive, and Alzheimer's disease. A review of the cMDS, with an assessment reference date of 6/14/24, reflected a BIMS score of 99, which indicated the resident was unable to complete the interview. Under Section M (Skin Conditions), the resident was coded as a risk for pressure ulcer/injury and the resident had an unhealed unstageable PU. A review of PO included the following: A PO dated 6/7/24, indicated Braden scale on admission times three weeks post admission every evening shift, every Friday for three weeks. Wound tx #1: A PO dated 6/7/24, indicated apply silver sulfadiazine cream (an antibiotic cream used to treat or prevent serious skin infections) 1% to sacral area topically every day and evening shift for wound care after cleansing with normal saline (NS) then cover with dry dressing. The order had a start date of 6/8/24, and was discontinued (d/c) on 6/17/24. Wound tx #2: A PO dated 6/17/24, indicated apply santyl ointment 250 Unit/gm (grams) (an ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) to sacrum topically every day shift for PU post cleanse with NS cover with dry dressing. The order had a start date of 6/18/24, and a d/c date of 7/1/24. Wound tx #3: A PO dated 6/24/24, indicated to apply compound ointment- (flagyl) metronidazole (an antibiotic) ointment 0.5% with (Bactroban) muciporin (cream used to treat skin infections) 1% (1:1) (100 gm) every day shift for PU post cleanse with Dakin's solution, cover with dry dressing. The order had a start date of 6/25/24, and was d/c on 7/23/24. Wound tx #4: A PO dated 7/1/24, indicated to apply Mupirocin Ointment (Bactroban) 2% to sacral area topically every day and evening shift for PU post hygiene, cleanse with Dakin's (mix with santyl). The order had a start date of 7/2/24, and was d/c on 7/8/24. Wound tx #5: A PO dated 7/1/24, indicated to apply santyl ointment 250 unit/gm to sacrum topically every day shift for PU post cleanse with Dakin's cover with dry dressing (Santyl mix with Bactroban [mupirocin]). The order had a start date of 7/2/24, and was d/c on 7/8/24. Wound tx #6: A PO dated 7/8/24, indicated to apply Mupirocin Ointment 2% to sacrum topically every day and evening shift for P4 [PU stage 4] post cleanse with Dakin's, pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/9/24, and was d/c on 7/12/24. Wound tx #7: A PO dated 7/8/24, indicated to apply to sacrum compound ointment -metronidazole ointment 0.5% with muciporin 1% (200 gm) every day shift for P4 post cleanse with Dakin's, pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/10/24, and a d/c date of 7/31/24. Wound tx #8: A PO dated 7/23/24, indicated to apply to sacrum compound ointment-metronidazole ointment 0.1% with gentamycin 1% (100 gm) every day shift for P4[PU stage 4] post cleanse with Dakin's. pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/29/24, and was d/c on 7/31/24. A review of WCN revealed the following: On 6/3/24, the WCP recommended wound orders for the resident's sacral PU to apply Silvadene two times a day and as needed (PRN) with hygiene. Miconazole (antifungal) cream to peri (around) wound. On 6/13/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with NS, apply santyl and 3 in 1 cream to peri-wound daily. On 6/18/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with NS, apply santyl and 3 in 1 cream to peri-wound daily. On 6/24/24, the WCP recommended wound orders for the resident's sacral PU to d/c santyl and 3 in 1 cream; to cleanse with dakin's solution, apply flagyl, and Bactroban daily. On 6/27/24, the WCP recommended wound orders for the resident's sacral PU as, cleansing with Dakin's solution, apply flagyl, Bactroban, and cover with dry dressing daily and PRN. On 7/1/24, the WCP recommended wound orders for the resident's sacral PU to d/c flagyl; cleanse with dakin's, apply santyl, Bactroban, and apply dry dressing daily and PRN. On 7/4/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with dakin's solution, apply santyl, Bactroban, and apply dry dressing daily and PRN. On 7/11/24, the WCP listed the resident's recommended wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN. On 7/15/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN. On 7/18/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN. On 7/22/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with calcium alginate, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound. On 7/22/24, the WCP listed the resident's wound orders to d/c calcium alginate; cleanse with Dakin's solution, pack with gauze, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound. On 7/25/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with calcium alginate, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound. A review of the June 2024 eTAR revealed: The order entries for wound tx #2 and #3 were both signed as administered for the resident's sacral wound from 6/26/24 to 6/30/24. A review of the July 2024 eTAR and the electronic Medication Administration Record (eMAR) revealed: The order entries for wound tx #3, #4, and #5 were signed as administered for the resident's sacral wound from 7/2/24 to 7/8/24. The order entries for wound tx #3, and #6 were signed as administered for the resident's sacral wound from 7/9/24 to 7/12/24. The order entries for wound tx #3, and #7 were signed as administered for the resident's sacral wound from 7/10/24 to 7/23/24. The order entries for wound tx #7 and #8 were signed as administered for the resident's sacral wound from 7/29/24 to 7/31/24. On 2/26/25 at 12:24 PM, S#2 interviewed the IP. The IP stated that the resident had one sacral wound which was present upon admission to the facility. The resident was seen by the wound consultants who recommended wound tx for the resident. The IP stated that there was wound tracking documentation for each resident that kept weekly track of their wound status and tx recommendations. The IP stated she would provide the wound tracking for the resident. On 2/27/25 at 11:40 AM, S#2 interviewed the DON and the ADON about Resident #302's wound. The ADON and DON stated the resident had one sacral pressure ulcer and had also received tx for moisture associated skin damage. The DON provided the wound tracking form, a facility tool used to keep track of the resident's wound progress and wound tx. The wound tx corresponded to the WCP notes. S#2 reviewed with the DON and ADON the eMAR and eTAR of Resident #302 about the multiple wound tx that were signed as administered to the resident's sacral wound. S#2 asked if the multiple wound tx signed were ordered to be administered together. The DON and ADON stated that an ordered topical tx may have been unavailable at the time, and another order was placed until the topical tx was available. The DON stated that if there was a temporary order until an original tx was available, the nurses should clarify the orders with the physician, d/c the original tx order while the alternative tx was ordered. The DON and ADON acknowledged it would be expected if there were multiple tx orders which did not specify to use in combination, the nurses should have called the physician to clarify the orders. The DON and ADON stated they would review further to provide any additional response. On 2/27/25 at 12:16 PM, S#2 notified the LNHA, the DON, and the ADON of the above concerns. On 3/3/25 at 9:46 AM, S#2 interviewed LPN #2 who stated Braden scale assessments were completely weekly x 3 after the resident's admission per admission protocol. LPN#2 stated it would be found documented under the forms section of the EMR when completed. A review of the June 2024 eTAR indicated a Braden scale assessment was to be completed on 6/14/24, 6/21/24, and 6/28/24. The eTAR entries for 6/14/24 and 6/21/24 were signed as completed by the nurses. The 6/28/24 entry was left blank by the nurse. A review of the EMR for Braden scale assessments revealed there were no Braden scale assessments found completed for 6/14/24, 6/21/24 and 6/28/24. On 3/3/25 at 10:00 AM, S#2 interviewed the DON about Braden scale assessments upon admission. The DON stated it was done as part of the facility's admission protocol and when completed could be found documented with the skin assessment of the resident. S#2 notified the DON of the concern that no Braden scale evaluation was found for Resident #302 for the 3 weeks after admission as per the PO and the facility's protocol. The DON stated she would review to provide documentation of the Braden scale evaluations completion. On 3/3/25 at 10:20 AM, the DON, ADON, and LNHA met with the survey team. The DON and ADON stated they had no additional information to provide for the concerns r/t Resident #302. A review of the facility's Medication and Treatment Orders Policy, revealed under Policy Statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Section: A review of the facility's Pressure Injury Risk Assessment Policy, revealed under General Guidelines revealed: . 4. Use only a facility-approved risk assessment tool to obtain risk assessment data . 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Orders for medications and treatments will be consistent with principles of safe and effective order writing . NJAC 8:39-27.1 (a)(e)

Based on interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times. This deficient practice was identified for 1 of 2 residents, (Resident #22), reviewed for dialysis services and was evidenced by the following: On 2/24/25 at 11:00 AM, the surveyor observed the Resident #22 lying in bed, who stated, I have dialysis on Tuesday, Thursday, and Saturday. I get picked up around 11:00 AM and I get back around 5:00 PM. A review of the admission Record (an admission summary) revealed diagnoses which included but not limited to end stage renal disease (ESRD-kidneys have permanently lost their ability to function adequately) and dependence on renal dialysis (procedure which removes wastes and excess fluid from the blood). A review of the resident's medications (meds) order summary revealed: -Hemodialysis Tuesday - Thursday - Saturday, chair time: 11:55 AM. -Humalog Injection Solution 100 unit/ML (milliliters) inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call MD (medical doctor) if greater than 400 mg/dl (milligrams/deciliter), subcutaneously before meals and at bedtime for diabetes mellitus-Start Date 1/30/2025-discontinue (d/c) date 2/11/25. -Humalog Injection Solution 100 unit/ml inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call MD if greater than 400 mg/dl, subcutaneously before meals for diabetes mellitus-Start Date 2/11/2025-d/c date 2/17/25. -Velphoro oral tablet (tab) chewable 500 mg give 1 tab by mouth three times a day for supplement (phosphorus binder), give with meals. Start date 2/3/25 and d/c 2/20/25. - Velphoro oral tab chewable 500 mg give 1 tab by mouth three times a day for supplement, give with meals. Chew or crushed, do not swallow whole. Start date 2/20/25. -Midodrine HCl tab 2.5 MG, give 1 tab by mouth every 8 hours for hypotension. Do not administer after the evening meal or 4 hours from bedtime to avoid supine hypertension (HTN). Please hold if systolic blood pressure (SBP) greater than 130 mm/hg (milliliters per mercury)-Start Date 1/30/25 and d/c date 2/11/25. -Midodrine HCl Tab 2.5 mg, give 1 tab by mouth three times a day for hypotension. Do not administer after the evening meal or 4 hours from bedtime to avoid supine HTN. Please hold if SBP greater than 130-Start Date 2/11/25. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference dated of 2/6/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the resident had a moderately impaired cognition. A review of the electronic Medication Administration Record (eMAR) revealed, Midodrine was scheduled on dialysis days to be given at 12 Noon, Velphoro was scheduled on dialysis days to be given at 11:30 AM. The blood sugar check and Humalog Insulin as per sliding scale was scheduled at 12 Noon on dialysis days for the months of January and February 2025. The nursing progress notes on some dialysis days revealed, nurses documented for meds to be on hold, patient is out for hemodialysis. Humalog Injection 100 Unit/ML as per sliding scale was timed for 12:00 PM, revealed on 2/13/25, out for dialysis. Midodrine was not given on 2/6/25, 2/8/25, 2/13/25, and 2/27/25. Velphoro was not given on 2/27/25 and 3/4/25. A review of the License Practical Nurse's #1 (LPN#1), Orders Administration Note in the Electronic Health Record (EHR) dated 2/13/25, revealed, Humalog Injection Solution as per sliding scale and Midodrine HCl Tablet 2.5 mg as Hold med Patient is out for dialysis. A review of the Registered Nurse's (RN) Orders Administration Note in the EHR dated 2/27/25 revealed, Velphoro Oral Tab Chewable 500 mg, patient out to hemodialysis (HD). On 3/4/25 at 9:16 AM, the surveyor observed the Resident #22 lying in bed, and stated, I get pick up for dialysis around 11 AM. I do not get the Midodrine at noon time because I'm in dialysis and Velsporo sometimes I take it but at times I miss some. I do not get blood sugar done anymore. On 3/4/25 at 9:22 AM, the surveyor interviewed LPN #2 and the Unit Manger (UM) on the 2nd floor. The surveyor reviewed the eMAR with the LPN #2 and UM for February 2025. LPN #2 stated, I do the blood sugar and blood pressure, give meds before the resident leaves for dialysis. The UM stated, The Midodrine and Velphoro should have been adjusted during dialysis days that's our process. Nursing can adjust the times; anyone can do it. LPN#2 and UM both confirmed that the meds should have been adjusted on dialysis days. On 3/4/25 at 11:40 AM, the surveyor notified the License Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant (DON), regarding the meds time of Midodrine, Velphoro, and Humalog Insulin/Blood Sugar not adjusted on dialysis days. A review of the facility's Administering Medications Policy, revealed, Meds are administered in accordance with prescriber orders, including any required time frame. NJAC 8:39-11.2(b), 27.1(a), 29.2(d)

Based on interviews and review of other facility documentation, the facility failed to ensure that the physician must review the resident's total program of care and date progress notes at each visit. This deficient practice was identified for 1 of 35 residents, (Resident #63), reviewed for physician services. This deficient practice was evidenced by the following: On 2/24/25 at 10:59 AM, the surveyor observed Resident #63 was seated in a wheelchair in front of their room, repeatedly stated, why, I am here, come here. The surveyor reviewed Resident #63's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. A review of the most recent comprehensive Minimum Data Set (MDS, with an assessment reference date of 1/10/25, reflected a brief interview for mental status (BIMS) score of 5 out of 15, that the resident's cognition was severely impaired. A review of the electronic medical records revealed that there was no documented evidence that the physician review the resident's care, medications, and date progress notes (PN) at each visit. On 2/26/25 at 10:59 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) regarding the physician's visits and notes. The RN/UM stated that the surveyor should ask the Director of Nursing (DON) about physician visits and about how often the physician should document and visit the resident. At that same time, the RN/UM confirmed after reviewing with the surveyor the resident's paper and electronic medical records, that she did not find the physician's visit notes. She further stated that the last time the physician documented in the PN was in paper medical record dated 2/6/24. On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns with physician services. On 3/4/25 at 10:15 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant DON (ADON), and the LNHA confirmed that the surveyor's concern about physician's timely monthly visits was not discussed in the most recent QAPI (Quality Assurance Performance Improvement) meeting, and the team decided to include it in the next planned meeting. On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.2(1); 23.2(b)

COMPLAINT #NJ175735 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide or obtain routine medications in order to meet the needs of each resident for 3 of 35 residents reviewed (Residents #5, #32, and #352). This deficient practice was evidenced by the following: 1. On 2/26/25 at 7:57 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepared and administered medications (meds) of Resident #5 (from the 2nd floor unit). LPN#1 informed the surveyor that there was no available Florastor (used as a probiotic, or friendly bacteria, to prevent the growth of harmful bacteria in the stomach and intestines) 250 mg (milligrams) in the medicine (med) cart. LPN#1 stated that she would check later in the back up machine for Florastor. LPN#1 did two residents for med pass observation. The surveyor did not observed LPN#1 went to get the Florastor or notified the physician of unavailable med. The surveyor reviewed the medical records for Resident #5. A review of the admission Record (AR, an admission summary) reflected that Resident #5 was admitted to the facility with the diagnoses which included but not limited to other sequelae of cerebral infarction (ischemic stroke) and ulcerative colitis (is a chronic condition characterized by an abnormal immune response where the immune system attacks the cells in the digestive tract. This leads to inflammation and ulcers in the lining of the large intestine and rectum), unspecified, without complications. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/8/25, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. A review of the electronic Medication Administration Record (eMAR) revealed that the resident had a physician's order (PO) with a start date of 4/21/22 for Florastor capsule (cap) 250 mg give one cap by mouth two times a day for GI (gastrointestinal) stabilizer. The above order for Florastor was transcribed to the February 2025 eMAR, to be administered at 9:00 AM and 5:00 PM. A review of the Order Audit Report revealed that the Florastor 250 mg cap was reordered by LPN#2 on 1/21/25 and the med was exhausted on 1/22/25. On 2/26/25 at 10:51 AM, the surveyor observed LPN#1 on the 1st floor. The surveyor asked if she was able to administer the Florastor to Resident#5, and she responded that she was about to go and get it from the backup machine. In the back up room, a contracted Staff from the backup company informed LPN#1 that it would be 15-20 minutes more before the LPN could use the machine. The surveyor asked LPN#1 if she notified the physician about the med, and she responded that she would call the physician later if she was unable to administer or get the med. LPN#1 further stated that she would call and follow up with pharmacy. A review of the medical records revealed that there was no documented evidence that Resident #5's physician was notified that the Florastor was unavailable. On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant DON (ADON), and the surveyor notified them of the concern with med pass observation and unavailable med of Resident #5. A review of the provided packing list of the ADON on 3/4/25 at 10:12 AM, for shipping dates of 12/13/24 and 12/18/24, revealed that the facility did not have a backup med for Florastor. 