**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00173585 Based on interviews, medical record review, and review of other pertinent facility documents on 6/25/24 it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policies and procedures for 1 of 4 residents (Resident #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Fracture of Unspecified Part of the Neck of the Right Femur, Parkinson Disease, and History of fall. The Minimum Data Set (MDS), an assessment tool, dated 2/5/24, revealed a Brief Interview of Mental Status (BIMS) of 0 which indicated the resident's cognition was severely impaired and the resident needed assistance with ADLs including toileting, eating, and transfer. A Care Plan (CP), initiated on 1/31/24 included that the Resident was dependent for ADL care. Review of Resident #3's DSR (ADL Record) and the progress notes (PN) for the month of 2/2024 revealed lack of documentation to indicate that the care for toileting, eating, and transfer was provided and/or the resident refused care on the following dates and shifts. Toileting and Transfer: 7:00 a.m.-3:00 p.m. shift on 2/2/24, 2/4/24, 2/6/24, 2/9/24, 2/10/24, 2/12/24, 2/13/24, 2/17/24, 2/18/24, and 2/19/24. 3:00 p.m.-11:00 p.m. shift on 2/3/24, 2/4/24, 2/5/24, 2/8/24, 2/9/24, 2/10/24, 2/15/24, 2/18/24, and 2/19/24. 11:00 p.m.-7:00 a.m. shift on 2/9/24, 2/11/24, 2/14/24, 2/15/24, 2/17/24, and 2/19/24. For Eating: On 2/13/24 and 2/17/24 to 2/19/24 at 8:00 am, on 2/2/24, 2/9/24, 2/10/24, 2/13/24, and 2/17/24 to 2/19/24 at 12:00 p.m., and on 2/2/24 to 2/5/24, 2/8/24 to 2/14/24, 2/18/24, and 2/19/24 at 6:00 p.m. During an interview with the surveyors on 6/25/24 at 1:00 p.m., Certified Nursing Assistants (CNA #1), who took care of Resident #3, stated that CNAs are responsible for documenting the ADL care provided into the Point of Care (POC), a mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation, at the end of the shift. During an interview with the surveyors on 6/25/24 at 1:24 p.m., the Unit Manager/Licensed Practical Nurse (UM/LPN#1), stated that CNAs were responsible for documenting the ADL care provided into the POC. The UM/LPN further stated that the CNAs need to document in the DSR even if the care was not provided due to refusal. She explained that the documentation must be completed in the residents' DSR by the end of each shift to show that the care was provided to the residents. During an interview with the surveyors on 6/25/24 at 2:58 p.m., the Director of Nursing (DON) stated that the CNA's were expected to document ADL care provided to the residents by the end of the shift in the DSR. She explained that Nurses, UMs, and ADON were to check the documentation to ensure that the DSR is completed at the end of the shift. The DON could not explain why there were blanks in the resident's DSR. Review of the facility policy titled Nursing Documentation, revised on 5/1/23, reflected POLICY Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's .condition, situation, and complexity .Documentation for subsequent and/or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools .Nursing documentation will follow established policies and procedures and federal and state regulations .PRACTICE STANDARDS 1. Documentation of nursing care is recorded in the medical record and is reflective of the care provided by nursing staff .3. Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion as outlined by other policies and procedures . Review of a facility policy titled Activities of Daily Living (ADLS), revised 5/1/23, reflected Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices the Center must provide the necessary care and services to ensure that a patients activities of daily living (ADL) abilities are maintained or improved and to not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. Activities of daily living (ADLs) include .Elimination - toileting .5. Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real time, as close to the time that care was provided, and information obtained as possible. ADL care is documented every shift by the nursing assistant. 5.1 The licensed nurse will document ADL care they provided, when applicable . NJAC 8:39-35.2(d)(9)

**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 issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for 1 of 3 residents (Resident #71) reviewed for facility change notifications. The deficient practice is as follows: The facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed Resident #71's Beneficiary Notification list which indicated that the resident was discharged from a Medicare Part A stay at the facility and was documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident # 71 was admitted to the facility on [DATE]. The last documented covered day of coverage for Medicare Part A service was 1/11/24. The facility did not present the resident with the proper required SNFABN form to notify them of the termination of insurance. On 2/2/24 at 11:45 AM, the facility Social Worker (SW) stated this resident had episode start date of 11/15/23 and last covered day for Medicare Part A was 1/11/24 and the SNFABN form was overlooked due to the position of the person completing this task is now remote and the previous person doing this task did complete and provide the appropriate forms. On 2/2/4 at 1:45 PM, the surveyor informed the Director of Nursing of the above concerns identified. No further documentation was provided. NJAC 8:39-5.4 (b)(c)

Based on observation, interview, and record review it was determined the facility failed to accurately assess a resident utilizing the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 1 (#57) of 30 residents reviewed for accuracy of assessment and is detailed as follows. On 1/30/24 at 11:36 AM, the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. The resident was admitted to the facility receiving hospice services and continued receiving services without interruption up to the time of the Standard survey. A review of the 12/31/23 Quarterly MDS, Section O, indicated the resident was no longer receiving hospice services. On 02/05/24 at 09:42 AM, the Director of Nursing confirmed that the resident continued to receive hospice services during the assessment period for the 12/31/23 MDS. A corrected MDS was submitted on 2/5/24 following the discussion with the DON. NJAC 8:39 - 33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for 1 of 27 residents reviewed for comprehensive care plans (Resident #79). This deficient practice was evidenced by the following: On 1/30/24 at 11:40 AM, the surveyor observed Resident #79 out of bed to a wheelchair, watching TV. The resident's room front door had a signage stop instructing the use of specific personal protective equipment (PPE) during care and before entering the room. Outside the resident's room are two plastic storage carts containing a box of gloves, gowns, masks, and goggles. The surveyor reviewed Resident #79 hybrid medical record (paper and electronic) which revealed the following: According to the admission Record (an admission summary), Resident #79 was admitted to the facility with diagnoses that included but were not limited to personal history of other infectious and parasitic (organism that lives in a host) diseases and Cerebral Infarction (disrupted blood flow to the brain). The Annual Minimum Data Set (MDS), an assessment tool to facilitate care, dated 12/17/23, indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 15 out of 15, which indicated that the resident is cognitively intact. A review of the progress note, dated 1/26/24 at 14:26, stated, Call received back from GI that they wanted to start patient on Vancomycin 125 mg qid x 10 days for recurrent c-diff infection. Patient is currently having one to two loose bm's at this time and has been on precautions for re-current c-diff. A review of the medication administration report with the started date on 1/27/24 revealed: Vancomycin HCl Oral Suspension (Vancomycin HCl) Give 125 mg by mouth four times a day for re-current C-diff for 10 Days. A review of the laboratory test with the received date on 1/4/24 stated, C. difficile toxin A/B result Positive. A review of the resident's care plan revealed no CP addressed the resident's actual clostridium difficile (a bacteria that causes diarrhea) (c-diff) infection. On 2/1/24 at 12:50 PM, the surveyor interviewed a Licensed Practical Nurse/Unit Manager. She stated she didn't know that the care plan for c-diff was resolved and that she had the care plan added. On 2/6/24 at 12:32 PM, the surveyor informed the Director of Nursing about the above concerns; the facility provided no additional information. A review of the facility's policy and procedure with a revision date of 10/24/22 stated, Care plan includes measurable objectives and timetables to meet the patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. NJAC 8:39-11.2(e)

Based on observation, interview, and record review it was determined the facility failed to revise a resident's care plan to reflect their current needs related to a fall and fracture. The deficient practice was cited for 1 of 30 residents (#57) reviewed for comprehensive resident-centered care planning and is evidenced by the following. On 1/30/24 at 11:36 AM the surveyor observed Resident #57 seated in a wheelchair in the nursing unit hallway. The surveyor again observed the resident on 01/31/24 at 09:45 AM seated in a wheelchair in the day room. A review of the electronic medical record revealed the following information. An 11/2/23 progress noted written at 17:50 revealed the resident fell from their wheelchair while self-propelling the chair in the hallway of the nursing unit. The surveyor reviewed the resident's current comprehensive care plan provided by the Director of Nursing (DON) on 2/1/24 at 11/30/24. The focus area of the fall care plan initiated on 6/30/23 and revised on 10/10/23 indicated the resident was at risk for falls due to cognitive loss and lack of safety awareness. The fall care plan focus area did not address the actual fall on 11/2/23 which resulted in a wrist fracture nor did it address additional interventions to care for the resident's additional needs. The pain care plan indicated the resident exhibited or was at risk for alterations in comfort related to a fracture of right wrist. The DON stated to the surveyor on 2/5/24 at 11:45 PM that the fall care plan should have been updated following the fall and fracture on 11/2/23. The care plan was revised to reflect this on 2/5/24 following the discussion. A review of the facility's policy and procedure revised on 10/24/22 indicated care plans should include measurable objectives and timetables to meet the patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. NJAC 8:39-11.2(f)(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents in accordance with professional standards of practice for one of two residents, (Resident #1) reviewed for respiratory care. This deficient practice was evidenced by the following: On 1/30/24 at 11:30 AM, the surveyor observed the oxygen signage by the door of Resident #1. The surveyor observed Resident #1 lying in bed, the oxygen concentrator by the left side of the bed with oxygen at 2 1/2 liters/minute, nasal cannula laying on the side of the mattress, no shortness of breath noted, oxygen tubing dated 1/19/24. The resident stated, I use my oxygen on and off every day. On 1/31/24 at 10:20 AM, observed the resident lying in bed with oxygen use on 2 1/2 liters/minute via nasal cannula and tubing dated 1/19/24. On 1/31/24 10:34 AM, the surveyor interviewed the primary nurse License Practical Nurse (LPN), who has been working in facility since July 2023. She stated, The resident is on oxygen as needed for shortness of breath.The Unit Manager (UM), LPN, who has been working here for 15 years, stated, The respiratory therapist changes the oxygen tubing every Friday. On 2/1/24 at 08:55 AM, observed the resident with oxygen use via nasal cannula on 2 1/2 liters/minute with the same tubing dated 1/19/24. The UM came into the room and acknowledged that the tubing should have been changed last week. On 2/1/24 at 09:30 AM, the Respiratory Therapist (RT) who has been working in the facility since January 2024, stated, I change the tubing every week, I had an emergency last week and had to leave. Usually, nursing will take over to change the tubing. On 2/2/24 at 1:20 PM, the surveyor informed the Director of Nursing (DON) and the Regional Director of Clinical Services, concerns regarding the care of oxygen tubing. The DON acknowledged and stated, Nursing should take over caring for oxygen tubing when respiratory therapist is not around, and it should be changed weekly. A record review of the resident's Electronic Health Record (EHR) revealed a diagnosis of shortness of breath (SOB) and Congestive Heart Failure (CHF), a condition in which the heart does not pump blood as well as it should. A record review of the order summary in the EHR revealed orders for: Oxygen tubing change weekly label each component with date and initials every Friday day shift. Oxygen at 2 1/2 liters as needed (PRN) for SOB, ordered 12/6/23. Respiratory Therapy (RT)- Evaluation & treatment as recommended, ordered 6/21/23. A review of the Minimum Data Set (MDS), a facility assessment tool, of the resident's Quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. A review of the resident's care plan revealed care plan for at risk for respiratory complications related to SOB and interventions for weekly oxygen tubing change. On 2/05/24 at 11:33 AM, the surveyor reviewed the most current policy and procedure titled, Respiratory Management, dated 12/1/21 which revealed, If respiratory care is needed, it will be performed by a licensed nurse who has been trained and has demonstrated competency. NJAC 8.39-25.2(c)3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FRI NJ00162201 Based on observation, interview, and record review of pertinent