Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 1 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #92). This deficient practice was evidenced by the following: On 02/27/2025 at 8:38 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #92 as follows: A review of the SNFBPNR for Resident #92 indicated a Medicare Part A start date of 11/27/2024 and last covered day was 01/10/2025 and Resident #92 remained in the facility. A further review of the SNFBPNR revealed under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was handwritten stayed in the facility. Under 2. Was a Notice of Medicare Non-Coverage (NOMNC) (CMS 10123) provided to the resident? There was nothing marked to indicate whether the resident received the NOMNC or not. During an interview with the surveyor on 02/27/2025 at 9:23 AM, Social Worker (SW #1), was questioned regarding Resident #92, who stayed in the facility after the provider initiated the discharge from Medicare Part A services without receiving the SNFABN and NOMNC. SW #1 said that Resident #92 did not these forms after staying in the facility following discharge from Medicare Part A services because she was unaware that these forms needed to be provided to Resident #92. During an interview with the surveyor on 02/27/2025 at 9:49 AM, the Director of Social Work (DSW) was questioned about Resident #92, who remained in the facility after the provider initiated the discharge from Medicare Part A services without receiving the SNFABN and NOMNC. DSW said that she recalls having a conversation with Resident #92 and their family regarding these forms, but she was unsure why they were not provided. NJAC 8:38-4.1(a)(7)

Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to develop and implement an individualized comprehensive care plan for a resident on antidepressant medication (medication used to treat clinical depression). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #12) and was evidenced by the following: On 02/24/2025 at 10:16 AM, during the initial tour, Resident #12 was identified as being on antidepressant medication. A review of Resident #12's Electronic Medical Record (EMR) on 2/24/2025 at 2:01 PM, revealed the following: A review of the admission Record reflected the resident had diagnoses that included history of falling and depression. A review of the most recent comprehensive Minimum Data Set, an assessment tool dated 1/7/2025, revealed that the resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. A further review of the MDS reflected use of antidepressant for Depression. A review of the Order Summary Report (OSR) with active orders dated 2/28/2025, revealed the following: Zoloft Tablet 50 milligrams; Give 2 tablets by mouth one time a day for Depression. A review of Resident #12's care plan did not include documentation that Resident #12 was on antidepressant medication. During an interview with the surveyor on 02/28/2025 at 08:30 AM, the Registered Nurse/ Unit Manager (RN/UM #2) stated that psychotropics (medications that affect the mind used to treat conditions such as depression) should have a care plan because of potential side effects. During an interview with the surveyor on 02/28/2025 at 09:11 AM, the Assistant Director of Nursing (ADON) stated that psychotropic medications needed to have a care plan. A review of the facility policy titled Psychotropic Policy (Behavior Management) with a reviewed date of 2/28/2025 revealed under Procedure #6: The goals of psychotropic medication . will be addressed in the resident's care plan. The care plan will also include the type of psychotropic drug(s) to be monitored for side effects daily, such as gait disorders, movement disorders, cognitive or behavior changes, discomfort (pain, constipation .), signs of hypotension . NJAC 8:39-11.2(e)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to update a resident care plan, specifically for newly identified wounds, for 1 of 30 residents reviewed for comprehensive person-centered care plans, (Resident #63). This deficient practice was evidenced by the following: During the initial tour of the facility on 02/24/2025 at 11:00 AM, Resident #63 was observed lying in bed with air mattress in place on the bed and bilateral heel booties in place. A review of the EMR on 02/24/2025 at 11:37 AM, revealed the following: According to the admission Record, Resident #63 was admitted to the facility with diagnoses including but not limited to: Palliative Care, Alzheimer's disease, and pressure ulcer left buttock stage 4. A review of the Quarterly Minimum Data Set, an assessment tool, dated 02/22/2025 revealed under section M Resident #63 had the following wounds; 1 stage 2, 1 stage 4 and 4 unstageable (Unstageable pressure ulcers are wounds that the bottom of the sore is covered by: slough, which is debris that appears tan, yellow, green, or brown in color or eschar that can be hard plaque that's tan, brown, or black in color) wounds. A review of the physician orders indicated active treatments to all identified wounds. According to the facility weekly wound observation tools completed by facility nursing staff revealed the resident had the following wounds: 1. previously identified pressure stage IV (4) left gluteus (commonly known as the buttocks) improving. 100% granulation (pink soft granular appearance on healing wound) tissue 2. on 01/17/2025 sacrum stage 2 and bilateral buttocks unstageable 40% slough; 60% granulation improving 3. on 02/08/2025 left ischium stage 2 100% granulation 4. on 02/15/2025 left lateral buttocks pressure unstageable improving 100% slough. A review of the current care plan showed a Focus area of; I have actual impairment to skin integrity of the left hip to gluteus related to poor circulation with initiated date of 09/20/2024. There was no care plan for the wounds on the sacrum, and bilateral buttocks, left ischium or the left lateral buttocks. During an interview with the surveyor on 02/28/2025 at 09:01 AM, Registered Nurse/Unit Manager (RN/UM#2) was asked who is responsible for doing care plans. RN/UM #2 responded we (nurses) initiate base line care plan upon admission and have 72 hours to complete. Since the person (residents) is here any one can adjust the care plan as needed. RN/UM #2 went on to say I am responsible to ensure the care plan is complete and accurate. All nurses can adjust the care plan. All disciplines are responsible to complete and update care plans. When asked what her expectations are of what would be on the care plan. RN/UM #2 replied ADL's (Activities of Daily Living), wounds, falls risk, infection, oxygen, anticoagulants, seizure, incontinence, and Foley. And whatever the system triggered based on resident needs and concerns. RN/UM #2 confirmed If there was a newly identified wound, the care plan should be updated to reflect new wounds and it should be myself, I should be capturing this. On 02/28/2025 at 01:23 PM, the surveyor requested a Comprehensive Care plan policy. The facility provided a Comprehensive Assessments and Care delivery Process policy that does not address when a care plan is to be revised and what should be included on the comprehensive care plan. During an interview with the surveyor on 02/28/2025 at 02:02 PM, the Assistant Director of Nursing (ADON) was asked what the expectations is for when a care plan needs to be revised/updated. The ADON replied absolutely a care plan should have updated at the time wounds were identified. The Nurse would have been responsible to update the care plan. When asked why is that important the ADON said So staff know the resident has a wound(s) and to follow the plan of care. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documents it was determined that the facility 1.) failed to perform a reweigh for a resident with greater than 5% weight loss in 30 day period for 1 of 3 residents investigated for nutrition (Resident #50) and 2.) failed to follow an order for wound vac dressing change for 1 (Resident #351) of 1 resident investigated for skin conditions. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 02/24/2025 at 11:01 AM, during the initial tour of the facility, Surveyor #1 observed Resident #50 lying in bed awake and alert, non-verbal. The Tube feeding was in progress providing Jevity1.5 (an enteral feeding providing 1.5 kilocalories per milliliter) at 50ml/hr (milliliters per hour). Resident #50 appeared well-nourished on visual observation. According to the admission Record, Resident #50 was admitted to the facility with the following but not limited to diagnoses: Diffuse traumatic brain injury, cerebral infarction, seizures, and bed confinement status. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/21/2024, revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #50 is rarely/never understood. Section K of the MDS revealed that Resident #50 had no significant weight loss or gain over the past 30 or 180 days and received 51% or more of total calories and 501cc/day (cubic centimeters or more) of average fluid intake via feeding tube. A review of the Order Summary Report with active orders as of 02/28/2025 revealed Resident #50 had the following physician orders: Nothing by mouth diet. Water flush G-Tube (feeding tube) with 125 ml of water every 6 hours for hydration. Jevity 1.5 Cal (calorie) liquid (Nutritional Supplements) Give 50ml/hr via G-tube every day shift for Nutrition. 7-3 nurse will turn off machine when Total Volume achieved of 1000 ml and record amount achieved. A review of Resident #50's comprehensive care plan revealed a care plan Focus: I have the potential for NUTRITIONAL deficits r/t (related to) my need/dependence for artificial nutrition through feeding tube to meet my nutrition and hydration needs, being under hospice/comfort care I am NPO (nothing by mouth) - I rely on a tube feed to meet my nutrition needs. A review of the Interventions/Tasks section of Resident #50's comprehensive care plan did not include monitoring of weights. On 02/24/2025 at 12:21 PM Surveyor #1 reviewed Resident #50's weights via the EMR. On 02/01/2025, Resident #50 had a monthly weight of 139.6 pounds. Resident #50 had a weight of 148.4 pounds on 01/05/2025. Resident #50 had an 8.8 pound weight decline over a 30 day period, which was significant at - 5.93% over a 30 day period. On 02/25/2025 at 12:39 PM, Surveyor #1 reviewed the 12/27/2024 Interdisciplinary Care Conference Meeting via the EMR (electronic medical record). The following entry was observed under Section C Dietitian Summary: NPO, receives TF (tube feed) for nutrition support. BMI (body mass index/used to categorize whether a person is underweight, normal weight, overweight, or obese depending on what range the value falls between) is in healthy range. Likely meeting > (greater than)75% of est (estimated) nutrition needs with TF regimen. Continue w/current TF + flushes as ordered. Continue to monitor TF tolerance, hydration, weights, skin, meds, labs. Continue POC (plan of care) and follow up/reassess PRN (as needed). On 02/27/2025 at 01:22 PM, Surveyor #1 again reviewed the EMR under the weights/vitals tab section. There was still no reweigh performed. revealed that Resident #50 still did not have a re-weight conducted after an acute 8.8# weight decline over the past 30 days, as indicated by Resident #50's weight obtained on 2/1/2025. On 02/28/2025 at 08:38 AM, the surveyor reviewed the EMR for Resident #50. The EMR revealed that Resident #50 had not had a reweight performed as of 2/28/2025 for a weight decline of greater than 5 pounds in a 30 day period. This was a period of 27 days since the monthly weight was obtained on 02/02/2025. During an interview with Surveyor #1 on 02/28/2025 at 10:50 AM, the Registered Nurse/Unit Manager (RN/UM #3), was asked what the facility practice was concerning monthly weights and acute/significant weight changes. RN/UM #3 said that weights are done by CNA's (Certified Nursing Assistants) at the beginning of the month unless they are on weekly weights. Once the weights are recorded, they are entered into the EMR. RN/UM #3 further explained that a weight obtained that was five pounds less or more than the previous weight on record would require the nurse to reach out to the doctor and let him/her know right away. RN/UM #3 further explained that we try to get the weight first thing in the morning. Surveyor #1 asked if Resident #50 should have been reweighed due to the 8.8 pound weight decline that occurred between 02/01/2025 and 01/05/2025. RN/UM #3 replied I don't want to give you the wrong answer concerning Resident #50's re-weight. I would have to speak to the DON (Director of Nursing) to get the answer. On 02/28/2025 at 11:01 AM the surveyors met with facility administration. The surveyor asked the facility DON if Resident #50 should have been reweighed according to their facility weight policy. The DON told the surveyor, Yes, Resident #50 should have had a re-weight conducted for an 8.8# weight decline. A review of a facility policy titled [facility name] with the subject: Weights / Re-Weights, revised 6/29/21, revealed the following under Policy: Thereafter all residents are to be weighed monthly and reweighed if a loss or gain of 5 pounds is noted (or 3 pounds if resident weighs </= 100 pounds). In addition, the policy further revealed at Procedure/Responsibilities/Action at 2. The unit manager compares the monthly weights to the previous month's weights and requests re-weights for any weight discrepancies over or under 5 pounds (or 3 pounds if resident is 100 pounds or less). 2. On 2/25/2025 at 8:39 AM, Resident #351 showed Surveyor #2 their wound dressing on the abdomen connected to the Wound VAC (Vacuum Assisted Closure a wound care treatment that uses negative pressure to promote wound healing). Resident #351 stated that it was not changed the previous day as scheduled. The surveyor observed the undated green dressing located in the resident's mid-abdomen stained with brownish material from the suction area downwards. On 2/25/2025 at 8:57 AM, a review of the EMR revealed the following: A review of the admission Record reflected the resident had diagnoses that included surgical aftercare following surgery on the digestive system (the body's system that ingests, breaks down and absorbs food, and eliminates waste) and anemia (not having enough hemoglobin to carry oxygen to the body's tissues). A review of the most recent comprehensive MDS dated [DATE], reflected a BIMS score of 12 out of 15, which indicated an intact cognition. A further review of the MDS reflected the resident received surgical wound care. A review of the Clinical Physician Orders included a physician's order (PO) initiated on 2/7/2025 and reordered on 2/24/2025 for the following: Wound vac set at 125 mm/hg every shift for wound healing; Change dressing every Monday, Wednesday, Friday for wound healing .mid abdomen wound vac set at 125 mm/hg; Clean site with normal saline solution, pat dry, apply wound vac dressing. A review of the corresponding February 2025 Treatment Administration Record (TAR) revealed the resident's wound vac dressing was changed on 2/24/2025 by the registered nurse on duty. However, the registered nurse's skilled charting notes reflected the wound vac in place on the abdominal midline area and that dressing change was not required. There was no documentation in the EMR why the dressing change was not required. During an interview with Surveyor #2 on 2/26/2025 at 12:30 PM, RN/UM #2 stated that wound treatments had to be dated and labeled with the nurses' initials. RN/UM #2 further stated that if a dressing was not changed, then the nurse had to write #9 in the TAR which would be linked to a progress note where the nurse had to write the reason why a dressing was not changed. The RN/UM #2 acknowledged that the registered nurse on duty should not have checked the TAR as that meant that the wound dressing was changed. During an interview with Surveyor #2 on 2/28/2025 at 9:11 AM, the Assistant Director of Nursing (ADON) stated that wound treatments should be followed as ordered and that the nurses needed to sign and date the wound dressing as well as sign the TAR. The ADON further stated that if the nurses are not able to do the treatment, they need to call the doctors and put in a progress note. A review of the facility provided policy titled Medication and Treatment Orders dated 10/15/2019 did not include the process for documenting and completing physician's order for wound treatments. NJAC 8:39- 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the electronic medical record (EMR), and review of other facility documentation, it was determined that the facility failed to consistently apply a hand splint as recommended by therapy. This deficient practice was identified for 1 of 1 resident reviewed for range of motion (Resident #1), and was evidenced by the following: During the initial tour on 02/24/2025 at 11:53 AM, the surveyor observed Resident #1 awake, non-verbal, lying in bed, with his/her right hand clenched in a fist position and pulled up toward the chest. There was no splint or hand roll in place at that time. The resident was cognitively impaired and was unable to provide health history or answer questions. On 2/25/25 at 1:23 PM, surveyor observed Resident #1 with no splint on right hand. On 2/26/25 at 9:29 AM, surveyor observed Resident #1 with no splint on right hand. A review of the Electronic Medical Record (EMR) on 02/24/2025, revealed the following: Resident #1 had a medical diagnoses that included but were not limited to: Intercranial Injury with paralytic syndromes, contracture of muscle, and encounter for fitting and adjustment of other specified devices. A review of the resident's most recent individual comprehensive care plan (ICCP) dated 12/18/24, revealed the following focus area: The resident has an ADL (Activity of Daily Living) self-care performance deficit related to limited ROM (Range of Motion), musculoskeletal impairment, hemiplegia (paralysis of one side of the body), activity intolerance, limited mobility, impaired balance and cognitive deficits. Goals included, The resident will maintain current level of function in all ADLs through the review date. Under Interventions included but were not limited to: Contracture Management: I wear a right-hand splint from 8am to 8pm. Make sure my skin is clean and dry with no skin issues. If anything is noticed, report to nurse right away. A review of the Occupational Progress Note/Discharge summary dated [DATE], revealed that Resident #1 was discharged from therapy on 03/9/2020. The Assessment Goals indicated that Resident #1 is on a Maintenance Program with staff for PROM (Passive Range of Motion) for RUE (Right Upper Extremity) and hand as tolerated during self-care. The Plan included, Patient discharged from therapy at this time. Resident sitting safely in a high back wheelchair with calf supports. Resident wearing Right Resting Hand Splint on 8 am and off 8 pm as tolerated with skin check during self-care. An Occupational Therapy Daily Note dated 06/17/2021 revealed, Patient provided with new WHFO (a wrist, hand, and finger orthosis medical device that supports and protects the wrist, hand and fingers) by orthotist on 06/16/2021. Follow up this day: Splint correctly donned. Patient with good wear tolerance and reports comfortable. During an interview with the surveyor, License Practical Nurse (LPN #3) when asked if Resident #1 used any adaptive equipment, LPN #3 stated she had to check. LPN #3 checked the EMR and identified under Task that Resident #1 wore a hand splint. LPN #3 was unable to provide any additional information at that time. On 02/26/2025 at 9:45 AM, during an interview with the surveyor, Registered Nurse/ Unit Manager (RN/UM#1), after reviewing the EMR, stated that Residents #1's Care Plan indicated that a right-hand splint was in use for contracture management. RN/UM #1 added that it is the responsibility of the Certified Nursing Assistant (CNA) to place and take off the hand splint. When the surveyor asked where the splint would be documented, RN/UM #1 stated that there is no place to document, just indicates it is care planned. Shortly after this interview, the surveyor and RN/UM #1 went to Resident #1's room. RN/UM #1 acknowledged that Resident #1 was not wearing a splint however, there was a rolled washcloth in the right hand. RN/UM #1 also acknowledged that there was no hand splint available in the resident's room. At that time, CNA #1 stated that the nurse (RN#2) just placed the washcloth in Resident #1's hand. When the surveyor inquired as to the use of the hand splint, CNA #1 stated that he/she recalled Resident #1 using a hand splint but was unable to determine how long ago it had been since Resident #1 had last worn it. On the same day at 1:17 PM, Resident #1 was observed at the nursing station wearing a right hand/wrist splint. On the same day at 1:33 PM during an interview with the surveyor, the Director of Therapy (DOT) stated that the nurse (LPN#2) called and stated that the resident was care planned for a hand splint and didn't have one. The DOT stated that therapy placed a hand splint on Resident #1 shortly after the call. The DOT was unable to state whether Resident #1 had a history of refusing the hand splint and that there was no documentation indicating refusal. The DOT added that Resident #1 was on Restorative Therapy that included Range of Motion (ROM) and skin checks. The DOT stated that the expectation for restorative therapy is that documentation would include tolerance of ROM and hand splint. The DOT confirmed that there was no documentation regarding the use of the hand splint. The DOT further stated that a new Plan of Care Note was added to apply splint handgrips to right hand topically every morning and remove at bedtime for contraction. During an interview with the surveyor on 03/03/2025 at 10:16 AM, the restorative CNA #2, stated that Resident #1 was not on her restorative therapy list. She added that Resident #1 is on Restorative Maintenance which is different than Restorative Therapy. Restorative maintenance is provided by the floor CNA's and involves doing ROM and adaptive devices during routine care. During an interview with the surveyor on 03/03/2025 at 11:10 AM, the Director of Nursing (DON) stated that a hand splint does not require a physician order. The DON added that the EMR was updated to provide an area to document the use of adaptive equipment by the CNA. On review of the facility policy titled, [facility name] Policy & Procedure, dated 07/22/2020, reflects the following: #7 Once restorative goals are achieved the resident will transfer to the Functional Maintenance/Restorative Program. #9 Any change in resident's status will be reported to the unit manager. The unit manager will re-evaluate to determine if resident needs to be evaluated by therapy for therapy services or rehabilitation/restorative service. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to a.) ensure there was a physician order for the use of a Foley catheter and care plan, b.) ensure a resident with a catheter had the catheter bag in a privacy bag for dignity, and c.) failed to ensure a catheter bag did not come in contact with the floor to prevention possible contamination. This deficient practice was identified for 3 of 3 Residents reviewed for catheter use (Resident #6, Resident # 17, and Resident #348) and was evidenced by the following: On 02/25/2025 at 12:57 PM, Surveyor #1 observed Resident #17 lying in bed with their catheter bag hanging from the bed frame. The catheter bag was not in a privacy bag and was visible from the hallway. On 02/25/2025 at 03:14 PM, a review of the EMR revealed the following: According to the admission Record, Resident #17 was admitted to the facility with diagnoses including but not limited to: Unspecified Dementia. A review of the quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #17 had an indwelling catheter. A review of the most recent Admit/Readmit screener indicated that Resident #17 had a catheter. A review of the Order Summary Report with Active Orders as of 02/28/2025 revealed that there was no physician order for the use of the Foley, or the reason and care of the Foley. A review of the Comprehensive Care plan did not include the use and care of the Foley. During an interview with Surveyor #1 on 02/28/2025 at 10:24 AM, Licensed practical Nurse (LPN #1) was asked does a Foley catheter use require a physician order. LPN #1 responded yes, there should be a physician order for use and care of the catheter. During an interview with Surveyor #1 on 02/28/2025 at 10:34 AM, Registered Nurse/Unit Manager (RN/UM #2) was asked does a Foley catheter use require a physician order. RN/UM #2 replied Yes, there should an physician order for the Foley. When questioned if a resident has a Foley catheter, should there be a care plan. RN/UM #2 said Yes, there has to be a care plan for the Foley. During an interview with the Surveyor #1 on 02/28/2025 at 02:05 PM, the Director of Nursing (DON) was asked what the expectation is for a resident who is admitted to the facility with a Foley catheter. The DON replied it is necessary to have a care plan. The DON confirmed Yes there should have been a physician order. The DON also said it is important to have dignity bag for dignity and infection control. On 02/28/2025 at 12:01 PM, a review of a facility policy titled Indwelling Urinary Catheter Care did not include that the resident would need a physician order or care plan for the use of a Foley. On 02/28/2025 at 01:26 PM, a review of a facility policy titled admission or re-admission updated 11/25/24, revealed under Procedure section 5. The RN or LPN will report and record all indwelling medical devices and obtain applicable order form the physician for instructed use (i.e. peripheral line, Foley catheters, ostomies). Upon initial tour of the facility on 2/24/2025 at 11:32 AM, Surveyor #2 observed Resident #6 lying in bed in his/her bedroom. The urinary drainage bag (a medical device used to collect urine) had no privacy cover and was visible from the hallway. On 02/24/2025 at 01:08 PM, Surveyor #2 reviewed the electronic medical records (EMR) for Resident #6 as follows: According to the admission Record Resident #6 was admitted to the facility with various diagnoses, including but not limited to urinary retention (a condition where a person cannot fully empty their bladder) and paraplegia (characterized by the loss of sensation and motor function in the lower half of the body). A review of Resident #6's Order Summary Report indicated the following: start date 6/19/2024, ensure Foley catheter bag is below the bladder, off the floor and in a dignity cover bag. During an interview with Surveyor #2 on 2/26/2025 at 9:38 AM, the Infection Preventionist said that residents with a Foley should have privacy covers to maintain dignity and protect against contamination, such as preventing the Foley bag from touching the floor. During an interview with Surveyor #2 on 2/28/2025 at 2:08 PM, the DON said that residents with a Foley should have a privacy cover for dignity and infection control purposes. 3. On 2/24/2025 at 10:09 AM, during the initial tour, Surveyor #3 observed Resident #348 in bed with an unsecured Foley catheter collection bag and tubing lying on the floor filled with urine visible from the hallway. On 2/25/2025 at 10:52 AM, a review of the EMR revealed the following: A review of the admission Record reflected the resident had diagnoses that included Acute Kidney Failure (a decrease in kidney function that leads to accumulation of waste products in the blood) and Retention of Urine. A review of the most recent comprehensive MDS dated [DATE], revealed Resident #348 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS further reflected the resident used an indwelling catheter. A review of the Order Summary Report (OSR) with active orders as of 2/28/2025 revealed the following physician orders: A physician order with a start date of 02/11/2025, indicating use of urinary drainage bag with anti-reflux chamber every shift for proper drainage and storage. The order also included to ensure Foley bag is below the bladder, off the floor and in a dignity cover bag. During an interview with Surveyor #3 on 02/25/2025 at 12:51 PM, the Infection Preventionist stated the urine bag should not touch the floor and should be put in a dignity bag to prevent spread of infection. During an interview with the surveyor on 02/26/2025 at 12:28 PM, RN/UM #2 stated the drainage bag needed to be in a dignity bag and cannot be on the floor. RN/UM #2 further stated that the staff were educated on this. During an interview with the surveyor on 02/28/2025 at 9:12 PM, the Assistant Director of Nursing (ADON) stated that urine bag should be in dignity bag and cannot be on the floor. A review of the facility-provided policy titled Urinary Catheter Bags Care Maintenance dated 2/7/2025, indicated under section Procedure #15: Check to ensure the catheter drainage tube is not touching the floor and the drainage bag is covered. NJAC 8:39-19.4(a) 27.1(a)(b)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure respiratory tubing, and nasal cannula were stored properly, and c.) obtain physician order for oxygen administration. This deficient practice was identified for 2 of 2 residents (Residents #75 and #349) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. The deficient practice was evidenced by the following: 1.) Upon initial tour of the facility on 02/24/2025 at 10:19 AM, Surveyor #1 observed Resident #75 using oxygen through a nasal cannula connected to an oxygen concentrator that provides extra oxygen to those who have difficulty breathing. However, the oxygen tubing was not labeled. Additionally, another nasal cannula was found resting on the seat of the resident's wheelchair, connected to a portable oxygen tank that was also unlabeled and exposed to the environment. On 02/25/2025 at 10:56 AM, Surveyor #1 reviewed the electronic medical records for Resident #75 as follows: According to the admission Record Resident #75 was admitted to the facility with diagnoses, including but not limited to Chronic Obstructive Pulmonary Disease, (a progressive lung condition that leads to breathing difficulties due to airflow obstruction). A review of Resident #75's Order Summary Report indicated the following: start date 9/28/2024, check pulse oximetry (SPO2) (a non-invasive test that measures the oxygen saturation level in a person's blood) every shift if the oxygen saturation is below 92% and the resident is short of breath (SOB) administer oxygen at a rate of 2 liters per minute via nasal cannula, every 8 hours as needed for SOB. A review of Resident #75's Treatment Administration Record (TAR) revealed an order for monitoring SPO2 every shift if it drops below 92% and for administering oxygen at 2 liters per minute via nasal cannula every 8 hours as needed for SOB. However, there was no documentation in the TAR indicating that the as needed oxygen was being administered. During an interview with Surveyor #1 on 2/26/2025 at 9:38 AM, the Infection Preventionist (IP) said that if oxygen tubing is not in use, it should be stored in a plastic bag and not left open to the environment for infection control purposes. During an interview with Surveyor #1 on 2/26/2025 at 1:22 PM, the Registered Nurse/Unit Manager #1 said that oxygen tubing should have a physician's order, be changed and dated every Friday, and be stored in a plastic bag when not in use for infection control purposes. Additionally, any oxygen used as needed should be recorded on the TAR. A review of the facility provided policy, with a review date of 2/28/2025, titled, Oxygen Administration revealed under the section titled Procedure that, Every nasal cannula, will be changed once per week on a selective day labeled appropriately. When not in use, nasal cannula and tubing will be placed in plastic bag and tied to tank and/or concentrator. 2. On 02/24/2025 at 10:13 AM, during the initial tour of the facility, Surveyor #2 observed Resident #349 in bed connected to an oxygen concentrator via nasal cannula (N/C) at 1 liter per minute (lpm). On 02/25/2025 at 8:25 AM, Surveyor #2 observed the resident in bed receiving continuous flow of 1 liter of oxygen per minute via nasal cannula connected to the concentrator. On 2/25/2025 at 11:00 AM, a review of the EMR revealed the following: A review of the admission Record reflected the resident had diagnoses that included history of falling and generalized muscle weakness. A review of the Clinical Physician Orders active and discontinued as of 2/27/2025 at 12:47 PM, did not include a physician order for oxygen administration since admission. A review of the Resident #349's comprehensive care plan did not reveal a goal and interventions for the focus of resident having periods of shortness of breath initiated on 2/24/2025. During an interview with the Surveyor #2 on 02/26/2025 at 12:20 PM, the Registered Nurse/ Unit Manager (RN/UM #2) stated that oxygen administration should have a physician order. During an interview with the Surveyor #2 on 02/28/2025 at 9:10 AM, the Assistant Director of Nursing (ADON) stated that a physician order was absolutely needed for oxygen administration. A review of the facility provided policy titled Oxygen Administration dated reviewed 2/28/2025, did not include physician orders for oxygen administration. NJAC 8:39-27.1(a)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to ensure accurate accountability of controlled drugs to prevent loss or diversion. This deficiency was identified for 2 of 4 medication carts inspected. This deficient practice was evidenced by the following: On 02/26/2025 at 11:30 AM, the surveyor inspected F-Hall medication cart in the presence of the Registered Nurse/Unit Manager #1 (RN/UM #1). A review of the shift-to-shift Narcotic Record Controlled Count Sign Sheet (NRCCSS), which is used in healthcare settings to track the administration and accountability of controlled substances, revealed missing signatures for the following dates and shifts: 2/01/2025 for the outgoing nurse (7:00 AM - 3:00 PM), and 2/09/2025, for both the incoming and outgoing nurses (11:00 PM - 7:00 AM). On 02/26/2025 at 11:38 AM, the surveyor inspected E-Hall medication cart in the presence of the RN/UM #1. A review of the shift-to-shift NRCCSS revealed missing signatures on the following dates and shifts: 02/05/2025 for both incoming and outgoing nurse (3:00 PM - 11:00 PM), and 2/18/2025 for the outgoing nurse (7:00 AM - 3:00 PM). During an interview with surveyor on 02/26/2025 at 1:22 PM, the RN/UM #1 said that the nurses are required to sign the NRCCSS for accountability of narcotics. During an interview with surveyor on 02/28/2025 at 2:04 PM, the Assistant Director of Nursing said that the NRCCSS should be completed at the beginning and end of each shift to ensure accurate narcotic counts and prevent drug diversion. A review of the facility provided policy, with a review date of 2/28/2025, titled, Counting Controlled Drugs and Drug Diversion revealed under the section titled Procedure that, All controlled drugs will be counted in the start and end of each shift by two (2) license nurses. Both parties sign the count sheet indicating that each controlled drug count is correct. NJAC 8:39-29.7(c)