2. On 2/24/25 at 11:06 AM, the surveyor observed Resident #32 seated in a wheelchair in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide, who informed the surveyor that the resident will be going down for lunch. The surveyor reviewed the medical records for Resident #32. A review of the AR reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified. A review of the most recent comprehensive MDS, with an ARD of 12/23/24, indicated that the resident had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive meds. A review of the eMAR revealed that the resident was on the following psychotropic meds: A PO dated 3/21/24, and was discontinued (d/c) on 2/18/25, for Risperidone 1 mg give 3 tablets (tabs) by mouth two times a day for bipolar disorder, 3 tabs=3 mg. A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for bipolar disorder to be given with 4 mg to equal a total of 5 mg. Further review of the above orders for Risperidone revealed that it was transcribed to the February 2025 eMAR, and from 2/18/25 through 2/22/25, the eMAR was not signed by nurses as administered, and was left blank. The Risperidone order was signed not until 2/23/25. The Risperidone was not administered for total of five days. A review of the medical records revealed that there was no documented evidence as to why the Risperidone was not administered. Further review of the Order Audit Report revealed: Risperidone 1 mg tab was on hand (available) and dispensed on 2/23/25. Risperidone 4 mg tab was on hand and dispensed on 2/23/25. On 2/27/25 at 12:16 PM, the survey team met with the LNHA, DON, and ADON. The surveyor notified of the concern regarding Risperidone not signed from 2/18-2/22/25. On 3/3/25 at 10:19 AM, the survey team met with the LNHA, DON, ADON, and the ADON stated we did staff education about missing meds and the physician of Resident #32 was notified about the Risperdal. On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there was no additional information provided by the LNHA. 3. A review of Resident #352's electronic health records (EHR) revealed: A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but not limited to Alzheimer's disease unspecified (a brain disorder that gradually destroys memory and thinking skills) and glaucoma (a condition where the eye ' s optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure). A review of the MDS, with an ARD of 7/10/24, reflected a BIMS score of 2 out of 15 indicating severely impaired cognition. A review of the eMAR revealed that the resident was on the following eyedrop meds: A PO for Alphagan P Solution 0.1 % (Brimonidine Tartrate) Instill 1 drop in both eyes every 12 hours for glaucoma, ordered 7/7/24, d/c on 7/8/24. A PO for Alphagan P Solution 0.1 % (Brimonidine Tartrate) Instill 1 drop in both eyes three times a day for glaucoma, start date 7/ 8/2024, d/c on 7/11/24. Further review of the eMAR revealed that Resident #352 did not receive Alphagan P Solution eye drops from 7/7/24 to 7/10/24 (total of 4 days). The eMAR was coded as 9 indicating other/see nurses notes. The nursing progress note (PN) revealed that the Medical Doctor (MD) was notified that med was unavailable on 7/7/24, and no MD notification from 7/8/24 to 7/10/24. A review of Registered Nurse #1's (RN#1) PN on 7/7/24, revealed a note text stating, Awaiting delivery from pharmacy MD aware. A review of the RN#2's PN on 7/9/24, revealed a note text stating, Pending pharmacy delivery. RN#2's PN on 7/10/24, revealed, Awaiting med from pharmacy. On 2/25/25 at 10:25 AM, the 3rd floor Licensed Practical Nurse/Unit Manager (LPN/UM) stated, If a med is not available, we call the doctor and get an alternate, or we hold it, we also have a for back up [name of machine] meds. On 2/26/25 at 10:45 AM, the LPN/UM stated, If the Alphagan med was not given, that means the med was not here. That is something that is not going to be in the backup machine. I do not recall about the eye drops why it was not given. There was no indication that the doctor or pharmacy was called. On 2/26/25 at 11:08 AM, the surveyor interviewed RN #2, who confirmed that she indicated on the eMAR 9 on 7/9/24 and 7/10/24, pending pharmacy delivery for the Alphagan P Solution eye drop. The surveyor asked what the process was when a med was not available and RN #2 stated, We notify the doctor and call the pharmacy if the med is not there. I do not know why I did not do that or document it. The LPN/UM and RN#2 confirmed that the process was not followed. On 2/27/25 at 12:26 PM, the surveyor notified the concern regarding Alphagan eye drops not being administered with the LNHA, DON, and ADON. A review of the facility's Administering Medication-Medication Unavailable Flow Chart Policy and Procedure revealed, Check med stock box; call pharmacy for Stat (immediate) delivery; notify supervisor and Medical Director; implement orders from physician; add a detailed entry to the medical record. On 3/3/25 at 10:40 AM, the survey team met with the LNHA, DON, ADON, and the ADON stated, We were able to narrow down on who the staff were that were involved, and we educated them regarding what to do when med is not available. NJAC 8:39-29.2(d); 29.6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medications (meds). This deficient practice was identified for 2 of 6 residents reviewed for psychoactive meds used (Residents #32 and #63), and was evidenced by the following: 1. On 2/24/25 at 11:06 AM, the surveyor observed Resident # 32 seated in a wheelchair (w/c) in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide #1 (RA#1), who informed the surveyor that the resident will be going down for lunch. The surveyor reviewed the medical records for Resident #32. A review of the admission Record (AR, an admission summary) reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified. A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 12/23/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive meds. A review of the electronic Medication Administration Record (eMAR) revealed that the resident was on the following psychotropic meds: A physician's order (PO) dated 3/21/24, and was discontinued (d/c) on 2/18/25, for Risperidone (antipsychotic medication) 1 mg (milligram) give 3 tablets (tabs) by mouth two times a day for Dx (diagnosis) bipolar disorder, 3 tabs=3 mg. A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for Dx bipolar disorder to be given with 4 mg to equal a total of 5 mg. A PO dated 3/19/24, Sertraline HCL (hydrochloride) Oral tab 100 mg give 1 tab by mouth one time a day for depression. A PO dated 3/18/24, Mirtazapine Oral tab 155 mg give 1 tab by mouth at HS for depression. A PO dated 4/26/24, Divalproex Sodium tab delayed release 500 mg give 3 tabs by mouth at HS for bipolar disorder, 3 tabs=1500 mg. A PO dated 6/12/24 and d/c on 2/7/25, Behavior Tracking: very demanding at times, can be resistant to care, every shift. A PO dated 2/20/25, Behavior Tracking: Sad affect every shift. A Review of Resident #32's eMAR and the electronic Treatment Administration Record (eTAR) did not include documentation that the facility was monitoring the resident's behavior for the use of psychotropic meds and target behavior was not identified for each identified psychotropic meds. A review of the individual comprehensive Care Plan (CP) which included the following focus area: A focus area date initiated 10/18/24, that Resident #32 at risk for behavior symptoms (resist care/treatments) related to (r/t) mental illness. Interventions included: administer meds per PO, observe for mental status/behavioral changes when new medication (med) started or with changes in dosage, Psych (Psychiatrist) referral as needed (PRN), and consistent approaches when giving care. A review of the medical records revealed that the Monthly Nursing Summary which included the evaluation for psychotropic meds were completed for dates 10/18/24, 12/16/24, and 1/28/25. Further review of the Nursing Summary revealed that there were no monthly summaries done from April 2024 through September 2024, and November 2024. The 1/28/25 Monthly Nursing Summary did not include the med Sertraline as part of psychoactive meds being reviewed and there was no documented mood and behavior identified to be reviewed. A review of the medical records also revealed that the AIMS (Abnormal Involuntary Movement, a 12-item clinician-rated scale to assess severity of dyskinesias (specifically, orofacial movements and extremity and truncal movements) in residents taking antipsychotic meds) assessment were completed for dates 4/26/24 and 10/18/24. A review of the 2/18/25 Psychiatric follow up consult revealed that the resident when asked when their last psychotic episode was, the resident stated that they did not recall ever hallucinating. On 2/26/25 at 10:59 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding the resident's psychoactive meds and behavior monitoring. The RN/UM stated that she was unsure if there should be a target behavior for each psychoactive meds. The RN/UM confirmed, after reviewing the medical records that the Monthly Nursing Summary were not done routinely as well as the AIMS. She further stated that the AIMS should be done quarterly according to MDS schedule that was being provided by the MDS Staff and the Monthly Nursing Summary with psychoactive summary should be done monthly, and it was the assigned nurse should be responsible for documenting them in the electronic medical records. On 2/26/25 at 11:42 AM, the surveyor observed the resident seated in a w/c in the ground floor dining area, assisted by RA#2 in cutting their food. Afterward, the surveyor interviewed RA#2, who informed the surveyor that the resident was cognitively intact, no unusual behavior, very sociable, loves bingo with friends, and very calm. 2. On 2/24/25 at 10:59 AM, the surveyor observed Resident # 63 was seated in a w/c in front of their room, repeatedly stated, why, I am here, come here. The surveyor reviewed Resident #63's medical records and revealed: A review of the AR reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. A review of the most recent cMDS, with an ARD of 1/10/25, revealed a BIMS score of 5 out of 15, reflected that the resident's cognition was severely impaired. A review of the eMAR revealed that the resident was on the following psychotropic meds: A PO dated 1/22/24, Depakote sprinkles oral capsule (cap) delayed release sprinkle 125 mg give one cap by mouth one time a day for mood disorder. A PO dated 4/2/24, Alprazolam tab 0.25 mg give one tab by mouth at HS for anxiety. A PO dated 10/03/24 and d/c on 2/21/25, Seroquel (Quetiapine Fumarate) Oral tab 25 mg give 0.5 tab (12.5 mg) by mouth one time a day for psychosis. A PO dated 2/23/25 and d/c on 2/25/25, Seroquel Oral tab 25 mg give 0.5 tab (12.5 mg) by mouth one time a day for psychosis. A PO dated 2/26/25, Quetiapine Fumarate tab 25 mg give one tab by mouth at HS for agitation. A PO dated 2/21/25, Lorazepam oral tab 0.5 mg give one tab by mouth every 24 hours PRN for anxiety x 14 days. A PO dated 3/21/24, Intrusive Wandering: going into other residents' room every shift. A PO dated 3/19/24, Verbally abusive: yelling and cursing staff and other resident every shift. A Review of Resident #63's eMAR and the eTAR did not include documentation that the facility was monitoring the resident's behavior for the use of psychotropic meds and target behavior was not identified for each identified psychotropic meds. A review of the individual comprehensive CP which included the following focus areas: A focus area date initiated 9/16/24, that Resident #63 was at risk for behavior symptoms r/t dementia: kneeling on bathroom floor I'm cleaning floor, pushing w/c while walking, continually saying where is [name], . in my nice house, and calling staff [derogatory word]. Interventions included: observe for mental status/behavioral changes when new med started or with changes in dosage, Psych referral as needed, redirected on how to push w/c, and use of consistent approaches when giving care. A focus area date initiated 7/18/22, that Resident #63 was at risk for changes in mood r/t cognitive loss, self-reported feelings of depression. Interventions included: assess for physical/environmental changes that may precipitate changes in mood, observe for mental status/mood state changes when new med was started or with dose changes, and offer choices to enhance sense of control. A review of the medical records revealed that the Monthly Nursing Summary which included the evaluation for use of psychotropic meds were completed for dates 2/12/24, 6/3/24, 7/11/24, 10/14/24, 11/6/24, and 12/5/24. Further review of the Nursing Summary revealed that there were no monthly summaries done from March 2024 to May 2024, from August 2024 to September 2024, and January to February 2025. The 12/6/24 Monthly Nursing Summary did not include the med Depakote as part of meds being reviewed, the documented mood and behavior were period of agitation, cursing and yelling, and did not indicate if the target behavior was increased or decreased. A review of the medical records also revealed that the AIMS assessment was completed for dates 5/10/24 and 9/26/24. There was no documented evidence that the AIMS were done prior to 5/10/24, and every quarter (none was done for December 2024) AIMS were not done. A review of the 2/21/25 Psychiatric follow up consult revealed that Staff report resident's mood was stable, but resident had some anxiety especially at night. The GDR (gradual drug reduction) was recommended and agreed by the Resident Representative (RR) for Seroquel to be d/c and to add Lorazepam 0.5 mg by mouth every 24 hours PRN for anxiety. Further review of the medical records revealed there was no documented evidence that the resident had presented behavior after the Seroquel was d/c on 2/21/25 and the PRN Lorazepam was not administered. On 2/26/25 at 10:59 AM, the surveyor interviewed RN/UM regarding the above concern with Resident #63 and why the Seroquel was increased on 2/25/25 without documented evidence that the resident had increased or presented behavior after the GDR was done on 2/21/25 (d/c Seroquel). The RN/UM responded that she was not the nurse who was giving meds and the surveyor should ask the Psychiatric doctor for that. On that same date and time, the RN/UM confirmed after reviewing the medical records that the AIMS assessment and Monthly Nursing Summary were not done according to their practice. The surveyor then asked the RN/UM what the facility's standard of practice for use of psychoactive meds will be, should there be a documentation of behavior and reason for increasing the meds, and she responded yes. On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns with the psychoactive meds and behavior monitoring. The DON stated that she was aware of the concern with the psychoactive meds that was why she had a meeting with the Psychiatrist, and educated the Psychiatrist that she should follow the regulation. A review of the Consultant Pharmacist (CP) Monthly Medication Review (MMR) for dates 10/8/24, 11/8/24, and 12/6/24, revealed that the resident's psychoactive summaries were not up to date. A review of the provided Employee Education Attendance Record dated 2/14/25 for an in-service r/t to content: antipsychotic meds, putting orders in electronic records, and GDR, reflected that the Advance Practice Nurse (APN) who did the follow up Psychiatric consult and Assistant Director of Nursing (ADON) signed the in-service that was presented by the Director of Nursing (DON). On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and ADON, and the surveyor notified them of the above concerns. The surveyor also asked the facility management about the provided in service dated 2/14/25, and the surveyor asked why after the in service provided to the APN, the problem still persisted when the resident's Seroquel was d/c on 2/21/25 and increased on 2/25/25 when there was no documented evidence of behavior was observed or increased, and the LNHA, DON, and ADON did not respond. On 2/27/25 at 1:00 PM, the surveyor interviewed the APN who provided a follow up psychiatrist consult for Resident #63. The APN informed the surveyor that she was unsure if the guidelines she followed for GDR was according to the regulations that the facility was following. The surveyor asked the APN if the target behavior was to be identified for each psychoactive meds in order to evaluate the effectiveness of meds and to be able to GDR the psychoactive meds, and the APN responded, it depends, because at times nurses had different views on what to monitor for behavior. The surveyor then asked the APN should the nurse and the APN communicated and discussed the appropriate behavior to effectively evaluate the resident's psychoactive meds, and the APN responded, that was a good idea. On that same date and time, the surveyor asked the APN, for Resident #63, what behavior should monitored by the staff, and she responded hitting. The surveyor then notified the APN of the above concerns that the medical records reflected that the yelling, screaming, and intrusive behaviors were documented behavior as being monitored for the resident. On 3/3/25 at 10:19 AM, the survey team met with the LNHA, DON, ADON, and the surveyor notified them of the above findings. The DON confirmed that the AIMS Assessment should be done quarterly and the Monthly Nursing Summary that included the monthly psychiatric summary should be done monthly. The DON stated no additional response with AIMS, monthly summary, moving forward were doing an audit. The surveyor asked if there was an additional information that the LNHA, DON, and ADON wanted to add, and they said no additional information as per LNHA. A review of the facility's Behavioral Assessment, Intervention and Monitoring Policy, with revision date of March 2019 revealed: Policy Statement: 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment . Management: 8. Interventions and approaches will be based on a detailed assessment of physical, psychological land behavioral symptoms and their underlying causes, as well as the h potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: b. targeted and individualized interventions for the behavioral and/or psychosocial symptoms; d. specific and measurable goals for targeted behaviors; and e. how the staff will monitor for effectiveness of the interventions . 10. When meds are prescribed for behavioral symptoms, documentation will include: e. specific target behaviors and expected outcomes; . h. monitoring for efficacy and adverse consequences; and i. plans (if applicable) for GDR . Monitoring: 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function . On 3/4/25 at 10:15 AM, during the Quality Assurance Performance Improvement (QAPI) meeting by the surveyor with the LNHA, DON, and the ADON, the DON confirmed that it was the surveyor who identified the concern with regard to quarterly AIMS assessment and Monthly Nursing Summary, and these will be added to their QAPI meeting. NJAC 8:39-27.1(a); 33.2(a)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to properly store medications securely and appropriately according to facility's policy and standard of clinical practice. The deficient practice was identified in 1 of 4 medication carts inspected on 3 of 3 units. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/3/25 at 12:04 PM, the surveyor entered the 1st floor nursing unit. The surveyor observed a medication storage cart (medcart) that was unlocked as evidenced by the locking button not pressed in and activated. The medcart was unattended by a licensed staff member. The surveyor approached the nurses' station and asked who was assigned to the medcart. A Licensed Practical Nurse (LPN) identified themselves as the assigned staff for the medcart assigned to 1st floor, wing 1. The surveyor asked the LPN if was common to leave a medcart open and unattended. The LPN stated, no, the medcart should always be locked when not in use and she had just walked away from it. The surveyor asked the LPN why it would need to be locked when unattended. The LPN stated that a resident or other person could get access to medications (meds). The surveyor continued the inspection of the medcart in the presence of the LPN. On 3/3/25 at 1:09 PM the survey team met with Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) to notify them the concern with the medcart and requested a medication storage policy. On 3/4/25 at 12:05 PM, the survey team met with the LNHA, DON and ADON. The facility had no further pertinent documentation to provide. A review of the facility's Medication Labeling and Storage Policy, dated February 2023 reflected under Policy Statement, the facility stores all meds and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. It also reflected under Medication Storage, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing meds and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. N.J.A.C. 8:39-29.4(h)

