Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the resident's furnishings and living area in a clean and home like environment. This deficient practice was identified for 1 of 2 residents (Resident #66) on 1 of 2 nursing units (West Unit) reviewed for a clean, comfortable, home like environment and was evidenced by the following: 1. On 12/4/24 at 10:44 AM, the surveyor entered Resident #66's room and observed that the floor was visibly dirty and was soiled with both dried paint and debris. The resident's over bed table frame was rusty. The surveyor reviewed the medical record for Resident #66. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: morbid (severe) obesity due to excess calories, osteomyelitis (bone infection) of vertebra, sacral (bottom of the spine) and sacrococcygeal (pertaining to both the sacrum and the coccyx (tailbone)) region, pressure ulcer of left heel stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of other site stage 4 , type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular (relating to the eye) edema bilateral, and depression. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 11/8/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had one Stage 4 pressure ulcer that was present upon admission/entry or reentry to the facility and one surgical wound of the foot. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 5/29/24, that the resident wished to remain in the facility for Long Term Care. Goals included that the resident will state he/she is comfortable and verbalize satisfaction with care and services. Interventions included: .Follow resident's wishes as he/she expresses them. On 12/6/24 at 1:53 PM, the surveyor observed Resident #66 tearful and crying while lying in bed. The surveyor noted that the resident's flooring was heavily soiled with a black substance. Next to the resident's bed there was a red and pink substance on the floor. The surveyor noted that the wood around the resident's window frame was peeling and chipped in multiple areas. The resident's television was turned on, but was not in service. The resident stated that the television was not working and he/she had no remote control. The surveyor also noted that the protective cover on top of the resident's over bed table was chipped and had exposed wood around the edges. There were no personal effects or decor noted to personalize the resident's room or offer a home like environment. On 12/6/24 at 2:14 PM, the surveyor interviewed Housekeeping (HK) #1 who stated that she had already cleaned Resident #66's room and cleaned the counter tops, sills, high and low dusting, and the bathroom. The surveyor asked if the floor was mopped and the HK stated, yes. On 12/6/24 at 2:19 PM, the surveyor accompanied HK #1 and the Housekeeping Director (HD) into the resident's room. When the surveyor questioned the HD about the condition of the resident's flooring she stated that in 2022, the facility changed the whole floor on the nursing unit, but not Resident #66's room. The HD stated that the red substance on the floor next to the resident's bed was ketchup and should have been cleaned. The HD stated that the dried pink stuff on the floor was cranberry juice. The HD stated that HK had to clean it. At that time, the surveyor showed the HD the condition of the resident's over bed table. The HD stated, We have to report and replace it soon because the resident could be cut. The HD further stated that the table had to be replaced because it was a safety issue. The surveyor asked the HD if HK was responsible to clean the dirt and debris off of the outer heater cover, and the HK stated that the flooring and the heater cover were the responsibility of maintenance. The HK then proceeded to remove the resident's over bed table from the room and stated that she would get another table now. The HD stated they had new tables. The HK stated that the rusted table was not supposed to be in the room. Resident #66 then stated that the table had been like that since he/she arrived at the facility. The HD proceeded to call the Director of Maintenance (DM) to the room. On 12/6/24 at 2:29 PM, the surveyor interviewed the DM about the peeling paint and holes above the resident's television and around the resident's window frame and heater cover, and the condition of the flooring and over bed table. The DM stated that he did not know when the resident's room was painted. The DM stated that he reported the condition of the resident's flooring to the Licensed Nursing Home Administrator (LNHA) many times. The DM stated that no one had reported the holes in the wall. The DM stated they had to clear the room so that he could paint. The DM further stated that this was the only resident room that was like that. The DM further stated, That table ought to be in the trash can. The DM stated that he did not know if anyone told him. The DM stated that the facility did not provide television remotes, but agreed to give the resident a new one. The resident stated, Thank you. At that time, the HD provided the surveyor with documentation that indicated the resident's room was last carbolized (deep cleaned) on 10/30/24. On 12/6/24 at 2:38 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she had not noticed the condition of the resident's over bed table previously. The table wobbled as the HD pushed it down the hall. On 12/9/24 at 1:43 PM, the LNHA, in the presence of the Director of Nursing (DON) and the survey team, acknowledged that the resident's overhead table should have been maintained in good condition. The LNHA stated, we do environmental rounds rounds twice weekly. The LNHA stated it was an older building, but it should still be clean. The LNHA stated we changed chemical companies and thought it would be better to a certain degree. The LNHA stated that he rounded with the maintenance director and had a plan in place to go through each room, but things got pushed off due to emergencies, and planned to get back to it. On 12/11/24 at 10:50 AM, The LNHA stated that they took the resident's room out of service and closed it down until repairs were made. The LNHA stated that, the resident will return to the room when it is in better condition. The LNHA further stated that the the resident was very happy. The LNHA stated the resident wanted to hang up pictures in the room. The surveyor asked why the facility had not hung any pictures up in the room prior to surveyor inquiry, and the Nurse Consultant (NC) who was present stated that the resident was short term, and the family had not brought anything in to hang up on the wall. The NC stated that she did not know if the resident was offered assistance prior to hang his/her pictures to ensure a home like environment. On 12/11/24 at 11:00 AM, The LNHA stated that they did an audit the day prior and there were eight over bed tables that were removed from resident rooms. The surveyor asked if the over bed tables had rusted frames and chipped protective coating on the surface, and the Nurse Consultant stated that, the over bed tables were not cosmetically desirable or aesthetically pleasing. The Licensed Practical Nurse/Unit Manager #2/Infection Preventionist (LPN/UM #2/IP), who was present at that time, stated that it was an increased risk for infection to have the protective cover chipped away from the top of the over bed table because particles could get stuck in the exposed particle board and could not be properly cleaned and sanitized. A review of the facility's policy, Homelike Environment updated April 2024, included, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary and orderly environment; .inviting colors and decor; personalized furniture and room arrangements; clean bed and bath linens that are in good condition; . A review of the facility's policy, Cleaning and Disinfecting Residents' Rooms reviewed April 2024, included, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. .Terminal Room Cleaning (fully cleaned and disinfectant surfaces in a patient room): Terminal room cleaning is done when the resident is transferred, discharged or expires . NJAC 8:39-31.4 (a), (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documents, it was determined that the facilty failed to ensure that an allegation of staff to resident abuse was immediately reported to a supervisor in accordance with the facility abuse policy to ensure the safety of all residents at the facility . This deficient practice was identified for 1 of 1 resident (Resident #33) reviewed for abuse and was evidenced by the following: On 12/6/24 at 9:04 AM, the surveyor completed a tour of the East Unit with Certified Nursing Assistant (CNA) #3. When interviewed, CNA #3 stated that on 12/5/24, Resident #65 reported that an aide twisted his/her roommate's fingers.(Resident #33) . The surveyor asked CNA #3 when she was supposed to report an allegation of abuse? CNA #3 stated that she was supposed to report any allegation of abuse to her supervisor right away. CNA #3 further stated that she did not report the allegation of abuse to the administration yet because Resident #65 stated that he/she wanted to speak with the state surveyor first. A review of Resident #65's most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/26/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that the resident had no behaviors. On 12/6/24 at 9:41 AM, the surveyor interviewed Resident #65 who stated that no one twisted Resident #33's fingers. Resident #65 then stated that Resident #33 twisted the staff's fingers. At that time, the surveyor observed Resident #33 lying in bed with their eyes closed and was unable to be interviewed at that time. A review of Resident #33's admission Record, an admission summary, revealed the resident had diagnoses which included, Alzheimer's Disease, unspecified, unspecified dementia, unspecified severity with other behavioral disturbance, senile degeneration of the brain, not elsewhere classified, delusional disorders and anxiety disorder, unspecified. A review of Resident #33's quarterly MDS, dated [DATE], included the resident had a BIMS score of 4 out of 15, which indicated the resident's cognition was severely impaired. On 12/6/24 at 1:39 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON). The LNHA stated that any alleged abuse should be reported to a supervisor right away. The LNHA further stated that they were not aware of any allegations of abuse and would begin the investigation right away. On 12/9/24 at 2:49 PM, the surveyor interviewed the Nurse Consultant (NC) who stated that CNA #3 should have told Resident #65 that it was her obligation to report the allegation of abuse immediately. On 12/11/24 at 11:05 AM, the LNHA, in the presence of the DON and the survey team, stated that CNA #3 received abuse training on 11/28/24, and that their process should be revisited. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy updated April 2024, included: If a resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported NJAC 8:39-4.1(a) 5

Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. This deficient practice was identified for 1 of 1 resident (Resident #20) reviewed for hospitalization and was evidenced by the following: On 12/4/24 at 10:22 AM, during the initial tour the surveyor observed Resident #20 lying in bed with their eyes closed. On 12/6/24 at 10:00 AM, the surveyor reviewed the medical record for Resident #20. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: cognitive communication deficit, chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), and muscle weakness. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 6/28/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had an admission reentry from the acute hospital. A review of the Progress Notes (PN) dated 6/5/24 at 11:34 PM, reflected the resident was admitted to the hospital for pneumonia, cellulitis (a bacterial infection that affects the skin and tissues beneath it), and acute kidney failure. On 12/6/24 10:09 AM, the surveyor interviewed the Nurse Consultant (NC) who stated that the notification to the State Long-Term Care Ombudsman (Ombudsman's office) was not completed. At that time, the surveyor requested a policy related to notification to the Ombudsman's office for transfers and discharges. On 12/9/24 at 11:44 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the Director of Social Work (DSW) was responsible for notifying the Ombudsman's office which was submitted monthly. The LNHA stated that he thought they were being sent monthly, but never obtained a copy to confirm it was being done. The LNHA stated that it was important to send a notification the Ombudsman's office because they were in partnership for care of the residents. On 12/9/24 at 11:55 AM, the surveyor interviewed the DSW who stated that he started at the facility in May 2024. He further stated that he was responsible for notifying the Ombudsman's office of the discharges and transfers and that he sent them monthly via email. The DSW confirmed Resident #20 was missed in June 2024, because he was still looking for the form and cleaning up the mess from the previous Social Worker. He stated that he did not start notifying the Ombudsman's office until September 2024 and did not go back and complete those prior to September. The DSW stated that it was important to notify the Ombudsman's office, so they know when the resident was transferred out to the hospital or discharged home. On 12/11/24 at 11:04 AM, the LNHA acknowledged in the presence of the Director of Nursing (DON), the Nurse Consultant (NC), and the survey team, that the notification to the Ombudsman's office should have been sent prior to surveyor inquiry. A review of the facility's Transfer or Discharge, Facility Initiated policy, dated October 2022, included, Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that include all notice content requirements). NJAC 8:39-4.1(a)3

Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain a professional standard of practice by ensuring a physician's order was in place for monitoring a resident's blood glucose levels. This deficient practice was identified during medication administration record review for 1 of 3 residents (Resident #25) on dialysis and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 12/4/24 at 10:12 AM, the surveyor observed that Resident #25 was not in their room. A review of the admission Record, an admission summary, revealed that Resident #25 was readmitted from an acute care hospital and had diagnoses that included, but were not limited to: end-stage renal (kidney) disease, dependence on renal dialysis, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and diabetes mellitus. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/8/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 6/8/22, that the resident was at risk for complications related to diabetes mellitus. The interventions included: Obtain finger sticks as indicated. A review of the physician's Progress Notes (PN) dated 11/9/2024 at 9:10 AM indicated to monitor blood sugars. A review of the Order Summary Report (OSR), active orders as of 12/3/2024, revealed no physician orders to monitor the resident's blood glucose levels. On 12/05/24 at 3:05 PM, the surveyor interviewed the Medical Director (MD), who stated that he saw Resident #25 yesterday (12/4/24). He further stated that the resident was on insulin, and he noticed that the resident did not have an order to monitor the blood glusose levels. The MD stated, he was going to order to montior the blood glucose levels and was unsure why it was not already ordered. He stated I am not going to lie, it probably was an oversight. The MD stated that the resident should have their blood glucose levels checks at least three (3) times per week. He emphasized I'll make sure, I put it in. On 12/11/2024 at 10:30 AM, the Nurse Consultant (NC) stated in the presence of the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), that if there was a discrepancy with monitoring the blood glucose levels after the resident returned from the hospital, her expectation would be for the nurse to ask the physician if they wanted to reorder to monitor the blood glucose levels. A review of the undated facility's Reconciliation of Medications on Admission policy did not include blood glucose monitoring. NJAC 8:39- 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide a wound treatment in accordance with the physician's orders, the facility policy, and professional standards of nursing practice. This deficient practice was identified for 1 of 3 residents (Resident #66) reviewed for pressure ulcers and was evidenced by the following: On 12/5/24 at 12:23 PM, the surveyor observed Resident #66 lying awake in bed on a large air mattress and the sheets were disheveled beneath the resident and left parts of the mattress uncovered. The resident had a gauze bandage that covered the resident's left ankle and shin that was dated 12/1/24. When interviewed, the resident stated that they also had a wound on their bottom. Certified Nursing Assistant (CNA) #1 was present and had begun to set the resident up to eat lunch. When interviewed, CNA #1 stated that she was only assigned to the resident today and floated throughout the facility. On 12/5/24 at 10:02 AM, the surveyor reviewed the medical record for Resident #66. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: morbid (severe) obesity due to excess calories, osteomyelitis (bone infection) of vertebra, sacral (bottom of the spine), and sacrococcygeal (pertaining to both the sacrum and the coccyx (tailbone)) region, Pressure ulcer of left heel stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of other site stage 4, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular (relating to the eye) edema bilateral, and depression. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 11/8/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had one Stage 4 pressure ulcer that was present upon admission/entry or reentry to the facility and one surgical wound of the foot. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/4/24, that the resident was at risk for potential pressure injury development related to bladder and bowel incontinence, limited mobility, and was updated on 9/16/24, to include a stage 4 pressure ulcer to the sacrum (triangular bone at the base of the spine) and left heel. Interventions included: Follow facility policies and protocols for the prevention/treatment of skin breakdown. Further review of the resident's ICCP included a focus area, dated 9/15/24, that the resident was on IV (intravenous) antibiotics due to osteomyelitis of a stage 4 pressure ulcer of the sacrum. Interventions included: Dressing change as ordered, and monitor for signs and symptoms of infection (i.e. Redness swelling, increased pain, purulent (pus) discharge at exit sites of tubes). A review of the Order Summary Report (OSR), dated as of 11/3/24, included the following physian orders (PO): 1. A PO, dated 11/3/24, for Povidone-Iodine Solution 10% Apply to left heel topically every day shift every Mon, Wed, Fri for wound care apply betadine soaked gauze ABD (abdominal, a type of dressing) pad and kling (type of gauze dressing). 2. A PO, dated 11/3/24, for Povidone-Iodine Solution 10% Apply to left heel topically every 8 (eight) hours as needed for wound care. Apply Betadine soaked gauze, ABD pad and kling. 3. A PO, dated 11/5/24, for Calcium Alginate-Silver External Pad 4 Calcium Alginate-Silver) Apply to sacrum topically every day shift for wound care. Cleanse with NSS (normal saline solution), pat dry, apply calcium alginate and bordered dressing. 4. A PO, dated 11/5/24, for Calcium Alginate-Silver External Pad 4 Apply to sacrum topically as needed for displacement/soilage. A review of the Progress Notes (PN) included a Skin/Wound Note (S/WN), dated 12/4/24 at 10:44 PM, which included the resident was seen by the wound Medical Doctor. Area to sacrum continued to improve. Ultrasonic mist treatment provided. Continue treatments as directed. Further review of PN indicated that there was no nursing note that referenced the resident's left heel wound dressing changes from 12/1/24 through 12/5/24. On 12/5/24 at 1:01 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she had worked on both 12/3/24 and 12/4/24. She further stated she left before the end of her shift at 10:30 AM on 12/4/24, and did not get around to doing the resident's left heel wound treatment. At that time, the surveyor noted that the resident's left foot and heel was not covered by the dressing and the resident's heel was in direct contact with the resident's mattress which was not covered by the bed sheet. The surveyor noted a yellow substance at the base of the dressing. When interviewed, LPN #1 stated that there was a risk for infection if the resident's left heel dressing was not changed when it was ordered. At that time, the surveyor reviewed the Treatment Administration Record (TAR) with LPN #1 which revealed a PO for Povidone-Iodine Solution 10% Apply to left heel topically every day shift every Mon, Wed, Fri for wound care, apply Betadine soaked gauze ABD pad and kling that was signed out as administered on Monday 12/2/24 and was also signed out as administered on Wednesday 12/4/24 by LPN #1, though the dressing was observed as dated 12/1/24. The surveyor asked LPN #1 why she signed out the treatment as administered if she had not changed the dressing on 12/4/24, and LPN #1 stated that she may have signed the order out early and had forgotten to do the treatment. LPN #1 further stated that she had also forgotten to report off to the oncoming nurse who covered her shift that she had not completed the resident's left heel wound dressing change before she left the facility for the day. On 12/5/24 at 1:11 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager #2/Infection Preventionist (LPN/UM #2/IP) who stated that she believed that the resident's left heel dressing change was ordered every other day. The LPN/UM #2/IP stated that the wound was not treated effectively if it were not covered. She stated that it was improper documentation and a failure to do the treatment if the dressing was dated 12/1/24 and was documented as administered on both 12/2/24 and 12/4/24. On 12/5/24 at 2:03 PM, the surveyor interviewed the Director of Nursing (DON) who stated that a wound treatment should be rendered per the doctor's order and documented. The DON stated that if the resident's dressing was dated 12/1/24, the treatment was not done and two treatments were missed. The DON stated, That runs the risk of infection. The DON stated that it could also cause the wound to worsen if the wound was not covered. On 12/6/24 at 2:05 PM, the surveyor interviewed LPN #1 and asked if she had completed the resident's sacral wound dressing before she left her shift early on 12/4/24 as she had documented on the resident's TAR, and LPN #1 stated no, unfortunately. LPN #1 stated that when she changed the wound dressing the day prior, on 12/5/24, she could not tell who changed it last because it had a lot of brown stuff on it and it was nasty. On 12/9/24 at 2:11 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that it was her expectation that the resident's wound treatments were rendered as ordered and documented accordingly. A review of the facility's undated Wound Care policy, included: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. .The following information should be recorded in the resident's medical record: The date and time the wound care was given. The type of wound care given. The name and title of the individual performing the wound care. Any changes in the resident's condition. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment, the reason for the refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. The signature and title of the person recording the data. .Notify the supervisor if the resident refuses the wound care. Report other information in accordance with the facility policy and professional standards of practice. NJAC 8:39-27.1(e), 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) adjust medication administration times to accommodate for scheduled dialysis times and b.) notify the physician that the resident missed medications during dialysis times. This deficient practice was identified for 1 of 3 residents (Resident #25) reviewed for dialysis and was evidenced by the following: On 12/4/24 at 10:12 AM, the surveyor observed that Resident #25 was not in their room. A review of the admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to: end-stage renal (kidney) disease, dependence on renal dialysis, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and diabetes mellitus. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 9/8/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 6/8/22, that the resident needed dialysis related to renal failure and that the resident went to dialysis on Mondays, Wednesdays, and Fridays, with a chair time (appointment time) of 5:15 AM. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times. A review of the Order Summary Report (OSR), dated as of 12/3/24, included the following physician orders (PO): A PO, dated 10/13/24, for hemodialysis on Mondays, Wednesdays, and Fridays with a chair time of 5:30 AM. A PO, dated 10/13/24, for budesonide suspension 0.5 milligrams (mg) orally via nebulizer two times a day for COPD which was scheduled to be administered at 9:30 AM and 9:30 PM. A PO, dated 10/13/24, for Humalog Kwik Pen subcutaneous 4 units, three times a day for diabetes, scheduled to be administered at 7:30 AM, 11:30 AM, and 4:30 PM. A review of the October 2024 Medication Administration Record MAR revealed that Resident #25 missed five doses of budesonide at 9:30 AM, on their scheduled dialysis days as follows: 10/16, 10/18, 10/21, 10/25, 10/28. Further review of the MAR revealed that Resident #25 missed six doses of Humalog at 7:30 AM, on their scheduled dialysis days as follows: 10/16, 10/18, 10/21, 10/25, 10/28, and 10/30. There was no documented evidence that the physician was not notified of the missed doses in October. A review of the November 2024 MAR revealed that Resident #25 missed a total of nine doses of budesonide at 9:30 AM on their scheduled dialysis days as follows:11/4, 11/6, 11/8, 11/11, 11/13, 11/15, 11/24, 11/26, and 11/29. Further review of the MAR revealed that Resident #25 missed a total of 10 doses of Humalog at 7:30 AM on their scheduled dialysis days as follows: 11/4, 11/6, 11/8, 11/11, 11/13, 11/15, 11/18, 11/24, 11/26, and 11/29. There was no documented evidence that the physician was not notified of the missed doses in November. A review of the December 2024 MAR revealed that Resident #25 missed a total of three doses of budesonide at 9:30 AM on their scheduled dialysis days as follows: 12/2, 12/6, and 12/11. Further review of the MAR revealed the resident missed two doses of Humalog at 7:30 AM on the following dialysis days: 12/2 and 12/4. There was no documented evidence that the physician was not notified of the missed doses in December. On 12/5/24 at 2:38 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM#2), who stated Resident #25's medications should be adjusted around their dialysis schedule. She further stated that if a resident was out of the facility and the medication was not given, the physician should be notified of the missed doses. On 12/6/24 at 11:28 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the medication times should accommodate the dialysis times. She further stated that the physician should be notified if the medication times did not accommodate the resident's dialysis times and of any missed doses. A review of the facility's Dialysis policy, updated April 2024, did not include accommodating the resident's medication administration times. A review of the facility's Medication Administration policy, updated April 2024 did not include missed doses. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medications properly. This deficient practice was observed in 1 of 4 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 12/5/24 at 2:14 PM, the surveyor observed the East Wing high treatment cart in the hallway next to the conference room. A tube of Santyl ointment 250 grams (gm) and a bottle of Nystatin External Powder 100000 UNIT/GM were left on the treatment cart, unattended by a licensed nurse. The surveyor knocked on the Nursing Office door to notify a licensed nurse. Licensed Practical Nurse/Unit Manager (LPN/UM) #1 confirmed that the medication was on the cart and immediately removed the medication. At that time, LPN/UM #1 stated that the medication should be stored in a plastic bag and secured in the treatment cart. On 12/6/24 at 11:41 AM, the surveyor interviewed the Director if Nursing (DON) who stated that the medications should be stored inside the locked cart. A review of the facility's Storage of Medications policy, updated April 2024, included, 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. NJAC 8:39-29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure adaptive dining equipment was provided to a resident during meal service as ordered by the physician and indicated on the resident's individual comprehensive care plan (ICCP). This deficient practice was identified for 1 of 1 resident (Resident #35) reviewed for adaptive dining equipment and was evidenced by the following: On 12/4/24 at 12:32 PM, during a lunch meal observation, the surveyor observed Resident #35's clothes contained droppings of pudding. The diet slip on the resident's lunch tray indicated that the resident should have built-up utensil handles, a sippy cup, and a curved spoon. The resident's lunch tray had a built-up fork, a standard spoon and knife, and the cranberry juice and milk were in their original containers with no sippy cup. On 12/5/24 at 12:07 PM, during a lunch meal observation, the surveyor observed the resident had a built-up spoon, built-up fork, and a sippy cup. The spoon was not curved. The surveyor reviewed the medical record for Resident #35. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: cerebral palsy, psoriatic arthritis mutilans (a rare, severe, and disabling form of psoriatic arthritis that causes joint inflammation and damage), dysphagia, dysarthria, and anarthria. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 11/2/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated a severely impaired cognition. Further review of the MDS revealed the resident depended on staff for the set-up or clean-up for eating. A review of the individual comprehensive care plan (ICCP), initiated 8/9/22, included a focus that the resident was at risk for unavoidable nutritional decline due to progressive disease, oropharyngeal dysphagia from the cerebrovascular accident (CVA - stroke), mechanically altered diet, history of weight loss. Interventions included: Assistive Feeding Devices: sippy cup, high sided dish, curved spoon. A review of the Order Summary Report (OSR) of active orders as of 9/24/24, included the follwing physician orders (PO): A PO, dated 8/25/24, of Assistive Feeding Devices: sippy cup, high-sided dish, and curved spoon. On 12/4/24 at 1:01 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #5, who stated that the Certified Nurse Assistant (CNA) ensured the resident had the right utensils. LPN #5 walked over to Resident #35's tray and confirmed that he/she did not have the appropriate adaptive equipment. On 12/5/24 at 12:40 PM, the surveyor interviewed the Director of Rehabilitation (DOR), who stated that Resident #35 had spastic movements and poor fine motor coordination, and she noticed over the past few months that he/she has had a decline. The DOR looked at the resident's diet slip and confirmed that according to the diet slip, the resident should have had a curved spoon, built-up utensils, and a sippy cup. At that time, she was unaware that a curved spoon was listed on the resident's diet slip. She further stated that should a resident require special equipment, the rehabilitation therapist would fill out a communication form, and copies would go to the dietary department, nursing, and dietician. On 12/5/24 at 2:16 PM, the surveyor interviewed the Food Service Director (FSD) who confirmed that according to the diet slip, Resident #35 should have had a curved spoon, built-up utensils, and a sippy cup during meals. On 12/6/24 at 11:49 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when the food carts arrived on the unit, the nurses and CNAs passed them out. She further stated the nurses, CNAs, and anyone passing trays were supposed to check the diet slip and that adaptive equipment should be provided. The DON stated that if they do not have the adaptive equipment on the meal tray, the kitchen should be contacted so it can be obtained. A review of the facility's Assistance with Meals policy, revised March 2022, included 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 2. Assistance will be provided to ensure than [sic] residents can use and benefit from special eating equipment and utensils if needed. NJAC 8:39-27.5 (b)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to a.) keep the dumpster area free of garbage and debris and b.) have a cover over the opening of 2 of 3 dumpsters. This deficient practice was evidenced by the following: On 12/4/24 at 10:30 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the facility's designated garbage disposal area. There were three garbage dumpsters that each contained two lids. Two of the garbage dumpsters each had one lid open, exposing trash bags inside. There was also garbage on the ground between the two open garbage dumpsters which included single-use gloves, plastic water bottles, plastic packaging, single-serve juice containers, plastic cup lids, paper debris, and cardboard. The surveyor interviewed the FSD at that time who stated the garbage dumpster lids should be closed and there should not be loose trash surrounding the garbage dumpsters. On 12/9/24 at 12:18 PM, the surveyor interviewed the Housekeeping Director (HD) who stated dietary, housekeeping, and maintenance take their own trash to the dumpsters. The HD further stated that the dumpster lids should be kept closed and that there should not be trash and debris surrounding the dumpsters for infection control reasons. On 12/9/24 at 12:23 PM, the surveyor interviewed the Director of Maintenance (DM) who stated housekeeping and dietary maintained the dumpster area when they dispose of trash, but maintenance would pick up trash and debris when it was observed. The DM further stated the dumpster lids should be kept closed and there should not be trash and debris surrounding the dumpsters to prevent pests from the area. On 12/9/24 at 1:27 PM, in the presence of the Nurse Consultant (NC), the Director of Nursing (DON), and the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the dumpster area. The LNHA stated the dumpster area should be kept clean with the dumpster lids closed. Review of the facility's Sanitization policy, revised November 2022, included, Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered), and, Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests. Review of the facility's Food-Related Garbage and Refuse Disposal policy, updated April 2024, included, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. NJAC 18:39-19.3(b)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the required committee members, specifically the Licensed Nursing Home Administrator (LNHA), was present for 1 of 4 Quality Assurance and Performance Improvement (QAPI) quarterly meetings reviewed. This deficient practice was evidenced by the following: On 12/4/24 at 10:10 AM, during the entrance conference with the LNHA and the Nurse Consultant (NC), the surveyor requested the last four quarters of the QAPI sign-in sheets. On 12/5/24 at 10:15 AM, the NC provided the last four quarters of the QAPI sign-in sheets. At that time, the surveyor requested the NC to identify the staff members that signed the sheets. On 12/5/24 at 10:24 AM, the NC provided the updated sign-in sheets, which revealed the LNHA did not sign in for the January 2024 QAPI meeting. A review of the QAPI book and the QAPI minutes reflected there was no documented evidence the LNHA was in attendance for the January 2024 meeting. On 12/9/24 at 11:33 AM, the LNHA stated, in the presence of the survey team, that QAPI met monthly with quarterly goals. He stated the Medical Director (MD) and/or a physician, the Director of Nursing (DON), the LNHA, and the department heads attended the QAPI meetings. When asked if the LNHA was required to attend, he stated it was always good for the LNHA to be there. On 12/9/24 at 11:38 AM, the LNHA reviewed the January 2024 QAPI sign-in sheet and confirmed there was no LNHA signature. The LNHA stated he could not speak to the missing signature as he was not the LNHA at that time. He stated that it was important for the LNHA to attend QAPI because the LNHA was the chairperson of the committee and ensured all concerns were followed through and presented at QAPI. The LNHA confirmed that the LNHA should have signed in. He emphasized he did not know what a QAPI would be without the LNHA present. On 12/11/24 at 11:10 AM, the LNHA stated he did not have any additional information and was unable to comment on the previous LNHA's attendance for the January 2024 QAPI meeting. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program - Governance Leadership policy, updated April 2024, included, 1. The administrator, whether a member of the QAPI committee or not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. 6. The following individuals serve on the committee: a. Administrator. NJAC 8:39-33.1(b)