Based on observation, interview and review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their monthly medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident # 66) and was evidenced by the following: During the Initial Tour of the facility on 02/24/2025 at 10:57 AM, Resident #66 was observed in a high back wheelchair in his/her room clean and groomed. Resident requested and received a cup of coffee. A review of the EMR on 02/24/2025 at 10:00 AM, revealed the following: According to the admission Record, Resident #66 was admitted to the facility with diagnoses including but not limited to: unspecified dementia with other behavioral disturbances. According to the most recent quarterly Minimum Data Set, an assessment tool dated 12/22/2024 revealed the resident had a Brief Interview for Mental Status of 6/15 MDS which indicated severe cognitive impairment. A review of the Order Summary Report revealed the following physician orders; Acetaminophen Tablet 325 MG (milligrams) Give 2 tablet by mouth every 6 hours for Pain Management ( mild pain 1-3). Do Not exceed 3000 mg of Tylenol per day give 2 tabs =650 mg with order date of 08/10/2024. Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Temperature > (greater than) 100 Fahrenheit Do Not exceed 3000 mg of Tylenol per day dated 08/10/2024. A review of the CP Therapeutic suggestion form dated 8/30/24 revealed the following: Routine order of 2.6 gm's (grams)/day of acetaminophen noted. To avoid potentially going over maximum recommended daily dosing, consider decreasing the frequency of PRN (as needed) acetaminophen or d/c (discontinue) PRN acetaminophen. On 09/09/2024 the Advanced Practice Nurse (APN) hand wrote on the Therapeutic suggestion form to decrease acetaminophen dose to 650 mg po (by mouth) q (every) 8 hours prn for fever/pain. There was no documentation in the EMR that the facility followed up on the CP recommendations and the APN acceptance dated 9/9/24 until 12/22/2024. This was not addressed in 102 days. During an interview with the surveyor on 02/27/2025 at 10:24 AM, the Director of Nursing (DON) was asked what the process is when the CP has a therapeutic suggestion. The DON replied She comes in monthly and reviews all residents. She sends us a report after she leaves unless major issue that requires immediate attention. She then writes a note in chart she reviewed. If there is recommendation will document there is recommendation. She then emails and sends via regular mail the reports and the Unit Managers address them. When asked if there is a specific time frame of when the suggestion needs to be addressed. The DON replied If nursing recommendation we have to do it right away. If it is a physician we send it to them and wait for their response. The APN or MD send back to the unit and the nurse addresses the changes and then gets filed in EMR under miscellaneous tab. The UM is responsible to follow-up with physicians. The DON went on to say that she is not sure if there is a time frame in the policy. It should be done as soon as possible. On 02/27/2025 at 10:31 AM, a further review of the EMR under the miscellaneous tab indicated the therapeutic recommendations form was uploaded into the record on 09/10/2024, however the facility did not address what was written by the APN. During an interview with the surveyor on 02/28/2025 at 02:00 PM, the DON was asked what is the facility expectations of time frame for follow-up with cp recommendations and prescriber's orders. The DON replied as soon as possible. When asked if it was acceptable to wait 102 days to address the cp report, the DON said it is not acceptable to wait that long . On 02/27/2025 at 12:17 PM, a review of a facility policy titled Change of Status/Monthly Pharmacy Review with last reviewed date of 2/27/25, revealed under Procedure section 5. The Pharmacy Consultant recommendations will be reviewed with the attending physician. The policy did not include a specific time frame for addressing CP recommendations. NJAC 8:39-29.3(a)(1)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow enhanced barrier precautions (EBP), a set of infection control measures aimed at reducing the risk of transmitting infectious agents. This deficiency was observed for 1 of 1 resident (Resident #49) reviewed for EBP. This deficient practice was evidenced by the following: On 02/24/2025 at 10:38 AM, upon initial tour of the facility the surveyor observed the Home Health Aide (HHA#1) giving a bed bath to Resident #49 in their bedroom, while the resident was in bed, without wearing personal protective equipment (PPE), despite a sign on the outside of the door indicating EBP and the proper PPE required for contact. A review of Resident #49's Order Summary Report located in the Electronic Medical Record revealed an order to maintain EBP due to the presence of a urinary drainage tube, a medical device used to drain urine from the bladder and a history of Extended-Spectrum Beta-Lactamase (ESBL) in the wound, a bacteria resistant to many commonly used antibiotics. During an interview with the surveyor on 02/24/2025 at 10:40 AM, HHA #1 said that no one at the facility had informed her that PPE was required when performing a bed bath, though it should be worn for infection control purposes. During an interview with surveyor on 02/26/2025 at 09:38 AM, the Infection Preventionist said that EBP are implemented for residents with multidrug-resistant organisms which are bacteria or microorganisms resistant to multiple antibiotics, as well as for those with medical devices, such as a urinary drainage tube. Healthcare providers must wear PPE when performing tasks like bathing, wound care, or managing the medical device. A review of a facility policy, with a review date of 01/16/2025 titled, Infection Prevention Policy and Procedure Manual, revealed under definitions, that Enhanced Barrier Precaution: This is an approach using PPE (ie. gowns and gloves) during high contact resident care, design to reduce the transmission of colonized MDROs. N.J.A.C.8:39-19.4(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 02/24/2025 from 09:43 to 10:09 AM, the surveyor, accompanied by the Food Service Manager (FSM), observed the following in the kitchen: 1. On the wall next to the solo standup solo freezer, a wall mounted knife container contained two knives with wooden handles. The wooden handles of the knives were exposed to the surveyor. They appeared to be old and had fine cracks in the handles on visual inspection, which would allow bacteria to remain in the wooden handles.When interviewed the FSM stated, Ok. I know that. The FSM removed the wooden knives from the wall monted knife container/holder. 2. The high temperature dish machine was observed to be in use and actively washing dishware on 02/24/2025 at 10:01 AM. The surveyor asked the FSM to provide the surveyor the dish machine temperature log for observation. Review of the [facility name] Temperature Log revealed the following: No temperature was recorded for the breakfast meal on 2/24/2025 and the dish machine was observed to be in active operation at 02/24/25 10:03 AM. According to the FSM, staff should document the temperatures of the dish machine prior to dishwashing to ensure the machine is operating at the correct minimum wash and rinse temperatures to ensure proper cleaning and sanitizing of dishware. Further review of the dish machine temperature log revealed the following: No breakfast temperatures were recorded on the following dates for February 2025: 2/3/2025, 2/12/2025, 2/13/2025, 2/15/2025, 2/17/2025, 2/20/2025. The facility failed to record dish machine temperatures at lunch on the following dates: 2/6/2025, 2/7/2025, 2/9/2025, 2/10/2025, 2/11/2025, 2/12/2025, 2/13/2025, 2/14/2025, 2/16/2025, 2/19/2025, 2/10/2025, 2/21/2025. The facility failed to record dish machine temperatures for dinner in February 2025 on the following dates: 2/1/2025, 2/2/2025, 2/3/2025, 2/4/2025, 2/6/2025, 2/7/2025, 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, 2/20/2025, 2/21/2025, 2/22/2025, and 2/23/2025. On 02/28/2025 from 09:03 to 09:17 AM, the surveyor, accompanied by the FSM, made the following observation in the dry storage room: 1. On an upper rack of a multi-tiered/rack canned good storage cart, a can of unsweetened applesauce had a significant dent on the bottom seam of the can. The FSM agreed and removed the can from the storage rack and to the designated dented can area. The surveyor reviewed the facility provided policy titled Dish Machine Cleaning, revised 1/21/2023. The following was revealed under the section PROCEDURE: Daily - Prior to loading the dish machine. 2. The wash temperature is to be at 160 or above and the rinse temperature is to be at 180 or above. 3. Document the date, and meal period, the wash and rinse temperatures and initials in the dish machine logbook. The surveyor reviewed the facility provided policy with the subject Food Storage, Policy Number: 5010. The following was revealed under PROCEDURE: 13. Storage areas are monitored by supervisory staff. Leaking, bulging or severely damaged cans or jars with leaky lids and other items identified as damaged or unusable are isolated and disposed of according to unit policy. N.J.A.C. 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT #NJ00175651 Based on observation, interview, and record review, on 08/02/24, it was determined that the facility failed to notify a resident in writing of a resident room change for 2 of 2 residents (Resident #1 and Resident #2). This deficient practice was identified and was evidenced by the following: 1). On 08/02/24 at 11:45 A.M., the surveyor observed Resident #1 awake in bed, watching television. The surveyor asked how long the resident had been in this room and the resident stated that he/she had been there for about three weeks. The resident stated that the unit manager [of the previous unit] and the social worker informed his/her that the resident was moving due to, something to do with my kidneys. The resident further stated that he/she had not received anything in writing prior to the move. Review of Resident #1's admission Record (AR) face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to: hypertension, chronic kidney disease with heart failure, and type II diabetes. Review of Resident #1's annual Minimum Data Set (MDS), an assessment tool to facilitate the management of care, dated 07/13/24 reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Review of Resident #1's progress notes (PN) revealed a social worker note, dated 06/19/24 at 12:04 P.M., that indicated that the resident was transferred to another room and that written notification was provided. A further review of the electronic medical record did not reveal evidence of the required written notification of the room change. 2). On 08/02/24 at 11:33 A.M., the surveyor observed Resident #2 seated at the bedside in a wheelchair, watching television. The surveyor asked how long the resident had been in this room and the resident stated, Sometime in July, maybe three weeks. The resident stated that the social worker informed his/her that the resident was contagious and needed to be moved. The resident further stated that he/she had not received anything in writing prior to the move. Review of Resident #2's admission Record (AR) revealed that the resident was re-admitted to the facility with diagnoses that included but were not limited to: resistance to multiple antimicrobial drugs, kidney failure, and anxiety. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Review of Resident #2's progress notes (PN) revealed a social worker note, dated 07/09/24 at 11:30 A.M., that indicated that the resident was transferred to another room and that written notification was not provided. A further review of the electronic medical record did not reveal evidence of the required written notification of the room change. During an interview with the surveyor on 08/02/24 at 12:42 P.M., the Director of Social Services (DSS) stated that she informed Resident #2 of the room change and that a notification was provided in writing to all residents. In a later interview, at 2:10 P.M., in the presence of the surveyor, the DSS reviewed a facility form titled, SUBJECT: Room Change, In-house. The DSS stated that residents received the form which informed them of the room changes; no form was provided to the surveyor for Resident #1 nor Resident #2. During an interview with the surveyor on 08/02/24 at 1:30 P.M., the Social Worker (SW) stated that she informed Resident #1 of the room change on the day of the move. She further stated that she had not provided the resident with a written notification. NJAC 8:39-4.1(a)

