Based on interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure accurate documentation of a residents' advance directives for 2 of 3 residents, (Resident #15, Resident #16) reviewed. This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #15, which revealed: A review of the admission Record (AR) (an admission summary) revealed that the resident was admitted with diagnoses that included but were not limited to, urinary tract infection and hypertension (high blood pressure). A review of the most recent discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A review of the personalized Care Plan (CP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, which did not reflect any documentation of the resident's advance directive (AD), code status or other resident wishes for life saving measures. A review of the Social Services Assessment (SSA) with an effective date of 2/13/25, reflected nothing on line six, for code status, reflected YES on line 6a. AD and reflected POLST (practitioner orders for life sustaining treatment) on record on line 6b. Comments/Notes. Further review of the SSA with an effective date of 11/4/24, also reflected nothing on line six, and reflected NO on line 6a and NO on line 6c. It also included If No AD, do you want the facility to initiate an AD? There was no further information provided on the assessment. The POLST form, located in the resident's paper chart, which was undated and not filled out, to indicate what AD, nor was it signed by the resident, attending physician or facility staff. There was no documentation in the medical records that indicated that the resident or Responsible Representative (RR) was educated on the AD process. A review of the resident's electronic medical record (eMR) did not indicate information that reflected AD status in the resident information area. 2. The surveyor reviewed the hybrid medical records of Resident #16, which revealed: A review of the AR that reflected that the resident was admitted with diagnoses that included but were not limited to spinal stenosis, lumbar region, (a condition characterized by the narrowing of the spinal canal in the lower back) and hypertension. A review of the comprehensive MDS, with an assessment reference date (ARD) of 3/30/25, reflected a BIMS score of 15 out of 15, which indicated resident's cognition was intact. A review of the personalized CP, reflected a focus on AD that was initiated on 4/4/24, revised on 12/30/24, with a target date for revision on 4/9/25. The CP interventions that was initiated on 4/4/24, reflected that the resident was a full code. A review of the SSA with an effective date of 1/15/24, reflected nothing on line six. Code Status reflected NO on line 6a. AD reflected NO on line 6c. The surveyor was unable to locate a POLST form in Resident #16's paper chart. There was no documentation in the medical records that indicated that the resident or RR was educated on the AD process. On 4/17/25 at 10:36 AM, the Licensed Nursing Home Administrator (LNHA) provided, after surveyor inquiry, signed POLST forms for Resident #15 dated 4/16/25, (time not legible), and Resident #16 dated 4/16/24 at 6:50 PM. The LNHA also provided a requested facility's Policy titled Advance Directives with revised date of 11/25. On 4/21/25 at 9:41 AM, the surveyor interviewed the Director of Social Services (DSS). The DSS stated that on admission, the resident or RR was asked if there was an AD or other statement of healthcare wishes currently in place. The DSS also stated that a packet of information about AD was provided to the resident or RR if required. The DSS further stated that the Social Worker will also explain any detail and ask what the wishes of the resident were. The DSS provided the surveyor with a copy of the packet. On that same date and time, the surveyor asked how the AD or POLST was communicated to the staff if there was an emergency. The DSS stated that they rely on the paper copy in the chart as a copy usually goes to the hospital with the resident if they were to go. The surveyor asked the DSS about the POLST that were missing from or not filled out in the paper charts. The DSS stated they could have been waiting for the physician to sign. The surveyor then asked the DSS would that be normal for several months if the physician comes in regularly, and the DSS stated no it should not be, but some residents change their mind or have not made a choice. At that same time, the surveyor notified the DSS that they could not find any documentation to support that. The surveyor asked the DSS about the SSA documents, the information and that line six was blank. The DSS stated that she does not fill in line six only 6a, 6b, or 6c which ask if the resident has an AD and/or if they would like one. Furthermore, the surveyor asked the DSS if the educational packet and forms were provided to resident and/or RR or were also put into the medical record. The DSS stated, no, just given to resident or RR depending on cognitive state. The DSS gave an example for Resident #16, who's RR was estranged and rarely comes as it upsets the resident. On 4/21/25 at 12:59 PM, the survey team met with the LNHA and Director of Nursing (DON) to discuss above concerns with AD documentation for Residents #15 and #16 for missing documentation in the paper chart for AD and no record of educational materials in the medical record. On 4/22/25 at 12:52 PM, the survey team met with the LNHA, DON, Chief Operating Officer (COO), and Regional DON (RDON). The DON stated that the AD material and other communications with the RR were sent through another electronic platform or tool the facility uses for outside communication. The surveyor asked if the communication tool was tied to the medical record, and the DON stated no it was not part of the medical record. A review of the facility's Advanced Directives Policy, with revised date of 11/25, reflected: Line 4. Information about whether or not the resident has executed an AD shall be displayed prominently in the medical record. Line 8. Changes or revocations of a directive must be submitted in writing to the Administrator, the Administrator may require new documents if the changes are extensive. The CP Team will be informed of such changes and/or revocations so that the appropriate changes can be made in the resident assessment (MDS) and CP. Line 9. The DON Services or designee will notify the attending physician of AD so that appropriate orders can be documented in the resident's medical record and plan of care. Line 10. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's AD regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. The facility did not provide any further pertinent documentation. N.J.A.C. 8:39-9.6(b)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified in dining room for 2 of 5 days observation, and was evidenced by the following: On 4/17/25 at 8:25 AM, the surveyor observed the dining room (and recreation area) with no residents inside the room. The surveyor observed the floor with accumulation of grayish and blackish substances, pieces of small plastic wrapper and paper, and the tv (television) with accumulation of grayish substances. There was a bed at the end of the dining area with no cover, with stack of different chairs, the windowsill with accumulation of grayish substances, and the vending machine near the window with plastic with papers, and with accumulation of grayish substances. Afterward, the surveyor was in the hallway between dining room and kitchen, and surveyor interviewed the Regional Food Service Director (RFSD), who informed the surveyor that the dining room was being used for lunch and dinner only, and once a month for breakfast for subacute residents. On 4/17/25 at 11:56 AM, the surveyor observed the dining room, there were six residents and three staff waiting for lunch to be served. The surveyor interviewed the Licensed Practical Nursing Supervisor (LPNS), who informed the surveyor that the kitchen staff were preparing the residents' meals, and it will be served shortly. Residents #6, #18, #27, #30, #31, and #37 were inside the dining room. On 4/17/25 at 12:10 PM, the surveyor observed in the dining room with the same six residents were served with soup. The surveyor observed the dining area on the end part by the window with stored bed with mattress with no cover with stained grayish color, stocks of regular chair with different colors, rollator, walker, folded long table which was visible to all residents and staff in the dining area, and where residents could go. The surveyor asked the LPNS about the equipment, bed, and chairs stocked in the area where the residents were using as the dining area, and the LPNS said that he would check why it was there. On that same date and time, the surveyor observed the vending machine had papers on top of it and the surveyor asked the LPNS what those papers were. The LPNS took the paper on top of the vending machine and showed it to the surveyor. The papers were emergency crash care checklist. The LPNS acknowledged that the accumulation of grayish substances on top of the vending machine were dust. On 4/21/25 at 11:15 AM, the surveyor observed the dining with staff and residents during recreational activity. The