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 1 of the 35 residents reviewed (Residents #107). This deficient practice was evidenced by the following: During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed. On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position. The surveyor reviewed the medical records of Resident #107 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral infarction (stroke) and hemiplegia (is a condition characterized by paralysis on one side of the body) and hemiparesis (is a condition characterized by one-sided muscle weakness, often caused by disruptions in the brain, spinal cord, or nerves connecting to the affected muscles) following cerebral infarction affecting left non-dominant side. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/7/25, with a brief interview for mental status (BIMS) score of 9 of 15, which reflected that the resident's cognitive status was moderately impaired. A review of the provided fall investigations revealed that the resident had two fall incidents/accidents. The 12/30/24 fall investigation resulted to a bump to left forehead and the resident's blood pressure was 205/125. The 1/15/25 fall investigation had no injury. A review of the Progress Notes (PN) that was electronically signed by the Physician revealed: -For effective date of 1/3/25 was created on 2/24/25. -For effective date of 12/3/24 was created on 2/6/25. -other late entry notes: 11/1/24, 10/01/24, 9/6/24, and 8/3/24. Further review of the above Physician PN revealed that Assessment and Plan dated 8/3/24, 9/6/24, 10/1/24, 11/1/24, 12/3/24, and 1/3/25, included requesting to change Seroquel (antipsychotic medication) to Trazodone (antidepressant) psych (Psychiatrist) to be contacted. The above 1/3/25 Physician PN did not reflect documented evidence that the physician assessed the resident post fall incidents on 12/30/24 and 1/15/25. A review of the physician orders (PO) revealed that the resident's order for Seroquel was discontinued on 12/29/23. A review of the February 2025 electronic Medication Administration Record (eMAR) revealed that the resident had no order for Trazodone. The February 2025 eMAR reflected a PO for Sertraline HCL (hydrocholoride) oral tablet (tab) 50 mg (milligram) one tab by mouth one time a day for MDD (Major Depressive Disorder) with a start date of 1/29/25. On 2/26/25 at 11:19 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), and the surveyor notified the RN/UM of the above findings and concerns. The RN/UM after reviewing the resident's paper and electronic medical records, she confirmed that the physician's PN were late entries and had duplicate notes about Seroquel, Trazodone, and Psych. The RN/UM stated that the surveyor should ask the Director of Nursing (DON) about what facility should follow with regard to physician's PN and could not speak on why the repeated documentation of the physician. On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns, and the DON stated that the physician should have done monthly and as needed notes for LTC (Long Term Care) residents. The DON acknowledged that the medical records should have been accurate according to the current condition of the resident. On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant Director of Nursing (ADON), and the surveyor notified them of the above concerns. On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for the surveyor's concerns, no further information to provide. NJAC 8:39-23.2 (a)(b); 35.2 (d)(6)

REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 3 staff (Licensed Practical Nurse) and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. On 2/26/25 at 7:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) during medication (med) administration, performed handwashing after removal of gloves inside the toilet room of Resident #5. The surveyor observed the LPN scrubbed her hands with soap under the stream of running water for 18 seconds. On 2/26/25 at 8:12 AM, the surveyor observed the LPN donned (put) gloves, disinfected the blood pressure (bp) apparatus, entered Resident #119's room, and checked the resident's bp with use of same gloves. The LPN did not doff (remove) used gloves after disinfecting the bp apparatus. After the LPN obtained the bp of the resident, the LPN doffed off gloves, and exited the room without performing hand hygiene. In addition, the LPN prepared and administered medications of the resident without performing hand hygiene. During an interview after med pass observation, the surveyor notified the LPN of the above hand hygiene concerns, and LPN stated that it was okay to perform hand scrubbing under the stream of water. The LPN further stated that she should have doffed off gloves and performed hand hygiene after disinfecting the bp app. On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant DON (ADON), and the surveyor notified them of the above concerns with med pass observation with regard to hand hygiene and gloves use. A review of the facility's Handwashing/Hand Hygiene Policy, with an edited date of 3/18/24, that was provided by the ADON revealed: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. immediately before touching a resident; . d. after touching a resident; . f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal . Washing Hands: 1. Wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet . On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-19.4(a)(1),(n)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 1 of five 5 Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 3/3/25 at 9:13 AM, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following: CNA #1 had a date of hire (doh) of 1/25/18. According to the Transcript, CNA #1 did not have QAPI training. CNA #2 had a doh of 11/20/07. According to the Transcript, CNA #2 did not have QAPI training. On 3/3/25 at 12:16 PM, the surveyor interviewed the Facility Educator (FE) regarding CNA education and mandatory topics. The FE stated that she tracked their education based on their anniversary date. She added that if a mandatory topic was done offline that it would still be logged on the staff's transcript. The surveyor asked the FE about the QAPI training. The FE stated that it was done offline but that it was tracked on the computer training transcript as offline. The surveyor notified the FE that CNA #1 and CNA #2 did not have QAPI training listed on their transcript. The FE stated that it could have been a transcription error on her part and that she did not put it in the system. The FE stated that she would look at the sign in sheet. On 3/3/25 at 12:25 PM, the FE provided the surveyor a sign in sheet for QAPI training that CNA #2 had signed as completed. The FE stated that CNA #1 had not completed the training. On 3/3/25 at 1:00 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant DON (ADON) the concern that CNA #1 did not have the QAPI inservice. On 3/4/25 at 11:33 AM, in the presence of the LNHA and ADON, the DON stated that CNA #1 was inserviced after surveyor inquiry on the topic of QAPI. A review of the facility's In-service Training, Nurse Aide Policy, with a revised date of August 2022, included the following: 9. Required training topics for all staff (including nurse aides) include: . d. quality assurance and performance improvement (QAPI) . N.J.A.C. 8:39-33.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00162219 Based on record review staff interviews, and facility policy review, the facility failed to ensure an injury of unknown origin was reported to appropriate entities in a timely manner for one of eleven residents (Resident (R) 1) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and the incident was not reported to the local Ombudsman, the family, or the State Agency. Findings include: Review of R1's admission Record, dated 01/26/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes and Alzheimer's Disease. Review of R1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/22 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R1 had severe cognitive impairment. The assessment indicated the resident exhibited physical, verbal, rejection of care, and other behavioral symptoms on one to three days of the assessment reference period. The assessment also indicated the resident required extensive assistance from staff for bed mobility and transfers in and out of her bed. Review of R1's Nursing Progress Note, dated 12/31/22 and found in the EMR under the Notes tab, revealed At 1 pm when I went to hand [hang] the IV [Intravenous] ABT [antibiotic] I notice(d) pt [patient] rt [right] middle finger was very blue and swollen and painful to touch OMD [On-Call Medical Doctor] notified new or send to ER [Emergency Room] for eval [evaluation] Family notified at 1:45 (PM) pt [patient] resident left the building. Documentation related to the reporting of R1's injury of unknown origin was requested by the survey team on 01/24/24 at 3:30 PM, however the facility was not able to produce any documentation to show the required reporting had been done. During an interview with the Director of Nursing (DON), the Administrator, and the Infection Preventionist/Wound Care Nurse (IP/WCN) on 01/25/24 at 11:46 AM, the DON and the Administrator stated they were not employed at the facility at the time of the incident. The IP/WCN stated she was familiar with R1 and was in charge of the unit R1 lived on while residing in the facility. She stated the resident went to the local Emergency Department and then did not return to the facility after being transferred to the hospital. She confirmed the resident's injury of unknown origin had not been reported to the State Agency, the local Ombudsman, the resident's representative, local law enforcement, or Adult Protective Services (APS). The DON stated her expectation was R1's injury of unknown origin should have been immediately reported to all relevant agencies, including the State Agency, the Ombudsman, and the resident's responsible party. The facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated 09/22, read, in pertinent part, All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management Findings of all investigations are documented and reported; and 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, b. The local/state ombudsman, c. The resident's representative, d. Adult protective services (where state law provides jurisdiction in long-term care), e. Law enforcement officials, f. The resident's attending physician, and g. The facility medical director. NJAC 8:39-9.4 (f), 13.1 (c), (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ00169205, NJ00162219 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a thorough investigation was conducted related to injuries of unknown origin for two of eleven residents (Residents (R) 1 and R4) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and R4 had a broken clavicle; these incidents were not investigated by the facility. Findings include: 1. Review of R1's admission Record, dated 01/26/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes and Alzheimer's Disease. Review of R1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/22 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R1 had severe cognitive impairment. The assessment indicated the resident exhibited physical, verbal, rejection of care, and other behavioral symptoms on one to three days of the assessment reference period. The assessment also indicated the resident required extensive assistance from staff for bed mobility and transfers in and out of her bed. Review of R1's Nursing Progress Note, dated 12/31/22 and found in the EMR under the Notes tab, revealed At 1 pm when I went to hand [hang] the IV [Intravenous] ABT [antibiotic] I notice(d) pt [patient] rt [right] middle finger was very blue and swollen and painful to touch OMD [On-Call Medical Doctor] notified new or send to ER [Emergency Room] for eval [evaluation]. Family notified at 1:45 (PM) pt [patient] resident left the building. Documentation related to an incident report or an investigation into the potential cause of the injury of unknown origin was requested by the survey team on 01/24/24 at 3:30 PM, however the facility was not able to produce any documentation to show an incident report had been initiated or an investigation of the incident had been done to rule out potential abuse/neglect. During an interview with the Director of Nursing (DON), the Administrator, and the Infection Preventionist/Wound Care Nurse (IP/WCN) on 01/25/24 at 11:46 AM, the DON and the Administrator stated they were not employed at the facility at the time of the incident. The IP/WCN stated she was familiar with R1 and was in charge of the unit R1 lived on while residing in the facility. She stated the resident went to the local Emergency Department and then did not return to the facility after being transferred to the hospital. She confirmed no incident report had been done related to the resident's injured finger and the incident had not ever been investigated to rule out potential abuse. The DON stated her expectation was any injury of unknown origin should be thoroughly investigated and staff and residents (including the subject of the allegation as well as other interviewable residents who might have been subjected to potential abuse/may have knowledge of the incident) were to be interviewed. 2. Review of the discharge record found under the Progress Notes tab in the EMR for R4 revealed an admission date on 10/18/23 for therapy related to a sixth thoracic vertebrae (T6) compression fracture. Review of the admission report indicated R4 was unable to communicate her wants and needs or how she was injured. Review of the initial nursing assessment provided by the facility dated 10/18/23 indicated R4 was oriented to self, skin was intact, no pain or shortness of breath, incontinent of bowel and bladder, dependent of staff for activities of daily living and was wearing briefs. Review of R4's Diagnosis tab located in the EMR revealed diagnoses which included wedge compression fracture of unspecified thoracic vertebra, subsequent encounter for fracture with routine healing, dementia, downs syndrome, mood and anxiety disorders, non-displaced fracture of olecranon process without intraarticular extension of left ulna, and initial encounter for closed fracture. Review of R4's Progress Notes tab located in the EM, dated 11/05/23 at 12:11 PM, revealed R4 was found in bed to have a swollen left elbow (wrong elbow reported) and scrape on left elbow at 9:30 AM. Review of Nursing Notes located in the EMR, dated 11/05/23, revealed it was reported at 9:14 PM an X-ray result indicating an acute nondisplaced olecranon fracture of unknown cause. The X-ray was completed at the facility. R4 was sent to the emergency department for further evaluation. Review of an IDT [Interdisciplinary Team] Note located in the EMR, dated 11/09/23, indicated an additional injury of the right clavicle fracture in addition to the right elbow fracture. The resident was discharged on 11/08/23. Review of the incident report dated 11/06/23 yielded no interviews or documentation related to an investigation other than the resident could not describe what happened. Further review and indicated the incident was reported to the state health department as an injury of unknown origin and that one nurse and two nurse aides were interviewed, one of which was interviewed on 11/07/23. During an interview on 01/25/24 at 3:05 PM, the Administrator and DON stated that no residents were interviewed from the unit or other units as to what they might have seen on 11/04/23 or 11/05/23. Five additional staff worked with R4 on 11/04/23 night shift and the next morning prior to the incident being reported. The five staff were not interviewed by the facility. No body checks were done on dependent residents living in the same assignment area as the R4. Review of an IDT meeting note found in the EMR under the Progress Notes tab dated 11/09/23, indicated that the resident fell, and this caused her injury. There was no mention of how she fell. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated 09/22, read, in pertinent part, All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management Findings of all investigations are documented and reported; and All allegations are thoroughly investigated. The administrator initiates investigations. NJAC 8:39-4.1 a(5) NJAC 8:39-27.1