Complaint#: NJ163798, NJ166210 Based on observation, interview, and review of pertinent facility documents on 8/7/2023 and 8/8/23, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of abuse when a resident (Resident#2) reported to a familiy member that he/she was grabbed by their wrist and shoved over their bed and called fat by the Certified Nurse Aide (CNA) while providing care. This deficient practice was identified for 1 of 3 residents reviewed for reportable events. This deficient practice was evidenced by the following. During an interview on 8/7/2023 at 2:38 P.M., the Administrator stated he received a phone call from the RN/ES that night around approximately 9:39 P.M., advising him of the incident that had occurred between a CNA and Resident #2. I told the RN/ES that I would communicate with Resident #2's family member. The Administrator continue to state,I told the RN/ES that night to immediately obtain witness statements from the CNA's. I was off on Monday (4/24/2023) and on Tuesday (4/25/2023), I spoke with Resident #2's family member on the phone in the presence of the Director of Nursing (DON). I told her we [administration] had to complete a thorough investigation about the incident.During the same interview when asked if the allegation was reported to the New Jersey Department of Health (NJDOH), the Administrator responded, No, we [administration] did not report the allegation. He continued to state, yes, the allegation should have been reported to the NJDOH by administration (Administrator/DON). Review of the facility policy titled, Abuse, Mistreatment, Exploitation, Neglect and Misappropriation of Property with revised date of 6/12/21 revealed the following: Under Policy include: All residents at Meadowview Nursing and Rehabilitation Center have the right to be free from abuse, mistreatment, exploitation, neglect, and misappropriation of property. This includes facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Under Procedure: #8. Reporting/response and Corrective Action: B. The results of the investigation shall be provided to the Office of the Ombudsman and the New Jersey Department of Health within five (5) working days of the incident. E. Should the investigation reveal that a false report was made/filed, the investigation shall cease. Residents, family, the Office of the Ombudsman, and the New Jersey Department of Health shall be notified of the findings. The facility couldn't provide documented evidence that the NJDOH was notified of this incident. NJAC 8:39-9.4

Complaint #: NJ163793, NJ166210 Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 8/7/23 and 8/8/23, it was determined that the facility failed to provide documented evidence of care provided to a resident (Resident #2). The facility also failed to follow the Certified Nursing Assistant's job discreption and its policies titled, CNA Care Delivery, ADLs for 1of 3 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the AR Resident #2 was admitted on with 3/28/23 with diagnoses which included but were not limited Obstructive Sleep Apnea, Morbid (Severe) Obesity Due to Excess Calories, Difficulty Walking, and Anxiety Disorder, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 7/5/23, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 needed total assistance and two-person physical assistance with most Activities of Daily Living (ADLs) and total dependence with locomotion on and off the unit. Review of Resident #2's ADL (Activity of Daily Living) Documentation, a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for September 4/23, showed blank spaces indicating the tasks were not completed as follows: Toileting on 4/2/23 and 4/22/23, on the night shift. On 4/2/23, 4/20/23, 4/22/23 and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23,4/27/23 and 4/28 on the evening shift. Eating on 4/4/23, 4/6/23, 4/8/23, 4/9/23, 4/11/23, 4/20,23, 4/22/23, and 4/26/23 on the day shift. On 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23,4/2/23 and 4/28/23 on the evening shift. Transferring on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Dressing on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23, 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23 through 4/28/23 on the evening shift. Personal Hygiene on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/26/23 through 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Bed Mobility 0n 4/22/23 on the night shift. On 4/2/23, 4/20/23, 4/22/23 and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the evening shift. Locomotion off the Unit on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Locomotion on the Unit on 4/2/23, 4/4/23, 4/6/23,4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/22/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Bathing on 4/2/23, 4/20/23, 4/22/23, and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the evening shift. During an interview on 8/8/23 at 11:43 A.M., the Certified Nursing Assistant (CNA) stated, If the ADLs sheet is not signed off [not initialed], then I would assume the task was done, but it was just not documented. When presented with the printed copy of the ADLs sheets and asked if the ADL sheets should be signed, the CNA stated, Yes, the ADL sheets should be signed off every day by the CNA at the end of each shift. During an interview on 8/8/23 at 4:35 P.M., the Director of Nursing (DON) stated, The CNAs provide ADLs for the residents, and it is documented on the ADL (Activity of Daily Living) sheet at the end of each shift. She further stated, There should be no blank spaces on the ADL sheets. When presented with the printed ADLs sheets from the kiosk, the DON stated, Looking at the ADL sheets with the blank spaces, that means the tasks were not completed. Review of the facility's document titled Certified Nurse Aide Job Description reveals under Job Summary: Performs various nursing care activities and related nonprofessional services necessary to care for the personal needs and comfort of the residents. Under the supervision and direction of the staff nurse or unit manager, the certified nursing assistant functions in a cooperative effort with all treatment modalities for emotional, intellectual, physical, social and spiritual well-being of the resident, in accordance with acceptable practice standards and policies, procedures and philosophies of this facility. Review of the facility's policy last updated on 7/2021, titled CNA Care Delivery, ADLs under Policy Statement To assure that the facility continues to provide individualized care in response to each resident's standardized, comprehensive assessment (RAI), and to assure accountability and consistency by the primary caregivers in the deliver of this individualized care, each resident's specific care needs will be communicated to the aides through documentation maintain in the electronic Medical records (EMR). Under Procedure: 7. CNA will document in the EMR, ADLs provided and well as additional documentation specified by resident's plan of care. The CNAs uses the Point of Care (POC) Portal through Point Click Care (PCC). NJAC 8:39-35.2 (a)(g)1