documentation, it was determined that the facility failed to implement their abuse policy and written regulations based on protecting their residents after the abuse investigation. This deficient practice was identified for one of two residents (Resident #91) reviewed for following the facility's abuse policy. The deficient practice was evidenced by the following: The surveyor investigated the Facility Reported Incident (FRI) sent in by the Executive Director, Licensed Nursing Home Administrator (LNHA) to the Department of Health (DOH) on 3/8/23 based on a resident to resident altercation between the Resident #91 and the Resident #39, which revealed the following: The facility reported that on 3/8/23, a staff member heard yelling from room [ROOM NUMBER]. Upon responding, the staff found Resident #91 (room [ROOM NUMBER]) walking out of Resident #39's (room [ROOM NUMBER]) room and stated, I didn't do anything get out of my way. Resident #39 stated, [she/he] was in here pulling my hair hard and pushing my chair. The Resident #91 was redirected back to their own room [ROOM NUMBER] next door. No injury or redness was noted to both residents. The facility reported that they didn't know what provoked the incident because it was unwitnessed. The family, Nurse Practitioner, [Name Reducted] Behavioral Health Services, Ombudsman, and police were notified. The resident was placed on one to one until the police arrived. According to Resident #91's care plan, the next time such behavior happened to send resident to crisis center. The resident went to the hospital via ambulance where the resident was found to have pneumonia and returned with antibiotic orders. The hospital emergency (ED) department record revealed, reason for visit to the ED is combative and diagnoses of dementia with aggressive behavior. The resident was ambulatory upon return from the hospital. A review of Registered Nurse (RN) statement on 3/8/23 confirmed the unwitnessed incident, Resident #91 went into Resident #39's room and pulled their hair. A review of the Order Summary for March of 2023 revealed the resident was on Doxycycline Hyclate (antibiotic to treat bacterial infections), one tablet of 100mg two times a day by mouth for 10 days for pneumonia (lung infection) when resident returned from the hospital; Olanzapine (antipsychotic) tablet 5mg 1 tablet by mouth one time a day for psychosis, ordered 3/7/23. A review of the [Name Redacted] Psychiatry NP progress notes on 3/9/23, one day after the ED visit, revealed, observe behaviors, send to crisis if behavior gets out of control, consider 1:1if unable to redirect, medications reviewed. A review of a general nursing note LPN documentation on 3/10/23 at 1:00, two days after the ED visit, stated, Resident noted ambulating in hallway this shift, no behaviors at this time. A record review of Resident #91's records revealed: diagnoses of unspecified dementia, depression, anxiety. A Quarterly Minimum Data Set (MDS), an assessment tool on 12/12/22, revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. The Care Plan review revealed: potential to demonstrate verbal and physical behaviors related to cognitive loss/dementia. The care plan intervention review revealed: monitor for pain; monitor for behaviors; remove resident from environment; provide a calm environment; social service support; divert resident and give activities; send to crisis center if behaviors worsen. On 1/30/24 at 11:45 AM, the surveyor observed the resident lying in bed, able to answer questions but confused. The resident's sister was in the room and stated, She/He has dementia, the incident happened last year with another resident but there were no injuries. She/He used to walk around in patient rooms but stopped doing that. On 2/2/24 at 12:10 PM, the surveyor interviewed Resident #39, who was sitting on a wheelchair in their room and stated, [Resident name] came in my room from next door because she/he thinks this is their room. There were no other incidents after that. She/He never came in and did it again. I feel safe now in my room. On 2/2/24 at 12:16 PM, interviewed Certified Nursing Assistant (CNA) who has been in the facility for three months. The resident stays in bed and gets out of bed 3x/week, it's their preference. On 2/2/24 at 12:22 PM, interviewed License Practical Nurse (LPN) who was the Unit Manager (UM) on the second floor. I am here, going on three years now, from what I remember, Resident #91was ambulatory, grabbed Resident #39's hair. Resident #91 was removed from the room, 1:1 supervision, called our psychiatry doctor and sent resident to emergency room. The resident came back and found to have pneumonia. Came back with antibiotic, and psychiatry did a medication adjustment. During any resident altercation we would separate them. She/He was still walking around in the unit after the hospital visit. I don't know why we didn't move her/his room when she/he came back from the hospital. There were no other incidents after that. It was a gradual process when she/he stopped walking. On 2/2/24 at 1:20 PM, the surveyor discussed with the Director of Nursing (DON) and the Regional Director of Clinical Services, concerns on how the facility did not provide a safe resident environment when Resident #91 came back from the hospital, knowing that the resident continued to ambulate around the unit. On 2/05/24 at 9:48 AM, the survey team met with the facility DON, Assistant DON, Director of PT, and IP for facility responses. The facility provided a fifteen-minute check log of Resident #91 on the day of the incident 3/8/23 but no 1:1 supervision log for when the resident came back from the ED visit. The survey team inquired if there is a resident-to-resident altercation, what would be the expectation be, the DON responded, Separate the residents involved and provide 1:1 supervision. The resident was not moved to another room at that time after returning from hospital. It should have been discussed after the resident returned from the hospital if room changed should have been done. There were no other altercations with Resident #91 and Resident #39 after the 3/8/23 incident. The resident gradually stopped ambulating around October of 2023 due to a change in condition. There was no additional documentation provided by the administration of 1:1 monitoring after resident returned from the hospital. Resident #91 and Resident #39 remained in their same rooms (222 and 223) and Resident #91 remained able to ambulate until October of 2023. A review of the investigation revealed the resident was able to ambulate until October of 2023. A review of the current facility policy and procedure dated 10/24/22 titled Abuse Prohibition revealed, patient who has in any way threatened or attacked another will be removed from the setting, options for room changes will be provided based on the situation. NJAC 8.39-13.4(c)2iii

Based on observation, interview, record review and review of other pertinent facility documentations, it was determined that the facility failed to evaluate the basis use or discontinuation of a gastrostomy tube device consistent with the resident's goals and wishes. This deficient practice was identified for one of two residents (Resident #83) reviewed. This deficient practice was evidenced by the following: On 1/30/24 at 11:20 AM, the surveyor observed the resident lying in bed. The resident stated, I have a tube, but I have not been using it for a long time. I have been asking them to remove it since I was admitted here about 2 1/2 years ago, everyone knows but they told me they can't find a doctor who can remove it because of my insurance. On 1/30/24 at 1:20 PM, the surveyor interviewed the Unit Manager (UM), License Practical Nurse (LPN) on the first floor, she stated, The resident does not use the tube, it's there because of the stroke the resident had in the past. The tube gets water flushes only. The resident and son does want the tube out but as per Social Worker, it's hard to find a doctor through the resident's insurance that can remove it. On 1/30/24 at 1:30 PM, a record review of the Electronic Health Records (EHR) revealed the Resident #83 is not getting feeding through the tube, the resident is receiving water flushes only every shift, the resident is on a regular diet by mouth, and no weight loss noted. On 1/30/24 at 1:30 PM, the UM gave a copy of a progress note done by the Social Worker (SW) on 5/19/23 at 13:48 stating, This worker spoke with [resident's name], DIL [daughter-in-law's name], and explained about [resident's name] request to get feeding tube removed. It was explained that team is having trouble finding a provider close by in her/his insurance plan. This worker advised that perhaps they may want to look into another insurance to better provide medical services for [resident name]. Will follow up and assist as needed. On 1/31/24 at 10:15 AM, observed the resident lying in bed and voluntarily showed the surveyor the gastrostomy tube (G-Tube/PEG), a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications, site on the abdominal area, which appeared intact, no redness, no swelling, no drainage. The resident stated, It's been bothering me lately for the last six months, it pulls at times and gives me discomfort. I eat and swallow everything by mouth including my medications, I don't need it. They can't find a doctor that takes my insurance. On 2/2/24 at 09:41 AM, the surveyor interviewed the Registered Dietitian (RD), who has been working in the facility for over 10 years. She stated, The resident has a tube and gets flushes for patency, does not need it for nutrition. It was brought up in Interdisciplinary Team (IDT) meeting and to the doctor that resident wants it taken out but there was something regarding her insurance. The resident does not need it for any medical reason. The weight is good, no issues with eating and does well. On 2/2/24 at 10:16 AM, interviewed the License Practical Nurse (LPN) on the first floor, she stated, I've been in this facility almost five years. I just flush it for patency, there was a discussion with the doctor who was trying to get in touch with the surgeon to remove it. The resident used to talk about it and wished to get it removed because she/he felt like she/he doesn't need it anymore. The resident does have a good appetite. On 2/2/24 at 10:23 AM, interviewed first floor Certified Nursing Assistance (CNA), who stated, I've been working here for years first through the agency. The only thing that the resident has mentioned she/he wants it taken out. On 2/2/24 at 10:28 AM, interviewed the resident, It's uncomfortable when it pulls at different times during the day, usually after it gets flushed. I usually tell my nurse that it bothers me, but she doesn't know why they haven't taken it out. I would like it to be taken out. I'm sure I've mentioned it during my care plans meetings. On 2/2/24 at 10:56 AM, the surveyor in the presence of another surveyor, interviewed the resident's primary physician, he stated, I don't recall if she/he was getting anymore tube feeding. I don't ever remember addressing it. If the tube is not being used, obviously the plan would be to remove the tube. She/He has never verbalized it to me that she/he wants it removed. She/He is not using it for medical or nutritional purposes. I don't know if water flushes would be a reason to keep it in. The IDT has not mentioned it to me. If a tube is not being used, we normally not recommend keeping it in, it would be unreasonable. I agree that the tube is unnecessary. The surveyor read the progress note of the SW from 5/19/23 and the doctor replied, Residents sometimes do not get the services needed because of insurance, it's insurance driven. The survey team informed the doctor that the facility is ultimately responsible for the resident's care regardless of insurance. On 2/2/24 at 11:20 AM, interviewed the Social Worker (SW) who stated, I've been here over a year. From what I understand, she/he has a tube, but they just flushed it. She/He wanted it out. UM and nurses were aware but was having trouble with insurance. I have informed the team during morning meeting and clinical meetings; it was mentioned to administration. The family have to look into the insurance. I am not aware that the facility is responsible to cover the cost. On 2/2/24 at 12:44 PM, interviewed the resident and stated, I didn't ask for pain medication because it's not that serious and I get tylenol anyway and that helps. I would like it taken out because it bothers me when it pulls and after the flushes. A record review of the EHR revealed the resident's diagnoses of: hemiplegia following cerebrovascular disease affecting left non-dominant side; encounter for attention to gastrostomy; personal history of transient ischemic attack and cerebral infarction without residual deficits. A review of the order summary revealed: Flush tube with 200 ML of water every 8 hours. total volume of flush to equal 600 ML/24hrs every shift for patency, ordered 7/30/21, end date 3/13/22; Flush tube with 200 ML of water every 8 hours, total volume of flush to equal 600 ML/24hrs every shift for patency, ordered 3/13/22; Regular diet ordered 7/30/21. A review of the resident's Minimum Data Set (MDS), an assessment tool, Quarterly MDS on 11/2/23 revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. A review of the resident's care plan revealed an intervention created on 12/11/23 to recommend Medical Director (MD) re-evaluate need for tube as resident is a no tube feed order. A review of the RD's note on 1/4/2024 revealed, weight 109 pounds stable for resident. Diet is regular tolerated well. G-tube flush continues for maintenance of tube. The previous weight of resident on 6/8/23 was 108 pounds. On 2/2/24 at 1:20 PM, the surveyor discussed with the Director of Nursing (DON) and the Regional Director of Clinical Services, concerns regarding resident's requests for tube removal since admission of July 2021. The regional staff acknowledged that it is ultimately the facility's responsibility to meet the resident's needs regardless of insurance. A record review of the progress notes by the Nurse Practitioner (NP) on 2/2/2024 revealed: Chief Complaint / Nature of Presenting Problem: Patient wants Percutaneous endoscopic gastrostomy (PEG) tube removed. Patient requests PEG tube be removed: Patient requests removal of the PEG tube again today as she/he hasn't used the tube and she/he have no intention of having tube feeding again. Patient has not had complications related with the tube however it's bothering her/him. Of note, patient wanted to remove the PEG tube in the past. Additional documentation by NP on 12/03/23 revealed, She/He wants to remove the PEG tube permanently. On 2/5/24 at 9:00AM, received three staff LPN's statements dated 2/2/24, from DON, revealing, that resident has not voiced complaints of pain or discomfort when flushed. On 2/5/24 at 9:48 AM, the survey team met with DON, Assistant DON, Director of Physical Therapy, and Infection Preventionist and were asked if the insurance is not able to cover the service for PEG removal, who will be responsible for this, the DON replied, We're still going to take care of this if the insurance does not cover the service. On 2/2/24 at 10:25 AM, reviewed the facility's current policy and procedure titled Enteral Management dated 03/01/22 which revealed, The physician and interdisciplinary care team must review the basis of the enteral tube and the patient's current condition to determine if there is a continued rationale for its use and ensure that its continued use is consistent with the patient's treatment goals and wishes. NJAC 8.39-25.2(c)2i