surveyor observed the floor with accumulation of grayish and blackish substance, pieces of small plastic wrapper and paper, the windowsill with accumulation of grayish substances, and the vending machine with accumulation of grayish substances. On 4/21/25 at 12:58 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA and DON acknowledged the surveyor's concerns about the dining room environment. Both the LNHA and DON confirmed that the dining room should not be used as storage and environment should be dust free and clean. On 4/22/25 at 12:52 PM, the survey team met with the LNHA, DON, Regional DON (RDON), and Chief Operating Officer (COO). The LNHA stated that education was provided to housekeeping department to maintain homelike environment and maintain free from dust and clutter. A review of the facility's Quality of Life-Homelike Environment Policy, with a revised date of October 2009, that was provided by the RDON, revealed, residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation: 2. The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse (IPN), and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:39-31.2(e), 31.4(a)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ#168277 Based on interview and review of facility documentation, the facility failed to provide and document sufficient preparation and orientation to resident to ensure safe and orderly transfer or discharge from the facility. This deficient practice was identified in 1 of 1 resident, (Resident #212), reviewed for discharge. The deficient practice was evidenced by the following: The surveyor reviewed the hybrid medical record (paper and electronic) for Resident #212. A review of Resident #212's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited vertebral disc displacement (when a disc in the spine shifts and may cause pain) and difficulty walking. A review of Resident #212's most recent discharge (d/c) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #212 had no cognitive impairment. The MDS also reflected, under section GG Functional Abilities and Goals- Discharge, the ability to go up and down 4 steps, partial/moderate assistance, and the ability to go up and down 12 steps, not attempted. A review of Resident #212's Progress Notes, including but not limited to Social Services Notes (SSN), therapy notes, and Interdisciplinary Care Plan Team (IDCP Team) notes revealed the following: An IDCP Team Meeting Note dated 9/27/23, that reflected that the team met with Resident #212 on 9/26/23, regarding her plan of care and d/c plan. The note reflected that the resident was able to walk 10 feet with assistance of a walker device but requires a great deal of assistance to do stairs. The d/c plan included referral for home care as well as a home health aide, and that the resident must use four steps to enter the residence and 14 additional steps once inside. A review of the resident's Physical Therapy Evaluation and Plan of Treatment (PTEPT) notes revealed a goal for the resident to be able to go up or down four stairs safely with a target date of 9/26/23, and a goal to go up or down 14 stairs safely with supervision with a target date of 10/18/23. The PTEPT notes also reflected that the resident's home had four steps outside to navigate as well as 14 steps inside. A review of the resident's Physical Therapy Discharge Summary (PTDS) revealed that a short-term goal for the resident to safely go up or down four steps was met on 10/9/23, and a long-term goal of being able to go up or down 14 steps safely was discontinued on 10/9/23, with the resident being able to navigate eight steps. The PTDS also revealed a d/c recommendations that reflected the resident was given safety precautions, had medical equipment ordered, and required a Home Exercise Program (HEP) (a program designed to facilitate rehabilitation through exercises performed at home supervised by a therapist), for safe d/c to home. A review of the resident's Physical Therapy Progress Report (PTPR) revealed a Justification for Skilled Services that reflected a requirement for services to increase independence, mobility, functional activity tolerance to enhance quality of life by improving ability to safely return to private residence. An SSN dated 10/11/23, reflected on 10/9/23, the facility was notified by Resident #212's insurance that the last covered day would be 10/9/23, and the facility notified the resident and provided a phone number for an appeal if the resident wished to. The SSN also reflected that the resident was going to appeal since they could not navigate the steps at home. The SSN revealed that the resident was upset with the process and short notice. The SSN reflected that the resident d/c home on [DATE]. A SSN dated 10/10/23, reflected that the Director of Social Services (DSS) was informed that multiple home care services would not be able to accept Resident #212's case. The note also included that the resident was unable to safely manage their own stairs at the current time and outpatient rehabilitation services (resident goes to an outside center) was not an option. A review of additional SSN dated 10/11/23, reflected that a home health agency agreed to accept the resident's case, and there would be a delay in getting physical therapy started, information which, was provided to the resident. On 4/22/25 at 12:52 PM, the survey team met with The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON (RDON), and Chief Operating Officer (COO) to discuss concerns with Resident #212's d/c. On 4/23/25 at 11:32 AM, the survey team met with the LNHA and DSS. The DSS stated the resident chose to go home because they did not want to have to pay for services if they were denied appeal. The DSS and LNHA did not dispute that there were no other options offered to the resident to stay in facility. The DSS stated that she called several home care agencies and finally got one after a second call to take the resident's case but there would be a delay of about a week to get therapy services in home. The DSS continued to assert that the resident was very worried about being able to pay and elected to go home. Furthermore, the DSS provided to the surveyor a copy of an e-mail sent to the resident with the contact information for the home health service that was willing to take the case. The email also reflected that there was a delay in physical therapy services. The facility did not provide any further pertinent information. N.J.A.C. 8:39-4.1(a)30,32

2. On 4/17/25 at 12:10 PM, Surveyor #2 (S#2) observed in the dining room six residents during lunch. S#2 also observed the vending machine had papers on top of it and the surveyor asked the Licensed Practical Nurse Supervisor (LPNS) what those papers were. The LPNS took the paper on top of the vending machine and showed it to S#2. The papers were emergency crash care checklist. On that same date and time, S#2 asked why the emergency crash care checklist last date was for September 2021 (9/24/21, last day it was filled out and signed), and the LPNS checked the other papers, and it were all for 2021 and 2020. There were no papers for 2022, 2023, 2024, and 2025. At that same time, S#2 observed a sign for AED (stands for automated external defibrillator, a device that can help those experiencing sudden cardiac arrest) in the dining room. S#2 asked the LPNS where the AED was located and the e-cart, and LPNS did not have a response. Then, the Regional Food Service Director (RFSD) came and helped the LPNS and surveyor to find the AED and the e-cart. Afterward, S#2, the LPNS, and the RFSD found the AED and e-cart in the next room next to the dining area. S#2, in the presence of the LPNS and RFSD observed the following expired supplies in the e-cart and inside the AED box: -ambu bag (also known as a manual resuscitator or bag valve mask, is a device used to provide respiratory support to patients in emergency and non-emergency situations. It consists of a self-inflating bag, a mask or mouthpiece, and a valve to control the flow of air) with a use by date of 211110. According to the FSD, the ambu bag was expired because the date 211110 meant November 10, 2021, for use by date. - suction tubing non-conductive sterile, use by date 2021-12-30 that was attached to the suction machine the tip and the tubing inside a bag. According to the RFSD, the suction tubing was expired. - prefilled humidifier 340 ml (milliliters) sterile water date 2024-12-16. The RFSD acknowledged that the prefilled humidifier sterile water was also expired and should not be in the e-cart. -the unopened AED pad, use before date of 2023-04-21 and the opened AED with a use before date of 2023-4-21. The RFSD stated and confirmed that AED pads were all expired and would be replaced. At that same time, S#2, LPNS, and the RFSD did not see a cardiac board and oxygen (O2) tank as indicated in the checklist. The LPNS and RFSD had no response when asked by S#2 why there was no O2 tank and cardiac board in the e-cart. S#2 also asked the LPNS and RFSD who was responsible for checking the e-cart, the AED, and filling out the emergency crash care checklist, and both LPNS and RFSD did not respond. On 4/21/25 at 12:58 PM, the survey team met with the LNHA and DON. The LNHA and DON acknowledged S#2's concerns about the expired supplies for e-cart and AED pads. A review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation (CPR) Policy, with a reviewed date of 6/2024, that was provided by the DON, revealed under Emergency Procedure-CPR . 