Based on observation, interview, and record review and review of other facility documentation, it was determined that the facility failed to ensure the accurate assessment of a resident's feeding tube and a pressure ulcer was documented in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 2 of 21 resident's reviewed for MDS accuracy (Resident #85 and #71), and was evidenced by the following: A. On 12/1/2022 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #85 in their wheelchair getting dressed. Resident #85 stated he/she had a feeding tube and they wanted it removed. The surveyor questioned if the resident was able to eat by mouth. Resident #85 responded, Yes. The surveyor asked how long the feeding tube had been in place. The resident responded, Too long. I want it out. A review of the admission Record revealed that Resident #85 was admitted to the facility with the diagnoses including but not limited to: vascular dementia, and dysphagia, oropharyngeal phase (difficulty initiating a swallow). A review of the 8/24/2022 admission MDS revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating he/she was cognitively intact. Section G of the MDS revealed Resident #85 was independent with eating and section K revealed that Resident #85 received a mechanically altered diet. Section K did not have a feeding tube while not a resident or while a resident in the facility documented. Resident #85 had a quarterly MDS assessment completed on 11/24/2022. Section G revealed Resident #85 was an independent eater and section K revealed Resident #85 received a mechanically altered diet and did not include documentation of the resident having a feeding tube while not a resident or while a resident at the facility. A review of Resident #85's Order Summary report, dated 12/9/2022 revealed the following physician orders: G.I. (Gastroenterology) consult re: removal of peg tube one time only for removal of peg for 30 Days (11/18/2022). Enteral Protocol: Cleanse tube feeding site with soap and water, pat dry and cover with drain sponge every evening shift (9/5/2022). Enteral Protocol: Check Proper Placement of Feeding Tube every shift for Proper placement prior to tube feeding, flush or medication. (8/17/2022). every 6 hours 250 ml (milliliter) flush AND every shift ENTERAL PROTOCOL: Flush with 10 ml between medications and 50 ml at start and end of medication administration (8/17/2022). A review of the 12/1/2022-12/31-2022 Medication Administration Record (MAR) revealed that Resident #85 had received every 6 hour 250 ml water flush via feeding tube at 0000, 0600, 1200, and 1800 for the dates 12/1/2022 up to and including 12/9/2022 at 0600. A review of Resident #85's comprehensive care plan with a date initiated of 8/17/2022 revealed the following under the Focus section: I have a tube in my bellie (sic) for my feeding because of dysphagia. Under the GOAL heading the following was revealed with a revision date of 09/07/2022: My goal is to be able to eat a regular diet and swallow normal thin liquids within 90 days. Interventions and tasks included but were not limited to the following: Check for tube placement and gastric contents/residual volume per facility protocol. Notify MD (medical doctor) if residual is greater than 100 ml (milliliters). Dietitian to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. On 12/9/2022 at 11:41 AM, the surveyor conducted an interview with the facility MDS Coordinator. The surveyor asked the MDS coordinator who is responsible for filling out the various sections of the MDS assessment tool. The MDS coordinator responded, Section K is filled out by the dietitian, section D and Q are filled out by Social Services and Section F is filled out by activities. I am responsible for filling out all the other sections, except section B which is filled out by the unit nursing managers. The MDS coordinator is responsible for checking accuracy prior to completion of the MDS. The surveyor went on to ask the MDS coordinator if Resident #85's admission assessment, dated 8/24/2022 should have revealed that Resident #85 had a feeding tube on admission to the facility. The MDS coordinator explained, The MDS should have captured that the resident was on a feeding tube. That was an interim dietitian that was filling in for our regular dietitian. I should have corrected that on review. I am responsible for the accuracy of the assessment. On 12/09/2022 at 12:28 PM the surveyor conducted a telephone interview with the facility Registered dietitian (RD). On interview the RD revealed the following: He/she came to us (facility) with a feeding tube, but he/she was also able to eat orally. I am responsible for section K of the resident assessment. The surveyor asked the facility RD if he should have captured the presence of the feeding tube on Resident #85's admission assessment and subsequent quarterly assessment. The RD responded, The admission assessment I would say yes, it should be captured. I'm not sure that the feeding tube should be captured on the quarterly if he/she is not receiving fluids or enteral formula through the tube. The surveyor then made the RD aware that Resident #85 had a current order to receive a 250 ml water flush every 6 hours via the feeding tube. The RD responded that he was not sure how to code the MDS for the feeding tube in that situation. B. On 12/1/2022 at 11:05 AM, during the initial tour of the facility the surveyor interviewed Resident #71 in their room. Resident #71 was lying in bed and stated, I've lost a considerable amount of weight due to my sickness. A review of the admission record revealed that Resident #71 was admitted to the facility with the following but not limited to diagnoses: Pressure ulcer of unspecified site, stage 4, osteomyelitis (an infection of bone), diabetes mellitus, paraplegia (paralysis of the legs and lower body). A review of the 10/18/2022 comprehensive admission assessment revealed that Resident #71 had a BIMS score of 15/15, indicating intact cognition. Section G revealed Resident #71 required total assist with all activities of daily living except eating, which he/she was independent. Section I of the MDS revealed an active diagnosis of pressure ulcer of unspecified site, stage 4. Section M that Resident #71 is at risk of developing pressure ulcers/injuries at M0150 and M0210 revealed that Resident #71 did not have one or more unhealed pressure ulcers/injuries upon readmission to the facility. A review of the Order Summary Report dated 12/9/2022 revealed the following orders for Resident #71: Measure sacral wound and complete wound assessment form every Wednesday 3-11. at bedtime every Wed for wound assessment every Wednesday 3-11. Order date 12/4/2022. Monitor wound vac machine for functioning & the placement to the sacrum every shift for wound care. Order date 10/12/2022. Wound vac set at 125 mm/hg (a unit of pressure based on an absolute scale) Change dressing every Mon, Wed, Fri for wound healing. Wound vac 1854: Cleanse sacral wound w/nss (with normal saline solution), apply Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) to wound base, cover w/sponger (sic) & vac drape. Attached to -125 suction. M-W-F. Order Date: 12/4/2022. Collagenase Ointment (Santyl) 250 unit/GM (gram) Apply to sacral wound base topically every evening shift every Mon, Wed, Fri for sacral wound pressure area-cleanse with normal saline-apply Santyl to wound bed & cover with vac sponge - Skin prep to peri-wound cover with wound vac drape and attach suction at - 125 mm hcg (millimeters of mercury). Order date:12/5/2022. A review of Resident #71's comprehensive care plan, date initiated 10/16/2022 and date of revision on: 10/21/2022, revealed the following under Focus: Skin Intergrity: I Was admitted with a stage IV wound on my sacrum . On 12/9/22 at 11:49 AM, the surveyor conducted an interview with the facility MDS coordinator. The surveyor asked the MDS coordinator why Resident #71's comprehensive admission assessment/MDS did not indicate that Resident #71 was readmitted to the facility with a stage IV sacral pressure wound. The MDS coordinator explained, The admission assessment completed on 10/18/2022 does not indicate that resident #71 has a sacral wound. I missed it but I can make a correction. I have to make a modification correction and resend it to the state for both residents. Sometimes we make mistakes. Once I find a discrepancy, I will correct it and resubmit it to the state. On 12/9/22 at 1:39 PM the surveyor met with the Licensed Nursing Home Administrator and the facility Director of Nursing (DON). The facility DON stated, The MDS coordinator has already made the necessary corrections to those assessments that were coded incorrectly. NJAC 18: 39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review and review of other facility documentation, it was determined that the facility failed to ensure that the residents had a comprehensive person-centered care plan that addressed all the resident's medical needs and diagnosis. This deficient practice was identified for 2 of 21 sampled residents, (Resident #30, Resident #15) and was evidenced by the following: 1. On 12/1/2022 at 10:47 AM, Resident #30 was observed in bed and not responsive to surveyor's presence. A review of the medical record indicated that Resident #30 was admitted to the facility with diagnosis which included, but not limited to: Heart Failure, Type 2 Diabetes Mellitus, and Complete Traumatic Amputation of the Toe. A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate care dated 11/17/2022, identified Resident #30 as severely impaired cognition. According to the resident's electronic medical record, Resident #30 was discharged to the hospital with a change in mental status and possible seizure activity. Approximately 5 days later, Resident #30 returned to the facility with orders for anti-seizure medication. A review of Resident #30 care plan on 12/2/2022 revealed that there was no care plan in place regarding Resident#30's new seizure diagnosis. During an interview with the surveyor on 12/07/2022 at 10:52 AM, Registered Nurse Unit Manager (RNUM#1) stated that care plan creation is team work and anyone can update according to resident needs. RNUM#1 identified that a resident discharged from the hospital with new diagnosis of seizures should be care planned accordingly since it is a standard care plan. When asked if Resident #30 has a seizure care plan RNUM#1 responded I don't see it, she should absolutely have one with a new diagnosis of seizures. During an interview with the surveyor on 12/08/2022 at 02:01 PM, the Director of Nursing (DON) advised the expectation for the Resident #30, who was discharged from the facility and returned to the facility with new diagnosis of seizures, was that she should have had a care plan for that. During the initial tour of the Garden Unit on 12/1/2022 at 11:14 AM, Resident #15 was observed in the hallway with a chair alarm in place. The resident said hi and denied any complaints. A review of the admission Record revealed resident#15 was admitted to facility with diagnoses of cerebral infarction (stroke), Alzheimer's dementia and Atrial fibrillation (A fib) (is an irregular and often very rapid heart rhythm that can lead to blood clots in the heart.) A review of the annual Minimum Data Set, dated [DATE], an assessment tool used to facilitate resident care, revealed a Brief Interview for Mental Status Interview score of 7/15 indicating Resident #15 had moderately impaired cognition. A further review revealed Resident #15 received anticoagulant therapy (blood thinner) 7/7 days. A review of the Order Summary Report with active orders dated 12/8/2022, revealed a physician order for Eliquis 2.5 mg (milligrams) (blood thinner) by mouth twice a day for A Fib. A review of Resident #15's care plan did not include a focus area for use of an anticoagulant. During an interview with the surveyor on 12/7/2022 at 9:17 AM, the assigned Licensed Practical Nurse (LPN #2) said the Unit Manager usually is the person to do care plans. During an interview with the surveyor on 12/7/2022 at 9:50 AM, Registered Nurse Unit Manager (RNUM #1) said the baseline care plan is initiated and done within 24 hours. It is teamwork and it is initiated by the person doing admission. She went on to say all disciplines do their portion. When asked by the surveyor if a resident was receiving an anticoagulant, should there be a care plan. RNUM #1 replied, Yes, the use of anticoagulant is required to be care planned. On 12/7/2022 at 10:05 AM, the surveyor requested RNUM #1 to review Resident #15's care plan for the use of an anticoagulant. RNUM#1 said, I don't see care plan for this. During an interview with the surveyor on 12/8/2022 at 2:09 PM, the facility Director of Nursing stated, Yes, I would expect use of an anticoagulant to be on the care plan. A review the facility Policy Titled Care Planning- Interdisciplinary Team Meeting on 12/2/2022 did not indicate what is to be included on resident care plan. NJAC 8:39-11.2(d)

Based on observation, interview, review of the medical record, and other facility documentation it was determined that the facility failed to follow acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes by not maintaining medication records that were complete with staff signatures for 1 of 22 sampled residents (Resident # 47). This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. According to the admission Record, Resident #47 was admitted to the facility with diagnoses that included, Acute Kidney Disease, Bilateral nephrostomy tubes, Hypokalemia, and Acute Diastolic Congestive Heart Failure. A review of the Physician Order Summary Report (POS) with active orders as of 12/8/2022 revealed a physician's order dated 12/28/2020; Empty Urine Bag from left and right nephrostomy site and document output every shift. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR), for the months of 09/2022, 10/2022, and 11/2022, revealed that on the following dates and times, there was no documentation to indicate that the bilateral nephrostomy tubes were emptied and documented as ordered on: 11/2/2022 evening shift 11/5/2022 evening shift 11/6/2022 evening shift 11/9/2022 evening shift 11/12/2022 evening shift 11/13/2022 night shift 11/16/2022 day shift 11/24/2022 evening shift 11/26/2022 day shift 11/27/2022 evening shift 11/27/2022 night shift 11/29/2022 day shift 11/30/2022 day shift. 10/8/2022 night shift 10/11/2022 evening shift 10/19/2022 night shift 10/25/2022 day shift 9/8/2022 evening shift 9/8/2022 night shift 9/12/2022 evening shift 9/13/2022 night shift 9/15/2022 night shift 9/29/2022 evening shift A review of the POS with active orders as of 12/8/2022 revealed a physician's order; Normal Saline Flush Solution (Sodium Chloride Flush), use 10 cubic centimeters (cc) via irrigation every shift for bilateral nephrostomy tube to keep patent. A review of the MAR and the TAR for the months of 09/2022, 10/2022, and 11/2022, revealed that on the following dates and times, there was no documentation to indicate that Normal Saline Flushes were administered to keep the nephrostomy tubes patent: 11/2/2022 evening shift 11/5/2022 evening shift 11/13/2022 night shift 11/24/2022 evening shift 11/26/2022 day shift 11/27/2022 evening shift 11/27/2022 night shift 10/8/2022 night shift 10/11/2022 evening shift 10/19/2022 night shift 10/20/2022 night shift 10/25/2022 day shift 10/27/2022 night shift 9/8/2022 evening shift 9/8/2022 night shift 9/12/2022 evening shift 9/15/2022 night shift 9/29/2022 evening shift On 12/08/22 at 2:00 PM During a follow up interview with the surveyor, the Director of Nursing, in the presence of the Administrator and the survey team, stated that the expectation was that the Medication and Treatment Administration Records should be complete and without blanks. NJAC 8:39-29.2(d), 29.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to update a resident care plan post fall and to follow their own policy titled Accidents & Incidents, Resident for 1 of 3 Residents reviewed for Accidents, (Resident #15). This deficient practice was evidenced by the following: During the initial tour of the Garden Unit on 12/1/2022 at 11:14 AM, Resident #15 was observed in the hallway with a chair alarm in place. Resident said hi and denied any complaints. A review of the admission Record revealed resident admitted to facility diagnosis of cerebral infarction (stroke), Alzheimer's dementia and Atrial fibrillation (A fib) (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart.) A review of the annual Minimum Data Set, dated [DATE], an assessment tool used to facilitate resident care, revealed a Brief Interview for Mental Status Interview score of 7/15 indicating Resident #15 had moderately impaired cognition. A further review revealed Resident #15 had no falls since admission and received anticoagulant therapy (blood thinner) 7/7 days. Section P of the MDS indicated that the resident used a bed alarm and chair alarm daily. A review of Fall Risk Evaluation dated 6/20/2022 revealed Resident #15 was high risk for falls. A review of the Order Summary Report with active orders dated 12/8/2022, revealed a physician order for a bed/chair Tab Alarm: Check for function and position every shift for Safety. A further review revealed a physician order for Eliquis 2.5mg (blood thinner) by mouth twice a day for A Fib. A review of a Care Plan with an initiated date of 3/19/2022 and last revised date of 5/21/2022 revealed a Focus area of I am at risk for falls because of my unsteady balance. Under the Goal section indicated I don't want to fall and sustain an injury. Interventions included but were not limited to; I have a clip alarm to remind me and alert staff that I am attempting to get up without calling for assistance. Check for functioning every shift. Anticipate my needs. Keep my personal items within reach when I am in bed as I am at risk for a fall. A review of a Fall report dated 8/13/2022 timed at 11:45 revealed that, Called by staff patient was on the floor. Walked in the patient's room, resident was sitting on the floor next to the bathroom, against bathroom door. Able to explain what happened. States he/she hit his/her head. on assessment skin is intact, no bump noted. However, he/she is on blood thinners. able to move all extremities freely and stand up with assist of 2 people. Resident said I was making my bed and fell. I hit my head. Upon further review the report indicated under immediate action, Patient was sent to emergency room for evaluation physician order, he/she is on blood thinners.' A review of a progress note dated 8/13/2022 timed at 10:49 revealed that Resident #15 resident was sent to emergency room for evaluation. A progress note dated 8/13/2022 timed at 18:44 (6:44 PM) revealed that Resident #15 returned from the emergency room at 4:00 PM. CT scan (uses X-rays and a computer to create detailed images of the inside of the body) of head done at emergency room. No report received. Offers no complaints. Ate dinner and took meds. During an interview with the surveyor on 12/7/2022 at 9:50 AM, RNUM #1 said If a resident falls, we are required to revise the care plan as to what can we do to prevent further falls. The supervisor or nurse does the update. RNUM #1 said, Yes, I do follow up and make sure something else is put into place. The Assistant Director of Nursing also reviews the care plan. This should be addressed within 24 hours, and you are monitoring the resident for 3 days. On 12/7/2022 at 10:05 AM, the surveyor requested RNUM #1 to review the fall care plan and she said it should have been revised after the fall. On 12/8/2022 at 9:06 AM, the surveyor requested the fall investigation from the Director of Nursing, and she said she wasn't sure what I wanted. Surveyor explained that according to the facility policy they are to get statements from staff. The RNUM#1 explained, Not always. If we can tell what happened, then we don't need statements. It is quick investigation. During an interview with the surveyor on 12/8/2022 at 10:37 AM, the assigned Certified Nursing Assistant (CNA #1) said if a resident falls, I call the nurse and the nurse calls the supervisor. We don't move them. I have to do incident report in the computer if I was the first person to get to the resident or whoever saw the resident and any witness. Only if I found the resident do I write a statement but not if I did not or wasn't around even as the assigned aide. If nobody found resident and I was the assigned aide, they would come back to me and ask where I left the resident and was his/her alarm on. During an interview with the surveyor on 12/8/2022 at 10:52 AM, the assigned Licensed Practical Nurse (LPN#1) said if a resident falls, I go to room make sure there is no distress, ask for help, call the supervisor, and stay with the patient. We assess the patient and make sure of no fracture, mental status is clear, no head injury, no skin open, no bleeding. After being assessed we get the patient up. If it is not safe to get the patient up, we call 911 and send to hospital if they hit their head or may have neck injury. We do an incident report standing form in the computer and we need witness statements from whoever found the resident and that also is in the computer. We give a paper to the CNA and after they write it up, we type it into the computer and then we give it to the unit clerk and put a copy in the patients file. LPN#1 further revealed that just supervisor's put statements in the computer. The supervisor does risk management form and neuro checks. We call family and physician. We monitor every shift for 3 days, vital signs. mental check and if able to move. We educate the patient to ask for help and closely monitor to make sure call light is within reach and alarms working to prevent future falls. The unit manager usually updates the care plan after a fall. LPN#1 stated, Yes, the care plan is supposed to be updated after any fall to make sure everything is working properly. During an interview with the surveyor on 12/8/2022 at 2:04 PM, the Director of Nursing (DON) said the process when a fall occurs is that the Registered Nurse has to come and assesses for an injury. If no injury, then they assist the resident back up. The nurses look for causative factor such as are lights off, trip hazards, check to make sure following interventions in care plan, and add new interventions if indicated. The DON went on to say that if the resident has an injury we provide first aide, if they are bleeding, we send out 911, and if the resident hits their head, we have to do neuro checks. When the surveyor asked if the care plan is to be updated after a fall, the DON responded, It depends on if something is indicated. The alarm string was pulled off the alarm, causing the alarm to not activate. Sometimes he/she does make his/her own bed. On 12/12/2022 at 10:27 AM the surveyor conducted a follow up interview with the DON regarding resident fall in the presence of the survey team. The surveyor asked what the cause of Resident #15's fall was. The DON replied, The cause of the fall was the string was pulled out of the alarm and it did not activate and that is what caused him/her to fall. The surveyor reviewed the facility policy with the DON regarding statements and the Supervisor of Nursing summary and the DON said aide statement and supervisor summary goes in the first part of the incident report and it was what the resident said occurred and what the supervisor saw. The alarm would just be replaced since it was disabled. The surveyor asked the DON how an alarm can cause a fall. The DON said the alarm did not alert us he/she was up. The surveyor also questioned if making the bed was something that would be put on care plan for staff to assist with, and the DON said I am not really sure the resident is making the bed as it is probably already made. He/she is probably touching the bed and thinks he/she is making the bed. A review of an undated facility policy titled Accidents & Incidents; Resident revealed the following under the Procedure section: The policy also includes under 6. c. Factors care plan should be reviewed and compared to ensure compliance with following plan of care. Under d. Witnesses Statement should be obtained even if incident not witness by staff i. licensed staff/SON (Supervisor of Nursing) to request statements immediately from all staff, visitors, or other residents involved or witnessed accident/incident. ii obtain statement from last staff member that saw the resident. Under e. Action section 1. Care Plan will be reviewed and updated as necessary. If all interventions were followed new interventions may be necessary. Under f. Notes section i. Completed by the SON. Minimally, the note consists of summary of what occurred, indication that care plan was reviewed and what new interventions were put into place to help prevent reoccurrence when impossible. ii. The Unit manager (UM) will review the following day for accuracy. Review if new intervention remains appropriate and additional notes added to the summary as indicated. A review of a the facility undated policy titled Fall and Fall Risk, Managing under Procedure section Prioritizing Approaches to Managing Falls and Fall Risk 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. NJAC 8:39-27.1(a)(b)