Based on the interview and review of the facility provided documents, it was determined that the facility failed to ensure that the care planning (care conference meeting) was scheduled and that the resident's representative (RR) was provided sufficient notice in advance of the meeting according to the facility practice and policy for one of three quarters care conference reviewed for Resident#83. This deficient practice was evidenced by the following: On 01/11/23 at 8:58 AM, the RR informed the survey team that he/she visits Resident #83 almost every day. The RR had a concern that care planning meetings stopped since August 2022 and no invitation was provided to the RR. On 01/11/23 at 11:04 AM, the surveyor observed Resident #83 seated in a wheelchair, clean and well-dressed. The surveyor reviewed the medical record of Resident #83. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia with other behavioral disturbance, major depressive disorder, peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), anemia (lack enough healthy red blood cells to carry adequate oxygen to your body's tissue), and essential hypertension (elevated blood pressure). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) 11/30/22 showed that the resident's cognitive skills for daily decision-making were severely impaired. The Care Conference Note (CCN) dated 9/07/22 which included that the meeting was held in person for a Quarterly meeting and the department and individuals present were the Social Services, Nursing, Nutrition, and Recreation. The CCN on 9/07/22 did not include that the resident and RR were invited. Further review of the CCN revealed that there was no further documentation that the CCN was done after the 9/7/22 meeting. There were CCN on dates 3/11/22, 6/08/22, and 9/07/22 which corresponded to the resident's quarterly MDS. There was no CCN for MDS that was done on 11/30/22. On 01/17/23 at 9:41 AM, the surveyor interviewed the Director of Social Services (DSS). The surveyor asked the DSS about the facility protocol and practice with regard to the care planning meeting. The DSS stated that the social workers are responsible for scheduling the care planning meeting. She further stated that the social worker documents the care planning meeting in the electronic medical records in the CCN. She indicated that the social worker will also document in the CCN the department and individuals who attended the care planning meeting which included the documentation that the resident and RR were invited and attended the meeting. On that same date and time, the surveyor notified the DSS of the above findings. The DSS stated that currently, the facility had two full-time social workers that were assigned to the 1st and 3rd-floor units. The DSS further stated that the Social Worker (SW) assigned to the 2nd floor where Resident #83 resided had left the facility and the DSS was unable to remember when the 2nd-floor social worker left. She indicated that the two remaining social workers now divide the task for the 2nd-floor residents for social services work which includes the care planning meeting. Furthermore, the DSS further stated that it was an expectation that the previous SW called the RR to schedule the care conference meeting. The surveyor then asked the DSS if she knew that the previous SW called and notified the RR of the care conference schedule on 9/07/22 and 11/30/22. The DSS did not respond. At that time, the surveyor asked the DSS what happened there was no further CNN after the 9/07/22 documentation, and the DSS did not respond. The surveyor asked the DSS to provide documentation that the RR was notified of the care planning meeting from 9/07/22 onwards, and she stated that she will get back to the surveyor. On 01/17/23 at 11:35 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC). The RN/MDSC stated that she does not attend the care planning meeting. She further stated that it was the responsibility of the MDS department to inform the other departments which included the Unit Manager (UM), Rehab, Dietitian, Director of Nursing (DON), and DSS for the upcoming schedule of MDS assessment for them to schedule the care planning meeting after the MDS assessment was completed. On 01/17/23 at 12:44 PM, the DSS informed the surveyor that it was an oversight from the facility team, and that the care planning meeting was not done after the 9/07/22 care conference. She further stated that there should have a CCN for the 11/30/22 MDS assessment. The DSS was not able to provide documentation that the RR was called or notified of the care planning meeting after the 9/07/22 care conference. On 01/17/23 at 01:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the facility management of the above findings. A review of the facility's provided Resident Participation-Assessment/Care Plan Policy by the DSS with a revised date on December 2016 included that the DSS or designee is responsible for notifying the resident and their representative and maintaining records of such notices for a care planning meeting and encouraged to participate in the resident's assessment and the development and implementation of the resident's care plan. A review of the provided payroll cycle of the previous second floor SW that was provided by the DSS showed that the SW last day of work was on 9/23/22. On 01/18/23 at 01:56 PM, the survey team met with the LNHA and the DON. The facility management did not provide additional information. NJAC 8:39-13.2(a)

Based on observation, interview, and review of pertinent documents, the facility failed to ensure that the method for filing a grievance was consistent with the facility's practice and policy. This deficient practice was identified for three of four grievance incidents of Resident #83. The evidence was as follows: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated that he started working at the facility three months ago. The DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse left the facility. On 01/11/23 at 8:58 AM, the resident representative (RR) informed the survey team that he/she visits Resident #83 almost every day. The RR stated that he/she complained to the previous administrator about the resident's arms discoloration and was told that it was taken care of and that the resident had fragile skin. The RR further stated that he/she had an issue with the Certified Nursing Aide (CNA) recently the RR asked the CNA to be removed from the assignment which was immediately resolved. The RR indicated that the CNA will not talk to the RR whenever the RR visited or ask a question and instead will be referred to the nurse or the Unit Manager (UM) that was why the RR asked the CNA to be removed from the resident's assignment. On 01/11/23 at 11:00 AM, the surveyor asked the LNHA for a copy of Resident #83's grievance reports for the last seven months, and the LNHA stated that he will get back to the surveyor. On 01/11/23 at 11:04 AM, the surveyor observed Resident #83 seated in a wheelchair with a covered sheepskin (chair pads add a soft, cushy comfort to any surface), clean and well-dressed. The surveyor reviewed the medical records of Resident #83. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia with other behavioral disturbance, major depressive disorder, peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), anemia ( a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissue), and essential hypertension (elevated blood pressure). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 11/30/22 showed that the resident's cognitive skills for daily decision-making were severely impaired. A review of the provided Grievance/Complaint Report (G/CR) showed that on 3/09/22, the RR visited on 3/08/22 at 7:00 PM and complained that the resident's wheelchair was dirty and was immediately cleaned and addressed the issue. On 01/17/23 at 9:41 AM, the surveyor interviewed the Director of Social Services (DSS). The DSS informed the surveyor that anyone can initiate a grievance when a resident or RR complained and had a concern, fill out the G/CR form, discuss it in the morning meeting, complete the G/CR form, then submit it to the DSS for filing after the interdisciplinary team or the specific department reviewed it, and this is according to the facility practice. On that same date and time, the surveyor notified the DSS of the above problem of the RR regarding the CNA and skin discoloration of the resident. The surveyor asked the DSS why there was no G/CR copy provided to the surveyor when the RR reported the above problem about the CNA and skin discoloration. The surveyor received one grievance report that was provided by the DON dated 3/09/22 regarding the dirty wheelchair of the resident. The DSS stated that she will get back to the surveyor. A review of the provided G/CR after further surveyor's inquiry showed the following: 1. The 01/20/22 G/CR copy was received by the surveyor on 01/17/23 at 12:44 PM after a second follow-up. Then, the attached investigation and statements were received by the surveyor on 01/18/23 at 8:06 AM after the third inquiry of the surveyor. The 01/20/22 G/CR showed that the RR complained that the resident was seen in bed at 7:00 PM and got upset with the aide because the RR wanted the resident to be back in bed at 8:00 PM and noted with a skin tear on the right arm. The incident was investigated and interventions were put in place. 2. The 8/05/22 G/CR copy was received by the surveyor on 01/17/23 at 12:44 PM after a second follow-up. The 8/05/22 G/CR showed that the RR complained to the nurse that the resident was not seen by the Psychiatrist for the resident's recent behavior of combativeness. The G/CR included that the nurse reminded the RR that the resident's behavior was not something new and was seen recently by the Psychiatric Nurse Practitioner on 7/28/22. In addition, a follow-up group meeting was held on 8/8/22 to discuss the issue. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and the Director of Nursing (DON). The surveyor asked the facility management about the process of handling grievances and the DON stated I don't know about the grievance process here. Then, the LNHA stated that once the grievance was reported, it will be followed up, and investigated. The LNHA further stated that he should be aware, and the grievance will be filed for document keeping by the Grievance Officer which is the DSS. At that time, the DON stated that she was the one who found the 01/20/22 and 8/05/22 G/CR from the piled files of the previous DON. The DON and the LNHA both acknowledged that the DSS was not aware of the two grievance reports and should have known about the incidents. On 01/18/23 at 9:00 AM, the surveyor interviewed the Certified Nursing Aide#1 (CNA#1). CNA#1 informed the surveyor that she was the assigned aide of Resident #83, and knew the resident well, and the RR. CNA#1 stated that Resident #83 was cognitively impaired with periods of combative behavior towards staff. She further stated that she knew the plan of care for the resident, able to understand the resident because both the resident and the aide speaks the same Spanish language. She indicated that she was educated on how to care for the Dementia resident. On that same date and time, CNA#1 stated that the RR visits the resident in the evening on weekdays and around 2:30 PM on weekends. She further stated that the RR asked questions about the resident and when unable to provide an answer will be referred to the nurse which the RR at times did not like. CNA#1 informed the surveyor that CNA#2 used to take care of the resident and then a few months ago, CNA#1 was unable to remember the date, and the resident was transferred to her assignment. CNA#1 was unable to state the reason why the resident was moved to her assignment. On 01/18/23 at 10:16 AM, the surveyor asked the LNHA why there was no G/CR provided to the surveyor regarding the change in the resident's aide when the RR complained and asked for a change in the aide. The LNHA stated that he forgot to mention the above issue to the surveyor when the surveyor was asking for the grievance report. The LNHA further stated that there was no report from RR about the issue regarding abuse except that the RR just did not like CNA#2. The surveyor asked the LNHA why there was no documentation about it and he did not write a grievance when the RR came forward to the LNHA about the problem, and the LNHA did not respond. Afterward, the LNHA stated that he cannot remember the exact date when it happened, it could be the date when I started, the RR came to me and talked about CNA#2, no care issues, the RR just did not like the aide because when the RR comes to visit, the aide will not talk to the RR. He further stated that the problem was immediately resolved because CNA#2 was removed from the assignment. A review of the Grievance/Complaints, Filing Policy that was provided by the DSS with a revised date of April 2017 and edited on 4/11/18 included that the Administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is the Social Worker and that upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit written report of such findings to the Administrator within five working days of receiving the grievance and/or complaint. On 01/18/23 at 02:16 PM, the survey team met with the LNHA and DON and there was no additional information provided by the facility regarding two grievance reports that DSS was not aware of and one complaint that the RR reported to the LNHA and did not follow the facility's grievance policy and practice of writing and filing the G/CR. NJAC 8:39-13.2(c)

Based on observation, interview, and review of medical records, it was determined that the facility failed to develop a person-centered comprehensive care plan to address the actual skin impairments for one of four residents (Resident #15) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse (IPN) left the facility. The DON further stated that the IPN was also the Wound Nurse (WN). On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical record. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included Diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin), chronic kidney disease (a gradual loss of kidney function over time), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside heart and brain to narrow, block, or spasm). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 12/19/22 showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The QMDS included that the resident had a facility-acquired stage four and unstageable deep tissue injury (DTI) pressure wounds. The Order Summary Report (OSR) showed that there was a physician's order dated 12/24/22 to apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) ointment to left bunion every evening shift daily and PRN (as needed). Another physician's order dated 11/11/22 for skin prep wipes (treats severely dry or chapped skin, minor burns, and other skin irritations) apply to the left plantar foot every day and evening shift and dated 12/30/22 skin prep apply to the left foot, left 5th toe two times a day for eschar (a collection of dry, dead tissue within a wound). There was no personalized care plan documented to reflect the actual wounds that the resident had on the left bunion, left foot, left plantar, and left 5th toe. On 01/09/23 at 11:50 AM, the surveyor interviewed the RN/UM. The RN/UM informed the surveyor that it was the responsibility of the WN to initiate the care plan for the resident with wounds. She further stated that she was unable to remember when the WN left the facility. The surveyor asked the RN/UM if Resident #15 had the care plan for left foot wounds, and the RN/UM responded that it should be in the electronic medical record. At that time, after the RN/UM checked the electronic medical record, the surveyor asked the RN/UM why the care plan for the left foot's multiple wounds was initiated after the surveyor's inquiry. The RN/UM did not respond. On 01/10/23 at 9:12 AM, the surveyor interviewed the DON. The DON stated that the MDS staff, DON, and ADON were responsible for initiating the care plan, and the UM revise or update the care plan. The surveyor asked the DON should the care plan reflect the left bunion wound on 8/4/22 according to the initial exam of the Wound Doctor not on 01/06/23 after the surveyor's inquiry. The DON responded yes, and stated that she did not know what happened and the care plan was not done. A review of the Care Plans, Comprehensive Person-Centered Policy that was provided by the DON with a revised date of March 2022 included 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. Policy Interpretation and Implementation: .12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessments (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. 14. The Interdisciplinary Team must review and update the care plan; a. when there has been a significant change in the resident's condition On 01/18/23 at 02:16 PM, the survey team met with the LNHA and DON, and there was no additional information provided by the facility. NJAC 8:39-11.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/09/2023 at 10:11 AM, the surveyor observed Resident#132 in bed sleeping with the left side floor mat flipped up and leaning against the wall approximately five feet from the bed. On 01/12/2023 at 9:54 AM, the surveyor observed the resident in bed sleeping. The left floor mat was located on the floor but was three feet from the edge of the bed. On 01/17/2023 at 9:40 AM, the surveyor observed the resident in bed sleeping. The left floor mat was missing, and the right floor mat was down. On 01/17/2023 at 9:45 AM, the surveyor observed the left floor mat on the other side of the room standing on its edge at the foot end of the roommate's bed. The surveyor reviewed resident's medical records: The AR indicated that the resident had diagnoses which included but not limited to respiratory syncytial virus pneumonia (RSV is the most common cause of bronchiolitis or inflammation of the small airways in the lung), type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), end stage renal disease (ESRD the gradual loss of kidney function reaches an advanced state), acquired right and left below knee amputations. The MDS dated [DATE] had a BIMS score of 9 of 15 indicated that the resident's cognitive status was moderately impaired. The personalized care plan with an initiated date of 7/16/2021 and revised on 7/16/2021 reflected that the resident was at risk for falls due to impaired balance /poor coordination and resident was a BTK (bilateral total knee) amputee. Interventions reflected floor mats at bedside initiated on 10/21/2021 and revised on 10/28/2022. A review of the incident and accident reports for falls revealed Resident #132 had three falls dated 8/12/2022, 10/20/2022, and 10/28/2022. All of which were unwitnessed falls and reported no injuries. Floor mats were indicated on the 10/28/2022 incident. The resident had a physician order dated 10/28/2022 indicated the order was active for bilateral floor mats when resident in bed, and to check placement every shift. On 01/12/2023 at 10:03 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN). The LPN stated that floor mats are used for safety because Resident #132 had several falls. She further stated that when the resident is in bed they are supposed to be always down and the proper positioning for bilateral floor mats was next to the bed. The LPN stated that the left one was not next to the bed probably when the aide was changing the resident. On 01/12/2023 at 10:12 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA). The CNA stated, resident has the floor mats to protect him/her from falling. The mats should be on the floor next to bed on each side. When we change the resident we put them up, but we put them back down after. They should be used while the resident is in bed. We pick them up, so they don't get dirty. We try not to step on them. On 01/12/2023 at 10:21 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM). The RN/UM stated nursing places the floor mats down once an order or intervention was received. She further stated that the mats get moved by housekeeping to clean the floor and then they get put back down when the floor dries. She indicated that nursing would move them to transfer the resident and the mats should not be moved at all for ADL care. A review of the Falls and Fall Risk, Managing, policy statement: section Resident-Centered approaches to managing falls and fall risk revealed, 1) the staff, with input of the attending physician, will implement a resident -centered fall prevention plan to reduce the specific factor of falls for each resident or with the history of falls. 