7. When the AED arrives, assess for need and follow AED protocol as indicated. a. Check AED machine for function daily, including battery test, extra AED pads available for use . On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse, and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:39-11.2(b), 29.2(d) REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physician's order with regard to medication with parameters for 1 of 4 residents, (Resident #44) and b.) ensure that the emergency cart (e-cart) was routinely check and supplies were not expired for 1 of 3 e-cart inspected, according to the standard of clinical practice and facility policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 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. 1. On 4/16/25 at 10:02 AM, Surveyor #1 (S#1) observed Resident #44 in their room, lying in bed with the television on. The resident stated that they were in the facility for Physical Therapy because two months ago they had a left leg surgical amputation and will see the surgeon in June for possible prosthesis. A review of the medical records of Resident #44, an admission Record (AR, an admission summary) revealed diagnosis that included but not limited to; hypertension (the pressure of blood circulating around the body is higher than normal), complete traumatic amputation at level between knee and ankle, left lower leg, subsequent encounter, and acquired absence of left leg below knee, gangrene, not elsewhere classified. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of (ARD) 3/8/25, revealed a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had intact cognition. A review of the resident's Order Summary Report reflected a physician's orders (PO): -start date 2/27/25, Metoprolol Tartrate Oral Tablet (tab) 50 mg (milligram), give 0.5 tab by mouth two times a day for hypertension (HTN). Hold if SBP (systolic blood pressure, is the first number, it is the pressure caused by your heart contracting and pushing out blood.) is less than 110 or HR (heart rate) less than 55. -start date 2/27/25 at 9:00 AM-d/c (discontinued) date 4/11/25 at 10:00 AM, Losartan Potassium Oral tab 50 mg, give 0.5 tab by mouth one time a day for HTN. Hold if SBP is less than 110 or HR less than 55. -start date 4/12/25 at 9:00 AM, Losartan Potassium Oral tab 50 mg, give 0.5 tab by mouth one time a day for HTN. Hold if SBP is less than 110 or HR less than 55. 0.5 tab = 25 mg. The above PO were transcribed to the electronic Medication Administration Record (eMAR) and revealed: Metoprolol Tartrate was found to have been given outside the SBP parameters on: 2/11/25 with a SBP of 109/63 at 8:00 AM (8 AM); 3/7/25 with a SBP of 98/60 at 5:00 PM, administered by License Practical Nurse (LPN) #1, 3/8/25 with SBP of 101/70 at 8 AM, 3/25/25 with SBP of 109/53 at 8 AM, administered by LPN #2, 4/18/25 with SBP of 108/66 at 8 AM, administered by LPN #2. Losartan Potassium Oral Tablet was found to have been given out of parameters on: 4/12/25 with a SBP of 108/62 at 9:00 AM (9 AM), administered by LPN #2, 4/18/25 with a SBP of 108/66 at 9 AM, administered by LPN #2. On 4/22/25 at 9:34 AM, S#1 interviewed LPN #2 regarding Metoprolol and Losartan medications (meds). The surveyor and LPN #2 reviewed the April 2025 eMAR, and LPN #2 stated, Instead of me clicking hold I pushed given but it was not given. It was an accident. LPN #2 further stated that the meds should have been held and follow the parameters when the blood pressure (BP) was below the parameters. LPN#2 also stated yes, I should have documented it, I should have double checked myself. On 4/22/25 at 1:13 PM, S#1 notified the License Nursing Home Administrator (LNHA), DON, Regional DON (RDON), and Chief Operating Officer (COO), regarding concerns with not following the PO for BP parameters for Metoprolol and Losartan. On 4/22/25 at 2:10 PM, the DON stated regarding meds with parameters, the nurses were expected to follow the PO for BP parameters and to document if it was outside the parameters. The DON further stated, I do weekly in-services, some were agency nurses, and yes the expectations are the same, they were in serviced too. On 4/22/25 at 2:15 PM, S#1 reviewed the in-services completed by the DON dated 3/8/25, for ensuring parameters were noted when administering BP meds, which revealed, both LPN#1 and LPN#2 signed the attendance sheet. A review of the facility's Administering Medications Using Electronic System Policy, dated 10/2024, that was provided by the DON, revealed on the Policy Statement: Meds shall be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation #3, further revealed, meds must be administered in accordance with doctor's orders, including any required time frame and following medication cautionary .

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 1 of 5 days during the annual re-certification survey. This deficient practice was evidenced by the following: On 4/16/25 at 9:00 AM, the survey team entered the facility. The surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the receptionist. The NHRCSR posted was dated 4/16/25 with a census of 60, for the [7:00 AM to 3:00 PM] day shift. On 4/16/25 at 9:30 AM, in the presence of the survey team, the admission Director, stated that the census (total number of residents) was 61. On 4/16/25 at 9:40 AM, the surveyor interviewed the License Practical Nurse/Unit Manage (LPN/UM) for both Units, who stated that census was 60. On 4/16/25 at 12:40 PM, the surveyor showed a copy of the NHRCSR posted on 4/16/25 from the receptionist desk and the census given by the LPN/UM as 60, to the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and the DON both confirmed the Census was 61. The LNHA stated, There was an admission before midnight last night, so the correct census is 61. On 4/17/25 at 9:00 AM, the surveyor interviewed the Receptionist. The surveyor asked the Receptionist what the process was of posting the NHRCSR, and she stated, I am responsible for posting and updating the form. The admission person will update the system for census and that is how I get my information. In the weekend, we will leave the forms on Friday for the weekend receptionist to post and update it. She further stated that she made a mistake yesterday with the census, I did not know there was an admission the night before, but I fixed it and posted the correct one. On 4/17/25 at 9:30 AM, the surveyor asked the LNHA regarding the incorrect posting of the NHRCSR census yesterday, 4/16/25, it was posted as a census of 60 and the census was 61. The LNHA confirmed that, The form needed to be corrected when admission staff comes in and put it in the system. On 4/21/25 at 9:50 AM, the LNHA stated that there was no policy for posting the staffing. On 4/21/25 at 12:59 PM, the survey team met with the LNHA and the DON to notify them of the above concern with posting. The surveyor asked what the expectation was for posting, and the LNHA responded that the expectation was after the admission person gets in and goes through the census line and updates the staffing, the posting will be done. The LNHA further stated they had an admission, and they did not clear the census line yet when the day the surveyors came in. The LNHA also stated that the admission staff gets in around 9:30 AM. At that same time, the LNHA confirmed, The visiting hours are 8:00 AM-8:00 PM. The expectation is for visitors to see the accurate posting when they come in the morning. On 4/22/25 at 9:32 AM, the LNHA responded regarding staffing posting/census updates, Moving forward, in the event the receptionist and/or admissions director is not in the facility, the nursing supervisor will be responsible to update the staffing posting at the front desk. Education has been initiated. NJAC 8:39-41.2(a,b,c,d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #33). The deficient practice was evidenced by the following: The surveyor reviewed Resident #33's electronic medical record (EMR) which revealed the following: A review of Resident #33's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia, (a reduced number of red blood cells) and major depressive disorder (persistent depressed mood). A review of Resident #33's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/20/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #33 had no cognitive impairment. A review of Resident #33's Order Summary Report (OSR), a listing of the resident's active physician's orders, revealed the following active as needed (PRN) medication (med) orders: Acetaminophen tablet (tab) (a pain reliever) 325 mg (milligram), give 2 tab by mouth every 4 hours PRN for pain- Mild Scale=1-3. Percocet Oral tab 5-325 mg Oxycodone w/Acetaminophen (a narcotic pain reliever), give 1 tab by mouth every 12 hours PRN for pain- Moderate Scale 4-7, Pain-Severe Scale=8-10. Percocet Oral tab 5-325 mg Oxycodone w/Acetaminophen, give 1 tab by mouth every 12 hours PRN for pain-Severe Scale=8-10. Tramadol HCL Oral tab 50 mg (a prescription