**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility-provided documents, it was determined that the facility failed to ensure that a) meals were consistently provided in a dignified and homelike manner and b) resident meal assistance was provided in a dignified manner. The deficient practice was observed in the recreation dining room for 2 of 6 residents (Residents #15 & #44). The deficient practice was evidenced by the following: On 12/15/24 at 11:46 AM, the surveyor observed the Kitchen Staff (KS) deliver the food truck to the recreation room, there were 6 residents, 4 residents at one table, 1 resident at one table, and another resident at one table, there were 2 Recreation Aides (RA) inside the dining area and later Registered Nurse Supervisor (RNS) came and assisted in distributing lunch trays. The surveyor observed RA #1, RA#2, and RNS assisted 5 of 6 residents with hand hygiene using individually wrapped hand wipes on each resident's lunch trays. The facility staff did not offer Resident #44 hand hygiene and the staff then proceeded to set up the resident's meal. At that same time, the surveyor observed 5 out of 6 residents eating lunch except for Resident #15, who was seated at the same table with the other 3 residents. The surveyor then asked RA#2 why Resident #15 had no tray, and RA#2 responded that she would get back to the surveyor. Later, the surveyor asked the RNS why Resident #15 had no tray while the rest of the residents at the same table were eating, and the RNS responded that she would ask someone to get the resident's tray. On 12/15/24 at 11:56 AM, the surveyor observed the KS delivered a tray to Resident #15, the RNS provided the tray, set up the tray, and the RNS left the recreation room. The surveyor observed there was no diet slip in the tray and the piece of paper with black marker written 19W. On 12/15/24 at 12:01 PM, the surveyor interviewed RA#2 regarding Resident#44's hand wipes not use, and RA#2 responded that the resident should have been provided an opportunity to perform hand hygiene and the hand wipes should have been used. RA#2 further stated that she was not the one who provided Resident #44's tray. The surveyor also asked RA#2 why Resident #15 had no diet slip and what 19W in the paper meant. RA#2 stated that 19W was the room number and resident should receive a meal ticket (diet slip; that included the resident's name and diet). She further stated that the resident was in room [ROOM NUMBER]W and not 19W. The surveyor then asked RA#2 what the diet of 15W was and 19W, and why Resident #15 received the wrong tray. RA#2 then went to the next table and took the paper, and RA#2 stated that according to the paper, Resident #15 who was in room [ROOM NUMBER]W diet was regular and room [ROOM NUMBER]W was also regular diet. RA#2 stated that Resident#15 should have a diet slip and should receive the right diet. The surveyor asked RA#2 why Resident #15 had to wait for 10 minutes while the 3 other residents were eating lunch at the same table, and RA#2 did not respond. A review of the medical records revealed: Resident#15's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/5/24, section C Cognitive Patterns included the brief interview for mental status (BIMS) score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. Resident#44's most recent significant change in status MDS with an ARD of 10/21/24, section C Cognitive Patterns included the BIMS score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. On 12/17/24 at 11:09 AM, the surveyor interviewed the Director of Nursing (DON) regarding dining services. The surveyor asked the DON what the facility's process for dining services was. The DON stated that the food truck comes in from the kitchen, the dietary staff brings the food truck trays, and then the recreation staff distributes the trays, always one assigned nurse for lunch and dinner, and breakfast residents eat in their room. The surveyor asked the DON who verified the meal ticket, and the DON responded that it was the recreation people who must check the meal ticket versus what was in the tray. The surveyor asked when and who offered assistance with hand hygiene during mealtime, the DON stated that the recreation staff or whoever bringing the tray to the resident should offer and assist residents in performing hand hygiene by using individual packets of hand wipes in the resident's tray be done before and after eating. On that same date and time, the surveyor notified the DON of the concerns with Resident # 15. The DON stated that the staff should have brought the resident inside their room or asked for the tray because residents should be eating all at the same time. The surveyor also notified the DON of the concerns with Resident # 44 with hand hygiene during lunch observation, and the DON stated that the staff should have checked and if not opened should been offered for hand hygiene. On 12/18/24 at 11:14 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the LNHA and the DON of the above findings and concerns. A review of the facility's Food, Dining Service and HS (bedtime) Snacks Policy with a reviewed date of 6/2024 that was provided by the LNHA revealed: Policy Explanation and Procedures: -Nursing staff will remind all residents/patients of the meal. Nursing is responsible for assisting those needed help. Individuals are assisted to prepare for the meal (glasses on, hearing aids in, hands washed, etc) . -Food service staff members will serve the food choices made with consideration given to dietary restrictions/texture modifications. Plates will be verified for accuracy of service . -Individuals are offered (or assisted to use) a hand wipe or cloth to wipe their hands prior to leaving the dining room . Eating Environment: -Staff will develop appropriate measures to try to maximize appropriate seating, positioning, and interactions among residents and to assure that each resident receives his or her prescribed diet A review of the Handwashing/Hand Hygiene Policy with a revised date of April 2010 that was provided by the LNHA revealed: Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals . On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, Regional DON #1 (RDON#1), RDON#2, Assistant Director of Nursing, and Co-President for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-4.1(a),12,28;27.1(a);27.3(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation of a resident's advance directives for 1 of 7 residents (Resident #10) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #10 which revealed: The admission Record (a summary of important information about the resident) revealed that the resident was admitted with diagnoses that included but were not limited to, chronic respiratory failure (a chronic condition when the airways in the lungs become damaged and narrow), anxiety disorder, and type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS) assessment tool used to facilitate the management of care, dated 11/30/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #10 scored a 14 out of 15, which indicated the resident had no cognitive impairment. The New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, which was undated and not filled out indicating what advance directives (AD) (directions for the type of life sustaining care to be given or not given) nor was it signed by the resident, attending or facility staff. There was no documentation that indicated what AD status the resident desired to have. A review of the physician's orders did not reveal any orders reflecting any AD status. A review of the resident's electronic medical record (eMR) did not reveal any information that reflected any AD status in the resident information area. On 12/16/24 at 11:51 AM the surveyor interviewed the Director of Social Services (DSS) and the Licensed Social Worker (LSW). The surveyor confirmed with the DSS that the Social Workers were part of the process for obtaining and documenting the AD and POLST status for residents. The surveyor asked how the DSS and LSW obtain and document AD and POLST status for residents. The DSS stated that the POLST was addressed in the resident assessment, and, depending on the resident's cognitive status, the forms are brought to the resident, everything was explained to the resident and forms were signed. The form was then signed by the physician, the form uploaded to the resident's eMR and the form was filed. The DSS further stated that the family can be contacted to confirm the resident's AD/POLST status if needed. The status should also be included in the resident's Care Plan (CP). The DSS also stated that as of September 2024, the Social Work department had an ongoing project to ensure all resident's have completed AD/POSLT and the results were reported to the facility's Quality Assurance Performance Improvement (QAPI) committee. The surveyor reviewed Resident #10's eMR and paper chart with the DSS. At this time the surveyor showed the DSS the blank POLST form and asked the DSS if there was any information in the medical record that indicates the AD or POLST status. The DSS stated they did not know why the blank form was in the chart and why there was no form uploaded, no note or order for an Advanced Directive. The DSS removed the blank form from the paper chart. The DSS stated they would get back to the surveyor with any additional information. On 12/16/24 at 1:29 PM the surveyor interviewed the LSW. The LSW stated that all residents that were full code prior to September did not have a POLST in the chart. In September, when the need was seen verify that there were AD/POLST in the medical records, the QAPI project was started. The LSW stated there was some difficulty getting the physicians sign POLSTs for residents who were full code. The LSW stated that Resident #10 had an admission date in August. The surveyor asked the LSW what would happen if a resident with no AD/POLST listed in the medical record needed to be checked for code status during an emergency, especially if the nurse on duty was unfamiliar with the resident. The LSW stated that the family would be called. The surveyor asked what if the family could not be reached. The LSW stated that the hospital records would be checked. The surveyor asked if these options could take extra time and possibly delay care. The LSW stated yes, they could. The surveyor asked the LSW if the missing documentation for Resident #10 could have been inadvertently missed or fell through the cracks. The LSW stated yes, it could have. At that time, the LSW stated that a progress note (PN) was placed in chart addressing the missing code status. A review of the resident's eMR revealed a new note by nursing recorded after surveyor inquiry. A review of the PN revealed: 12/16/2024 13:30 Note Text: PMD (primary medical doctor) notified of (redacted name) code status as full code, code status updated. On 12/18/24 at 10:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and made them aware of the concern with the missing documentation for Resident #10's code status. A review of the facility's Advance Directive Policy, revised 11/2021, provided by the LSW revealed: 4.executed advance directive be displayed prominently in med record. The policy does not reflect anything specific about full codes and POLST/AD. The facility did not provide any further pertinent information. N.J.A.C. 8:39-9.6(b)

COMPLAINT NJ#169518 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative (RR) of a change in condition for 1 of 24 sampled residents (Resident # 239). This deficient practice was evidenced by the following: The surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. Resident #239's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing foods or liquids), dementia (group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident #239's Universal Transfer Form (UTF) from the return to the facility after the first rehospitalization, indicated that the resident did not have any wounds. A review of Resident #239's progress notes (PN) included a wound note written by a Physician Assistant (PA) dated 9/5/23 which included the following: being seen today for a follow up wound evaluation .patient with multiple wounds. I was asked to evaluate and manage wound care for this patient Further review of the wound notes written by the PA indicated that the next visit was 10/3/23. There were three weeks of wound notes that were not in the resident's medical record. The next wound note written by the PA was dated 10/03/23. There was no documented evidence of wound measurements or appearance during those 3 weeks in Resident #239's medical record. There was no documentation in the PA's note that the RR was notified. Further review of Resident #239's PN did not include a documented notification of the RR regarding the DTI (deep tissue injury; a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact) identified on 9/5/23. On 12/18/24 at 9:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding Resident #239's wound. The ADON stated that the resident did not have any wounds on readmission from the hospitalization but that on 9/5/23 there was a reoccurrence of a DTI on the resident's buttock and bilateral heels. The surveyor asked the ADON if there was documented notification of the family of the DTI's. The ADON stated that she would have to check the medical record. On 12/18/24 at 3:00 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that there was no documented evidence that the RR was notified of the change in condition, specifically the DTIs that were investigated on 9/5/23 in the resident's medical record. On 12/19/24 at 9:59 AM, in the presence of the survey team, the ADON stated that the notification of the DTIs to the RR was documented in the Facility Acquired Pressure Injury Investigation Form. The surveyor asked if the investigation form was part of the medical record. The ADON stated that she would have to ask because she was not sure. The ADON then confirmed that there was no documentation in the electronic medical record that the RR was notified of the DTI on 9/5/23. On 12/19/24 at 10:18 AM, in the presence of the survey team, the ADON confirmed that the investigation form was not part of the medical record. On 12/19/24 at 12:31 PM, in the presence of the survey team, LNHA, DON, ADON, Regional DON #1, Regional DON #2 and the Co-President, the surveyor asked if the notification of the RR should be documented in the resident's medical record and the ADON stated yes. A review of the facility provided policy titled, Acute Condition Changes-Clinical Protocol with a revised date of 6/2024, included the following under Cause Identification: .2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . The facility did not provide any additional information. N.J.A.C. 8:39-13.1(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 3 of 21 residents reviewed, Resident #48, #71 and #47. The deficient practice was evidenced by the following: 1. During the initial tour of the facility on 12/15/24 at 11:35 AM, the surveyor observed room [ROOM NUMBER]-LW and Resident #48 was not in the room. The surveyor observed dressers on both sides of the bed. Some areas of the wood on the left dresser and the edges of the right dresser were peeled, exposing the underlying particle board which created a rough surface and edges on the dressers. The heater unit in room [ROOM NUMBER]-LW was observed without the front grill cover. The front grill cover was observed laying against the wall. The surveyor also observed Resident #48's bed frame visibly soiled with a dry, brown substance on the right, foot side of the bed frame. On 12/15/24 at 11:51 AM, the surveyor observed the Resident #48 in the activity room, sitting on a wheelchair. The surveyor attempted to interview the resident but did not answer any questions. The surveyor reviewed the medical records of Resident #48 and revealed: The admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with a diagnoses which included but not limited to unspecified dementia unspecified severity without behavioral, psychotic, mood and anxiety disturbance, and Alzheimer's late onset. According to the Quarterly Minimum Data Set (QMDS), an assessment tool which drives the plan of care, dated 11/1/24 revealed a Brief Interview of Mental Status (BIMS) score of 0 out of 15 indicating impaired cognition. On 12/16/24 at 12:18 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) and stated, I have reported about the drawers being jammed, and the grill cover since last week. I wrote on the maintenance book about the drawers. I told the Unit Manger (UM), that the grill was falling off. I did not notice the stain on the bed board. The resident does not complain, the resident is not alert. At that same time, the surveyor and the CNA reviewed the Maintenance Logbook together and found a log for 12/12/24 for dresser drawer being jammed but not for the wood edges peeling or heating unit grill cover missing. On 12/16/24 at 12:49 PM, the UM of the B Unit confirmed in room [ROOM NUMBER]-LW the two side drawers with peeled wood, and the bed stain on right side of the bed frame. The UM stated, I was not aware that the wood for the dressers were like that, and I do not know what that brown substance on the bed frame is. I will call maintenance and housekeeping. On 12/16/24 at 1:51 PM, the surveyor observed maintenance staff in room [ROOM NUMBER]-LW putting new drawers in the room after surveyor's inquiry. The surveyor interviewed the Regional Maintenance Director (RMD) who was also in the room at that time. The RMD, who has been with the company for four years stated, Usually the turnaround time for work orders is 24 hours. The surveyor requested for the policy for work orders. On 12/17/24 at 9:00 AM, the surveyor interviewed the License Nursing Home Administrator (LNHA), regarding the facility Policy and Procedure for maintenance work orders and he stated, We do not have a formal work order policy but usually if the equipment needs to be ordered, it can take time, it depends but we usually get it done as soon as we can. The LNHA stated that the facility did not have a maintenance policy. On 12/17/24 at 9:15 AM, the surveyor notified the LNHA, regarding the drawers with the rough edges near the Resident #48's head of the bed, the heating system grill cover off and laying against the wall and the brown substance on the foot of the bed frame found during initial tour on 12/15/24. 2. During the initial tour of the facility on 12/15/24 at 11:12 AM, the surveyor observed the Resident #71 lying in bed in room [ROOM NUMBER]-D, and the resident was unable to answer questions at that time but waved at the surveyor. The surveyor observed the closet with no door. The surveyor reviewed the medical records of Resident #48 and revealed: The AR reflected that the resident had diagnoses which included but not limited to obstructive and reflux uropathy unspecified, cerebral infarct due to thrombosis (formation of blood clot) of left middle coronary artery, vascular dementia unspecified severity with behavioral disturbance. According to the Annual MDS (AMDS) dated [DATE], revealed a BIMS score of 2 out of 15 indicating severely impaired cognition. On 12/16/24 at 9:47 AM, the surveyor observed room [ROOM NUMBER]-D still missing the closet door. The surveyor interviewed the UM of the B Unit, who confirmed the closet had no door. The UM stated, I will find out why there is no door to the closet. I did not notice that before. On 12/16/24 at 11:56 AM, the surveyor reviewed the Maintenance Request Book in the nursing unit from October to December 2024 and found no work order submitted for room [ROOM NUMBER]-D's missing closet door. On 12/16/24 at 12:07 PM, the UM stated, [Name Redacted] from maintenance took the door out on Friday to replace it with a lighter door. I do not know why it was not on the maintenance book log. On 12/16/24 at 12:12 PM, the surveyor interviewed the Director of Maintenance (DoM), who has been working in the facility for two years. The DoM stated, That door was heavy, off the track, one of the aides told me, a lot of things are not listed on the logbook, and we do it when it happens. I had to order the door, already picked up the door, will put it in today or tomorrow. On 12/16/24 at 1:57 PM, the surveyor requested for the requisition order form from the RMD for the new closet door. On 12/17/24 at 9:15 AM, the surveyor notified the LNHA regarding the above findings and concerns with the closet door missing in room [ROOM NUMBER]-D observed during the initial tour. On 12/17/24 at 10:40 AM, the surveyor interviewed the DoM who stated, I ended up picking up the door at the other facility in [Name Redacted], we share things. I do not work on weekends that was why I put the door in on Monday. On 12/17/24 at 11:45 AM, the surveyor requested for the facility's Maintenance Policy and the LNHA stated, We do not have a Maintenance Policy. On 12/19/24 at 9:00 AM, the surveyor requested from the LNHA any Policy and Procedure for Environment, specifically, residents' rooms. On 12/19/24 at 10:50 AM, the surveyor requested from the LNHA the policy for Environment. There was no policy for Environment was provided. On 12/19/24 at 11:38 AM, the survey team met with the LNHA, DON, Regional DON#1 (RDON#1), RDON#2, Assistant Director of Nursing (ADON), and the Co-President. The LNHA stated, Hinge was broken in the closet door, we removed it, it was fixed after the surveyors saw it. The surveyor notified the LNHA and his staff that the RMD confirmed that maintenance issues had a 24 hour turn around. The closet door was reported and taken out on Friday and not replaced until 3 days later. On 12/19/24 at 1:05 PM, the LNHA stated, Some projects take more time, we were going to order the door, but we found one off site. 3. On 12/17/24 at 1:28 PM, the surveyor conducted the Resident council meeting. During the Resident Council meeting, Resident #47 stated, There are still cobwebs on top of my mirror, ceiling, and on top of my dresser, they have not cleaned it. I told them last month. I think it's dust bunnies I do not think it was cobwebs because I do not see anything crawling. A review of the Resident Council minutes completed on 11/22/24, revealed that Resident #47 complained of spider webs in the resident's room. The previous Activity Director, who was no longer working in the facility, filled out the grievance form titled Resident Council Concern Form on 11/22/24. The Housekeeping Director signed the form ten days later 12/2/24 and under action taken, Had [Name Redacted] clean the cobwebs. On 12/17/24 at 2:32 PM, the surveyor and Resident #47 observed room [ROOM NUMBER]-W, with dust above the top of the dresser, cobwebs on the ceiling on the right side of the windows, heating unit grill covered with dust and dirt, and the windowsill with dirt and dust. On 12/17/24 at 2:41 PM, the Licensed Practical Nurse (LPN) confirmed dust on top of dresser, spiderwebs on the right side of the room by the ceiling, the windowsill dirty and heating unit grill with dirt and dust. The LPN stated, I have not seen that before. On 12/17/24 at 3:00 PM, the surveyor requested from the LNHA the facility Policy and Procedure for housekeeping. The surveyor reviewed the medical records of Resident #47 and revealed: The AR reflected that the resident was admitted to the facility with diagnoses which included but not limited to emphysema (a long-term lung condition that causes shortness of breath), anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), and peripheral vascular disease (a slow and progressive disorder of the blood vessels). According to the AMDS, dated [DATE], which revealed a BIMS score of 14 out of 15 indicating intact cognition. On 12/18/24 at 11:13 AM, the surveyor discussed above concerns with the DON and the LNHA and both were notified of the Resident Council minutes for November which mentioned cobwebs. A review of the facility's Cleaning and Disinfecting Residents' Rooms Policy and Procedure revealed that Housekeeping surfaces will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. NJAC 8:39-31.4(a)(c)(f)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary service to maintain good personal grooming for a resident who was unable to carry out activities of daily living (ADL). This deficient practice was identified for 1 of 21 residents reviewed for care, Resident #71. The deficient practice was evidenced by the following: On 12/15/24 at 11:12 AM, the surveyor observed Resident #71 lying on an air mattress inside their room. The resident waved to the surveyor but was unable to answer questions at that time. The surveyor observed Resident #71 unshaven, with hair stubbles on both cheeks, and beard on chin. On 12/16/24 at 11:28 AM, the surveyor observed the Resident #71 sitting on the wheelchair (w/c) inside their room, unshaven, and Certified Nursing Assistant #1 (CNA#1) was combing the resident's hair. The resident communicated to the surveyor and whispered their name when the surveyor asked for the name of the resident. On 12/16/24 at 11:39 AM, the surveyor interviewed CNA #1, who stated, I wash them, answer call bells, the resident is total assist. I have not been the regular aide, I was not here this weekend, sometimes the resident does not like to be shaved because he/she gets angry, says don't touch me but today the resident is fine and will try later to shave. The surveyor reviewed the medical records of Resident #71 and revealed: The admission Record (an admission summary) reflected that the resident was admitted to the facility with a diagnosis which included but not limited to cerebral infarct due to thrombosis (formation of a clot) of left middle cerebral artery, vascular dementia unspecified severity with behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, and delusional disorders. According to the Annual Minimum Data Set (MDS), an assessment tool to drive the plan of care dated 9/27/24 revealed a Brief Interview of Mental Status (BIMS) score of 2 out of 15 indicating severe impaired cognition. The section GG in the MDS revealed ADLs for personal hygiene, the resident requires substantial/maximal assistance from staff. On 12/17/24 at 11:15 AM, the surveyor observed the resident sitting on the w/c in the resident's room, with both cheeks and chin shaven. On 12/18/24 at 9:30 AM, the surveyor interviewed License Practical Nurse #1 (LPN#1). The LPN stated, The resident is a total care, will nod to questions, does not usually refuse care for me. On 12/18/24 at 10:46 AM, the surveyor interviewed CNA #2. CNA#2 stated, I do hygiene care every morning. The resident likes care later in the morning, sometimes they will refuse shaving but once you tell the resident and explain, they will allow you to do it. On 12/18/24 at 11:13 AM, the surveyor notified the above concerns to the Director of Nursing (DON) and the License Nursing Home Administrator (LNHA). A review of the facility's Activities of Daily Living Policy, last reviewed on 10/2024 revealed that A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. On 12/19/24 at 11:38 AM, the survey team met with the LNHA, DON, Assistant DON, Regional DON #1 (RDON#1), RDON#2, and the Co-President. The LNHA stated, [Name Redacted] was observed not to be shaved. The care plan was updated to include refusal to be shaved and to reflect in the documentation the refusal and to ask the resident to be shaved in a later time. NJAC 8:39-27.2(g)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for 1 of 24 residents, Resident #86, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/18/24 at 9:31 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #86. The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, type 2 diabetes mellitus with chronic kidney disease, dementia, colostomy (a surgical opening into the colon from the outside of the body), and anxiety disorder. A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/19/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #86 scored a 9 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order dated 9/25/24 documented chest x-ray (CXR) stat for congestion. A skilled progress note (PN) dated 9/25/24 at 12:31 PM revealed Licensed Practical Nurse #1 (LPN#1) documented the physician visited the resident and orders for intravenous (IV) hydration, blood lab works, and a CXR. There was no further documentation about the CXR status in the PN. There was no documentation of the stat CXR results in the paper chart or the EMR. A review of the resident's blood pressure (BP) results revealed: -9/26/24 at 5:32 AM, the resident's documented BP was 88/55. There were no other vital signs (VS; includes BP, pulse, respiratory rate, temperature, oxygen saturation) documented for the resident at this time. -9/26/24 at 6:05 AM, the resident's documented BP was 96/67. There was no other VS documented for the resident at this time. A review of the resident's BP in September 2024 revealed the resident's systolic (top number and refers to the amount of pressure experienced by the arteries while the heart is beating) BP was higher than 139 for 75 of the 98 BPs documented for the resident. A review of the PN, indicated there was no documentation of the physician being notified of the resident's low BP. On 12/18/24 at 10:25 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that if there was a change of condition with the resident an SBAR [Situation, Background, Assessment, and Recommendation; a tool that can be used to help healthcare teams share information about a patient's condition or concerns] and the physician should be notified for any orders to be carried out. The surveyor asked the RN/UM if a resident's BP was outside of the baseline for the resident, what would be expected of the nurses. The RN/UM stated that the physician should be made aware of the resident's BP for any orders. The surveyor asked the RN/UM about what would be expected for a stat CXR. The RN/UM stated that the CXR would be called in or entered in their electronic system and the technician would be expected within 3-4 hours. The RN/UM further explained that she had never experienced any issues with stat orders and if they did not arrive that it would be expected to call the vendor, notify the physician, and the DON (Director of Nursing). The surveyor discussed the concern that the results for Resident #86's stat CXR was not found in the paper chart and the EMR. The RN/UM stated she would follow up to provide additional information. On 12/18/24 at 10:54 AM, the surveyor interviewed LPN #2 over the phone. The LPN stated that if there was a change with a resident, the resident needed to be assessed, an SBAR completed, the physician notified for orders and the RN supervisor notified to assess the resident. LPN #2 stated if a change in BP from baseline occurred, the physician and supervisor should be notified for interventions. The surveyor asked if it would be documented in the EMR. The LPN replied that it would be documented in the PN of the EMR. The surveyor asked about Resident #86. LPN #2 replied that she could not recall everything as some time had passed and that anything pertinent would be documented in her PN in the EMR. On 12/18/24 at 11:14 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the DON of the above concerns of the stat CXR that was not completed, and no documentation of the physician being made aware of the resident's low BP results. On 12/18/24 at 11:44 AM, the RN/UM provided a CXR requisition form for Resident #86 and attached email. A review of the email document indicated that the vendor called the facility a notified a named facility staff member that they were overwhelmed and would be able to send a technician in the morning of 9/26/24. On 12/19/24 at 11:38 AM, the LNHA, the DON, the Assistant Director of Nursing (ADON), Regional DON #1, Regional DON #2, and the Co-President met with the survey team. The surveyor asked who was the staff that was notified by the vendor that would not be able to do the CXR stat and what would be expected of the staff once notified. The DON stated it was a nurse supervisor who was notified, and it was protocol to call the physician to notify that there would be a delay. The RDONs and the DON stated the nurse supervisor spoke with the physician. The surveyor asked if there was any documentation that the physician was notified. The facility stated they would review to provide any additional information. The surveyor asked if there was any response for the resident's BP and the physician not being notified. The facility stated they would also review to provide additional information. On 12/19/24 at 1:05 PM, the LNHA stated that the resident's BP went back up upon the resident's re-check and that was why the nurse did not notify the physician. There was no additional information provided by the facility. A review of the facility's Acute Condition Changes-Clinical Protocol Policy, with a last revised dated of June 2024. Under Assessment and Recognition, it specified, .5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the Physician; for example, history of present illness and previous and recent test results for comparison. Under Treatment/Management it documented, The physician will help identify and authorize appropriate treatments. Under Monitoring and Follow-Up, it documented, 1. The staff will monitor and document the resident's progress and responses to treatment and the Physician will adjust treatment accordingly. A review of the facility's Lab (laboratory) and Diagnostic Test Results- Clinical Protocol Policy, with a last revised dated of June 2024. The policy did not address the protocol for when a diagnostic test could not be performed by the diagnostic radiology provider. N.J.A.C. 8:39-3.2 (a), (b); 27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and the facility's policy and procedure, specifically, administer oxygen therapy according to the physician's order by documenting the date and time the oxygen tubing was changed for 1 of 1 resident, Resident #10. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/15/24 at 11:55 AM, during initial tour the surveyor observed Resident #10 in a wheelchair (w/c), awake, with oxygen (O2) being administered by nasal cannula (N/C) (tubing that fits around the face and provides O2 into the nostrils) attached to and O2 concentrator (a machine that gathers O2 from room air and delivers it by tubing to a resident). The surveyor did not observe a label or other marking on the O2 tubing denoting when it was changed for a new set. On that same date and time, the surveyor interviewed Resident #10. The surveyor asked the resident how they use the O2 and if the staff prepares it or replaces the tubing. The resident stated that the staff does change the tubing but was unsure when that happens. The resident also stated they were in the process of weaning off the O2, and sometimes does not use it. On 12/16/24 at 10:11 AM, the surveyor observed Resident #10 in a w/c with O2 being used. The surveyor observed that the O2 tubing had date written on a piece of surgical tape and applied near the connection to the O2 concentrator. The date reflected 12/16/24 (Monday). The surveyor reviewed the hybrid (electronic and paper) medical record for Resident #10. The Resident admission Record (a summary of important information about the resident) revealed that the resident was admitted with diagnoses that included but were not limited to, chronic respiratory failure (a chronic condition when the airways in the lungs become damaged and narrow), anxiety disorder, and type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/30/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #10 scored a 14 out of 15, which indicated the resident had no cognitive impairment. Further review of the MDS, Section O, revealed the resident was using O2. A review of the resident's Care Plan (CP) initiated 8/21/24, (a list of interventions and goals related to the resident's care), revealed that Resident #10 received O2 for difficulty breathing and symptoms of poor O2 absorption. A review of the resident's Physician Order Sheet (POS) revealed an order dated 8/22/24: Change O2 tubing, cannula/mask weekly. Label with date, time, and nurse's initials every night shift every Wed (Wednesday) for preventative care and as needed for soiled/wet. The above orders for O2 tubing was transcribed to the December 2024 electronic Medication Administration Record (eMAR). There was no documented evidence that the PRN order for O2 tubing change was signed on 12/16/24 according to the POS. On 12/18/24, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the LNHA and the DON of the above findings and concerns. On 12/19/24 at 11:39 AM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON), Regional DON #1 (RDON#1), RDON#2, and Co-President for facility's responses from the above concerns and findings. The facility management response included documentation that reflected that the facility considered it an isolated event and was immediately corrected, and there was a possibility the date label fell off at some time. On 12/19/24 at 11:45 AM, the surveyor interviewed the DON and the ADON after the response. The surveyor asked how the date was applied to the tubing. The ADON stated that it was written on a piece of surgical tape, then applied to the tubing. The surveyor further inquired if there was any additional documentation that the label was replaced, would the nurse document the current day, would the nurse document under the PRN order and if the tape fell off, would it be considered not secure. The DON responded that the reasoning that the tape fell off or was knocked off by the resident was a possible answer being provided, and there was no absolute way to know. After the facility response, the facility did not provide any further pertinent information. A review of the facility's Oxygen Administration Policy dated 10/2024 revealed: Preparation: 1. Verify that there is a physician's order (PO) for this procedure. Review the PO or facility protocol for O2 administration. Documentation: 1. The date and time that the procedure was performed. The policy did not reflect any mention of applying a date to the O2 tubing specifically. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 1 resident (Resident #25), reviewed for dialysis services. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/15/24 at 10:36 AM, the surveyor observed Resident #25 sitting in a wheelchair at their bedside. Resident #25 was alert, oriented, and verbally responsive. The resident stated they went to dialysis 3 times a week and had no concerns with their care. On 12/16/24 at 11:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to care for Resident #25. The LPN stated the nurses documented on the dialysis communication form (DCF) when sending the resident to the dialysis center, including vital signs (VS; blood pressure (BP), pulse, respiratory rate, and temperature) and any changes or concerns. The dialysis center would document on the second portion of the form, which included pre and post treatment dialysis weight and BP, any medications (meds) given to the resident during dialysis and any concerns during the dialysis session. The LPN provided the dialysis communication binder for Resident #25. The binder included 2 DCF. The surveyor requested the additional DCF for Resident #25. On 12/16/24 at 12:02 PM, the Registered Nurse/Unit Manager (RN/UM) stated the DCF were uploaded to the resident's EMR and the original copies were kept in a binder for the year. The RN/UM, in the presence of the surveyor reviewed the resident's EMR which revealed the scanned copies of November and December 2024 DCFs. On 12/18/24 at 9:28 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #25. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, end stage renal (kidney) disease, and dependence on renal dialysis. A comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the management of care, dated 11/15/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #25 scored a 15 out of 15, which indicated the resident was cognitively intact. A review of the scanned DCF for December 2024, revealed the following: On 12/7/24, under the facility section it was written I left a Zofran (a medication (med) indicated for nausea and vomiting) in book .Please give before leaving. There was no further documentation on the form about the Zofran med. On 12/10/24, under the facility section of the form it was written Zofran in Book. Under the dialysis section of the form it was written pt [patient] vomited post tx [treatment]. On the bottom of the form it was written, Zofran 4 mg[milligram] tab[tablet] was sent to dialysis, not given still in binder. On 12/12/24, under the dialysis section of the form it was written Zofran given. There was no further documentation on the form about the Zofran med. On 12/14/24, a dialysis center communication log form, under the post dialysis section it was written for meds given Zofran 4 mg given. There was no further documentation on the form about the Zofran med. On 12/17/24, under the dialysis section of the form it was written Ondansetron [Zofran] given post dialysis. There was no further documentation on the form about the Zofran med. A physician's order (PO) dated 11/09/24 documented the resident had dialysis on Tuesday (Tue), Thursday (Thu), and Saturday (Sat) with a pickup time of 8:15 AM. A PO dated 12/17/24 documented the resident was to receive Zofran (Ondansetron Hydrochloride) 4 mg tablet (tab), 1 tab by mouth in the morning every Tue, Thu, Sat for nausea at 7:45 AM. A PO dated 12/17/24 documented the resident was to receive Zofran (Ondansetron Hydrochloride) 4 mg tab, 1 tab by mouth every 6 hours as needed (PRN) for nausea. There were no additional orders for Zofran. A review of progress notes (PN) for December 2024 revealed: On 12/10/24 at 5:47 PM a PN written by the RN/UM indicated per the DCF the resident vomited post dialysis tx and the Zofran sent to dialysis with the resident was not administered, still in the binder. The dialysis nurse was called, reviewed that the resident had a Zofran order, the med was in the binder to be given to the resident. There were no other PN related to the resident receiving Zofran in dialysis. On 12/18/24 at 9:52 AM, the surveyor interviewed the LPN who stated that the resident had episodes of having nausea when returning from dialysis and the physician ordered Zofran for the resident. The LPN stated the Zofran was an individual dose sealed in its original packaging. The Zofran packaged dose would be placed in a clear plastic bag and attached inside of the binder. The LPN stated it would be documented on the dialysis communication book if the resident received the med in dialysis. On 12/18/24 10:07 AM, the surveyor interviewed the RN/UM about Resident #25 receiving Zofran in dialysis. The RN/UM stated the PO for the resident to receive med post dialysis due to nausea and vomiting. The RN/UM further explained the dialysis center did not have the med and that was why the med was being sent with the resident. The RN/UM confirmed there should be a PO for sending the med with the resident to dialysis and stated that the resident did have one. The RN/UM showed the surveyor the resident binder which had a print out of a PO to send Zofran 4 mg with the resident to dialysis, dated 12/3/24. The surveyor asked the RN/UM to review the PO in the EMR. The RN/UM could not find an active order for Zofran 4 mg to be sent to dialysis with the resident. The RN/UM found an order that was discontinued (d/c) on 12/13/24. The RN/UM could not speak to what happened and would have to follow up. The surveyor asked the RN/UM about accountability for the Zofran med. The RN/UM stated that it would be written on the DCF if the resident received the med and if the med returned in the binder the med was not given. The RN/UM added if the DCF did not document if the resident received or if there was a concern about Zofran administration, the staff would call the dialysis center to confirm it was given or not. The surveyor asked about the documentation of the time the Zofran med was administered in dialysis as the resident also had a PRN Zofran order. The RN/UM stated that it was given post dialysis. The RN/UM acknowledged the exact time the med was received was not known as it was not documented on the DCF and the facility nurse would have to call the dialysis center to find out that information. The surveyor informed the RN/UM