11. Resident #10's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023, December 2023, and January 2024. 12. Resident #48's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 13. Resident #62's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 14. Resident #74's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 15. Resident #103's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 7. The surveyor reviewed the Resident #69 hybrid medical records which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023. 8. The surveyor reviewed the Resident #1 hybrid medical records which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 9. The surveyor reviewed the Resident #91 hybrid medical records which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023. 10. The surveyor reviewed the Resident #83 hybrid medical records which revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023 and January 2024. 16. The surveyor reviewed the OSR for Resident #35 which revealed that the physician did not sign and date the monthly OSR for November 2023, December 2023, and January 2024. 17. The surveyor reviewed the OSR for Resident #79 which revealed that the physician did not sign and date the monthly OSR for November 2023, December 2023, and January 2024. 18. The surveyor reviewed the OSR for Resident #102 which revealed that the physician did not sign and date the monthly OSR for November 2023, December 2023, and January 2024. On 1/30/24 at 10:56 AM, the surveyor observed Resident #35 in bed wearing a gown covered with a blanket, lying comfortably awake, alert, and able to answer the surveyor's inquiry. The surveyor reviewed Resident #35's hybrid medical records (paper and electronic). According to the admission Record (an admission summary) (AR), Resident #35 was admitted to the facility with diagnoses that included but were not limited to dementia (impairment of memory) mild with anxiety. A review of the PPN revealed that Resident #35's primary physician last documented that he had visited and examined the resident on 8/31/23. The NP, who worked with the primary physician, documented a practitioner progress note at least monthly when visiting and examining the resident between September 2023 and November 2023. The primary physician documented no progress note at least every 60 days between September 2023 to November 2023 to indicate a face-to-face visit and examination of Resident #35. The surveyor reviewed Resident #79's hybrid medical records. On 01/30/24 at 11:40 AM, the surveyor observed Resident #79 out of bed to a wheelchair, watching TV. According to the AR, Resident #79 was admitted to the facility with diagnoses that included but were not limited to Cerebral Infarction (disrupted blood flow to the brain). A review of PPN revealed that Resident #79's primary physician last documented that he had visited and examined the resident on 9/7/23. The NP, who worked with the primary physician, documented a practitioner progress note at least monthly when visiting and examining the resident between October 2023 to December 2023. The primary physician documented no progress note at least every 60 days between November 2023 and December 2023 to indicate a face-to-face visit and examination of Resident #79. On 02/02/24 at 1:41 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the missing signature of the physician's monthly order from the primary doctor and PPN. The LPN stated that the NP signed the monthly order, but the primary doctor and PPN were unsure. On 02/06/24 at 12:38 PM, the surveyor team informed the Director of Nursing (DON) of the concern regarding physician orders and visits and stated she was aware. A review of the facility policy titled Physician/Advanced Practice Provider (APP) Orders with a review date of 3/1/22 that the DON provided did not include information about monthly signed orders by the primary physician. A review of the facility policy titled Physician Services with a review date of 8/7/23 that the DON provided did not include information about physician's visits at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter or alternate 30-day visits by NP. NJAC 8:39-23.2(b)(d) 3. Resident #4's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023 and January 2024. 4. Resident #9's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023 and January 2024. 5. Resident #40's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023 and January 2024. 6. Resident #72's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for November 2023, December 2023 and January 2024. Based on observation, interview, and record review, it was determined that the facility failed to: a) assure that the physician responsible for supervising the care of residents signed and dated monthly physician's orders. This deficient practice was observed for 18 of 27 residents reviewed (Resident #110, 57, 4, 72, 9, 40, 69, 1, 91, 83, 48, 103, 62, 74, 10, 35, 79, and 102); and b) wrote physician progress notes (PPN) at least every 60 days with alternating nurse practitioner (NP) visits for 2 of 27 residents reviewed (#35 and #79). The deficient practices were evidenced by the following: 1. The surveyor reviewed the Order Summary Report (OSR) for Resident #110 which revealed that the physician did not sign and date the monthly OSR for the month of December 2023. 2. The surveyor reviewed the OSR for Resident #57 which revealed that the physician did not sign and date the monthly OSR for the month of January 2024.

Complaint NJ00163544 and NJ00161527 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties; and (3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum . A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports was performed during the Standard survey of 2/6/2024. The Staffing Reports were divided into 3 time periods. The results are as follows: 1. For the week of Complaint staffing from 02/12/2023 to 02/18/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in CNAs to total staff on 3 of 7 evening shifts, and deficient in total staff for residents on 2 of 7 overnight shifts as follows: -02/12/23 had 7 CNAs for 106 residents on the day shift, required at least 13 CNAs. -02/12/23 had 5.75 CNAs to 13 total staff on the evening shift, required at least 6 CNAs. -02/12/23 had 7.25 total staff for 106 residents on the overnight shift, required at least 8 total staff. -02/13/23 had 9.5 CNAs for 105 residents on the day shift, required at least 13 CNAs. -02/14/23 had 11 CNAs for 104 residents on the day shift, required at least 13 CNAs. -02/14/23 had 6 CNAs to 14.5 total staff on the evening shift, required at least 7 CNAs. -02/15/23 had 8.5 CNAs for 103 residents on the day shift, required at least 13 CNAs. -02/16/23 had 10 CNAs for 103 residents on the day shift, required at least 13 CNAs. -02/17/23 had 9 CNAs for 101 residents on the day shift, required at least 13 CNAs. -02/17/23 had 5.75 CNAs to 14 total staff on the evening shift, required at least 7 CNAs. -02/17/23 had 5.5 total staff for 101 residents on the overnight shift, required at least 7 total staff. -02/18/23 had 11.5 CNAs for 101 residents on the day shift, required at least 13 CNAs. 2. For the week of Complaint staffing from 04/16/2023 to 04/22/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in total staff for residents on 1 of 7 evening shifts, deficient in CNAs to total staff on 1 of 7 evening shifts and deficient in total staff for residents on 4 of 7 overnight shifts as follows: -04/16/23 had 9.25 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/16/23 had 6.75 total staff for 108 residents on the overnight shift, required at least 8 total staff. -04/17/23 had 8.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/17/23 had 6 total staff for 108 residents on the overnight shift, required at least 8 total staff. -04/18/23 had 8.25 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/19/23 had 7.5 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/19/23 had 6.5 total staff for 108 residents on the overnight shift, required at least 8 total staff. -04/20/23 had 9.75 CNAs for 109 residents on the day shift, required at least 14 CNAs. -04/21/23 had 9.25 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/21/23 had 5.25 CNAs to 16.25 total staff on the evening shift, required at least 8 CNAs. -04/22/23 had 5.75 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/22/23 had 10 total staff for 108 residents on the evening shift, required at least 11 total staff. -04/22/23 had 6.25 total staff for 108 residents on the overnight shift, required at least 8 total staff. 3. For the 2 weeks of staffing prior to the Standard survey from 01/14/2024 to 01/27/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in CNAs to total staff on 2 of 14 evening shifts as follows: -01/14/24 had 11.75 CNAs for 128 residents on the day shift, required at least 16 CNAs. -01/15/24 had 10 CNAs for 128 residents on the day shift, required at least 16 CNAs. -01/15/24 had 8.75 CNAs to 17.5 total staff on the evening shift, required at least 9 CNAs. -01/16/24 had 7.25 CNAs for 128 residents on the day shift, required at least 16 CNAs. -01/17/24 had 8.75 CNAs for 128 residents on the day shift, required at least 16 CNAs. -01/18/24 had 12 CNAs for 134 residents on the day shift, required at least 17 CNAs. -01/19/24 had 10.5 CNAs for 134 residents on the day shift, required at least 17 CNAs. -01/20/24 had 11.5 CNAs for 134 residents on the day shift, required at least 17 CNAs. -01/21/24 had 11.5 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/22/24 had 11.5 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/23/24 had 11.25 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/24/24 had 10 CNAs for 135 residents on the day shift, required at least 17 CNAs. -01/25/24 had 9.5 CNAs for 135 residents on the day shift, required at least 17 CNAs. -01/25/24 had 8.5 CNAs to 17.25 total staff on the evening shift, required at least 9 CNAs. -01/26/24 had 10 CNAs for 135 residents on the day shift, required at least 17 CNAs. -01/27/24 had 14.5 CNAs for 135 residents on the day shift, required at least 17 CNAs. During the Entrance Conference with the surveyor on 1/30/24 at 10:00 AM, the Administrator and Regional Director of Clinical Services stated that the facility is short staffed and that they were aware of the likelihood of being cited for deficient staffing. The surveyor toured the ground floor unit on 01/30/24 at 11:40 AM. A CNA stated to the surveyor that the facility is short staffed. She stated that staff has a hard time being able to get their work done and staff is concerned about this. The CNA stated that the facility administration is aware of the staffing storage. On 02/02/24 at 10:30 AM, a resident (Resident #1) who was attending the Resident Council Group Meeting stated to the surveyor that they did not get a shower for several weeks. The resident was given bed baths instead, but preferred to receive a shower. Another resident (Resident #2) attending the Group Meeting stated that getting a shower depends on which CNA is working. The resident stated when the regular CNA is off, showers are not given. Resident #1 stated that when their regularly scheduled CNA is off, they do not get their scheduled shower. On 02/02/24 at 10:32 AM, 5 of 6 residents at the Group Meeting stated call bell response can be slow on all shifts. Resident #2 stated there were too many call outs or no shows and those CNAs are not replaced. Resident #2 stated that the nurses try help the CNAs, but they are busy also. Resident #3 stated he/she recently used the call bell to get assistance for toileting. The resident stated there was a long wait time and as a result became incontinent. On 2/6/2024 at 4:00 p.m., the surveyor informed the Director of Nursing (DON) , Administrator and other administrative personnel of the staffing ratio concerns and related interviews with residents and staff. The surveyor reviewed the facility policy for staffing (revised 8/7/23) which was provided by the DON on 2/6/24. The 'purpose' of the policy indicated the facility will ensure that appropriate levels of staffing are scheduled and maintained. The 'process' of the policy indicated the facility will meet or exceed the staffing levels maintained by state and federal staffing. NJAC 8:39-25.1; 25.2(a)(b); 26.1.