Based on observation, interview and record review, it was determined that the facility failed to ensure that transmission-based precautions were followed to prevent spread of infections to include hand washing. This deficient practice was identified for 1 Certified Nursing Assistant (CNA #2) and 2 Laundry Staff (LS#1 and LS#2) who did not properly utilize personal protective equipment (PPE) while handling equipment or items that were likely contaminated with infectious bodily fluids. 1. On 12/7/2022 at 09:19 AM, the surveyor observed the Garden Unit on the ground floor. The surveyor observed a resident room with a Stop Sign at the entrance that read Enhanced Barrier Precautions: Everyone Must: Clean their hands including before entering and when leaving the room. Providers and Staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering; Transferring; Changing linens; Providing Hygiene; Changing briefs or assisting with toileting; device care or use: central line urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing. No isolation bin was observed in the proximity of the room. The surveyor observed Certified Nursing Assistant #2 (CNA#2) in the resident's room providing direct care and only wearing gloves. CNA#2 then exited the room wearing the same gloves utilized while providing direct care, reached into the clean supply cart, and returned into the resident room. CNA#2 confirmed she was the CNA for the resident and was an agency nurse. During an interview with the surveyor on 12/7/2022 at 9:26 AM, CNA#2, advised that she changed an incontinence brief and emptied both the left and right nephrostomy bags. When asked what precaution the resident was on, CNA#2 stated that she was not aware of any contact precautions. The surveyor pointed to the sign located on the outside of the Resident's room. CNA#2 responded, there are two (residents) in the room and I didn't know. During an interview with the surveyor on 12/7/2022 at 9:38 AM, Registered Nurse Unit Manager (RNUM#1) confirmed that agency nurses receive education on the different forms of contact precautions during their orientation. When asked if it is the CNA's responsibility to be looking at contact precaution signs before walking into rooms, RNUM#1 responded yes, absolutely. The surveyor inquired if the CNA caring for the resident should be providing care without Enhanced Precautions. RNUM#1 confirmed no obviously, she is agency, there is no excuse, she knows. During an interview with the surveyor on 12/7/2022 at 12:21 PM, the Director of Nursing (DON) reported that Enhanced Barrier Precautions include masks, gloves, gown, and goggles during direct care. The surveyor inquired what should be done with gloves when exiting a room, the DON stated gloves should be taken off thrown away and hands washed. The DON advised that CNA#2 was familiar with the facilities' policies and was actually in-serviced a couple months ago. 2. On 12/7/2022 at 12:18 PM, during a tour of the laundry room, the surveyor observed the laundry staff loading soiled linens into the washing machine. At that time, the surveyor observed Laundry Staff #1 not wearing a gown. On the same date at 12:20 PM, during an interview with the surveyor, Laundry Staff #2 stated he forgot to wear a gown. On the same date and time, during an interview with the surveyor, Laundry Staff #2 stated, Whenever we put in soiled laundry we have to put on a gown. On 12/8/2022 at 2:07 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator stated, I checked with out Infection Preventionist and that's the policy and recommendation; that they wear the gowns when moving soiled linens. A review of an undated facility Policy Titled Infection Prevention Policy and Procedure Manual on 12/7/2022 revealed, Purpose: To prevent the transmission of healthcare associated (HAI) or Community Acquired Organisms and/or infection pathogens to our residents, family, visitors, and staff. [Facility name] recognizes the challenges for trying to balance room to prevent transmission with resident's quality of life. Under Section B. Categories of Precautions: Enhanced Barrier Precaution Applies to: All residents with colonization with novel or MDRO (multi drug resistant organism) when contact Precautions do not apply. During high contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devise care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. PPE use for these situations: hand hygiene with ABR preferred prior to entering and leaving room; gloves and gowns prior to any high contact resident care activities; change PPE before care of another resident; eye protection may also be needed if performing activity with risk of splash or spray. Room Restriction: None A review of an undated facility policy titled, Laundry and Bedding, Soiled revealed under, Procedure number 3. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). NJAC 8:39 - 19.4(a)(2) NJAC 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice occurred on 2 of 3-unit nourishment rooms (unit 1 and unit 2) and was evidenced by the following: On 12/6/2022 from 9:19 AM to 9:37 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) observed the following on the 2nd unit nourishment room: 1. In an upper cabinet the surveyor observed (9) 4 oz (ounce) nectar thickened cranberry juices. The thickened cranberry juices had a best if used by date of 19 [DATE]. In addition, an upper cabinet above the microwave had (2) 46 Fl oz (fluid ounce) containers of orange juice concentrate. The orange juice containers had a use by date of 08/16/2022. On interview the LPN/UM stated that, Maintenance is responsible for monitoring the dates of foods in the nourishment room. 2. On 12/6/2022 at 9:37 AM, the surveyor conducted an interview with the Supervisor of Housekeeping, Laundry, and Maintenance (SHLM). When asked who is responsible for monitoring food dates in the nourishment rooms in the facility the SHLM responded, Housekeeping staff are responsible to stock the nourishment rooms and ensure that all products are monitored for use by dates. These items are going to be thrown in the trash because they are past the use by dates. On 12/6/2022 at 10:10 AM, the surveyor, accompanied by the Registered Nurse/Unit manager (RN/UM) observed the following on the first unit nourishment room: 1. On an upper shelf in the refrigerator the surveyor observed a resident provided bottle of French Dressing. The bottle was dated with resident name and dated 11/30/2022. The bottle had a manufacturer's best if used by date of [DATE]. The RN/UM stated, That is almost 1 month old. The surveyor reviewed the facility policy with Subject: Food Brought by Family/Visitors, dated 8/17/21. The policy revealed the following under the Procedure heading: 7. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 8. Staff is responsible for discarding perishable foods on or before the use by date. NJAC 8:39-17.2(g)

Based on interview and review of other facility documentation, it was determined that the facility failed to accurately track and document facility and contracted staff vaccination status to include primary series and boosters when eligible. This deficient practice was evidenced by the following: On 12/1/2022, during entrance conference, the facility was asked to provide documentation of their staff and contracted staff vaccination status. On 12/2/2022 the facility provided a spread sheet for the facility staff. A review of the facility staff vaccination spread sheet showed that 3 staff members were eligible/due for their booster in June of 2022. There was no documentation provided to indicate the boosters were received. On 12/5/2022 the facility provided a spread sheet for the contracted staff who provide services at the facility. A review of the spread sheet did not include documentation of the dates that 8 of the 12 Independent Licensed Practioners received the initial covid vaccines. The spread sheet also revealed that 2 of 21 Therapy Department, Dietician, Security, Entertainer, did not have any vaccinations documented as having been completed. 3 of 53 Hospice providers at the facility did not have documentation the initial series of vaccinations were administered. The spread sheet further revealed that 41 of the total contracted staff eligible/due for boosters did not receive the boosters. During an interview with the surveyor on 12/5/2022 at 10:21 AM, the Infection Preventionist (IP) said she is the facility IP and responsible for tracking all vaccinations. The IP said the majority of staff are boosted. When asked by the surveyor if any staff were not boosted, she replied, No, I have no one who hasn't been boosted. When surveyor questioned the IP regarding the four staff that are marked as unvaccinated on the Covid-19 Staff Vaccination Status Matrix, the IP said, Yes, they refused and are direct care staff. I have to look at why they are not unvaccinated. I don't want to misspeak. The surveyor also questioned why some of the contracted staff who were eligible for their 1st booster are not boosted despite the requirement that all healthcare workers were to have received the initial vaccination series and 1 booster. The IP stated she had to look at it and it (spread sheet) was not updated. On 12/05/2022 at 1:44 PM, the IP apologized to the surveyor and said she had more exemptions than she thought and the 4 she had as unvaccinated were in fact granted exemptions. During an interview with the surveyor on 12/6/2022 at 9:40 AM, the IP said it is me that is responsible to oversee the vaccine effort. She also said she is responsible to track vaccinations of facility staff and contracted staff at the facility. When asked what the process was to track vaccinations, the IP said, Most of the time staff get the vaccinations here and if elsewhere I have to chase them down, so it becomes more complex. This is for both covid and flu vaccinations. The IP went on to say when the contracted staff come into the building for the first time, they have to present their vaccination records and we make a copy. If this doesn't happen, we call the agency or office and get a copy. This is the same for hospice staff and security staff also. The surveyor asked if security were required to be vaccinated. The IP replied, Yes, security is also required to have 1 or 2 initial vaccine and 1 booster unless they have an exemption. The surveyor asked the IP if all the facility staff and contractors received their 1st booster if eligible. The IP said all the facility staff have received their vaccines and boosters, but I have not accurately tracked the contracted staff for their vaccination status. When asked if it was accurate to say she had not tracked both facility staff and contracted staff vaccinations/boosters the IP said, Yes, it is accurate to say I haven' been tracking staff and contracted staff vaccines and boosters. On 12/06/2022 at 10:40 AM, the IP provided the surveyor with an updated covid 19 staff matrix for vaccination numbers, and it still indicated (4) staff as being not vaccinated without exemption. When questioned as to who the 4 staff members are, the IP was unable to say and said, I will check and get back to you. The IP also said 9 total staff have either medical or religious exemptions. The Director of Nursing provided the surveyor with the current staff exemptions for surveyor review. While reviewing the exemptions, (1) staff had a physician note that indicated, Until issue resolved, would hold off on the booster.: There is no further documentation of the outcome of the delay. A 2nd staff member had a temporary medical exemption until 11/18/2022. There was no further documentation regarding the delay. During a follow up interview with the surveyor on 12/06/2022 at 12:41 PM, the IP said the four unvaccinated are staff members who had a reaction to the covid vaccines, and they are medical exemptions. That is where I screwed up. The staff who had a temporary delay for the vaccination until 11/18/2022 had a pending religious exemption. The IP said she will be following up with the staff who had a recommendation in April to hold off before getting the booster. A review of an undated facility policy titled Mandatory Employee Covid-19 Vaccination, revealed the following under the Policy section: All [facility name] employees including those who are not responsible for direct resident care, per diem (as needed) and contract employees are required to have at least the primary series and one booster. The policy further revealed Under the Procedure section: 3. Record Keeping- The facility must maintain a record of vaccinations, attestations and Exemption record for each employee and contract employees. NJAC 8:39-19.4(a)

Based on interview, review of medical record (MR), and other facility documentation, it was determined that the facility failed to report an elopement of a resident that occurred on 7/29/20, to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 resident's (Resident #304) and was evidenced by the following: According to the facility admission Record, Resident #304 was admitted in 9/2015 with diagnoses which included, but not limited to, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), Parkinson's Disease (a nervous system disorder that affects movement), and unsteady on his/her feet. On 10/5/20 at 10:21 AM, the surveyor reviewed the facility investigation dated 7/29/20 that was prepared by the Infection Prevention/Staff Development/Supervisor of Nursing and included the following: Resident #304 left the facility to go to a local fast food restaurant to get pancakes. The Resident wandered down the road on which the facility was located and turned onto an adjacent road. Resident #304 was intercepted by facility staff in a vehicle. Resident #304 was resistant to returning to the facility with staff. The local police were notified and arrived at Resident #304's location. Police had transported the resident back to the facility. Attached to the investigation was a statement dated 7/29/20 from the Security Guard which revealed that they had attempted to stop the Resident from leaving and was pushed out of the way by the Resident. Resident #304 continued to proceed out of the door and left the facility. An additional statement dated 7/29/20, from the Restorative Nursing Assistant (RNA) revealed that they responded to the Nursing Stat page and observed Resident #304 leaving the facility. The RNA proceeded to get into a vehicle accompanied by another staff member. Resident #304 was intercepted by the facility staff that were in the vehicle. Resident #304 was resistant to returning to the facility with staff. The local police were notified and arrived at Resident #304's location. Police had transported the resident back to the facility. The facility investigation did not include documentation that the NJDOH had been notified of this incident. On 10/7/20 at 1:02 PM, the surveyor reviewed Resident #304's Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 8/31/20, which revealed a Brief Interview of Mental Status score of 15 which indicated the resident was cognitively intact. On the same day at 3:25 PM, the surveyor reviewed a Care Plan (CP) that was initiated on 1/06/20, that indicated Resident #304 was at high risk to wander and had a history to leave the facility unattended. The CP also reflected that the Resident walked fast and had a lack of safety awareness. The intervention initiated on 1/06/20 reflected that Resident #304 was to have the placement and function of the Wander Guard (a device worn to alert others that a person has left the safety area) checked on every shift. An additional intervention initiated on 3/16/20 reflected that Resident #304 was to be checked for observation every 30 minutes. On 10/06/20 at 3:12 PM, the Administrator and Director of Nursing (DON) were interviewed in the survey team's presence. The Administrator mentioned that Resident #304 had been on a 1:1 (continuous visual observation/monitoring) since the COVID pandemic in March 2020. Administrator continued to mention that Resident #304 has a history of schizophrenia and hears voices. DON stated that the incident dated 7/29/20 was not reported to the NJDOH because staff had been with the resident the entire time which conflicted with the investigative statements. DON continued to mention that she could not confirm if there was a physician order for 1:1 observation. Review of a facility policy and procedure titled, Elopement, dated 8/18/2020, Section: B 4 read: Staff members are to remain with a resident who has exited the building, keeping them in eyesight as much as possible. N.J.A.C. 8:39-9.4

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow a physician order for a wound treatment. This deficient practice was identified for 1 of 1 resident's (Resident #73) observed for wound care and was evidenced by the following: On 9/29/20 at 11:08 AM, the surveyor observed Resident #73 in bed and lying on their right side with the head of bed slightly elevated. The resident wouldn't speak specifically to the surveyor's inquiry as he/she mentioned they were tired. The resident stated that they had a wound and demonstrated by pointing to their lower back. On 10/01/20 at 10:02 AM, the Licensed Practical Nurse (LPN) confirmed the physician order on the Treatment Administration Record (TAR) in the presence of the surveyor. The LPN removed the Dakins solution (an antiseptic) 0.125% and dermal wound cleanser from the treatment cart and placed the items on the clean field (an area kept free from microorganisms) located on Resident #73's overbed table. At 10:08 AM, Resident #73 was lying in bed on their left side and held by the Certified Nursing Assistant (CNA). Resident #73 denied discomfort prior to the procedure. The LPN then removed the old dressing that was packed in the wound located on the right sacrum. The LPN sprayed the dermal wound cleanser onto sterile 4 x 4 gauze pads and cleansed the wound several times. The LPN then performed hand hygiene and returned to Resident #73's bedside to dry the wound with clean gauze. The LPN then poured Dakins solution onto sterile gauze pads and continued to pack the sacral wound with the saturated gauze pads. The LPN then covered the wound with the abdominal dressing and secured it with tape. According to the facility admission Record, Resident #73 was admitted in June 2013 with diagnoses including, but not limited to COVID-19, peripheral vascular disease (a blood circulation disorder that affects blood flow to the arms, legs, or other body parts), abnormal gait and mobility, and Diabetes Mellitus (a disorder resulting in high sugar levels in the blood). On the same day at 10:42 AM, the surveyor interviewed the LPN that was assigned to the resident. The LPN read the TAR, in the presence of the surveyor, on the computer that was located on top of the medication cart. The LPN stated that the normal saline solution (NSS) was not the same as the dermal wound cleanser. The dermal wound cleanser was used to remove dead tissue. The LPN mentioned that the resident had specific orders for the use of normal saline solution and added that she had difficulty seeing with her glasses due to the small print. The LPN confirmed that, I should have used the normal saline solution. On 10/05/20 at 1:31 PM, the Unit Manager (UM) confirmed that the dermal wound cleanser should not be used as a substitute for the normal saline solution and that the LPN should have followed the physician's order. On 10/06/20 at 10:33 AM, the Advanced Practice Nurse (APN) for the facility Wound Consultant was interviewed in the survey team's presence and confirmed that the LPN should have followed the physician's order. At 3:02 PM, the Administrator and Director of Nursing (DON) were interviewed in the survey team's presence. The Administrator and DON stated that the normal saline solution and dermal wound cleanser were not to be used interchangeably; and confirmed that the LPN should have followed the physician's order. On 10/7/20 at 1:57 PM, the surveyor reviewed the Minimum Data Set, an assessment tool used to facilitate care management, dated 8/25/2020, which revealed that the Brief Interview of Mental Status (BIMS) was 14, which indicated that Resident #73's cognition was intact. A review of the Order Summary Report (OSR) revealed a current physician's order dated 9/22/20 for Dakins (1/4 strength) Solution 0.125% (Sodium Hypochlorite) apply to sacral-gluteal wound topically two times a day for deep tissue injury (DTI) Sacrum, cleanse with normal saline solution (nss), pack with Dakin's, cover with abdominal (abd) dressing (drsg), tape minimally. A review of October 2020 TAR reflected that the resident had a physician's order dated 9/22/20 for Dakins (1/4 strength) Solution 0.125% (Sodium Hypochlorite) apply to sacral-gluteal wound topically two times a day for DTI Sacrum, cleanse w/nss, pack w/abd drsg, tape minimally. A review of the resident's Care Plan (CP) reflected a focus area for developing pressure ulcers. The goal of the CP reflected that the resident will not develop a new pressure wound during the 90 days. Interventions for the CP included to follow facility policies/protocols for the prevention/treatment of skin breakdown. When interviewed on 10/07/20 at 3:43 PM, the Infection Preventionist/Staff Development Coordinator stated that the LPN did not have a wound competency on file. Review of a facility policy and procedure titled, Skin Care Protocol, dated 10/15/2019, under number 3 it read: All nursing staff have a responsibility to be aware of the skin integrity of our residents and are expected to initiate appropriate care as needed. N.J.A.C. 8:39-27.1(e)