2.) On 12/4/24 at 10:01 AM, during the initial tour, the surveyor observed Resident #37 lying in bed awake. The surveyor interviewed the resident who stated they were on hospice. On 12/9/24 at 10:45 AM, the surveyor reviewed the medical record for Resident #37. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: malignant neoplasm of brain (brain cancer), malignant neoplasm of prostate (prostate cancer), and malignant neoplasm of skin (skin cancer). A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/14/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated a moderate cognitive impairment. Further review of the MDS revealed the resident was on hospice. A review of the ICCP included a focus area, dated 11/8/24, that the resident had an advanced directive/wishes in place. Interventions included: code status do not resuscitate (DNR) and do no intubate (DNI). Further review of the ICCP did not include a hospice focus area or interventions. On 12/9/24 at 12:17 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated the care plan was in the resident's medical records. LPN #1 stated that the Unit Manager (UM) was responsible for developing the care plan. She stated that a care plan ensured the resident received the proper care from everyone. On 12/9/24 at 12:24 PM, the surveyor interviewed LPN #2 who stated the nurses were responsible for creating the care plans. She stated that a care plan was how staff knew how to care for the resident. She further stated that if a resident was on hospice there should be a care plan related to hospice because we still have to care for the resident. On 12/9/24 at 12:33 PM, the surveyor interviewed the LPN/UM #1 for the East Wing who stated the UMs updated the care plan, but any nurse could create one. She stated that the care plan was the guideline for resident specific plan of care. She further stated that the importance of the care plan was to ensure residents were receiving the specific and appropriate plan of care. LPN/UM #1 stated that if a resident was on hospice there should be a care plan. At that time, LPN/UM #1 confirmed Resident #37 was on hospice. On 12/9/24 at 12:39 PM, the surveyor and LPN/UM #1 reviewed the ICCP in the electronic medical record (EMR). LPN/UM #1 confirmed the resident did not have a focus area or interventions related to hospice. She stated that the care plan should have been developed within 72 hours of the resident being admitted on hospice. At that time, LPN/UM #1 stated she was going to develop the hospice care plan. On 12/11/24 at 11:15 AM, the Nurse Consultant (NC) stated, in the presence of the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the survey team, that the hospice care plan should have been developed prior to surveyor inquiry. A review of the facility's Care Plans, Comprehensive Person-Centered policy, updated April 2024, included, The interdisciplinary team (IDT) . develops and implements a comprehensive, person-centered care plan for each resident, and, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Further review of the policy included, The comprehensive, person-centered care plan: . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . and, reflects currently recognized standards of practice for problem areas and conditions. A review of the facility's Hospice Program policy, updated April 2024, included, 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility. NJAC 8:39-11.2 (e), 27.1 (a) Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan (ICCP) to include a.) a resident's use of anticoagulant medication (blood thinning medication) and, b.) a resident's hospice services. This deficient practice was identified for 1 of 5 residents (Resident #70) reviewed for medication regimen and 1 of 2 residents (Resident #37) reviewed for hospice and was evidenced by the following: 1.) On 12/5/24 at 12:21 PM, the surveyor observed Resident #70 eating lunch in his/her room. On 12/6/24 at 11:29 AM, the surveyor reviewed the medical record for Resident #70. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: atrial fibrillation (A-Fib; a heart condition that causes an irregular, rapid heart beat and increases the risk for blood clots). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/15/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident was taking an anticoagulant medication. A review of the Order Summary Report, dated as of 12/10/24, included the following Physician Orders (PO): A PO, dated 7/11/24, for apixaban (an anticoagulant medication) 5 milligrams by mouth every 12 hours for prophylaxis, observe for any bruising, dark urine, and black tarry stools. A PO, dated 8/1/24, for anticoagulant medication monitoring - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. A review of the December 2024 Medication Administration Record (MAR) included the above PO for apixaban and anticoagulant monitoring. A review of the resident's individual comprehensive care plan (ICCP) did not include the resident's diagnosis of A-Fib or the use of anticoagulant medications. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated nurses should monitor residents who were on anticoagulant medications for signs and symptoms of bleeding. The LPN further stated the unit managers were responsible for developing the resident's ICCP so that the staff know how to properly care for the resident safely. On 12/9/24 at 12:11 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated nurses should monitor residents who were on anticoagulant medications for bruising, bleeding, and bloody urine. The LPN/UM further stated that any nurse could develop the resident's ICCP because it is the map to the resident's care and tells staff what they need to know about the resident. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated the unit managers and the DON were responsible for developing the resident's ICCP so that the proper plan of care is executed for the resident. At that time, the surveyor informed the DON of Resident #70's ICCP and the DON confirmed the ICCP should have included the resident's diagnosis of A-Fib and the use of anticoagulant medications.

Based on interview, record review, and review of facility documents, it was determined that the facility failed to accurately utilize an infection assessment tool for 7 of 7 residents (Resident # #11, #39, #54, #65, #70, #328, #329) reviewed that were prescribed antibiotic medications in the facility. This deficient practice was evidenced by the following: A review of the facility's Antibiotic Stewardship line list for September, October and November 2024, revealed the following residents were prescribed antibiotics while at the facility: 1. Resident #328 was prescribed an antibiotic on 9/4/24 for seven (7) days for a skin infection. The line list further indicated that in infection assessment tool was completed with antibiotic use criteria not met. 2. Resident #11 was prescribed an antibiotic on 9/18/24 for five (5) days for a tooth infection. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 3. Resident #329 was prescribed an antibiotic on 9/28/24 for 7 days for a urinary tract infection (UTI). The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 4. Resident #54 was prescribed an antibiotic on 9/20/24 for 5 days for a UTI. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 5. Resident #39 was prescribed an antibiotic on 10/20/24 for 7 days for a skin infection. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 6. Resident #65 was prescribed an antibiotic on 10/22/24 for 5 days for a UTI. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 7. Resident #54 was prescribed an antibiotic on 10/6/24 for 3 days and then another antibiotic on 10/15/24 for 5 days both for a UTI. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. 8. Resident #70 was prescribed an antibiotic on 11/4/24 for 5 days for a UTI. The line list further indicated that an infection assessment tool was completed with antibiotic use criteria not met. On 12/6/24 at 10:26 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that she worked full time as a Licensed Practical Nurse (LPN) and was the Unit Manager (UM) for the [NAME] Wing and the IP. She stated that she contributed at least 20 hours a week for her role as the IP. The IP stated that she used the McGeer for infection surveillance which determined if an antibiotic was appropriate. She further stated that she reviewed the diagnostics testing and the nurses and physician's documentation to determine if the criteria was met. She stated that if the criteria was not met then she would notify the physician to see if they want to continue the antibiotic. When asked how the data was analyzed, the IP stated she tracked it on the Infection Log monthly and the surveillance checklist. The IP further stated that she did not notice any trends, but if she did, then she would notify the physicians and explain to them that the criteria was not met. On 12/6/24 at 11:10 AM, the IP provided a copy of the Infection Logs and the infection surveillance checklist. At that time, the surveyor continued to interview the IP who stated that if a resident was started on an antibiotic while at the facility and criteria was not met then the nurse should called the physician and would document it in the electronic medical record (EMR). The surveyor and the IP reviewed the Infection Log and she confirmed the 7 residents were prescribed an antibiotic even though the criteria was not met. The IP acknowledged there should be documentation, but there was no documentation that physician was notified that the antibiotic did not meet the criteria for the 7 residents that were at the facility and started on an antibiotic. The IP stated the importance of following the criteria was to prevent antibiotic resistant and for the risk of Multidrug Resistant Organisms (MDRO - bacteria that is resistant to many antibiotics). On 12/11/24 at 10:57 AM, the Nurse Consultant (NC) stated, in the presence of the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the survey team, that for the antibiotic stewardship they were going to revamp it and ensure it was followed. The NC stated that it was important to follow the criteria and that it was met so they are not overusing the antibiotic. A review of the facility's Antibiotic Stewardship policy, updated April 2024, included, 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. A review of the facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, reviewed April 2024, included, 2. The IP or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (4) therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings. NJAC 8:39-19.4(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 12/5/24 at 12:01 PM, the surveyor reviewed the medical record for Resident #69 A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: high blood pressure, pneumonia, and chronic respiratory failure with hypoxia (the body is not receiving enough oxygen). A review of the resident's Immunization Audit Report, as of 12/5/24, did not include any documentation related to the pneumococcal vaccine. A review of the resident's admission Minimum Data Set (MDS), an assessment tool, dated 9/25/24, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident was offered, but declined, the pneumococcal vaccine. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #69's pneumococcal vaccine consent which was signed on 12/10/24, after surveyor inquiry. Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the pneumococcal vaccination or the influenza vaccination was offered to residents upon admission to the facility for 4 of 5 residents (Resident #14, #66, #69, and #70) reviewed for immunizations. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Pneumococcal Vaccine for Adults Aged >19 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP), United States, 2023 Recommendations and Reports / September 8, 2023 / 72(3);1-39 Adults aged >19 years who have received PCV13 only are recommended to receive a single dose of PCV20 at an interval >1 year after receipt of the PCV13 dose or to receive >1 dose of PPSV23 to complete their pneumococcal vaccine series. -When PPSV23 is used instead of PCV20, the minimum recommended interval between PCV13 and PPSV23 administration is >8 weeks for adults with an immunocompromising condition, a CSF leak, or a cochlear implant and >1 year for adults without these conditions. Either PCV20 or a second PPSV23 dose is recommended >5 years after the first PPSV23 dose for adults aged 19-64 years with specified immunocompromising conditions but not for adults with a CSF leak or a cochlear implant. In addition, those who received both PCV13 (at any age) and PPSV23 (no PCV20) but have not received a dose of PPSV23 at age >65 years are recommended to receive either PCV20 or a single and final dose of PPSV23 at age >65 years and >5 years since the previous PPSV23 dose. Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2024-25 Influenza Season Recommendations and Reports / August 29, 2024 / 73(5);1-25 Routine annual influenza vaccination of all persons aged >6 months who do not have contraindications continues to be recommended. All persons should receive an age-appropriate influenza vaccine (one that is approved for their age) 1.) On 12/6/24 at 10:19 AM, the surveyor reviewed the medical record for Resident #14. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, and chronic viral hepatitis C. A review of the resident's Immunization Audit Report, as of 12/5/24, did not include any documentation related to the pneumococcal vaccine. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/16/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident was offered, but declined, the pneumococcal vaccine. On 12/6/24 at 10:39 AM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist (IP) who confirmed administration or declination of vaccinations was documented in the immunization tab (Immunization Audit Report) of the resident's electronic medical record. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated the unit managers offered the residents their vaccines and obtained the consents or declinations. The LPN confirmed that immunization information was documented in the resident's electronic medical record and stated it was important to offer residents vaccines to help prevent sickness such as the flu, pneumonia, or COVID-19. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), the Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated upon admission, the resident's immunization information was included in the admission packet to determine if the resident received or would like to receive immunizations. The DON further stated that any of the nurses could obtain consent or declination for the vaccines and that consents/declinations were documented in the resident's medical record. The DON added that the importance of offering immunizations was so the resident can be vaccinated for anything that is possibly harmful. At that time, the surveyor informed the DON of the missing pneumococcal vaccine information for Resident #14, and the DON confirmed the resident should have been offered a pneumococcal vaccine. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #14's pneumococcal vaccine declination which was signed on 12/9/24, after surveyor inquiry. On 12/11/24 at 10:30 AM, in the presence of the NC, DON, LNHA, and the survey team, the surveyor interviewed the IP who stated the pneumococcal vaccine consents and declinations should have been obtained upon admission. 2.) On 12/6/24 at 10:23 AM, the surveyor reviewed the medical record for Resident #70. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: immunodeficiency due to drugs. A review of the resident's Immunization Audit Report, as of 12/5/24, included a historical immunization record that the resident received the pneumococcal conjugate vaccine 13 (PCV13) on 6/18/18. There was no other documentation of a pneumococcal vaccination after 2018. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/15/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident was offered, but declined, the pneumococcal vaccine. On 12/6/24 at 10:39 AM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist (IP) who confirmed administration or declination of vaccinations was documented in the immunization tab (Immunization Audit Report) of the resident's electronic medical record. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated the unit managers offered the residents their vaccines and obtained the consents or declinations. LPN #1 confirmed that immunization information was documented in the resident's electronic medical record and stated it was important to offer residents vaccines to help prevent sickness such as the flu, pneumonia, or COVID-19. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), the Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated upon admission, the resident's immunization information is included in the admission packet to determine if the resident received or would like to receive immunizations. The DON further stated that any of the nurses could obtain consent or declination for the vaccines and that consents/declinations were documented in the resident's medical record. The DON added that the importance of offering immunizations was so the resident can be vaccinated for anything that is possibly harmful. At that time, the surveyor informed the DON of Resident #70's pneumococcal immunization status, and the DON confirmed the resident should have been offered a pneumococcal vaccine. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #70's pneumococcal vaccine consent which was signed on 12/9/24, after surveyor inquiry. On 12/11/24 at 10:30 AM, in the presence of the NC, the DON, the LNHA, and the survey team, the surveyor interviewed the IP who stated the pneumococcal vaccine consents and declinations should have been obtained upon admission. 4.) On 12/5/24 at 9:59 AM, the surveyor reviewed the medical record for Resident #66. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: morbid (severe) obesity due to excess calories, osteomyelitis (bone infection) of vertebra, sacral (bottom of the spine), and sacrococcygeal (pertaining to both the sacrum and the coccyx (tailbone)) region, pressure ulcer of left heel stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of other site stage 4, type 2 (two) diabetes mellitus with mild nonproliferative diabetic retinopathy without macular (relating to the eye) edema bilateral, and depression. A review of the resident's Immunization Audit Report, as of 12/5/24, did not include any documentation related to the influenza or pneumococcal vaccination administration. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 5/28/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that both the influenza and pneumococcal vaccines were not administered and were not offered. A review of the resident's quarterly MDS, dated [DATE], included the resident had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that both the influenza and pneumococcal vaccines were offered and declined. On 12/5/24 at 1:19 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that she had worked at the facility since September 2024. The IP stated that she reviewed the resident's admission assessments and their medical records to determine the resident's immunization status. The IP stated that she had called the resident's responsible party to determine if the resident had previously received the influenza and pneumococcal vaccines, but did not document the call and had not heard back. The IP stated that she was unable to find any immunization history for the resident in the immunization data base, hospital records or under the immunization tab in the resident's EHR. The IP stated there was no data to be found for the resident to indicate that the resident's immunization status was previously assessed or if the resident was offered the pneumococcal or influenza vaccines upon admission/readmission or when they were offered at the facility during vaccine clinics. The surveyor reviewed the resident's past four Admission/readmission Evaluations and the Immunization sections were incomplete and failed to indicate if the resident had previously received the influenza or pneumococcal vaccines. On 12/5/24 at 2:08 PM, the surveyor interviewed the Director of Nursing (DON) who stated the admission nurse was responsible to determine if the resident had already received the influenza or pneumococcal vaccines. The DON stated the IP was responsible to ensure that the resident's immunization status was accurately reflected on the Immunization Audit Report. The DON further stated the IP should have documented attempts to contact the resident's family in the resident's EHR. On 12/6/24 at 11:42 AM, the surveyor interviewed the MDS Coordinator, via telephone, who stated that she worked at the facility since 10/1/24. The MDS Coordinator stated she reviewed the resident's historical immunization history in the resident's EHR and only noted a historical tuberculosis testing. The MDS Coordinator stated that she documented that the influenza and the pneumococcal status as offered and declined, and, unfortunately, I did just copy the information from the previous MDS. The MDS Coordinator stated that she should have looked in the resident's EHR and attempted to find a vaccination refusal. On 12/9/24 at 1:24 PM, The surveyor interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated that it was important to be vaccinated in order to prevent anything that may be hurtful to the resident. The DON stated the resident should have been offered the influenza and the pneumococcal vaccines if they were a resident during the time they were offered. On 12/11/24 at 9:31 AM, the DON provided the surveyor with an Informed Consent for Influenza Vaccination and Pneumococcal Vaccinations and both consents were refused by the resident on 12/9/24, after surveyor inquiry. A review of the facility's Pneumococcal Vaccine policy, updated February 2024, included, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident has already been vaccinated, and, Administration of the pneumococcal vaccines or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) recommendations at the time of the vaccination. A review of the facility's Influenza Vaccine policy, updated April 2024, included, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote benefits associated with vaccinations against influenza. .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. .Administration of the influenza vaccine will be made in accordance with current centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) recommendations at the time of vaccination. NJAC 8:39-19.4 (i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 12/5/24 at 12:01 PM, the surveyor reviewed the medical record for Resident #69 A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, high blood pressure, pneumonia, and chronic respiratory failure with hypoxia (the body is not receiving enough oxygen). A review of the resident's Immunization Audit Report, as of 12/5/24, did not include any documentation related to the COVID-19 vaccine. A review of the resident's admission Minimum Data Set (MDS), an assessment tool, dated 9/25/24, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #69's COVID-19 vaccine declination which was signed on 12/10/24, after surveyor inquiry. Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents an updated COVID-19 vaccine for 4 of 5 residents (Resident #14, #66, #69, and #70) reviewed for immunizations. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Use of COVID-19 Vaccines for Persons Aged >6 Months: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2024-2025 Weekly / September 19, 2024 / 73(37);819-824 On June 27, 2024, the Advisory Committee on Immunization Practices recommended 2024-2025 COVID-19 vaccination with a Food and Drug Administration (FDA)-authorized or approved vaccine for all persons aged >6 months. In August 2024, the FDA approved and authorized the Omicron JN.1 lineage (JN.1 and KP.2), 2024-2025 COVID-19 vaccines by Moderna and Pfizer-BioNTech (KP.2 strain) and Novavax (JN.1 strain). Persons aged >12 years without moderate to severe immunocompromise need 1 dose of 2024-2025 COVID-19 vaccine (Moderna, Novavax, or Pfizer-BioNTech) to be up to date. Persons aged >12 years who have not previously received any COVID-19 vaccines and choose to get Novavax should receive 2 doses of the 2024-2025 Novavax vaccine. 1.) On 12/6/24 at 10:19 AM, the surveyor reviewed the medical record for Resident #14. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, and chronic viral hepatitis C. A review of the resident's Immunization Audit Report, as of 12/5/24, included a historical immunization record that the resident received a COVID-19 vaccination on 8/15/21 (Step 1), 9/12/21 (Step 2), and 9/28/22 (Booster). There was no documentation that the resident received or declined an updated COVID-19 vaccination after 2022. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/16/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. On 12/6/24 at 10:39 AM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist (IP) who confirmed administration or declination of vaccinations was documented in the immunization tab (Immunization Audit Report) of the resident's electronic medical record. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated the unit managers offered the residents their vaccines and obtained the consents or declinations. The LPN confirmed that immunization information was documented in the resident's electronic medical record and stated it was important to offer residents vaccines to help prevent sickness such as the flu, pneumonia, or COVID-19. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), the Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated upon admission, the resident's immunization information is included in the admission packet to determine if the resident received or would like to receive immunizations. The DON further stated that any of the nurses could obtain consent or declination for the vaccines and that consents/declinations were documented in the resident's medical record. The DON added that the importance of offering immunizations was so the resident can be vaccinated for anything that is possibly harmful. At that time, the surveyor informed the DON of Resident #14's COVID-19 immunization status, and the DON confirmed the resident should have been offered an updated COVID-19 vaccine. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #14's COVID-19 vaccine declination which was signed on 12/10/24, after surveyor inquiry. On 12/11/24 at 10:30 AM, in the presence of the NC, DON, LNHA, and the survey team, the surveyor interviewed the IP who stated the COVID-19 vaccine consents and declinations should have been obtained upon admission. 2.) On 12/6/24 at 10:23 AM, the surveyor reviewed the medical record for Resident #70. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: immunodeficiency due to drugs. A review of the resident's Immunization Audit Report, as of 12/5/24, included a historical immunization record that the resident received a COVID-19 vaccination on 4/9/21 (Step 1), 4/30/21 (Step 2), 3/1/22 (Booster), and 10/4/22 (Booster). There was no documentation that the resident received or declined an updated COVID-19 vaccination after 2022. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/15/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. On 12/6/24 at 10:39 AM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist (IP) who confirmed administration or declination of vaccinations was documented in the immunization tab (Immunization Audit Report) of the resident's electronic medical record. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated the unit managers offered the residents their vaccines and obtained the consents or declinations. LPN #1 confirmed that immunization information was documented in the resident's electronic medical record and stated it was important to offer residents vaccines to help prevent sickness such as the flu, pneumonia, or COVID-19. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), the Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated upon admission, the resident's immunization information is included in the admission packet to determine if the resident received or would like to receive immunizations. The DON further stated that any of the nurses could obtain consent or declination for the vaccines and that consents/declinations were documented in the resident's medical record. The DON added that the importance of offering immunizations was so the resident can be vaccinated for anything that is possibly harmful. At that time, the surveyor informed the DON of Resident #70's COVID-19 immunization status, and the DON confirmed the resident should have been offered an updated COVID-19 vaccine. On 12/11/24 at 9:30 AM, the DON provided the surveyor with Resident #70's COVID-19 vaccine consent which was signed on 12/9/24, after surveyor inquiry. On 12/11/24 at 10:30 AM, in the presence of the NC, the DON, the LNHA, and the survey team, the surveyor interviewed the IP who stated the COVID-19 vaccine consents and declinations should have been obtained upon admission.4.) On 12/5/24 at 9:59 AM, the surveyor reviewed the medical record for Resident #66. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: morbid (severe) obesity due to excess calories, osteomyelitis (bone infection) of vertebra, sacral (bottom of the spine), and sacrococcygeal (pertaining to both the sacrum and the coccyx (tailbone)) region, pressure ulcer of left heel stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), pressure ulcer of other site stage 4, type 2 (two) diabetes mellitus with mild nonproliferative diabetic retinopathy without macular (relating to the eye) edema bilateral, and depression. A review of the resident's Immunization Audit Report, as of 12/5/24, did not include any documentation related to the COVID-19 vaccine administration. A review of the resident's quarterly MDS, dated [DATE], included the resident had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that the resident's COVID-19 vaccination was not up to date. The surveyor reviewed the resident's past four Admission/readmission Evaluations and the Immunization sections were incomplete and failed to indicate if the resident had previously received the SARS-COV-2 (COVID-19) vaccine. On 12/5/24 at 2:08 PM, the surveyor interviewed the Director of Nursing (DON) who stated the admission nurse was responsible to determine if the resident had already received the COVID-19 vaccine. The DON stated the IP was responsible to ensure that the resident's immunization status was accurately reflected on the Immunization Audit Report. The DON further stated the IP should have documented attempts to contact the resident's family in the resident's EHR. On 12/5/24 at 1:19 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that she had worked at the facility since September 2024. The IP stated that she reviewed the resident's admission assessments and their medical records to determine the resident's immunization status. The IP stated that she had called the resident's responsible party to determine if the resident had previously received the COVID-19 vaccine but did not document the call and had not heard back. The IP stated that she was unable to find any immunization history for the resident in the immunization data base, hospital records, or under the immunization tab in the resident's EHR. The IP stated there was no data to be found for the resident to indicate that the resident's immunization status was previously assessed or if the resident was offered the COVID-19 vaccine upon admission/readmission. On 12/6/24 at 11:42 AM, the surveyor interviewed the MDS Coordinator, via telephone, who stated that she worked at the facility since 10/1/24. The MDS stated she reviewed the resident's historical immunization history in the resident's EHR and only noted a historical tuberculosis testing. The MDS Coordinator stated, unfortunately, I did just copy the information from the previous MDS. The MDS Coordinator stated that she should have looked in the resident's EHR and attempted to find vaccination information. On 12/9/24 at 1:24 PM, the surveyor interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated that it was important to be vaccinated in order to prevent anything that may be hurtful to the resident. The DON stated the resident should have been offered the COVID-19 vaccine. On 12/11/24 at 9:31 AM, the DON provided the surveyor with a COVID-19 Vaccination consent with documented resident refusal that was signed by the resident on 12/9/24, after surveyor inquiry. A review of the facility's COVID-19 Vaccination policy, updated April 2024, included, When COVID-19 vaccine is available to the facility, each resident and staff member who has not already been immunized and does not have medical contraindications will be offered the vaccine. Further review of the policy included, Prior to vaccination, informed consent will be obtained, and, The resident, resident representative, or staff member has the opportunity to accept or refuse the COVID-19 vaccine and change their decision about vaccination at any time. Refusal of the vaccine shall be documented. NJAC 8:39-19.4(a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary medication storage room. This deficient practice was identified in 1 of 2 medication storage rooms (West Wing med room) and was evidenced as follows: On 12/5/2024 at 9:04 AM, the surveyor entered the medication (med) storage room located on the [NAME] Wing, accompanied by Licensed Practical Nurse (LPN) #1; upon