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) clarification of a physician's order for the frequency of the application time of a medicated patch (Lidocaine) (an anesthetic medicated patch applied to relieve pain) for one (1) of five (5) residents, (Resident #53), observed during the medication administration observation, b.) vital parameters, blood pressure and heart rate, were obtained just prior to administration of medications that had physician's orders that based the results of the parameters on whether to administer the medications for (2) of five (5) residents, (Resident #53 and #113), observed during medication administration observation and c.) accurate documentation on the electronic medication administration records for four (4) of five (5) residents, (Resident #53, #84, #99 and #182), during the medication administration observation for two (2) of two (2) nurses observed during the medication administration observation. 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. The deficient practices were evidenced by the following: 1.On 2/1/24 at 10:20 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) administer a Lidocaine 4 percent (%) patch to the right knee of Resident #53 and attempted to administer another Lidocaine Patch 4% patch to the resident's lower back. At that time, the resident stated to the RN that he/she had not wanted the Lidocaine Patch applied to the lower back. The RN complied with the resident's request and had not applied the Lidocaine patch to the lower back. In addition, there was no observation of a Lidocaine patch being removed from either the right knee or lower back. On 2/1/24 at 10:26 AM, the surveyor interviewed the RN who stated that she worked per diem (as needed) but had worked in the facility frequently and was familiar with the resident's that had medications in that cart. The RN electronically signed for the administration of the Lidocaine 4% patch to the right knee in the electronic medication administration record (EMAR) and stated that the resident refused the Lidocaine to the lower back. The RN also stated that the removal of Lidocaine patches was signed separately from the application of the Lidocaine patch in the EMAR. The surveyor reviewed the medical record for Resident #53. A review of the Medication Review Report (MRR) revealed a physician's order (PO) with a start date of 12/5/23 for Lidocaine External Patch 4 %, Apply to right knee topically one time a day for pain management and remove per schedule. In addition, a PO with a start date for Lidocaine External Patch 4%, Apply to lower back topically one time a day for pain management and remove per schedule. A review of the EMAR revealed the above PO for the Lidocaine patches with an electronic signature for removal of both patches at a time of 8:59 AM. In addition, the EMAR reflected that the Lidocaine patch was applied to the lower back at 9:00 AM on 2/1/24. The surveyor observation was inconsistent with the EMAR documentation that both Lidocaine patches were removed at 8:59 AM and that the Lidocaine patch was applied to the lower back on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that a Lidocaine patch was to be applied for a maximum of 12 hours and that the PO should indicate the number of hours for application. The CP added that usually the EMAR would indicate the time of removal and the time of application separately for the nurses to sign. In addition, the CP stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. Further review of the MRR and the EMAR revealed that there was no indication in the PO as to the number of hours that the Lidocaine patch was to be applied for. On 2/2/24 at 1:21 PM, the survey team met with the Director of Nursing (DON) and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON stated that the Lidocaine patch PO to the lower back for Resident #53 had been discontinued because the resident no longer wanted the patch to be applied to the lower back. In addition, the DON acknowledged that the Lidocaine patch POs should have been clarified to indicate the number of hours for the application. The DON then stated that the Lidocaine patch PO to the right knee for the resident had been clarified for an application time and a removal time. The DON added that the RN was nervous and should have signed the EMAR for a refusal of the Lidocaine patch to the lower back. 2. On 2/1/24 at 9:57 AM, the surveyor observed the RN preparing to administer medications which included a 50 MG tablet of Hydralazine (a medication used to lower blood pressure (BP)) and Labetalol (a beta blocker medication used to lower BP) to Resident #113. The RN stated that according to the PO, the Hydralazine was to be held if the systolic blood pressure (SBP) was less than 130 and the Labetalol was to be held if the SBP was less than 120 and/or the heart rate (HR) was less than 60. The surveyor observed the RN refer to a paper and the RN stated that the resident's SBP was 176 and the HR was 67 so she was allowed to administer the medications. The surveyor had not observed the RN obtain a BP or HR from Resident #113. On 2/1/24 at 10:26 AM, the surveyor interviewed the RN who stated that she had written the vital signs that she had obtained for her residents on a paper that she was referring to. The RN then stated that she had taken the vital signs when she had done her rounds in the morning after report which was approximately 7:20 AM to 7:30 AM. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that vital signs such as a BP or HR should be taken just prior or close to the administration of a medication when a PO indicated to hold a medication based on the results of the vital signs. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the nurses should obtain vital signs such as a BP and HR for a PO with specific hold parameters just prior to the administration of the medication. 3. On 2/1/24 at 10:04 AM, the surveyor observed the RN preparing to administer medications which included a 30 MG tablet of Isosorbide Dinitrate (a medication used to lower BP) and Losartan (a medication used to lower BP) to Resident #53. The RN stated that both the medications had PO to hold the medications if the SBP was less than 110. The surveyor observed the RN refer to a paper and the RN stated that the resident's SBP was 152 so she was allowed to administer the medications. The surveyor had not observed the RN obtain a BP from Resident #53. On 2/1/24 at 10:26 AM, the surveyor interviewed the RN who stated that she had written the vital signs for her residents on a paper that she was referring to. The RN then stated that she had taken the vital signs when she had done her rounds in the morning after report which was approximately 7:20 AM to 7:30 AM. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that vital signs such as BP or HR should be taken just prior or close to the administration of a medication when a PO indicated to hold a medication based on the results of the vital signs. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the nurses should obtain vital signs such as a BP and HR for a PO with specific hold parameters just prior to the administration of the medication. 4. On 2/1/24 at 8:40 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #99 which included a 25 milligram (MG)/100 MG tablet of Carbidopa-Levodopa (Sinemet) (a medication used to treat movement disorders). At that time, the LPN stated that the PO for the Sinemet was highlighted in red on the EMAR because the time of administration was designated as due at 7:30 AM and the red highlight meant the time of administration was out of the timeframe of one hour before and/or one hour after the administration time. The LPN added that the PO indicated to administer the Sinemet before a meal and the breakfast had not been delivered yet, so she was able to administer the Sinemet. On 2/1/24 at 8:52 AM, the surveyor observed the LPN administer the Sinemet to Resident #99. The surveyor reviewed the medical record for Resident #99. A review of the EMAR revealed a PO with a start date of 7/8/23 for Carbidopa-Levodopa oral tablet 25-100 MG, Give 1 tablet by mouth before meals for Parkinson's. The EMAR also reflected that the LPN signed an administration time of 7:30 AM for 2/1/24. The surveyor observation was inconsistent with the EMAR documentation that Sinemet was administered at 7:30 AM on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the EMAR documentation should reflect accurately the time of administration. 5. On 2/1/24 at 10:04 AM, during the medication administration observation, the surveyor observed the RN preparing to administer medications to Resident #53. The RN stated that Bisoprolol 5 MG, (a beta blocker medication used for heart diseases such as high blood pressure), was due for administration but was unable to find the resident's Bisoprolol in the medication cart. At that time, the surveyor observed the RN tell the Unit Manager (UM)/Licensed Practical Nurse (LPN) that there was no supply of Bisoprolol for the resident. On 2/1/24/at 10:20 AM, the surveyor observed the RN administer medications to Resident #53. There was no observation that the Bisoprolol 5 MG was administered. On 2/1/24 at 10:27 AM, the surveyor observed the UM/LPN explain to the RN that the Nurse Practitioner was writing a PO to hold the Bisoprolol morning dose and that the Bisoprolol would be administered in the afternoon when the medication was received from the pharmacy provider. The surveyor reviewed the medical record for Resident #53. A review of the MRR revealed a PO with a start date of 7/29/23 and a discontinue date of 2/1/24 for Bisoprolol Fumarate Tablet 5 MG, Give 1 tablet by mouth one time a day for hypertension hold if dizziness or systolic blood pressure (SBP) less than 120. A review of the EMAR revealed the above PO with an electronic signature for the RN indicating that the Bisoprolol was administered at 9:00 AM on 2/1/24. Further review of the MRR and EMAR revealed a PO with a start date of 2/1/24 for Bisoprolol Fumarate Tablet 5 MG, Give 1 tablet by mouth one time a day for hypertension hold if dizziness or systolic blood pressure (SBP) less than 120. The EMAR revealed that the Bisoprolol was electronically signed as administered at 5:00 PM on 2/1/24. The surveyor observation was inconsistent with the EMAR documentation that the Bisoprolol was administered at 9:00 AM on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the RN should not have signed that the Bisoprolol was administered at 9AM and indicate the medication was held. The DON stated that the RN was nervous and should have signed the EMAR accurately. 6. On 2/1/24 at 9:18 AM, the surveyor observed the RN preparing to administer medications to Resident #182. The RN stated that according to the EMAR there was a PO for Senna Plus (a combination medication used to relieve constipation) which was a house stock medication, meaning that the facility provided the medication because Senna Plus was an over-the-counter medication. The RN then stated that she was unable to find a house stock bottle of Senna Plus in the medication cart. On 2/1/24 at 9:28 AM, the surveyor observed the RN tell the UM/LPN that she was unable to locate a house stock bottle of Senna Plus. On 2/1/24 at 9:47 AM, the surveyor observed the UM/LPN tell the RN that she was still looking for the Senna Plus but might have to get a PO to administer one tablet of Senna and one tablet of Colace, which are the ingredients of Senna Plus. On 2/1/24 at 9:54 AM, the surveyor observed the UM/LPN tell the RN that she found the Senna Plus and gave the RN a house stock bottle of Senna Plus tablets. On 2/1/24 at 9:56 AM, the surveyor observed the RN administer one tablet of Senna Plus to Resident #182. Upon returning to the medication cart, the RN stated that she was unable to sign the EMAR electronically for the administration possibly because the UM/LPN was changing the PO. The RN stated that the PO would be fixed, and she would sign for the administration of the Senna Plus. The surveyor reviewed the medical record for Resident #182. A review of the EMAR revealed a PO for Senna Plus with a start date of 1/19/24 and a time of administration for 9:00 AM and a Hold Date of 2/1/24 with a time of entry for 9:50 AM to continue until 2/2/24 with a time of 9:22 AM. There was a blank space meaning that there was no electronic signature that the Senna Plus had been administered on 2/1/24 at 9:00 AM. The EMAR documentation was inconsistent with the surveyor observation that the Senna Plus was administered at 9:00 AM on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON stated that the RN was nervous and should have signed the EMAR accurately. 7. On 2/1/24 at 8:58 AM, the surveyor observed the LPN preparing to administer medications to Resident #84. The LPN stated that the resident had a PO for Insulin, but she had to wait until the resident ate breakfast before administering the Insulin according to the PO that based whether to administer the Insulin on the resident's meal consumption. The surveyor had not observed the Insulin administration at that time because the resident's breakfast had not arrived. The surveyor reviewed the medical record for Resident #84. A review of the EMAR for Resident #84 revealed a PO with a start date of 12/15/23 for Humolog KwikPen Subcutaneous (SC) Solution Pen-injector 100 units (U)/milliliter (ML) (Insulin Lispro), Inject 3 U SC after meals for diabetes mellitus, hold if eats less than 50 % of meal. The time of administration for the Insulin Lispro PO was 7:30 AM. The EMAR further revealed that the LPN had held the Insulin Lispro and signed for the time of 7:30 AM on 2/1/24. The time of the surveyor's observation was inconsistent with the EMAR documentation of the LPN's signature of holding the Insulin Lispro at 7:30 AM on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. The CP acknowledged that the Insulin POs that based the dose or administration after the meal consumption and had a 7:30 AM time of administration was not indicative of the actual time of administration and would have to review. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the EMAR should reflect the time of administration. The DON stated that the times of administration for Insulin administration that had a PO based on the resident's meal consumption had to be changed. 