pain reliever), give 1 tab by mouth every 12 hours PRN for pain- Moderate Scale=4-7. A review of the resident's electronic Medication Administration Record (eMAR) reflected the same orders that were found on the OSR. A review of the resident's Pain Assessment/Evaluation dated 2/21/25, reflected that the resident reported occasional generalized pain over the past five days daily with a scale of five or moderate. A review of the resident's Comprehensive Care Plan dated 2/27/25, reflects a Focus, Goals, and Intervention put in place for pain treatment. On 4/21/25 at 11:08 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN). The surveyor asked if and how the resident expresses or verbalizes pain. The LPN/CN stated that Resident #33 verbalized their needs and any pain well. The LPN/CN further stated that mostly generalized pain, usually upon waking, with some muscle spasms. The surveyor asked the LPN/CN about Resident #33's PRN medications (meds) used for pain. At that same time, the surveyor asked how the nursing staff differentiates which med or how much to give as there were multiple orders. The LPN/CN stated yes that it could be confusing for which order to use as it looks [NAME] there was a duplicate and that one tab of Percocet for moderate pain and the same dose for severe pain was confusing as well. The surveyor asked the LPN/CN about the resident's Tramadol order. The LPN/CN stated that they would call the resident's primary physician (MD) to clarify the PRN orders and find out which Percocet order to keep and what to do with the Tramadol. On 4/21/25 at 11:33 AM the surveyor interviewed Resident #33 in their room. The resident stated they were doing okay, and that the pain med makes the pain tolerable. The resident stated the staff do come to give pain meds when they ask. On 4/21/25 at 11:50 AM, the Director of Nursing (DON) stated that Resident #33's MD will be called to clarify the PRN pain orders as they could be confusing. On 4/21/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss concerns for duplicate Percocet and pain orders for Resident #33. A review of the facility's Administering Medications Using Electronic System Policy, dated as updated 11/2024, reflected, under item 4. If a dosage is believed to be inappropriate .the person preparing or administering the med shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The LNHA did not provide any further pertinent information. N.J.A.C. 8:39-27.1(a)

**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 ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 5 residents. There were 26 opportunities for error, 2 errors were observed which calculated to a med administration error rate of 7.69%. This deficient practice was identified for 1 of 5 residents, (Resident #3), that was administered meds by 1 of 3 nurses that were observed. 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 4/17/25 at 8:23 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare meds for Resident #3. The meds included an active physician's orders (PO) for the following: Docusate Sodium 100 mg (milligram) capsules (cap) give 1 cap by mouth two times a day for constipation. (a med that softens the stool). Albuterol Sulfate HFA Inhalation Aerosol 108 mcg (microgram) 1 puff inhale orally two times a day for asthma. (a med that opens the lung airways). Trelegy Elipta Inhalation Powder Breath Activated 100-62.5-25 mcg 1 puff inhale orally every 12 hours for asthma. (a combination of 3 long-acting powder meds, that reduce lung inflammation and relax airway muscles). The surveyor observed the LPN prepare and administer Resident #3's meds which included one (1) Docusate Sodium 100 mg tablet. The surveyor then observed the LPN administer the inhaled meds to the resident. The LPN first administered the Albuterol, had the resident rinse their mouth, then immediately after, administer the Trelegy and have the resident rinse their mouth. The surveyor asked the LPN to show him the stock bottle that they took the Docusate from and compare it to what was indicated on the electronic Medication Administration Record (eMAR) that reflected the PO. The LPN showed the surveyor the bottle that she took the Docusate from and stated it reflected tablets. The LPN compared it to the eMAR and stated that the order reflected capsules. The LPN then located another Docusate bottle in the med cart (med-cart) that reflected capsules. The LPN stated she should have used those. The surveyor asked the LPN if there was a procedure that was followed when a resident was administered two or more inhaled meds, specifically if there was any waiting time. The LPN stated yes, I think you should wait a minute, maybe two between inhalers. The surveyor completed the med pass observation with the LPN. The surveyor reviewed the electronic medical record (EMR) for Resident #3 including, but not limited to, the Order Summary Report (OSR), a listing of the resident's active PO, and eMAR. Both the OSR and eMAR reflected orders for: Docusate Sodium 100 mg cap give 1 cap by mouth two times a day for constipation to be given at 9:00 AM and 5:00 PM. Albuterol Sulfate HFA Inhalation Aerosol 108 mcg 1 puff inhale orally two times a day for asthma to be given at 9:00 AM and 5:00 PM. Trelegy Elipta Inhalation Powder Breath Activated 100-62.5-25 mcg 1 puff inhale orally every 12 hours for asthma to be given at 9:00 AM and 9:00 PM. On 4/17/25 at 12:01 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) by telephone. The surveyor asked the CP if they did any education on medication pass (medpass), specifically using inhalers and following physician orders. The CP stated yes, education was done, the staff gets a copy of the in-service, and it includes topics on checking the medication against the eMAR and separating different inhalers by 1 to 2 minutes. On 4/21/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss concerns with medpass. A review of the reference material [name] Drug Guide for Nursing Students, 14th Edition, reflected, administer bronchodilators first and wait several minutes before administering inhaled corticosteroids to allow optimal penetration . A review of the facility's Administering Medications Using Electronic System Policy, dated updated 11/2024, reflected under item 3. Meds must be administered in accordance with doctor's orders, . and under item 6. The individual administering the med must check the label three times to verify the right med, . The LNHA did not provide any further pertinent information. N.J.A.C 8:39-29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring, a.) that the Infection Preventionist Nurse (IPN) was aware in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread and b.) the water management plan was implemented. This deficient practice was identified for 1 of 2 positive water testing results reviewed. This deficient practice was evidenced by the following: According to Centers for Disease Control & Prevention (CDC), Water Management in Healthcare Facilities, March 15, 2024, Key points: CDC recommends that healthcare facilities develop and implement comprehensive water management programs. They can help reduce the risk for Legionella growth and transmission. They can also help control other waterborne pathogens. On 4/21/25 at 9:04 AM, the surveyor interviewed the Director of Maintenance (DoM), who informed the surveyor that he was responsible for water management in the building, and it was facility's process to do annual test of water for Legionella. The surveyor asked for the policy and procedure for water management and water testing results, and the DoM said he would get back to the surveyor. On 4/21/25 at 9:16 AM, the DoM provided Water Management binder that included water testing results and Water Management Plan. The surveyor asked the DoM for the monitoring and accountability log that the plan was implemented, and the DoM said he would get back to the surveyor and will ask the Regional Maintenance Director (RMD). A review of the provided Laboratory Certificate of Results dated 3/6/24, revealed, room [ROOM NUMBER] bath sink with comment PR. The comment table for PR indicated that any numerical result is a cause for concern. Further review of the provided Laboratory Certificate of Results, revealed, dated 3/26/24, for a sample date of 3/25/24, reflected that room [ROOM NUMBER] bath sink comment not detected. A review of the provided documentation for Water Management Plan and binder, revealed, the following Control Measures to follow for the following but not limited to risk factors: -Eyewash Station. Plumbed units are to be activated weekly to flush the line and verify operation; at least a 3-minute flush is recommended. -Ice Machine. Clean and disinfect ice machine based on equipment manufacturer's instructions. Change filter and clean, if installed. -Medical Device. Clean and sterilize medical devices according to the manufacturers' instructions in their prescribed manner and procedure; or as required or necessary as determined by the Program Team. -[NAME] Filter/Point of Use Filter. Replace as directed according to the manufacturers' instructions; or as required or necessary as determined by the Program Team. -Expansion Tank. Check for leaks, calcifications