7) In conjunction with the attending physician, staff will identify and implement relevant interventions as applicable to minimize serious consequences of falling. A review of the Certified Nursing Assistance Position Summary indicated under section, Essential Duties and Responsibilities; adhere to and practice safety, sanitation, and infection control practices. indicated under section; Daily Task section; Apply safety devices per physician's order following policy and procedure and follow established safety precautions in the performance of all duties. N.J.A.C. 8:39-27.1 (a) Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to a) initiate a baseline care plan which included at risk for falls within 48 hours of admission and thoroughly and completely investigate a fall to include the addition of interventions to prevent a fall for one of four residents reviewed for falls, Resident #321; and b) failed to follow and maintain fall prevention interventions as written on the resident's plan of care for one of four residents reviewed for falls, Resident #132. The deficient practice was evidenced by the following: 1. On 01/05/23 at 12:05 PM, the surveyor observed Resident #321 in a reclined chair in the day room of the third floor unit. The resident's right side of the upper face was bruised. On 01/09/23 at 9:45 AM, the surveyor reviewed Resident #321's electronic medical record. The admission Record (AR; or face sheet; an admission summary) indicated that the resident had diagnoses which included but were not limited to cerebral amyloid angiopathy (condition in which proteins called amyloid build up on the walls of the arteries in the brain and can cause bleeding into the brain (hemorrhagic stroke) and dementia), cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain) and repeated falls. A review of the electronic medical record included the following Minimum Data Set (MDS), an assessment tool used to facilitate the management of care,: MDS dated [DATE] coded as discharge assessment-return anticipated. MDS dated [DATE] coded as discharge assessment-return anticipated. The MDS dated [DATE] indicated the resident was admitted on [DATE]. The resident had a brief interview for mental status (BIMS) score coded as 99, which indicated the resident was unable to complete the interview. The resident's Cognitive Skills for Daily Decision Making was coded as three, severely impaired. The electronic Progress Notes included the following: On 12/22/22 Resident #321 was found on the floor and transferred to the ER. The resident was then discharged home to the family on 12/22/22. On 12/23/22 Resident #321 was readmitted to the facility. On 12/28/22 Resident #321 was found on the floor and transferred to the hospital. On 01/02/23 Resident #321 was readmitted to the facility. The resident's individualized comprehensive care plan included a care plan for at risk for falls due to history of falls, impaired balance/poor coordination, medication side effects, unsteady gait. 12/28/22 Actual Fall with Injury. Date Initiated: 01/05/2023. created by MDS Coordinator. Revision on: 01/10/2023. created by Director of Nursing (DON). The interventions listed included the following: Patient assessed by 2 nurses on floor, vitals taken, 911 call placed for immediate hospital transfer to [name redacted]. Date Initiated: 12/28/2022 Created by: DON Therapy evaluation and treatment as ordered Date Initiated: 01/05/2023 Created by: MDS Coordinator Have commonly used articles within easy reach Date Initiated: 01/05/2023 Created by: MDS Coordinator Maintain bed in low position Date Initiated: 01/05/2023 Created by: MDS Coordinator Provide assistance to transfer and ambulate as needed Date Initiated: 01/05/2023 Created by: MDS Coordinator Reinforce the need to call for assistance Date Initiated: 01/05/2023 Created by: MDS Coordinator Report development of pain, bruises, change in mental status/ADL function, appetite, or neurological status per facility guidelines. Date Initiated: 01/05/2023 Created by: MDS Coordinator There was no documented evidence that a care plan for risk of falls was initiated at the time of Resident #321's admission or within 48 hours of admission or subsequent readmissions after the resident's discharges with return anticipated. On 01/11/23 at 10:35 AM, the DON provided the surveyor two incident/investigations for Resident #321 which the surveyor had requested any incidents or investigations since the resident's admission to the facility. A review of the facility provided incident/investigations included the following: 1. Fall 12/22/2022 09:35. Incident Description: .resident was observed on the floor lying on the left side .Immediate Action Taken: During assessment, vs was taken .resident transferred back to bed, able to move extremities. No injury noted. Order received to sent resident to hospital by 911, family made aware. Attached was a Pain Evaluation Form and a Progress Note which included the same information in the incident form. There were no statements from staff members. There was no evidence an interdisciplinary team (IDT) meeting was held. There was no conclusion of the investigation. There was no added intervention to prevent a fall. 2. Fall 12/28/2022 13:00. Incident Description: .Resident found lying flat on floor with eyes closed .patient was arousable and opened eyes .patient assessed on floor .Spinal precautions maintained .Staff in patients presence while waiting for EMTs. Observed new discoloration to patients right side of forehead. It is an unwitnessed and unknown injury. Immediate Action Taken: Patient assessed by two nurses on floor, vitals taken, 911 call placed for immediate hospital transfer Attached was a Fall Risk Evaluation Form, a Pain Evaluation Form and a Progress Note which included the same information in the incident form. There were no statements from staff members. There was no evidence an IDT meeting was held. There was no conclusion of the investigation. There was no added intervention to prevent a fall. On 01/11/23 at 11:15 AM, the surveyor asked the DON if the incident investigations that were provided to the surveyor were the complete and thorough investigation since there were no staff statements and no conclusion. The DON stated that she would look to see where the statements were and added that she just started here on 12/16/22. The surveyor then asked the DON what the process was after a resident fall. The DON stated that the staff would complete an incident report, do a fall assessment, send the resident to the hospital if needed. She then stated that someone would obtain statements from staff, usually team will meet and care plan would be updated with a new intervention to prevent fall. She added that she would have to talk to the UM to see if statements were obtained. On 01/12/23 at 11:34 AM, the surveyor asked the UM what the process was when a resident was admitted in regard to the initial care plan. The UM stated that the supervisor who initiated the resident's admission would do the care plan which included falls, Activities of daily living, skin integrity, there are eight total and it is done in the electronic medical record. She then added that after the resident was here would do a comprehensive care plan and add medications and diagnoses. The surveyor asked if the resident had an initial care plan. The UM stated that she would not be able to view only the initial baseline care plan. She added that the baseline care plan should be the date of admission. On 1/12/23 at 11:45 AM, the surveyor interviewed the third floor UM regarding the process when a resident had a fall. The UM stated that the nurse and supervisor would be called and they would assess the resident. That if there was an injury the staff would provide first aid or call 911. The family and physician would be notified. The nurse would then initiate an incident report which included statements from staff. The same day or the following day the IDT would meet which included the DON, the assistant DON, physical therapist, recreation staff and Social Worker to discuss interventions [to put in place to prevent a fall]. She then added that if the fall was not witnessed the staff would investigate how the fall happened and how to prevent another fall. On that same date and time, the surveyor then asked the UM the reason why Resident #321's care plan did not include an additional intervention to prevent a fall after each fall. The UM stated that Resident #321 was transferred to the hospital both times after the falls. That the resident was sent out and did not come back and that the staff would revisit what intervention to put in place when the resident returned. The UM then stated that the first fall occurred on 12/22/22 and that the resident went to the hospital and the family took the resident home from hospital. The resident was then readmitted to the facility here on 12/24/22. The UM added that she was not here [when the resident returned]. The surveyor then asked the UM the reason why an intervention to prevent a fall was not implemented on 12/24/22. The UM stated that the resident did not return to the facility right away so it [an added intervention] was not revisited. She added that the resident was not our patient anymore so it [an added intervention] was not triggered to be revisited. The UM then stated that the resident was considered a new admission so there was not a trigger for the IDT team to meet. At that time, the surveyor then asked the UM if there was a IDT team meeting and any additional intervention was added to the care plan to prevent another fall when the resident returned to the facility. The UM stated that the IDT did not meet, so no additional interventions were added. The UM added that the resident had the interventions that were already in place. The surveyor then asked the UM why the date on care plan for fall risk was initiated (started) on 01/05/23 which indicated that the interventions listed were not implemented until 01/05/23. The UM stated that she did not know why the care plan had the date of 01/05/23 as when the care plan was initiated. The surveyor then asked the UM if Resident #321 had a care plan for fall risk initiated on admission. The UM stated that she could not say if the resident had the care plan for fall risk initiated on admission since she was not the person that did it. She added that during that time she had been the nurse on the medication cart so that was the reason why she did not know about the dates on the care plan. Furthermore, the UM then stated that the second fall was on 12/28/22 when the resident was noted to be on the floor in a storage room. The resident was transferred to the hospital and returned to the facility on [DATE]. The UM then stated that there was an IDT meeting but there was not an IDT note. She added that the interventions were to have physical therapy, given a recliner chair and to be supervised in the dayroom. She stated that the interventions were documented on 01/04/23 in the Progress Notes but that the interventions were not on the care plan. On 01/12/23 at 12:21 PM, the surveyor interviewed the UM again and asked the UM if the expectation was for Resident #321 to have a care plan for risk for falls prior to 01/05/23. The UM stated that she would expect the resident to have a care plan prior to 01/05/23 but that things are being done but not always on the care plan. She added that she did not know if the interventions would have been any different [prior to 01/05/23] then what was currently on the resident's care plan. The UM then stated that the process was to find out why they were falling to stop the next fall. She added that if warranted would put an additional intervention in place after a fall. The UM then stated that she wanted to clarify that the IDT was the one that put interventions into place on the care plan and that the nurses on floor did not. She added that the nurse may implement an immediate intervention but that the nurse does not update the care plan. The surveyor asked the UM is she was part of the IDT. The UM stated that she usually was part of the IDT but that because she had been working on the floor as a staff nurse she was not involved at the time. On 01/17/23 at 9:10 AM, the surveyor asked the DON where the statements for the investigations for Resident #321 were. The DON stated the UM didn't give it to you. Will check. On 01/17/23 at 11:30 AM, the surveyor interviewed the UM regarding the process for an incident investigation and if staff statements were obtained as part of the process. The UM stated that part of incident report is staff statements and that she gave the staff statements for Resident #321 to the DON last week. She then stated that the nurse assigned does the incident report and that the conclusion and intervention is done by the IDT. She stated that since the resident was discharged to the hospital and then discharged from the hospital to their home that a IDT meeting would not have been done. The surveyor then asked if after the second admission if a care plan should have been initiated. The UM stated that she was on a medication cart and did not check to see if the care plan was initiated after admission. She added that the Assistant DON (ADON) and DON are also responsible to look if the care plan is initiated at the time of admission. The UM then stated that when the second fall happened, they talked about it [fall] as it [fall] happened. The resident fell due to the obstruction in the storage room. The intervention was to check the storage room lock and send the resident to the hospital. On 01/17/23 at 11:42 AM, the surveyor asked the DON the reason why the staff statements were not with the incident reports and were not originally provided to the surveyor. The DON stated she did not have all the paperwork together because she had recently started at the facility and did not have an ADON or Infection Preventionist (IP) and was working the night shift at the facility. She added that the UM had the statements in her office and that the UM was on the medication cart two to three days a week. At that same time, the surveyor then asked the DON what the process was after a resident had a fall. The DON stated that at morning meeting the staff would discuss the fall and make physical therapy aware. The team would discuss why the fall happened and what the team could do to mitigate (to lessen the seriousness of) any risk for injury. She added that the nurse does the incident report and the nurse manager would review the incident report. She stated that she had just started. She stated that the IDT meeting should be documented in the electronic medical record and the care plan would typically be updated with any new interventions. Furthermore, the surveyor asked the DON if Resident #321 should have had a care plan for the risk for falls when the resident was admitted to the facility. The DON stated that the resident should have had a care plan and that the ADON or IP would have initiated the care plan. The DON then stated that the resident went to the hospital after both falls. The surveyor then asked the DON if Resident #321 should have had an intervention put in place after each fall. The DON stated that the staff would ask for a physical therapy evaluation and that it would depend on the fall. She added that it may not be a new intervention that is put in place but that it may be a continuation of fall precaution and it would depend on the cause of the fall. The surveyor then asked the DON if all the documents for an incident investigation was kept together. The DON stated that normally everything would be together for incidents and that they usually would be kept in nursing office. She added that she did not get to put it all together. The DON then stated that she was reprinting the incident reports and would make a copy of staff statements. On 01/17/23 at 12:34 PM, the DON provided the surveyor with two incident investigations for Resident #321. The surveyor asked the DON if they were the complete and thorough investigations. The DON checked the documents and stated that there was a page missing. On 01/17/23 at 12:59 PM, the DON provided the surveyor two additional documents which were Progress Notes and included the following: 1. 12/22/2022 13:00 Care Conference Note. LATE ENTRY. IDT met to discuss Resident #321's fall on 12/22/22 .Per IDT will reassess interventions once resident returns from ER. 2. 12/28/2022 19:49 Care Conference Note. LATE ENTRY.Team recommends to have resident follow up with rehab upon return to facility. A review of the facility provided incident investigations did not include documented evidence that an intervention was added to Resident #321's care plan after each fall. On 01/17/23 at 01:41 PM, the surveyor in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #321 did not have a care plan for risk of falls initiated upon admission and that there were no added interventions after each fall to prevent another fall. On 01/17/23 at 1:44 PM, the surveyor, in the presence of the survey team and the LNHA, asked the DON what the purpose of an investigation of a fall was. The DON stated that the goal was to minimize risk for potential injury. She added that the IDT was to put in a plan and that an intervention would go directly on the care plan to prevent a further fall. She then stated that the nurse manager is responsible to update the care plan. On 01/18/23 at 12:43 PM, the DON, in the presence of the survey team and the LNHA, stated that Resident #321 fell on [DATE] and that the intervention was to send the resident out to the hospital. She added that the family took the resident home from hospital and that when the resident came back to the facility that the resident was a new admission. The surveyor asked the DON if the resident was a discharge with a return anticipated (expected to return to the facility). The DON stated that it depended and that there was nothing documented. The DON then stated that the resident came back to the facility and a new assessment was done. She then stated that on 12/28/22 the resident went to the hospital. The surveyor asked the DON if the expectation after a fall was to add an additional intervention to prevent another fall. The DON stated not if they left there is no expectation for an added intervention to prevent a fall. The DON then stated that the intervention at that time was to go to the hospital. The surveyor asked the DON if the expectation was for a resident to have a care plan for risk of falls. The DON stated that all residents should have a care plan upon admission for a fall risk. The surveyor then asked the DON if the expectation was to have a thorough and complete investigation to include an intervention added. The DON stated that it was not expected to have a thorough investigation and an intervention if the resident went to the hospital. The surveyor then asked the DON if an investigation should be closed. The DON stated yes it should have been done. The surveyor then asked if the resident should have had a care plan initiated before 1/5/23. The DON stated that she would have done a care plan based on the resident's assessment when the resident returned to the facility. A review of the facility provided policy titled, Falls and Fall Risk, Managing with a revised date of March 2018, included the following: Under Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under Policy Interpretation and Implementation Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. if a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at one). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable Under Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. A review of the facility provided policy titled, Fall Risk Assessment with a revised date of March 2018, included the following: Under Policy Statement The nursing staff, in conjunction with .others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Under Policy Interpretation and Implementation 1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time . 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility provided policy titled, Assessing Falls and Their Causes with a revised date of March 2018, included the following: Under Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Under General Guidelines .4. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly . Under Steps in the Procedure After a Fall: .8. Complete an incident report for resident falls no later that 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Under Documentation When a resident falls, the following information should be recorded in the resident's medical record: .6. Appropriate interventions taken to prevent falls. A review of the facility provided policy titled, Care Plans-Baseline with a revised date of March 2022, included the following: Under Policy Statement A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Under Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly car for the resident including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; . 2. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary per-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. 3. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements . A review of the facility provided policy titled, Care Plans, Comprehensive Person-Centered with an edited date of 4/25/2022, included the following: .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; .

Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure that the Registered Nurse (RN) had the specific competencies and skill sets necessary to care for residents' needs. This deficient practice was evidenced by the following: On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical records. The admission Record (AR; or face sheet which included the admission summary) showed that the resident was admitted to the facility with diagnoses that included Diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin), chronic kidney disease (a gradual loss of kidney function over time), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside heart and brain to narrow, block, or spasm). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 12/19/22 showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The QMDS included that the resident had a facility-acquired unstageable deep tissue injury (DTI) wound. The Order Summary Report (OSR) showed that there was a physician's order dated 12/24/22 to apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) ointment to left bunion every evening shift daily and PRN (as needed). Another physician's order dated 11/11/22 for skin prep wipes (treats severely dry or chapped skin, minor burns, and other skin irritations) apply to the left plantar foot every day and evening shift and dated 12/30/22 skin prep apply to the left foot, left 5th toe two times a day for eschar (a collection of dry, dead tissue within a wound). The personalized care plan did not reflect the actual wounds that the resident had on the left bunion, left foot, left plantar, and left 5th toe. The Wound Consult (WC) notes dated 01/05/23 showed the left bunion, left plantar foot, left distal lateral foot, and left lateral 5th toe were all pressure ulcers. The 01/05/23 WC notes included that the left bunion was a stage four (is the most severe form of bedsore, also called a pressure sore, pressure ulcer, a deep wound reaching the muscles, ligaments, or bones) and left plantar foot, left distal lateral foot, and left lateral 5th toe were all DTI (deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). A review of the Braden Scale for Predicting Pressure Sore Risk (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure; currently a tool used by the facility in the assessment of a resident ) was last done on 6/21/22. A review of the [name redacted] transcript record for RN/UM education that was provided by the Director of Nursing (DON) showed that the RN/UM had education about Pressure Injury Assessment, Interventions, and Prevention that was completed on 12/12/21. There was no education provided for pressure injury in 2022. On 01/09/23 at 11:22 AM, the RN/UM informed the surveyor that she was the assigned nurse to the resident. Both the surveyor and the RN went to the resident's room to observe the status of the resident's left foot wounds. At that time, the RN/UM removed the left foot dressing of Resident #15 and showed the left bunion and left distal lateral foot wounds to the surveyor. The surveyor asked the RN/UM to describe the wounds including the stage of the wound. The RN/UM was not able to describe the wounds and stated I have to check the record first. On 01/09/23 at 11:50 AM, during an interview of the surveyor with the RN/UM, the RN/UM stated that the Wound Nurse (WN) left the facility, and the responsibility of weekly wound monitoring was now transferred to the RN/UM. She further stated that the responsibility of WN included once a week of rounding with the Wound Doctor (WD) and verifying wound staging and orders. The RN/UM was not able to state the exact date and approximation of when the WN left. On 01/10/23 at 9:12 AM, the surveyor interviewed the DON. The surveyor asked the DON what was the expectation for nurses with regard to wound care and management. The DON stated that it was an expectation that nurses will be able to describe the wound that included the stage of the wound and its location. The surveyor notified the DON of the above findings. On that same date and time, the DON stated that I don't know what her (RN/UM) skill set was. The DON acknowledged that the RN/UM should be able to describe the wound as a nurse and an RN for her to notify the physician when a new wound developed, be able to suggest appropriate treatment, and not wait for the WD who comes once a week for the resident to get the treatment and care needed in the management of the wound. At that same time, the DON informed the surveyor that the left foot wounds were probably diabetic wounds, and not pressure ulcers. The surveyor asked the DON if that was the case, and why the RN/UM did not verify that the wounds were not pressure ulcers since the left bunion was identified on 8/04/22, the DON had no answer. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and the DON and were made aware of the above findings. The surveyor followed up regarding the RN/UM's signed job responsibility, and the DON did not provide additional information. On 01/18/23 at 9:42 AM, the surveyor met with the RN/UM in the presence of the Licensed Practical Nurse (LPN). The RN/UM stated that she was unable to remember that she did the competency for medication and treatment pass in the facility. The RN/UM further stated that she did not sign UM Job responsibility. Furthermore, the RN/UM stated that she was off from November 2022 and came back on January 3rd of 2023. She further stated that the resident was due on September 2022 for a Braden Scale for Predicting Pressure Sore Risk assessment and it was not done probably because she was pulled all over places and at times was assigned to the cart, and it was missed. The RN/UM further stated honestly, it was not done, as it was supposed to be done quarterly. A review of the facility provided Unit Manager Essential Duties and Responsibilities (UMEDR) that was provided by the DON showed that the document was signed by the RN/UM on 01/18/23. The UMEDR was signed after the surveyor's inquiry. In addition, the UMEDR daily responsibilities included that the UM will review the following documentation for completion and identification of potential issues that included but were not limited to weekly head-to-toe skin assessments. On 01/18/23 at 02:16 PM, during the exit conference of the survey team with the LNHA and the DON, there was no additional information provided by the facility. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain the kitchen in a sanitary manner as evidenced by the following: On 01/06/23 at 11:31 AM, the surveyor toured the kitchen on the second day with Food Service Director (FSD). The surveyor observed the food prep area with open food and kitchen staff preparing the lunch meal trays. Above the prep area were two kitchen tiles in between two air vents with an accumulation of black debris. At that time, the FSD stated that the black debris was an accumulation of dust. The surveyor asked the FSD regarding the cleaning schedule of air vents and above kitchen tiles. The FSD informed the surveyor that the air vents and above tiles should be cleaned once a month by the night shift kitchen staff and that there was a log for cleaning. In addition, the surveyor asked the FSD to show the cleaning log and when was the last time it was cleaned. On that same date and time, the FSD was not able to provide documentation and log that the air vents and tiles were cleaned. The FSD stated that there were no cleaning logs. He further stated that the air vents and above tiles should have been cleaned and that there should be no accumulation of dust because it was directly below the food prep area with open food. A review of the facility's Sanitization Policy with an edited date of 12/29/22 that was provided by the FSD included that the food service area is maintained in a clean and sanitary manner and that all kitchens, kitchen areas are kept clean, free from garbage and debris, and protected from rodents and insects. On 01/17/23 at 01:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and were made aware of the above findings. The LNHA stated that there was no additional information. NJAC 8:39-19.7 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/05/23 at 12:11 PM, the surveyor toured wing one of the third floor unit 3rd floor. The surveyor observed room [ROOM NUMBER] with a sign that indicated the unsampled resident was on TBP and required a gown, gloves, N95 mask and eye protection to be donned (put on) prior to entering the room. On 01/05/23 at 12:14 PM, the surveyor observed CNA#3 exit room [ROOM NUMBER] with a yellow disposable gown on and doffed (take off) the gown and placed it in a covered garbage gown that was across the hallway. The surveyor then asked CNA#3 the reason she did not doff the gown before exiting the room. CNA#3 stated that she used the garbage can in the hallway because the garbage can was full in the room. On 01/05/23 at 12:18 PM, the surveyor interviewed LPN#2 that was in the hallway. The LPN confirmed that she observed CNA#3 doff the gown in the hallway. The surveyor asked the LPN what the process was to exit a TBP room. The LPN stated that the gown should be taken off and put in the garbage in the room before exit. On 01/17/23 at 01:41 PM, the surveyor, in the presence of the survey team, notified the LNHA and DON the concern regarding the doffing of the gown in the hallway. On 01/18/23 at 12:31 PM, the DON, in the presence of the survey team and the LNHA, stated that the staff were educated on donning and doffing for TBP. She added that the gown should have been doffed inside the room. NJAC 8:39-19.4(a)(1)(n) Based on observation, interview, and review of the facility documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two of eight staff and, b) properly dispose of PPE (personal protective equipment) for one of two staff observed in TBP (transmission based precautions) room in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, and this should be done outside the water when rubbing your hands, then rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. 1. On 01/05/23 at 10:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that the most recent COVID-19 outbreak was on 01/04/23 with three residents. On 01/06/23 at 8:38 AM, the surveyor observed Certified Nursing Aide#1 (CNA#1) picked up a plastic bag of garbage from Resident#119's room, walked outside the room with both gloves on, discarded the plastic bag in the covered bin in the hallway, removed and discarded the used gloves into the same covered bin, and entered the resident's room without performing hand hygiene. The resident's room was not in isolation and there was no TBP sign. On that same date and time, the surveyor observed inside the resident's room, CNA#1 placed a clean towel on top of the unmade bed, transferred Resident#119 from a wheelchair into the bed, and CNA#1 exited the resident's room without performing hand hygiene. At that time, the surveyor interviewed and asked CNA#1 about hand hygiene and infection control. CNA#1 stated that she was educated about hand hygiene and infection control by the Nurse Educator (NE). She further stated that hand hygiene should be performed immediately after removing gloves, before exiting the resident's room, before and after direct contact with the resident, and there should be no gloves in use while in the hallway. The surveyor then asked CNA#1 if she performed hand hygiene according to what she explained when she took care of Resident #119, CNA#1 stated I should have. CNA#1 acknowledged that she did not perform hand hygiene. On 01/06/23 at 8:55 AM, the surveyor observed CNA#2 did not perform hand hygiene before and after entering the TBP room [ROOM NUMBER] for less than one minute after picking up the tray. CNA#2 informed the surveyor that the room was in isolation for COVID-19 and was aware that hand hygiene should be performed before and after going out of the room. There were signs outside the room for Contact/Droplet precautions and instructions to perform hand hygiene before entering and after leaving the room. CNA#2 performed hand hygiene with the use of ABHR after the surveyor's inquiry. At that same time, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that the resident in room [ROOM NUMBER] was on TBP for COVID-19, was negative from the most recent COVID-19 testing, asymptomatic, and just waiting to complete the 10th day of isolation. On 01/09/23 at 11:13 AM, the surveyor observed room [ROOM NUMBER] had no signs for TBP and no PPE hung outside the door. The Registered Nurse/Unit Manager (RN/UM) stated that the resident completed the 10 days of isolation and remained asymptomatic. On 01/11/23 at 12:11 PM, the survey team met with the LNHA and DON and were made aware of the above findings. On 01/17/23 at 8:40 AM, the surveyor in the presence of the survey team met and asked the DON who was also the Infection Preventionist Nurse (IPN) regarding facility protocol for hand hygiene and PPE use. The DON stated that anytime the staff enters the room, after direct care, or removal of PPE, staff should use ABHR (alcohol-based hand rub), and hand washing with soap and water after three to five direct care of residents. The DON further stated that it does not matter if there's an isolation sign or not, before entering the room, staff should perform hand hygiene, remove gloves and immediately perform hand hygiene before exiting the room. On that same date and time, the DON stated that all facility staff received in-service about hand hygiene and PPE use, and that staff should know what to do. She further stated that the above protocol of the facility was based on CDC. The DON stated that she spoke with CNA#1 and #2 about the above findings and acknowledged that the two aides did not perform appropriate hand hygiene. The DON did not refute the surveyor's findings. A review of the facility's Handwashing/Hand Hygiene Policy with a reviewed date of 02/28/20 that was provided by the DON included that all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitor. Hand hygiene is the final step after removing and disposing of PPE, the use of gloves does not replace hand washing/hand hygiene. In washing hands.

