Based on observations, interviews, record review and facility documents, it was determined that the facility failed to report an Injury of Unknown origin to the New Jersey Department of Health (NJDOH), for 1 of 7 residents (Resident #138), reviewed for accidents. This deficient practice was evidenced by the following: On 08/19/24 at 11:27 AM, during initial tour, the surveyor observed Resident #138 sitting with staff, in the main activity area. The resident was wearing a black helmet. On 08/21/24 at 09:30 AM, the surveyor reviewed the electronic Medical Record (eMR) for Resident #138 which revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's Disease, Unspecified and Anxiety Disorder, Unspecified. A review of the quarterly Minimum Data Set, an assessment tool dated 05/07/24, revealed the resident had a Brief Interview for Mental Status (BIMS) of two (2), indicating the resident was severely cognitively impaired. Further review revealed, the resident did not have upper/lower extremity impairment. A review of the Care plan (CP) revealed: Focus: The resident has a behavior problem r/t Dementia: - I like to say I'm going to kill you but I don't mean it, I would say it to my children when disciplining them. - I am physically aggressive (hit, bite, twist staff arms, slap) with staff during care. - I may bump into furniture/walls when walk around unit and other residents' rooms - Crawls under bed at times. Sits on nurses station. Redirected. Revision on 8/11/23. On 08/21/24 at 12:31 PM, during an interview with Licensed Practical Nurses (LPN) #1 and #2, they both stated that an injury of unknown origin should be documented, reported to the supervisor/Director of Nursing (DON) and statements would be taken. A review of the facility provided Skin Injury report, Dated 06/01/2024 08:30 revealed: Incident Description: Nursing Description: Called to room by CNA (Certified Nursing Assistant) at approximately 8am, resident noted with red linear mark, on cheek discoloration to bridge of nose. Further review revealed a Memorandum from LPN #1(who was the assigned nurse at the time) On 5/31/24 (11-7 shift) this writer observed resident leaning on the table resident was redirected and taken back to bedroom. A further review of the Skin Injury report revealed: NOTES: 6/5/2024 IDC(Interdisciplinary Care) team met and concluded the following: LTC (Long Term Care) resident with diagnosis of Dementia. BIM'S 1. With behavior of Fast-paced walking that is uncontrolled on unit and in an out of other rooms. Team met to discuss the discoloration on the bridge of nose and the red linear mark, on cheek. (Red linear mark is kind of a Derm. (dermatitis) mark. The resident has a potential for impairment to skin integrity (bruising, discolorations) r/t (related to) bumping into furniture/walls when ambulating aimlessly on the unit. Will continue to redirect resident as much as possible, and weekly skin checks to continue. CP reviewed. A review of the additional staff statements did not reveal staff had witnessed a behavior or an occurrence that resulted in the linear mark on the bridge of the nose or discoloration under the resident's eye. A review of the progress notes revealed: 6/1/2024 10:19 Nurses Note: Note Text: Skin injury: Called to room at 8am by CNA, resident sitting by bedside, red linear mark/red bruising noted underneath right eye, no swelling or opening seen. None tender to touch, resident confused and unable to verbalize needs or how injury occurred. Notified supervisor on duty, assessed resident in room. Incident report initiated . Further review of the progress notes revealed: 6/1/2024 14:58 Nurses Note: Note Text: NP (Nurse Practitioner) returned phone call regarding unknown skin injury/bruising to face, this writer informed her that the bridge of resident's nose has bruising as well, bruising has spread to the left under eye . A review of the physician progress notes revealed: 6/4/2024 07:49, Physician/NP Note .Pt (patient) seen and examined. Pt w/ (with recent unexplained facial bruising followed by witnessed fall w/o (without) apparent change in neurologic status .SKIN: . (+) (positive) facial bruising along forehead and bridge of nose to under b/l (bilateral) periorbital (around the eyes) area- now yellowish in color . On 08/23/24 at 10:54 AM, during an interview, the Risk Manager (RM) stated abuse could be physical, mental, financial, denying care, forcing care, ignoring a patient, or an injury of unknown origin. She stated any allegation would be investigated and the facility would do a look back (review of staff working and caring for the resident) for the last 3 days and take statements from them to see if they witnessed anything. She stated the purpose of an investigation was to rule out abuse and to see if there is a trend. On 08/23/24 at11:47 AM, during an interview with the DON, the DON stated that if there is an injury of unknown origin an investigation would be done to find out if there was a root cause. She stated statements would be done to see if somebody saw something. The DON stated it was a reportable event if they were unable to rule out abuse and it would be reported to the NJDOH) within 24 hours. The DON reviewed the facility provided above-mentioned investigation in the presence of the surveyor and confirmed that it was the complete investigation. She then stated the resident's behaviors were the cause of the injury. On 08/23/24 at 12:55 PM, during an interview with the Licensed Nursing Home Administrator (LNHA), the LNHA stated he was the abuse coordinator. He stated an injury of unknown would be reported to the NJDOH within 2 hours. He then stated they would err on the side of caution and report it (to the NJDOH). At that time, in the presence of the surveyor, the LNHA reviewed the above-mentioned incident investigation. After reading the investigation, the surveyor asked the LNHA what the cause of the injury was? The LNHA stated he would have to look into it further. The surveyor asked if the completed investigation ruled out abuse, the LNHA stated, I want to get back to you. The LNHA confirmed that the above-mentioned incident was not reported to the NJDOH. On 08/26/24 at 10:26 AM, the surveyor interviewed the [NAME] President of Clinical (VPC), the DON, and LNHA. The surveyor asked the cause of the injury. The VPC stated, The resident has the behavior of walking into walls and climbing under furniture. She then confirmed the staff statements did not reveal the staff witnessed the injury. The LNHA stated, the preliminary did not show a cause. The LNHA and the VPC both acknowledged that the incident should have been reported to the NJDOH but it was not. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 9/2023, revealed: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Finding of all investigations are documented and reported .Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies; a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman .3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via carrier, fax, e-mail, or by telephone . NJAC 8:39-9.4 (f)

Based on observations, interviews, record review and review of other facility documentation, it was determined that the facility failed to ensure heel booties (minimize the risk of pressure damage to heels) were consistently applied to prevent skin breakdown. This deficient practice was identified for Resident #89, 1 of 2 residents reviewed for position and mobility. This deficient practice was evidenced by the following: On 08/19/24 at 12:14 PM, during initial tour, the surveyor observed Resident #89 sitting in a reclining chair in the main activity area. The resident was wearing blue socks with their heels resting on the footrest. On 08/19/24 at 12:31 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #89 which revealed the following: A review of the admission Record revealed the resident was admitted to the facility with diagnoses including but not limited to: unspecified dementia and anxiety disorder. A review of the annual Minimum Data Set, an assessment tool dated 06/16/24, revealed the resident was unable to be interviewed for Brief Interview for Mental Status (BIMS) due to the resident is rarely/never understood. A review of the Care Plan (CP) revealed a Focus: [name redacted] has risk to skin integrity r/t (related to) fragile skin, Date initiated: 08/18/2020. Goal: I will not experience any skin breakdown, Revision on: 06/24/2024. Interventions: Heel booties to bilateral (both) heels at all times, Date Initiated: 09/02/2022. A review of the Order Summary Report revealed a physician's order (PO) for bilateral heel booties every shift, start date 01/02/2024. On 08/20/24 at 10:34 AM, the surveyor observed the resident sitting in a reclining chair in the main activity area. The resident was wearing pink socks with their heels resting on the footrest. On 08/21/24 at 12:51 PM, the surveyor observed the resident sitting in a reclining chair in the main activity area. There was a staff member sitting with the resident, feeding the resident lunch. The resident was wearing brown socks with their heels resting on the footrest. On 08/22/24 at 11:07 AM, the surveyor observed the resident sitting in a reclining chair in the sensory room. The resident was wearing blue socks with their heels resting on the footrest. There was a staff member sitting with the resident massaging their hand. A review of the August 2024 Treatment Administration Record (TAR) revealed the PO for bilateral heel booties every shift was signed as being completed for Day (7am to 3 pm shift) 08/19/24, 08/20/24, 08/21/24, and 08/22/24. The surveyor did not observe booties on the resident as mentioned above. On 08/22/24 at 11:35 AM, during an interview with Resident #89s assigned Certified Nursing Assistant (CNA), the CNA stated the resident required total care. The CNA stated she puts heel booties on the resident every time she put the resident in bed. She stated she took the resident's booties off this morning before she assisted the resident out of bed. The CNA took the surveyor to the resident's room and showed the surveyor where the heel booties were located. On 08/22/24 at 11:45 AM, during an interview, the Licensed Practical Nurse (LPN) stated the resident wears heel booties at nighttime. At that time, the LPN reviewed the order in the EMR, in presence of the surveyor. She stated, heel booties every shift, means when in bed. She stated the purpose of heel booties was to prevent skin break down. On 08/22/24 at 11:55 AM, the Registered Nurse/Clinical Coordinator (RN/CC) reviewed the order in the