of the concern that the administration time was unknown and Zofran was sent with the resident without a PO. On 12/18/24 at 11:14 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns related to the resident's Zofran med. On 12/19/24 at 11:38 AM, the LNHA, the DON, the Assistant Director of Nursing (ADON), Regional DON #1 (RDON#1), Regional DON #2 (RDON#2), and the Co-President met with the survey team. The facility stated the there was a PO for Zofran and provided the Medication Administration Record (MAR). A review of the MAR revealed the Zofran order was dated 12/17/24 and timed for administration 7:45 AM. It did not indicate Zofran 4 mg should be sent with the resident to dialysis. The surveyor rediscussed concern for Resident #25's Zofran. The facility stated they would review to provide any additional information. On 12/19/24 at 12:59 PM, RDON#2 provided a physician PN, dated 12/17/24, which indicated the physician wanted to continue the Zofran orders. The surveyor asked RDON#2 if it would be expected for there to be PO for the nurses to follow. RDON#2 acknowledged that there should have been a PO for it. There was no additional information provided by the facility. A review of the facility's End-Stage Renal Disease, Care of a Resident Policy with a last updated date of 10/2024 revealed: Under the Policy Statement it was written Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Under Policy Interpretation and Implementation, it documented, .7. Facility will send dialysis communication form or communication book to dialysis Center. This communication form/book will be returned to the facility for review for orders, med administered at the Center, latest lab works, resident weights, or any significant changes . A review of the facility's Administering Medications Using Electronic System, with a last reviewed date of 6/2024 revealed: Under the Policy Statement it was written Meds shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, it documented, .3. Meds must be administered in accordance with doctor's orders, including any required time frame . NJAC 8:39 - 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report posted was accurate and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/15/24 at 8:56 AM, the survey team entered the facility. The surveyor did not observe a 24-hour staffing report in the initial hallway leading to the nursing station or at the nursing station. The surveyor then turned right and proceeded down a different hallway, which contained the lower odd numbered resident rooms and observed a staffing report sheet that was posted on the right wall next to the menu. The surveyor observed that the posting would not be accessible or visible to residents and visitors that were located or visited the resident rooms that were in the hallway that contained the higher odd numbered rooms. The posting observed was dated 12/13/24 evening shift with a census of 85. The posting had not been updated for that day and did not include the accurate census which the Registered Nurse Supervisor informed the survey team was 86. On 12/16/24 at 9:15 AM, the surveyor observed the staffing report that was posted was dated 12/16/24 day shift with a census of 85. The posting was accurate. On 12/17/24 at 8:45 AM, the surveyor observed the staffing report that was posted was dated 12/16/24 evening shift. The posting had not been updated for that day. On 12/17/24 at 10:43 AM, the surveyor interviewed the Director of Nursing (DON) regarding the posting of the staffing report. The DON stated that the Unit Clerk (UC) posted the staffing report and that she believed it was posted for the whole day. On 12/17/24 at 11:31 AM, the DON stated that the UC placed the 3 different sheets, 1 sheet for each shift, in the clear plastic sleeve that was located on the wall. She added that when the UC comes into the facility around 8 AM, she placed all 3 shifts and that when the UC left, she would remove the day shift report to reveal the evening shift report. The DON then stated that the 3-11 Supervisor at the end of the evening shift would remove the evening shift report to reveal the night shift report. The surveyor asked the DON who was responsible on the weekend to post the staffing reports. The DON stated that the UC would print out all 3 days on Fridays and that the Supervisors on the weekend were supposed to post them each shift. The surveyor asked the DON if the posting should be prominent for all residents and visitors. The DON stated that it should be prominent. On 12/17/24 at 12:26 PM, the surveyor interviewed the UC regarding posting of the staffing report. The UC stated that she would print all 3 shifts which included the next day's day shift report and put them in the sleeve. She added that the Supervisor on the night shift would reveal the day shift report. The surveyor asked the UC who was responsible on the weekend. The UC stated that the Supervisors were responsible on the weekend. On 12/18/24 at 10:01 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a facility policy for the posting of the staffing report. The LNHA stated that the facility did not have a policy for posting and that they followed the regulation. The LNHA then stated that the staff brought it to his attention about the concerns with the posting and that he placed an additional posting in a different area. On 12/18/24 at 11:38 AM, in the presence of the survey team, the surveyor notified the LNHA and DON the concern that the staffing report was not posted in a prominent place within the facility readily accessible to the residents and the visitors and was not accurate and up to date on 12/15/24 and 12/17/24. On 12/19/24 at 11:47 AM, in the presence of the survey team, DON, Regional DON #1 (RDON#1), RDON#2 and Co-President, the LNHA stated that he had a statement from the person that switched out the posting. The LNHA then stated that he felt that the posting was visible since that was where the menus were located but that however he added a posting to another area. RDON# 1 stated that all 3 shifts were posted in the sleeve but that they were behind the one posted and that each shift was not visible. The COO stated that she talked to the UC and other staff to make sure it was visible at all times. The facility did not provide any additional information. N.J.A.C. 8:39-41.2 (a)(b)(c)

Complaint NJ#169518 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 24 residents reviewed (Resident #239). This deficient practice was evidenced by the following: On 12/18/24 at 9:01 AM, the surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. A review of Resident #239's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing foods or liquids), dementia (group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident #239's Universal Transfer Form (UTF) from the return to the facility after the first rehospitalization, indicated that the resident did not have any wounds. A review of Resident #239's progress notes (PN) included a wound note written by a Physician Assistant (PA) dated 9/5/23, which was approximately a week after return to the facility, included the following: being seen today for a follow up wound evaluation .patient with multiple wounds. I was asked to evaluate and manage wound care for this patient Further review of the wound notes written by the PA indicated that the next visit was 10/3/23. There were 3 weeks of wound notes that were not in the resident's medical record. The next wound note written by the PA was dated 10/3/24. The surveyor also did not observe any documented measurements or appearance of the wounds during those 3 weeks in Resident #239's medical record. On 12/18/24 at 01:53 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the process of wound PA visits. The ADON stated that the wound PA visited weekly if the resident had a deep tissue injury (DTI) or a wound. The surveyor asked the ADON about the missing 3 weeks of the wound notes by the PA. The ADON stated that it was not followed up by the wound doctor because there were no changes to the DTI and that the wound nurse observed it weekly. The surveyor then asked the ADON if the wound nurse had documented the size and appearance of the DTI in the resident's medical record. The ADON stated that she had the weekly measurements on her tracking form. The surveyor asked the DON if her tracking form was part of the medical record. The ADON stated that the tracking form was not part of the medical record. On 12/18/24 at 3:00 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that the complete medical record was not accessible in the computer system. On 12/19/24 at 9:59 AM, in the presence of the survey team, the ADON stated that the wound PA had the missing 3 weeks of wound PN but that she had not placed them in the electronic medical record. The ADON stated that she had not checked in the computer prior to surveyor inquiry. The ADON stated that she had uploaded the missing notes that day under the miscellaneous tab of the resident's electronic medical record. The ADON provided the surveyor a copy of the wound notes that she uploaded into the medical record. The surveyor then reviewed the resident's electronic medical record and observed that there was an upload of Wound Care PN dated 12/19/24. On 12/19/24 at 12:31 PM, in the presence of the survey team, DON, Regional DON #1, Regional DON #2 and Co-President, the LNHA stated that the PA had done the wound notes. The surveyor asked if the wound notes should have been in the medical record prior to surveyor inquiry. The Regional DON #1 stated that they did not know what happened to the notes. A review of the facility provided policy titled, Medical Records with a reviewed date of 11/2024, included the following: Policy Statement Medical records shall be retained by the facility in accordance with current applicable laws. Policy Interpretation and Implementation 1. Medical records of discharged residents will be retained for a period of 10 years. The facility did not provide any additional information. N.J.A.C. 8:39-35.2

3. On 12/17/24 at 8:23 AM, the surveyor began the Medication (med) Pass Observation task. At 9:02 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepare and administer medications (meds) to Resident #45. The resident had a total of 4 meds to be administered. The meds included 10 milliliters (ml) of guaifenesin DM (Dextromethorphan belongs to a group of medications called antitussives (cough suppressants) liquid. The surveyor observed LPN#1 poured the guaifenesin DM more than the order indicated. Then LPN#1 poured the excess liquid into a second dose cup to get the proper amount. The surveyor observed LPN#1 dispose of the second dose cup with the excess liquid in the trash receptacle located on the side of the med cart (medcart). The surveyor observed the cup remain upright and not spill into the trash. Resident #45 refused the guaifenesin DM liquid. The surveyor observed LPN#1 dispose of the refused med into an approved med disposal system located in the bottom of the medcart. The surveyor asked LPN#1 what the policy or procedure on disposal of unused, refused, or extra meds was, and LPN#1 responded that they should be put in the med disposal system. At 9:15 AM, the surveyor observed LPN#2 prepare and administer meds to Resident #339. The resident had a total of 2 meds to be administered. The meds included 1 tablet (tab) of Sucralfate 1 gram (a drug used to treat ulcers and protect the stomach), ordered for 10:00 AM. During the administration of the meds to Resident #339, the surveyor observed the resident's breakfast tray present on a bedside table next to the resident. The surveyor observed that at least 50% of the meal was consumed. The surveyor asked Resident #339 when and if they had finished with the breakfast meal. The resident stated that they eat quickly and was finished eating approximately 8:15 AM to 8:20 AM. The surveyor reviewed the electronic medical records (eMR) for Resident #45 and Resident #339. Resident #45's eMR revealed a PO and eMAR for guaifenesin DM 10 ml TID (3 times a day) for cough for 7 days scheduled at 9:00 AM, 1:00 PM, and 5:00 PM. Resident #339's eMR revealed a PO and eMAR for Sucralfate Oral Tab 1 gram, 1 tab by mouth TID a day for gastric ulcer scheduled at 10:00 AM, 2:00 PM, and 8:00 PM. Resident #339's eMR also reflected a nurse's progress note that revealed an assessment that the resident was alert and oriented. A review of the manufacturer's informational package insert (PI) for Sucralfate which reflected, the recommended adult oral dosage for duodenal ulcer was 1 gram four times per day on an empty stomach. On 12/18/24 at 11:15 AM, the survey team met with the LNHA and DON, and the surveyor notified the above findings and concerns. The surveyor asked the DON when meds were administered, what would be considered an empty stomach. The DON stated that it was usually 1 hour before a meal or 2 hours after a meal. The surveyor asked the DON what the policy or procedure was for properly disposing of excess meds. The DON stated that meds should be disposed of in the drug disposal system in the medcart. On 12/18/24 at 12:19 PM, the surveyor interviewed the facility Consultant Pharmacist (CP) by telephone. The surveyor discussed the concerns with the med pass observation. The surveyor asked the CP when meds were administered, what would be considered an empty stomach. The CP stated the standard would be 1 hour before meals or 2 hours after meals. The surveyor asked the CP if excess meds should be disposed of in the trash receptacle on the side of the medcart. The CP stated, no, meds should be disposed of in the approved med disposal system in the cart. On 12/19/24 at 11:39 AM, the survey team met with the LNHA and DON, and the facility had no further pertinent information to provide. A review of the facility's Administering Medications Using Electronic System Policy dated 6/2024. The policy reflected under 3. Meds must be administered in accordance with doctor's orders, including any required time frame and following med cautionary. The policy did not reflect any information regarding disposal of unused or excess meds during the med pass. NJAC 8:39-11.2(b); 29.2 (d); 29.4(g) Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to adhere to professional standards of clinical practice by failing to: a.) follow the residents' meal tickets for 2 of 2 meal observations for Residents #41, #43, and #44; b.) clarify the physician's order with regard to supplement for 1 of 24 residents, Resident #41; and c.) ensure medication was administered in accordance with the manufacturer's specifications, and d.) ensure proper disposal of excess medication in a safe and approved manner for 2 of 6 residents, Residents #45 and #339, reviewed during the medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 12/15/2024 at 11:46 AM, the surveyor observed in the recreation room during lunch 6 residents and 3 staff. The surveyor observed Resident #41 received their tray and the meal ticket revealed that the resident should receive a magic cup. Resident #41 did not receive a magic cup. The surveyor asked Recreation Aide #1 (RA#1) about the magic cup in the resident's meal ticket, and RA#1 could not state where the magic cup was. The surveyor asked the Registered Nurse Supervisor (RNS) about Resident #41's magic cup and the RNS asked RA#1 to get it from the kitchen. The RNS acknowledged that the resident should receive what was on the meal ticket, including the magic cup. On 12/15/24 at 12:01 PM, the surveyor observed RA#1 offered the with magic cup that was taken from the kitchen and Resident #41 refused the magic cup. A review of the provided Minimum Data Set (MDS) by the Director of Nursing (DON) revealed: -Resident # 41's most recent quarterly MDS (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/7/24, Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 1 out of 15 reflected that the resident's cognitive status was severely impaired. A review of the Order Listing Report revealed an active physician's order (PO) dated 9/2/24 for Magic cup two times a day for supplement provide with lunch and dinner for Resident #41. The above order for the magic cup was transcribed to the December 2024 electronic Medication Administration Record (eMAR) and signed by nurses as administered (provided). On 12/15/24 at noon eMAR, the Registered Nurse (RN) electronically signed the eMAR as administered. The eMAR did not include information of resident's amount of intake and refusal. On 12/19/24 at 8:42 AM, the surveyor interviewed the RN who signed the eMAR on 12/15/24 at noon for Resident #41's magic cup. The RN confirmed that she was the nurse who signed the 12/15/24 at noon eMAR of Resident #41 for the magic cup. The RN acknowledged that she was not in the recreation dining room on 12/15/24 to observe the resident's intake of the magic cup and did not receive a report about the resident's refusal to take the magic cup. The surveyor asked the RN why she signed the magic cup on 12/15/24 if the resident did not take the magic cup at lunchtime, and the RN did not respond. On that same date and time, the RN informed the surveyor that the PO for the magic cup for Resident #41 should have been clarified with the physician to include the amount or percentage of intake of the magic cup as what was ordered in the health shake as best practice. 2. On 12/17/24 at 8:31 AM, the surveyor observed the recreation room for breakfast and there was a total of 4 residents and 2 staff. The surveyor observed Resident#43's meal ticket and revealed that the resident should receive a nectar-thickened orange juice (oj). The surveyor observed there was no nectar-thickened oj in the resident's tray. The surveyor asked RA#2 and RA#3 why the resident did not have nectar-thickened oj, and RA#2 responded that there was no nectar-thickened oj in the kitchen that was why the nectar-thickened cranberry juice was provided instead. On that same date and time, the surveyor observed Resident #44's meal ticket for 2 cups of coffee and the resident did not receive two cups of coffee. The surveyor asked RA#2 and RA#3 why the resident did not receive 2 cups of coffee according to what was in the meal ticket and RA#3 responded that it was the Certified Nursing Aide (CNA) who brought the breakfast tray and there was only one cup of coffee in the tray. On 12/17/24 at 8:44 AM, the surveyor went to the kitchen and interviewed the Food Service Director (FSD). The FSD showed what the facility fluids could offer to the residents during mealtime. The surveyor observed the kitchen stocks for the pre-thickened honey and nectar water, pre-thickened honey and nectar cranberry juice, cranberry juice, apple juice, oj, and strawberry juice. The surveyor did not see a supply of pre-thickened nectar oj and the FSD confirmed. Later, the Regional FSD (RFSD) joined the FSD during the interview. The FSD stated that the facility had thickened powder that could be mixed with water and juice. The FSD further stated that she was responsible for mixing the thickened powder and ensuring that the meal ticket corresponded with what should be on the tray. The surveyor notified the RFSD and the FSD of the above findings and concerns regarding meal tickets of Residents #41, #43, and #44. The surveyor also asked both FSDs, if the facility had a supply of thickened powder and oj, and why Resident #43 did not receive nectar oj, and both FSDs did not respond. On 12/17/24 at 11:09 AM, the surveyor interviewed the DON regarding dining services. The surveyor asked the DON what the facility's process for dining services was and who verified the meal tickets. The DON responded that it was the recreation people responsibility to check the meal ticket and what was in the tray. She further stated that it was an expectation if there was a discrepancy with the meal ticket, it should be checked with the nurse or dietary. The surveyor notified the DON of the above findings and concerns. The surveyor asked the DON why Resident #43 did not receive nectar oj when there was a thickened powder and oj, and the DON did not respond. At that same time, the surveyor also notified the DON of the concern with Resident # 44 that the resident did not have two cups of coffee in their tray and the meal ticket revealed that the resident should have two cups of coffee. the DON had no response when asked by the surveyor what should be the expectation when verifying the meal ticket and the tray, and the DON had no response. On 12/18/24 at 10:20 AM, the surveyor interviewed the Clinical Dietitian (CD). The CD informed the surveyor that everybody should have meal tickets in their trays. The surveyor asked what the importance of the preferences was in the meal ticket, and the CD responded that everybody was unique and for safety. The surveyor asked who should be checking the meal ticket and what was in the tray, and the CD responded that the aide serving should check. The surveyor notified the CD of the concern regarding Resident#43, and the CD responded that the RAs should follow the meal ticket for oj. At that same time, the surveyor notified the CD of the concern regarding Resident#44's coffee, the CD stated the meal ticket should have been followed for 2 cups of coffee. Furthermore, the surveyor notified the CD of the concerns regarding Resident #41. The CD stated that Resident #41 was on the magic cup and multiple supplements. She further stated that her notes on 12/5/24 reflected that the resident had a stable weight for the past 3 months and a one-month history of fluctuating weight due to advancing dementia. The CD also stated that the FSD was responsible for the tray line and following the diet according to the meal ticket. On 12/18/24 at 11:14 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the LNHA and the DON of the above findings and concerns. On 12/18/24 at 3:01 PM, the RFSD acknowledged that the meal ticket should be followed. The RFSD stated that Resident#43's preference was cranberry juice which was why the resident received the nectar cranberry juice. The surveyor then asked the RFSD and the CD, if the resident's preference was cranberry juice and why the meal ticket did not specify that. The surveyor asked the RFSD and the CD if