Based on observation, interview and record review, it was determined that the facility failed to: a) accurately document the administration of controlled medication for Residents #2, #28, #60, and #61 and; b) maintain a system of record keeping that ensures an accurate inventory of controlled medications. This deficient practice was identified on 3 of 4 medication carts reviewed and evidenced by the following: 1. On 09/29/20 at 10:40 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN#1), inspected the A-Hall cart. A review of the reconciliation of the narcotics stored in the secured and locked narcotic box to the declining inventory sheet revealed Resident #28's lorazepam 0.5 milligram (mg) tablets, a medication used for anxiety, did not match. The blister pack contained 12 half tablets and the declining inventory sheet accounted for 13 tablets administered. LPN #1 stated that she forgot to sign the declining inventory sheet for the dose she had given that morning. She further acknowledged she should have recorded on the declining inventory sheet immediately after removing the medication from the blister pack. On 9/30/20 at 9:13 AM, the surveyor, in the presence of the LPN #2, inspected the D-Hall Cart. At 9:28 AM, A review of the reconciliation of the narcotics located in the secured and locked narcotic box to the declining inventory sheet revealed Resident #2's lorazepam 0.5 mg tablet did not match. The blister pack contained four tabs and the declining inventory sheet accounted for five tabs administered. Further reconciliation revealed Resident #60's oxycodone ER 10 mg tabs, a medication used for pain, did not match. The blister pack contained nine tablets and the declining inventory sheet accounted for 10 tablets administered. Lastly, Resident # 61's oxycodone/acetaminophen 7.5 mg/325 mg, a medication used to treat pain, did not match. The blister pack contained 14 tablets and the declining inventory sheet accounted for 15 tablets administered. At 9:35 AM, LPN #2 stated that they should have signed the declining inventory sheet when they removed the medication from the blister pack. 2. On 9/29/20 at 10:47 AM, the surveyor, in the presence of the LPN #3 inspected the B-Hall Cart. At 10:59 AM, The surveyor along with the LPN #3 reviewed the Narcotic Medication binder located on B-Hall cart. The form titled, Record of Controlled Drug Count sheet revealed the nurse had pre-signed the 3:00 PM outgoing nurse slot. LPN #3 stated that they shouldn't have signed the outgoing slot before doing the narcotic count at 3:00 PM with the incoming nurse. LPN #3 explained that the incoming and outgoing nurse count the narcotics together to ensure the count was correct, then together sign the book. At 11:29 AM, the surveyor interviewed the covering supervisor of the Garden Unit, the Infection Preventionist/Staff Development Coordinator (IPC), who stated that LPN #3 should not have pre-signed the Record of Controlled Drug Count sheet because there was no witness to an accurate narcotic count and that it was not yet 3:00 PM. On 9/30/20 at 9:13 AM, the surveyor, in the presence of the LPN #2, inspected the D-Hall Cart. A review of the Record of Controlled Drug Count sheet revealed that LPN #2 had not signed the incoming nurse slot on 9/30/20 at 7:00 AM. LPN #2 stated that she had forgotten to sign the sheet that morning. LPN #2 explained that the incoming and outgoing nurses count the narcotics together, to make sure the count was correct and that was why there was a double sign. On 10/7/20 at 12:53 PM, the survey team met with the facility Administrator and the Director of Nursing (DON). The DON explained the facility's process for narcotic administration was that the nurse should check to be sure the medication was correct, the resident was correct and then remove the medication from the blister pack and sign it out on the declining inventory sheet. She continued that once the medication was administered the nurse should sign the dose as given on the electronic Medication Administration Record (eMAR). The DON further stated the incoming and outgoing nurses count to make sure the narcotic count was correct. That they both sign off on the log after the count was completed and the reconciliation was made. The purpose of them doing the count together was to prevent drug diversion. A review of the Facility's Policy and Procedure titled, Medication Requirement dated 10/17/19 revealed; Controlled Inventory Record, 1. Kept in the Med Count Book and counted and signed by each shift incoming and outgoing nurse immediately after the count, and; Individualized Narcotic Record, 1. Declining inventory must be maintained for each dose administered to each resident, 2. The records for each resident will be kept in the Med Count book and, 3. Controls must be signed out on the declining inventory immediately after removal from bingo card. N.J.A.C. 8:39-29.7

Based on observation, interview and review of other facility documentation, it was determined that the facility failed to; properly store, label and dispose of medications in 3 of 4 medication carts and 1 of 2 medication refrigerators inspected This deficient practice was evidenced by the following: On 9/29/20 at 10:40 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) inspected the A-Hall medication cart. The inspection revealed four loose pills in drawer two and drawer three. A further review of the controlled substance inventory secured in the narcotic box revealed medications being stored that were awaiting destruction were as follows; Resident #5's lorazepam 0.5 milligram (mg) tablets, a medication used for anxiety, order had been discontinued but remained on the active medication cart. Resident #254 passed away July of 2020, tramadol 50 mg tablets, a medication used for pain, as well as lorazepam 1 mg tablets remained on the active medication cart. Resident #255 passed away in July of 2020, tramadol 50 mg tablets, and morphine sulfate solution, both medications used for pain remained on the active medication cart. LPN #1 stated the medications for Resident #5, #254 and #255 should have been brought to the Assistant Director of Nursing (ADON) for wasting. LPN #1 stated the medications had not been in use for a while and should have been removed. On 9/29/20 at 10:47 AM, the surveyor in the presence of LPN #2, inspected the B- Hall medication cart. The inspection revealed one loose pill in drawer three. In the top drawer there was an undated insulin glargine pen for Resident #87. A further review of the medication cart and the controlled substance inventory secured in the narcotic box revealed medications being stored that were awaiting destruction were as follows: Resident #256 passed away September of 20202 had morphine sulfate solution, a medication for pain, and lorazepam 0.5mg tablets, a medication used for anxiety, remained on the active medication cart. discharged Resident #257 was transferred in August of 2020 had clonazepam 0.5 mg tablets, a medication for anxiety, remained on the active medication cart. Resident #49's lorazepam 0.5 mg tablets whose order had been discontinued, remained on the active medication cart. At that same time, LPN #2 stated the process was that the manager takes the narcotics that are no longer in use and then returns them to the pharmacy. These medications should not be stored in the cart if they're not being used. At 11:12 AM, The surveyor along with LPN #2 inspected the Garden Floor Medication room refrigerator located in the medication room. The freezer portion of the refrigerator was frosted over with ice. The surveyor also observed an expired Flu vaccine multidose vial that had expired on 5/9/20. Inspection of the medication refrigerator also revealed food items being stored in the medication refrigerator. The refrigerator contained two cups of applesauce, two cups of pudding and two large containers of coffee creamer. LPN #2 confirmed that food should not be stored in the medication refrigerator and the freezer section should not be frosted over. At 11:29 AM, the surveyor interviewed the covering supervisor of the Garden Unit, the Infection Preventionist/Staff Development Coordinator (IPC) who stated there should not be loose pills in the medication carts. The IPC stated the expired or discontinued narcotics go to the ADON. Then the ADON and the Director of Nursing (DON) destroy the medication together and do the paperwork. This process should happen twice a week. The IPC further stated that insulin pens should be dated when they are opened and acknowledged the one for Resident #87 should have been dated before being placed in the medication cart. The IPC also confirmed that there should not be food stored with medications in medication refrigerator. A review of the Manufacturer's Specifications for glargine insulin 100 units/milliliter (u/ml), 3 milliliter (ml) prefilled pen, once opened must be discarded after 28 days. On 10/7/20 at 12:53 PM, the survey team met with the facility Administrator and the DON. The DON stated they have no excuses for the food being stored in the medication refrigerator and that food should never be stored with medications. The medication carts should be inspected by the nurses every shift and were on a scheduled rotation to be emptied and then brought to cleaned by housekeeping. Medications that are discontinued are picked up by the supervisors and brought to the ADON's office and was done once a month. The reason for removing the medications from the medication cart as soon as possible was to avoid drug diversion. The DON added that Insulin syringes should be dated when opened and placed in the medication cart. A review of the facility's policy titled, Labeling Insulin Pens with a reviewed date of 10/17/19, read; Insulin pens will be dated upon opening according to the type of insulin pen. The attached [Provider Pharmacy] guidance revealed Insulin pens should be refrigerated until needed, then dated and stored at room temperature. A review of the facility's policy titled,Medication and Treatment Cart Cleaning dated 2/17/15, read: 1. Monthly schedule will be created by 11-7 supervisor and written in the appropriate space on the lower right-hand corner of the daily sheet. A review of the facility's policy titled, Disposal of Unused Medications and Narcotics dated 4/4/17, read: 5. The unused, unneeded, or expired prescription drug(s) will be taken out of their original containers and disposed of as per guidelines, and; 9. Discontinued medications awaiting return to the pharmacy or for destruction at facility are stored in a locked, secure area designated for that purpose. A review of the facility's provided document titled, Daily Medication Room Refrigerator schedule dated 6/27/14 included the following instructions, Refrigerator check includes: 1. Clean and neat refrigerator, 2. No staff food in refrigerator, 3. No expired medications and, 4. All insulin bottles are dated. N.J.A.C. 8:39-29.4

Based on observation, interview, and record review, it was determined that the facility failed to: a) provide an individualized assessment of possible food related weight changes by a qualified nutritional professional and failed to offer residents an individualized nutritionally equivalent food substitute/nourishment; b) ensure their Enhanced Calorie Program provided a super cookie calorically equivalent to their policy; and c) periodically update and ensure the adequacy of their the Enhanced Calorie Program by a qualified nutritional professional. This deficient practice was evidenced by the following: On 10/2/2020 at 9:23 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the facility currently had no Registered Dietitian (RD) so the nurses were reviewing resident's weight loss. The RN/UM stated that if a resident was losing weight, they spoke to the resident's primary care physician (PCP) to determine if the resident should be placed on the facility's Enhanced Calorie Program (ECP). This program included foods that contained higher calories to increase the resident's caloric intake. When the RD was employed at the facility, she determined who was on the program and what the resident received. Currently, the Food Service Manager (FSM) was in charge of the ECP program. On 10/2/2020 at 9:42 AM, the FSM informed the surveyor that residents on the ECP received pink colored meal tickets which indicated to staff that particular resident was on that program. Residents on that program received enhanced super cookies (nutrition supplemental cookies containing increased calories and protein), super cereal (hot wheat-based cereal with increased calories), cheddar mashed potatoes (super mashed; mashed potatoes with higher caloric count than regular mashed potatoes), milkshakes (nutrition supplemental health shakes with extra calories and protein), and magic cup (frozen nutritional dessert cup with increased calories and protein) in addition to the regular meal the facility served for the day for each meal. The FSM stated that the foods rotated on a daily basis according to a menu designed by a previous RD. The FSM confirmed that she was not a RD and had no formal nutrition or dietetics degree, but was a certified Professional Food Manager after taking a food and beverage safety training course. At this time, the Food Service Supervisor (FSS) stated that if a resident had not liked a certain item, than the kitchen gave the resident a different item. The FSS stated that a resident might not want super cereal for breakfast so the kitchen could provide a milkshake instead. Once a resident was on the ECP, the Dietitian Helper (DH) interviewed the resident to determine what foods the resident wanted from the ECP list. The FSS confirmed that she was not an RD and no formal nutrition or dietetics degree, but was a Certified Food Handler (a food and beverage safety training course). At 9:51 AM, the surveyor interviewed the DH who stated that her job was to interview residents on their preferences and dislikes. If a resident was not eating a certain food, then she took that item off the resident's meal ticket. In the past, communicated this to the RD, but now she informed the UM if a resident was not eating a certain food. The DH stated that she was a food service worker for the past ten years and was recently promoted to this job. The DH stated that she was ServeSafe certified (a food and beverage safety training course) and held no formal degree in nutrition or dietetics. The surveyor reviewed the ECP menu the facility provided. According to the ECP menu, the menu items yielded the following calories (cal): super cereal 470 cal; super mashed potatoes 150 cal; super cookie 200 cal; magic cup 290 cal; and milkshake 200 kcal. Each day of the week and meal had a designated menu item for that day and meal based on the diets received of pure dysphagia (a level 1 nutritional diet serving only pureed foods); puree, and regular. On 10/5/20 at 10:45 AM, the Licensed Nursing Home Administrator (LNHA) stated that the ECP was developed by an RD. Menu items were substituted for a meal based on resident's likes. If a resident refused the super mashed potatoes, then the resident might receive a magic cup or super cookie. The menu items were also adjusted based upon allergies. At 11:54 AM, the surveyor observed lunch service in the kitchen. According to the ECP menu, super mashed potatoes were to be served to all resident's unless they were on the puree dysphagia diet, in which they received a magic cup. The surveyor observed the following: Residents #25, #32, #44, #92, and #94 received no super mashed potatoes (150 cal) but received a magic cup (290 cal). Resident #62 received no super mashed potatoes (150 cal), but received super cereal (470 cal). Residents #29 and #88 received no super mashed potatoes (150 cal), but received a super cookie (200 cal) Resident #102 received in addition to the super mashed potatoes (150 cal), a magic cup (290 cal). At 12:19 PM, the FSM informed the surveyor that a super cookie was an enhanced calorie cookie. The FSM provided the surveyor with the facility's super cookie. The surveyor reviewed the [Brand Name] soft baked oatmeal cookie which yielded for the one cookie serving 90 cal and 1 gram of protein. At 1:46 PM, the FSM stated that the facility also provided the residents with the sugar cookie as the other super cookie. The FSM provided the surveyor with the manufacturer's nutritional facts for the sugar cookie, which indicated that one cookie contained 90 cal and zero grams of protein. The surveyor reviewed the facility's standardized recipes for the super mashed potatoes and the super cereal. The standardized recipe for the super mashed potatoes yielded 160 cal, which was an additional 10 cal form the 150 cal on the ECP menu. The standardized recipe for super cereal yielded 516 cal, which was an additional 46 cal from the 470 cal on the ECP menu. On 10/7/2020 at 2:16 PM, the LNHA, in the presence of the survey team, stated that after a previous survey, when a resident had significant weight loss that was not addressed, the RD developed the ECP. The facility rotated different menu items so that the resident was not receiving the same item every day. The LNHA stated that some residents just liked the magic cup and they wanted the magic cup all the time. The facility also received pushback from residents when taken off the ECP, that they wanted to continue to receive items like the magic cup. The facility monitored to see if a resident on the program was gaining weight, then the resident would be taken off the program. The LNHA confirmed that the residents should have been given three cookies that day and not the one cookie to get more calories. A review of the facility's untitled Policy and Procedure regarding therapeutic diets dated 2/5/13 included that the ECP provides additional hi-calorie food items on a rotating schedule. One item was provided at each meal which included super-cereal, super cookie, super mashed potatoes, milk shake, or magic cup. The surveyor reviewed the facility's New Jersey Civil Service Commission's Dietitian Helper job specifications which included under direction, assists a dietitian in the planning of diets and serving of meals. The job title does not include any education or experience. A review of the facility's New Jersey Civil Service Commission's Dietitian job specifications includes under direction, plans and develops and implements dietary plans based on nutritional assessment and the special nutritional needs of individuals. The education required includes graduation from an accredited college with a Bachelor's degree with a major concentration in dietetics, nutrition, food, food science, or Food Service Management. Experience includes the completion of a dietetic internship and professional experience. N.J.A.C. 8:39-17.4 (c) Refer to F801