entering, there was a musty odor and the following was observed: The floor tile was discolored with stains and small particles in various areas. The floor was raised and buckled in the area closest to the left wall. There was a crack extending across the ceiling. There was piping that was detached piping laying on the floor in front of the sink. In the cabinet under the sink, there was a moist soiled white blanket containing brown stains and debris. The lower bilateral sides of the interior of the cabinet were discolored grayish black. On 12/5/2024 at 10:54 AM, the surveyor interviewed the Director of Maintenance (DM), who stated he was responsible for repairing the med room piping and floor. He stated that the pipes in the med storage room broke about three weeks ago and that he ordered the parts. He further stated he was not at work for about a week after he ordered the parts and that while he was out nothing was done since he was the only maintenance person on staff. On 12/05/24 at 2:29 PM, the surveyor conducted a follow-up visit to the [NAME] Wing med storage room, accompanied by LPN #3 and LPN/UM #2. When LPN#3 turned on the faucet, water came out of the pipe under the sink and onto the white blanket. There was no signage indicating that the sink was not in working condition. At that time, LPN/UM #2 stated that the med room sink was nonfunctional. When asked if there was any hand sanitizer, she replied, no there was no hand sanitizer in the med storage room. On 12/6/2024 at 12:14 PM, the surveyor interviewed LPN/UM#1 , who stated the sink has been nonfunctional for about a month. She further stated something under the sink was cracked or broken because when she washed her hands she could hear water dripping under the sink. She also stated that the facility knew that the floor was pushing in and squishy. On 12/6/2024 at 1:25 PM, the surveyor conducted a follow-up interview with LPN #1, who stated when she washed her hands at the sink in the med storage room, she would hear water dripping under the sink. She then stated that the floor had been soft and wet for months. She further stated that the DM was informed, but she did not recall when he was notified. On 12/6/24 at 1:33 PM, the surveyor interviewed LPN #3, who stated that she has not been washing her hands in the med room for about one month due to the sink being out of order. She further stated that she was unsure of when the water leaked onto the floor. On 12/6/2024 at 1:39 AM, the surveyor conducted an interview with LPN/UM #2, who stated that since September there has been a leak onto the med storage floor and the damage progressed. She further stated, You can tell it was wet in there, and you could see that the tiles had obviously gotten wet. She also stated that there was a maintenance log and and all issues where documented on the maintenance log. On 12/9/2024 at 9:03 AM, the surveyor conducted a follow-up interview with the Licensed Nursing Home Administrator (LNHA). When asked if the condition of the med storage room floor was reported to him, he stated that he received reports related to some water on the floor. The LNHA further stated that the floor, the faucet and the cabinet should be maintained in good repair. On 12/9/2024 at 2:26 PM, the surveyor interviewed the Consultant Pharmacist (CP), who stated that medications should be stored in a clean, dry, organized, temperature-controlled, and sanitary environment. She stated that she toured the medication storage rooms once per month and her last visit was on 12/5/24. She further stated when she toured the [NAME] Wing med storage room this month, she noticed that there was something going on and told the facility that it was unacceptable. When asked, what would be her recommendation if the med storage room had a leak, she replied that the facility would have to rectify that immediately, because if an air quality test were to be done, it would not be considered a dry cool room. A review of the facility's Storage of Medications policy updated April 2024 included 3. The nursing staff is responsible for maintaining medication storage and preparation areas clean, safe, and sanitary. A review of the facility's Maintenance Service undated policy included, Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. NJAC 8:39-31.4(a)

Complaint #: NJ176956 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/4/24 at 9:45 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. When the surveyor and the FSD approached the designated handwashing sink, a dietary staff member removed items from the sink. When asked what the items were, the FSD stated the dietary staff member removed a fork and spatula from the sink that was used to make sandwiches. The FSD further stated that there should not be food prep items in the designated handwashing sink. There was no signage to indicate the sink was to be used for handwashing purposes only. 2. In the walk-in refrigerator, there were three metal shelving units used to store food items. The three shelving units had rust on the shelves. 3. In the dish washing area, there was a build-up of black substance in the calking between the counter and the wall. The FSD stated the area was cleaned daily, but the dietary staff had not gotten to cleaning the area yet. 4. In the area identified by the FSD as the storage area for plates to be used for meal service, there were four ceramic meal plates that were chipped. The FSD stated the chipped plates should be thrown away and removed them from the storage area. On 12/5/24 at 9:57 AM, the surveyor interviewed the FSD who stated the dietary staff were unable to remove the black substance from the dish washing area and would have to contact maintenance for assistance. The FSD further stated the dish washing area should be kept clean to prevent contamination. When asked about the shelving units in the walk-in refrigerator, the FSD stated they should not have rust because rust is a possible contaminate. When asked about the chipped ceramic plates, the FSD stated chipped dishware should not be used for the safety of residents. On 12/9/24 at 1:27 PM, in the presence of the Nurse Consultant (NC), the Director of Nursing (DON), and the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the concerns in the kitchen. The LNHA stated used utensils should not be stored in the designated handwashing sink. The LNHA further stated that if there was rust on the shelving units in the walk-in refrigerator, the dietary staff should have reported it to maintenance and not stored food on those shelves until the rust was addressed. The LNHA also stated the dietary staff should have cleaned the black substance in the dish washing area or notified housekeeping and maintenance for further assistance. The LNHA added that the dietary staff should have thrown away any chipped dishware. Review of the facility's Handwashing, Kitchen policy, updated 4/2024, included, Hand washing facilities should be readily accessible and equipped with hot and cold running water, paper towels, soap, trash cans, and signage notifying employees to wash their hands. Review of the facility's Food Receiving and Storage policy, revised November 2022, included, Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. Review of the facility's Sanitization policy, revised November 2022, included, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris. Further review of the policy included, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning, and, Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. NJAC 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 12/4/24 at 10:10 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Nurse Consultant (NC), the surveyor requested the facility's water management program with evidence of monitoring. On 12/6/24 at 10:26 AM, the surveyor interviewed the Infection Preventionist (IP). When asked if there had been a case of Legionella or other waterborne pathogen illness in the facility, the IP stated the facility did not have any cases. On 12/6/24 at 12:09 PM, the surveyor interviewed the LNHA who stated they hired an outside company for the well water (water that comes from a well, which is a hole dug into the ground to access groundwater) system. The LNHA stated he thought the outside company completed the Legionella testing, but confirmed it was not tested. He further stated that the facility was constantly cleaning to ensure there was no still water. The LNHA stated that the outside company informed him that the chemicals used helped with preventing Legionella. He further stated the Director of Maintenance (DM) oversaw the water management program and could not fully speak to what was done. On 12/6/24 at 12:23 PM, the surveyor interviewed the DM, in the presence of the LNHA and survey team, who stated that the process for the water management was the facility had an outside company that came in and treated the water. He stated that they came to test the water every two weeks to ensure the levels, which included the salt, chlorine, nitrate, and pH for the well water, were good. When asked if there was a process for monitoring waterborne pathogens such as Legionella, the DM stated there was no process and that they did not monitor for Legionella. He further stated that he did ensure there was no stagnate water and that he kept a report of it. A review of the records indicated the facility monitored the lead and copper levels. There was no documented evidence for the monitoring of waterborne pathogens. On 12/11/24 at 10:30 AM, the LNHA stated, in the presence of the Nurse Consultant (NC), the Director of Nursing (DON), the Infection Preventionist (IP), and the survey team, that the testing that was provided did not specifically include Legionella. He further stated that he spoke with the outside company that tested their well water and they informed him the usage of the chemicals would take away Legionella. The LNHA then emphasized he just scheduled an official testing for Legionella. The LNHA confirmed that he created the water management program over the weekend (12/7/24, after surveyor inquiry) since they did not have one prior. A review of the facility's Water Supply policy, reviewed April 2024, included, Purpose: to maintain a sanitary water supply and control the spread of waterborne microorganisms. NJAC 8:39-19.1 NJAC 8:39-19.4 (m)(n) Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to a.) follow appropriate infection control practices by not performing hand hygiene during the meal pass for 1 of 2 units (West Wing) observed, and b.) have a water management program in place to prevent the growth of Legionella (a waterborne pathogen). The deficient practice was evidenced by the following: On 12/5/24 at 12:09 PM, the surveyor observed the following during the meal pass on the [NAME] Wing unit: Certified Nursing Assistant (CNA) #2 picked up a tray from the meal cart, brought it to room [ROOM NUMBER]-B, and set up the tray for the resident. The CNA then left the room without performing hand hygiene and picked up another tray from the meal cart, brought it to room [ROOM NUMBER]-A, and set up the tray for the resident. The CNA then left the room without performing hand hygiene and picked up another tray from the meal cart, brought it to room [ROOM NUMBER]-A, and set up the tray for the resident. The CNA then left the room without performing hand hygiene and picked up another tray from the meal cart. The CNA entered Resident #34's room, put the tray on the overbed table, moved the overbed table closer to the resident with ungloved hands, put on gloves to assist the resident to a sitting position by holding the resident's hand, set up the resident's tray, and tore open a sweetener packet for the resident's coffee while still wearing gloves used to assist the resident. Wearing those same gloves, the CNA then went to the roommate's (Resident #61) meal tray, opened the resident's coffee, tore a sweetener packet to put in the coffee, and touched the resident's eating utensils to cut up the resident's food. The CNA then disposed of her gloves, left the room without performing hand hygiene, and went to the meal cart to pick up another tray. At that time, before the CNA picked up another tray from the meal cart, the surveyor interviewed CNA #2. The CNA stated that staff were supposed to perform hand hygiene between each meal tray that was passed out to prevent the transfer of germs between residents. The CNA confirmed that she did not perform hand hygiene during the surveyor's observation of the meal pass. On 12/9/24 at 12:03 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated staff should perform hand hygiene between each meal tray that is passed out to prevent the spread of germs from resident to resident. On 12/9/24 at 12:11 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2, who was also the Infection Preventionist (IP), who stated staff should perform hand hygiene before picking up the next meal tray to deliver to the next resident to prevent contamination and spreading any potential infection. On 12/9/24 at 1:19 PM, in the presence of the Nurse Consultant (NC), Licensed Nursing Home Administrator (LNHA), and the survey team, the surveyor interviewed the Director of Nursing (DON) who stated staff should perform hand hygiene when exiting each resident's room during meal pass for infection prevention. At that time, the surveyor informed the DON of the meal pass observation and the DON confirmed that CNA #2 should have performed hand hygiene after passing out each meal tray and should not have worn the same gloves for Resident #34 and Resident #61. A review of the facility's Handwashing/Hand Hygiene policy, updated April 2024, included to use an alcohol-based hand rub, or soap and water, for the following situations: before and after assisting a resident with meals.

B.) On 08/24/2023 at 11:52 AM, during the initial tour, Surveyor #2 observed Resident #32 awake in bed. Resident #32's call device was clipped to a cord extending from the wall. Resident #32 could not reach the device. On 08/25/2023 at 09:10 AM, Surveyor #2 observed Resident #32 resting in bed. The call device was clipped to a cord extending from the wall. The device was not in reach of Resident #32. On 08/29/2023 at 08:52 AM, Surveyor #2 observed Resident #32 in bed. The call device continued to be clipped to a cord extending from the wall. It was not within Resident #32's reach. On 08/30/2023 at 09:32 AM, Surveyor #2 observed that Resident #32's call device was not within reach. The call device was on the floor, underneath the roommate's bed. On 09/05/2023 at 12:40 PM during an interview with Surveyor #1 and Surveyor #2, Certified Nurse Aide (CNA) #1 replied, The policy is to answer them as soon as possible when asked what the policy on call devices was. CNA #1 also replied, They [call devices] should be placed by the resident if they sit in their chairs or by the bed if they are in bed when asked where should call devices be placed. On 09/06/2023 at 12:53 PM, during an interview with Surveyor #2, the Licensed Nursing Home Administrator (LNHA) stated, Within reach when asked where should a call device be placed within a resident's room. The LNHA replied, To call for help when they have a need when asked by Surveyor #2 why it was important to place call device within a resident's reach. A review of the undated facility policy titled, Call System, Resident revealed under Policy Interpretation and Implementation that, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed or other sleeping accommodations. 8:39-31.8(c)9 Based on observation, interview, record review, and review of other facility documentation it was determined that the facility failed to ensure residents call device was within reach of the residents. The deficient practice occurred for 2 of 5 residents (Residents #38, #32). The deficient practice was evidenced by the following: A.) On 08/24/2023 at 09:43 AM, during the initial tour of the facility, Surveyor #1 observed Resident #38 in bed in his/her room. Surveyor #1 observed the call device attached to the cord near the wall input out of reach from the resident. On 08/28/2023 at 09:57 AM, Surveyor #1 observed Resident #38 in bed in his/her room. Surveyor #1 observed the call device attached to the cord near the wall input out of reach from the resident. On 08/29/2023 at 08:48 AM, Surveyor #1 observed Resident #38 in bed in his/her room. Surveyor #1 observed the call device attached to the cord near the wall input out of reach from the resident. At that time, Surveyor #1 activated the call device to ensure it worked. Once the call device was activated, the light outside of the room illuminated, an audible sound could be heard, and facility staff began to walk towards the doorway. A review of Resident #38's Care Plan revealed a Care Plan focus for the potential for falls related to dysfunctional gait (changes in normal walking pattern), fall history, medications. A further review of the Care Plan revealed an intervention revised on 06/13/2022 that the call light is within reach, and reorient as needed. On 09/05/2023 at 12:40 PM, during an interview with Surveyor #1 and Surveyor #2, Certified Nursing Assistant (CNA #1) replied, The policy is to answer them as soon as possible when asked what the policy on call devices was. CNA #1 also replied, They [call devices] should be placed by the resident if they sit in their chairs or by the bed if they are in bed when asked where should call devices be placed. On 09/06/2023 at 12:53 PM, during an interview with Surveyor #1, the Licensed Nursing Home Administrator (LNHA) stated, Within reach. They [residents] need access to call for help when asked where should call devices be placed within a resident's room. The LNHA replied, No when asked by Surveyor #1 if call devices should be attached to the cord by the wall input while the resident is in bed.