EMR, in the presence of the surveyor. The RN/CC stated the order meant while in bed. The surveyor asked if the heel booties should be placed while the resident was in a recliner. The RN/CC stated, yes. The RN/CC reviewed the resident's CP at that time, which revealed an intervention of heel booties to bilateral heels at all times. He then stated it meant the resident should have had booties on at all times. On 08/22/24 at 12:08 PM, the DON reviewed the PO for bilateral heel booties in the presence of the surveyor. She stated the booties should be worn every time while in bed or while in a recliner. She stated the purpose of the heel booties was to prevent friction to prevent pressure wounds. The DON stated the purpose of the CP was so everyone knew the daily care of the residents. A review of the facility's undated policy, Pressure Injury Prevention Guidelines revealed: Policy: To prevent the formation of avoidable pressure injuries and promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all resident who are assessed at risk or who have a pressure injury present. Policy Explanation and Compliance Guidelines: .3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. NJAC 8:39-27.1(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to assure that one (Resident (R) 408) of 36 sampled residents did not self-administer medication without first being assessed to determine whether the self-administration of medication by the resident was clinically appropriate. This failure resulted in R408 receiving an extra dose of her prescribed medication. Findings include: Review of R408's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE]. R408's diagnoses included heart failure, chronic obstructive pulmonary disease, cardiomyopathy, and hypertension. Review of R408's Brief Interview for Mental Status (BIMS) located in the Minimum Data Set (MDS) with a date of 12/05/22 located in the Assessment tab of the EMR, revealed R408 scored a 15/15, which indicated R408 was cognitively intact. Review of R408's Clinical Physician Orders located in the Orders tab of the electronic medical record (EMR), revealed that on 12/02/22, R408 was ordered Finerenone (Kerendia - a medication used to treat kidney disease) one 20 milligram (mg) tablet by mouth daily. During an interview that was being conducted with R408 on 12/06/22 at 12:44 PM, observation revealed a pill bottle labeled Finerenone on the resident's overbed table. R408 stated that, I am in a study. My doctor gave them to me, and I take them myself. During interview on 12/06/22, at 1:17 PM, Licensed Practical Nurse (LPN) 2 stated a researcher for a clinical study gave R408 the Finerenone medication on 12/05/22 without telling facility staff. LPN2 stated the researcher should have told the nurses that the pills were given directly to R408. LPN2 added that, due to not knowing that the resident had also self-administered this medication, I gave the medication today and the patient took a pill of her own. She received two doses today. LPN2 stated when she notified the physician of the medication error, he told her the researcher gave R408 the medication on 12/05/22 without realizing there was a protocol [for self-administration of medication] to be followed. Per LPN2, the physician ordered follow up labs due to the R408 receiving more than the ordered dose of Finerenone. During an interview on 12/07/22 at 11:02 AM, the Director of Nursing (DON) verified that the research team left the medication at R408's bedside without telling facility staff. The DON said I called the MD [Medical Doctor] yesterday after the pill bottle was found and we determined that she took two pills, she said she took the medication. The MD ordered a repeat blood draw because the nurse gave the medication, and the resident took her own. She received two doses on Tuesday. The DON stated We have a process for self-administration, but no one is on it now. We do an assessment. During an interview on 12/08/22 at 8:54 AM, the DON verified that, in response to this incident, a medication error investigation was started. Review of the investigation summary, written by the DON and dated 12/05/22, revealed that, This writer proceeded to call Dr . office and related all that had happened. He was sorry and said he was unaware of the Nursing home policies, that he usually gives the medications directly to his patients, and this was his first case in a Nursing home. When asked about the resident, having received a double dose, he said it was fine because it is low dose. This writer also informed the primary MD responsible for [R408's] care while at the facility, she ordered a BMP [Basic Metabolic Panel] for the next day. Labs were done and the results called to Primary MD. and no new orders were ordered Review of the facility's 4.0 Self Administering Medications policy, dated 04/2018, revealed that Customers desiring to self-medicate and who are deemed appropriate candidates by the interdisciplinary team must receive medication education from the nursing staff and be able to meet the following objectives .be able to state the name, dose, strength, frequency and purpose for use of his/her medications .demonstrate how to correctly administer . medications . must demonstrate . ability to correctly store the medication in a locked compartment. NJAC 8:39-29.2(c)4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure that each mandatory assessment accurately reflected the resident's status for two residents (Resident (R) 144 and R23) reviewed in a total sample of 36 residents. Minimum Data Set (MDS) inaccuracies were noted in the areas of Active Diagnoses and Falls. Findings include: 1. Review of R144's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R144 was admitted on [DATE] with a diagnosis of dementia. Review of R144's New Jersey Universal Transfer Form dated 07/11/22, located in the EMR under the Misc tab, also revealed a diagnosis of dementia. Review of R144's 'Physician Note in the Progress Note tab dated 09/29/22 revealed the physician had documented that the resident had a diagnosis of dementia with behavior issues. Review of the resident's comprehensive Care Plan related to dementia, which was dated 07/12/22 and revised 07/20/22, revealed that the resident had impaired cognitive function/dementia and required a wander guard related to wandering. Review of the 10/2022 Treatment Administration Record (TAR) revealed that staff documented that they checked the placement of the wander guard every night shift during the month. Review of R144's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/17/22 revealed that, although the physician documented a dementia diagnosis in the 60 days prior to the ARD and the resident received active treatment (monitoring of the wander guard) in the seven days prior to the ARD, the 10/17/22 MDS did not reflect that R144 had an active diagnosis of dementia. During an interview on 12/07/22 at 3:06 PM, the MDS Coordinator (MDSC) 1 stated, She [R144] does have a dementia diagnosis. Yes, it [MDS Section I - Active Diagnoses] should have been coded as dementia. During an interview on 12/07/22 at 3:12 PM, MDSC2 stated she was the MDSC for long term care. MDSC2 stated, She [R144] does have a dementia diagnosis. On October 1st, the dementia diagnosis codes changed so now it now longer automatically populates [in the electronic program where MDS data is recorded.] I have to go in and manually add. I was confident that I added it for her, but I must not have. I should have been added it. I will go in and modify now. 2. Review of R23's undated admission Record, located in R23's EMR under the Profile tab, revealed the facility admitted R23 on 04/07/22 with diagnoses including Alzheimer's disease. a. Review of R23's 09/01/22 General Note, located in the Notes tab of the EMR, revealed that staff, Observed resident lying on the floor next to her bed. Position on the right side. Bed was in the lowest position. Call bell was attached to linens however not alarming. Body assessment completed no acute skin discolorations noted. During assessment no raised or open areas noted. passive range of motion to upper and lower extremities without any guarding, moaning, or facial grimacing. b. Review of R23's 09/24/22 Nurse's Note in the Notes tab of the EMR revealed, This writer was walking on the unit at approximately 4 AM and heard resident calling out from her room 'Mommy, mommy.' This writer quickly entered resident's room and observed resident sitting on her buttocks on the floor with her back leaning against her bed. Bed was noted in the lowest position . skin tear was noted to resident's left lower forearm. Review of R23's quarterly MDS assessment, with an ARD of 10/13/22, indicated R23 was unable to complete the BIMS test and had severely impaired cognition. Per this MDS, the assessment documented R23 experienced one fall (rather than two) in the last three months/since the previous assessment. On 12/13/22 at 11:25 AM, MDSC1 confirmed that R23 experienced two falls in the look-back period for the 10/13/22 MDS assessment. She stated that both falls should have been reflected on the assessment, adding that it was an oversight. She stated she would correct the assessment immediately. Review of the facility policy titled, Certifying Accuracy of the Resident Assessment, updated 10/2022 revealed, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide assistance with Activities of Daily Living (ADL) for two (Resident (R) 127 and R49) of three residents reviewed for ADLs in a total sample of 36 residents. Facility staff failed to provide nail care and/or oral care for the two residents, who were dependent on staff for assistance with ADLs. Findings include: 1. Review of R127's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R127 was admitted on [DATE] with diagnoses of hemiplegia affecting right side and diabetes. Review of R127's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/22/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Per the MDS, R127 required extensive assistance with personal hygiene. During an observation on 12/05/22 at 1:01 PM, R127's fingernails were observed to be unclean and untrimmed. During this observation, R127 stated, I do not know how long it has been since the staff cut them. I used to bite my nails. I would like for them to be cut. During an observation on 12/06/22 at 1:05 PM, R127 was observed eating lunch in his room. R127's fingernails remained unclean and untrimmed. During an observation on 12/07/22 at 9:46 AM, R127's fingernails remained unclean and untrimmed. During an observation and interview on 