was there documented evidence of the resident's preference for nectar cranberry juice and not nectar oj, and the CD responded that she would get back to the surveyor. A review of the provided documents by the DON revealed: -Resident # 43's most recent qMDS with an ARD of 10/11/24, Section C Cognitive Patterns revealed a BIMS of 5 out of 15 reflected that the resident's cognitive status was severely impaired. -Resident # 44's most recent significant change in status MDS with an ARD of 10/21/24 revealed a BIMS score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. On 12/19/24 at 11:38 AM, the survey team met with the LNHA, DON, Regional DON #1 (RDON#1), RDON#2, Assistant DON (ADON), and the CO-President. The surveyor notified the facility management of the above concerns and findings regarding Resident #41. A review of the facility's Food, Dining Service and HS (bedtime) Snacks Policy with a reviewed date of 6/2024 that was provided by the LNHA revealed: Policy Explanation and Procedures: -Food service staff members will serve the food choices made with consideration given to dietary restrictions/texture modifications. Plates will be verified for accuracy of service . Eating Environment: -Staff will develop appropriate measures to try to maximize appropriate seating, positioning, and interactions among residents and to assure that each resident receives his or her prescribed diet On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, RDON#1, RDON#2, Co-President, and the ADON for an exit conference. The facility did not provide additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 12/15/24 at 10:40 AM, the surveyor observed Housekeeper #1 (HK #1) exit a resident room (Resident #5 and Resident #84), remove their gloves while standing in front of their cart outside the room door. HK #1 disposed their gloves in a garbage bin on the cart and retrieved cleaning supplies from the cart. The HK returned inside the room without performing hand hygiene. The surveyor observed HK #1 inside the resident room apply gloves and cleaned inside the room. On 12/15/24 at 10:43 AM, the surveyor observed HK #1 exit the resident's room, removed their gloves while going to their cart located at the door. HK #1 disposed of their gloves in the garbage bin on the cart, went into their cart for more cleaning supplies, and returned inside the room. The surveyor observed the HK did not perform hand hygiene. On 12/15/24 at 10:45 AM, the surveyor interviewed HK #1 about hand hygiene upon their exit from the resident's room. HK #1 stated that hand hygiene should be performed when entering a resident room, when finished cleaning up, and when putting on gloves, when removing gloves, and in between changing gloves. The surveyor informed HK #1 of the above observations. The HK acknowledged she did not wash her hands between changing gloves and stated it was supposed to be done. On 12/15/24 at 1:46 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) about hand hygiene. The RN/UM stated hand hygiene should be performed between changing gloves and when exiting rooms. The surveyor informed the RN/UM of the above observations of HK #1. The RN/UM acknowledged she should have washed her hands in between changing gloves and when exiting the room. The RN/UM stated she would follow up with the HK to provide re-education. On 12/18/24 at 11:14 AM, the surveyor informed the LNHA and the DON of the observed concern of HK #1 not performing hand hygiene during changing of gloves. On 12/19/24 at 11:38 AM, the LNHA, DON, Co-President, ADON, RDON#1 and RDON#2 met with the survey team. The LNHA stated in-service education was provided to HK #1. 4. On 12/18/24 at 11:32 AM, the surveyor observed Dietary Staff (DS) #1 (DS#1) with gloves on for the start of tray line service of the lunch meal. DS#2 moved a wet floor sign to the hallway area between the food prep and dishwashing area. DS #2 removed their gloves, disposed of gloves, and put on a new pair of gloves. The surveyor observed DS #2 did not perform hand hygiene. The surveyor asked the Regional Food Service Director (RFSD) present in the kitchen about hand hygiene. The RFSD stated hands should be washed when changing gloves. The surveyor informed the RFSD of the above observation of DS #2 and stated states hands should be washed when changing gloves. The RFSD instructed the staff to remove their gloves and perform hand hygiene, and re-educated DS #2 that hand hygiene should be performed when gloves were changed. On 12/18/24 at 11:45 AM, during tray line the surveyor observed DS #3 while serving the food, removed their gloves and placed new gloves without washing their hands. The surveyor informed the RFSD of the observation. The RFSD and FSD instructed DS #3 to remove their gloves and wash their hands. On 12/18/24 at 12:41 PM, the surveyor informed the DON and LNHA of the hand hygiene concerns observed during tray line in the kitchen. There was no additional information provided by the facility. A review of the facility's Handwashing/Hand Hygiene Policy, last reviewed in May 2024 revealed: Under Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .u. after removing gloves . 6. If hands are not visibly soiled, use an alcohol-based hand rub containing at least 70% ethanol or isopropanol for all of the following situations .j. After removing gloves . 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. N.J.A.C. 8:39-19.4(a)(1,2),(l,n) REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 5 of 11 staff (1 Housekeeper,1 Recreation Aide, 2 Dietary Staff, and 1 Physician), b.) disinfect the examination area after use, and follow appropriate infection control practices during meal observation, environment tour, and kitchen tour, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 12/15/24 at 11:58 AM, the surveyor observed the Recreation Aide (RA) with a surgical mask in use while distributing lunch trays in the recreation room. The RA's nose was not fully covered by the surgical mask and it was pulled below his mouth. The surveyor interviewed the RA regarding the surgical mask. The RA stated that the surgical mask kept going down his nose and the RA acknowledged that the surgical mask should be properly worn and cover his nose. The RA further stated that he received education on proper hand hygiene and the use of PPE. On that same date at 12:05 PM, the surveyor observed the RA took the tray of the resident from the table. Afterward, the RA used hand wipes to clean his hands. The RA did not discard the used hand wipes, went to the next dining room, left the dining room, and re-entered the recreation room with the same hand wipes in his hands. The surveyor asked the RA what was on his hands, and he responded that was the hand wipes he used for cleaning both hands. The surveyor asked the RA why he did not dispose of the used hand wipes and whether should he dispose of them immediately after use, and the RA responded, I guess not. A review of the Handwashing/Hand Hygiene Policy with a revised date of April 2010 that was provided by the Licensed Nursing Home Administrator (LNHA) on 12/16/24 at 9:37 AM revealed: Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals . 2. On 12/17/24 at 8:58 AM, Surveyor #1 (S#1) observed the provider (a Physician) and the Infection Preventionist Nurse (IPN) inside room [ROOM NUMBER]. The IPN talked to the Physician and left the room. The surveyor observed the Physician with a luggage bag inside the room and attended to Resident #241, the Physician performed handwashing inside the room, and the she donned (put on) gloves. The Physician took an alcohol individual pack, disinfected the lenses of two equipment, and placed them on top of the resident's table without disinfecting the table. During an eye examination, S#1 observed the Physician interchange the two pieces of equipment on top of the table without disinfecting the entire equipment. There was a personal belonging on top of the resident's table near the equipment. After the examination, the Physician discarded the used gloves in the garbage receptacle near the sink, put back the equipment inside the luggage bag, exited the resident's room without disinfecting the table, and did not perform hand hygiene. Outside the resident's room, S#1 interviewed the Physician. The surveyor asked the physician what she did inside the room and the physician stated that she examined the resident's eye with the use of a custom refractor (white equipment) which was used for measuring refraction of glasses and black equipment was the fundus camera. The surveyor asked the Physician why she did not perform hand hygiene after she doffed off her gloves and when she left the room. The Physician stated that when she grabbed all her stuff, it did not make any sense for her to perform hand hygiene even when she exited the room. She acknowledged that after she removed gloves inside the room, she did not perform hand hygiene. In the nursing station, S#1 asked the Physician if she was aware of the posted sign for EBP (enhanced barrier precautions; an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission MDROs [multidrug-resistant organism]) in room [ROOM NUMBER] and what was the EBP for, and the Physician responded that she did not know. Immediately, S#1 notified the IPN of the concerns that the Physician did not perform hand hygiene and did not disinfect the table used for putting the equipment. The IPN stated that staff, visitors, and vendors should perform hand hygiene before and after gloves use and follow the posted sign and she stated that she would talk to the Physician about it. On 12/17/24 at 9:50 AM, S#1 and Surveyor #2 (S#2) interviewed the IPN. S#1 asked the IPN about Standard Precaution or Universal Precaution, and the IPN responded that it applied to everyone (all staff, visitors, and vendors) and that gloves, after use, should be discarded and perform hand hygiene and that was basic. S#2 asked the IPN if the facility provided disinfecting wipes or PPE to the Physicians and vendors when they come to provide services. The IPN stated that she had to check first and would get back to the surveyors. S#1 asked if the facility provided education or information to the Physician about the facility's practice and policy about EBP or other infection control guidance that the facility followed, and the IPN responded that she was unsure. S#2 asked the IPN if that was something she should know as part of infection control. The IPN stated that she started in April this year and unsure if that was provided to the Physician before her starting in the facility as IPN. On 12/17/24 at 12:22 PM, S#1 and S#2 met with the Regional Director of Nursing #1 (RDON#1) and LNHA. The surveyor notified the LNHA and RDON#1 of the above concerns with the Physician. S#1 asked what the facility's practice was about disseminating information to providers and vendors with regard to the facility's policy and practice with EBP and other infection control practices. RDON#1 stated that she knew that the Physicians of the facility especially the Medical Director and the Infectious Disease Doctor were aware of the facility's practice and protocol with regard to infection control and was unsure about the other providers and vendors. RDON#1 acknowledged that the facility had the responsibility to notify the vendors and providers about it. RDON#1 further stated that hand hygiene should be done before gloves and after gloves use, disinfect the area to be used and used for treatment and examination. On 12/17/24 at 2:00 PM, the survey team met with the Co-President and the owner of the company (vendor) where the Physician who provided an eye examination to Resident #241. The vendor informed S#1 that it was not part of their protocol and policy to disinfect the table where the Physician placed our equipment. The vendor further stated that the Physician certainly for this day, removed her gloves and did not wash her hands. On 12/18/24 at 11:14 AM, the survey team met with the LNHA and the Director or Nursing (DON). S#1 notified the LNHA and the DON of the above findings and concerns regarding the RA and the Physician. On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, RDON#1 and RDON#2, Co-President, and Assistant DON (ADON) for an exit conference. The facility did not provide additional information.

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/15/24 at 9:28 AM, the surveyor, in the presence of the Food Service Director (FSD) and Regional FSD (RFSD), observed the following during the kitchen tour: 1. In the juice dispenser area, there were three 5-gallon beverage boxes that were past their best used by date. A thickened water (nectar consistency) 5-gallon box had a best if used by date of 9/11/24. A thickened water (honey consistency) 5-gallon box had a best if used by date of 7/31/24. A diet lemonade 5-gallon box had a best if used by date of 10/3/23. The FSD stated that the beverage boxes were good for 6 months after their best if used by date. The FSD acknowledged the diet lemonade was expired. The surveyor requested documentation from the RFSD and FSD which indicated the beverage boxes were still good to be used 6 months after the best if used by date. 2. On a food preparation (prep) table there was a food processor machine. The surveyor observed a single fiber- like strand, more than 3 inches long with the top compartment cover of the machine. The surveyor pointed out the observation to the RFSD who took off the top of the machine off and took the hair strand. On the food prep table next to the machine there were food items covered with clear plastic wrap. The surveyor asked the RFSD and FSD if there was any concern with the fiber strand being found on the food processor machine and the area being a food prep area. The RFSD stated the strand was part of a hairnet, it was outside of the machine, and there was no food in the machine. The RFSD and FSD confirmed the items on the table were being prepared for the next meal and the table was a food prep area. 3. In the drying rack storage area, 1 of 3 small veggie steam pans checked was observed to be soiled with a dry, hard food-like debris on the side wall of the pan. The FSD confirmed the pan was soiled that it was expected to have been clean and would put the pan to be re-washed. On 12/16/24 at 10:48 AM, the surveyor, in the presence of the FSD and RFSD, observed the following during a kitchen tour: 4. The surveyor observed Dietary staff (DS) #1 exit the dishwashing area and walking through the food prep area to exit the kitchen. DS #1 had facial hair including a mustache and facial hair on their chin. DS #1 was not wearing a beard restraint (used to contain facial hair, such as, beards, mustaches, and goatees to prevent it from falling into food and contaminating it). The surveyor asked the RFSD about the observation of DS #1 with facial hair and not wearing a beard restraint. The RFSD stated DS #1 did not have facial hair. The surveyor interviewed DS #1 in the presence of the RFSD. The DS #1 acknowledged he had a mustache, facial hair on his chin, and that it should have been covered with a beard restraint. The surveyor asked DS #1 if there were any available beard restraints for him. DS #1 was not able to provide a verbal response. The surveyor asked the RFSD about beard restraints available for staff. The FSD went to look for the beard restraint supplies for the staff. 5. In the dishwashing area, the three-compartment sink had 1 of the 3-compartment filled with sanitizing solution water, and soaking dishes. No staff were in the dishwashing area. The RFSD stated the dishes were still in progress of being washed by staff. On a metal table in which clean dishware would come out from the dishwasher there was white solid, food-like debris on the table. 6. In the dishwashing area on a shelf above the 3-compartment sink, there were three serving trays filled with dessert bowls which were faced down on it. The RFSD stated it was to dry the dish ware and the shelf area was considered a clean area. The surveyor asked about the soiled dishes still being washed in the 3-compartment sink below the shelf and if there was a risk of contamination of the dishes. The RFSD replied that the clean dishes were not kept on that shelf when dirty dishes were being washed. The surveyor informed the RFSD of the dishwashing area being in use prior to the surveyor entering area. There was no additional verbal response by the RFSD about the clean bowls on the trays. Next to the trays on the shelf were four 5-gallon food bins on the shelf right side up and uncovered. The surveyor asked the RFSD what the bins were used for. The RFSD stated that the bins were considered clean and were used to store the dessert bowls when they dried. The RFSD further stated the bins would be covered once the bowls were stored inside. The surveyor asked to check the inside of all 4 of the uncovered bins. The first bin had an accumulation of clear liquid on the bottom of the bin. The RFSD stated that the bin was drying. The second bin had 1 dessert cup inside of it. The third bin had several loose dessert cups stored in it, and the last bin was empty. The outside of the bins had discolored stains/spots. The surveyor asked the RFSD if it was considered clean. The RFSD replied that the dishware was stored inside and covered for storage. 7. In the dishwashing area on the shelf above the 3-compartment sink there was a crumpled washcloth against the wall and next to one of the trays of the dessert bowls. The RFSD took the washcloth, confirmed it was wet and acknowledged it should not have been up there. The FSD stated she did not find any beard restraints and told DS #1 to wear a face mask to cover their facial hair. The FSD acknowledged DS #1 had facial hair and stated that he should have been wearing a beard restraint. The surveyor asked the FSD about the clean and soiled areas of the dishwashing area. The FSD stated the metal table in which the clean dishware comes out of dishwashing machine was considered a clean area. The surveyor asked about the white colored food-like debris observed on the table. The FSD acknowledged that the area was not clean and that it should have been clean. The surveyor asked the FSD about the concern of clean dessert bowls being stored on the shelf above the 3-compartment sink and the use of the 5-gallon bins being used to store dishware. The FSD replied that the clean dishware would be removed from the dishwashing area placed on a cart which was kept between the dishwashing and food prep areas. There was no additional verbal response by the FSD. 8. The surveyor accompanied by the FSD in the drying rack storage area, observed 1 of 2 long vegetable pans was soiled with dry, solid, food-like debris on the side wall of the pan. The FSD confirmed the pan was soiled and that it needed to be washed again. The surveyor requested from the RFSD and FSD for policies on kitchen cleanliness, storage, and hair restraints. On 12/16/24 at 12:46 PM, the surveyor interviewed the LNHA about if it was expected for beard restraint supply to be available in the kitchen for staff. The LNHA, replied Yes. The surveyor informed the LNHA of the concern that there was none available as per the FSD. The LNHA stated he would follow up. On 12/17/24 at 10:47 AM, the surveyor with the Registered Nurse/Unit Manager (RN/UM) inspected the nutrition refrigerator on the unit. The RN/UM stated the refrigerator was used to store snacks from the kitchen and resident food items, including food from outside the facility. The RN/UM further explained items were stored for up to 3 days in the refrigerator, housekeeping (HK) would clean the refrigerator, throw away outdated food every 3 days. The surveyor in the presence of the RN/UM observed the following: 9. In the refrigerator, there was a white bag with packaged food items that was labeled with a resident's name and room number. There was no date on the bag to indicate when it was placed in the refrigerator. There was also a fast-food brand bag which had the resident's name and room number written on it. There was no date on the bag to indicate when it was placed in the refrigerator. 