and corrosion around attachment fittings. Frequency: annually. -Water Heater. Check flow and return temperatures (temp) at hot water heater. Monitoring: Supply temp should be checked at the outlet of the hot water heater and should not be lower than 140 degrees Fahrenheit (F). The return temp should also be checked monthly and should not be lower than 122 degrees F. -Backflow Preventer/Check Valve. Identify and test the integrity of all backflow preventers and check valves to ensure protection of domestic water from cross-contamination with processed water through a building code-approved method. Frequency: Biannually or as required by state or local authorities. -Cooling Tower. Check the appearance of the recirculation water, check if clean and clear without sediment or foaming. Frequency: weekly. -Electronic and Manual Faucets. Ensure typical daily use of the faucet occurs. The water flow decreases the possibility of bacterial colonization. -Infrequently Used Fixtures. Flush infrequently used fixtures. Flush for several minutes, until temp stabilizes and is comparable to supply water. Frequency: twice weekly where users are at high risk, weekly in all other buildings. -Showerhead, Hose, and Sink. Replace or dismantle, disinfect, and eliminate all deposits of scale from all shower heads, hoses, sinks, aerators or flow restrictors. Frequency: quarterly or as necessary. Further review of the reports, documents, and binder provided by the DoM, revealed that there was no accountability log on the above risk factors and followed the control measures for Water Management. On 4/21/25 at 10:18 AM, the RMD was unable to provide documentation and accountability log for the above water management monitoring, and what was done to correct the detected Legionella on 3/6/24. The RMD stated that whatever was provided to the surveyor would be the process the facility followed. The RMD also stated that the 3/6/24 detected or positive results for Legionella testing was corrected after following the water management plan, and that was why the 3/25/24 report came out not detected when another test was done. The RMD further stated that he was unsure what was missing in the report and documents provided but he would get back to the surveyor. On 4/21/25 at 9:35 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the above concerns with Legionella and that surveyor asked the Regional Director of Nursing (RDON) for the documents regarding the Legionella positive test on 3/6/24. The LNHA stated that she was aware and that they were putting all the documents together to be given to the surveyor. On 4/22/25 at 1:45 PM, the surveyor asked the LNHA for the monitoring and accountability log done in accordance with the Water Management Plan of the facility that was previously asked by the surveyor, and the LNHA stated that she would get back to the surveyor. On 4/23/25 at 8:29 AM, the surveyor met with the DoM for a follow up interview about the water management implementation, and the DoM stated that they have the plan that was in the binder. The surveyor asked the DoM what the facility should do with their plan, and he did not respond. The surveyor asked how the facility monitor and follow the water management plan, and he responded that he checks water temperature (temp) routinely. The surveyor asked to provide documentation, and he said he would get back to the surveyor. On 4/23/25 at 8:38 AM, the surveyor and the Regional Food Service Director (RFSD) went to the eye wash station near the reception area. Both the surveyor and the RFSD observed the eye wash was covered with brownish hard substances. The surveyor asked the RFSD what the brown substances was, and the RFSD stated that it looks like chocolate. The RFSD stated that it should have been cleaned. On 4/23/25 at 8:43 AM, the surveyor interviewed the LNHA, DON, and the Infection Preventionist Nurse (IPN) regarding the water management. The IPN informed the surveyor that it was the DoM who was responsible for water management and as an IPN she should be aware of the results of the water testing and if there would be a positive test that could affect the resident. The surveyor asked the IPN if she was made aware that the February 2025 test had an issue with one tube broken and the last year report was positive, and the IPN responded that she was unaware of the February 2025 issue and that she was not at the facility yet at the time on March 2024. The IPN stated that I know they must check the temp and any issue or concern I need to be aware. On that same date and time, the DON stated that there should be a report to local health department if there was a positive result. The surveyor notified the LNHA, DON, and IPN of the above concerns that for the last four days since the entrance conference meeting, the surveyor asked for documentation and an accountability log for the water management plan implementation, and the facility was unable to provide documentation. The surveyor also notified the LNHA, DON, and IPN about the concern with the eye wash area, and the IPN stated that it should have been cleaned. On 4/23/25 at 9:06 AM, the surveyor in the presence of the LNHA and IPN went to the DoM's office. Inside the office was also the RMD. The surveyor asked and followed up with the DoM the monitoring and accountability log that the surveyor asked, and the RMD stated that he did not know what else the surveyor was asking for if the facility had provided the water management plan. The DoM was unable to provide documentation and accountability log except for the water temp log. On 4/23/25 at 9:12 AM, the surveyor, LNHA, and the IPN went to the Spectrum Unit shower room. The surveyor, LNHA, and IPN observed the shower head with whitish substances. The surveyor asked the LNHA and the IPN what was the white substances, and the LNHA stated it was the calcium deposit, while the IPN stated it was the soap residue. Both acknowledged that it should have been cleaned and if the water flushing was being done according to the water management plan, that should have been checked and corrected. On 4/23/25 at 9:22 AM, the DoM, in the presence of the survey team informed the surveyor that to be honest, I was unable to follow the Water Management Plan with regard to monitoring what supposed to monitor except for the water temp routinely. He further stated that he checked the eyewash monthly, but he did not have an accountability log to show the surveyor. On 4/23/25 at 9:34 AM, the survey team met with the LNHA to discuss the above concerns with water management that the plan was not all implemented, and that the DoM had no accountability log for the monitoring of risk factors except for the water temp log. The LNHA stated that she was not the administrator in March 2024, she knew that when the result was positive for legionella testing, it should have been communicated to the local health department and test resident if applicable. On that same date and time, the LNHA confirmed that according to the provided documents to the surveyor the facility followed the recommendation of the vendor with regard to flushing, unable to provide documentation, it was tested back again and came out negative. She further stated that it was an expectation to follow the water management plan and there should be an accountability for monitoring on what was on the plan. She also stated that she just found out after surveyor's inquiry that it was not being done accordingly. She acknowledged also what the RMD had stated to the surveyor earlier that he was unsure what was the surveyor was asking for, but it should have been done. On 4/23/25 at 9:41 AM, the DoM came back and stated to the survey team that he wanted to correct himself that he was checking the eye wash station weekly, and not monthly, and that he did not have an accountability to show the surveyor. A review of the facility's Legionella Water Management Program Policy, with a revised date of July 2017, that was provided by the LNHA, revealed under Policy Interpretation and Implementation . 5. The water management program includes the following elements . f. The control limits or parameters that are acceptable and that are monitored . j. Documentation of the program. A review of the facility's Infection Preventionist Job Description that was provided by the LNHA, revealed under Position Responsibilities and Qualifications, in this key position, essential job duties and responsibilities include: -Partners with the Medical Directors and medial personnel to implement and evaluate infection prevention goals and action plan . -Oversees the operations of the infection prevention, epidemiology, industrial hygiene, and relevant safety programs, -Accountable for surveillance of healthcare acquired and community acquired infections . On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, Regional DON, IPN, and Chief Operating Officer for an exit conference. The LNHA did not provide additional information. NJAC 8:39-19.1, 19.4(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice, by failing to ensure; a.) physicians' orders and approved plan of care were followed, b.) provider's (consultant) recommendation was followed through for 1 of 17 residents, (Resident #27), from March 2024 through April 2025, for a total of 13 months, and c.) routine Braden scale assessment was done for residents with history of facility acquired wounds, for 1 of 2 residents, (Resident #27), reviewed for pressure ulcer. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/17/25 at 8:30 AM, the surveyor observed Resident #27 inside their room eating breakfast. The surveyor reviewed the resident's diet slip and revealed that orange juice (OJ) was not provided to the resident's meal tray. The resident's fluid restriction indicated in their diet slip was 1500 ml/day (milliliters/day) fluid restriction and the amount of 600 ml was below coffee. The surveyor observed the following fluids that were in the meal tray were 4 ounces (oz) regular milk and a cup of coffee. The resident confirmed that they supposed to have the OJ and stated, probably, they do not have it. On 4/17/25 at 8:33 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the breakfast tray of the resident and what was in the diet slip that the resident received. The LPN/CN confirmed the resident did not have an OJ in their meal tray as part of the diet slip. The LPN/CN stated that the diet slip did not have a breakdown of the amount of fluids resident received, except for the information that the total fluid restriction was 1500 ml/day and below the coffee 600 ml. She further stated that it should have been clarified. On 4/17/25 at 8:43 AM, the surveyor went to the kitchen and met with the Regional Food Service Director (RFSD) and the facility FSD. The surveyor asked the RFSD and FSD if the facility had OJ. The RFSD then asked the FSD if the facility had the pre-poured OJ, and the FSD stated they do not have it, but they have the fountain for OJ. On that same date and time, the surveyor notified the RFSD of the concern that the diet slip did not match what the resident supposed to get about OJ, and that the resident's fluid restriction was not clear for amount of each fluid for milk, OJ, and coffee. The surveyor asked the RFSD the oz and ml per cup of coffee, OJ, and milk the resident should receive, and the RFSD stated that she would get back to the surveyor. On 4/17/25 at 8:55 AM, the RFSD provided the fluid restriction information. After reviewing, the surveyor asked the RFSD, how do staff know in the information provided how much milk, juice, and coffee to give if they were not included in the diet slip, and the RFSD stated that she would get back to the surveyor. The RFSD further stated, as far as she knew, the facility had only one type of coffee container for meals, unsure of how many oz the coffee container, and it was 4 oz for juice and milk. A review of the provided Fluid Restriction information by the RFSD, revealed that the 1500 ml/24 hour fluid restriction included: -All liquids shift: 7 AM-3 PM (7:00 AM-3:00 PM) shift 1320 ml: Dietary Breakfast tray=600 ml, Dietary Lunch tray=420 ml, Nurse 7-3 shift 300 ml 3 PM-11 PM (3:00 PM-11:00 PM) shift 420 ml: Dietary Dinner tray=300 ml, Nurse 3-11 shift=120 ml 11 PM-7 AM (11:00 PM-7:00 AM) shift 60 ml: Nurse 11-7 shift=60 ml The surveyor reviewed the medical records of Resident #27, and revealed: A review of the admission Record (an admission summary) reflected that Resident #27 was admitted to the facility with medical diagnoses which included but not limited to; unspecified systolic (congestive) heart failure, essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and anemia (deficiency of healthy red blood cells in blood. Red blood cells (RBCs) are essential to carry oxygen to all parts of the body). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 4/15/25, with a brief interview for mental status (BIMS) score of 14 out of 15, reflected that the resident's cognition was intact. A review of the current Resident #27's personalized care plan (CP) reflected a focus CP for altered cardiovascular status related to (r/t) diagnosis (dx) of HTN (hypertension), PVD (Peripheral vascular disease is a slow and progressive disorder of the blood vessels), and new dx of CHF (congestive heart failure occurs when the heart is unable to pump blood throughout the body efficiently) that was initiated on 8/12/24. The CP interventions included but were not limited to; cardio/vascular medications as ordered, fluid restriction of 1.5 L/day (liters/day) [1500 ml/day], and notify MD (medical doctor) of significant abnormalities. Further review of the CP reflected a focus for potential for impairment of skin integrity r/t history of DTI (deep tissue injury, refers to damage that occurs beneath the skin's surface, affecting muscles, bones, or connective tissues), impaired mobility, and bladder and bowel incontinence that was initiated on 7/30/22, and revised on 11/15/22. The CP interventions included but were not limited to, educate resident/family/caregivers of causative factors and measures to prevent skin injury and follow facility protocols for treatment of injury. A review of the Braden Scale (standardized, evidence-based tool to assess and document a patient's risk for developing pressure injuries) for Predicting Pressure Score Risk revealed that the most recent assessment was done 1/10/25, with a score of 13, which reflected that resident had moderate risk. A review of the Report of Consultation of Nephologist revealed: -3/21/24, recommendations: increase Furosemide (also known as Lasix, a diuretic (water pill) medication (med) that prevents body from absorbing too much salt, causing it to be passed in urine. Lasix treats fluid retention (edema) in people with congestive heart failure, liver disease, or kidney disorders such as nephrotic syndrome) to 40 mg (milligram) BID (twice a day). -9/19/24, recommendations: continue with Lasix 40 mg BID. There was a handwritten note from the LPN/CN that the recommendations were noted and carried out. -3/20/25, recommendations: increase Lasix 40 mg BID. A review of the March 2024 Progress Notes (PN) revealed that there was no documented evidence that the MD was notified of the recommendation to increase the Lasix BID, or documented evidence that the recommendation was declined or followed through. A review of the 6/21/24 Nurse Practitioner PN, revealed, the resident was seen and examined in their room, the bp (blood pressure) was controlled since nephrology increased furosemide to 40 mg BID, the case was discussed with the MD, and the plan was approved. A review of the 11/4/24 and 12/2/24 Physician Assistant PN revealed, the resident was seen and examined in their room, the bp was controlled since nephrology increased furosemide to 40 mg BID, the case was discussed with the MD, and the plan was approved. A review of the 3/20/25 PN of Licensed Practical Nurse #1 (LPN#1) revealed that Resident #27 had an appointment today with the Nephologist and returned from the appointment with recommendations of Lasix 40 mg BID, and orders carried out. A review of the Physician's Orders (PO) from March 21, 2024, through April 17, 2025, the recommendation and plan for Lasix 40 mg BID was not carried out and followed, and revealed: -order date 2/24/25, CHF: Fluid restriction 1500 ml/24 hour every day shift 1080 ml (Nursing=240 ml, Dietary Breakfast tray=600 ml & Dietary lunch tray=240 ml), Every evening shift 360 ml (Nursing=120 ml, Dietary Dinner tray=240 ml), and Every night shift 60 ml (Nursing) -order date 1/28/25, Lasix oral tablet (tab) 40 mg, give one tab by mouth once a day for CHF. On 4/22/25 at 8:21 AM, the surveyor asked the LPN/CN to go with the surveyor to resident's room and to check resident's breakfast. Inside the room, the resident informed the surveyor that they just about to start breakfast. Both the surveyor and the LPN/CN observed the breakfast tray with 4 oz of OJ, 8 oz of regular milk, 8 oz coffee, two pancakes, scrambled egg, and farina. The LPN/CN confirmed the fluid amount by ounces. Outside the resident's room, the LPN/CN confirmed that the resident should have received 8 oz of milk on 4/17/25, and 4 oz of OJ to total 600 ml for breakfast. In the nursing station, the surveyor asked the LPN/CN to review the resident's electronic medical records (EMR). The LPN/CN informed the surveyor that Resident # 27 was cognitively intact, non-compliant with fluid restriction which the family and physicians were aware, and with order for Lasix 40 mg once day. The LPN/CN also stated, I think resident used to be on Lasix 20 mg and it was increased to 40 mg. She further stated that the resident with order for ace wrap in lower extremities due to chronic legs edema, no SOB (shortness of breath), and being followed up by nephrologist. Upon opening the computer, the LPN/CN stated that with regard to Nephrologist consult on 3/21/24, the nurse should have a documentation, and notified the physician about the recommendation of the Nephrologist for Lasix 40 mg BID in the PN. The LPN/CN confirmed that the PN of the Nurse Practitioner on 6/21/24, was about that the primary physician agreed with the plan for Lasix 40 mg BID. The LPN/CN also stated that on 9/19/24, the Nephrologist consult that the Lasix should be on 40 mg BID, and she did not know what happened why it was not followed. She also confirmed that on 9/19/24 PN of the nurse documented that resident should be on Lasix 40 mg BID, and