12/08/22 at 8:40 AM, R127 was observed to be eating breakfast. R127's fingernails were observed to be trimmed on his left hand. When asked if staff trimmed the fingernails, R127 stated, No, I got tired of waiting and bit them off. See the thumb nail is still there and my weak hand I couldn't get to it, so they are still long and dirty. R127's right hand was unable to be observed at this time, as it was under the linen and R127 was unable to lift it During an interview on 12/08/22 at 9:27 AM, Certified Nursing Assistant (CNA) 3 stated, Fingernails are trimmed and cleaned on shower days. I have given him a shower before but have not trimmed his nails. When asked why R127 nails were not trimmed during his shower, CNA3 was unable to provide an answer. During an interview on 12/08/22 at 9:32 AM, CNA2 stated, Nails are cleaned and trimmed on shower days. With men, we first shave them and clean and trim their nails. I have given him [R127] a shower before but I have never trimmed his fingernails. If they are diabetic, the nurse trims. CNA2 stated, I do not know if the resident is diabetic. During an interview and observation 12/08/22 at 9:37 AM, Licensed Practical Nurse (LPN) 1 and a member of the survey team entered R127's room to observe his fingernails. LPN1 stated, Oh no, those need to be trimmed. R127 stated, They were trimmed about three weeks ago. My friend was visiting, and he did them for me. LPN1 stated, He is diabetic, and the nurse has to trim his nails. The CNA should report to the nurses when nails needed to be trimmed. During an interview on 12/08/22 at 10:02 AM, the Director of Nursing (DON) stated, For nail care, if the resident is diabetic, the nurses do the fingernails, and the podiatrist does the toenails. The CNA should report it to the nurse. My expectation is daily care as needed, not only just on shower days. The DON further stated, CNAs know which residents are diabetic and know to report to the nurse if the nails need to be trimmed. Also, when it is the resident's shower day, the CNA and nurse go in in the shower together with the resident because the nurse does a head-to-toe skin check at that time, and I expect the nurses to see the resident's nails and to address if they need to be trimmed. This is a second look in case it was missed during the daily care. 2. Review of R49's admission Record located under the Profile tab of the EMR revealed R49 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and dysphagia. Review of R49's annual MDS located in the EMR, under the MDS tab with an ARD of 10/05/22, revealed a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Per the MDS, R49 required total dependence with personal hygiene. During an observation on 12/05/22 at 1:36 PM, R49 was observed to have severe plaque buildup on his bottom teeth. During this observation, R49 stated he received oral care but was unable to state the last time he had his teeth brushed. During an observation on 12/06/22 at 12:54 PM, R49's bottom teeth remained unclean with severe plaque buildup. During an observation on 12/07/22 at 8:29 AM, R49's bottom teeth remained unclean with plaque buildup. During an observation on 12/08/22 at 9:42 AM, R49's teeth appeared clean. R49 stated, Staff brushed my teeth this morning. During an interview on 12/08/22 at 9:27 AM, CNA3 stated, I do oral care daily. I have noticed the buildup. I don't know why it is there. I reported it to the nurses. During an interview on 12/08/22 at 10:02 AM, the DON stated, I expect oral hygiene to be done daily. He [R49] cannot perform hygiene on his own. The CNAs are responsible, and nurses are to check behind them. Review of the facility's policy titled, Activities of Daily Living, updated 06/2021, revealed that Facility must ensure that: A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. NJAC 8:39-4.1(a)22 NJAC 8:39-27.2(f)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for two (Resident (R) 97 and R40) of two residents reviewed for respiratory care out of a total sample of 36 residents. Oxygen concentrator filters were not cleaned as needed, Respiratory equipment, such as tubing and/or nasal cannulas, was not stored in a sanitary manner. Findings include: 1. Review of R97's undated admission Record, located in the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had multiple diagnoses including heart failure. Review of R97's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/22 and located in the EMR under the MDS tab, revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 13/15, Review of R97's current 12/2002 Physician's Orders, under the Orders tab located in the EMR, revealed staff were to provide O2 [oxygen] at 2 LPM [two liters per minute] via nasal cannula [NC] as needed for O2 less than 92% [out of 100 percent] every 24 hours as needed. Phone Active 08/15/22. Further review of the current orders revealed there was no order on how to store the oxygen tubing or instructions on how often to clean the oxygen concentrator filter. Review of R97's current comprehensive Care Plan located under the Care Plan tab in the EMR, revealed it showed a revision date of 09/28/21 and a target date of 02/13/23. The care plan, which noted the resident received oxygen, did not include interventions for maintaining oxygen equipment to include cleaning the oxygen concentrator filter. During an observation and interview on 12/05/22 at 11:12 AM. R97 stated she wore oxygen at night. R97 had an oxygen concentrator at her bedside which was turned off. R97 had nasal cannula oxygen tubing, dated 12/01/22, connected to her oxygen concentrator, which was laying across the top of her oxygen concentrator. The nasal cannula prongs were touching the floor and were not stored in a manner to protect them from contamination. R97's oxygen concentrator filter vent cover on the back of the oxygen concentrator was unclean and had moderate dust particles on it. During an observation and brief interview on 12/07/22 at 10:20 AM, R97 was awake and sitting on the side of her bed in her room. R97 stated that every night she slept with her oxygen on and pointed at her nose. At this time, R97 was not receiving oxygen and the oxygen concentrator was turned off. R97's nasal cannula oxygen tubing, which was connected to the oxygen concentrator, was not stored in a manner to prevent contamination. The tubing was draped over her oxygen concentrator and the prongs were touching the floor. R97's oxygen concentrator filter vent cover on the back of the oxygen concentrator was unclean and had moderate dust particles on it. During an interview on 12/07/22 at 10:27 AM, Licensed Practical Nurse (LPN) 10 stated she was an agency nurse who had worked at the facility for five to six months. LPN10 stated that the resident's nasal cannula and tubing should be stored in a bag when not in use. LPN10 stated it was important to store the oxygen tubing in a bag and to keep the tubing clean and avoid germs. During an observation on 12/07/22 at 10:38 AM, LPN10 confirmed R97's oxygen concentrator filter vent cover on the back of her oxygen concentrator was unclean and had dust particles on it. During an interview on 12/07/22 at 4:06 PM, the Clinical Coordinator (CC) stated R97 was administered oxygen treatment as needed. The CC stated she was unsure what staff was responsible for cleaning the oxygen concentrator filters or how often the oxygen concentrator filters should be cleaned. The CC stated the resident's care plan should include interventions on how to maintain the oxygen equipment. The CC stated she was unsure if an intervention should be included on the care plan for cleaning the oxygen concentrator filter. The CC confirmed if the resident's nasal cannula oxygen tubing was not in use, it should be stored inside a bag. 2. Review of R40's undated admission Record, in the EMR revealed she was admitted to the facility on [DATE] and had multiple diagnoses including chronic obstructive pulmonary disease. Review of R40's 12/2022 Physician's Orders 12/22 under the Orders tab located on EMR revealed staff were to provide O2 @ 3L via n/c continuously every shift. Phone Active 01/26/202. Further review of the current orders revealed no order for cleaning the oxygen concentrator filter. Review of R40's comprehensive care plan, located under the Care Plan tab in the EMR, revealed the resident had Impaired Gas Exchange - Chronic Obstructive Pulmonary Disease (COPD) and was to receive oxygen. The care plan, which showed an initiation date of 06/16/20 and a revision date of 02/01/21, failed to include interventions for maintaining the oxygen equipment related to cleaning the filter on the oxygen concentrator. Review of R40's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 11/2022 and 12/2022 under the Orders tab located on her EMR revealed there was no evidence that the resident's oxygen concentrator filter was being cleaned, During an observation on 12/05/22 at 1:01 PM, R40 was receiving oxygen via nasal cannula. Further observation revealed the oxygen concentrator filter vent was covered with dust particles and unclean. During an additional observation on 12/07/22 at 10:53 AM, the resident was laying on her bed in her room asleep. R40 had oxygen administered via nasal cannula. The oxygen concentrator filter vent cover was unclean and covered with dust particles. During an observation conducted with the CC on 12/07/22 at 4:16 PM of R40 receiving oxygen via nasal cannula, the CC confirmed R40's oxygen concentrator filter vent on the back of the concentrator was not clean and had dust particles. During an interview on 12/07/22 at 05:13 PM, the Administrator stated the internal and external filters for the oxygen concentrators were cleaned/serviced every six months by an outsourced company and were last cleaned/serviced in 06/2022. During an interview on 12/08/22 at 3:15 PM, the Respiratory Therapist (RT) stated she was not responsible for maintaining oxygen equipment. The RT confirmed the facility had a company that maintained the oxygen concentrator's filter and the company services the equipment every six months and was set up by someone at the facility. During an interview on 12/08/22 at 4:24 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON confirmed the oxygen concentrator filters (both internal and external) were cleaned by an outsourced company every six months and were last done in June 2022. The ADON stated it was important to have the oxygen equipment maintained to prevent infections and ensure the resident received the proper oxygen therapy. Review of an undated facility, titled, Oxygen Concentrator, revealed Cleaning