10. In the freezer of the refrigerator, there were 3 wrapped foiled food items in a plastic storage bag which had the resident's name and room number written on it. The items were not dated to indicate when it was placed in the refrigerator. Additionally, there was an unopened bag of edadame beans which was dated 12/16/24. The packaging did not have a resident's name or a room number on it. The RN/UM stated that the items should have the appropriate labeling which would include the resident's name, room number and the date the item was placed in the refrigerator. The RN/UM stated she would follow up with the residents about the items. She would discard outdated and food items that could not be verified. On 12/17/24 at 10:57 AM, the surveyor interviewed the Housekeeping Director (HKD) who stated HK would clean the refrigerator every Friday. The HKD further explained the refrigerator was cleaned thoroughly inside, anything not labeled with a name or date would be thrown away. The HKD added that items more than 3 days after their written date would be thrown away. The surveyor asked if the refrigerator was checked by HK on other days besides Friday. The HKD stated that during the week the refrigerator would be checked periodically by HK staff. The HKD further explained there was no set schedule besides the Friday and it would not be documented if the refrigerator was checked on other days of the week. The HKD stated there was a log for when the refrigerator was cleaned and checked on every Friday. The HKD added besides the log, he had additional documentation in his office. The surveyor accompanied the HKD to check the log posted on the refrigerator which read that the refrigerator was to be cleaned every Friday. A review of the log which included the date and the signature of the staff cleaning the refrigerator revealed there was no documentation for 12/13/24 and no signature indicating that the refrigerator was cleaned. The HKD stated he was the one who cleaned the refrigerator and that he must have forgotten to sign the form. The surveyor accompanied the HKD to his office to check for any additional documentation of the refrigerator being cleaned on 12/13/24. The HKD was unable to provide any additional documentation for the date in question. On 12/17/24 at 11:03 AM, the RN/UM informed the surveyor for the foiled food item in the freezer (Resident #61) it was brought in on Friday and was discarded. The fast-food bag was brought in last night. The RN/UM stated she still had to find out who the edamame package belonged to and when the white bag of food items was brought in. The RN/UM added if unable to determine the food items would be disposed. The surveyor asked the RN/UM about the protocol for the food storage in the nutrition refrigerator. The RN/UM stated it was expected for the food items to be labeled with the resident's name, room number, and date the item was brought in. The RN/UM stated HK cleaned out the refrigerator every Friday. The RN/UM further explained the staff that placed food items for residents in the refrigerator were responsible for ensuring the food items were labeled appropriately and she was not aware if anyone else was responsible for checking food items in the refrigerator. On 12/18/24 at 11:14 AM the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns during the kitchen tours and inspection of the nutrition refrigerator on the unit. The LNHA was also informed that the FSD and RFSD stated they were going to provide supportive documentation that the beverage boxes were good for use 6 months after their best if used by date and no documentation had been provided. On 12/18/24 at 12:05 PM, during observation of tray line in the kitchen, the surveyor observed DS #2 enter the kitchen from the dining area. DS #2 was observed with hair bangs uncovered with the rest of their hair contained with a hair net. DS #2 walked through the food prep area and went to back area of the kitchen. DS #2 returned the same way, her hair bangs remained uncovered and exited the kitchen to the dining area. The surveyor asked the RFSD about hair restraint protocol. The RFSD stated all hair should be covered with a hairnet. The surveyor informed the RFSD of the observation. The RFSD acknowledged all of DS #2's hair should be contained with the hairnet. The RFSD stated she would go to speak with DS #2 and exited the kitchen. On 12/18/24 at 12:41 PM, the surveyor informed the LNHA and DON of the observed concern of DS #2's hair bangs remaining uncovered while passing through the food prep area during tray line. On 12/19/24 at 11:38 AM, the LNHA, the DON, the Assistant Director of Nursing (ADON), Regional DON #1, Regional DON #2, and the Co-President met with the survey team. The LNHA stated for the nutrition refrigerator that the HKD forgot to sign off the log and that he cleaned all refrigerators including the break room refrigerator in which he had signed the log. The surveyor asked the LNHA if it was expected for the HKD to have signed the cleaning log for the nutrition refrigerator after cleaning. The LNHA acknowledged that it should have been signed by the HKD. The LNHA stated for the fiber strand found on the food processor machine, stated that it was outside of the machine not inside and that there was no food in the machine. The surveyor asked if there would be a concern for something like that being found in a food prep area. The LNHA replied that staff wore hairnets in the kitchen. There was no additional response provided by the facility. The LNHA stated for the pans found soiled in the clean drying rack storage areas, the items were cleaned by the FSD after the observations. LNHA acknowledged it would be expected that the items were cleaned. The LNHA stated DS #2 was in-serviced on use of hairnet and that a restraint did not have to be used unless it was longer than ½ inch. The surveyor asked the LNHA about the guidance followed for kitchen policies. The LNHA replied that the references for their hair restraint policy was provided. The surveyor asked if the references and facility policies were based on regulations and from nationally recognized organizations and based on regulations. Regional DON #2 stated that the regulations did not specify the length and only indicated facial hair should be covered. The surveyor asked if the regulations did not specify the length of facial hair that should be restrained, was it ok for less than ½ inch to be without a beard restraint. There was no additional response by the facility. The LNHA stated the clean dishware were removed from the dishwashing area and would be stored in another area for drying storage. The LNHA stated for the nutrition refrigerator that items from the kitchen to the refrigerator were labeled every day prior to delivering. The LNHA stated that resident visitors sometimes brought food and forgot to date the food items. The LNHA added the staff regularly checked food items for dates and discarded when not dated. There was no additional information provided by the facility. There was no documentation provided by the facility to indicate that the beverage boxes were okay to be used up to six months after their best if used by date. A review of the facility's Hair Restraints Policy, with a last reviewed date of June 2024 revealed: Under Policy: All Dietary Staff shall wear hair restraints such as hats, hairnets and beard restraints if you have any facial hair growth, to keep their hair from contacting exposed food, clean equipment's, utensils and linens. Under Procedure: 1. Always cover all head hair with hair restraint .2. Always cover all facial hair with beard net .3. Never leave bangs or other part of your hair hanging outside of hair restraint. A review of the facility's Cleaning and Sanitation Equipment Policy, with a date of June 2023 revealed: Under Policy: Cleaning and sanitation of equipment is to remove food debris that bacteria need to grow and to kill those bacteria that are present. It is important that the clean and sanitized equipment are stored dry so as to prevent bacteria growth. A review of the facility's Food Storage Policy, with a last reviewed date of October 2024 revealed: Under Policy: Food storage areas shall be maintained in a clean, safe, and sanitary manner. The policy did not further address use of food items by manufacturer best if used by dates. A review of the facility's Food Brought in for Patients and Residents Policy, with an effective date of 1/5/24 revealed: Under Purpose: To ensure the safe consumption of food brought in to patients/residents. Under Procedure: for food brought in that required refrigeration: .1.2 Food items that require refrigeration must be labeled with the patient/resident's name and the date the food was brought in .1.5 Food will be held in the refrigerator for 3 days following the date on the label and will be discarded by staff upon notification to patient/resident. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a fracture of unknown origin on 3/02/23 of Resident#10. This deficient practice was identified for one (1) of three (3) residents reviewed for incident/accident and was evidenced by the following: On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room, with one floor mat to the left side of the bed. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. At the same time, Certified Nursing Aide#1 (CNA#1) who was also inside the room informed the surveyor that she was the aide of the resident. The CNA stated that the fall incident happened not on her shift. On 7/11/23 at 9:09 AM, the surveyor observed the resident was not in their room, there was one floormat on the floor to the left side of the bed. On 7/11/23 at 9:10 AM, Licensed Practical Nurse#1 (LPN#1) informed the surveyor that Resident #10 was in the hospital, transferred to ER (emergency room) on 7/06/23 s/p (status post) fall due to the x-ray was done and resulted in left hip fracture. The LPN stated that the resident fell the night before. She further stated that the resident had multiple h/o (history) of falls with injuries from the community, resident was non-compliant at times with safety precautions, and feels that the resident thinks that the resident can still do things on their own despite the education provided to the resident. On that same date and time, LPN#1 informed the surveyor that the resident requires extensive assistance with one person assists with adls (activities of daily living) except eating. She further stated that the resident was able to make needs known to staff with periods of confusion. The surveyor reviewed Resident #10's medical record. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had a diagnosis of unspecified dementia without behavioral disturbance, essential hypertension (elevated blood pressure), anemia (low blood count), spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), chronic pain syndrome, major depressive disorder, age-related osteoporosis without current pathological fracture (a condition of reduced bone mass, with decreased cortical thickness and a decrease in the number and size of the trabeculae of cancellous bone (but normal chemical composition), resulting in increased fracture incidence), and anxiety disorder. The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 4/21/23 reflected that the Brief Interview for Mental Status (BIMS) score of 3 (three) which indicated that the resident's cognition was severely impaired. The Reportable Event Record/Report (RER/R) indicated that the significant event was called in on 3/03/23 at 11:47 AM for an unknown date and time of the event on Resident #10's complaint of pain, x-ray was completed, and showed a fracture. Attached to RER/R was a document with typewritten information that included that the incident date was 3/02/23 included that the resident was asked about the incident and that there were two RNs (registered nurses; who were not identified) who did the head-to-toe assessment. The typewritten document included a conclusion that based on staff and resident statements there was no fall or specific trauma that transpired and there was no evidence of trauma therefore abuse and neglect were unsubstantiated. There were no statements from the staff regarding the provided RER/R and attachments that were provided to the surveyor on 7/11/23 at 11:07 AM by the Licensed Nursing Home Administration (LNHA). The provided Risk Management (investigation) dated 3/02/23 by the LNHA included that Assistant Director of Nursing#1 (ADON#1) prepared the incident report that showed that the resident complained of right shoulder pain, denied falls and trauma and that the resident was unable to give a description. The investigation included that no witness was found. A review of the above investigation that was provided to the surveyor and a review of the electronic medical records (EMR) did not reflect that staff statements from different shifts were obtained for an injury of unknown origin. On 7/13/23 at 12:33 PM, the survey team met with the LNHA, Director of Nursing (DON), ADON#1 and #2, Regional DON (RDON), Regional Interim DON (RIDON), and Assistant Administrator (AA). The surveyor asked if the documents previously provided to the surveyor for the requested investigation were provided including statements of staff. ADON#1 stated that everything including statements was provided to the surveyor. The surveyor then asked the facility management what was their facility's policy and protocol with regard to obtaining staff statements for injuries of unknown origin. At this time, RDON informed the survey team that for unwitnessed incidents, we ask to write in a piece of paper, or blank paper, or pre-printed statement form the staff statements and that the lookback period will be 48 hours. The surveyor then asked if that will be the facility's practice or policy. The RDON stated that I do not know if it is in our policy, but it is a standard of practice. The LNHA stated that they will get back to the surveyor. The surveyor notified the facility management of the above findings that there were no staff statements for an injury of unknown origin reported. On 7/13/23 at 01:30 PM, ADON#1 provided copies in addition to investigation papers that were provided by the LNHA on 7/11/23. The provided documents now included the following: a. Statement from LPN#2 dated 3/06/23 indicated that the statement typewritten and signed by LPN#2 was in reference to the condition and events on 02/26/23 and 02/27/23 at the 3-11 shift. b. Statement from LPN#3 dated and signed on 3/06/23 indicated on the typewritten statement that LPN#3 was a regular nurse worked on 3/01/23 and that the resident did not fall. A review of the above 7/13/23 provided documents of ADON#1 revealed that there were no statements from other shifts and other staff that also had direct care to the resident which included CNAs. On 7/14/23 at 12:10 PM, the survey team met with the DON, ADON#1 and #2, RIDON, RDON, LNHA, and AA, and made aware of the above findings. On 7/17/23 at 9:59 AM, the LNHA provided additional documents with regard to the above investigation that included statements from: CNA#2 on the 3-11 shift of 02/27/23-3/01/23 CNA#3 on the 7-3 shift of 02/27/23-3/01/23 CNA#4 on the 11-7 shift of 02/27/23-02/28/23-3/01/23 LPN#4 on the 11-7 shift of 02/28/23-3/01/23 LPN#5 on the 11-7 shift of 02/27/23 At the same time, the surveyor asked the LNHA why the above statements from CNA#2, #3, and #4 including LPN#4 and #5's statement were not included in the previously provided investigation to the surveyor. The surveyor asked also when the statements were obtained, and the LNHA stated that he will get back to the surveyor. On 7/17/23 at 10:38 AM, ADON#1 informed the surveyor in the presence of another surveyor that the statements that were provided by the LNHA on 7/17/23 at 9:59 AM were interviews of ADON from the assigned staff based on the schedule on 02/27/23, 02/28/23, and 3/01/23 for the investigation on 3/02/23. She further stated that the above statements from CNA#2, #3, and #4, including statements from LPN#4 and #5 were obtained after the surveyor's inquiry. On 7/17/23 at 11:36 AM, the survey team met with the RIDON, RDON, DON, ADON#1, LNHA, and AA. The RIDON acknowledged that there should be statements from staff at least 48 to 72 hours of lookback for injuries of unknown origin that make a complete investigation. A review of the facility's Accidents and Incidents-Investigating and Reporting with a reviewed/Revised date of 3/2023 revealed there was no information included with regard to injuries of unknown origin on gathering staff statements. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with facility LNHA, AA, DON, RIDON, RDON, ADON#1, and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and facility management both stated that there was no additional information. NJAC-8.39-27.1(a)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #10. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual October 2019 page 2-22 (pages 44-49) included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room with a floormat to the left side. On 7/11/23 at 9:10 AM, the Licensed Practical Nurse (LPN) informed the surveyor that Resident #10 was in the hospital. The LPN stated that the resident required extensive assistance with one person assists with adls (activities of daily living) except eating. She further stated that the resident was able to make needs known to staff with periods of confusion. She further stated that the resident had periods of incontinence both bladder and bowel elimination. The surveyor reviewed Resident #10's medical record. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility and had a diagnosis of unspecified dementia without behavioral disturbance, essential hypertension (elevated blood pressure), anemia (low blood count), spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), chronic pain syndrome, major depressive disorder, age-related osteoporosis without current pathological fracture (a condition of reduced bone mass, with decreased cortical thickness and a decrease in the number and size of the trabeculae of cancellous bone (but normal chemical composition), resulting in increased fracture incidence), and anxiety disorder. The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 4/21/23 reflected that the Brief Interview for Mental Status (BIMS) score of 3 (three) which indicated that the resident's cognition was severely impaired. The qMDS Section E Behavior was coded 1 (one) reflected that behavior occurs one to three days toward others. Section G Functional Status for walk in room and corridor was coded as 8 (eight) which indicated that activity did not occur. Section H Bladder and Bowel was coded as 2 (two) which indicated frequently incontinent for both bladder and bowel elimination. A review of the annual MDS (aMDS) with an ARD of 7/19/22 for Section C revealed a BIMS score of 10 which indicated that the resident's cognition was moderately impaired. The aMDS Section E was coded with no behavior. Section G walk in room and corridor was coded as 3/2 which reflected that the resident was able to walk with the extensive assistance of one person. Section H was coded as 0 which reflected that the resident was continent of both bladder and bowel elimination. Further review of the above MDS revealed that the resident was noted with a decline in cognitive status, behavior noted, decline in adls specific to able to walk, decline in elimination from being continent to incontinence, and an SCSA not done on ARD of 4/21/23. The personalized care plan of the resident showed a focus on the resident's confusion and forgetfulness related to (r/t) the diagnosis of dementia with a revision date of 4/25/23. Focus on adl self-care performance deficit r/t Alzheimer's, dementia, disease process, depression, and impaired mobility due to arthritis and fracture of right humerus left hip fracture that was initiated on 4/21/20 and revised on 7/13/23 included an intervention for restorative nursing ambulation was resolved on 3/07/23. On 7/14/23 at 10:51 AM, the surveyor in the presence of another surveyor interviewed the MDS Coordinator/Licensed Practical Nurse (MDSC/LPN). The MDSC/LPN informed the surveyors that the facility had no specific policy regarding MDS, the facility follows the RAI Manual. The MDSC/LPN stated that the MDS Coordinators were responsible for answering MDS Sections C, G, H, and J. She further stated that information in the MDS was gathered from the resident's medical records from nurses and other interdisciplinary team assessments and documentation. On that same date and time, the MDSC/LPN informed the surveyors that if there will be two or more changes either improvement or decline in the resident's status, that will be the criteria that the MDS assessment for SCSA will be done. The surveyor then asked the MDSC/LPN why the resident's qMDS on ARD 4/21/23 was not an SCSA considering the above change and decline in resident's status in comparison to aMDS on 7/19/22, and the MDSC/LPN stated that she will get back to the surveyor. On 7/17/23 at 12:05 PM, the survey team met with the Regional MDS/Registered Nurse (RMDS/RN) and MDSC/LPN. The MDSC/LPN informed the surveyor that the SCSA for the resident was not done because the resident was picked up for Skilled Rehab Services back in 3/2023 and when the resident was discharged from Skilled Rehab, the resident went back to baseline afterward. The surveyor then asked the facility management if the resident had declined in bowel and bladder elimination from continent to frequently incontinent, noted with behavior, and not able to ambulate why the mentioned criteria still did not meet the SCSA. The RMDS/RN responded that the April 2023 qMDS of Resident#10 should have been a SCSA. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the facility's Licensed Nursing Home Administrator, Assistant Administrator, Director Of Nursing (DON), Regional Interim DON, Regional DON, and Assistant Director Of Nursing#1 and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management stated that there was no additional information. NJAC 8:39-11.1