that the physician agreed should be followed. She further stated that the Physician Assistant documented on 11/5/24, that the primary physician agreed on Lasix 40 mg BID should have been followed, as well as the 3/20/25 PN of the nurse documented that the Lasix 40 mg BID physician notified and ordered. At that time, the LPN/CN acknowledged that the resident should have been on Lasix 40 mg BID from 3/21/24 through April 2025. On 4/22/25 at 8:48 AM, the surveyor asked the LPN/CN about Braden scale, and the LPN/CN responded that as per facility's process and policy, it was being done by nurses as scheduled quarterly, and usually within the period or date of quarterly MDS. The LPN/CN also stated that it should be in the assessment of the EMR, and it will show in red if needed to be done. She further stated that it was important to do the Braden assessment, specially for the resident with pressure ulcer or at risk for pressure ulcer, like history of pressure ulcer to determine plan of care and prevent wound. At that time, the surveyor notified the LPN/CN of the concern that the Braden assessment was in red in the EMR, and the last Braden was done on 1/10/25. The LPN/CN checked the EMR and stated that the Braden should have been done on 4/15/25. She acknowledged that it was red in the assessment which meant that it should have been done, and she stated that it was overdue. On 4/22/25 at 12:52 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON (RDON), and Chief Operating Officer (COO). The LNHA stated that we did the in service for fluid restriction and following order for each resident, and following proper meal tickets for choices. The RDON stated that I am still investigating the concern with Resident # 27's Nephrologist recommendation for Lasix 40 mg BID, and we are waiting for the return call of the physician. On that same date and time, the surveyor also notified of the concern regarding the Braden scale not done. The RDON confirmed that the policy that was provided today, for Pressure Ulcer Risk Assessment discussed about risk assessment, and it was the Braden assessment that was being identified in the policy. The following policies were provided by the RDON on 4/22/25 at 11:57 AM: -A review of the facility's Pressure Ulcer Risk Assessment Policy, with revised date of October 2010, revealed under Assessment: 1. Risk Assessment: a pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes . -A review of the facility's Nutritional Assessment Policy, with a reviewed date of 10/2024, did not include information about fluid restriction. -A review of the facility's Resident Hydration and Prevention of Dehydration Policy, with a revised date of December 2008, revealed under Policy Interpretation and Implementation . 8. Orders may be written for extra fluids to be encouraged between meals and/or with med passes. A specific minimum amount should be included in the order (e.g. 240 ml fluids BID with med pass) . On 4/22/25 at 2:24 PM, the RFSD provided a copy of the resident's diet slip that included the ounces in the fluids and she stated that the diet slip should have the amount in fluids for fluid restriction. On 4/23/25 at 11:59 AM, the survey team met with the LNHA, DON, and RDON. The RDON stated that there were three dates the resident went to the Nephrologist with recommendations to increase Lasix BID 40 mg, 2 of 3 nurses documented that orders were carried out. The RDON further stated that we did an investigation, it was the LPN/CN, LPN#1, and LPN#2 were the nurses involved. The RDON also stated that LPN#2 was not at the facility anymore, who never called the physician to notify the recommendation to increase the Lasix. She further stated that disciplinary action was provided to other nurses for this was considered a med error. At that same time, the RDON informed the surveyor that we called the current physician about the above concerns with Lasix. The RDON further stated that the physician told her that he would not increase this time the Lasix because the resident was stable. The RDON also stated that we called the cardiologist and did not recommend this time to increase the Lasix but added another blood pressure med and a PN was documented yesterday after surveyor's inquiry. She further stated that the Assistant DON did an assessment yesterday and no negative effect, the resident was not hospitalized , and we also audited all medical records yesterday to make sure that we did not miss anything from the consultant recommendations, we realized it could get out of hand, the good thing no negative outcome. Furthermore, the RDON stated another Braden scale was done yesterday. On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse, and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:39-3.2(a,b); 11.2(b); 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to notify the resident's representative in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #60 reviewed for hospitalization. The deficient practice was evidenced by the following: On 2/21/23 at 11:50 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #60. The nurse progress notes revealed that the resident was transferred to the hospital on 1/25/23 at 2:45PM. According to the Discharge Minimum Data Set, an assessment tool used to facilitate the management of care dated 1/25/23, reflected that Resident #60 was discharged to the hospital with a return not anticipated to the facility. On 2/22/23 at 12:07 PM, the surveyor interviewed the facility's Social Services Director who provided a documentation indicating that the Long-Term Care Ombudsman was notified. However, the resident's responsible party was not provided with a written notification of the reason for an emergency transfer. A review of the facility's policy titled, Making an Emergency Transfer or Discharge with a review date on 6/2022. 1.) Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedure . e. Notify the representative (sponsor) or other family member. On 2/22/23 at 12:45 PM, the survey team met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse and Infection Preventionist. The above concern was discussed. There was no further information provided. NJAC 8:39-5.3; 5.4

**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 professional standards of practice to hold a medication used to treat high blood pressure in accordance with the physician's order (PO) for 2 of 2 residents reviewed, Resident #50 and Resident #59. The deficient practice is evidenced by the following: Reference: New Jersey Statuses 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 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 otherwised 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 casefinding; 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 [DATE] at 11:35 AM, the surveyor observed Resident #50 in bed in his/her room. The surveyor reviewed Resident #50's hybrid medical records that revealed the following: The admission Record (an admission summary) revealed that Resident #50 was admitted to the facility with a diagnosis that included but not limited to Hypertensive Heart Disease with Heart Failure. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. The January and February 2023 electronic Medication Administration Record (eMAR) included a physician's order for Amlodipine Besylate 5 mg tablet- Give 1 tablet by mouth two times a day for Hypertension with a start date of [DATE]. The medication had instructions to obtain blood pressure (BP) and to hold the medication if the Systolic Blood Pressure (SBP) (top number of a blood pressure reading) was less than 110 and Heart Rate (HR) less than 55. A review of the documentation on the eMAR revealed that the medication Amlodipine Besylate was administered once in [DATE] and 4 times in February 2023 when the medication should have been held due to SBP below 110. On [DATE] at 11:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) and discussed the above concern. LPN #1 acknowledged that the BP medication was administered and should have been held due to SBP below 110. LPN #1 stated, the nurses should ensure that they check three times prior to administering the blood pressure medication and to make sure the blood pressure and heart rate are not outside the parameters. 2. On [DATE] at 9:53AM, the surveyor reviewed the hybrid medical records for Resident #59. The resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. A review of the electronic Order Summary Report for [DATE] reflected a PO dated [DATE] for a medication, Hydrochlorothiazide tablet. The PO specified to give 1 tablet (25mg) by mouth one time a day for Hypertension and to hold the medication for SBP less than 110. Further review of the electronic PO reflected an order dated [DATE] for a medication, Metoprolol Tartrate tablet. The PO specified to give 1 tablet (25mg) by mouth two times a day for Hypertension and to hold the medication for a SBP less than 110 and HR less than 55. A review of the eMAR for [DATE] through [DATE] reflected that the medication Hydrochlorothiazide was to be administered at 0900 (9AM). The eMAR reflected that the Hydorchlorothiazide was signed as given when the resident's SBP was less than 110. Further review of the documentation on the eMAR revealed that the medication was administered 2 times in [DATE] times in [DATE], and 7 times in [DATE]. A review of the eMAR for [DATE] through [DATE] reflected that the medication Metoprolol Tartrate was to be administered at 0830 (8:30AM and 1630 (4:30PM). The eMAR reflected that the Metoprolol Tartrate was signed as given when the resident's SBP was less than 110 and heart rate was less than 55. Further review of the documentation in the eMAR revealed that the medication was administered 3 times in [DATE] times in [DATE], and 9 times in [DATE]. A review of the facility policy titled, Administering Medications Using Electronic System (PCC), with a revised date of [DATE] under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. A further review of the policy under Policy Interpretation and Implementation indicated, 3. Medications must be administered in accordance with doctor's orders, including any required time frame and following medication cautionary. 