the Cabinet Filter .DO NOT operate the concentrator without the installed or with a dirty filter. There is one cabinet filter located on the back of the cabinet .Remove the filter and clean as needed Environmental conditions that may require frequent inspection and cleaning of the oxygen filter include, but are not limited to . high dust, air pollutants, etc. NJAC 8:39-19.4(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy and Food and Drug Administration (FDA) information, the facility failed to attempt alternatives prior to installing bed rails for one (Resident (R)23) of four residents reviewed for accident hazards. In addition, the facility failed to ensure the correct installation, use, and ongoing maintenance of bed rails (also known as side rails) for R23, which placed the resident at unnecessary risk of injury or entrapment. Findings include: Review of R23's undated admission Record, located in R23's electronic medical record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R23's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/22 and located in the MDS tab of the EMR, indicated R23 was unable to complete the Brief Interview for Mental Status test and staff assessed her with memory problems and severely impaired cognition. R23 did not exhibit any mood or behavioral symptoms and was totally dependent on staff for bed mobility. a. Use of Bed Rails: Review of R23's 09/26/22 Care Plan, located in the Care Plan tab of the EMR, revealed, The resident has limited physical mobility and needs assistance with ADLs [activities of daily living] r/t [related to] Alzheimer's and end of life . The approaches included: Resident is dependent on staff for all ADLs . Provide supportive care, assistance with mobility as needed. The comprehensive Care Plan did not address use of bed rails on R23's bed. Review of R23's 10/07/22 Side Rail Assessment Screening, found in the Assessments tab of the EMR, revealed R23 was not able to turn side-to-side in bed without assistance and did not use side rails for positioning and support. Review of R23's EMR and paper chart revealed there was no evidence of consent for use of bed rails. Review of R23's 12/2022 Physician Orders, located in the EMR under the Orders tab, revealed there was no order for use of bed rails. Observation of R23 on 12/05/22 at 10:22 AM revealed she was lying in bed on an air mattress. There was a half bed rail at the head of the bed on each side of the bed. The bilateral bed rails were in the raised position. In an interview on 12/08/22 at 9:59 AM, Certified Nurse Aide (CNA) 7 stated R23 moved her arms and legs sometimes while in bed, and would scoot toward the edge of the bed, but was not very mobile, saying that, She is really dependent on staff to move her. CNA7 stated R23 did not use the bed rails to move in bed, and she did not know the reason for the resident's use of the rails. In an interview on 12/08/22 at 10:11 AM, Licensed Practical Nurse (LPN) 5 stated she believed the bed rails were used for safety so she would not fall off the side of the bed. She stated R23 doesn't really move much and added R23 was unable to adjust herself in bed, stating she was dependent on staff for bed mobility. In an interview on 12/08/22 at 3:40 PM, the Director of Nursing (DON) stated the facility did not use side rails (another term for bed rails); instead, they used bed enablers. The DON stated every bed in the facility had bed enabler rails attached to them and they were typically in the up position for all residents to assist them with bed mobility. The DON indicated all residents had bed rails to enable bed mobility, adding, We don't use them as side rails. The DON indicated that no less-restrictive approaches were attempted with R23 as the bed rails were used as bed enablers, not side rails. The DON stated the bed rails were not used to treat R23's medical symptoms or to assist with mobility and transfers because they were bed enablers, not side rails. Review of the facility's Proper Use of Side Rails policy, dated 10/2021, revealed that Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfers of residents . Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. b. Maintenance/Safety a. During the above referenced observation of R23 in bed on 12/05/22 at 10:22 AM, the observation revealed that the left side of the bed was against the wall. Further observation revealed there was a noticeable gap between the mattress and the left bed rail at the head of the bed, and the left bed rail was noticeably crooked. Observation of R23 on 12/06/22 at 10:14 AM revealed the resident was seated in her wheelchair in her room. The resident did not respond to questions when asked. R23's bed was observed with an air mattress. At this time, the gap between the left bed rail and the mattress was found to measure five inches. The left bed rail was noticeably crooked and wobbled back and forth approximately 1.5 inches when pushed or pulled. Observation of R23 on 12/07/22 at 11:14 AM revealed R23 was seated in her wheelchair in her room. The left bed rail continued to be noticeably crooked and wobbly when touched. The gap between the mattress and the left bed rail at the head of the bed continued to measure 5 inches. Review of R23's 10/07/22 Side Rail Assessment Screening, found in the Assessments tab of the EMR, documented, The side-rail has been measured and the gaps between the rail(s) themselves and the gaps between the side-rail and the mattress are conducive to resident safety as based on this individual resident. In an interview on 12/08/22 at 9:59 AM, CNA7 was unaware, until surveyor intervention that the left bed rail was crooked and loose, creating a large gap between the mattress and the rail. In an interview on 12/08/22 at 10:11 AM, LPN5 was unaware, until surveyor intervention, that the left bed rail was crooked and loose, creating a large gap between the mattress and the rail. LPN5 stated she would report the loose bed rail to maintenance to address. In an interview on 12/08/22 at 2:52 PM with the Director of Operations (DO), he stated he conducted spot checks using a machine to measure the entrapment zones of bed rails once a year. However, the DON continued, the machine had been loaned out to another facility. The DO stated that the last fit test was conducted, without the machine, on 09/28/22. The DO stated the beds and rails were manufactured to fit together, so there was basically no risk of entrapment. The DO stated, however, that if the mattress or rails were compromised, there was a potential for a larger gap between the rails and mattress that could potentially pose an entrapment risk. He stated he not received any reports from nursing staff about a broken or compromised bed rail. Further interview on 12/08/22 at approximately 3:45 PM with the DO confirmed R23's bed rail was loose on the bed, and maintenance had already tightened the fit and fixed the problem. In an interview on 12/08/22 at 3:40 PM, the DON stated the nursing staff was responsible for reporting broken or loose-fitting bed rails to maintenance for repair. Review of the Food and Drug Administration's (FDA) 03/10/06 Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment indicated, For 20 years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail8, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries .These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement . Long-term care facilities reported the majority of the entrapments . FDA uses the term 'hospital bed' in this guidance to refer to a variety of medical devices that are classified as beds . used for patients in acute care, long-term care, or home care setting . Bed rails, also called 'side rails,' may be an integral part of the bed frame or they may be removable and at times are used either as a restraint, a reminder, or an assistive device. Bed rails may consist of one full-length rail per side or one or more, shorter rails per side . FDA is recommending a dimensional limit of less than 120 mm [millimeters] (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. NJAC 8:39-5.1(a) NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to promptly notify the physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results for one (Resident (R) 86) of a total sample of 36 residents. This failure had the potential to delay treatment or lead to a worsening condition. Findings include: Review of R86's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R86 was admitted to the facility on [DATE]. R86's diagnoses included diabetes, chronic kidney disease, obstructive uropathy (blockage in the urinary tract), and chronic urinary tract infection. Review of R86's 11/30/22 Nurses Note located in the Progress Notes tab of the EMR documented that the Writer informed of resident's aggressive behavior cursing and yelling. Ordered UA/CS [urinalysis/culture and sensitivity] for change in behavior and ID [infectious disease] consult to review lab [laboratory] results. On 12/06/22, review of R86's Labs located in the Results tab of the electronic medical record (EMR), revealed R86's UA results ordered on 12/01/22 were available since 12/03/22. Further review revealed the results were still in the To Be Reviewed status. No evidence of physician notification and/or nursing progress notes was found in the clinical record. During an interview on 12/07/22 10:41 AM, [NAME] Clerk (WC) 1 said the nurses looked at the labs in the computer and then printed a copy to put in the chart.WC1 was unable to locate a copy of R86's printed lab results. During an interview on 12/07/22 at 10:41 AM, the Director of Nursing (DON) said the lab results were in the computer and pulled them up for review. The results showed available but continued to remain in the To Be Reviewed status. The DON verified the results were there but added, I don't see follow up. I will need to follow this up. Further interview with the DON revealed that the UA results showed abnormalities that should be reviewed by the physician. The DON was unable to find a printed copy of R86's lab results and said one should be in the chart for the physician to review and note. The DON stated if the physician were notified of the results, documentation would be in the record. The DON was unable to locate documentation of physician notification. During an interview on 12/08/22 at 8:41 AM the DON said the nurse should have notified the physician regarding R86's lab results on 12/03/22 when they arrived. Review of the facility's Lab Processing policy, updated 10/20/22, revealed, To ensure that Diagnostic tests are processed, ordered, obtained, performed, and results received timely. Test results are communicated to the physician in a timely manner with documentation present in the medical record. Process/Procedure: Tracking the Physician Order: 1. Check Results tab in PCC [Point Click Care, an electronic medical record (EMR) system] for all diagnostics test results. 