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. The deficient practice was identified for 1 of 1 resident (Resident #271) investigated for Bladder and Bowel Incontinence and was evidenced by the following: A review of Resident #271's admission Record revealed diagnoses of but not limited to; epileptic seizures related to external cause (brain disorder that causes recurring seizures), nondisplaced fracture of seventh cervical vertebra, multiple fractures of ribs, difficulty in walking, and major depressive disorder. A review of Resident #271's Care Plan revealed that there was only one care plan focus since the resident was admitted to the facility. The care plan focus was dated 08/19/2023 and revealed that Resident #271 was at risk for malnutrition related to decreased intake and skin impairments. On 09/06/2023 at 11:26 AM, during an interview with the Surveyor, Licensed Practical Nurse (LPN) #2 replied, The baseline should be started as soon as they arrive; right after the initial assessment when the Surveyor asked when does the facility want a baseline care plan started. When the Surveyor asked what might be included in the baseline care plan LPN #2 replied, Pain, risk for falls, oral care, dentures, and also psychotropics. When the Surveyor asked if there was a timeframe that the facility wants the baseline care plan completed by LPN #2 replied, I think twenty-four hours. On the same date at 12:53 PM, during an interview with the Surveyor, the Director of Nursing replied, Seven days when the Surveyor asked when should a baseline care plan be completed. The [NAME] President of Clinical Services (VPCS) added, A baseline care plan is generally started immediately upon arrival and within three days. Falls, pain, skin, advanced directives, ADLs [Activities of Daily Living], risk for rehospitalization .We are trying to get to three days when asked by the Surveyor what should a baseline care plan include. A review of an undated facility policy titled, Care Planning-Interdisciplinary Team revealed under Policy Interpretation and Implementation that, 1. Resident care plans are developed according to the timeframes and criteria established by §483.21. 8:39-11.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C/O# NJ160875 Based on observation, interviews, and record review, as well as review of facility documentation, it was determined that the facility 1.) failed to follow their policies and procedures for investigating and reporting of accidents and incidents that occur in the facility and 2.) the facility failed to ensure a resident who was a known fall risk and sustained multiple falls, had new or revised interventions to prevent subsequent falls or injuries. This deficient practice occurred for 2 of 4 residents reviewed for accidents (Resident #120 and Resident #49) and was evidenced by the following: 1. The admission Record revealed that Resident #120 was admitted to the facility with the following but not limited to diagnoses: Muscle weakness, acute and chronic respiratory failure with hypoxia (a condition in which the body is deprived of adequate oxygen supply at the tissue level), difficulty in walking, heart failure, and type 2 diabetes mellitus. According to the Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #120 had a staff assessed Brief Interview for Mental Status (BIMS) Score of short-term memory problem and staff assessed long-term memory to be ok. Section E determined that Resident #120 did not exhibit the behavior of wandering. According to Section G of the MDS, Resident #120 required extensive assist of one person for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. Section H revealed that Resident #120 was occasionally incontinent of urine and continent of bowel. A review of the Order Summary Report dated 01/01/2023-2/01/2023 revealed that resident #120 had a physician's order for the following: Arixtra Subcutaneous Solution (a medication used to treat blood clots and prevent them from forming after hip, knee, or stomach surgery) 7.5 MG (milligrams)/0.6ML (milliliters) (Fondaparinux Sodium) Inject 7.5 milliliter subcutaneously in the evening for PPX (prophylaxis). A review of the baseline care plan revealed that Resident #120 had a care plan Focus relate to, The resident is at risk for falls Confusion, Gait/balance problems, Vision/Hearing problems, Date Initiated: 01/14/2023. The following was observed under Goal: The resident will be free of falls through the review date. Date Initiated: 01/14/2023. The following was observed under the heading Interventions: Anticipate and meet the resident's needs. Date Initiated: 01/14/2023 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs as needed. Date Initiated: 01/14/2023 Ensure that the resident is wearing appropriate footwear when ambulating/transferring as needed. Date Initiated: 01/14/2023 Further review of the baseline care plan revealed that Resident #120 also had a baseline care plan with a Focus: The resident has had an actual fall with no injury, r/t (related to) unsteady gait. The following was listed under Interventions: For no apparent acute injury, determine and address causative factors of the fall. Date Initiated: 01/14/2023 PT (physical therapy) consult for strength and mobility. Date Initiated: 01/14/2023. According to the Incident/Accident report, dated 1/14/2023 at 04:08, #121 for Fall, Resident #120 was found lying on the floor next to his/her bed. No injuries were noted, and the form indicated that Agency/People Notified were the physician at 1/14/2023 at 04:38. There was no documentation that the family was notified of Resident #120's fall. The surveyor reviewed the 01/14/2023 at 05:16 progress note in Resident #120's MR. The progress note stated, Resident was found lying on the floor next to resident's bed, no apparent injuries noted, no c/o (complaints of) pain noted @this time, will continue to monitor. The progress note did not indicate/document that the family was notified of Resident #120's fall. On 09/01/2023 at 01:32 PM the surveyor reviewed the electronic medical record (EMR) of Resident #120. According to a progress note, dated 1/14/2023 at 05:16:00, Resident #120 was found lying on the floor next to resident's bed, no apparent injuries noted, no c/o pain noted @this time, will continue to monitor. The progress note did not indicate that the physician or family was notified of the fall. An additional progress note, dated 1/14/2023 at 14:56:00, revealed the following: Resident received in bed, alert and oriented x3. Able to make all needs known. O2 on at 4L/min via n/c. SP02 97%. Lungs clear. No cough present. Consumed over 50% of breakfast. Am care given by CNA. Cont (continent) of urine. Ambulated to the bathroom with assist of CNA and use of walker. Daughter vss early am questioning about her fall from last evening. No injuries were reported. Vital signs this am T-97 P-80 R-20 B/P 148/86. SPO2 97%. Daughter requesting her mom to be sent to ER for eval, supervisor aware and notified Dr. Conti. Tri-care was contacted. Before Tri-care arrived family called 911. Resident left via 911. Vital signs stable T-97 P-60 R-18 B/P 109/77. Daughter, grandson and girlfriend accompanied resident. On 09/05/23 at 08:26 AM the surveyor reviewed the Reportable Event Record/Report, dated 1/16/2023. According to the report the reportable event concerning Resident #120 was called in on 1/15/2023 at 12:31 PM. The reportable was called in secondary to resident daughter reporting on 1/15/2023 that when resident fell on 1/14/2023 at approximately 12:30 AM, an unidentified nurse kicked him/her in the head and raised their voice at him/her. Family called state police and resident was sent to local emergency room at family request for evaluation. Internal investigation was completed, based on staff statements abuse claims were determined to be unsubstantiated. According to page 3 of the Reportable Event Record/Report the physician was notified and daughter was notified, however there were no dates or times listed for notification of the physician and family. 2. On 8/24/2023 at 10:38 AM, Resident #49 was observed lying in bed asleep with a wander guard to right ankle. On 8/28/2023 at 12:10 PM, Resident #49 was observed lying in bed sleeping and observed wander guard to right ankle. No baby dolls or stroller observed to be in room. On 9/05/2023 at 11:44 AM, Resident #49 was observed being returned to unit from activities and placed at nurses' station in w/c. According to the admission Record, Resident # 49 was admitted to the facility with diagnoses including but not limited to: displaced fracture of the lateral malleolus left fibula, unspecified dementia without behavioral disturbance. A review of a Significant change MDS dated [DATE], revealed a BIMS score of 3/15 indicating Resident #49 had severe cognitive impairment. Section G indicated Resident #49 required extensive assist of 1 staff for transfers and extensive assist of 1 staff for ambulation in room and on the unit. A review of a care plan with a Focus area of {resident name] has potential for falls related to ambulatory dysfunction, new environment, mediations {sic} {medications}. Walks until exhausted ambulating mediations {sic} [medications]. Walks until exhausted ambulating throughout unit with an initiated date of 06/06/2023. Under the Goal section; Resident will not sustain serious injury through the review date with an initiated dated of 06/02/2023, Resident will have minimized injuries from fall with initiated date of 06/07/2023. The resident will be free of minor injury through the review date with an initiated date of 08/27/2023. Under the intervention section Bed at acceptable height to promote staff transfers with initiated date of 6/07/2022 and revision date of 6/13/2022. Call light in reach, reorient prn (as needed) with initiated date of 06/06/2022 and revision date 06/13/2022. Encourage frequent rest periods of resident with initiated date of 08/22/2023. Encourage Resident to use WC (wheelchair) for locomotion around facility with an initiated date of 08/28/2023. Ensure proper fitting shoes or nonskid socks are present prior to transfer/ambulating with an initiated date of 06/06/2022 and revision date of 06/13/2022. Ensure that resident is wearing appropriate non-skid footwear when ambulating or mobilizing w/c with an initiated date of 06/16/2023 and revision date of 08/28/2023. Follow facility fall protocol with initiated date of 06/02/2023. Frequent close monitoring throughout shift with initiated date of 06/06/2022 and revision on 06/13/2022. IDT team met and recommended use of helmet and hipsters (padding to help protect a resident's hips if a fall occurs), family not in agreement with recommendations at this time with initiated date of 06/07/2023. Maintain a clutter free environment with initiated date of 06/06/2022 and revision date of 06/13/2022. Offer activities that require (him/her) to sit, snacks, diversional activities etc. with initiated date of 08/24/2023. Offer resident a nap after lunch with initiated date of 12/16/2022. Offer resident a nap after lunch with an initiated date of 12/06/2022. Physical Therapy Evaluation Ordered with an initiated date of 04/18/2023. Place frequently used items with in close reach with initiated date of 06/06/2022 and revision date of 06/13/2022. Pt (physical therapy) evaluate and treat as ordered or PRN with initiated date of 06/23/2023. Stand by assist when patient is not utilizing baby stroller during ambulation with initiated date of 06/06/2022 and revision date of 06/13/2022. Therapy consult prn with initiated date of 06/06/2022 and revision date of 06/13/2022. Verbal reminders prn to utilize the call light when assistance is needed with an initiated date of 06/06/2022 and revision date of 06/13/2022. A review of Fall incident dated 3/14/2023 timed at 19:53 (7:53 PM), revealed resident found laying on ground. resident unable to confirm pain. Resident able to stand up with assistance and ambulated to nearby chair w/o injury or discomfort noted. Resident stated, I was just playing around with her and then she clunked me down referring to another resident. A review of a resolved care plan dated 6/16/2023, did not include interventions or revisions to prevent further falls. A review of a fall incident dated 4/9/2023 timed at 23:55 (11:55 PM), revealed Heard noise Went to room and saw resident sitting on buttocks between his/her bed and chair no apparent injuries Resident denied hitting his/her head and denied pain. Resident stated he/she was sitting on floor because she wants. A review of a resolved care plan dated 6/16/2023, did not include new interventions or revision to prevent further falls. A review of a Fall dated 5/13/2023 timed at 05:10 (05:10 AM), revealed Patient was walking facility all night, unstable. When trying to redirect pt (patient) to lay down, pt continued to walk halls going to east wing. Nurse on east wing called and stating Pt was on floor due to a fall. Under resident description I don't know. A review of a resolved care plan dated 6/16/2023, did not include new interventions or revisions to prevent further falls. A review of a Fall dated 5/19/2023 timed at 18:58 (6:58 PM), revealed CNA called me to Alcove at nursing station and stated [resident name] tried to stand up and fell back onto buttocks and then hit his/her head on wooden drawers on desk/counter area. A review of a resolved care plan did not include new interventions or revisions to prevent further falls. A review of a Fall dated 5/20/2023 timed at 19:53 (7:53 PM) revealed called to east wing dining area to observed resident siting on buttocks on floor leaning on right side yelling help me up help me up upon evaluation he/she was able to stand and bear weight. Resident unable to give description. A review of a resolved care plan dated 6/13/2023 did not include new interventions or revisions to prevent further falls. A review of a Fall date 6/2/2023 timed at 15:33 (3:33 PM) revealed Resident slid out of wheelchair on to buttocks. A review of a resolved care plan dated 6/13/2023 did not include new interventions or revisions to prevent further falls. A review of a Fall dated 7/17/2023 timed at 14:55 (2:55 PM), revealed [resident name] had a fall in hallway coming out of his/her bedroom . A review of a care plan with an initiated dated of 06/06/2023, did not include new interventions or revisions to prevent further falls. A review of a Fall dated 8/13/2023 timed at 05:05 (05:05 AM), revealed Resident found sitting on floor in front lobby. No apparent injury at this time. Resident unable to give description. A review of a care plan with an initiated dated of 06/06/2023, did not include new interventions or revisions to prevent further falls. A review of a Fall dated 8/13/2023 timed at 05:25 AM, revealed Resident found sitting on floor in front lobby, no apparent injury at this time. Resident ambulates without difficulty noted. A review of a care plan with an initiated dated of 06/06/2023, did not include new interventions or revisions to prevent further falls. A review of a Fall dated 8/17/2023 timed at 05:18 (05:18 AM), revealed resident found sitting next to his/her bed, bed in lowest position. No apparent injury at this time. A review of a care plan with an initiated dated of 06/06/2023, did not include new interventions or revisions to prevent further falls. During an interview with the surveyor on 9/05/2023 at 11:10 AM, CNA #2 who said If someone falls I get the nurse and let the nurse know. They evaluate the resident and let us know what we do next. We have to write a statement and make sure our statement goes to Director of Nursing before the end of the shift Duirng an interview with the surveyor on 9/5/2023 at 10:54 AM, Licensed Practical Nurse (LPN #1) was asked what the facility policy was for what is done after a resident fall. LPN #1 responded, If someone falls, the Certified Nursing Assistant (CNA) calls the nurse immediately and if a Licensed Practical Nurse (LPN) is there we (LPN) can't touch them. We get the Registered Nurse (RN) to come over and do an assessment and they will determine if we can move the resident after a full body assessment. Then we get them up and call the MD and family and get treatments, if needed. We put them on the 24-hour report for 3 full days every shift. We conduct full vitals and nurses notes in the EMR. We do incident report as well and document the incident in the progress notes in the EMR. We gather statements from anyone on duty that shift even though they may not have been assigned to that resident on that shift. We staple the witness statements to the incident report, and we hand it off to the Director of Nursing. During an interview ith the surveyor on 9/5/2023 at 11:31 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN) was asked what the facility process after a resident is after a resident had fallen. The UM/LPN responded, If someone falls, I immediately keep them safe and notify my direct supervisor. I do an assessment. The assessment can be done by an RN or LPN. We do a full body assessment for range of motion, neurological checks and check for any injuries and complete vital signs. The surveyor asked the UM/LPN where this information should be documented. The UM/LPN replied, It would be documented in risk management (incident and accident reports). I always document in risk management and then copy and paste into a nurse's progress note. I notify the physician and the family and write that on the incident report, and I put my note in risk management. UM/LPN went on to sat that regardless of if resident sat self on floor or fell, we need to do incident report. If resident unable to tell us