Based on observation, interview, and record review, it was determined that the facility failed to: a) follow a physician's order with regards to the use of an assistive device for one of three residents, Resident #5 reviewed for the limited range of motion (ROM); b) utilized the Braden Scale for Predicting Pressure Sore Risk (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ) for two of four residents, Residents #15 and #83 reviewed for pressure ulcers; c) follow a physician's recommendation and discontinuing a wound treatment for a healed wound in a timely manner for one of four residents (Resident#136) reviewed for wounds. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 01/06/23 at 9:02 AM, the surveyor observed Resident #5 seated in a wheelchair inside their room and not wearing an assistive device (splint) to the left hand with limitation. The surveyor reviewed the resident's medical record. The resident's admission Record (AR; or face sheet that included admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to Heart failure, peripheral vascular disease ( a slow and progressive circulation disorder), and essential hypertension (elevated blood pressure). The Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 12/01/22, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which reflected that the resident's cognition was moderately impaired. The QMDS revealed that the resident had a functional limitation in ROM in the upper extremity and lower extremities. The Order Summary Report (OSR) for December 2022 revealed an order dated 4/14/22 for a splint-apply left-hand grip roll after morning care and remove after dinner as tolerated, to release during care, ADLs and skin check, every day and evening shift for contracture prevention and to document if refused. The OSR for January 2023 showed that the 4/14/22 order was updated on 1/13/23 and revealed the same order for the left-hand grip roll. On 01/09/23 at 11:38 AM, the surveyor observed the resident seated in a wheelchair inside their room with no splint left-hand grip roll. There was no splint at the bedside. On 01/09/23 at 11:39 AM, the surveyor interviewed the Certified Nursing Aide#1 (CNA#1) and informed the surveyor that she was the aide of Resident #5. CNA#1 stated that the resident was cognitively impaired, required total assistance with care and activities of daily living (ADLs), and was able to feed themselves post set up. She further stated that the resident had no splint or other assistive device. On that same date and time, CNA#1 acknowledged that the resident had a limitation on the left side of the body. She further stated that was on functional maintenance program (FMP) active ROM in both upper and lower extremities and well tolerated. She indicated that there were no significant changes noted with the resident's ADLs, the resident had limitations to extremities and not something new to the resident. On 01/10/23 at 11:05 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1). LPN#1 stated that Resident #5 was cognitively impaired. At that time, both the surveyor and LPN#1 entered the resident's room and observed the resident seated in a wheelchair not wearing a splint left-hand grip roll. Upon exiting the resident's room, the surveyor asked the nurse if the resident was wearing an assistive device. LPN#1 stated that she did not see the resident wear a splint or any assistive device. Furthermore, the surveyor asked LPN#1 why she signed the January 2023 electronic Treatment Administration Record (eTAR) for having the left-hand grip roll when she did not observe and applied a splint to the resident, and LPN#3 did not respond. LPN#1 acknowledged that she worked on January 2023 and she signed the eTAR that the left-hand grip roll was applied even though it was not. LPN#1 indicated that there were no significant changes noted with the resident and that the limitation to the resident's left hand was not something new to the resident. On 01/11/23 at 12:11 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and were made aware of the above findings. A review of the facility's Physician Orders Policy with a revision date of 9/29/15 that was provided by the DON included that policy directives known as Physician Orders will be obtained to manage the medical condition and a plan of care for each resident should be followed. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and the DON. The DON stated that there was no additional information. The DON did not refute that there was an order for a left-hand grip roll for Resident #5. 2. According to the RAI (Resident Assessment Instrument) Manual (helps nursing home staff in gathering definitive information on a resident's strengths and needs which must be addressed in an individualized care plan) revised on October 2019 M-2: Pressure Ulcer/Injury Risk Tools, screening tools that are designed to help identify residents who might develop a pressure ulcer/injury. The common risk assessment tool is the Braden Scale for Predicting Pressure Sore Risk. On 01/05/23 at 12:20 PM, the surveyor interviewed Registered Nurse/Unit Manager#1 (RN/UM#1) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical records. The AR showed that the resident was admitted to the facility with diagnoses that included Diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin), chronic kidney disease (a gradual loss of kidney function over time), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside heart and brain to narrow, block, or spasm). The QMDS with an ARD of 12/19/22 showed a BIMS score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The QMDS included that the resident had a facility-acquired unstageable deep tissue injury (DTI) wound. The electronic medical record showed that the Braden Scale assessment was last done on 6/21/22. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and the DON and were made aware of the above findings. On 01/17/23 at 02:27 PM, the surveyor met and asked RN/UM#1 regarding the facility practice and protocol with regard to the use of the Braden Scale, how often it should be done, and who was responsible for completing the assessment in the presence of another surveyor and the facility's Director of Social Services (DSS). The RN/UM stated that the facility's protocol was that the Braden Scale assessment was the responsibility of the nurses, ultimately the Unit Manager (UM), and should be done every three months (quarterly). On that same date and time, the surveyor asked RN/UM#1 why the resident's Braden Scale assessment was last done on 6/21/22. The RN/UM stated that she was off from November 2022 and came back on January 3rd of 2023. She further stated that the resident was due on September 2022 for a Braden Scale assessment and it was not done probably because she was pulled all over places and at times was assigned to the cart, and it was missed. RN/UM#1 further stated honestly, it was not done, as it was supposed to be done quarterly. On 01/18/23 at 01:56 PM, the DON provided a copy of the Braden Scale for Predicting Pressure Sore Risk for an effective date of 9/13/22 and electronically signed (esigned) by RN/UM#1 on 01/18/23. The surveyor asked and verified with the DON why the 9/13/22 Braden Scale assessment was signed on 01/18/23 after the surveyor's inquiry. The DON acknowledged that the Braden Scale assessment for the date 9/13/22 was backdated (to date earlier than the actual date; predate; antedate) and was done and esigned on 01/18/23. The DON did not refute the findings. On 01/18/23 at 02:16 PM, during the exit conference of the survey team with the LNHA and the DON, there was no additional information provided by the facility. 3. On 01/11/23 at 11:04 AM, the surveyor observed Resident #83 seated in a wheelchair with a covered sheepskin (shearling chair pads add a soft, cushy comfort to any surface), clean and well-dressed. The surveyor reviewed the medical records of Resident #83. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia with other behavioral disturbance, major depressive disorder, peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart), anemia ( a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissue), and essential hypertension (elevated blood pressure). The QMDS with an ARD 11/30/22 showed that the resident's cognitive skills for daily decision-making were severely impaired and at risk for developing a pressure ulcer. The QMDS revealed that there was no wound identified during the lookback period. The resident's personalized care plan with a focus that the resident was at risk for alteration in skin integrity related to impaired mobility and incontinence was created on 9/06/18 with a goal to decrease/minimize skin breakdown. The electronic medical record showed that the last Braden Scale assessment was on 4/19/22 with an incomplete assessment. The 4/19/22 Braden Scale assessment was incomplete because it was not esigned. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and the DON and were made aware of the above findings. On 01/18/23 at 9:42 AM, the surveyor interviewed RN/UM#1 in the presence of LPN#1 regarding the resident's Braden Scale assessment. The surveyor asked the RN/UM why the last Braden Scale assessment that was done on the resident was on 4/09/22 and if the assessment should have been done every quarter every time the MDS assessment was done. RN/UM#1 stated that the Braden Scale assessment was not done probably because she was pulled all over places and at times was assigned to the cart, and it was missed. On 01/18/23 at 12:29 PM, the survey team met with the LNHA and the DON. The DON stated that the Braden Scale for Predicting Pressure Sore Risk was the assessment tool that the facility utilized for the resident who is at risk for developing a pressure ulcer and should have been done every quarter. On 01/18/23 at 02:16 PM, during the exit conference of the survey team with the LNHA and the DON, there was no additional information provided by the facility. 4. On 01/05/23 at 10:46 AM, the surveyor interviewed RN/UM#2 who stated that Resident #136 had a pressure ulcer on the sacrum that was there upon admission. On 01/05/23 at 11:53 AM, the surveyor observed Resident #136 in bed with eyes closed, lying flat on their back. The resident responded to the surveyor knocking on the door and stated that he/she was watching the television had fallen asleep. The resident stated that he/she had no concerns and had no knowledge of any issues with his/her skin. On 01/10/23 at 11:08 AM, the surveyor interviewed LPN#2 who stated that she was responsible for administering any treatments to Resident #136 but was not the usual nurse and was a floater, meaning that she was not always working on the same floor. The LPN added that she knew she had to administer a cream for Resident #136 but was unsure of the cream and would have to check. LPN#2 added that previously the facility had a wound nurse who was doing treatments. LPN#2 added that she knew the resident currently had no wounds. On 01/10/23 at 12:01 PM, the surveyor interviewed CNA#2 who stated that she performed total care for Resident # 136. The CNA stated that she had seen a cream on the resident's sacrum area but thought there was no wound. On 01/10/23 at 12:30 PM, the surveyor reviewed the medical record for Resident #136. The resident's AR revealed a diagnosis of Alzheimer's disease with late onset, anorexia (a loss of appetite) and pressure ulcer of sacral region, stage 2. The admission MDS (AMDS) with an ARD dated 11/29/22, reflected a BIMS score of four (4) out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's January 2023 eTAR) revealed that there was a physician's order (PO) dated 11/26/22 for Silver Sulfadiazine (Silvadene) (an antimicrobial cream used to decrease the possibility of an open wound from becoming infected.) cream 1%, apply to bilateral buttocks topically every day and evening shift for care. Apply post care twice a day (BID). In addition, the eTAR revealed that the PO was being signed as administered by the nurses on the day shift and on the evening shift. The resident's wound physician's consultation dated 01/05/23 revealed that pressure ulcer located on the left buttock was resolved. Further review revealed a plan of care: Plan of care discussed with facility staff-although the left buttock has been resolved, continue moisture barrier cream. On 01/11/23 at 11:19 AM, the surveyor interviewed LPN#2 who stated that she administered the Silvadene cream to Resident #136's sacral area according to the physician's order. The LPN added that she thought the Silvadene cream was being used prophylactic(to prevent a wound from occurring) but could not speak to whether that was appropriate use of Silvadene cream on a healed wound. The LPN added that the resident had a prior wound on the sacrum that was treated with Silvadene cream and that the wound had healed but was unsure of the date the wound healed. The LPN then stated that a wound physician came in every week on Thursday mornings. On 01/12/23 at 10:25 AM, the surveyor interviewed via telephone the Regional Trainer Scribe Supervisor (RTSS) who stated that she was the scribe who works with the wound physician assigned to the facility. The RTSS stated that she works for the medical group of wound consultants and had been coming to the facility for years because she was assigned to the facility. In addition, the RTSS stated that she works closely with the physician assigned to the facility and would be able to answer any questions regarding the residents at the facility because she had all the records and the physician assigned to the facility had office hours and may not be available. The RTSS stated that she was at the facility that morning with the physician and had not seen Resident #136. The RTSS stated that she completes the recommendations as per the physician's orders and leaves the recommendations with the facility and then uploads them to her computer at the office. At that time, the RTSS was able to review her notes regarding Resident #136 and stated that the resident was seen by the physician from 11/24/22 until 01/05/23. The RTSS added that 01/05/23 was the last consult because the wound was healed and that was indicated on the wound consult left at the facility. In addition, the RTSS stated that the wound consult recommendation on 01/05/23 was to apply a moisture barrier cream. The RTSS stated that the Silvadene cream should have been discontinued on 01/05/23 because the wound was healed, The RTSS stated that Silvadene cream was not a prophylactic treatment because it does not work that way. The RTSS stated that she thought the facility would automatically discontinue the Silvadene cream because the wound was healed, and the moisture cream barrier was used for prophylaxis. The RTSS stated that she had been leaving the recommendations with a wound nurse from the facility, but that wound nurse had left the facility back in December. The RTSS stated that she currently left the paperwork, which was the recommendations, with the unit manager on each floor and does discuss recommendations with them if they were there but sometimes, she was in the facility in the early morning and the unit manager may not be there. The RTSS added that if there was no unit manager for the floor that she left the paperwork in the unit manager's office and if there were any questions, she was readily available. On 01/12/23 at 12:00 PM, the surveyor further reviewed the medical record for Resident #136. A review of the resident's electronic ORS revealed that there was a PO with a start date of 11/26/22 for Silver Sulfadiazine (Silvadene) cream 1%, apply to bilateral buttocks topically every day and evening shift for care. Apply post care BID. In addition, the PO had a discontinued date of 01/11/23. Further review of the electronic ORS revealed that the PO for Silvadene dated 11/26/22 was discontinued on 01/11/23 after surveyor inquiry. Further review of the January eTAR revealed that the Silvadene cream was applied from 01/05/23 until surveyor inquiry on 01/11/23. On 01/12/23 at 12:37 PM, the surveyor interviewed the DON who stated that the wound physician and RTSS came to the facility every Thursday and left recommendations. The DON added that the unit manager on the floor was responsible for following up with the recommendations for the residents on that floor. The DON stated that there was a disconnect because the RTSS left the consult recommendations with the RN/UM on the first floor and the RN/UM had unexpectedly called out and was not returning to the facility because she had previously resigned, and the recommendation was not done. The DON stated that the Silvadene should have been discontinued on 1/5/23. The DON added that a moisture barrier cream order was corrected yesterday. On 01/17/23 at 01:20 PM, the survey team met with the LNHA and DON. The DON stated that she was unsure if there was a policy and procedure for the wound consultant. The DON added that the procedure or process was that the recommendations from the wound consultant would go to the wound nurse or unit manager, whoever was designated that day and they would follow up with the recommendations. The DON stated that what happened with Resident #136 was that the RN/UM had not shown up on 01/06/23 and the recommendation was not done. The surveyor was not provided with a policy on the process for the wound consultant. A review of the facility's Pressure Injuries Overview Policy with a revised date of March 2020 that was provided by the LNHA included that the purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries that can be included but not limited to MDS assessments reference current definitions in the RAI User's Manual. A review of the facility's Pressure Injury Risk Assessment Policy with a revised date of March 2020 that was provided by the DON revealed that the purpose of this procedure is to provide guidelines for the assessment of the structure and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries included the use of only a facility-approved risk assessment tool to obtain risk assessment data. NJAC 8:39- 11.2(b), 27.1(a), 29.2(d)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received performance review for four of five CNA files reviewed. The deficient practice was evidenced by the following: On 01/12/23 at 12:50 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the education, competencies and performance reviews for five CNA's. On 01/13/23, the facility provided the education and competencies for four of the five CNA's. The facility indicated that one of the five CNAs had resigned. The facility did not provide performance reviews for the five CNAs. On 01/17/23 at 01:45 PM, the surveyor, in the presence of the survey team and the Director of Nursing (DON), asked the LNHA to provide the performance reviews for the four CNAs. The facility did not provide performance reviews for the five CNAs. On 01/18/23 at 9:00 AM, the surveyor, in the presence of the survey team, asked the DON and LNHA for the performance reviews for the five CNAs. The DON stated that she would have to check with Human Resources again. On 01/18/23 at 12:51 PM, the surveyor, in front of the survey team and DON, asked the LNHA what the purpose of the performance review was. The LNHA stated that the purpose was to review the job expectations and to see if the staff were meeting the expectations. The surveyor then asked the LNHA how often the performance reviews should be done. The LNHA stated that it was done annually. The surveyor asked the LNHA if the performance reviews were done for the five CNAs. The LNHA stated that he did not know if they were done. The surveyor then asked who was responsible for the performance reviews. The DON stated that the unit managers did the performance reviews and that the documentation then goes to Human Resources. On 01/18/23 at 12:53 PM, the surveyor then asked the LNHA if he could provide the performance reviews for the five CNAs. The LNHA stated that he did not have the performance reviews at this time. On 01/18/23 at 01:59 PM, the survey team met with the LNHA and DON to give them the opportunity to provide additional information. The LNHA stated that some processes needed to change. The LNHA did not provide the performance reviews for the five CNAs. On 01/18/23 at 02:04 PM, in the presence of the survey team. The LNHA asked the surveyor for the names of the five CNAs that the performance reviews were requested for. He stated that he had them [their performance reviews]. The LNHA left the conference room. On 01/18/23 at 02:06 PM, the LNHA entered the conference room and stated that he did not have the performance reviews. A review of the facility provided undated policy titled, Performance Evaluations included the following: 1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter . N.J.A.C. 8:39-43.17 (b)

Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired narcotic medications were removed from active inventory b) dispensed and received medication from the pharmacy were reconciled for accuracy which resulted in the wrong dosage stocked in the active inventory c) expired biological from 6/22 were removed from active inventory This deficient practice was identified for one of one of the electronic emergency (backup) machine [name redacted] observed and was evidenced as follows: 1. On 01/17/23 at 9:59 AM, the surveyor received the [name redacted] Inventory report from the Director of Nursing (DON). On 01/17/23 at 10:14 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that as a supervisor, she was responsible for the reconciliation of the narcotic medications stored in the backup machine (cycle counts) with another supervisor. The Supervisors alternate days as assigned. The UM/RN also stated, we do not reconcile the non-controlled substances. On 01/17/23 at 10:19 AM, the surveyor observed the RN/UM with the Licensed Practical Nurse (LPN) begin the cycle count for the controlled substance (narcotic) medications. At that time, the surveyor in the presence of the RN/UM and LPN, observed 15 of the 22 tablets for Lorazepam (medication used to treat anxiety) 0.25 milligram (mg) tablet that expired on 12/22/22. On 01/17/23 at 10:40 AM, the surveyor in the presence of the RN/UM and LPN observed one (1) of nine (9) tablets of Acetaminophen with Codeine (controlled pain medication) 300 mg/30 mg that expired on 12/15/22. At that time, the RN/UM stated expired medications should not have been in the backup machine. She informed the surveyor that during the narcotic cycle counts, the supervisors also checked for expiration, and it was missed. The RN/UM stated that she and the LPN were going to remove the expired narcotic medication, adjust the inventory, and notify the pharmacy. The removal was important to avoid administration to a resident who would not have received the full effect of the narcotic medication. 2. On 01/17/23 at 11:01 AM, the surveyor observed the RN/UM and the LPN begin the cycle count for the non-controlled substance medications. On 01/17/23 at 11:13 AM, in the presence of the RN/UM and LPN observed the compartment for Pramipexole (medication used to treat Parkinson disease) of 0.25 mg that contained six (6) tablets of Pramipexole 0.125 mg. Further review of the [name redacted] Inventory report reflected only a listing for Pramipexole 0.25 mg with a quantity on hand (QOH) of six. The RN/UM confirmed the same list did not include Pramipexole 0.125 mg and instructed the LPN to write the name of the medication name and the dose for further investigation. A review of the electronic Medical Record, Order Review Report dated 10/17/22 to 01/17/23. The report did not reveal Pramipexole 0.25 mg was ordered within the date range reviewed. 3. On 01/17/23 at 12:19 PM, in the presence of the RN/UM and LPN observed two (2) of four (4) syringes for Enoxaparin (medication used to prevent formation of clot) 30 mg that expired on 6/22. On 01/17/23 at 01:02 PM, during an interview with the surveyor, the RN/UM stated that the DON and the Assistant Director of Nursing (ADON) restocked the non-controlled medications. At that time, the surveyor received the [name redacted] Controlled Drug Count Record (CDCR) dated January 2023 from the RN/UM. The RN/UM stated that after the cycle count for the narcotic medications were completed each nurse signed the CDCR. The surveyor reviewed the CDCR dated 01/01/23 to 01/17/23 [up to the 7-3 AM shift] which reflected the dates reviewed were signed. A review of the facility provided CP Unit Inspection report in the past four months for the [name redacted] backup machine revealed the following: 10/11/22 -[name redacted] signature log, checked, indicated yes Back-up Box: -[name redacted] inventory par level (minimum and maximum quantity limits that was set for a certain item) checked, indicated not applicable -Comments: [name redacted] noted to have unresolved discrepancies at the time of inspection 11/8/22 -[name redacted] signature log checked, indicated yes Back-up Box -[name redacted] inventory par level checked, indicated not applicable 12/6/22 -[name redacted] signature log, checked, indicated yes Back-up Box -[name redacted] inventory par level checked, indicated not applicable -Comments: [name redacted] log missing counts 12/1, 12/3, 12/4, 12/5 and 12/6 1/9/23 -[name redacted] signature log, checked, indicated yes Back-up Box -[name redacted] inventory par level checked, indicated not applicable On 01/17/23 at 01:58 PM, the DON stated that the nursing supervisors checked the inventory counts and expiration of the narcotic medications daily while the Consultant Pharmacist (CP) checked the narcotic medication, and non-controlled medications once a month. The expired medications when found, was removed, and the manager was informed. On 01/18/23 at 9:50 AM, the surveyor called and left a message with CP's office. On 01/18/23 at 12:30 PM, in the presence of the survey team, the DON stated that it was to her impression the CP checked the back up machine for expired medications. The Pharmacist from the provider pharmacy filled the medication in the machine. The DON also stated that the facility did not receive the medication that was placed in the back up machine. The DON stated our process involved the supervisors who checked for expiration date and reconciled the medications in the backup machine. The DON acknowledged the supervisors should have checked for narcotic medications and non-controlled medications. On 01/19/22 at 9:52 AM, the surveyor called the CP's office and was informed that the CP had returned the call to the facility yesterday and thought that the inquiry was resolved. On 01/19/22 at 10:11 AM, the CP returned the call of the surveyor. During the interview with the surveyor, the CP stated she was familiar with the facility but had only started a few months ago since the facility had a different CP. The CP explained her responsibilities which included drug regimen review, medication pass observation, and unit inspections. She clarified part of her role in the unit inspection was to check the shift-to- shift log, which indicated if the narcotic count was done and recorded. The CP stated that she had no access to the backup machine since that was the property of the provider pharmacy. The CP stated she had not checked the expiration dating of the medications contained in the [name redacted] machine. She only checked expiration dating of medications in the carts or rooms. At that time, the CP stated that the unit inspection form had a section for back up box, the CP clarified that was not the backup machine. The CP stated the DON was new and LNHA was also fairly new and maybe there was a miscommunication. The backup machine was the property of the provider pharmacy and thought the maintenance of the backup machine would have been done through the provider pharmacy. A review of facility policy provided, Storage of Medications revised on 11/2020, included . Policy Interpretation and Implementation under section 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Section 4. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. NJAC 8:39-29.3(a)6, 29.4 (g)

Based on observation, interview, and record review it was determined that the facility failed to complete a wound treatment in accordance with the physician's order. This was identified for 1 of 1 residents (Residents #135) reviewed for wounnd treatments. The deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. 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 well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/22/21 at 11:23 AM, the surveyor observed a wound treatment to the sacral wound of Resident # 135. The wound treatment was done by the Licensed Practical Nurse (LPN) who was assigned to Resident # 135. There was a second LPN present for the treatment who was identified as the facility's wound nurse. According to the wound nurse and the LPN, the wound nurse was present to assist with positioning the resident. The wound nurse and the LPN washed their hands and began the wound treatment. The LPN set up a clean field after cleaning the overbed table and placing a barrier on the table to establish a clean field. The LPN placed items for the procedure on the clean field such as gauze, saline, and Z-Guard paste (a protective ointment used to relieve symptoms associated with prolonged exposure to moisture) which she squeezed from a tube into a plastic medicine cup and placed it on the clean field with the other items. The wound nurse positioned the resident and the LPN removed the dressing from the wound, cleaned the wound with saline soaked gauze, applied the Z-Guard paste with a gauze pad to the inside of the wound, then placed a border gauze on top. The surveyor asked the LPN to review the order as the surveyor watched. The LPN showed the surveyor the order on the Electronic Treatment Administration Record (ETAR) that read Z Guard paste to sacral peri wound daily and cover with dry dressing every day shift for wound care. The surveyor asked the LPN if she knew the meaning of peri wound. The LPN did not answer. The surveyor explained that the peri wound is the skin surrounding the wound. The LPN did not answer. On 1/22/21 at 12:15 PM, the surveyor reviewed the medical record for Resident # 135 which revealed the following: According to the face sheet the resident had been admitted to the facility with diagnoses which included Pressure Ulcer of the Sacral Region, Stage 4. The Physician's Order Sheet (POS) included an order that read Z-Guard paste to sacral peri wound daily and cover with dry dressing every day shift for wound care. The start date for the order was 9/18/20. A second physician's order concerning the wound which read Silver Sulfadiazine Cream 1% Apply to Sacrum topically every evening shift for wound care. Apply post NS and cover with dry dressing daily. The start date for the order was 1/22/21. The prior order concerning the sacral wound read Cleanse with saline and apply Silversorb and cover with dry dressing daily, every evening shift for wound care. The start date for that order was 12/31/20 and it had a stop date of 1/22/21. The most recent Minimum Data Set, an assessment tool dated 12/23/20, indicated that the resident scored a 99 when the Brief Interview for Mental Status was done. A score of 99 indicated that the resident was unable to complete the interview. On 1/22/21 at 12:30PM the surveyor asked the Unit Manager/Registered Nurse (UM/RN) about the physician's order for Z Guard paste to the peri wound. The UM/RN explained that the order was to apply the Z Guard paste around the wound. The Surveyor then spoke with the Wound Nurse and asked what the order meant, she agreed that the order meant to apply the Z Guard paste around the wound and that there was no cleansing of the wound ordered for the day shift. The wound nurse further stated that the order was confusing and she would contact the doctor for clarification. The surveyor noticed on the ETAR that most days the LPN who had been observed doing the wound treatment was the LPN who had signed for the treatment. The surveyor asked the LPN if she did the wound treatment every day the way she had done it today. She said the order was always changing. The surveyor pointed out to the LPN that the treatment order had been in effect since 9/18/20. The LPN did not respond. On 1/26/21 at 9:00 AM the surveyor reviewed the facility's policy and procedure titled Clean Dressing Change. Under the heading Process number 1 read; Review physician's order for wound cleansing and treatment. Number 5 read; Clean the wound as indicated or according to physician's order. Number 6 read: Treat the wound as ordered by applying any medicated ointments, packings, etc. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to obtain a physician's order for the use of Oxygen and failed to maintain safe cleaning and storage of BiPAP (a Bi-level positive pressure airway ventilation machine to improve oxygenation) equipment according to professional standards of practice. This deficient practice was observed for 2 of 3 residents (Resident #21 and #177) reviewed for oxygen use and was evidenced by the following: 1. On 1/19/21 at 11 AM, the surveyor observed Resident #21 in bed awake and alert to person, place and date. The resident was receiving Oxygen 2 liters per minute (LPM) via a nasal cannula. The surveyor observed the tubing was dated 1/18/21. During the interview, the surveyor observed a BiPAP machine on top of the resident's dresser. The surveyor asked the resident about the use of the BiPAP machine. The resident stated that the 3-11 shift nurse places the face mask and connects the tubing to the machine each night to help her breathe easy as he/she sleeps and the 11-7 shift nurse removes the mask and tubing at approximately 6 AM. The surveyor observed the BiPAP mask and tubing lying in the top drawer of the dresser co-mingled with other items in the drawer. The surveyor also observed approximately one quarter inch of water inside the water chamber that was attached to the BiPAP machine and there was condensation of water droplets throughout the chamber. The oxygen tubing attached to the BiPAP had a change date of 1/6/21. Resident #21 stated at that time that the mask, tubing and water chamber should be cleaned after each use but the nurses were not cleaning it. The resident stated I wish they would clean it everyday. I don't understand why they don't. When the surveyor asked the resident how it made her/him feel, the resident responded that it upsets me, at least they could wipe the mask clean, I tell them but they don't do it. The resident stated as recent as the morning of 1/19/21, the nurse did not clean the equipment. On 1/22/21 at 12:40 PM, the surveyor observed the BiPAP machine water chamber with the approximately one quarter inch water at the bottom of the chamber. The surveyor observed the mask and tubing secured in a plastic bag. The resident stated they still haven't cleaned my equipment. The resident further stated that she/he stopped asking for the equipment to be cleaned because the nurses didn't do it. At 12:45 PM, the surveyor interviewed the Licensed Practice Nurse (LPN #1) who was assigned to the resident. LPN #1 stated that she didn't notice that there was water left in the water chamber and wasn't aware that the equipment was not cleaned after use. She stated the 11-7 shift was responsible for removing and cleaning the BiPAP equipment. At 1 PM, the surveyor spoke to the Registered Nurse Unit Manager (RNUM). The RNUM confirmed that 11-7 shift nurses were responsible for cleaning the equipment after each use. The RNUM was not aware of the resident's concerns nor was she aware that the equipment wasn't being clean. The surveyor reviewed Resident #21's medical record that revealed the following: According to the admission Record, Resident #21 was admitted in January 2016 with diagnoses that included Chronic Obstructive Pulmonary Disease, Asthma, and Obstructive Sleep Apnea. The Quarterly Minimum Data Set (MDS) an assessment tool dated 10/31/21, indicated that the facility performed a Brief Interview for Mental Status (BIMS) to determine the resident's cognitive status. The resident scored a 12 out of 15, which indicated that the resident was cognitively intact. The January 2021 Order Summary Report revealed the resident had a physician's order for BiPAP to be placed on at 10:15 PM and removed at 7:00 AM. There was an additional physician's order for the tubing and chamber to be changed monthly for BiPAP maintenance. However, there was no physician's order to maintain the cleaning and proper storage of the BiPAP equipment after each use. The January 2021 Electronic Treatment Record (ETAR) showed that there was no physician's order for the proper cleaning and storage of the BiPAP after each use. The nurses were signing that the BiPAP was placed on at 10:15 PM and removed at 7:00 AM. Resident #21's care plan At risk for respiratory impairment related to hypercapnia, h/o sleep apnea, asthma, CHF, use of O2 via NC included one intervention under Intervention/Tasks dated 1/16/20: Bipap machine at 20/7 with O2 at 2l/m, check skin integrity q shift. There were no other interventions to include the safe care and proper storage of the BiPAP equipment after use. At 1:45 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing (DON) and requested the policy and procedure for BiPAP care. On 1/26/21 at 9:30 AM, the surveyor interviewed an RN who worked 11-7 shift. She stated she cleans the mask with a wipe. The surveyor asked if the mask was only to be wiped after use. The RN stated she cleans the mask, tubing and water chamber with soap and water and allows the equipment to air dry. When the surveyor informed the RN of the observations and the resident's concern that the BiPAP equipment was not cleaned, she had no further comment. The surveyor was not able to contact the other 11-7 shift nurses identified on the ETAR for comment. The surveyor reviewed the facility's policy titled CO CPAP/BiPAP Support dated 6/7/18 that revealed under General Guidelines for Cleaning: Daily Masks and nasal pillows: clean daily with mild soap and warm water. Rinse thoroughly with warm water and allow to air dry. Weekly Headgear (strap) & Tubing: Clean weekly with mild soap and warm water. Rinse thoroughly with warm water and allow it to air dry. Machine cleaning: Wipe machine with damp cloth once a week and as needed. Humidifier, a. Use clean, distilled or steril water only in the humidifier chamber. Avoid leaving water in the chamber between uses. b. Clean humidifier weekly with warm water and mild soap; air dry. Filter cleaning; Rinse washable filter under running water once a week to remove dust and debris. Replace the filter at least once a year. Monthly: Replace disposable filters monthly. 2. On 1/19/21 at 11:08 AM the surveyor observed Resident # 177 in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at slightly above 2 LPM. On 1/20/21 at 12:00 PM the surveyor observed Resident # 177 in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at slightly above 2 LPM On 1/20/21 at 12:17 PM the surveyor reviewed the resident's medical record which revealed the following: According to the resident's face sheet the resident was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease. The most recent Minimum Data Set (MDS) an assessment tool dated 1/11/21, revealed the resident scored a 15 of a possible 15 when the Brief Interview for Mental Status was done, which indicated the resident was cognitively intact. The surveyor reviewed the physician's order sheet (POS) for January 2021 and it did not include a physician's order for oxygen therapy. The only order associated with oxygen therapy read change nasal cannula every week on wed one time a day every Wed and it had a start date of 10/9/19. On 1/20/21 at 12:26 PM the surveyor spoke with LPN #3 who was assigned to Resident # 177. The surveyor asked LPN #3 where the physician's order for oxygen therapy was. LPN #3 checked the POS and did not see an order. The surveyor asked how long the resident had been receiving oxygen therapy. LPN #3 stated She's been using the oxygen for as long as I've been here. I've been here a year. They should have an order if they are on oxygen. She looked again and there was no physician's order for the oxygen. She said she would call the physician. On 1/21/21 at 11:14 AM the surveyor observed the resident in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 LPM. The surveyor reviewed a physician's order dated 1/21/21 at 06:22 AM which read Oxygen at 3 Liters/minute Via: NC every shift. On 1/21/21 at 1:22 PM the surveyor spoke with LPN #3 who was assigned to the resident and asked about the physician's order for 3 LPM of oxygen. LPN #3 didn't know about the order. She looked at the POS and said I don't know, it does say 3 LPM let me find out. LPN #3 went to another LPN (LPN #4) and asked about the new physician's order for 3 Liters of oxygen. The surveyor spoke with LPN #4 and asked her about the new physician's order for 3 Liters of oxygen. LPN #4 explained that when she started her shift that day she noticed that another nurse had obtained a physician's order for oxygen at 2 LPM. The LPN explained that she knew the resident well and the resident needed more than 2 LPM because at 2 LPM the resident's oxygen level would decrease. LPN #4 said she called the physician and obtained an oxygen order for 3 LPM. The surveyor reviewed the resident's oxygen levels for the month of January 2021 which were recorded on the Medication Administration Record and they were all between 96% and 99%. On 1/25/21 at 1:00 PM, the survey team spoke with the Administrator and the Director of Nursing (DON) and shared the concern of Resident # 177 receiving oxygen therapy without a physician's order. The DON stated that she knew the resident did have a physician's order for the oxygen therapy in the past but it must have gotten dropped at some point. On 1/26/21 at 9:00 AM the surveyor reviewed the facility's policy and procedure titled Oxygen Administration. Under the heading Purpose it read The purpose of this procedure is to provide guidelines for safe oxygen administration. Under the heading Preparation number one read Verify that there is a physician's order for this procedure. NJAC 8:39-27.1(a)