2. Document the physician notification in the resident's clinical record (progress notes). lnclude in this documentation: Physician name Date and Time of physician notification Lab results communicated Method of communication (fax, phone, etc) Any new orders NJAC 8:39-13.1(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure staff followed standard infection prevention precautions for one (Resident (R) 407) of five residents reviewed for wound care. The failure to perform hand hygiene and change gloves as indicated during wound care has the potential to lead to cross contamination and infection. Findings include: Review of R407's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R407 was admitted to the facility on [DATE]. R407's diagnoses included sepsis (severe infection complication) pressure ulcers, and urinary tract infection. Review of R408's current Clinical Physician Orders, located in the Orders tab of the EMR revealed that on 12/02/22, R407 had an order for daily dressing change orders for pressure ulcers at the sacrum and right lateral ankle areas. During the wound care observation on 12/07/22 at 4:10 PM, Licensed Practical Nurse (LPN) 3 washed her hands, applied gloves, removed the soiled dressing at the sacrum area, and then cleansed the area and applied a clean dressing. Then without washing the hands or changing gloves, LPN3 removed the soiled dressing from the right lateral ankle wound, cleansed it, and applied a new dressing. LPN3 wore the same gloves throughout both dressing changes without performing hand hygiene (washing hands or using hand sanitizer). During an interview on 12/07/22 at 04:16 PM, LPN3 stated she should have washed her hands and changed the gloves before and after both dressing changes. She said I should have washed hands after taking off the dirty dressing. I was supposed to wash the hands and change gloves. During an interview on 12/08/22 at 08:54 AM, the Director of Nursing (DON) said It is unacceptable. She was supposed to wash hands, remove the dressing, wash hands, and put on new gloves. She should wash hands and change gloves between both wound dressing changes. Review of the facility's Wound Care policy, updated 10/2021, revealed that staff were to, Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached .Wash and dry your hands thoroughly .Put on exam glove. Loosen tape and remove dressing . Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Put on gloves . Cleanse wound with normal saline or as ordered using sterile technique, apply treatment as indicated .Dress wound .Wash and dry your hands thoroughly. NJAC 8:39-19.4(a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to assure that three (Resident (R) 80, R92, and R22) of 36 sampled residents were treated in a respectful and dignified manner during dining. Staff stood over the residents while feeding them their meals, rather than sitting at the resident's eye level, maintaining face-to-face contact. In addition, staff failed to refer to an unidentified resident with dignity. Staff referred to a resident by the level of assistance they need, rather than in a person-centered manner. Findings include: 1. Review of R80's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R80 was admitted on [DATE] and had diagnoses including dementia. Review of R80's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 09/21/22, revealed the resident required supervision during meals. Per this MDS, the resident was severely cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of seven out of 15. An interview was attempted with R80 on 12/06/22 at 1:04 PM, and resident was found to be non-interviewable. During a dining observation on 12/05/22 at 12:49 PM, Certified Nursing Assistant (CNA) 1 was observed standing over R80 while feeding the resident, R80 was seated in a wheelchair in her bedroom at the time of observation. A chair was available in R80's room for CNA1's use; however, CNA1 was observed for a three-minute continuous period, as well as additional intermittent observations during the meal, to stand over the resident while feeding her. During a dining observation at 12/07/22 at 8:34 AM, CNA1 was observed setting up R80's breakfast tray. CNA1 was observed standing over R80 while feeding the resident a bite of oatmeal. R80 was seated in a wheelchair in her bedroom at the time of observation. CNA1 then walked out of R80's room to continue passing meal trays. There was a chair available in R80's room for CNA1's use. 2. Review of R22's admission Record located under the Profile tab of the EMR revealed R22 was admitted on [DATE] and had diagnoses including dementia. Review of R22's quarterly MDS, located in the EMR under the MDS tab with an ARD of 11/03/22, revealed R22's BIMS score of one out of 15, indicating the resident was severely cognitively impaired The MDS also revealed R22 required total dependence during meals. During a dining observation on 12/07/22 at 1:16 PM, CNA1 was observed setting up R22's lunch tray. CNA1 was then observed standing over R22, feeding the resident. This action was continuously observed for four minutes. R22 was observed in her bed, in an upright position at the time of observation. There was a chair available in R22's room for CNA1's use. During an interview on 12/07/22 at 1:19 PM, CNA1 stated staff should sit while feeding a resident to be at their level. CNA1 confirmed she was standing while feeding both R80 and R22. 3. Review of R92's admission Record located under the Profile tab of the EMR revealed R92 was admitted on [DATE] and had diagnoses including dementia and aphasia (communication disorder). Review of R92's annual MDS, located in the EMR under the MDS tab with an ARD of 09/08/22, revealed the resident was rarely/never understood, and staff assessed the resident as severely cognitively impaired. Per the MDS, R92 required total dependence during meals. During a dining observation on 12/07/22 at 12:58 PM, CNA3 was observed standing over R92, feeding the resident. This action was continuously observed for five minutes. R92 was observed seated upright in her Geri-chair at the time of observation. There was a chair available in R92's room for CNA3's use. During an interview on 12/07/22 at 1:06 PM, CNA3 stated, We are supposed to sit when feeding a resident to be at their level. CNA3 also stated, I was standing at first, then remembered, so I sat. 4. During an observation by two members of the survey team on 12/08/22 at 8:39 AM, Licensed Practical Nurse (LPN) 1 stated, I have to get someone to help me for wound care. I can't get the aide; she is with a 'feeder' at this time. When questioned by a member of the survey team about the use of the word feeder (indicating a resident who required assistance with feeding), LPN1 stated, Sorry, didn't mean to say that. During an interview on 12/08/22 at 10:02 AM, the Director of Nursing (DON) stated, When feeding a resident, the staff should sit beside them, not stand. This is for dignity purposes, and it just makes the whole situation more personable. It makes the staff slow down and give the resident that moment to spend time and visit. When asked about the use of the term feeder to describe a resident, the DON stated, Residents should not be referred to that way. They should be referred as 'residents who need assistance with feeding.' I will talk with staff about this and do an in-service. During an interview on 12/08/22 at 3:48 PM, the Social Worker (SW) stated, Staff should always sit while feeding the resident. They should be at the same level as the resident and have a conversation during the meal. It makes the resident feel more human. The SW further stated, Staff should never refer to resident as a 'feeder'. They [residents] are people and should not have labels put on them. They should be referred to as Mr. or Mrs. such and such who needs assistance with eating. Review of an undated facility policy titled, Procedure of Feeding a Resident revealed that the policy, Explains procedure to resident, speaking clearly, slowly, and directly, and maintaining face-to-face contact, sit at eye level, whenever possible. NJAC 8:39-4.1(a)12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJAC 8:39-19.4(a)5 NJAC 8:39-33.2(c)5 Based on observation, interview, record review and facility policy review, the facility failed to ensure four (Resident (R) R557, R133, R5, and R43) of five residents reviewed for catheter use received appropriate catheter care. Specifically, R557 had no order to indicate the size of the condom catheter needed to prevent leakage. R133 had two conflicting orders for catheter sizes. R5's catheter tubing was in contact with the floor, and R143's catheter tubing was not anchored as ordered. These failures had the potential to lead to increased urinary tract infections, pulling of the catheter tubing, or use of the wrong size catheter. Findings include: 1. Review of R557's undated admission Record, located in Profile tab of the electronic medical record (EMR) revealed R557 was admitted to the facility on [DATE] with a diagnosis of urinary tract infection. Review of R557's 12/06/22 Active Orders, found in the Orders tab of the EMR, revealed orders for Texas (condom) catheter care every shift and to document Texas catheter output, both initiated on his admission date, 11/30/22. There was no order to indicate the specific size of the condom catheter. Review of R557's 11/30/22 Progress Note, located in the Notes tab of the EMR, revealed, Bowel and bladder assessment completed today. Voids appropriately without incontinence: Always. The note did not address R557's use of a condom catheter to manage incontinence. Review of R557's 12/05/22 Care Plan, located in the Care Plan tab of the EMR, revealed, Resident likes to use an external Texas catheter. The interventions included: Ensure that the external catheter is in place at all times . Assess the application site for any skin breakdown . [and] Empty the catheter bag when it is 2/3 full. The care plan did not address the specific size of the condom catheter. Observation on 12/05/22 at 9:51 AM revealed R557 was in bed, with his call light not activated. The resident appeared angry, as he yelled loudly that he needed help. When interviewed, R557 stated his condom catheter had fallen off