what happened, I ask staff when resident was last time was seen and what was the resident doing. Staff do write paper statements and there is a section we can type them in as well on the incident report. When asked is the care plan reviewed or updated UM/LPN replied I would look and see what interventions are on the care plan and if needs to be tweaked and add any new interventions. You should have a new intervention. If we are doing what is on the care plan, then something needs to be adjusted. Absolutely a care plan is to be updated after a fall. On 9/6/2023 at 1:02 PM, the surveyor conducted an interview with facility administration including the Director of Nursing (DON), the [NAME] President of Clinical Services (VPCS) and the Licensed Nursing Home Administrator. The surveyor asked the administrative staff what their expectation was when an accident or incident occurs in the facility? Who is to be notified and when should they be notified? The VPCS stated, The resident would be assessed, vitals checked, neuro checks, and notification of the family and MD. The surveyor questioned what the expected time frame would be after the incident occurred to notify the family and physician of the incident. The VPCS replied, The time frame would be as soon as possible, but my expectation is within a few hours regardless of what time the incident occurred. The surveyor then asked the VPCS if she would have expected that the family of Resident #120 should have been notified of Resident #120's fall prior to arriving to the facility approximately 12 hours after the fall. The VPCS responded, I would have expected the family to be notified prior to them arriving to the facility approximately 12 hours later and being told by the resident. When the surveyor asked the DON what her expectation was for a resident who has had multiple falls, she replied they (resident who fell) are reviewed by Interdisciplinary team and MD part of plan of correction, and interventions are to be put in place. Yes, there should be documentation of revision or new interventions on the care plan after each fall. The DON also said that the DON, UM are responsible to update the care plans after falls. VPCS added that the floor nurses can as well (update care plan). The surveyor reviewed a facility policy titled Accidents and Incidents-Investigating and Reporting, last updated 4/2023. The Policy Statement revealed the following: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The following was revealed under the heading Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shell be included on the Report of Incident/Accident form: g. The time the injured person's attending physician was notified, as well as the time the physician responded and his/her instructions. h. The date/time the injured person's family was notified and by whom. A review of a facility policy titled Falls-Clinical Protocol undated revealed under Cause Identification section 1. For an individual who has fallen, the staff and practitioner will begin to try identifying possible causes within 24 hours of the fall. A further review of the policy under the treatment/Management section 1. based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Under the Monitoring and Follow-up section 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to follow professional standards of practice by providing a respiratory treatment without physician's order for 1 of 3 residents (Resident #320) reviewed for Respiratory Care. This deficient practice was evidenced by the following: On 08/28/2023 at 11:01 AM, the surveyor observed a bilevel positive air pressure (BiPAP) device in Resident #320's room. The face mask on top of the device appeared to have white and yellow liquid substance inside of it. The mask was exposed to the environment. At that time, Resident #320 stated, I have been using it [BiPAP] every night when asked by the Surveyor if he was using the BiPAP device. On 08/29/2023 at 08:47 AM, the surveyor observed the face mask on top of the BiPAP device. The mask appeared to have white and yellow liquid substance from within. During that time, Resident #320 added, I have been using the BiPAP every night since I got here. A review of admission Record found in Electronic Medical Record (EMR) revealed that Resident #320 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Chronic Obstructive Pulmonary Disease (COPD; a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident #320's admission Minimum Data Set (MDS; an assessment tool) dated 08/23/2023 revealed that Resident #320 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. A review of EMR revealed no physician's orders for bilevel positive air pressure treatment nor settings. A review of Progress Notes revealed Nursing Note dated 08/20/2023 at 11:14 PM which indicated . He is currently in bed with CPAP running per orders . On 09/06/2023 at 11:33 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN #3) stated, No, we have to have a doctor's order when asked if doctor's order is needed to administer respiratory treatment such as BiPAP. On 09/06/2023 at 12:56 PM, during an interview with the surveyor, the [NAME] President of Clinical Services (VPSC) stated, Absolutely! when asked if a respiratory treatment requires physician's order. A review of a facility policy updated 04/2023 and titled Medication and Treatment Orders revealed that Orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. A review of an undated facility policy titled CPAP/BiPAP Support revealed, 3. Review physician's order to determine the oxygen concentration and flow, and PEEP pressure (CAPA, IPAP, and EPAP) for the machine. NJAC 8:39-44.2(b)(2)

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis schedule for 1 of 1 resident (Resident #28) reviewed for dialysis. This deficient practice was evidenced by the following: On 08/23/2023 at 9:40 AM, Resident #28 was observed sitting in a wheelchair getting items out of his/her closet. Resident #28 said he/she goes to dialysis on Monday, Wednesday, and Friday. Resident #28 stated that he/she usually back to the facility by lunch time. A review of the Electronic Medical Record revealed Resident #28 was admitted to the facility with diagnoses including but not limited to, End Stage Renal Disease, Diabetes, Dependence on dialysis and Hypertension. A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 06/13/2023, revealed a Brief Interview for Mental Status score of 15/15, indicating Resident #28 was cognitively intact. The MDS further revealed Resident #28 received dialysis while a resident at the facility. A review of the Clinical Physicians Orders revealed a physician order for Hemodialysis, per physician order: -Hemo dialysis three times weekly on Monday/Wednesday/Fridays, Chair time 5:30 AM. A further review of the physician orders revealed the following orders: -NovoLog Injection Solution (Insulin Aspart) Inject 4 unit subcutaneously three times a day every Mon, Wed, Fri for DM dialysis days 11:30 -Losartan Potassium 50MG Give 1 tablet orally one time a day for HTN (Hypertension) 09:00 AM -Aspirin EC 81MG TABLET Give 1 tablet orally one time a day 09:00 AM -Hydralazine 25MG TABLET Give 1 tablet orally two times a day for HTN 09:00 AM -Clopidogrel Tablet 75MG Give 1 tablet orally one time a day for DVT (Deep Vein Thrombosis) prophylaxis 09:00 AM -Ipratropium-Albuterol Inhaler 1 vial inhale orally via nebulizer four times a day for COPD (Chronic Obstructive Pulmonary Disease) 09:00 AM -Budesonide 0.5MG/2 1 vial inhale orally via nebulizer two times a day for COPD 09:00 AM -Mucinex Table 600MG ER Give 1 tablet orally every 12 hours for COPD 09:00 AM -THEO-24 CAP 200MG CR Give 1 capsule orally one time a day for COPD 09:00 AM - NovoLog FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject subcutaneously three times a day every Mon, Wed, Fri for DM 181 - 240 = 2 units; 241 - 300 = 4 units; 301 - 360 = 8 units; 361 - 400 = 10 units; 401 - 450 = 12 units Call MD if less than 60 or greater than 450, subcutaneously four times a day every Mon, Wed, Fri. 09:00-14:00-21:00 A review of the Medication Audit Report for June 2023 revealed: Hydralazine 25 milligrams (MG) was administered on the following dates and times: 06/02/2023 scheduled for 09:00 AM and given at 10:57 AM 06/07/2023 scheduled for 09:00 AM and given at 11:35 AM 06/16/2023 scheduled for 09:00 AM and given at 10:45 AM 06/19/2023 scheduled for 09:00 AM and given at 11:12 AM 06/30/2023 scheduled for 09:00 AM and given at 11:22 AM Aspirin EC 81MG Tablet was administered on the following dates and times: 06/02/2023 scheduled for 09:00 AM and given at 10:57 AM 06/16/2023 scheduled for 09:00 AM and given at 10:45 AM 06/19/2023 scheduled for 09:00 AM and given at 11:12 AM 06/30/2023 scheduled for 09:00 AM and given at 11:22 AM Losartan POT Tab 50 MG was administered on the following dates and times: 06/02/2023 scheduled for 09:00 AM and given at 11:02 AM 06/07/2023 scheduled for 09:00 AM and given at 11:35 AM 06/17/2023 scheduled for 09:00 AM and given at 10:45 AM 06/19/2023 scheduled for 09:00 AM and given at 11:12 AM 06/30/2023 scheduled for 09:00 AM and given at 11:22 AM`` Novolog Injection Solution (Insulin Aspart) 4 units was administered on the following dates and times: 06/05/2023 scheduled for 11:30 AM and given at 14:18 PM Budesonide Suspension 0.5 MG was administered on the following dates and times: 06/07/2023 scheduled for 09:00 AM and given at 11:35 AM 06/19/2023 scheduled for 09:00 AM and given at 10:45 AM 06/30/2023 scheduled for 09:00 AM and given at 11:22 AM Ipratropium-Albuterol INH. SOLN 1 vial was administered on the following dates and times: 06/07/2023 scheduled for 09:00 AM and given at 11:34 AM 06/17/2023 scheduled for 09:00 AM and given at 10:45 AM 06/19/2023 scheduled for 09:00 AM and given at 11:12 AM 06/30/2023 scheduled for 09:00 AM and given at 11:22 AM Theo-24 200 MG was administered on the following dates and times: 06/07/2023 scheduled for 09:00 AM and given at 11:35 AM 06/16/2023 scheduled for 09:00 AM and given at 10:45 AM A review of the Medication Audit Report for July 2023 revealed: Hydralazine 25 milligrams (MG) was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:37 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Losartan POT Tab 50 MG was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:42 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Budesonide Suspension 0.5 MG was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:42 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Aspirin EC 81MG Tablet was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:42 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Novolog Injection Solution (Insulin Aspart) 4 units was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 12:50 PM 07/10/2023 scheduled for 09:00 AM and given at 12:43 PM 07/14/2023 scheduled for 09:00 AM and given at 10:43 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Ipratropium-Albuterol INH. SOLN 1 vial was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:42 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM Theo-24 200 MG was administered on the following dates and times: 07/03/2023 scheduled for 09:00 AM and given at 10:19 AM 07/10/2023 scheduled for 09:00 AM and given at 12:42 PM 07/14/2023 scheduled for 09:00 AM and given at 10:30 AM 07/17/2023 scheduled for 09:00 AM and given at 10:31 AM 07/24/2023 scheduled for 09:00 AM and given at 10:58 AM A review of the Medication Audit Report for August 2023 revealed: Hydralazine 25 milligrams (MG) was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM Losartan POT Tab 50 MG was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM Budesonide Suspension 0.5 MG was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM Aspirin EC 81MG Tablet was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM Ipratropium-Albuterol INH. SOLN 1 vial was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM Theo-24 200 MG was administered on the following dates and times: 08/11/2023 scheduled for 09:00 AM and given at 12:07 PM 08/14/2023 scheduled for 09:00 AM and given at 10:10 AM 08/21/2023 scheduled for 09:00 AM and given at 12:47 PM 08/25/2023 scheduled for 09:00 AM and given at 10:58 AM During an interview with the surveyor on 09/05/202 at 11:22 AM, the Licensed Practical Nurse (LPN) #4, on the same unit as Resident #28 stated; All medications are to be given no earlier or later than 1 hour before and 1 hour after the scheduled time. If my resident is unavailable or sleeping, I will call the doctor and report and see if he wants to reschedule the medication time. I will also write a nursing note to explain the situation. If I have a resident that is out of the building consistently, such as for dialysis, I will call the doctor to have the medications re-plotted according to their pickup and return to the facility time. During an interview with the surveyor on 09/06/2023 at 12:53 PM, the Director of Nursing stated that residents on hemodialysis should have their medications plotted around the time that the resident is out of the building. It is the responsibility of all nursing staff to monitor times and assure that medications are schedule appropriately. A review of a facility policy titled, Administering Medications, with a date of 04/2023, revealed the following: #4 Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. A review of a facility policy title, Dialysis Communication, did not address the medication and treatment times. NJAC 8:39-27.1(a)

Based on interview and record review and review of other facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 4 of 5 resident's reviewed for unnecessary medications (Resident #61, Resident #1, Resident #3, and Resident #27), and was evidenced by the following: On 8/29/2023 at 10:42 AM, the Surveyor #1 reviewed the medical records for Resident #61. According to the admission Record, Resident #61 was admitted to the facility with the following but not limited to diagnoses: Type 2 diabetes mellitus, paranoid schizophrenia, generalized anxiety disorder, and depressive disorder. According to the quarterly Resident Assessment Instrument Minimum Data Set (MD'S), an assessment tool, dated 7/14/2023, Resident #61 had a Brief Interview for Mental Status score of 12/15, indicating moderate cognitive impairment. Section MN revealed that Resident #61 received insulin injections daily, an antipsychotic daily, and antidepressant daily. On 4/06/2023 the CP suggested Please clarify the Lidocaine patch orders. The nighttime order still states to apply but also remove. Contradicting. Update nighttime order directions. Facility responded on 5/4/2023 with changing the nighttime order to read: Lidocaine patch remove Q (every) hs (night) in the evening -Start Date05/04/2023 2100 -D/C Date08/10/2023 1337 On 5/10/2023: The CP recommended Please chart a blood sugar value for the accucheck (a device used to conduct daily blood sugar checks) to help manage diabetes) 3x (times) daily order. Currently not shown on MAR. The facility failed to respond to CP suggestion until 8/31/2023. Review of the May 2023, June 2023, July 2023, and August 2023 MAR revealed that accuchek blood sugar values were not recorded on the MAR from 5/02/2023 through 8/31/2023 at 0800, 1130, and 1630. On 5/10/2023 the CP suggested, Identify and monitor the behavior being exhibited for Buspar and other psychotropic medications. Behavior monitoring order not entered into PCC. Facility responded on 8/26/2023 with the following order: BEHAVIORS - MONITOR FOR THE FOLLOWING: () RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, PSYCHOSIS, AGRESSION, REFUSING CARE. Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. every shift -Start Date08/26/2023 1500 The facility failed to respond for approximately 90 plus days. On 6/09/2023 the CP made the following recommendations/suggestions: Regarding the comment made on 04/06/2023: Please clarify the Lidocaine patch orders. The nighttime order still states to apply but also remove. Contradicting. Update nighttime order directions. **The Pharmacy Consult was not addressed. The facility did not respond until 8/10/2023 by discontinuing all Lidocaine orders, approximately 4 months later. Regarding the comment made on 5/10/2023: Please chart a blood sugar value for the accucheck 3x daily order. Currently not shown on MAR. *The Pharmacy Consult was not addressed. Blood sugar already being documented with the Insulin Lispro order. Other accucheck order is extra. The facility failed to respond to the CP recommendation until 8/31/2023 through 0900, approximately 90 days after the original suggestion. On 8/10/2023 the CP made the following recommendation/suggestion: Regarding the comment made on 06/09/2023: Please chart a blood sugar value for the accucheck 3x daily order. Currently not shown on MAR. *The Pharmacy Consult was not addressed. Blood sugar already being documented with the insulin Lispro order. Other accucheck order is extra. The facility responded on 8/31/2023 at 0949 b y discontinuing the accucheks, approximately 60 plus days after the CP suggested. 2. According to the admission Record, Resident #1 was admitted to the facility with diagnoses including but not limited to: Cerebral Infarction (a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). A review of the Consultant Pharmacist Monthly report dated 5/10/2023 indicated Identify and monitor the behavior being exhibited for Buspar (medication used for anxiety). Please add the orders to monitor for side effects and behaviors in [name of electronic medical record]. A review of the Order Summary Report with Active orders as of 05/01/2023 through and including 08/01/2023-08/25/2023 did not include a physician order to add Identify and monitor the behavior exhibited for Buspar. There was no documentation that the CP recommendations were addressed. 