3. On 7/10/23 at 10:59 AM, the surveyor observed Resident #11 seated in a wheelchair inside their room with one floor mat to the left side of the bed. On 7/12/23 at 9:45 AM, the surveyor observed the resident was not in their room, there was one floormat on the floor to the left side of the bed. The surveyor reviewed Resident #11's medical record. The resident's AR reflected that the resident was admitted to the facility and had a diagnosis but not limited to unspecified dementia, unspecified severity with agitation, (person's mild cognitive impairment has yet to be diagnosed as a specific type of dementia), The resident's most recent qMDS with an ARD of 12/09/22 reflected that the resident's cognition was severely impaired and unable to complete the interview. The resident's qMDS with an ARD of 3/10/23 and 6/08/23 revealed Section M Skin Conditions, M0100 B. Formal Assessment Instrument/tool, (e.g., Braden) was checked off which means that the facility utilized a formal assessment instrument or tool in answering this section. A review of the assessment in the EMR revealed that BSPPSR was done on 11/18/2022. The next Braden scale completion done on 7/17/2023 after surveyor inquiry. Further review of the assessment in the EMR revealed that there was no BSPPSR done for March 2023 to reflect in the 3/10/23 qMDS. The assessment in the EMR for BSPPSR was also in red which means that the assessment was not done for March 2023 for BSPPSR Further review of the assessment in the EMR revealed that there was no BSPPSR done for June 2023 to reflect in the 6/08/23 qMDS. The assessment in the EMR for BSPPSR was also in red which means that the assessment was not done for June 2023 for BSPPSR. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the LNHA, AA, DON, RIDON, RDON, ADON#1, and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management both stated that there was no additional information. NJAC 8:39-33.2(d) Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 3 (three) of 19 residents, (Residents #10, #11 and #54) reviewed, and was evidenced by the following: 1. On 7/06/23 at 10:59 AM, the surveyor observed Resident #10 seated in a wheelchair inside their room with the Certified Nursing Aide (CNA) with one floor mat to the left side of the bed and informed the surveyor that she was the aide of the resident. The resident stated to the surveyor that he/she had a fall incident last night while in the bathroom. The CNA stated that the fall incident happened not on her shift. On 7/11/23 at 9:09 AM, the surveyor observed the resident was not in their room, there was one floormat on the floor to the left side of the bed. On 7/11/23 at 9:10 AM, the Licensed Practical Nurse (LPN) came and informed the surveyor that Resident #10 was in the hospital, transferred to ER (emergency room) on 7/06/23 s/p (status post) fall due to the x-ray was done and resulted in left hip fracture. The LPN stated that the resident fell the night before. She further stated that the resident had multiple h/o (history) of falls with injuries from the community, resident was non-compliant at times with safety precautions, and the resident thinks that the resident can still do things on their own despite the education provided that the resident required assistance with ADLs (activities of daily living). On that same date and time, the LPN informed the surveyor that the resident requires extensive assistance with one person assists with ADLs except eating. She further stated that the resident was able to make needs known to staff with periods of confusion. The surveyor reviewed Resident #10's medical record. The resident's admission Record (AR or face sheet; admission summary) reflected that the resident was admitted to the facility and had a diagnosis but not limited to unspecified dementia without behavioral disturbance, essential hypertension (elevated blood pressure), anemia (low blood count), spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots), chronic pain syndrome, major depressive disorder, age-related osteoporosis without current pathological fracture (a condition of reduced bone mass, with decreased cortical thickness and a decrease in the number and size of the trabeculae of cancellous bone (but normal chemical composition), resulting in increased fracture incidence), and anxiety disorder. The resident's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an Assessment Reference Date (ARD) of 4/21/23 reflected that the Brief Interview for Mental Status (BIMS) score of 3 (three) which indicated that the resident's cognition was severely impaired. Section J Health Conditions showed that the resident had no falls since admission or reentry or prior assessment. Further review of the MDS showed a PPS (Prospective Payment System) assessment ARD 3/09/23 BIMS score of 2 (two) which indicated also that the resident's cognition was severely impaired. Section J indicated that the resident had one fall incident with no injury. A review of the unwitnessed report dated 3/04/23 showed that the resident had a fall with a complaint of pain. According to the RAI (Resident Assessment Instrument) Manual for answering Section J1900, the MDS with an ARD of 3/09/23 should have been coded as one fall with injury (except major) for any fall-related injury that causes the resident to complain of pain because the resident had a fall incident on 3/04/23 that the resident had complained of pain. On 7/14/23 at 10:51 AM, the surveyor in the presence of another surveyor interviewed the MDS Coordinator/LPN (MDSC/LPN). The MDSC/LPN informed the surveyors that it was her responsibility and that other MDSCs to answer Sections C, G, H, and J in the MDS. The surveyor asked for the facility's policy with regard to MDS and the MDSC/LPN stated that there was no specific policy for MDS and that the facility followed the RAI Manual. At that same time, the surveyor then asked the MDSC/LPN what documents and information that she looks at to answer Section J of MDS about falls. The MDSC/LPN stated that I look at Risk management (investigation report) to check if there's a fall incident. The surveyor asked the MDSC/LPN why section J was coded as one fall with no injury if there was a fall with a complaint of pain on the 3/04/23 unwitnessed investigation. The MDSC/LPN stated that she will get back to the surveyor. On 7/17/23 at 12:05 PM, the survey team met with the Regional MDS/Registered Nurse (RMDS/RN) and MDSC/LPN. Both the RMDS/RN and the MDSC/LPN acknowledged that Section J should have been coded as one fall with injury (except minor) because the resident had a complaint of pain on the 3/04/23 fall incident investigation. 2. On 7/11/23 at 9:00 AM, the surveyor observed Resident#54 laying on a specialized mattress covered with a blanket and there was no foul odor. The resident stated that breakfast was done and no complaints with care. The surveyor reviewed Resident #54's medical record. The resident's AR reflected that the resident was admitted to the facility and had a diagnosis of but not limited to type 2 (two) diabetes, chronic kidney disease stage 3 (mild to moderate damage, and less able to filter waste and fluid out of blood), and essential hypertension. The resident's most recent qMDS with an ARD of 6/20/23 reflected a BIMS score of 12 indicated that the resident's cognition was moderately impaired. Section M Skin Conditions, M0100 B. Formal Assessment Instrument/tool (e.g. Braden) was checked off which means that the facility utilized a formal assessment instrument or tool in answering this section. A review of the assessment in the electronic medical record (EMR) revealed that Braden Scale for Predicting Pressure Sore Risk (BSPPSR) was done on 4/15/23 with a score of 12 (high risk). Further review of the assessment in the EMR revealed that there was no BSPPSR done for June 2023 to reflect in the 6/20/23 qMDS. The assessment in the EMR for BSPPSR was also in red which means that the assessment was not done for June 2023 for BSPPSR. On 7/14/23 at 9:59 AM, the survey team met with Assistant Director of Nursing#1 (ADON#1) and ADON#2 and discussed about skin impairment and skin assessments in accordance with the facility's practice and policy. According to ADON#1, the Braden scale is utilized for admission, I believe when there's a quarterly for MDS, and when a resident had a skin breakdown they (nurses) suppose to use that also. ADON#1 stated that anyone can utilize Braden but honestly some agency nurses don't know what the Braden is. On that same date and time, DON#1 stated that if there's an admission we open Braden, mostly the admission is in the 3-11 shift, and that the 3-11 supervisor knows how to open that. At that same time, ADON#2 stated that it was the responsibility of the Unit Manager (UM) to check that the Braden assessment was done. On 7/14/23 at 10:51 AM, the surveyor in the presence of another surveyor met with MDSC/LPN. The MDSC/LPN stated that she was responsible for coding Section M in the MDS and that the information was gathered from her review of admission and readmission nursing assessment and skin assessment. She further stated that part of the skin assessment was the BSPPSR which should be done on admission and readmission, after 4 weeks, and then quarterly assessment. On that same date and time, the MDSC/LPN informed the surveyors that the UDA (user define assessment) in the EMR was being scheduled by the UM that included the BSPPSR schedules for quarterly which corresponds to the schedule of MDS that the MDSC/LPN provided to the UM. She further stated that because it was given to the manager, the MDSC/LPN was on the assumption that the BSPPSR was completed. In addition, the MDSC/LPN stated that there were missing assessments even before and that the facility discussed this in QAPI (Quality Assurance Performance Improvement) for a while (but unable to remember when) and that she encountered doing MDS. The surveyor asked if this include the findings of the surveyor for no BSPPSR for June 2023 that correspond to the qMDS on 6/20/23, and the MDSC/LPN responded Not on this particular, I have done previous residents. The surveyor asked the MDSC/LPN if the MDS was coded accurately when the MDS was checked off for formal method of skin assessment but no Braden assessment was done, and the LPN stated that since you brought to us the concern that no Braden assessment correspond the MDS, yes base from the findings from today the MDS for section M0100 was coded inaccurately. On 7/14/23 at 12:10 PM, the survey team met with the Director of Nursing (DON), ADON#1 and #2, Regional Interim DON (RIDON), Regional DON (RDON), Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA). The surveyor notified the facility management of the above findings regarding the MDS accuracy. On 7/17/23 at 11:36 AM, the survey team met with the RIDON, RDON, DON, ADON#1, LNHA, and AA. The RDON informed the survey team that the Braden scale assessment should be done for admission and quarterly assessments.

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to follow and revised the diet slip of one (1) of 19 residents, Resident #32 observed during breakfast observation according to the standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/12/23 at 8:12 AM, the surveyor observed the Certified Nursing Aide (CNA) standing at the bedside of the resident while Resident#32 was seated on the bed. The resident was able to feed self. The surveyor observed the breakfast tray with the following: 4 (four) oz (ounces) orange juice mechanical soft/chopped scrambled egg yellow in color cinnamon oatmeal (plastic cover showed printed sticker super) mechanical soft/chopped blueberry muffin margarine 4 oz milk cup of coffee On that same date and time, the surveyor asked the CNA if the surveyor could check the diet slip that was under the resident's plate and the CNA stated yes, and provided the diet slip. The diet slip showed the resident's name and room number and the following information: regular-mechanical soft/chopped, allow soft sandwiches/rolls, dated Wednesday breakfast 7/12/23, and that included everything on the tray except that the diced peaches were missing, and the diet slip indicated that the resident should get soft/chopped hard-boiled eggs instead of scrambled eggs. At that time, the surveyor asked the CNA where the diced peaches and the CNA did not respond. The surveyor asked why there were no soft/chopped hard-boiled eggs and the CNA stated that the resident likes scrambled eggs anyway instead of hard-boiled eggs. During an interview outside the resident's room, the CNA informed the surveyor that Resident#32 was cognitively impaired. The CNA confirmed that there were no diced peaches on the tray and no mechanical soft/chopped hardboiled egg instead it was a scrambled egg. The CNA stated that the resident did not like peaches. On 7/12/23 at 8:29 AM, the surveyor interviewed Assistant Director of Nursing#1 (ADON#1). The surveyor and ADON#1 went inside the resident's room. ADON#1 confirmed that the resident did not receive diced peaches and received scrambled eggs instead of hard-boiled eggs that were written in the diet slip. The ADON stated that she will get back to the surveyor about the concerns. On 7/12/23 at 8:40 AM, the surveyor interviewed the Food Service Director (FSD). The surveyor asked the FSD who was responsible for the tray line to make sure that the diet slip matches the actual tray and she responded that it was her responsibility and she was the one assigned today. The surveyor then asked why the resident did not receive mechanical soft/chopped hard-boiled eggs, instead the resident got scrambled eggs. The surveyor asked the FSD also why there were no diced peaches in Resident #32's breakfast tray. On that same date and time, the FSD informed the surveyor that she spoke to the responsible party (RP) of the resident yesterday and the RP notified her that the resident preferred scrambled eggs instead of hard-boiled eggs. The FSD stated that she did not know why there were no diced peaches in the resident's tray, and that the facility had available peaches. At that time, the surveyor asked the FSD who was responsible for changing the diet slip according to the resident's preference. The FSD stated that she can change the diet preference in the diet slip and also the Dietician. The surveyor asked the FSD if she knew that the resident preferred the scrambled eggs, and why she did not change the diet slip. The FSD stated that she should have changed it. On 7/12/23 at 11:56 AM, the survey team met with the Regional Director Interim Director of Nursing (RIDON), Regional DON (RDON) Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), DON, Assistant DON#1 (ADON#1) and #2, and were notified of the above findings. The RIDON informed the survey team that the dietary staff and CNAs have to double-check the diet slip. She further stated that Today I talked to the Dietician she had to review the diet slip and assess the resident. The surveyor reviewed the medical records of Resident#32. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but not limited to unspecified dementia without behavioral disturbance, history of falling, muscle weakness, dysphagia oral phase (problems with using the mouth, lips and tongue to control food or liquid), essential hypertension (abnormal blood pressure), and major depressive disorder. The most recent quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/01/23 revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated that the resident's cognitive status was severely impaired. A review of the facility's Therapeutic Diets Policy with a revised date of December 2008 that was provided by the LNHA included that mechanically altered diets, as well as diets modified for medical or nutritional needs, will be considered therapeutic diets. The Food Service Manager will establish and use a tray identification system to ensure that each resident receives his/her diet as ordered. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the facility's LNHA, AA, DON, RIDON, RDON, and ADON#1 and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management stated that there was no additional information. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to assess for risk for pressure ulcer quarterly and accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of three (3) residents reviewed for pressure ulcer/injury (Resident #40). The deficient practice was evidenced by the following: On 7/06/23 at 10:48 AM, the surveyor observed Resident #40 lying in bed with an air mattress. The surveyor reviewed the medical records of Resident #40 which revealed the following: The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with medical diagnoses that included but were not limited to dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), anemia (condition marked by a deficiency of red blood cells or of hemoglobin in the blood) and chronic kidney disease (a gradual loss of kidney function over time). The most recent quarterly MDS (qMDS), with an Assessment Reference Date (ARD) of 4/28/2023, showed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which reflected that the resident's cognition was severely impaired. Review of Section M Skin Conditions indicated the following: M0100. Determination of Pressure Ulcer/Injury Risk. The following were checked to indicate they applied to Resident #40. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Formal assessment instrument/tool (e.g. Braden, [NAME], or other); Clinical Assessment. M0150. Risk of pressure Ulcers/Injuries indicated that Resident #40 was at risk of developing pressure ulcers/injuries. M0210. Unhealed Pressure Ulcers/Injuries indicated that Resident #40 had one or more unhealed pressure ulcers/injuries. M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage indicated Resident #40 had two (2) Stage 4 pressure ulcers that were not present upon admission/entry or reentry [into the facility]. The 5-day Medicare Part A Stay MDS, with an ARD of 12/08/2022, showed that the resident had a BIMS score of 01 out of 15 which reflected that the resident's cognition was severely impaired. Review of Section M Skin Conditions indicated the following: M0100. Determination of Pressure Ulcer/Injury Risk. The following were checked to indicate they applied to Resident #40. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Formal assessment instrument/tool (e.g. Braden, [NAME], or other); Clinical Assessment. M0150. Risk of pressure Ulcers/Injuries indicated that Resident #40 was at risk of developing pressure ulcers/injuries. M0210. Unhealed Pressure Ulcers/Injuries indicated that Resident #40 had one or more unhealed pressure ulcers/injuries. M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage indicated Resident #40 had two (2) Stage 1 pressure injuries and one (1) Stage 4 pressure ulcers that was not present upon admission/entry or reentry [into the facility]. The qMDS, with an ARD of 10/05/2022, showed that the resident had a BIMS score of 02 out of 15 which reflected that the resident's cognition was severely impaired. Review of Section M Skin Conditions indicated the following: M0100. Determination of Pressure Ulcer/Injury Risk. The following were checked to indicate they applied to Resident #40. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Formal assessment instrument/tool (e.g. Braden, [NAME], or other); Clinical Assessment. M0150. Risk of pressure Ulcers/Injuries indicated that Resident #40 was at risk of developing pressure ulcers/injuries. M0210. Unhealed Pressure Ulcers/Injuries indicated that Resident #40 had one or more unhealed pressure ulcers/injuries. M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage indicated Resident #40 had two (2) Stage 1 pressure injuries. The Significant Change MDS, with an ARD of 8/17/2022, showed that the resident had a BIMS score of 03 out of 15 which reflected that the resident's cognition was severely impaired. Review of Section M Skin Conditions indicated the following: M0100. Determination of Pressure Ulcer/Injury Risk. The following was checked to indicate it applied to Resident #40. Clinical Assessment. M0150. Risk of pressure Ulcers/Injuries indicated that Resident #40 was at risk of developing pressure ulcers/injuries. M0210. Unhealed Pressure Ulcers/Injuries indicated that Resident #40 did not have one or more unhealed pressure ulcers/injuries. The annual MDS, with an ARD of 6/22/2022, showed that the resident had a BIMS score of 03 out of 15 which reflected that the resident's cognition was severely impaired. Review of Section M Skin Conditions indicated the following: M0100. Determination of Pressure Ulcer/Injury Risk. The following were checked to indicate they applied to Resident #40. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device; Formal assessment instrument/tool (e.g. Braden, [NAME], or other); Clinical Assessment. M0150. Risk of pressure Ulcers/Injuries indicated that Resident #40 was at risk of developing pressure ulcers/injuries. M0210. Unhealed Pressure Ulcers/Injuries indicated that Resident #40 had one or more unhealed pressure ulcers/injuries. M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage indicated Resident #40 had two (2) Stage 1 pressure injuries. A review of the assessments tab in the electronic medical record indicated that the last Braden Scale For Predicting Pressure Sore Risk assessment (Braden Scale, a formal assessment tool used by health professionals, especially nurses, to assess a patient's risk of developing a pressure ulcer) was done on 01/24/21. Under next assessment due was (in red lettering) Braden Scale For Predicting Pressure Sore Risk 808 days overdue-4/24/21. A review of the Braden Scale For Predicting Pressure Sore Risk dated 01/24/21 indicated the score was 14 and the resident had a moderate risk. The facility did not perform quarterly Braden Scale assessments. The facility coded four of the last five MDS' incorrectly which indicated the facility used a formal assessment tool when the facility did not. On 7/12/23 at 10:52 AM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the Braden Scale assessments. The UM/RN stated that the assessments would be in the electronic medical record under the assessment tab and that the assessments were done according to the MDS. On 7/13/23 at 11:39 AM, the surveyor asked the UM/RN to view Resident #40's electronic medical record. The UM/RN confirmed that Resident #40's last Braden Scale assessment was done on 01/21/21. She also confirmed that there was an indication in red that the next Braden Scale assessment was due 4/24/21 which was 810 days overdue. The surveyor then asked the UM/RN what the purpose of the Braden Scale assessment was. She stated that the purpose for the Braden Scale was to determine if a person was at risk for skin breakdown. She added that it helps to indicate if they need interventions to prevent a pressure ulcer. The surveyor asked the UM/RN if Resident #40 should have had quarterly Braden Scale assessments. The UM/RN stated that Resident #40 should have had Braden Scale assessments. She added that even though the assessments were not done, the resident had interventions in place including an air mattress and the wound physician visited the resident weekly. On 7/14/23 at 10:00 AM, in the presence of another surveyor, the surveyor interviewed Assistant Director of Nursing (ADON) #1 and ADON #2 regarding the protocol for assessing risk for pressure ulcer. ADON #2 stated that the facility used the Braden Scale assessment and that it was done on admission and that she believed quarterly with the MDS. The surveyor then asked where the assessment would be located. ADON #2 stated that it was in the electronic medical record under the assessment tab. She added that the facility mostly had agency nurses (nurse employed by an outside agency, not the facility) and that some of them did not know what a Braden Scale was. On 7/14/23 at 10:25 AM, in the presence of another surveyor and ADON #1, the surveyor interviewed ADON #2 regarding Resident #40. ADON #2 stated that Resident #40 should have had quarterly Braden Scale assessments and that she was not aware that there were missing Braden Scale assessments. The surveyor then asked ADON #2 who was responsible for checking that the assessments were done. ADON #2 stated that the Unit Manager should have checked that the Braden Scale was done. On 7/14/23 at 10:51 AM, in the presence of another surveyor, the surveyor interviewed the MDS Coordinator/Licensed Practical Nurse (MDSC/LPN) regarding Resident #40's MDS and how the assessment was done for Section M skin conditions. The MDSC/LPN stated that on admission she would review the orders and check the assessment that was done by the nurse that admitted the resident. She stated that it populates a quarterly assessment and that she provided a calendar to the unit managers which indicated when the assessment was due. She stated that the assessment is then scheduled by the unit manager according to the schedule that she provided them. The MDSC/LPN stated that it was an assumption that the assessment would be completed. She added that if an assessment was missing she would have populated a QAPI (Quality Assurance and Performance Improvement is a data driven and proactive approach to quality improvement). The surveyor then asked the MDSC/LPN how she coded Resident #40's MDS accurately when she indicated that a formal assessment tool was used when the last Braden Scale that was done was 1/24/21. The MDSC/LPN stated that the MDS would be inaccurate based on the findings for today. She added that she had done a QAPI on Braden Scale assessment on 8/24/22. The surveyor then asked the MDSC/LPN should Resident #40's missing Braden Scale assessments been picked up at that time. She confirmed that the missing assessments should have been noticed during the 8/24/22 QAPI. On 7/14/23 at 12:39 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administration (LNHA), Assistant Administrator (AA), Director of Nursing (DON), Assistant Director of Nursing (ADON) #1, ADON #2, Regional Interim DON (RIDON) and Regional DON (RDON) the concern that facility had not done quarterly Braden Scale assessments and that the MDS' were coded incorrectly for Resident #40. On 7/17/23 at 11:48 AM, in the presence of the survey team, LNHA, AA, DON, ADON #1 and RDON, the RIDON stated that Resident #40 should have had Braden Scale assessments done quarterly. She added that the Braden Scale assessments should be done on admission and quarterly. A review of the facility provided policy titled, Pressure Ulcer Risk Assessment with a reviewed/revised date of 10/22/2022, included the following: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers Assessment: 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly , annually and with significant changes . 