7. The following information must be check/verified for each resident prior to administering medication: .b. Vital signs, if necessary. On [DATE] at 12:49 PM, the team met with the Licensed Nursing Home Administrator (LNHA), Regional Nurse, Director of Nursing (DON), and Infection Preventionist (IP). The surveyor discussed the above concern. The DON acknowledged that the blood pressure medications should have been held as indicated in the PO. NJAC 8:39- 29.2 (d)

Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was observed and evidenced by the following: On 2/15/23 at 10:00 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: At 10:20 AM, in the presence of the FSD, the surveyor observed the following in the walk-in refrigerator: 1. One fan covered with a heavy build up of a gray fuzzy substance. The FSD identified the substance as dust build up and acknowledged that the substance could dislodge from air blowing and go onto the food. 2. On all the wire racks in the refrigerator (five racks with four shelves each), the surveyor observed a sticky brown and black debris (which could be wiped off with a paper towel). The FSD was unable to identify the substances. The surveyor further observed the following during the kitchen tour in the presence of the FSD: 3. The dual stack standing oven had a white chalk-like substance on the side of the top oven doors and a gray dust like substance on the top on the oven. The substance was able to be wiped off with a paper towel. The FSD was unable to identify the substance. 4. A small shelf connected to the back of the six-range stove top had a heavy buildup of a sticky green colored substance. The FSD described it as grease. The substance was able to be partially wiped off with a paper towel. 5. The top of the steamer was observed with a heavy build-up of a brown and black-colored caked on substance. The substance was not able to be wiped off with a paper towel. The FSD was unable to identify the substance. On 2/15/23 at 10:50 AM, the FSD stated, the walk-in refrigerator should be cleaned weekly and all the other equipments should be cleaned daily at the end of the evening shift. The FSD provided the surveyor with a copy of the daily cleaning schedule which revealed that from 2/1/23 through 2/15/23 the kitchen shelves were being checked off as cleaned. The FSD could not speak to the accountability of cleaning the walk-in refrigerator and other kitchen equipment. A review of the facility policy titled, Cleaning and Sanitation of Equipment with a revised dated of 9/13/2022 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 cleaned and sanitized equipment are stored dry so as to prevent bacteria growth. A further review of the policy under Procedure indicated Cleaning and Sanitation: 1. Refrigerator - Walk-In. Shelving. Frequency: Weekly. a. Remove all food shelves b. Scrub shelves with sanitizing solution and clean cloth. DO NOT USE ABRASIVES. c. Wash walls with sanitizing solution and clean cloth. d. Allow air dry. e. Return food to shelves. 2. Oven - Convection - Frequency: Immediate. a. Remove spills, spillovers, and burned food deposits. Frequency: Daily a. Wipe cool over exterior and interior with wet cloth. b. Remove and scrape drip pans, send through dishwasher cycle, and allow air dry. Frequency: Weekly a. Wipe and clean oven exterior. Use damp cloth. On 2/17/23 at 12:45 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing and discussed the above concerns during the initial kitchen tour. The LNHA acknowleged with the findings above. No further information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident #24. This deficient practice was evidenced by the following: On 3/8/21 at 10:38 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) perform a wound treatment for Resident #24's hospital-acquired right heel wound; LPN #2 assisted LPN #1 with the positioning of the resident during the treatment. The surveyor reviewed the March 2021 Physician Order Summary, which reflected a Physicians' order (PO) to cleanse the right heel wound with ¼ strength Dakin's Solution, pat dry, apply Santyl, Mupirocin, Calcium Alginate Wound Dressing, and cover with a dry dressing daily. The PO was noted on the March 2021 Electronic Treatment Administration Record. The surveyor observed LPN #1 wash his hands, put on gloves, and disinfect the over-bed table with Super Sani-Cloth Germicidal Disposable Wipes, which have a recommended 2 minute dwell time (the amount of time it takes for the product to disinfect the surface properly.) LPN #1 immediately covered the over-bed table with a plastic barrier without waiting the 2 minute dwell time. LPN #1 then disinfected scissors with a Sani-Cloth Wipe, opened the treatment cart outside of the room, gathered all the supplies, and opened the supplies wearing the same contaminated gloves. The surveyor then observed LPN #1 remove the previously contaminated gloves, wash his hands, put on a new set of gloves. LPN #1 removed the Sterile Calcium Alginate Wound Dressing from its sterile package and placed it directly onto the plastic barrier. LPN #1 also placed a plastic trash bag on top of the resident's bed to discard all contaminated supplies. The surveyor observed LPN #1 wash his hands, change to a clean set of gloves, remove the heel boot, remove the soiled dressing, tossed the contaminated dressing into the plastic garbage bag located on the resident's bed. LPN #1 then approached his treatment cart located in the hallway, still wearing the contaminated gloves, and obtained a paper measuring ruler. The surveyor observed LPN #1 continued to do the treatment; He washed his hands, changed to a clean set of gloves, measured the wound, cleansed the wound with Dakin's solution, applied the Santyl, and Mupirocin Ointments. The surveyor stopped LPN#1 just before applying the Sterile Calcium Alginate Wound Dressing and asked LPN #1 to step outside of the room. The surveyor asked LPN #1 why he completely removed the Sterile Calcium Alginate Wound Dressing from its packaging and placed it directly on the barrier pad, contaminating the pad. LPN #1 replied that he should have left the Sterile Calcium Alginate Wound Dressing in its Sterile package. On 3/8/21 at 11:53 AM, the surveyor interviewed LPN #1 and discussed the breaks in Infection Control technique. LPN #1 acknowledged that he should have removed his gloves and sanitized his hands after cleaning the table and scissors before exiting the Resident's room and obtaining supplies from the treatment cart. He further stated that he hadn't been aware that the Sani-Wipes had a 2 minute dwell time. LPN #1 also recognized that he should not have completely removed the Calcium Alginate Wound Dressing from its packaging and placed it onto the barrier pad but should have left the dressing in its original packaging. The surveyor reviewed the admission Minimum Data Set (MDS), an assessment tool dated 11/22/20 with a Brief Interview for Mental Status score of 12, which reflected the resident had a moderately impaired cognition. The surveyor reviewed the Admission/readmission Screening Skin Evaluation, which indicated that Resident #24 was admitted from the hospital with a stage 4 wound to the right heel, which measured 10 cm x 7 cm with eschar, slough, and biofilm (a thin film of bacteria that adheres to a surface.) The surveyor reviewed the wound evaluation & management summary dated 12/18/20, which reflected the wound measured 8 x 6 cm. The surveyor reviewed the wound evaluation & management summary dated 3/5/21, which reflected the wound measured 2 x 2.8 x 0.1 cm with 90% granulation tissue. The wound was healing and was noticeably smaller in size. The surveyor reviewed the facility's Handwashing/Hand Hygiene policy dated as revised November 2020. The policy's statement reflected, This facility considers hand hygiene the primary means to prevent the spread of infection. Further review reflected that use of an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap and water should be used : a. before handling clean or soiled dressings b. after contact with a resident's intact skin c. after handling soiled dressings d. after removing gloves. On 3/8/21 at 1:39 PM, the survey team met with the LNHA and DON; The facility provided no further information. NJAC 8-39-19.4 (a)