3. On 10/01/20 at 10:22 AM, following wound care treatment, the surveyor observed the Certified Nursing Assistant (CNA) walk towards the sink that was in the resident's room. The Licensed Practical Nurse (LPN) was at the sink washing her hands. The CNA applied soap to hands, wet both hands, and washed hands with friction for three seconds away from the sink. CNA used her elbow to open the door of the resident's bathroom, turned on the spigots of water with her soapy hands, placed hands under the water and rubbed them together under the running water for five seconds. CNA removed a bunch of paper towels, dried hands and used the same paper towels to turn off the spigots. CNA walked towards the Unit Manager who was at the Resident's bedside and dropped a paper towel on the resident's bed without picking it up. CNA proceeded to walk out of the room holding the dirty paper towels in her hands. CNA did not discard the paper towels in the trash receptacle prior to leaving the room. On 10/01/20 at 10:26 AM, the surveyor observed a CNA enter into Resident #73's room to wash her hands. The CNA walked towards the sink that was in the resident's room, applied soap to her hands, turned on the spigots to wet her hands, and applied friction to both hands for five seconds. he rinsed her hands under the spigot of water for five seconds, dried her hands with a bunch of towels, and discarded them in the trash receptacle. The CNA turned off the spigots with her bare hands. At 1:04 PM, the surveyor interviewed the CNA who stated the procedure for handwashing was as follow: turn on the spigots, apply soap, wash hands with friction for 20 seconds out of flow of water, rinse hands, dry hands with paper towels, turn off the spigots with the same paper towel, discard paper towel in trash receptacle. CNA mentioned that they were last in-serviced in 2019 and was educated to turn off the faucet with the same paper towel. CNA continued to mention that she should have waited to wash her hands because the LPN was at the sink. On 10/06/20 at 3:02 PM, the Administrator and Director of Nursing (DON) were interviewed in the survey team's presence. The DON stated that staff were to wash their hands before and after resident care and the process was as follow: turn on spigot, wet hands, apply soap to hands with friction for 20 seconds out of flow of water, rinse hands in downward position, use a paper towel to dry hands, another paper towel to turn off the spigot. On 10/07/20 at 9:20 AM, the IP and DON were interviewed in the survey team's presence. The IP stated the process for handwashing was as follow: turn on the water, wet hands, obtain soap, use heavy amount of friction and cover all areas of fingers, under nails, thumb, and wash up the arm. Rinse hands thoroughly in a downward motion and dry hands using a clean paper towel. Dispose of paper towel in trash receptacle. The IP also stated that handwashing was done for 20 seconds and in front of the sink. According to CNA's completed competency form titled, Hand Hygiene dated 6/20/20, section #1 thru #8 reflected: 1. Turns on water and adjust flow 2. Wet hands 3. Applies cleanser or soap to wet hands and vigorously rubs hands together for a minimum of 30 seconds 4. Cleans under nails and around cuticle 5. Rinses hands thoroughly from wrist to fingertips, keeping fingertips down 6. Dries hands with paper towels and discards 7. Obtains clean paper towel and turns off faucet 8. Discards second paper towel According to the facility policy titled, Hand Washing and Resident Care Area, dated 11/17/2014, section A(6) read, wash well using friction for not less than 20 seconds and section A(10) turn faucet off with a clean dry paper towel. According to the facility policy titled, Hand Hygiene and Glove Use, dated 10/9/2019, section #1 compliance with proper hand hygiene before and after resident contact is an expectation of all staff. N.J.A.C. 8:39 - 19.4 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control procedures to address the risk of the spread of infection, for 2 of 25 Residents (Resident #33 and #73) observed and the annual review of the facility Antibiotic Stewardship Program (ASP). This deficient practice was evidenced by the following: 1. On 10/6/2020 at 12:22 PM, the surveyor observed Resident #33 sitting in a wheelchair by the door to their room. There was a sign outside the door that read, Stop, see nurse before entering the room. Resident #33 had an indwelling urinary catheter that was in a blue privacy bag and was secured to the left side of the residents wheelchair frame. The surveyor observed there was shared bathroom with the unoccupied room next door. There was a urinal in a bag that was secured to the grab bar. There was a small pink plastic bedpan that was not labeled or in a storage bag tucked behind the bathroom grab bar and a white plastic urine measuring device that was not labeled or in a storage bag placed directly on the bathroom floor under the bathroom sink. On the same day at 12:24 PM, the surveyor interviewed the Registered Nurse/Minimum Data Set (RN/MDS) Coordinator who had been reassigned to the Garden Hall on this day. The RN/MDS Coordinator stated that Resident #33 was on Enhanced Precautions for colonized (means the germ is present on their skin or in a body opening, but they have no signs of illness) Extended Spectrum Beta-Lacatamase (ESBL-enzymes produced by some bacteria that make them resistant to some antibiotics) in the urine. He then stated that the storage of equipment would include cleaning it and storing it in the bathroom and that he thought it should be covered with a plastic bag and labeled with the resident's name. At 12:41 PM, the surveyor interviewed the facility Infection Preventionist (IP) who stated that she was not sure why Resident #33 had a urinal stored in the room and that the graduated cylinder used to measure the urine output should be rinsed out after used and stored upside down on a papertowel on the back of the toilet. She then added that the bedpan should be cleaned and stored in a plastic bag after it had been labeled with the residents room number. At 12:48 PM, the surveyor and the IP went to bathroom of Resident #33. The IP confirmed that the items in the bathroom had not been stored correctly. At the time of this observation, the pink plastic bedpan was no longer in the bathroom. The IP picked up a clear plastic cylinder that was on the floor under the toilet, rinsed it with the toilet water spray arm, turned it upside down and placed in on a clean papertowel behind the toilet. She then picked up the measuring device from the floor and removed the bag with the urinal from the grab bar, bagged the items, and discarded them in the soiled utility room. At 1:00 PM, the surveyor reviewed the admission Record of Resident #33 that revealed they had been admitted to the facility in March of 2020 with diagnoses that included difficulty walking, muscle weakness, hypertension, hyperlipidemia, mild cognitive impairment, sepsis, acute kidney failure and dysphagia. The Order Summary Report identified an active Physicians Order dated 7/8/2020 that read, Change Foley Catheter as needed and on 9/20/2020 for enhanced barrier precautions. Barrier precaustions are required for residents diagnosed with or suspected of having infectious microorganisms transmitted by both droplet and contact routes. On 10/7/2020 at 1:58 PM, The Administrator stated that they did not have any good reason for the way the supplies were stored in the bathroom. The surveyor then reviewed the facility Policy and Procedure titled, Indwelling Urinary Catheter Drainage Bags, dated 10/8/2019 and read under equipment needed: labeled graduate of urinal. Under Procedure it read: 10. Take graduate/urinal into bathroom and empty into toilet. 11. Rinse container using toilet spray arm and empty rinse water. 12. Place container in plastic bag and hang on bathroom bar. 2. On 10/7/2020 the surveyor reviewed the Infection Prevention and Control Program (IPCP) policies and procedures that included the facility policy titled, Antibiotic Stewardship Program (ASP) which was dated 8/9/2017. On the same day at 9:20 AM, the surveyor interviewed the IP, in the presence of the Director of Nursing (DON), who confirmed that the IPCP policy and procedure had not been reviewed annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a) address and implement appropriate interventions for resident's with a significant weight gain or loss, and, b) provide a comprehensive nutritional assessment to identify the nutritional needs of a resident newly admitted to the facility. This deficient practice was identified for 4 of 6 residents reviewed for nutrition (Resident #8, #33, #37 and #204), and was evidenced by the following: 1. On 10/1/ 2020 at 12:39 PM, the surveyor observed Resident #204 sitting in their wheelchair in his/her room waiting for lunch. The resident stated that they recently had surgery, pointed to their abdominal region, and said they still had some pain in that area. The resident stated that since they were in some pain, they probably would not eat lunch. The resident stated that they ate when they wanted to. The surveyor questioned the resident if they had lost weight since admission to the facility. The resident stated that they think his/her weight was around 175 pounds, but at one point this year the resident reported to weigh 235 pounds. The resident could not recall exactly when that was, and stated that they were not good with time. At 12:58 PM, the surveyor observed the resident inform their Certified Nursing Assistant #1 (CNA) that they were finished eating lunch and was not that hungry. The CNA removed the resident's tray. The resident's CNA informed the surveyor that the resident ate 100% of the vanilla pudding dessert and the juice. They ate maybe a bite of the main meal and sides since almost 100% of those were left, a sip of coffee, and no milk. The CNA stated that the resident usually ate the entire meal for breakfast and dinner, but ate smaller amounts of lunch. The CNA reported that this morning the resident ate 100% of the egg sandwich and 100% of the hot breakfast cereal, drank black coffee but did not drink the milk. At 1:20 PM, the surveyor interviewed CNA #2 who stated that Resident #204 was a good eater. The surveyor reviewed the medical record for Resident #204. A review of the admission Record (an admission summary), reflected that the resident was admitted to the facility in September of 2020 with diagnoses which included intestinal adhesions (bands of scar tissue in the intestines), dementia without behavioral disturbance, retention of urine, colostomy status (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall), disorders of electrolyte and fluid balance (condition caused by electrolyte level imbalance such a low or high calcium levels), paroxysmal atrial fibrillation (irregular heart rate), and elevated white blood count. A review of the admission Minimum Data Set (MDS), an assessment tool to facilitate the management of care, indicated that the assessment was in progress. A review of the electronic Progress Notes (ePN) reflected a COMS - Skilled Evaluation dated 9/17/2020 which indicated that the resident was alert and oriented to person, place and time which indicated a fully intact cognition. A review of the Clinical Physician Orders included a Physician Order (PO) dated 9/16/2020 for weekly weights every Monday for four weeks starting 9/21/2020. A review of the resident's weights were as followed: 9/16/2020 183.2 pounds (.lbs) and 9/30/2020 158 .lbs. The Weights and Vital Summary also reflected that on 9/30/2020, that the Social Worker documented that the weight was incorrect. The summary also reflected that on 9/30/2020 that two weights were obtained and both weights were 158 lbs. This had not reflected weekly weights every Monday on 9/21/2020 and 9/28/2020. A review of the Mini Nutritional Assessment Screening (a screening tool utilized to identify residents at risk for malnutrition) dated 9/20/2020 reflected that Resident #204 was at risk for malnutrition. The assessment also reflected that the resident's weight was 183.2 .lbs. There was no evidence of a comprehensive nutrition assessment completed to address the risk including but not limited to usual body weight, diagnoses, pertinent medications, calorie needs, protein needs, fluid needs used to determine nutrition diagnoses to determine the problem, etiology, signs and symptoms to determine the appropriate nutrition interventions to implement based on the resident's individual nutrition risks and needs in accordance with professional standards of practice. A review of the resident's individualized person centered care plan initiated 9/17/2020 and last revised on 9/28/2020 reflected that the resident had nutritional problems or potential nutritional problems with regards to being slightly overweight with a Body Mass Index (BMI) 26 (A BMI over 25 and below 30 indicated overweight). Interventions included to explain and reinforce the importance of maintaining the diet ordered; encourage resident to comply; explain consequences of refusal; and provide and serve supplements as ordered. Review of the Laboratory Results Report (labs) dated 9/18/2020 documented the resident had low levels of hemoglobin (red protein that carries oxygen in the blood); hematocrit (the measurement of the amount of red blood cells in someone's blood); Blood Urea Nitrogen (BUN; measures the function of the liver or low protein); and total protein. A further review of the ePN included a Plan of Care Note dated 9/22/2020 that noted the physician was aware of laboratory results with no new orders except to monitor the incision site for signs and symptoms of infection. A review of the Order Summary Report indicated a PO dated 9/30/2020 for ProSource Powder (nutritional supplement) give one scoop two times a day. On 10/2/2020 at 8:50 AM, the surveyor observed Resident #204 in their bed eating breakfast. The resident had consumed 100% of the juice and hot cereal, was still eating the eggs and as yet had not consumed the milk or coffee. At 8:52 AM, CNA #1 stated that the weights were taken by the Restorative Nursing Aide (RNA) and added that the CNA's could take the weights, but usually the RNA took the weights. The facility used a Hoyer lift scale (a scale attached to a mechanical lift) or a weight chair. The RNA entered the weights into the computer. The CNA stated that the resident was a good eater for breakfast and that the resident usually only ate small amounts of lunch, but liked to eat the dessert and drink the coffee and juice. The resident liked to have drinks and was always drinking water. At 9:00 AM, the resident's Licensed Practical Nurse (LPN) #1 stated that the RNA took the weights and entered the weights in the electronic medical record. The LPN stated that Resident #204 had a colostomy and wounds. The LPN stated that she was not consistently the resident's nurse, but thought the resident ate well. The LPN stated that she would have received a report if the resident ate poorly since this was the rehabilitation unit. At 9:23 AM, the Registered Nurse/Unit Manager (RN/UM) stated that weights were taken the day of admission and then taken again the next day. Weights were taken weekly for four weeks upon admission; that it was a standard and that since there was no Registered Dietitian (RD) currently at the facility, the nurses reviewed the residents' weights. The UM also now completed the Mini Nutrition Assessment which assessed weight, height, any change in appetite past three months, any stress in the past three months, if the resident was walking or not, and the BMI. If a resident was a new admission and not alert and oriented, family was called to answer these questions. Then the UM reviewed the form, if resident was losing weight, then would recommend supplements to the physician or discussed putting the resident on the facility's Enhanced Calorie Program (ECP). She added that when the RD was at the facility, she was the one who made these decisions, and now it was a team effort. The RN/UM stated she was unsure how many calories, how much fluid, or protein a resident individually required, but the facility tried their best with no RD to determine. At 10:00 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the current Unit Manager (UM) was out so she was the UM for the Garden Unit. The ADON stated that weights were done on residents monthly, unless the doctor ordered weights more frequently. Weights were also done upon admission and weekly after that for four weeks. The RNA usually weighed the residents, but also the resident's CNA could weigh the resident. Weights were entered directly into the computer. The ADON stated that there was no current RD at the facility so she was in charge of monitoring the resident's nutrition status on the Garden Unit. The ADON stated that she looked at weights, looked at the previous RD recommendations, and completed the Mini Nutrition Assessment since there was no RD to complete a full nutrition assessment. The physician determined if the resident required a nutritional supplement at this time, but the nurse also recommended the supplements if a resident was losing weight. At 10:23 AM, the surveyor interviewed the Director of Nursing (DON) who stated that weights were done upon admission, then weekly for four weeks, and then monthly if there were no weight concerns. The DON stated that there was no RD as of right now so the UMs or the ADON were reviewing the weights and nutrition of the residents. The DON stated that the UM's completed a nutrition assessment which determined if the resident needed to be placed on the facility's ECP, needed a nutritional supplement, or needed to discontinue a nutritional supplement. The DON stated that monthly she met with the UMs and the ADON to review the residents' nutrition statuses. The DON stated that residents all started on a regular diet upon admission. The facility determined if the resident needed additional protein if a review of their albumin (protein found in the bloodstream produced in the liver) or pre-albumin levels on their labs were low and a review of the resident's Blood Urea Nitrogen (BUN; indicates liver function and low protein levels) to determine if the resident needed increased fluids. When the surveyor asked how the facility determined the resident's estimated energy needs (calorie needs), the DON stated that was determined by the resident's BMI (a measure of body fat based on height to weight). The DON acknowledged that the facility had not used a formula calculation to determine the calorie needs, protein needs, or fluid needs of each individual resident. At 10:33 AM, the LNHA stated that the facility had a RD until April of 2020. The facility was unable to replace the RD, and had a RD from the Strike Team from 6/15/2020 to 6/26/2020 who completed nutrition assessments for all the residents. At 10:57 AM, the surveyor interviewed Resident #204's primary care physician (PCP) via the telephone. The PCP stated that he has only been the resident's physician since their admission to the facility. The surveyor reviewed the resident's labs from 9/18/2020 with the PCP. The PCP stated that the low lab levels were to be expected from a resident who was post-surgical status. The PCP stated that he had just seen the resident yesterday and stated that the resident was doing well. The PCP stated that the resident could benefit from nutritional intervention, but usually the RD evaluated and assessed the resident's dietary needs and then they addressed those needs with the physician. The PCP stated depending on how many residents the RD had or their schedule in the building, the RD might not have assessed the resident yet. On the same day at 1:27 PM, the survey team interviewed the Medical Director (MD) who stated that he was aware the facility had no RD and was actively seeking one. The MD stated that he was unaware of any negative outcomes as a result of having no RD. At 1:58 PM, the survey team met with the DON and LNHA to request additional information in regards to Resident #204's comprehensive nutrition assessment. On 10/6/2020 at 9:07 AM, the surveyor interviewed the RNA who stated that she took weekly and monthly weights on residents. The RNA stated that everyone on the floor had a PO for monthly weights, but if a resident had weight loss or gain of five pounds, then their weight was taken weekly. The RD was the person who recommended the residents who should have a weight done weekly, but since there was no RD, the UM determined that. If the weight was considered incorrect, or a five pound weight loss or gain occurred, then a re-weight was taken the following day. All weights were entered into the electronic medical record. On 10/7/2020 at 12:53 PM, the RN/UM, in the presence of the LNHA, DON, and the survey team, stated Resident #204 was admitted to the facility post abdominal surgery. She had followed up with the resident's family member who stated that the resident had a weight loss back in February of 2020, and the resident's weight in February was around 156 lbs. Based on that information it was determined that the resident had not lost weight at the facility. The RN/UM could not speak to why the weekly weights were not taken as ordered. The RN/UM stated that the facility added ProSource as a nutritional supplement for extra protein on 9/30/2020. When questioned why the supplement had not been ordered until 9/30/2020; the RN/UM stated that was when she spoke with the PCP. The RN/UM stated that the PCP ordered Ensure Plus (a supplement) three times a day on 10/3/2020 . The resident had follow-up labs done on 10/5/2020 which reflected that the hemoglobin and hematocrit levels had improved. Lab results dated 10/6/2020 reflected the BUN and total protein were now within normal levels, and that the albumin level had improved. A review of the facility's policy titled, Weights/Re-weight dated revised 10/15/19, included that all residents will be weighed on the day of admission or readmission and then re-weighed on the second day and thereafter for the next four weeks. The policy also included that the resident's weight changes will be addressed individually and interventions will be made accordingly. The facility was unable to provide the surveyor with a written policy regarding nutrition assessments, but provided a Nutrition Risk Assessment - V 3 which was a four page comprehensive nutrition assessment. 2. On 9/29/2020 at 12:57 PM, the surveyor observed Resident #33 sitting in his/her room eating lunch. The surveyor observed that the resident ate 100% of the potato salad and half of a chicken salad on a croissant sandwich thus far. The surveyor observed an opened Ensure Plus (a nutrition supplemental beverage) on the tray table. The resident stated that the lunch tasted good. The surveyor reviewed the medical record for Resident #33. A review of the admission Record (admission summary), reflected that the resident was admitted to the facility in March of 2020 with diagnoses which included retention of urine, essential hypertension (high blood pressure), hyperlipidemia (high blood cholesterol), acute kidney failure, and sepsis (a life-threatening infection in the bloodstream). A review of the ePN reflected an admission summary dated July of 2020 that revealed Resident #33 was admitted from the hospital with diagnoses which included sepsis, hyperkalemia (high potassium levels), urinary retention, and chronic kidney disease. A review of the most recent significant change MDS, an assessment tool used to facilitate the management of care, dated 7/14/2020, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of the resident's weights were as followed: 6/2/2020 185 pounds (.lbs) 7/13/2020 173.2 .lbs with a re-weight of 174.8 .lbs 7/20/2020 169.4 .lbs 8/1/2020 169.4 .lbs 9/1/2020 192.8 .lbs 9/2/2020 192.8 .lbs (this reflected a 23.4 lbs. weight gain or 13.8% significant weight gain in one month) There was no evidence that the resident's weight was taken upon readmission date of July 8, 2020. A review of the resident's individualized person-centered care plan dated 7/11/2020 and last revised on 7/27/2020 with a copy provided by the DON on 9/30/2020 had not addressed that the resident was at nutrition risk or required nutrition interventions. A review of the resident's last quarterly Nutritional Risk Assessment completed by an RD dated 6/19/2020 indicated that the resident had relevant diagnoses which could affect their nutrition status which included high blood pressure, heart disease, liver failure, and end stage renal disease. The RD calculated that the resident's caloric needs were 1932 calories per day with 67-84 grams (g) of protein required per day based on 0.8 to 1.0 g of protein per kilogram of body weight per day. The RD stated that the resident had a weight gain over the past quarter that was not nutritionally significant, but has had a decreased intake over the past five days. The RD recommended to continue the Ensure Plus twice a day which yielded 26 g of protein in total. There was no evidence of a comprehensive nutrition assessment for Resident #33's readmission to the facility. A review of the Mini Nutritional Assessment Screening dated 7/13/2020 reflected that the resident was malnourished. There was no evidence of a comprehensive nutrition assessment to address the resident's malnutrition. A review of the current Clinical Physician Orders dated 9/30/2020 reflected no PO for Ensure Plus. A further review of the Clinical Physician Orders reflected a PO dated 7/17/2020 for Juven Packet (a nutritional supplement) to give two times a day mixed in water for a total yield of 5 Gm of protein and ProSource Powder supplement, give one scoop daily for a yield of 6 Gm of protein. There was also a PO dated 8/31/2020 for Remeron Tablet 15 milligrams (mg) to give once a day at bedtime for an appetite stimulant. This was prescribed one day prior to the 23.4 lbs./13.8% significant weight gain. A review of an ePN reflected a Weight Change Note dated 9/23/2020 which indicated a weight warning of a 13.8% weight change on 9/2/2020. The note indicated that the resident was currently on a regular diet with Ensure Plus, ProSource, and Juven supplements and Remeron. The recommendation was to discontinue the Remeron and Ensure Plus and to continue the ProSource and Juven. On 9/30/2020 at 9:24 AM, the surveyor observed the resident sitting in his/her room. Their breakfast tray was cleared and the resident had a paper cup and an opened container of Ensure Plus on the tray table. At this time, the resident's Licensed Practical Nurse (LPN) #2 identified the paper cup as the resident's Juven. LPN #2 stated that she gave the resident the Ensure Plus with breakfast, and that the resident drank it throughout the day. LPN #2 stated that she checked on the resident throughout the day, and then recorded the amount of the Ensure Plus the resident drank on the electronic Medication Administration Record (eMAR). At this time, LPN #2 checked the eMAR and stated that the resident had no PO for the Ensure Plus so they should not be drinking the supplement. LPN #2 stated that she misspoke before and that the night time nurse must have given the resident the Ensure Plus and not her. At this time, LPN #2 removed the Ensure Plus from the resident. LPN #2 informed the surveyor that the resident usually ate 50-100% of all meals. LPN #2 stated that the Ensure Plus was a nutritional supplement given to residents if they ate poorly. LPN #2 stated that usually the RD recommended the supplements to the physician who then gave a PO for the supplement. LPN #2 stated that there was currently no RD at the facility. On 10/1/2020 at 12:21 PM, the surveyor observed the resident in his/her room with an opened Ensure Plus. At this time, the surveyor interviewed LPN #3 who stated that the resident received Ensure Plus daily. LPN #3 stated that she gave the resident the Ensure Plus around 10:00 AM this morning. LPN #3 then reviewed the resident's PO with the surveyor. LPN #3 acknowledged that the resident had no current PO for Ensure Plus. At this time, LPN #3 removed the Ensure Plus. On 10/2/2020 at 10:00 AM, the surveyor interviewed the ADON who stated that the current Unit Manager (UM) was out of the facility on medical leave so she was the UM for the Garden Unit. The ADON stated that weights were done on residents monthly unless the doctor ordered the weights more frequently. Weights were also done upon admission and weekly after that for four weeks. She added that the RNA usually weighed the residents, but also the resident's CNA weighed the resident and were entered directly into the computer. The ADON stated that there was currently no RD at the facility so she was in charge of monitoring the resident's nutrition status on the Unit. The ADON stated that she looked at weights, looked at the previous RD recommendations, and completed the Mini Nutrition Assessment since there was no RD to complete a full nutrition assessment. The physician determined if the resident received a nutrition supplement at this time, but the nurse also recommended the supplements if a resident was losing weight. At 10:23 AM, the surveyor interviewed the DON who stated that weights were done upon admission, then weekly for four weeks, and then monthly if there were no weight concerns. The DON stated that there was no RD currently so the UM's or the ADON were reviewing the weights and nutrition of the residents. The DON stated that the UMs completed a nutrition assessment which determined if the resident needed to be placed on the facility's Enhanced Calorie Program (ECP), needed a nutritional supplement, or needed to discontinue a nutritional supplement. The DON stated that monthly she met with the UMs and the ADON to review the residents' nutrition statuses. The DON stated that residents all started on a regular diet upon admission. The facility determined if the resident needed additional protein if a review of their albumin (protein found in the bloodstream produced in the liver) or pre-albumin levels on their labs were low. If a review of the resident's Blood Urea Nitrogen (BUN; indicates liver function and low protein levels) to determine if the resident needed increased fluids. When the surveyor asked how the facility determined the resident's estimated energy needs (calorie needs), the DON stated that was determined by the resident's Body Mass Index. The DON acknowledged that the facility had not used a formula calculation to determine the calorie needs, protein needs, or fluid needs of each individual resident. At 10:33 AM, the LNHA stated that the facility had a RD until April of 2020. The facility was unable to replace the RD, and had an RD from the Veteran's Affair Strike Team from 6/15/2020 to 6/26/2020 who completed nutrition assessments of all the residents. At 11:37 AM, the surveyor interviewed the resident's CNA (#3). CNA #3 stated that Resident #33 had a big appetite and ate all his/her meals and snacks. The resident liked to have snacks after all three meals. They added that the resident liked ice cream, pretzels, and breakfast biscuit cookies. CNA #3 stated that the RNA weighed the resident. At 11:45 AM, the surveyor interviewed LPN #4 who stated that the physician and the RD usually decided on residents' nutrition programs and supplement needs, but at this time the facility had no RD. The RD requested calorie counts if a resident was losing weight. At this time, the nurse informed a supervisor if the resident was eating poorly. If the supervisor wanted the food intake monitored, then the nurse recorded the percentage of the meal eaten on the meal ticket. That meal ticket went to the Food Service Manager (FSM) and the supervisor to review. If the intake was low, the supervisor may recommend to the physician a nutrition supplement. At 1:27 PM, the survey team interviewed the Medical Director (MD) who stated that he was aware the facility had no RD, and that the facility was actively seeking an RD. The MD stated that he was unaware of any negative outcomes as a result of having no RD. On 10/06/20 at 09:13 AM, the surveyor observed Resident #33 drinking an Ensure Plus. At this time, the Register Nurse (RN)/MDS Coordinator confirmed that the resident had an Ensure Plus. The RN/MDS Coordinator stated that the floor nurse had called out for that shift so he was the floor nurse for that shift. The RN/MDS Coordinator confirmed that there was no PO for the Ensure Plus so the resident should not have it. The RN/MDS Coordinator stated that he had not given the resident that Ensure Plus. The surveyor continued to review Resident #33's medical record. A review of the weights reflected a weight of 205 lbs on 10/5/2020; which was a 12.2 lbs or 6.3% weight gain in one month. A review of the ePN reflected a Practitioner Progress Note dated 9/30/2020, which indicated that the resident's extremities had edema (swelling caused by excess fluid in the extremities). A review of an ePN Plan of Care Note dated 10/4/2020 indicated that the resident had three plus pitting edema to both lower extremities with a pedal pulse present. A call was placed to the physician who ordered the diuretic Lasix once a day. On 10/7/2020 at 1:34 PM, the ADON, in the presence of the LNHA, DON, and the survey team, stated that the resident was given a Mini Nutrition Assessment Screening on 7/13/2020 and provided the survey team with additional information regarding the Mini Nutrition Assessment Screening. The ADON stated that the Juven and the ProSource ordered on 7/17/2020 were added as protein sources for the nutritional treatment of wounds the resident had at the time. The ADON confirmed the resident's skin was currently intact and could not speak to why that nutrition intervention was not discontinued or reviewed at the time of wound healing. The ADON was unable to speak to why the Remeron was ordered on 8/31/2020, one day prior to the significant weight gain of 23.4 .lbs or 13.8% significant weight gain. The ADON stated that the Remeron was discontinued on 9/23/2020. The ADON stated that the weight gain was not acknowledged for three weeks because that was the date of when the facility met to discuss weights. The ADON confirmed that the resident showed no signs of edema until 9/30/2020, that the resident was monitored. The ADON stated that the resident liked the Ensure Plus so the facility discussed with the physician ordering the Ensure Plus once a day. A review of the facility's policy and procedure titled, Weights/Re-weight policy dated and revised 10/15/19, included that all residents will be weighed on the day of admission or readmission and then re-weighed on the second day and thereafter for the next four weeks. The policy also included that the resident's weight changes will be addressed individually and interventions will be made accordingly. A review of the facility's policy and procedure titled, Weight Loss - Enhanced Calorie Program, dated and revised 9/26/13 included that if a resident lost weight of greater to or equal to four percent (4%) in one month or greater than or equal to eight percent (8%) in six months, then the following should be implemented as appropriate for the individual resident. The policy included attempt to determine the cause of the weight loss and treat appropriately. The policy included if weight loss continues and consumption is inadequate, as determined by the RD, the physician will be notified and an order for an appropriate nutritional supplement should be obtained. The policy included after a nutritional supplement was added and if weight loss continued, to consider an appetite stimulant. A review of the Mini Nutritional Assessment by the [Company Name] dated printed 10/6/2020 was provided to the survey team by the ADON in the presence of the DON and LNHA. The information included that malnutrition significantly increases morbidity and mortality and compromises the outcomes of other underlying conditions and diseases. The Mini Nutritional Assessment is a screening tool validated specifically for the elderly. It was developed to provide a simple, reliable way to screen nutritional status of persons over age [AGE] and to add a nutrition component to the Comprehensive Geriatric Assessment. The Comprehensive Geriatric Assessment begins with the screening process, but also includes a nutritional assessment. 3. On 9/30/2020 at 12:26 PM, the surveyor observed Resident #37 eating lunch in their room. The surveyor observed that the resident had eaten 100% of the rice pudding and was currently eating a cookie. The surveyor observed on the plate ground ham, mashed potatoes, and cabbage. The resident had a pink colored meal ticket. The resident informed the surveyor that the meal was good. On 10/1/2020 at 12:20 PM, the surveyor observed Resident #37 eating lunch in their room. The resident had ground turkey, ground vegetables, and mashed sweet potatoes. The resident had a pink colored meal ticket. The resident stated that the food was good. On 10/2/2020 9:23 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the facility currently had no Registered Dietitian (RD). The RN/UM stated that the UM's and the ADON were addressing nutritional needs and care plans. The RN/UM stated that weights were taken on the first day of admission and then again on the second day. After that, weights were taken for four weeks, which was standard. After that weights were taken once a month unless there was a weight loss concern. The Restorative Nursing Aide (RNA) took the weights and inputted them into the electronic Medical Record (eMR). Since there was no RD, the RN/UM stated that she was conducting the Mini Nutrition Assessment which assessed the resident's weight, height, any changes in appetite the past three months, any stress in the past three months, and if the resident was walking. After the form was completed, you determined if the resident was losing weight. If resident was losing weight this was discussed with the primary care physician (PCP) to determine if the resident should go on the facility's Enhanced Calorie Program (ECP). The ECP has foods such as super cereal (enhanced calorie hot breakfast cereal) or a health shake (nutritional milkshake-like supplement containing extra calories and protein), depending on what the kitchen had. When the RD was here, she was in charge of the program. At 9:42 AM, the surveyor interviewed the Food Service Manager (FSM) who stated that residents on the ECP had pink colored meal tickets to distinguish they received enhanced calorie foods. The residents received super cookies (nutritional cookie containing extra calories and protein), super cheddar mashed potatoes (higher caloric mashed potatoes), super cereal, and health shakes. The FSM showed the surveyor a menu with all seven days of the week and all three meals. The menu contained three dietary food texture categories: dysphagia puree, puree, and regular. Depending upon the resident's dietary texture, the day of the week and the meal, determined what the resident should have received. The FSM stated that some residents might not want the super cheddar mashed potatoes, and like the super cereal so will give that instead. The FSM stated that the menu was established by a RD years ago. The FSM confirmed that she was not a RD and had no formal nutrition or dietetics degree, but was a Certified Professional Food Manager (a food and beverage safety certification). At this time, the Food Service Supervisor (FSS) confirmed that if a resident did not like a certain food item, then the kitchen would substitute an enhanced food item based on preferences. The Dietitian Helper (DH) asked the residents' their preferences. The FSS confirmed that she was not a RD and had no formal nutrition or dietetics degree, but was a Certified Food Handler (a food and beverage safety certification). At 9:51 AM, the surveyor interviewed the DH who stated that her role was to inte[TRUNCATED]