8. On 2/1/24 at 9:18 AM, during the medication administration observation, the surveyor observed the RN preparing to administer medications which included an Insulin Lispro pen injector to Resident #182. The RN stated that the Insulin Lispro was a short-acting insulin and that she had to wait until she spoke with the resident because the PO on the EMAR indicated two different doses dependent on the resident's meal consumption. On 2/1/24 at 9:35 AM, the surveyor observed the RN obtaining blood sugar results from Resident #182. The resident stated that he/she had eaten his/her breakfast. The RN then dialed the insulin Lispro pen to 12 U and injected the resident's abdomen. The surveyor reviewed the medical record for Resident #182. A review of the EMAR revealed a PO with a start date of 1/22/24 for Insulin Lispro Injection Solution, Inject 12 U SC after meals for type 1 Diabetes Mellitus. hold if meal intake less than 50 %. See other order if meal intake less than 50 %. Further review of the EMAR revealed that the time of administration for the Insulin Lispro was 7:30 AM and the EMAR was signed by the RN as administered at 7:30 AM on 2/1/24. The surveyor observation was inconsistent with the EMAR documentation for the time of administration of 7:30 AM for the Insulin Lispro on 2/1/24. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that the EMAR should be indicative of the administration of the medications such as the time of administration, whether the medication was refused or held. The CP acknowledged that the Insulin POs that based the dose or administration after the meal consumption and had a 7:30 AM time of administration was not indicative of the actual time of administration and would have to review. On 2/2/24 at 1:21 PM, the survey team met with the Director of Nursing (DON) and the Regional Director of Clinical Services. The surveyor reviewed the concerns of the medication administration observation. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON acknowledged that the EMAR should reflect the time of administration. The DON stated that the times of administration for Insulin administration that had a PO based on the resident's meal consumption had to be changed. A review of the current facility policy for General Dose Preparation and Medication Administration with a revision date of 1/1/22 provided by the DON which reflected to Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. In addition, If necessary, obtain vital signs. Also, Administer medications within timeframes specified by Facility policy or manufacturer's information. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.3(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical records to the facility. This deficient practice was observed for the following residents: 1. On 2/2/24 at 11:15 AM, the surveyor reviewed the electronic medication administration records (eMAR) of Resident #74. Resident #74 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (a condition where the kidney does not function properly resulting in increased blood pressure). The surveyor reviewed the December 2023 eMAR and the current Physician's Order sheet which reflected an order for Midodrine 2.5 milligrams (mg) (a medication that is used to increase blood pressure) give one (1) tablet three (3) times a day for Hypotension (low blood pressure) with a starting date of 12/15/23. Review of the medication administration times reflected that the medication was to be administered at 10:00 PM. Further review of the October 2023 and November 2023 eMAR reflected an order for Midodrine 2.5mg give one (1) tablet three (3) times a day hold for SPB (systolic blood pressure) greater than 130 with a starting date of 10/18/23 and medication administration times of 6:00 AM, 2:00 PM, and 10:00 PM. The surveyor reviewed the medication information documentation for Midodrine. The section, Dosage and Administration reflects In order to reduce the potential for supine hypertension during sleep, midodrine hydrochloride tablets should not be given after the evening meal or less than 4 hours before bedtime. On 2/5/23 at 11:59 AM, the surveyor interviewed the CP by phone. The CP stated that the last dose of Midodrine should not be scheduled or given after 5pm. The CP stated that if such an order was reviewed that they would comment in the record and send that comment to the facility for action. On 2/6/23 at 10:40 AM, the surveyor reviewed the CP comments in the electronic medical record for Resident #74 and the CP reports that were sent to the facility for the months of October 2023, November 2023, December 2023 and January 2023. Review of the electronic medical records and the CP reports did not reflect a comment of any irregularity with the Midodrine being given at 10:00 PM for Resident #74. REFER to F759 2. On 2/1/24 at 9:45 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) preparing to administer medications to Resident #111. The RN removed one tablet of 600 milligrams (MG)/200 international units of Calcium D and one tablet of 325 MG of Iron from bottles stored in the medication cart that had no resident name on the label. The RN stated that both medications were considered house stock meaning that the facility provided these medications because they were over the counter medications and the bottles were used for any resident that had a PO for that medication. At that time, the RN stated that she was familiar with the residents that received medications from this medication cart. The RN added that there were no cautionary statements on the electronic medication administration record (EMAR) and that the medications were able to be administered together. On 2/1/24 at 9:52 AM, the surveyor observed the RN administer the Calcium and Iron tablets to Resident #111. The surveyor reviewed the medical record for Resident #111. A review of the Medication Review Report revealed a physician's order (PO) with a start date of 11/5/23 for Calcium-Vitamin D Tablet 600-200 MG-Unit, Give 1 tablet by mouth one time a day for supplementation. In addition, a PO with a start date of 12/27/23 for Ferrous Sulfate Tablet 325 (65 Fe (iron)), Give 1 tablet by mouth two times a day for iron deficiency anemia. A review of the EMAR reflected the above PO with both the Calcium and Iron time of administration indicated for 9:00 AM. On 2/2/24 at 9:14 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she had not provided the facility with any handouts regarding medications that should be separated and had not performed any medication administration observations. The CP added that she thought the EMAR would not have cautionary statements and that the cautionary statements were on the label from the provider pharmacy. The CP added that she would make recommendations to separate medications if she saw the medications with the same time of administration. The CP also stated that she was unsure of an interaction with Calcium and Iron and would have to check. On 2/2/24 at 11:16 AM, the surveyor interviewed the Unit Manager (UM)/Licensed Practical Nurse (LPN) who stated that the EMAR had no cautionary statements and thought the CP usually made recommendations regarding medications that she would change on the EMAR. The UM/LPN was unsure if Calcium and Iron had to be separated but thought the CP would have made the recommendation. A review of the Consultant Pharmacist's Medication Regimen Review: Listing of Resident's Reviewed with No Recommendations form that was prepared by the CP and dated 1/28/24 revealed that a medication regimen review was performed by the CP for Resident #111 during the CP's visit and had not required any recommendations. There was no recommendation made by the CP regarding separating the Calcium and Iron that had the same time of administration. On 2/2/24 at 1:21 PM, the survey team met with the Director of Nursing (DON) and the Regional Clinical Nurse. The surveyor reviewed the results of the medication administration observation. The DON stated that she was unsure if there was a handout provided to the nurses regarding which medications should be separated. On 2/5/24 at 12:01 PM, the surveyor interviewed the CP via the telephone who stated that Calcium and Iron should be separated and not administered together. A review of the manufacturer's specifications for Iron Supplement reflected Precautions: Do not take iron supplements and antacids or calcium supplements at the same time. It is best to space doses of these 2 products 1 to 2 hours apart, to get the full benefit from each medicine or dietary supplement. NJAC 8:39-29.3(a)(1), 29.4(c)(d)(3)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 2/1/24, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 34 opportunities, and five (5) errors were observed which calculated to a medication administration error rate of 14.7%. This deficient practice was identified for three (3) of five (5) residents, (Resident #99, #111 and #182), that were administered medications by two (2) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. On 2/1/24 at 8:40 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #99 which included a 25 milligram (MG)/100 MG tablet of Carbidopa-Levodopa (Sinemet) (a medication used to treat movement disorders) and a 325 MG tablet of Ferrous Sulfate (Iron) (a supplement). At that time, the LPN stated that the physician's order (PO) for the Sinemet was highlighted in red on the electronic medication administration record (EMAR) because the time of administration was designated as due at 7:30 AM and the red highlight meant the time of administration was out of the timeframe of one hour before and/or one hour after the administration time. The LPN added that the PO indicated to administer the Sinemet before a meal and the breakfast had not been delivered yet, so she was able to administer the Sinemet. The LPN added that the next time of administration for the Sinemet was 11:30 AM. On 2/1/24 at 8:52 AM, the surveyor observed the LPN administer the Sinemet to Resident #99. Upon returning to the medication cart, the surveyor interviewed the LPN who was unable to speak to the importance of Sinemet being administered close to the time of administration. (ERROR #1) On 2/1/24 at 12:02 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that 7:30 AM medications were the responsibility of the 7 AM to 3 PM nurses to administer. The UM/LPN added that the nurse should go out for a first medication pass to administer any early medications such as the 7:30 AM medications. The UM/LPN was unable to speak to why the LPN had not administered the 7:30 AM Sinemet. The UM/LPN also stated that sometimes the per diem nurses do not know who has a 7:30 AM medication. On 2/1/24 at 12:28 PM, the surveyor interviewed the LPN who stated that the 7:30 AM Sinemet was her responsibility to administer but was unaware of which residents had a 7:30 AM medication. The LPN added that she was unfamiliar with the hallway that the medication cart was associated with. The surveyor reviewed the medical record for Resident #99. A review of the resident's admission Record (AR) revealed diagnoses which included Parkinson's Disease (a movement disorder). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 1/9/2024, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Medication Review Report (MRR) revealed a PO with a start date of 7/8/23 for Carbidopa-Levodopa oral tablet 25-100 MG, Give 1 tablet by mouth before meals for Parkinson's. A review of the current EMAR revealed the above PO with the times of administration indicated for 7:30 AM, 11:30 AM and 4:30 PM. On 2/2/24 at 9:14 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that the EMAR should be indicative of the administration time and acknowledged that the time of administration was one hour before or 1 hour after the indicated time of administration. On 2/2/24 at 11:16 AM, the surveyor interviewed the Unit Manager/LPN who stated that the Sinemet for Resident #99 was ordered before meals which would be indicated with a time of administration of 7:30 AM and thought the resident had Parkinson's Disease so that was probably why the neurologist wanted the Sinemet early in the morning when the resident was getting up. On 2/2/24 at 1:21 PM, the survey team met with the Director of Nursing (DON) and the Regional Director of Clinical Services. The surveyor reviewed the results of the medication administration observation. The DON acknowledged that Sinemet should be administered as close to the time of administration as possible to benefit the resident's movement disorder. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team for responses to concerns identified. The DON stated that she would expect the nurse from the 11 PM to 7 AM shift that had that medication cart to inform any new nurse on the 7 AM to 3 PM shift, who was taking over the medication cart, of any early morning medication that needed to be administered during the shift-to-shift report. On 2/6/24 at 9:40 AM, the surveyor interviewed Resident #99 who stated that the nurses gave him/her whatever medications he/she needed. The resident was unable to speak to what times the medications were administered. The resident was unable to speak to his/her Sinemet medication. The resident stated, Everything is fine. A review of the current facility policy for General Dose Preparation and Medication Administration with a revision date of 1/1/22 provided by the DON reflected Administer medications within timeframes specified by Facility policy or manufacturer's information. A review of the manufacturer's specifications for Sinemet reflected Information for patients: The patients should be informed that SINEMET is an immediate release formulation of carbidopa-levodopa that is designed to begin release of ingredients within 30 minutes. It is important that SINEMET be taken at regular intervals according to the schedule outlined by the physician. 