4. Because a resident at risk can develop a pressure injury within 2 to 6 hours of the onset of pressure, the at at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure injuries. The admission evaluation helps define those initial care approaches . 8. The comprehensive assessment, which includes the Resident Assessment Instrument (RAI)/MDS, evaluates the resident's intrinsic risks, the resident's skin condition, other factors (including causal factors) which place the resident at risk for developing pressure ulcers and/or experiencing delayed healing, and the nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors can be removed or modified . Equipment and Supplies: The following equipment and supplies will be necessary when providing a pressure ulcer risk assessment: 1. Resident's medical record, including admission data; 2. MDS assessment form; 3. Assessment tools such as the Braden Scale or Norton Plus Pressure Ulcer Scale; and 4. Personal protective equipment . N.J.A.C. 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to: a) label and properly store the nebulizer (neb) mask for one (1) of two (2) residents, (Resident#126) reviewed for respiratory care and b) perform hand hygiene appropriately for one (1) (Licensed Practical Nurse) of three (3) staff observed during medication (med) administration in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 01/08/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. In addition, wear gloves, according to Standard Precautions, when it can be anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment could occur; gloves are not a substitute for hand hygiene; if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment, and after removing gloves. When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry them. Use a towel to turn off the faucet. 1. On 7/06/23 at 11:13 AM, the surveyor observed Resident #126 laying on a specialized mattress with a responsible party (RP) at the bedside. The RP informed the surveyor that the resident was newly diagnosed with COPD (chronic obstructive pulmonary disease; a disease that damages the lungs in ways that make it hard to breathe). The RP further stated that the resident was not on the neb at home and was not sure how often the resident use the neb at the facility. On that same date and time, the surveyor observed the neb mask on top of the nightstand was not properly stored, directly in contact with the paper, and not dated. On 7/06/23 at 12:51 PM, the Assistant Administrator (AA) informed the survey team that the facility was 15th day of the COVID-19 outbreak. On 7/11/23 at 9:01 AM, the surveyor and Assistant Director of Nursing#1 (ADON#1) went inside the resident's room. The resident was laying on the bed and awake. Both the surveyor and ADON#1 observed the neb machine on top of the nightstand table and a tubing connector was inside the nightstand drawer, and the surveyor asked the ADON to check the resident's neb inside the drawer. The ADON opened the drawer and showed the surveyor the neb mask inside a plastic bag and the surveyor asked the ADON to check if there was a label or date in the neb tubing and the ADON did not respond. Later on, the ADON stated that she will discard the neb mask and replace a new one because there was no date. Furthermore, the ADON stated that it should be dated. The surveyor reviewed Resident#126's medical record. The resident's admission Record (or face sheet; an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to muscle weakness, essential hypertension (abnormal blood pressure), chronic kidney disease, COPD, and type two diabetes mellitus with unspecified complications (a chronic disease affecting blood glucose regulation). The most recent admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with a brief interview for mental status (BIMS) score of 14 which reflected that the resident's cognitive status was intact. On 7/12/23 at 11:56 AM, the survey team met with the Regional Interim Director of Nursing (RIDON), Regional DON (RDON), Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), DON, Assistant Director of Nursing#1 (ADON#1), and ADON#2 and were made aware of the above findings. At that time, ADON#1 stated that according to the Registered Nurse Supervisor (RNS) that there was a clear plastic tape with the 7/09/23 date wrapped around the neb tubing when both the surveyor and ADON saw the resident on 7/11/23. ADON#1 further stated that she did not see the tape, and that clear tape should not be used because it was not according to the facility's protocol to use clear tape. On that same date and time, ADON#1 informed the surveyor that the neb mask should not be on top of the nightstand table and not properly stored when not in use. She further stated that it should be stored inside a plastic bag when not in use according to the facility's protocol and practice. On 7/13/23 at 12:33 PM, the survey team met with the LNHA, DON, ADON#1 and #2, RDON, RIDON, and AA. The RDON informed the survey team that neb tubing and mask were the responsibility of the 11-7 shift nurse to change once a week every Wednesday. The RDON further stated that the accountability for changing the neb mask and tubing should be documented in the resident's electronic Treatment Administration Record (eTAR) and that there should be an order for it. The surveyor then notified the facility management that there was no order and there was no documented evidence in the eTAR that the neb change once a week was being done. The RIDON stated that she will get back to the surveyor why there was no order and no documentation in the eTAR. A review of the facility's Oxygen/Nebulizer Care Policy that was provided by the LNHA updated on 4/18/23 included care of the nebulizer: store nebulizer head and tubing in a plastic bag when dry; change neb tubing and head weekly. The policy did include accountability documentation for weekly change. 2. On 7/10/23 at 8:54 AM The surveyor observed the Licensed Practical Nurse (LPN) enter and exit room [ROOM NUMBER] after administration of meds without performing hand hygiene. During an interview, the surveyor asked the LPN what was in her med cart garbage, immediately the LPN donned (applied) new pair of gloves without performing hand hygiene, and grabbed a white [NAME] size tablet from the garbage. The LPN stated that the med should have been disposed of in the drug buster (which provides immediate disposal of unused medications and drugs). Afterward, the LPN doffed off (removed) the used gloves and did not perform hand hygiene. On 7/10/23 at 8:59 AM, the surveyor observed the LPN prepared meds for Resident#21. The LPN entered Resident#21's room and performed handwashing and scrubbed both hands for 13 seconds under the stream of running water. Then, the LPN administered all meds by mouth, immediately donned a new pair of gloves without performing hand hygiene, and handed the resident the Combivent Respimat (a combination medication used to treat chronic obstructive pulmonary disease) inhaler. On that same date and time, the LPN while inside the resident's room performed handwashing, and scrubbed both hands under the stream of running water for 33 seconds. On 7/10/23 at 9:33 AM, the surveyor interviewed the LPN. The LPN informed the surveyor that she was from an agency, and it was her third time working in the facility. The surveyor asked the LPN if she had an education and competency about hand hygiene at the facility, and the LPN stated that she was not sure. The LPN further stated that I know that handwashing should be at least 20 seconds. On that same date and time, the surveyor asked the LPN to state the process of handwashing and the LPN stated that handwashing or scrubbing of hands should be under the stream of water. The surveyor then asked the LPN if she washed her hands for 20 seconds and she did not respond. On 7/11/23 at 8:15 AM, the surveyor met with the LNHA and the AA and was made aware of the above findings. On 7/12/23 at 11:56 AM, the survey team met with the RIDON, RDON, LNHA, AA, DON, ADON#1, and ADON#2 and were made aware of the above findings. A review of the facility's Handwashing/Hand Hygiene Policy with a revised date of 4/2010 that was provided by the LNHA included that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Employees must perform hand hygiene but not limited to after removing gloves; hand hygiene is the final step after removing and disposing of personal protective equipment; before and after direct resident contact; after contact with the resident's intact skin. The use of gloves does not replace hand washing/hand hygiene. The washing of hands procedure included vigorously lathering hands with soap and rubbing them together, creating friction to all surfaces, for at least 20 seconds. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the facility LNHA, AA, DON, RIDON, RDON, and ADON#1 and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management stated that there was no additional information. NJAC 8:39-19.4 (a)(1)(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ00154277 Based on the interview, review of the facility closed record, and the review of facility provided documents, it was determined that the facility failed to: a) document the skin impairment of the resident, b) provide scheduled showers, c) administer medications according to the order of the physician, and d) notify the physician of late administration of prescribed medications in accordance with the resident's preferences, goals for care and professional standards of clinical practice for one (1) of 19 residents, (Resident#127) reviewed for quality of care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission Record (or face sheet; an admission summary), Resident #127 was admitted to the facility with a diagnosis that was not limited to muscle weakness, a history of falling, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), anxiety disorder, major depressive disorder, essential hypertension (abnormal blood pressure), adjustment disorder with anxiety, and unspecified mood disorder. The most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an ARD (assessment reference date) of 4/18/22 showed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which reflected that the resident's cognition was intact. Section M Skin Conditions indicated that the resident had MASD (Moisture Associate Skin Damage). The Report of Consultation dated 4/20/22 showed that the resident was seen by a Dermatologist and the findings were erythematous, crusted papules (small, raised, solid pimple or swelling, often forming part of a rash on the skin and typically inflamed but not producing pus) on periumbilical skin, buttocks, groin, and arms) with a diagnosis (dx) of scabies (an itchy skin rash caused by a tiny burrowing mite). A review of the resident's medical records revealed that there was no skin assessment done by the facility nurse on 4/20/22 when the resident came back from the Dermatologist consult. The Medication Review Report for April 2022 showed a physician order for the following: 1. Order date 7/13/21 for skin observation weekly: (I) intact or (NI) not intact with a progress note every night shift every Tue (Tuesday) for routine skin monitoring. 2. Order date 02/17/22 for [NAME] lotion (formula provides intensive relief for eczema and dry skin conditions) 0.5-0.5% apply to ble (bilateral lower extremities) topically every day and evening shift for itchiness. The above physician orders were transcribed into the electronic Treatment Administration Record (eTAR) for April 2022 and revealed that on 4/19/22 a nurse documented I and on 4/26/22 another nurse documented I for the night. The order for [NAME] lotion was also signed every day and evening shift as administered in the April 2022 eTAR. The Skilled Note in the Progress Note (PN) dated 4/19/22 at 3:00 PM signed by Registered Nurse#1 (RN#1) included that the resident was provided [NAME] lotion secondary to pruritus. On 4/19/22 PN at 6:49 PM signed by RN#2 showed that [NAME] lotion was provided secondary to pruritus. On 7/13/23 at 10:21 AM, the surveyor interviewed the Regional Director of Nursing (RDON). The surveyor asked the RDON about the resident's consultation dated 4/20/22 with dx of scabies and what will be the expectation for the facility with regard to assessment. The RDON stated that skin assessment should be done in the assessment part of the electronic medical record (EMR) and body assessment notes at least in the PN by the nurse. She further stated that usually in nurse's notes skin assessment should include what the rashes look like, and check the room for signs of scabies, and that was the protocol that we follow. On that same date and time, the surveyor asked the RDON to provide a copy of the facility's protocol for scabies, skin/body assessment notes, nursing and aides assignments including the shower schedule for April 15-30, 2022, and the orders and electronic Medication Administration Record (eMAR) and eTAR for April 2022 and she stated she will get back to the surveyor. On 7/13/23 at 01:26 PM, the surveyor reviewed the provided documents of the RDON and showed the following: 1. On 4/21/22 at 01:00 PM. Skin checks were done on A-side residents, no new onset of rashes in other residents except Resident # 127. 2. Conclusion: after investigation, it was determined that there was no further incident of scabies in the building. 3. Body Check Sheet dated 4/21/22 of Resident#127. Comments: small rashes on between fingers, knocks, under the armpit, groin, all over the body signed by LPN#1. 4. The Documentation Survey Report (tasks of CNAs) provided did not include information that a shower was provided to the resident on April 2022. On 7/14/23 at 8:46 AM, the surveyor asked the Licensed Nursing Home Administration (LNHA) for a copy of the showers that were done to the resident for the whole month of April 2022 and he stated that he will get back to the surveyor. On 7/14/23 at 9:59 AM, the survey team met with Assistant Director of Nursing#1 (ADON#1) and #2 and discussed about skin impairment and skin assessments in accordance with the facility's practice and policy. According to ADON#2 skin assessment is usually done by an RN, I believe in the morning we document in the progress notes. At that same time, ADON#1 informed the surveyors that if there will be a skin impairment like skin tear and rashes, we document in PN and Risk Management. ADON further stated, for the rashes I have to clarify, if noted fungal rash from the diaper, we call the doctor and get the treatment order. In addition, ADON#2 informed the surveyors that she was aware of the resident's scabies incident. The surveyor notified the two ADON about the above April 2022 eTAR 4/19/22 and 4/26/22 for two nurses who coded I (intact) for weekly skin even though on 4/20/22 Derma Consult showed multiple areas of rashes. The surveyor also asked why there was no actual skin assessment done on 4/20/22. ADON#2 stated I don't know what happened or why the skin assessment was done late. She further stated that maybe the nurse waiting for the doctor. The surveyor then asked the ADON what will be the expectation for the nurse to do if the resident came back with the doctor's note about scabies. ADON#2 stated that there should be a kind of note that describes the resident's skin, color, and measurement when the resident came back from the 4/20/22 consult. Furthermore, the surveyor asked for the full names and titles of the 4/19/22 and 4/26/22 nurses who signed the eTAR and if they still work at the facility for the surveyor to interview them, and both ADON#1 and #2 stated that they will get back to the surveyor. On 7/14/23 at 12:10 PM, the survey team met with the Director of Nursing (DON), ADON#1 and #2, Regional Interim DON (RIDON), RDON, LNHA, and, Assistant Administrator (AA), and made aware of the above findings. The surveyor asked the facility management when the scheduled shower of the resident and the facility stated that they will get back to the surveyor. On 7/14/23 at 01:20 PM, the surveyor reviewed the provided documents by the LNHA that was handwritten on a white bond paper that included the following information for shower and with attached notes: 5/23/22 page 81 5/19/23 page 91 5/18/23 page 91 4/22/22 page 143 4/21/22 page 150 4/21/22 page 149 4/20/22 page 151, 159 4/9/22 page 186 Attached were PN: Page 186 showed that the effective date was 4/09/22 at 10:42 PM showered this shift.-electronically signed by LPN#2 Page 151 showed that the effective date was 4/20/22 at 7:25 PM .for 1 day to entire body from neck down leave on overnight for 8 hrs then shower repeat in 5 day.-electronically signed by LPN#3 Page 159 showed that the effective date was 4/20/22 at 3:30 PM Resident came back from dermatology consult .Endorsed to the nurse about the treatment plan for the resident.-electronically signed by RN#4 Page 149 showed that the effective date was 4/21/22 at 10:07 PM showered as ordered.-electronically signed by RN#5 Page 150 showed that the effective date was 4/21/22 at 3:36 PM Patient was given the permethrin cream during am care and was told he/she will shower at 7-8 PM .-electronically signed by LPN#4 Page 143 showed that the effective date was 4/22/22 at 3:58 PM .Resident showered and put on the treatment cream for scabies on all body part on 7 PM, 4/21/22.-electronically signed by LPN#1 Page 91 showed that the effective date was 5/18/22 at 10:24 PM had shower.-electronically signed by RN#3 Page 91 showed that the effective date was 5/19/22 at 6:02 PM had shower.-electronically signed by RN#2 Page 81 showed that the effective date was 5/23/22 at 10:32 PM had shower.