and urine had soaked the bed. The resident stated that he very uncomfortable from sitting in a wet bed for some time, and he had put his call light on for assistance; however, the staff had turned off the call light and stated they would be back later. R557 stated the facility did not use the correct size of condom catheter, as they did not have it available, and that is why his catheter leaked. At this time, Licensed Practical Nurse (LPN) 4 was alerted to R557's situation, and she stated she was just about to provide care for R557's catheter. In an interview on 12/08/22 at 9:29 AM, Certified Nursing Assistant (CNA) 4 stated R557 wore a condom catheter, and on 12/05/22, the catheter had come off and leaked in his bed because it was the wrong size. In an interview on 12/08/22 at 9:36 AM, CNA6 stated R557 required a size 25 condom catheter; however, on 12/05/22, a larger size was used and it had come off and leaked in his bed. In an interview on 12/08/22 at 9:41 AM, LPN4 stated R557 used a condom catheter per his preference because of urinary incontinence. She stated the resident told them that he required a size 25 catheter, but the facility only stocked sizes 23 and 30. She stated the size 23 was difficult to put on and was too small, and the size 30 was too large and would fall off. LPN4 stated when the admission orders were entered, the required catheter size should have been included to ensure the facility had the correct size in stock and staff should have used the correct size for the resident. LPN4 added the size should also be included in the Care Plan. LPN4 stated she had ordered size 25 catheters on 12/05/22 after she found the resident's catheter had come off and leaked in his bed. 2. Review of R133's undated admission Record revealed he was admitted to the facility on [DATE] with diagnoses of urinary retention and obstructive and reflux uropathy (a condition where urine cannot flow, either partially or completely, through the ureter, bladder, or urethra due to some type of obstruction. Instead of flowing from the kidneys to the bladder, urine flows backward, or refluxes, into the kidneys.) Review of R133's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/14/22, located in the MDS tab of the EMR, revealed he was unable to complete the Brief Interview for Mental Status (BIMS) test and had severely impaired cognition. Per the MDS, R133 used an indwelling catheter. Review of R133's 04/27/21 Care Plan, located in the Care Plan tab of the EMR, revealed, The resident has an Indwelling Foley Catheter: Neurogenic bladder. The approaches included: Change catheter as ordered . The resident has (16 Fr [French] Foley Catheter). Review of the 12/05/22 Active Orders, located in the Orders tab of the EMR, revealed two conflicting current catheter orders: a. Foley Catheter Size 18 Fr, which originated on 02/28/22. b. Change Foley (16 Fr [NAME] [sic - coude catheters are slightly bent at the tip which helps them move past a blockage] once every month, which originated on 07/05/22. In an interview on 12/08/22 at 10:11 AM, LPN5 stated R133 used a size 18 French catheter. She was unaware of the order and Care Plan which indicated a size 16 French should be used and stated she would need to clarify which order was correct. In an interview on 12/08/22 at 12:41 PM, the Director of Nursing (DON) stated R133 came to the facility with a size 16 French; however, the resident had issues with it dislodging. According to the DON, R133 had been sent out to the hospital and came back with an order for an 18 French catheter. The DON stated the staff were currently using the size 18 French, and the order for the 16 French size should have been discontinued. 3. Review of R5's undated admission Record, located in the Profile tab of the EMR, revealed R5 was admitted to the facility on [DATE] with a diagnosis of neurogenic bladder (urinary condition in people who lack bladder control due to a brain, spinal cord, or nerve problem). Review of R5's admission MDS assessment, with an ARD of 09/13/22 and located in the MDS tab of the EMR, revealed R5 scored 6/15 on the BIMS test, indicating she was severely cognitively impaired. R5 required extensive assistance with bed mobility and used an indwelling catheter. During an observation on 12/06/22 at 9:30 AM, R5 was lying in her bed, which was in a low position. R5's catheter bag was hanging off the left side of her bed in a privacy cover, and the tubing was lying on the floor next to the bag. A hospice staff member was seated in the room with the resident. During an observation on 12/08/22 at 9:50 AM, R5 was lying in her bed, which was in a low position. The catheter bag was in the privacy cover, and the tubing was lying on the floor next to the bag. During an observation and interview on 12/08/22 at 10:05 AM, CNA6 stated the hospice staff had just finished providing a visit to R5, adding that the hospice staff would lower the bed, which caused the catheter tubing to touch the floor. CNA6 stated the facility staff knew the bed was not to be lowered and the catheter bag and tubing should never touch the floor; however, the hospice staff might not be aware of this. CNA6 observed and verified R5's catheter tubing was lying on the floor, and then proceeded to raise the bed until the tubing was no longer in contact with the floor. During an interview on 12/08/22 at 10:07 AM, LPN5 stated the catheter bag and tubing should never be in direct contact with the floor or another surface, as this was an infection control risk. She stated the staff would wipe the tubing to clean it after contact with the floor or change the tubing if necessary. 4. Review of R43's undated admission Record located in EMR revealed she was admitted to the facility on [DATE] and had multiple diagnoses, including chronic kidney disease. Review of R43's current Physician's Orders under the Orders tab in the EMR revealed the resident had an order for a urinary catheter. Further review of the Orders revealed staff was to Check Stat-Lock placement to thigh every shift. Phone Active 11/18/2022. Review of R43's comprehensive Care Plan under the Care Plan tab located on his EMR revealed staff was to Position catheter bag and tubing below the level of the bladder .Date Initiated: 10/20/2022 Revision on: 10/20/2022. The care plan did not include an intervention/directive to ensure the indwelling catheter tubing was secured with stat lock. The care plan did not include that the Stat-Lock placement was to be checked every shift, per the 11/18/22 physician's order. Review of R43's Treatment Administration Record (TAR) dated 12/2022 revealed that staff had initialed the order to indicate that they followed the order to Check Stat-Lock placement to thigh every shift between 12/01/22 and 12/06/22, when the order was marked as discontinued at 7:22 PM. An observation was conducted on 12/05/22 at 2:17 PM of CNA8 providing R43 with assistance in transferring from the resident's wheelchair to her bed. R34's urinary collection bag was in a blue cloth bag, with the white handles tied to the arm of her wheelchair, above the level of her bladder. CNA8 untied the blue cloth bag containing the urinary collection bag and placed it behind R43's back on her wheelchair, again above the level of her bladder. CNA8 then moved R43's urinary collection bag and placed it on the bottom of her bed, above the level of her bladder. During this observation, CNA8 confirmed R43 did not have a leg strap/stat lock on her upper leg to secure the urinary catheter tubing. During an observation and interview on 12/06/22 at 1:40 PM, R43 was laying on her bed in her room, awake and alert. CNA8, who was present at this time, verified R43 did not have a stat lock to secure her urinary catheter tubing. In addition, CNA8 stated that R43's drainage bag should remain below the bladder. CNA8 confirmed that when she transferred R43 from her wheelchair to her bed on 12/05/22, she did not ensure the resident's catheter drainage bag was below the level of her bladder. CNA8 stated she strapped the urinary collection bag to the handle of R43's wheelchair to avoid the bag getting caught up with the wheelchair. CNA8 confirmed she should have kept R43's urinary collection bag below the level of her bladder during transfer. CNA8 stated it was important to keep R43's urinary collection bladder below her bladder to ensure urine did not back up in her bladder and cause a urinary tract infection. During an interview on 12/06/22 at 01:59 PM, the Clinical Coordinator (CC) revealed that stat locks are placed on a resident's leg to secure the catheter tubing and ensure it was not pulled out and injured the resident. The CC confirmed the urinary catheter collection bag should be kept below the level of the bladder so as to avoid urine from back flowing into the bladder, which could cause a urinary tract infection. The CC also confirmed R43's urinary collection bag should not be tied to the arm of her wheelchair, placed on her lap, placed on the wheelchair behind her back or laid on her bed because these positions were above the level of her bladder and could potentially cause a urinary tract infection. [NAME] additional interview was conducted with the CC on 12/06/22 at 2:21 PM while observing R43, who was in her room, on her bed awake. Interview with the CC at that time confirmed R43 did not have a stat lock on her leg but should have. During an interview on 12/08/22 at 4:28 PM with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the DON confirmed she expected the facility staff to ensure residents had a securing device for the indwelling catheter tubing. The ADON stated it was important to have a securing catheter tubing device to prevent the tubing from pulling or dislodging. The ADON stated that catheter tubing dislodgement with the balloon intact could injure a resident. Both the ADON and DON stated both nursing and CNA were responsible for ensuring residents had a catheter tubing securing device on their leg. Review of the facility-provided policy titled Emptying a Urinary Bag, revised 01/2022 revealed the instructions to Keep the drainage bag below the level of the bladder. Review of the facility's 01/2022 Catheter Care policy revealed, Ensure catheter is anchored using strap or other anchoring device. Review of the facility's January 2019 Urinary Tract Infections (Catheter- Associated) Prevention Guidelines Policy revealed, Insert catheters only for indicators deemed appropriate for urinary catheter insertion, and as ordered . Maintain unobstructed urine flow . Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the door.