2. On 2/1/24 at 8:40 AM, during the medication administration observation, the surveyor observed the LPN preparing to administer medications to Resident #99 which included one 25 MG/100 MG tablet of Sinemet and one 325 MG tablet of Ferrous Sulfate. At that time, the LPN stated that the PO for the Sinemet was highlighted in red on the EMAR because the time of administration was designated as due at 7:30 AM and the red highlight meant the time of administration was out of the timeframe of one hour before and/or one hour after the administration time. The LPN added that the PO indicated to administer the Sinemet before a meal and the breakfast had not been delivered yet, so she was able to administer the Sinemet. In addition, the LPN added that the Iron was highlighted in yellow because yellow meant the medication was due at that time. On 2/1/24 at 8:46 AM, the LPN stated that she was ready to administer the medications, which included the Sinemet and Iron tablets, to Resident #99. At that time, the surveyor stopped the LPN from walking into the resident's room to administer the medications. The surveyor, with the LPN, reviewed the EMAR and the label of the Sinemet for cautionary statements. The LPN stated that the EMAR had no cautionary statements. The LPN then reviewed the label on the Sinemet which revealed a cautionary statement Separate 2 hours from iron-containing products. The LPN then stated that she should not administer the two (2) medications together and called the Unit Manager/LPN to the medication cart. (ERROR #2) On 2/1/24 at 8:50 AM, the surveyor observed the LPN review the Sinemet and Iron medications with the UM/LPN who told the LPN to not administer the Sinemet and Iron together. The surveyor observed the UM/LPN remove the Iron tablet. The UM/LPN stated that she was going to destroy the Iron tablet and call the physician to change the time of the Iron administration. The surveyor reviewed the medical record for Resident #99. A review of the resident's AR revealed diagnoses which included Parkinson's Disease and iron deficiency anemia (low iron levels). A review of the annual MDS with an assessment reference date of 1/9/2024, reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the MRR revealed a PO with a start date of 7/8/23 for Carbidopa-Levodopa oral tablet 25-100 MG, Give 1 tablet by mouth before meals for Parkinson's and a PO with a start date of 7/7/23 for Ferrous Sulfate tablet (65 Fe (iron)), 325 MG give 1 tablet by mouth one time a day for supplementation. A review of the current EMAR revealed the above PO with the administration time for Sinemet at 7:30 AM and the administration time of Iron at 9:00 AM. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that she was unsure if cautionary statements were on the EMAR. The CP added that she thought cautionary statements were on the labels of the medications from the provider pharmacy. The CP also stated that she would make a recommendation to separate Sinemet from Iron if the medications had the same time of administration. On 2/2/24 at 1:21 PM, the surveyor team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the results of the medication administration observation. The DON stated that she was unsure if there was a handout provided to the nurses regarding which medications should be separated. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team for responses to identified concerns. The DON stated that the UM/LPN called the physician, and the Iron was changed to a bedtime dose to be separated from the Sinemet. The DON also stated that the nurses would have to electronically add any cautionary statements to the PO and that the cautionary statements were on the labels of the medications from the pharmacy provider. The DON added that she would expect the nurses to follow any cautionary statements. On 2/6/24 at 9:40 AM, the surveyor interviewed Resident #99 who stated that the nurses gave him/her whatever medications he/she needed. The resident was unable to speak to what times the medications were administered. The resident was unable to speak to his/her Sinemet medication. The resident stated, Everything is fine. A review of the current facility policy for General Dose Preparation and Medication Administration with a revision date of 1/1/22 provided by the DON reflected Follow manufacturer medication administration guidelines (e.g., rotating transdermal patch sites, providing medication with fluids or food, shaking medications prior to pouring, rotating injection sites), and A review of the manufacturer's specifications for Sinemet reflected to avoid taking iron supplements which can make it harder for your body to digest and absorb carbidopa and levodopa. In addition, Iron salts (such as in multivitamin tablets) may also reduce the amount of levodopa available to the body. 3. On 2/1/24 at 9:18 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) preparing to administer medications to Resident #182 which included two different insulin pen injectors. At that time, the RN stated the resident had insulin Glargine which was a long-acting insulin and the dose that was due to be administered according to the EMAR was 18 units. The RN showed the surveyor the insulin Glargine pen had a dial which she turned to the indicated 18 units. In addition, the RN stated that the insulin Lispro was a short-acting insulin and that she had to wait until she spoke with the resident because the PO on the EMAR indicated two different doses dependent on the resident's meal consumption. On 2/1/24 at 9:35 AM, the surveyor observed the RN obtaining blood sugar results from Resident #182. The resident stated that he/she had eaten his/her breakfast. The RN then dialed the insulin Lispro pen to 12 units and injected the resident's abdomen. Then, the RN injected the insulin Glargine 18 units to the resident's abdomen. The surveyor had not observed the RN prime either of the two different insulin pens. (ERROR #3 and ERROR #4) On 2/1/24 at 10:36 AM, the surveyor interviewed the RN who stated that she was told that she did not have to prime the insulin pens. The RN added that she did not remember an inservice but thought that was how she was trained. On 2/1/24 at 11:58 AM, the surveyor interviewed Resident #182 who stated that he/she was not familiar with the pen injectors and used vials at home. On 2/2/24 at 9:00 AM, the surveyor reviewed a Medication Administration Observation form provided by the DON that was dated 10/31/23 for the RN and completed by the Assistant Director of Nursing (ADON). The form revealed that the RN had a checkmark for yes in the section of Injections that the Insulin is rolled not shaken. Prime Pens with 2 units prior to administration. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that all insulin pens must be primed prior to each administration because if the pen was not primed then there could be bubbles in the needle and that may affect the dose. On 2/2/24 at 11:16 AM, the surveyor interviewed the UM/LPN who stated that she was unsure if there was an inservice on the Insulin Pen injector technique but knew that the pen had to be primed prior to each dose. On 2/2/24 at 12:24 PM, the surveyor interviewed the ADON who stated that she had performed a med pass with the RN on 10/31/23 when the RN had started working at the facility. The ADON stated that she specifically goes over the insulin pen administration technique because prior there were only vials and now there were injector pens used to administer insulin. The ADON added that she wrote in the instructions Prime Pens with 2 units prior to administration on all the Medication Administration Observation forms to review with all the nurses during her medication observation. The surveyor reviewed the medical record for Resident #182. A review of the resident's AR revealed diagnoses which included diabetes mellitus (DM) (high blood sugar levels). A review of the admission MDS with an assessment reference date of 1/19/2024, reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the MRR revealed a PO with a start date of 1/22/24 for Insulin Lispro Injection Solution, Inject 12 unit (U) subcutaneously (SC) after meals for type 1 DM. hold if meal intake less than 50 percent (%). See other order if meal intake less than 50 %. In addition, a PO dated 1/25/24 for Insulin Glargine SC Solution Pen-injector 100 U/milliliter (ML), Inject 18 U SC one time a day for DM. A review of the current EMAR reflected the above PO. On 2/5/24 at 9:34 AM, the survey team met with the Administrative team. The DON stated that the RN was inserviced again on the proper technique for insulin administration with a pen injector which included priming the insulin pen with 2 units prior to each administration. A review of the current facility policy Insulin Pens with a revision date of 2/28/21 provided by the DON revealed that Insulin pens are to be primed prior to each use to prevent the collection of air in the insulin reservoir. A review of the manufacturer's specifications for insulin pen injectors reflected that a safety test be done prior to each injection which involved dialing two (2) units and pointing the insulin injector pen towards the ceiling and pressing the button to visualize insulin solution coming out of the needle tip to ensure that the pen is working correctly. 4. REFER to 756 On 2/1/24 at 9:45 AM, during the medication administration observation, the surveyor observed the RN preparing to administer medications to Resident #111. The RN removed one tablet of 600 MG/200 international units of Calcium D and one tablet of 325 MG of Iron from bottles stored in the medication cart that had no resident name on the label. The RN stated that both medications were considered house stock meaning that the facility provided these medications because they were over the counter medications and the bottles were used for any resident that had a PO for that medication. At that time, the RN stated that she was familiar with the residents that received medications from this medication cart. The RN added that there were no cautionary statements on the EMAR and that the medications were able to be administered together. On 2/1/24 at 9:52 AM, the surveyor observed the RN administer the Calcium and Iron tablets to Resident #111. (ERROR #5) The surveyor reviewed the medical record for Resident #111. A review of the resident's AR revealed diagnoses which included anemia (deficiency of red blood cells) and moderate protein-calorie malnutrition. A review of the MRR revealed a PO with a start date of 11/5/23 for Calcium-Vitamin D Tablet 600-200 MG-Unit, Give 1 tablet by mouth one time a day for supplementation. In addition, a PO with a start date of 12/27/23 for Ferrous Sulfate Tablet 325 (65 Fe (iron)), Give 1 tablet by mouth two times a day for iron deficiency anemia. A review of the EMAR reflected the above PO with both the Calcium and Iron time of administration for 9:00 AM. On 2/2/24 at 9:14 AM, the surveyor interviewed the CP via the telephone who stated that she had not provided the facility with any handouts regarding medications that should be separated and had not performed any medication administration observations. The CP added that she thought the EMAR would not have cautionary statements and that the cautionary statements were on the label from the provider pharmacy. The CP added that she would make recommendations to separate medications if she saw the medications with the same time of administration. The CP also stated that she was unsure of an interaction with Calcium and Iron and would have to check. On 2/2/24 at 1:21 PM, the survey team met with the DON and the Regional Director of Clinical Services. The surveyor reviewed the results of the medication administration observation. The DON stated that she was unsure if there was a handout provided to the nurses regarding which medications should be separated. On 2/5/24 at 12:01 PM, the surveyor interviewed the CP via the telephone who stated that Calcium and Iron should be separated and not administered together. A review of the manufacturer's specifications for Iron Supplement reflected for Precautions: Do not take iron supplements and antacids or calcium supplements at the same time. It is best to space doses of these 2 products 1 to 2 hours apart, to get the full benefit from each medicine or dietary supplement. NJAC 8:39-11.2(b), 29.2(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 follow appropriate measures to prevent and control the spread of infection during a Covid-19 outbreak on the ground floor of the facility for: a.) failure to properly wear N95/respirator masks for 4 of 4 staff members observed on the ground unit, and b.) failure to wear a fit tested N95/respirator mask for 2 of 4 staff members observed on the ground unit. The deficient practices were evidenced by the following: On 2/6/24 at 2:00 PM, the surveyor toured the ground floor unit. At the nurse's station, the surveyor observed Licensed Practical Nurse (LPN) who was wearing a DS-N95-1 mask with the straps cut, tied and the straps were then tied behind her ears. The surveyor asked the LPN why the N95 mask was worn that way and the LPN stated the mask was uncomfortable, so I cut, tied it and wore it like that. She stated she was fit tested for this mask and should have worn it the way she learned during fit testing. At 2:05 PM, the surveyor observed Certified Nursing Assistant (CNA # 1), who was exiting a resident's room on the ground floor, CNA # 1 was wearing a DS-N95-1 mask with the straps cut, tied and the straps were then tied behind her ears. The surveyor asked the LPN why the N95 mask was worn that way and the LPN stated, the mask was uncomfortable, so I cut, tied it and wore it like that. She stated that she was not sure what mask she was fit tested to wear and could not provide information about how the mask should be worn. At 2:09 PM, the surveyor observed CNA # 2, who was walking down the resident hallway on the ground floor. The CNA # 2 was wearing a 3M VFLEX 1804 N95 mask, with her nose exposed and not covered by the N95 mask. The CNA # 2 stated that she should have the N95 over her nose and was fit tested for this mask. At 2:12 PM, the surveyor observed an Occupational Therapist (OT), in a resident's room on the ground floor. The resident was in bed with no mask on and the OT was sitting on a chair at the resident's bedside near the window. The OT wore a DS-N95-1 mask on his chin, exposing both his mouth and nose. The surveyor interviewed the OT and he stated that this resident was exposed to Covid-19 but that he could not breathe while he interviewed the resident, so he pulled the mask off of his nose and mouth while he was in the room with the resident. At 2:50 PM, the surveyor received and reviewed the fit testing results for the following staff: The LPN was fit tested on [DATE] for 3M VFLEX 1804 N95 and the LPN was not wearing that mask upon observation. The CNA # 1 was fit tested on [DATE] for DS-N95-1 and the CNA # 1 was wearing that mask upon observation. The CNA # 2 was fit tested on [DATE] for the 3M VFLEX 1804 N95 and the CNA # 2 was wearing that mask upon observation. The OT was fit tested on [DATE] for 3M VFLEX 1804 N95 and the OT was not wearing that mask upon observation. At 3:10 PM, the surveyor discussed the above concerns with the DON, who stated that the staff should have worn their N95 masks appropriately and they should have worn the ones that they were fit tested for. The facility did not provide a policy for N95 mask use. NJAC 8:39-19.4 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00163946 Based on observation, interviews, and record review, as well as review of pertinent facility documents on 5/16/23, 5/17/23, and 5/22/23, it was determined that the facility failed to a.) ensure that Resident #1 did not receive food that the resident was allergic to, and b.) check the dietary menu for food allergy for 2 of 4 sampled residents (Resident #2 and Resident # 3) reviewed for food allergy. This deficient practice was evidenced by the following: During the tour of the