-electronically signed by RN#3 There were no other showers provided for April 2022 except for 4/22, 4/21, 4/20, and 4/9/22. On 7/17/23 at 8:24 AM, the RDON in the presence of ADON#2 and the survey team informed the surveyor that according to LPN#4, who usually works 11-7 and who worked on that date on 4/19/22 at 3-11 shift and signed skin intact thought that if the resident had already previous documentation of MASD does not need to document that the skin was not intact because it was not something new to the resident and that eTAR only pertains to pressure ulcer. The RDON further stated that education was provided to the nurse regarding the appropriate documentation and that it should have been documented as NI (not Intact) on 4/19/22. In addition, the RDON stated that LPN#5 who coded I (Intact) skin on 4/26/22 of the 3-11 shift left and last work day was on 12/24/22. On that same date and time, the RDON also provided a copy of the signed attestation of RN/Supervisor (RN/S) stating that he was the nursing supervisor for the 3-11 shift on 4/21/22, the signed attestation was dated 7/14/23. The RDON indicated that according to the attestation, the RN/S remembered that date on 4/21/22 that the RN/S was told by the previous DON to conduct body checks on all the residents on the A side using the body check sheet because one of the residents in the A side was found to have scabies, so they needed to proactively check the rest of the residents on the same side. The RDON further stated that the RN/S instructed the evening nurses on the A side to complete the body checks and alert him if there are any new rashes or evidence of scabies so the RN/S can perform a skin assessment, and the RN/S recalled that there was no any reports of new rashes or signs of scabies. The surveyor then notified the facility management that based on the explanation of the RDON from the RN/S signed statements, still no RN assessment on that same date of 4/20/22 that will show that body assessment was done that will include a description of skin impairment, location, and size according to the facility practice and protocol that was mentioned by the facility management, not until 4/21/22. At that same time, the surveyor followed up again with the RDON and ADON#2 on the shower days of the resident and how often in a week the resident gets a shower. The RDON informed the surveyor that the resident gets a shower 2 x/a week and will provide the surveyor with a copy of the shower list but just right now it's being updated, and will get back to the surveyor about the actual dates of the shower the resident gets to shower every 3-11 shift. The surveyor asked the facility management what is the acceptable shower time in the 3-11 shift the resident gets a shower and if should it be documented when the shower provided at a later time in the 3-11 shift. The RDON stated that the acceptable time is at least before 10 PM not even after 8:30 PM because the resident is prepping for bedtime already. The RDON further stated that she will get back to the surveyor for the shower policy of the facility. In addition, the surveyor asked the RDON and ADON#2 why the shower was given only on 4/09/22, 4/20/22, and 4/21/22 according to the provided documentation if the resident was supposed to get showered 2 x/a week and documented time for 4/09/22 for showered given was at 10:42 PM, and the RDON stated that she will get back to the surveyor. The RDON stated that showers should be given 2 x/a week and there should be documentation for refusal, a care plan, and notes if showers were not provided. The surveyor also asked for a copy of the April 2022 eMAR of the resident that included the time meds were administered and both stated that they will get back to the surveyor. On 7/17/23 at 11:25 AM, the surveyor reviewed the provided printout of the resident's April 2022 Medication Admin Audit Report that was provided by the RDON showed that there were multiple 8 AM and 9 AM meds that were administered beyond an hour or more and not according to the physician's ordered time to administer medications as follows: 1. Lidocaine patch 4% to right shoulder topically one time a day for right shoulder pain. Scheduled Administration (SA) time 8:59 AM =administered: 4/01/22 at 02:04 PM, 4/04/22 at 12:53 PM, 4/06/22 at 12:19 PM, 4/11/22 at 02:23 PM, 4/12/22 at 12:23 PM, 4/13/22 at 11:58 AM, 4/14/22 at 5:07 PM, 4/19/22 at 02/51 PM, 4/22/22 at 11:36 AM, 4/23/22 at 11:40 AM, 4/25/22 at 11:36 AM, 4/26/22 at 11:15 AM 2. Glycolax powder give 17 grams by mouth one time a day for constipation. SA time 9:00 AM=administered 4/01/22 at 02:04 PM, 4/09/22 at 12:00 PM, 4/13/22 at 11:58 AM, 4/14/22 at 5:08 PM, 4/22/22 at 11:36 AM, 4/23/22 at 11:41 AM, 4/25/22 at 11:37 AM, 4/26/22 at 11:15 AM 3. Gabapentin 600 mg (milligram) by mouth 3 x/a day for neuropathic pain. SA time 9:00 AM=administered 4/01/22 at 02:04 PM, 4/25/22 at 11:37 AM, 4/26/22 at 11:15 AM 4. Bengay Ultra strength patch 5% apply to neck nap area topically one time a day for neck pain. SA time 9:00 AM=administered 4/01/22 at 02:05 PM, 4/04/22 at 12:53 PM, 4/06/22 at 12:19 PM, 4/11/22 at 02:23 PM, 4/12/22 at 12:23 PM, 4/19/22 at 02:52 PM, 4/23/22 at 11:40 AM, 4/25/22 at 11:37 AM, 4/26/22 at 11:15 AM 5. Clonazepam tablet (tab) 1 (one) mg give one tab by mouth every 12 hours (hrs) for anxiety time 9:00 AM=administered 4/01/22 at 4:50 PM, 6. Colace 100 mg one capsule (cap) by mouth 2 x/a day for constipation. SA 8:00 AM=administered 4/05/22 at 9:52 AM, 4/09/22 at 11:59 AM, 4/12/22 at 10:15 AM, 4/13/22 at 10:14 AM, 4/17/22 at 9:43 AM, 4/19/22 at 9:51 AM, 4/21/22 at 9:56 AM, 4/22/22 at 9:59 AM, 4/25/22 at 11:36 AM, 4/28/22 at 9:53 AM 7. Aspirin tab chewable 81 mg one tab by mouth one time a day for blood clot prevention. SA time 8:00 AM=administered 4/08/22 at 9:39 AM, 4/12/22 at 10:16 AM, 4/13/23 at 10:14 AM, 4/17/22 at 9:43 AM, 4/21/22 at 9:56 AM, 4/22/22 at 9:59 AM, 4/25/22 at 11:36 AM, 4/28/22 at 9:51 AM 8. Fluoxetine HCL (hydrochloride) cap 20 mg one cap by mouth one time a day for depression. SA time 9:00 AM=administered 4/09/22 at 11:07 AM, 4/25/22 at 11:37 AM 9. Baclofen tab 10 mg one tab by mouth every 12 hrs for muscle pain and spasms. SA time 9:00 AM=administered 4/25/22 at 11:37 AM, 4/26/22 at 11:15 AM 10. Breo Elliopta aerosol powder breath activated 100-25 mcg/inh (microgram/inhalation) one puff inhale orally one time a day for asthma maintenance. SA time 9:00 AM=administered 4/25/22 at 11:37 AM, 4/26/22 11:15 AM 11. Amlodipine 5 mg give one tab by mouth one time a day for hypertension. SA time 9:00 AM=administered 4/25/22 at 11:37 AM, 4/26/22 at 11:15 AM 12. Xiidra solution 5% instill one drop in both eyes 2 x/a day for dry eyes. SA time 9:00 AM=administered 11:17 AM 13. Depakote ER 500 mg give one tab by mouth one time a day for mood stabilizer. SA time 9:00 AM=administered 4/26/22 at 11:15 AM At that same time, the surveyor notified ADON#2 of the above concern and asked the ADON why the medications were administered beyond the physician's order and she stated that she will get back to the surveyor. On 7/17/23 at 11:36 AM, the survey team met with the RIDON, RDON, DON, ADON#1, LNHA, and AA. The RDON stated that after the investigation, I think what happened was the resident was given a shower at 6 or 7 PM and the nurses documented late. The RDON further stated that But I don't have proof that this happened, I'm just talking about my experience that no CNA gave a shower late. The RDON stated that I know the UM (unit manager) reminding to give a shower but not documented. On that same date and time, the RDON informed the surveyors that the facility documentation about showers was not tight, and the problem was I can't prove to you that shower was provided. On 7/17/23 at 12:34 PM, The RDON provided a Census list for the resident that showed that Resident#127 was in room [ROOM NUMBER]-D, attached documents indicated that the resident's shower schedule for the 3-11 shift was highlighted every Wednesday and Saturday. On 7/18/23 at 10:07 AM, the survey team met with the LNHA, AA, DON, RIDON, RDON, ADON#1, and #2. The RDON informed the surveyors that she interviewed the assigned nurses of the resident who administered late medications to the resident on April 2022 for one hour, two hours, and thirty minutes. The RDON stated that RN#1 works with LPN#5, the resident preferred RN#1 over LPN#5 and that was the reason why medications were administered some days late because RN#1 had to finish his assigned residents first before going to Resident #127. She further stated that at times when RN#1 was about to administer medications to Resident #127, the resident will decline and will come back to administer medications. On that same date and time, the surveyor asked the facility management what was their policy and protocol with regard to late administration of medications, was this specific behavior for late administration of medications and staff preference for nurse administering medications were included in the resident's care plan, and if the physician was notified about late administration of medications and documented. The facility management acknowledged that the care plan did not include specific focus problems and interventions regarding the late administration of medication and that the doctor was notified of the late administration because there was no documentation in the resident's medical records about it. At that time, the RIDON stated I agree with that 100%, and agreed that the care plan should include the preference of the resident and intervention appropriate to a specific problem to target the interventions and prevent further problems. The RDON also acknowledged that there was no documentation that the above problem for late administration of medications was discussed and put into the care plan. The facility management acknowledged that this should have been done since it was repeatedly administered late. On 7/18/23 at 01:09 PM, the surveyor reviewed the provided documents by the LNHA on 7/18/23 at 10:07 AM included the following: 1. Patient and Family Concerns dated 10/29/21 reported by the resident showed that the resident had a concern that the resident did not receive a scheduled shower on Thursday. Action: 3-11 supervisor was notified and the resident received a shower on Friday and ongoing education with staff to follow the resident's shower schedule. Follow-up: the facility has developed QAPI to follow resident's shower schedules and this is ongoing. This was reviewed and signed by the LNHA. 2. The documented interview of the nurses who administered late medications to the resident on April 2022 showed that: a. 7-3 LPN#6 stated that the resident sometimes will ask the nurse to come back when medications were to be administered. b. 7-3 RN#1 stated that the resident likes him to administer resident's medications and when the nurse is ready to administer medication, the resident will refuse and ask the nurse to come back at a later time. According to the provided Medication Administration Documentation investigation summary that was provided by the LNHA on showed that based on record review and staff interview, the resident was stable, no significant changes documented and the vital signs were within normal range despite medications being administered beyond the prescribed time of the physician. This investigation summary was provided after the surveyor's inquiry. A review of the facility's Nursing Skin Assessment Policy with the last reviewed date of 10/2022 that was provided by the LNHA included that it is the facility's policy to perform a full body skin assessment as part of the facility's systematic approach for pressure ulcer prevention and the promotion of healing of various skin conditions. Documentation of skin assessment: include date and time of assessment, name, and title of doing the assessment, document observations (i.e. skin conditions, how the resident tolerated the procedure, etc.), document type of wound (measurements, color, type of tissue in wound bed, drainage, odor, pain), document if resident refused assessment and why. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the facility LNHA, AA, DON, RIDON, RDON, and ADON#1 and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management stated that there was no additional information. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility provided documents, it was determined that the facility failed to ensure a) proper storage of medication (med) for one (1) of 19 residents, Resident #32 observed during the first day of tour; b) med was available for one (1) of four (4) residents, Resident#45 during med administration observation; c) proper disposal of med for one (1) of three (3) nurses observed during med administration; d) med was administered according to the order of the physician for one (1) of 19 residents, Resident#129 observed during med cart inspection according to the standards of clinical practice and facility policies. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/06/23 at 10:50 AM, the surveyor observed Resident #32 seated in a wheelchair with the Certified Nursing Aide (CNA) at the bedside. The surveyor observed a closed bottle of [name redacted] vitamins with the resident's last name and room number. The surveyor asked the CNA what was the bottle and who was for, and the CNA stated that it was for the resident and the family probably brought it. On 7/06/23 at 11:24 AM, the surveyor went back to the resident's room with the Director of Nursing (DON) and observed the same bottle of vitamins at the same location on top of the nightstand. The surveyor asked the DON should the med be at the bedside and the DON stated that she will get back to the surveyor. On 7/06/23 at 12:27 PM, the surveyor interviewed the DON. The surveyor asked the DON should the bottle of vitamins be at the resident's bedside, and the DON stated The answer is no, I took it out and gave it to the nurse, and the unit clerk now calling the doctor if the doctor wanted to order the med since the resident had no order for it. The DON further stated that the MD (medical doctor) was called to notify of the concern. The surveyor notified the DON that at the time the surveyor observed the med was when the CNA was at the bedside. At that time, Licensed Practical Nurse#1 (LPN#1) came and informed the surveyor in the presence of the DON that the CNA should have told her that she saw the med at the bedside and that the med should not be left at the bedside. LPN#1 confirmed that the resident had no order for the vitamin that was found at the bedside. The surveyor reviewed the medical records of Resident#32. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but not limited to unspecified dementia without behavioral disturbance, history of falling, muscle weakness, dysphagia oral phase (problems with using the mouth, lips and tongue to control food or liquid), essential hypertension (abnormal blood pressure), and major depressive disorder. The most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/01/23 revealed a brief interview for mental status (BIMS) score of 00, which indicated that the resident's cognitive status was severely impaired. A review of the July 2023 Order Summary Report (physician's orders) revealed that there was no order for the above vitamins. On 7/10/23 at 9:47 AM the Licensed Nursing Home Administrator (LNHA) provided a copy of the summary in regards to the bottle of vitamins that were found at the resident's bedside which showed that when the surveyor observed during the round on 7/06/23 a bottle of multivitamins (MVI) at the resident bedside, immediately the physician was notified. The summary also included that it was the responsible party who brought the MVI and that the resident was assessed and there were no significant changes noted to the resident. On 7/12/23 at 11:56 AM, the survey team met with the Regional Interim Director of Nursing (RIDON), Regional Director of Nursing (RDON), LNHA, Assistant Administrator (AA), DON, Assistant DON#1 (ADON#1) and ADON#2, and were made aware of the above findings. The RIDON stated that meds should not be left at the bedside. The ADON acknowledged that the CNA should have notified the nurse immediately of the MVI at the bedside and it should have been properly stored, and not left at the bedside. On 7/13/23 at 8:49 AM, the RDON in the presence of the LNHA stated that the facility's protocol should have been followed when med was found at the bedside, the staff should notify the nurse, not leave at the table, and call the doctor. 2. On 7/10/23 at 7:50 AM, during med administration, the surveyor observed LPN#1 prepared and administered med to Resident #45. The med Apple pectin 500 mg (milligram) one tablet (tab) order to be given was not available. On that same date and time, both LPN#1 and Registered Nurse/Supervisor (RN/S) confirmed that the Apple pectin med was not available. LPN#1 stated that the med will be held and will call the doctor and pharmacy because it's not an in-house stock. A review of Resident#45's electronic Medication Administration Record (eMAR) for July 2023 showed that Apple Pectin Tablet 500 mg oral give one (1) tab by mouth two times a day for diarrhea was ordered on 5/22/2023 and remained as an active order. Further review of the July 2023 eMAR order for Apple Pectin showed that on 7/02/23, 7/04/23, and 7/10/23 at 9 AM and 7/01/23 and 7/09/23 at 5 PM, the eMAR was coded as 9 which indicated other/see progress notes. A review of the packing slip from the pharmacy dated 5/31/23 showed med Apple pectin 500 mg tab and quantity delivered was 60 tabs. The packing slip from the pharmacy dated 7/11/23 for Apple pectin 500 mg tab and quantity delivered was 60 tabs. On 7/10/23 at 9:41 AM, The surveyor observed LPN#1 in the nursing station, and LPN#1 informed the surveyor that the med Apple pectin of Resident#45 was held by the doctor, and the pharmacist was called to deliver the med. The LPN showed the July 2023 eMAR from 7/01/23-7/10/23. The surveyor asked the LPN what was code 9 (nine) in the eMAR meant for, and the LPN stated that the med was not available and waiting for delivery. On 7/12/23 at 11:56 AM, the survey team met with the RIDON, RDON, LNHA, AA, DON, ADON#1 and #2, and ADON and were notified of the above findings. The RDON stated that about Resident#45's med, the facility had a process that we follow in the facility, which was to call the pharmacy and follow up med, to notify the supervisor if not available, call the doctor, and document. The surveyor then asked the RDON if the process was followed and the RDON stated I did not see, that was why we QAPI (Quality Assurance Performance Improvement) it. 3. On 7/10/23 at 8:54 AM, during med administration observation, the surveyor observed LPN#2's open med cart garbage with one white [NAME]-shaped (an elongated elliptical shape with pointed ends) tablet, inside the garbage receptacle mixed with a wrapper of COVID kit and used gloves. The surveyor asked LPN#2 what was inside her med cart garbage receptacle and she responded that it was a Torsemide (called diuretics or water pill) 40 mg tablet (tab) med and it was not her, that it was probably the 11-7 shift nurse who throw the med in the garbage. She further stated that the med should have been thrown in the drug buster (the medication disposal system quickly turns most non-hazardous medications into a non-toxic slurry that can be safely put in the trash) not in the garbage. The LPN then took the Torsemide med and disposed of it into the drug buster that was inside her med cart. On that same date and time, the surveyor asked LPN#2 how did she know that it was a Torsemide 40 mg. The LPN stated that I just knew, because she encountered the medication previously and had been giving meds. The surveyor then asked the LPN if she knew who was the resident that have an order for Torsemide in her assignment, and the LPN responded I do not know. On 7/17/23 at 11:16 AM, the DON provided documents and informed the surveyor that after investigation, it was Resident #39 who had the Torsemide 40 mg pill found in the garbage on 7/10/23 med administration observation of the surveyor. She further stated that Resident #39 was one of the residents that was on LPN#2's assignment. On 7/17/23 at 11:36 AM, the survey team met with the RIDON, RDON, DON, ADON#1, LNHA, and AA. The RDON stated that there were two residents on Torsemide. The DON stated that she looked at all B1 residents that LPN#2 had on 7/10/23 and it was concluded that the Torsemide in the garbage was from Resident #39, based on the date meds were ordered, the timing of med, how many were delivered, and how many were administered to the resident. 4. On 7/14/23 at 11:56 AM, the surveyor observed LPN#3 in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) opened the B2 med cart during med cart inspection. The surveyor observed a cup of medicine filled with 7 (seven) different meds. The surveyor asked LPN#3 what medications, and to whom the meds belong. LPN#3 stated that the meds were for Resident #129 and that she did not know that the resident was not in the room at the time when she poured the medications. LPN#3 further stated that the 7 (seven) meds were for 11 AM. On that same date and time, the surveyor asked LPN#3 if the facility allowed the nurse to pre-pour meds and what she should have done with the meds when she found out that the resident was not in the room. LPN#3 did not respond. The LPN/UM then responded that it was not allowed to pre-pour the meds and that the nurse should have discarded it in the drug buster if she realized that the resident was not in the room and not left it in the med cart. ADON#1 provided a handwritten list of Resident#129's pre-poured 7 (seven) meds and showed that the meds were not for 11 AM as follows: 1. Amlodipine (blood pressure med) 5 mg at 9 AM 2. ASA (aspirin) 81 mg at 9 AM 3. Metoprolol Succinate (blood pressure med) ER (extended-release) 25 mg at 8 AM 4. Wellbutrin ER (for depression) 150 mg at 9 AM 5. Zoloft (for depression) 100 mg at 9 AM 6. Metformin (for diabetes) 500 mg at 8 AM 7. Sodium Bicarbonate (supplement) 650 mg at 8 AM On 7/17/23 at 11:36 AM, the survey team met with the RIDON, RDON, DON, ADON#1, LNHA, and AA, and were made aware of the above findings. The RDON stated that an investigation was done with regard to Resident#129's meds that were pre-poured by an agency nurse, LPN#3. The RDON further stated that the seven meds were discarded to the drug buster and that according to the LPN/UM, the doctor was notified and ordered to administer the new batch of meds around 12:30 PM for 8 AM and 9 AM meds. The facility management acknowledged that the doctor was notified of 8 AM and 9 AM meds were not administered on time after the surveyor's inquiry. A review of the facility's Storage Medications Policy that was provided by the LNHA with a reviewed/revised date of 10/20/22 included that the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining med storage and preparation areas in a clean, safe, and sanitary manner. A review of the undated Medication Re-Ordering Process that was provided by the LNHA included that if any medication is not available or not delivered in your shift: 1. call the pharmacy to check availability/delivery times 2. notify your supervisor/DON 3. if medication not available, inform MD and get orders 4. document. A review of the Ordering and Receiving Non-Controlled Medications Policy with a revision date of 08-2020 that included that reorder medications based on the estimated refill date ([NAME]) on the pharmacy Rx label, or at least three days in advance, to ensure an adequate supply is on hand; and that the refill order is called in, faxed, sent electronically, or otherwise transmitted to the pharmacy. Delivery records are retained in accordance with facility policy. A review of the facility's Physician Medication Orders Policy with a reviewed/revised date of 10/2022 that was provided by the LNHA included that drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available. On 7/18/23 at 02:42 PM, the survey team met for an exit conference with the facility LNHA, AA, DON, RIDON, RDON, and ADON#1 and #2. The surveyor asked the facility management if there will be additional information for the findings that were notified to the facility, and the facility management stated that there was no additional information. NJAC 8:39-11.2(b), 29.2(d)