Based on observation, interview, and record review, it was determined that the facility failed to employ a Registered Dietitian and was evidenced by the following: On 9/29/2020 at 11:41 AM, the Food Service Manager (FSM) informed the surveyor that the facility currently did not have a Registered Dietitian (RD) employed. The FSM stated that the facility had a full-time RD, but was unsure when the RD left the facility. The FSM informed the surveyor that the Licensed Nursing Home Administrator (LNHA) could provide any additional information. On 9/30/2020 at 8:29 AM, the LNHA informed the survey team that the facility's RD resigned in April of 2020. The LNHA stated that the facility was a Civil Service Environment (government position) and the job required a Civil Service list. The List was posted, but only one person was on that list who had not met the facility's expectations. The facility posted the position and received no applicants. The facility re-posted the position and now had two applicants scheduled to be interviewed. The LNHA stated that during Novel Corona Virus 19 (COVID), a Strike Team had an RD who assessed the resident's of the facility. The LNHA stated that the facility had not utilized a consultant RD. Currently, the nursing staff and the Speech Language Pathologist were involved in the resident's nutrition assessment and interventions. On 10/5/2020 at 8:44 AM, the LNHA provided the survey team with a timeline regarding the RD position. The timeline was as followed: On 2/1/19 the Civil Service Test was announced for the previous RD to receive permanent appointment. On 7/1/19 the Civil Service Test results were announced and the previous RD was the only applicant. On 3/24/2020, the facility posted the position for an RD on the County Website, two Community Alliances, job posting website, and a college positing site that disperses to several universities in the Mid-Atlantic region. On 3/31/2020, one applicant had accepted the position, but then withdrew his/her acceptance. From 6/15/2020 through 6/26/2020, The Strike Team provided the facility with an RD. On 9/8/2020, the facility posted the position for an RD on the County Website, community organizations, advertising sites, and a job posting website. On 9/25/2020, the facility had two candidates who met the minimum Civil Service Criteria. N.J.A.C. 8:39-17.1(a), (c); 17.3(a)