unit on 5/16/23 at 8:56 am, the Unit Manager/Licensed Practical Nurse (UM/LPN #1) revealed that Resident # 2 had food allergies which included but was not limited to Egg and Resident #3 had food allergies to included but was not limited to Milk. Review of the facility's Allergy Report, dated 5/16/23, reflected that Resident #2 was allergic to Egg and Resident #3 was allergic to Milk. 1. According to the admission record (AR), Resident #2 was admitted on [DATE], with food allergies which included but was not limited to Egg. The Minimum Data Set (MDS), an assessment tool dated 4/25/23, revealed a Brief Interview for Mental Status (BIMS) of 14/15, which indicated intact cognition. The Care Plan (CP) and Order Summary Report (OSR), reflected Resident #2 was allergic to Egg. The surveyors reviewed the meal ticket menu options offered to Resident #2: The meal ticket menu, for Tuesday, lunch, dated 5/16/23, reflected that Resident #2 was allergic to Eggshell Membrane, EGG DERIVED PRODUCTS, egg Dishes, Egg. The meal ticket menu revealed Selection 1 Sloppy [NAME] on Roll Parsley Garnish Deviled Egg Potato Salad was circled. During the meal observation on 5/16/23 at 12:15 pm, the surveyors observed Resident #2's ticket was at the nurse's station with a bowl of potato salad (untouched). The UM/LPN#1 stated that the potato salad was removed from Resident #2's room because the Certified Assistant Nurse (CNA #1) realized that the resident was allergic to eggs and the Deviled Egg Potato Salad (DEPS) was circled as indicated on Resident #2's menu/ticket. The UM/LPN further stated that CNA #1 also visualized that the potato salad had pieces/chunks of eggs. During an interview with the surveyor on 5/16/23 from 12:18 pm and 12:30 pm, the Registered Dietitian (RD) stated that the resident could fill out his/her meal ticket menu by her/himself. The RD stated that according to Resident #2, he/she made a mistake of circling the DEPS and cannot eat the DEPS because he/she was allergic to eggs. The RD further stated that Resident #2 can have eggs that are mixed with bread but not straight eggs. The RD explained that Resident #2 can have food that contained eggs such as French toast but not straight eggs. During an interview with the surveyor on 5/16/23 at 12:20 pm, Resident #2 stated that he/she made of mistake of choosing the DEPS. Resident #2 refused to answer further questions. During an interview with the surveyor on 5/16/23 at 2:03 pm, Dietary Aid (DA #1), who performed the final check and placed Resident #2's tray to the meal truck stated that he was aware that Resident #2 was allergic to eggs and he did not place the DEPS on Resident #2's tray. DA #1 was unable to explained how the DEPS was placed to Resident # 2's tray, left the kitchen, and was delivered to his/her room. During an interview with the surveyor on 5/16/23 at 2:18 pm, DA #2, who delivered the food truck to the second floor, stated that she did not place the DEPS on to Resident #2's tray. DA #2 further stated that after the final tray check in the kitchen by the line checker, she does not add/remove any items from the tray. During an interview with the surveyor on 5/16/23 at 2:32 pm, CNA #1 stated that she took Resident #1's tray and brought it to the resident's room. CNA #1 stated she saw the menu which indicated Resident #1 was allergic to eggs and the DEPS was circled. CNA #1 immediately removed the DEPS and gave it the facility's Dietitian. CNA #1 further stated that Resident #2 did not touch or eat the DEPS. Review of the Deviled Egg Potato Salad, Corporate Recipe, undated, reflected that the recipe contained Hard Cooked EGG .1/4 each [serving] .1. Prepare Hard Cooked Egg per recipe. 2. Chop eggs .5. In a mixing bowl, combine remain ingredients stirring well to blend. Pour over potatoes and vegetables mixture, stirring to Review of the job description titled Line Checker, indicated .check trays for accuracy and place on truck 2. According to the facility's AR, Resident #3 was admitted on [DATE], with diagnosis that included but was not limited to: Dementia. The MDS dated [DATE], revealed a BIMS of 9, which indicated resident cognition was moderately impaired. During an interview with the surveyor on 5/17/23 at 12:19 pm, CNA #2 stated that when passing tray to residents, staff must check the ticket/menu to make sure it is accurate and does not have foods that the residents are allergic to. CNA #1 further stated that she did not check Resident #3's tray and meal ticket menu today (5/17/23) for accuracy because she was distracted. During an interview with the surveyor on 5/17/23 at 1:06 pm, the UM/LPN #1 stated that the staff must check the meal ticket for accuracy. She further stated that if the meal ticket was not check for accuracy, the staff may deliver foods that were not according to the resident's preference and/or may received foods that they are allergic to and can cause complications. The job description for line Checker indicated 11:30 [am] Start lunch line, check trays for accuracy and place on truck . Review of the facility's policy titled Meal Service, dated 6/1/21, reflected .Person-centered meal service includes the delivery date of a safe, sanitary, and comfortable environment for meals which accommodates patient/resident (hereafter patient) preference and personal choice .3.2 when serving meals in the patient 's room [ROOM NUMBER].2.2 Assure the correct meal is served to the patient . NJAC 8:39 - 17.4 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C #: NJ00152409 NJ00163946 NJ00155111 Based on interviews, medical record review, and review of other pertinent facility documents on 5/16/23, 5/17/23, and 5/22/23, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 3 of 5 residents (Resident #2, Resident #3, and Resident #5) reviewed for documentation. This deficient practice was evidenced by the following: Review of a facility policy titled Activities of Daily Living (ADLS), revised 5/1/23, reflected .5. Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real time, as close to the time that care was provided and information obtained as possible. ADL care is documented every shift by the nursing assistant. 5.1 The licensed nurse will document ADL care they provided, when applicable . 1. According to the admission Record (AR), Resident #1 was admitted on [DATE], with diagnosis that included but were not limited to: Cerebral Infarction. The Minimum Data Set (MDS), an assessment tool, dated 4/23/23, revealed a Brief Interview of Mental Status (BIMS) of 0 which indicated the resident's cognition was severely impaired and the resident needed total assistance with ADLs including toileting and bed mobility. A Care Plan (CP), initiated on 1/16/23 and revised on 4/14/23 included that the resident was dependent for ADL care. Review of Resident #1's DSR (ADL Record) and the progress notes (PN) for the month of 3/2023, 4/2023, and 5/2023, lack any documentation to indicate that the care for toileting and bed mobility was provided and/or the resident refused care on the following dates and shifts; 7:00 am-3:00 pm shift on 3/9/23, 3/15/23, 3/17/23, 3/25/23, 3/26/23, 4/8/23, 4/9/23, 4/22/23, 4/23/23, 5/6/23, and 5/20/23. 3:00 pm-11:00 pm shift on 3/13/23, 4/1/23, 4/7/23, 4/10/23, 4/15/23, 4/16/23, 4/21/23, 4/24/23, 5/5/23, 5/12/23, 5/14/23, and 5/19/23. 11:00 pm-7:00 am shift on 3/14/23, 3/17/23, 3/25/23, 3/26/23, 5/14/23, 5/15/23, and 5/20/23. 2. According to AR, Resident #3 was admitted on [DATE], with diagnoses that included but was not limited to: Muscle Weakness and Dementia The MDS, dated [DATE], revealed a BIMS of 9 which indicated the resident's cognition was moderately impaired and the resident needed extensive assistance with ADLs. The CP, revised on 11/08/22, included that Resident #3 required assistance for ADL care. Review of Resident #3's DSR and PN for the month of 4/2023 and 5/2023, lacked documentation that the care was provided and/or the resident refused care for toileting and bed mobility on the following dates and shifts; 7:00 am-3:00 pm shift on 4/1/23, 4/8/23, 4/22/23, 5/6/23, 5/15/23, 5/18/23, 5/20/23, and 5/21/23. 3:00 pm-11:00 pm shift on 4/1/23 to 4/4/23, 4/7/23, 4/14/23, 4/21/23, 4/25/23, 4/26/23, 4/28/23, 5/1/23, 5/3/23, 5/6/23, 5/9/23, 5/12/23 to 5/16/23, 5/19/23, and 5/21/23. 11:00 pm-7:00 am shift on 4/14/23, 4/27/23, 4/28/23, 5/3/23, 5/4/23, 5/6/23, 5/9/23, 5/10/23, 5/13/23, 5/14/23, 5/16/23 to 5/18/23, and 5/20/23. 3. According to AR, Resident #5 was admitted on [DATE], with diagnoses that included but was not limited to: Muscle Weakness and Difficulty in Walking. The MDS, dated [DATE], revealed a BIMS of 7 which indicated the resident's cognition was moderately impaired and the resident needed extensive assistance with ADLs. Review of Resident #5's DSR and PN for the month of 3/2022, lacked documentation that the care was provided and/or the resident refused care for toileting and bed mobility on the following dates and shifts; 7:00 am-3:00 pm shift on 3/12/22 to 3/14/22, 3/16/22, 3/17/22, and 3/20/22 to 3/2822. 3:00 pm-11:00 pm shift on 3/17/22, 3/21/22, and 3/24/22 to 3/28/22. 11:00 pm-7:00 am shift on 3/19/22, 3/22/22, and 3/24/22 to 3/28/22. During an interview with the surveyor on 5/16/23 at 9:08 am and 5/17/23 at 1:06 pm, the Unit Manager/Licensed Practical Nurse (UM/LPN) stated that Certified Nursing Assistants (CNAs) were responsible for documenting the ADL care provided into the Point of Care (POC), a mobile-enabled app that runs on wall-mounted kiosks or mobile devices that enables care staff to document activities of daily living at or near the point of care to help improve accuracy and timeliness of documentation. The UM/LPN further stated that the CNAs need to document in the DSR even if the care was not provided due to refusal. She explained that the documentation must be completed in the residents' DSR by the end of each shift to show that the care was provided to the residents. UM/LPN also stated that she was responsible to make sure that the residents' DSR was completed at the end of the shift, however, UM/LPN could not explain why there were blanks in the sampled resident's DSR. During an interview with the surveyor on 5/16/23 at 10:10 am, CNA #1, who took care of Resident #2 during 7:00 am to 3:00 pm shift, stated that CNAs are responsible for documenting the ADL care provided into the POC at the end of the shift. CNA #1 further stated that she would document even if the care was not provided due to refusal. During an interview with the surveyor on 5/3/23 at 10:57 am, Licensed Practical Nurse (LPN #1) stated that the CNA's were expected to document ADL care provided to the resident by the end of the shift in the DSR. She explained that Nurses and the Unit Managers (UM) were to check the documentation to ensure that the DSR is completed at the end of the shift. LPN #1 could not explain why there were blanks in the resident's DSR but stated that they should have been completed to show that the care was/was not provided from the CNAs. NJAC 8:39-35.2(d)(9)

2. On 10/12/21 at 1:03 PM, the surveyor observed Resident #600 in the resident's room. The resident was on transmission based precautions with proper signage noted at the entrance of the resident's room. The surveyor reviewed Resident #600's EMR that revealed the following: According to the admission Record, Resident #600 was admitted to the facility with diagnoses that included Dementia, Parkinson's Disease, difficulty walking, and generalized muscle weakness. The 10/4/21 admission MDS revealed that Resident #600 was severely cognitively impaired. The nursing Progress Notes indicated that on 10/4/2021 the resident fell due to confusion while climbing out of bed without assistance. The Event Summary Report revealed that on 10/4/2021 Resident #600 fell out of bed and was found on the floor by facility staff. The facility documented that under Corrective Actions: TABS alarm added to resident to replace bed alarm. Consistent checking of resident to anticipate needs. Give snacks for comfort/ calming. The Nursing Documentation V10 completed on 9/28/21 indicated that the resident had several risk factors for falls which included a history of falls prior to admission and was taking several medications that increased the risk for falls. The surveyor reviewed the resident's care plan and observed that the facility had not developed a comprehensive care plan to address the resident's risks for falls, to update it to include the 10/4/21 fall with interventions listed on the Event Summaary. On 10/18/21 at 12:07 PM, the surveyor spoke to the Administrator and the DON The DON stated that she would have expected to see a fall risk care plan in place for this resident. A review of the facility policy titled Person-Centered Care Plan revised 7/1/19, revealed that the facility must develop and implement a baseline person-centered care plan within 48 hours and that a comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient. N.J.A.C 8:39-11.2(e) Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive care to address the treatment needs for Resident #64 and Fall Risk for Resident #600, 2 of 23 residents reviewed. The deficient practice was evidenced by the following: 1. On 10/15/21 at 12:16 PM, surveyor observed Resident #64 in bed with Oxygen going at 2 liters/minute (l/m) via a nasal cannual. The resident was awake watching television. There was a pressure relieving mattress on the resident's bed. The resident's lower extremities were wrapped with ace bandages. The surveyor reviewed Resident #64's electronic medical record (EMR) that revealed the following: According to the admission Record, Resident #64 was admitted to the facility with diagnoses that included Cellulitis of the right lower limb, Lymphedema, Type II Diabetes Mellitus, and Morbid Obesity. The Annual Minimum Data Set (MDS) an assessment tool dated 9/4/21 indicated that the facility performed a Brief Interview for Mental Status and the results showed a score of 15 out of 15 which indicated the resident had no cognitive impairment. According to the electronic Treatment Administration Record (eTAR), the resident physician's orders to provide treatments to the sacral area, left posterior buttock and thigh, right lower leg and right thigh. There was documentation on the eTAR that the nurses were performing the treatments as ordered. Upon review of the resident's care plans, the surveyor observed that there wasn't a comprehensive care plan developed to address the current treatments to the areas mentioned above. On 10/19/21 at 10:36 AM, the surveyor spoke to the Director of Nursing (DON), who was responsible for the development of care plans, regarding no care plan was developed to address Resident #64's current treatments. No additional information was provided.