Based on observation, interview and policy review, the facility failed to ensure the dumpster area remained free of garbage to prevent the harborage of pests and rodents on three of three days for which observations were made during the survey. This had the potential to affect staff, visitors, and all 167 residents residing in the facility. Findings include: During an observation on 12/05/22 at 09:55 AM, the outside dumpster area revealed two dumpsters next to each other. Dumpster 1 had a lid broken off at the hinge on one side and the other side was propped up and open with a mound of garbage bags. Dumpster 2 had a lid that was open and had four garbage bags in it. Two gloves, a spoon, two plastic knives, a grape and other garbage was noted on the ground around the dumpsters. During an observation on 12/06/22 at 08:37 AM, Dumpster 1 was full and overflowing with garbage bags. One lid remained completely broken off, while the other was unable to close due to it resting on piled garbage bags. Dumpster 2's bin was a quarter full and both lids were open. During an observation on 12/07/22 at 08:28 AM, Dumpster 1 was overfilled with garbage bags above the dumpster's rim. One of the lids remained broken and the other was open. Dumpster 2's lids were open and the dumpster was a quarter full. Gloves, a milk container, plastic silverware, a grape and various pieces of garbage were littering the area around the dumpsters. During an observation and interview on 12/07/22 at 08:37 AM, the Dietary Manager (DM) said, They need to pick it up and the lids should be closed, the lids is broken. Birds and rodents could get into it. During an interview on 12/07/22 at 02:49 PM, the Administrator said he knew the dumpster top was broken and he had emailed the garbage removal company the previous day. The Administrator said he had previously contacted the company and that it has taken some time. During an interview on 12/08/22 at 11:10 AM the Dietary Manager (DM) revealed that he was unaware, prior to surveyor intervention, that the dumpster area was the responsibility of the dietary department. The DM stated, Now I know it is my responsibility for the dumpster area and will take care of it. During an interview on 12/08/22 at 11:49 AM the Registered Dietician (RD) confirmed the dumpster area was a responsibility of the kitchen During an interview on 12/08/22 at 11:50 AM, the Regional Registered Dietician (RDD) stated, The dumpster area should be free of debris on the ground and lids closed to dumpsters. This is needed for pest control and infection control. During an interview on 12/08/22 at 02:50 PM, the Director of Operations (DO) verified that the dumpster lid has been broken for about two weeks. Review of the undated Dispose of Garbage and Refuse policy provided by the facility revealed The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris .The Dining Services Director will ensure that Appropriately lined containers are available within the food services area for .disposal of garbage or other refuse Appropriate lids are provided for all containers. NJAC 8:39-19.7(b)

Based on observation, interview, and record review, it was determined that the facility failed to properly prepare and administer medications as per physician orders in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 7 residents (Resident #64) reviewed for medication administration and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 9/17/20 at 9:39 AM, the surveyor observed pills in two separate medication cups and one medication cup filled with applesauce and a spoon on Resident #64's overbed table. The medications consisted of one whole white oval pill and one white, oblong pill cut in half. The surveyor observed the resident self-administer the contents in the medication cups. Resident #64 verbalized that he/she did not know the medications received in the cups but took medicine by themselves, all the time. The surveyor observed that there were no other residents in the vicinity at this time. A review of the Minimum Data Set, an assessment tool used to facilitate care management, dated 6/30/2020, revealed that the resident's cognition was intact. A review of the Order Summary Report (OSR) revealed a physician's order dated 6/23/20 for Acidophilus (a probiotic product) capsule give 2 capsules orally two times a day for intestinal flora. The OSR showed a physician's order dated 8/27 with a start date of 8/29 for Potassium Chloride (KCL) ER (a medication used to prevent or treat low blood levels of potassium) Tablet Extended-Release 10 mEq (milliequivalent) give 1 tablet by mouth one time a day for supplement. The OSR also showed an additional physician's order dated 8/31 with a start date of 9/1 for Potassium Chloride ER Tablet Extended-Release 20 mEq give 1 tablet by mouth one time a day for supplement; Give 1 tab of KCL 10 mEq with KCL 20 mEq tab for a total of KCL 30 mEq. Swallow whole. Don't chew/crush. Take with plenty of water. Avoid lying down x 10 minutes after. May open/sprinkle on soft food. A review of the September 2020 Medication Administration Record (MAR) revealed Acidophilus two capsules, Potassium Chloride ER 10 mEq one tablet, and Potassium Chloride ER 20 mEq one tablet was documented with a checkmark and LPN #1's initials to reflect that the medication was given as ordered daily. A review of the Medication Administration Audit Report (MAAR) reflected the administration details of the Acidophilus and the Potassium Chloride. The MAAR indicated that the Potassium Chloride ER 10 mEq tablet and Potassium Chloride ER 20 mEq tablet were administered on 09/17/2020 at 09:15 AM and documented 09/17/2020 at 09:18 AM. The Acidophilus two capsules were documented as administered on 09/17/20 at 09:16 AM and documented on 09/17/2020 at 09:18 AM. The surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to the resident at 9:48 AM on 9/17/20. LPN #1 identified the pills in the medication cups as one whole Acidophilus capsule and one Potassium Chloride tablet cut in half. LPN #1 stated that she could not confirm if the potassium tablet in the medication cup was 10 mEq or 20 mEq. LPN #1 said she left the pills with Resident #64 because she had to go to the bathroom. LPN #1 also stated that the nurse was to remain with the resident during medication administration because it was the facility's policy. LPN #1 confirmed that she should not have left the medications with Resident #64. At 10:02 AM, the surveyor and LPN #1 went to the medication cart outside of Resident #64's room. The surveyor observed the computer screen located on the medication cart had a list of medications (Acidophilus 2 capsules, Potassium ER 20 mEq one tablet, and Potassium ER 10 mEq one tablet) that were highlighted in green with a checkmark. LPN #1 stated that a green highlight with a checkmark indicated that the medication was documented as given. LPN #1 confirmed that the physician order indicated that Resident #64 was to receive one Potassium Chloride 10 mEq tablet and one Potassium Chloride 20 mEq tablet for a total of Potassium Chloride 30 mEq and two Acidophilus capsules. When interviewed on 9/18/20 at 11:39 AM, the Clinical Coordinator stated that during the administration of medications, the nurse should not sign off the medications as given in the computer because the resident may refuse to take the medications. The Clinical Coordinator also confirmed that the nurse should not leave residents with medications unsupervised and that the facility policy reflected her statement. On 9/23/20 at 2:14 PM, the Director of Nursing (DON), Director of Clinical Services, and Administrator were interviewed in the survey team's presence. The DON also acknowledged that LPN #1 should not have left the medications with the resident unsupervised. On 9/24/20 at 12:07 PM, the Administrator, DON, and Director of Clinical Services, in the surveyor team's presence, provided copies of LPN #1's latest Medication Pass Observation Worksheet. The Administrator mentioned that medications must be taken in the presence of the nurse. The Director of Clinical Services stated that LPN #1 should not have left medications at the bedside and indicated that This is a standard of practice. The Director of Clinical Services reconfirmed and stated that it was a standard of practice for the nurse not to leave medications at the bedside. The DON indicated that any resident that can self-medicate without the nurse must have a physician order and competency. According to LPN #1 ' s nursing competency form titled, Medication Pass Observation Worksheet dated 11/18/2019, Section 9(c) indicated the following: The resident/patient was observed to ensure medication was swallowed. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a) honor a resident's food preferences; and, b) ensure a meal did not contain beef, which the resident had listed as a preference of no beef on the meal ticket. This deficient practice was identified for 1 of 6 residents reviewed for nutrition (Resident #139) and was evidenced by the following: On 9/16/20 at 10:56 AM, the surveyor interviewed Resident #139 in their room. The resident informed the surveyor that they disliked the food at the facility and found that the food received was, potluck. The resident stated that they had received eggs that contained peppers one day, which made the resident vomit, so after that, the resident said that he/she requested no more eggs at meals. The resident complained that every morning he/she still received eggs. The resident stated that they had expressed their concerns about receiving eggs to both the nursing and kitchen staff. The surveyor then reviewed the medical record of Resident #139. A review of the admission Record reflected that the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, hyperlipidemia (high blood cholesterol), hypertension (high blood pressure), and infection following a surgical procedure. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 8/19/20, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the admission Nutrition assessment dated effective 8/14/20, included a nutrition intervention for dietary to provide extra protein for meals in essence (i.e.) eggs and peanut butter. A further review of the assessment had not reflected any dietary preferences. A review of the electronic Progress Notes (ePN) did not included any Dietary/Nutrition Notes. On 9/17/20 at 8:10 AM, the surveyor observed Resident #139 in their room eating breakfast. The tray contained untouched scrambled eggs, pancakes, and cereal. The resident reported eating the toast. The resident was unhappy that they had received scrambled eggs and happy that they were being discharged from the facility the next day. At 9:44 AM, the surveyor interviewed the Food Service Director (FSD), who stated that the Registered Dietitian (RD) interviewed the resident regarding food preferences. If there were any changes to the resident's preferences after that, the resident could speak with a Certified Nursing Aide (CNA) or nurse to make dietary changes. The nursing staff would then inform the kitchen of dietary changes. Dietary staff then inputted the resident's preferences into a computer system that removed any items the resident disliked from their meal ticket. The resident would not receive an item that was listed on their meal ticket as no. At 10:04 AM, the surveyor interviewed the resident's CNA, who stated that the resident was alert and able to tell you what they wanted. The CNA stated that the resident disliked eggs and did not want them. The CNA stated that the resident would say, I do not want these eggs, and the nurse called down to the kitchen for a different food item. At 10:13 AM, the surveyor interviewed the resident's Licensed Practical Nurse #2 (LPN #2), who stated that the RD interviewed the resident upon admission for their food likes and dislikes. If a preference changed, the nurse would call the kitchen to let them know to send something different to the resident. The