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of practice by not documenting that a resident was receiving oxygen and not monitoring oxygen saturation (O2 sats)levels according to the physician's orders for 1 of 2 residents (Resident #37) reviewed. This deficient practice was evidenced by the following: On 10/13/21 at 10:23 AM, the surveyor observed Resident #37 sitting on the bed with oxygen (O2) on via nasal cannula at 2 liters/minute (l/m). On 10/14/21 11:37 AM, the surveyor observed Resident #37 lying across the bed with oxygen running at 2 l/m via nasal cannula, watching television. The resident informed the surveyor that the resident uses the oxygen all the time. The surveyor reviewed Resident #37's electronic medical records that revealed the following: According to the admission Record, Resident #37 was admitted to the facility with diagnoses that included Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Obesity. The Quarterly Minimum Data Set an assessment tool dated 8/19/21, indicated that the facility performed a Brief Interview for Mental Status interview and Resident #37 scored a 13 out of 15, which determined the resident was cognitively intact. According to the Order Summary Report, Resident #37 had a physician's order dated 10/30/2020 for Oxygen at 2 l/m via nasal cannual titrate to keep spo2 [a test to check the O2 sats levels] 88-92% as needed for SOB [shortness of breath] Post treatment evaluate heart rate, respiratory rate, pulse oximetry. Resident #37 had two care plans that had interventions that addressed the resident's oxygen needs. The interventions included O2 2 liters per minute via nasal cannula and monitor O2 sats] as ordered and report abnormalities to physician. The electronic Medication Administration Record (eMAR) revealed the physician's order was on the eMAR but there was no documentation from 10/1/21-10/14/21 that the O2 saturation levels were being monitored and that the resident was receiving oxygen at 2 l/m daily. On 10/15/21 at 10:36 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #37. She stated that since covid [the resident] had been receiving oxygen but [the resident] doesn't need it. The LPN also stated that she hasn't been monitoring O2 sats levels and hasn't been documenting on the eMAR that the resident was receiving oxygen. On 10/15/21 at 12:55 PM, the surveyor spoke to the Administrator and Director of Nursing regarding the above concerns. There were no additional information provided. NJAC 8:39-27.1(a)

Based on observation, interviews, and review of pertinent facility documentation, it was determined that the facility staff failed to follow appropriate infection control guidelines for Personal Protective Equipment (PPE), handwashing, and disinfection of shared medical equipment for 1 of 3 nurses observed during medication pass observation. This deficient practice was evidenced by the following: On 10/18/21 at 8:20 AM, the surveyor observed a Registered Nurse (RN) during medication pass observation on the ground floor of the facility. The RN was wearing a N 95 mask (a filtering facepiece respirator) with the two straps of the face mask around her neck. At 8:28, the RN entered the room of Resident #550 and donned (put on) clean gloves. The RN administered oral medications to the resident, gave the resident a Lovenox injection (a medication that helps prevent the formation of blood clots) in the abdomen, and applied a Lidocaine Patch 5% (an anesthetic used to prevent and treat pain) to the resident's right thigh. The RN doffed (removed) gloves and immediately donned new gloves. The RN did not perform hand hygiene between doffing the first pair of gloves and donning the new pair of gloves. The RN then measured the resident's vitals using a thermometer, blood pressure cuff, and a pulse oximeter (device used to measure the blood oxygen saturation and heart rate). The medical equipment was not cleaned or sanitized afterwards. At 8:53 AM, the RN began to prepare medications for Resident #551. Resident #551 had a sign on their door indicating that they were on isolation precautions and that an isolation gown should be worn in addition to a N 95 face mask and face shield. The isolation gown used by the RN had a strap at the neck and a strap at the waist. The RN donned the isolation gown and tied the strap only at the neck. The RN entered Resident #551's room and measured the resident's vitals including the temperature, blood pressure, pulse, and oxygen saturation using the same thermometer, blood pressure cuff, and pulse oximeter used for Resident #550 which had not been sanitized. At 8:59 AM the surveyor interviewed the RN about the observations. The RN stated that the second strap of her N 95 mask should be worn at the crown of her head but that it slipped down. She stated that she should perform hand hygiene between donning and doffing gloves before providing resident care. The RN stated that an isolation gown should be tied at both the neck and the waist. She also stated that shared medical equipment such as a thermometer, blood pressure cuff, and pulse oximeter should be sanitized after use on every resident. At 12:07 PM, the surveyor spoke to the Administrator and the Director of Nursing (DON). The DON stated that PPE should be worn properly, and that medical equipment should be sanitized in between each resident. A review of the facility policy titled, Hand Hygiene revised on 11/15/20, indicated that hand hygiene should be performed before and after patient care. A review of the facility policy titled, Cleaning and Disinfecting revised on 11/15/2020, indicated that multi-patient equipment must be cleaned and disinfected after patient use. N.J.A.C. 8:39-19.4(l)(n)

Based on observation, interview and record review, it was determined that the facility failed to maintain the respiratory equipment in a sanitary manner for 2 of 4 residents (Resident #2 and Resident #45) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 10/21/19 at 10:00 AM, during the initial tour in Resident #2's room, the surveyor observed the nebulizer mask connected to the tubing uncovered, lying directly on the bedside table next to the nebulizer machine. The mask was not in use and was not stored in a bag. A nasal cannula attached to oxygen tubing was directly touching the floor. Resident #2 was not in the room during the initial tour. On 10/23/19 at 9:50 AM, Resident #2 was observed in the bathroom with the Certified Nurse Assistant. The oxygen tubing was placed directly on the bed, uncovered, while not in use. On 10/24/19 at 9:45 AM, Resident #2 was not in the room. The oxygen tubing with the nasal canula attached was observed hanging by the oxygen concentrator, uncovered, and not stored in a bag while not in use. 2. On 10/21/19 at 10:10 AM, during the initial tour while in Resident #45's room, the surveyor observed the nebulizer mask uncovered and lying directly on the bedside table next to the nebulizer machine. The mask was not in use and was not stored in a bag. On 10/24/19 at 10:08 AM, Resident #45 was observed in the wheelchair with their eyes closed. The surveyor found the nebulizer tubing placed on the bedside table uncovered next to the nebulizer machine while not in use. The surveyor interviewed the nurse assigned to the resident, who stated that if the oxygen and nebulizer tubing is not in use, the tubing is supposed to be stored in a bag. The Unit Manager (UM) accompanied the surveyor to the rooms of Resident #2 and Resident #45. The UM agreed that the nasal cannulas and nebulizer masks should have each been stored in bags when not in use. The surveyor reviewed the facility's Policy and Procedure titled, Oxygen: Nasal Cannula #16. Date and store in treatment bag when not in use. NJAC 8:39-19.4(a)(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10/24/19 at 9:26 AM, the surveyor observed Resident #115 ambulating with a rolling walker in the hallway towards her/his room. The surveyor interviewed Resident #115, who was observed not wearing dentures and had many missing teeth. The resident informed the surveyor, I don't like to wear dentures, I had them before, I spit them out and added, I have no problem eating. On 10/24/19 at 12:47 PM, the surveyor reviewed Resident #115's ARF. The ARF reflected that Resident #115 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with the following diagnoses: Type 2 Diabetes Mellitus, Spinal Stenosis, Osteoarthritis, Morbid Obesity, Presence of Left Artificial Shoulder Joint, Gastro-Esophageal Reflux Disease without Esophagitis and Anxiety Disorder. A review of the resident's MDS dated [DATE], reflected that the resident was cognitively intact and independent with ADLs. On 10/25/19 at 10:55 AM, the surveyor interviewed the resident who stated that they would want to see the dentist for an annual exam. On 10/28/19 at 11:30 AM, the surveyor reviewed the consult section of the resident's medical chart and noted that the last dental consult was 8/22/19. The resident was not scheduled for any follow-up visit. There were no other dental records in the chart. On 10/29/19 at 10:30 AM, the surveyor reviewed the facility's Dental Services Policy with a revision date of 7/24/18, which presented: Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g. taking impressions for dentures and fitting dentures. On 10/25/19 at 10:30 AM, the surveyor team met with the Director of Nursing (DON), who agreed that the facility did not arrange for annual dental examinations in a timely manner. NJAC 8:39-15.1(a) 2. On 10/21/19 at 11:45 AM, the surveyor observed Resident #18 ambulating with a walker in the hallway to the dining room. The surveyor reviewed the ARF for Resident #18. The ARF documented that Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Heart Failure, Hypertension, Myocardial Infarction, Dementia, and Cardiac Pacemaker. The surveyor reviewed Resident #18's Annual MDS dated [DATE]. The MDS reflected that Resident #18 was assessed as cognitively impaired. On 10/23/19 at 11:05 AM, the surveyor reviewed the consult section of the resident's medical record. The surveyor could not find any dental records that identified Resident #18 as having an annual dental exam. The surveyor was unable to interview Resident #18, as the resident was cognitively impaired. On 10/28/19 at 11:14 AM, the surveyor interviewed the LPN who cared for Resident #18. The LPN stated that this resident had not had an annual dental exam. Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary annual dental care services in a timely manner for 3 of 28 residents, Resident #89, #18 and #115 reviewed. This deficient practice was evidenced by the following: 1. On 10/22/19 at 9:45 AM, the surveyor observed Resident #89 in the resident's room, lying in bed. Resident #89 had an Intravenous pole on the left side of the bed with a hanging bottle of Glucerna (a food supplement), that the resident was not receiving at the time of the observation. The surveyor interviewed Resident #89, who stated that he/she was fed through a gastric tube, which is usually stopped from 9:00 AM to 12:00 AM. The surveyor reviewed the admission Record Facesheet (one-page summary of important information about a resident) (ARF) for Resident #89. The ARF reflected that Resident #89 was admitted to the facility on [DATE] and readmitted on [DATE] and 9/13/18 from an acute care hospital with the following diagnoses: Type 2 Diabetes Mellitus, Myotonic Muscular Dystrophy, Gastrostomy, Aplastic Anemia, Malnutrition, Dysphagia, Gastro-Esophageal Reflux Disease (GERD), Shortness of Breath and Cachexia. The surveyor reviewed Resident #89's Annual Minimum Data Set (MDS), a standardized assessment tool that measures health status, dated 9/20/19. The MDS reflected that Resident #89 was cognitively intact, however, required extensive assist of one staff member with Activities of Daily Living (ADL). On 10/24/19 at 11:10 AM, the surveyor reviewed the consult section of the resident's medical chart. The surveyor could not find any dental records that identified that Resident #89 was scheduled for or had a dental exam. On 10/24/19 at noon, the surveyor interviewed Resident #89, who stated that he/she had asked the nursing staff to see a dentist in the past, but it was never followed up with a dental appointment. On 10/24/19 at 12:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) taking care of Resident #89. The LPN stated that there is no facility dentist at this time. The LPN said that residents are taken out to the dentist when they have issues. The LPN informed the surveyor that Resident #89 did not have an annual dental exam.

Based on observation, interview and record review, it was determined that the facility failed to a.) clean and sanitize steam table pans in a manner to prevent microbial growth; and b.) failed to maintain the kitchen environment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 10/21/19 at 09:24 AM, in the presence of the Account Manager (AM), the surveyor observed the following: 1. On a shelf in the dishwashing area, the surveyor observed stacked steam table pans. The AM stated that these are clean steam table pans. The surveyor observed one steam table pan with white particulates around the sides of the pan and three other steam table pans with plastic wrap adhered to sides of the pans. 2. In the dry storage room, the surveyor observed a #10 sized can of vegetarian beans with three different dents located on the can. The surveyor found two ½ inch sized dents located on the upper lip of the can, and on the same can, the surveyor observed a 1 ½ inch dent on the body of the can. 3. In the dry storage, the surveyor observed brown colored debris on top of five of nine spice top containers on the shelf. On another shelf in the dry storage room, the surveyor found 1/8 full container of low sodium soy sauce with a dried and sticky to the touch brown colored liquid downside of the bottle, and there was no visible date on the bottle as well. The surveyor also observed a 1/4 full gallon container of Worcestershire sauce with an open date of 10/23/18; the container was soiled with a dried and sticky to the touch brown colored liquid down the side of the bottle. On 10/21/19 at 01:52 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. NJAC 8:39-17.2(g)