nurse also filled out a dietary requisition form to communicate with the kitchen any preference changes. The nurse stated that Resident #139 did not want eggs but stated that the resident might want eggs one day, so she did not send a form to the kitchen. The LPN #2 stated that she checked on the resident daily to see if their breakfast was okay or if the resident wanted something else. The LPN #2 reported that she had not checked on the resident's breakfast today. At 10:35 AM, the surveyor conducted a follow-up interview with the resident's CNA, who confirmed that the resident never ate their eggs. The CNA stated that the resident complained right away when they received eggs. The CNA reported that she had not lifted the resident's lid on their breakfast tray today, so she was unaware what was served to the resident. At 12:08 PM, the surveyor observed Resident #139 in their room eating lunch. The surveyor observed untouched beef pepper steak on the resident's plate. The resident stated that they did not want beef and had told the kitchen this already. The surveyor observed the resident's meal ticket, which reflected no beef. At 12:10 PM, the Registered Nurse/Unit Manager (RN/UM) accompanied the surveyor into the resident's room. The RN/UM compared the resident's meal ticket with the resident's meal received. The RN/UM confirmed that the resident should not have received beef steak for lunch. At this time, the resident stated that receiving beef was just like how he/she received eggs in the morning. The resident expressed that they were thankful that they were not allergic to these items. The surveyor continued to interview the RN/UM in private, who stated that the resident disliked eggs. The RN/UM noted that sometimes the resident made a big deal about the eggs. The resident liked pancakes and french toast. The RN/UM stated that she had called the kitchen and told them not to send the resident eggs, but said she never filled out a dietary requisition form with this request. The RN/UM stated that she spoke with someone in the kitchen, but it was not the FSD. The RN/UM confirmed that the resident did not like eggs, the staff was aware of this dislike, and the resident should not receive eggs. At 12:17 PM, the surveyor interviewed the RD, who stated that she screened all residents upon admission, quarterly, annually, and for any significant changes. The RD reported receiving the resident's dietary preferences upon admission and would inform the dietary staff. The RD stated that she documented resident preferences in her Dietary/Nutrition Notes in the ePN and the care plan; The kitchen was notified of any preference changes. The RD confirmed that if a resident disliked a particular food, the resident should not be served that food. The RD stated that the resident was relatively new and was speaking with dietary regarding their preferences. The RD noted that the care plan reflected i.e., extra eggs. At 12:31 PM, the surveyor interviewed the Food Clerk, who stated that she was in charge of the meal tickets. She inputted dietary preferences and types of diets on the meal ticket. The Food Clerk noted that she received her information from the nurse or the RD. The Food Clerk stated that the resident had received western scrambled eggs and did not want those eggs, so she had put that on his/her meal ticket, no western egg scramble. The Food Clerk reviewed the activity log with the surveyor, which indicated on 8/28/20 that the resident disliked western scrambled eggs. The Food Clerk stated that she was unaware the resident disliked all eggs and that on 9/4/2020, someone changed in the computer system to add double eggs to the resident's meal. The Food Clerk stated in regards to the no beef, that the resident was not allergic to beef, but it was a preference. The resident ate beef because sometimes he/she asked for a hamburger. The preferences on the meal ticket were just used as guidance. On 9/18/2020 at 8:07 AM, the surveyor observed the resident eating breakfast. The resident stated that they were happy that they had not received eggs today. The resident said that they spoke with the FSD yesterday about their meal preferences and stated that the FSD was very persistent that the resident should receive hard-boiled eggs. The resident expressed being happy that they were being discharged that day. At 9:49 AM, the FSD, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, stated that the resident's preferences had changed. The FSD noted that the resident was not allergic to beef, but it was a preference. The FSD reported that if a ticket reflected that a resident had preferred not to have an item, the resident should not receive that item unless the resident requested it. At this time, the LNHA confirmed that the resident was alert and oriented with no confusion and made their needs known. A review of the facility's policy titled, Dining and Food Preferences and revised 9/17, included that the individual tray assembly ticket will identify all food items appropriate for the resident based on diet order and allergies, intolerances, and preferences. The policy further included that any resident with expressed or observed refusal of food will be offered an alternate selection of comparable nutrition value upon meal service. N.J.A.C. 8:39-17.4(a)1

Based on interview and review of facility documents, it was determined that the facility failed to ensure that all Drug Enforcement Administration (DEA) 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications for 7 of 8 DEA 222 forms provided. This deficient practice was evidenced by the following: On 9/24/2020 at 10:54 AM, the surveyor reviewed all DEA 222 forms from a binder provided by the Director of Nursing (DON) for the last six months. The surveyor reviewed the documents and noted the following: 1. A DEA 222 form dated 04/14/2020, under Part 1: To Be Filled In By The Purchaser, the last line under Item was left blank and Part 5: To Be Filled In By Purchaser had the date received as 4/16/20 with an attached Packing Slip signed by a Registered Nurse (RN) dated 4/17/20. 2. A DEA 222 form dated 05/15/2020, under Part 5 had the date received as 5/18/20 with an attached Packing Slip signed by an RN and dated 5/19/20. 3. A DEA 222 form dated 06/26/20, under Part 5 column, Number Received, there was the number one circled and the Date Received column had 7/1/20 written. Both of these were written above the Item line. Also, under Part 1, Item 1, there was one (1) package of Fentanyl (an opioid medication used to treat pain) Patch 50 mcg (micrograms) written, and under Part 5, the date received was not written on the Item line. Under Part 1, Item 2, there was one (1) package of Fentanyl Patch 25 mcg and Part 5 column Number Received and Date Received were left blank. The attached Packing Slip indicated that both of the above medications had been received as noted by a signature and dated 7/1/20. 4. A DEA 222 form dated 7/20/20, under Part 1, Item 1 was documented as Oxycontin (an opioid medication used to treat pain) 10 mg (milligrams) Tab (tablet) and Under Part 5 revealed Number Received as 30 and Date Received was 7/21/20. Part 1 also listed Item 2 as Hydromorphone (a narcotic medication used to treat pain) 2 mg tab. Under Part 5, Item 2, did not have the Number Received and Date Received documented. It was blank. The attached Packing Slip indicated that both medications had been signed as received by an RN and Licensed Practical Nurse (LPN) and was dated 7/22/20. 5. A DEA 222 form dated 07/22/2020 had no numbers entered for the Supplier DEA Number # on the top right of the form. It was left blank. Also, under Part 1, revealed the Item Fentanyl Patch 25 mcg was noted with Date Received under Part 5 was 7/24/20. The attached Packing Slip indicated that the Fentanyl 25 mcg was received on 7/25/20 and signed by an RN. 6. A DEA 222 form dated August 27, 2020 revealed that Item 1 was Oxycodone IR (an immediate-release medication used to treat pain) 5 mg tab and under Part 5 had the Date Received as 8/28. Then for Item 2 was documented as, Oxycodone/APAP (Acetaminophen) 5/325 mg tab and under Part 5 the Date Received was 8/28. The attached Packing Slip was signed as received by an LPN and RN on 8/29/20. 7. A DEA 222 form dated 9/4/2020 revealed under Part 1, Item 1 had the number of packages ordered was 1, with the size of the package written was 15 for Morphine Sulfate 10 mg/0.5 ml syringe and under Part 5, the Number Received for Item 1 was blank and the Date Received was documented as 9/7. Also, Item 2 had the number of packages noted as 1, with the package size of 30 for Oxycontin 10 mg tablet and under Part 5, Item 2 line under Number Received was blank and the Date Received documented was 9/7. The attached Packing Slip revealed that both of the medications ordered had been signed by a nurse as received on 9/7/20. On 9/24/2020 at 11:06 AM, the surveyor interviewed the Facility's DON who stated it was her responsibility to maintain the DEA 222 form. The DON said that the facility did not have their own policy related to receiving narcotics and completing the DEA 222 form but used the policy from their contacted Pharmacy. The DON confirmed that the medications ordered on the DEA 222 forms were for the back up supply of medications stored in the automated pharmacy machine on the third floor. The surveyor then reviewed the [Pharmacy] Policy and Procedure titled, Controlled Dangerous Substance Inventory Back Up Box and Emergency Kits with a revised date of April 2018 which read under Policy, [Pharmacy] and the facility will properly distribute, maintain, and dispense controlled substances that are stored within the back up box or emergency kit. All controlled dangerous substances (CDS) are dispensed and handled in accordance with state and federal regulations. The policy continued under Procedure A. CDS (Controlled Dangerous Substances) in Back-Up Supply - Schedule II CDS: 1. A DEA Form 222 must be completed to obtain the par level quantity of Schedule II CDS in back up supply. Upon signature of the Medical Director or his/her designee, the two copies are sent to the pharmacist in charge at [Pharmacy]. The purchaser's copy is kept on file and maintained at the facility. The surveyor then reviewed the instructions for DEA Form 222 which read under Part 5. Controlled Substance Receipt: 1. The Purchaser fills out each section on its copy of the original order form. 2. Enter the number of packages received and the date received on each item. 3. Purchaser must keep its copy of each executed order form and all copies of unaccepted or defective forms and any attached statements or other related documents available for inspection for a period of two years. On the same day at 11:52 AM, the surveyor interviewed the retiring DON and Training DON (TDON), who stated that [Pharmacy] delivers the narcotics at varying times and that the 11:00 PM - 7:00 AM Supervisor signed and dated the form when the medication was received. The DON then stated that the DEA 222 form does not go to the nursing units. That it stays with the DON and that the Packing Slip was attached to the medication that was entered into the automated pharmacy machine. At 12:55 PM, the surveyor interviewed the Retiring DON, the TDON, Consultant Pharmacist (CP) and the Director of Clinical Services (DCS). The DCS stated that the dates were different because the pharmacy delivered the medication before midnight. The retiring DON then said that she would put the Number Received and Date Received that she took from the date on the top left of the packing slip, not always the date that the staff had signed as received. The TDON, Retiring DON, CP and DCS confirmed that the date on the DEA 222 form should be the same date as the date received and signed for on the Packing Slip. The CP, in the presence of the TDON, Retiring DON and DCS, confirmed that the DEA 222 forms should be accurate and completed in its entirety. N.J.A.C. 8:39 - 29.7(c)