3. According to the admission Record, Resident #3 admitted with diagnoses including but not limited to: Atrial Fibrillation (an irregular and often very rapid heart rhythm) and Chronic Obstructive Pulmonary Disease (COPD) (a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of a CP report dated 3/8/23 which indicated regarding the comment made on 01/12/2023: Please clarify and updated the diagnosis for Buspirone. Not indicated for depression. Only indication is anxiety. Verify with Physician. *The Pharmacy Consult was not addressed. A review of the OSR with active orders as of 01/01/2023 revealed a physician order for Buspirone Tab (tablet) 10 MG (milligrams) give 1 tablet orally two times a day for depression. A review of the OSR with active orders as of 02/01/2023 through 03/09/2023 indicated the same physician order for the Buspirone 10 Mg give 1 tablet orally twice a day for depression. A review of the CP report for May 2023 indicated with date of 5/10/23 Regarding the comment made on 02/10/2023: Please update the indication for PRN (as needed) Duoneb (medication used for COPD a combination of two medicines called bronchodilators). COPD is a diagnosis, not an indication. Consider using SOB (shortness of breath) or wheezing. The Pharmacy Consult was not addressed. A review of the OSR with active orders as of 02/01/2023 through 05/24/2023 revealed a physician order for IPRATROP/ALBUT 0.5-3MG/3ML (milliliter) NEB (nebulizer a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) 1 vial inhale orally via nebulizer every 6 hours as needed for COPD. There was no documentation in the medical record that the CP recommendations were addressed. 4. According to the admission Record, Resident #27 was admitted to the facility with diagnoses including but not limited to: Fracture of the Right Femur. A review of a CP report for July 2023 revealed a recommendation dated 7/14/23 to clarify if the order for Aspirin 81 mg is for enteric coated aspirin 81mg or chewable aspirin 81mg. A review of the OSR dated 06/01/2023-09/06/2023, revealed Aspirin Oral Capsule 81 MG (Aspirin) Give 1 tablet by mouth one time a day for DVT (Deep Vein Thrombosis) PPX (prophylaxis). A further review of the CP report revealed a recommendation dated 7/14/23, There are PRN (as needed) orders with the same or overlapping indications for use. Please sequence or differentiate the indications for PRN: Tylenol and Percocet. A review of the OSR dated 06/01/2023-09/06/2023 indicated Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) *Controlled Drug* with original order date of 7/5/23 Give 0.5 tablet by mouth every 4 hours as needed for breakthrough pain. A further review of the OSR revealed a physician order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) with order date 6/22/23 Give 2 tablet by mouth every 4 hours as needed for Pain. There was no documentation in the medical record to indicate the CP recommendations were addressed. On 9/6/2023 at 1:13 PM, the surveyors conducted an interview with the [NAME] President of Clinical Services (VPCS). The surveyors asked the VPCS what the facility process was for responding to the CP monthly report for medication recommendations/suggestions. The VPCS explained, Within a day or 2 we get a report that is received by the facility Director of Nursing and Unit Managers (UM). The DON and Unit Manager would be responsible for responding to the suggestions/recommendations within 30 days once we receive the monthly report from the CP. We identified that it was a problem, and we are addressing it at this time. A review of a facility policy titled Medication Regimen Reviews last updated 4/2023, which revealed under the Policy Interpretation and Implementation section 8. Within 72 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians and for each resident identified as having a non life threatening medication irregularity. A further review revealed 14. The Consultant Pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Follow up will be completed within 30 days. NJAC 8:39-29.3(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to use appropriate precautions to disinfect and store respiratory equipment to prevent the risk of infections. The deficient practice was observed in 3 of 3 residents (Resident #320, Resident #1, and Resident #3) reviewed for Respiratory Care. This deficient practice was evidenced by the following: 1.) On 08/24/2023 at 10:03 AM, Surveyor #1 observed a bilevel positive airway pressure (BiPAP) device on Resident #320's nightstand with a face mask on top of the device. The face mask was exposed to the environment. The mask appeared to have white and yellow liquid substance from within. On 08/28/2023 at 11:01 AM, Surveyor #1 observed Resident #320's BiPAP face mask on top of the device. It was exposed to the environment and continued to appear to have white and yellow liquid substance inside. At that time, Surveyor #1 asked Resident #320 if he/she was using the BiPAP device. Resident #320 stated, I have been using it [BiPAP] every night. On 08/29/2023 at 08:47 AM, Surveyor #1 observed BiPAP face mask on top of the BiPAP device and exposed to the environment. At that time, Resident #320 stated, I have been using the BiPAP every night since I got here. When asked by Surveyor #2 if staff cleans his/hers BiPAP face mask Resident #320 replied, Not yet, but they will clean it today. On 08/30/2023 at 09:30 AM, Surveyor #2 observed BiPAP facemask on top of the device. The mask continued to be exposed to the environment. [NAME] and yellow liquid substance appeared to be inside of the mask. A review of admission Record revealed that the Resident had diagnosis of chronic obstructive pulmonary disease (COPD; a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident #320's admission Minimum Data Set (MDS; an assessment tool) dated 08/23/2023 revealed that Resident #320 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating that his/her cognition was intact. 2. During the initial tour on 8/24/2023 at 10:55 AM, Surveyor #2 observed Resident # 1 nebulizer machine with the mouthpiece on top) in a bed side chair uncovered and exposed. On 8/28/2023 at 10:09 AM, Surveyor #2 observed Resident #1's nebulizer machine on the bedside table. The mouthpiece was sitting on top of the machine uncovered and exposed. The tubing was dated 7/24. On 8/29/2023 at 10:30 AM, Surveyor #2 observed Resident #1's nebulizer machine on the bedside table with the mouthpiece sitting on top, uncovered and exposed tubing dated 7/24. According to the admission Record Resident #1 was admitted to the facility with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD) (a condition involving constriction of the airways and difficulty or discomfort in breathing.). A review of the MDS dated [DATE] revealed Resident #1 had a BIMS score of 13/15 indicating Resident #1 was cognitively intact. A further review revealed under section O Resident #1 received 5 days of Respiratory Therapy. A review of the Order Summary Report (OSR) with active orders as of 08/01/2023 revealed a physician order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML(milliliter) 3 cc (cubic centimeter) inhale orally every 6 hours as needed for wheezing/sob (shortness of breath). A review of the Medication Administration Record (MAR) for July 2023 and August 2023 revealed Resident #1 received a nebulizer treatment on 7/2/2023, 8/17/2023 and 8/18/2023. There is no indication in the medical record as to when the nebulizer tubing is to be changed. During an interview with the Surveyor #2 on 8/28/2023 at 10:06 AM, when asked if staff cover the nebulizer mouthpiece or change the tubing on the nebulizer, Resident #1 replied no staff never cover nebulizer, no don't change the tubing. Resident #1 said he/she used 1 time in the past month. 3. During the initial tour on 08/24/23 10:16 AM, observed bipap mask in a basin next to a humidification bottle uncovered and exposed. On 8/28/2023 at 10:01 AM, Surveyor #2 observed Resident #3's C-pap mask in basin on bedside table. During an interview with Resident #3 at that time, Resident #3 said he/she is not able to place his/her cpap mask in the basin and that staff takes it off and places it on for him/her. On 8/29/2023 at 10:28 AM, Surveyor #2 observed Resident #3's C-pap mask on top of bath towel in a basin on bedside table. According to the admission Record Resident #3 was admitted to the facility with diagnoses including but not limited to: Obstructive Sleep Apnea (episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep). A review of an MDS dated [DATE] revealed Resident #3 had a BIMS score 11/15, indicating Resident #3 had moderately impaired cognition. A review of OSR revealed physician orders as follows; Nocturnal (nighttime) Auto C-Pap Hs (hour of sleep) & remove on day shift at bedtime apply C-Pap at HS. Nocturnal Auto C-Pap Hs (hour of sleep) & remove on day shift every day shift Remove C-Pap on day shift. Rinse Face mask with warm water and let dry Q (every) Friday on 7-3 shift. On 08/30/2023 at 10:50 AM during an interview with Surveyor #1 attended by [NAME] President of Clinical Services (VPCS) and Unit Manager/Licensed Practical Nurse (UM/LPN), the VPCS replied, Rentals go back. Owned equipment is cleaned and stored in plastic bags. If used by resident, they should be bagged and dated when asked about facility's procedure for respiratory equipment storage. During the same interview, both VPCS and UM/LPN replied, No when asked by Surveyor #1 if it was acceptable to store BiPAP or nebulizer mask not in a plastic bag. Further, the UM/LPN stated, It is a potential for airborne infections when Surveyor #1 asked why it was unacceptable to not contain the BiPAP mask in a plastic bag. During an interview with surveyor #2 on 9/05/2023 at 10:58 AM, Licensed Practical Nurse (LPN #1) was asked how c-pap mask is stored when removed. LPN #1 said, c-pap tubing is dated and changed weekly and stored in a bag when not in use. During an interview with Surveyor #2 on 9/05/2023 at 11:44 AM, Unit Manager/Licensed Practical Nurse (UM/LPN) who said oxygen and nebulizer tubing is changed once weekly on Monday 11-7 shift. She went on to say we store tubing in plastic bag when not in use. Surveyor #2 accompanied by the UM/LPN went to Resident #1's room. The surveyor and UM saw the nebulizer sitting on top of the machine uncovered and exposed. The UM/LPN confirmed it should be stored in a bag. UM/LPN also said that c-pap and bipap are also stored in a bag when not in use. During an interview with Surveyor #2 on 9/06/2023 at 12:55 PM, the Director of Nursing (DON) was asked how C-pap and nebulizer should be stored when not in use. The DON replied C-pap and nebulizer should be stored in plastic bag when not in use. The DON was also asked how often nebulizer is tubing to be changed. The DON replied nebulizer tubing is to be changed weekly and it is in as a physician order. A review of an undated facility policy titled CPAP/BiPAP Support did not address storage of the equipment. NJAC 8:39-19.4(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ165382 Based on observations, interviews, review of medical record (MR) and other pertinent facility documentation on 7/28/23, it was determined that the facility failed to a.) maintain professional standards of practice by not ensuring the medication nurse consistently followed the cautionary instruction for a medication administered. The deficient practice was identified for 1 of 7 residents (Resident's #5) by 1 of 3 nurses observed during medication pass and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/28/23 at 8:58 AM, the surveyor observed the Licensed Practical Nurse (LPN #3) prepare five medications for Resident #5. LPN #3 administered the five medications to Resident #5, exited the room, and signed the medications as administered on the Medication Administration Record (MAR). At 9:15 AM, the surveyor observed LPN #3 prepare an additional medication for Resident #5. The surveyor observed that the resident's 7/2023 MAR reflected an order for Trelegy Ellipta 100-62.5-25 (a steroid medication used long term to treat Chronic Obstructive Pulmonary Disease (COPD)) (steroid inhaler) and to administer one puff daily related to COPD. The surveyor further observed that the Trelegy medication box contained a cautionary instruction (a method or procedure intended to prevent or avoid adverse outcomes with medication administration) to RINSE MOUTH THOROUGHLY AFTER EACH USE. The surveyor observed LPN #3 administer the medications to the resident. During administration of the resident's medication, LPN #3 held the steroid inhaler to Resident #5's mouth and instructed to resident to inhale deeply. LPN#3 then exited the resident's room. The surveyor did not observe LPN #3 offer or instruct Resident #5 to rinse their mouth thoroughly after the administration of the steroid inhaler. After assisting another resident, the surveyor observed LPN #3 begin to push the medication cart down the hallway away from Resident #5's room. At which time, the surveyor questioned the nursing practice when administering steroid inhalers. LPN #3 stated that she would normally have the resident rinse their mouth out with water and spit it out. LPN #3 added that Resident #5 had some confusion and that she did not offer the resident to rinse their mouth out because the resident would not spit it out but would just drink it. LPN #3 added that steroid inhaler can cause thrush (fungal infection that can grow in your mouth, throat, and other parts of your body) and that it was important to rinse their mouth after administration. According to the admission record, Resident #5 was admitted to the facility on [DATE] with diagnoses which included but were not limited to COPD, dementia, and cognitive communication deficit. Review of the Order Summary Report for Resident #5 for active orders as of 7/28/23 revealed a 6/27/22 physician order (order), with a start date of 9/14/22, for Trelegy Ellipta 100-62.5-25 and to administer one puff daily related to COPD. The order did not include the cautionary to rinse mouth thoroughly after each use. Review of the Resident #5's 7/2023 MAR revealed the corresponding 6/27/22 order, with the start date of 9/14/22, for Trelegy Ellipta 100-62.5-25 and to administer one puff daily related to COPD. The MAR did not include the cautionary to rinse mouth thoroughly after each use. During an interview on 7/28/23 at 11:03 AM, the LPN/Infection Preventionist (LPN/IP) stated that nurses should take a cup of water into the resident's room when administering a steroid inhaler. The LPN/IP added that the nurse should explain and/or demonstrate the rinse and spit process to the resident. The nurse would then have the resident rinse their mouth with water after administering a steroid inhaler to prevent the resident from developing thrush. The LPN/IP stated that LPN #3 should have at least offered the resident water because confused residents can develop thrush too. During an interview on 7/28/23 at 12:04, the Director of Nursing (DON) stated the administering nurse should have the resident rinse and spit after the administration of a steroid inhaler to prevent thrush or irritation in their mouth. The DON added that the physician should be contacted for another option if a resident is unable to rinse and spit. Review of the facility's Administering Medications through Metered Dose Inhaler did not address medication cautionary instructions. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ165382 Based on observations, interviews, review of medical record and other pertinent facility documentation on 7/28/23, it was determined that the facility failed to: a.) maintain infection control practices when administering insulin. The facility also failed to follow its policy titled Insulin Administration. The deficient practice was identified for 1 of 7 residents (Resident's #4) by 1 of 3 nurses observed during medication pass and was evidenced by the following: On 7/28/23 at 8:25 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare three medications for Resident #4. The medications included: two units of Humalog (insulin) via an insulin syringe, a Gabapentin (medication used to treat nerve pain) 400 milligrams (mg) capsule, and a Fludrocortisone (steroid medication) 0.1 mg tablet. LPN #1 entered the resident's room to administer the three medications to Resident #4. The surveyor observed LPN #1 place the insulin syringe on the resident's overbed table alongside the resident's personal belongings while she administered the Gabapentin capsule and Fludrocortisone tablet. LPN #1 did not clean and sanitize the overbed table prior to placing the insulin syringe. LPN #1 then picked up the insulin syringe and injected the medication to Resident #4's right arm. LPN#1 did not cleanse the injection site with an alcohol wipe prior to inserting the insulin syringe into Resident #4's right arm. LPN #1 then exited the room and began to walk to her medication cart. At which time, the surveyor questioned the nursing practice when administering insulin. LPN #1 said Oops, sorry! and further stated that she was supposed to cleanse the injection site prior to administering the insulin injection. According to the admission record, Resident #4 was admitted to the facility on [DATE] with diagnoses which included but were not limited to cognitive communication deficit, Type II Diabetes Mellitus (DM), and acute osteomyelitis (infection in a bone) of right ankle and foot. Review of the Resident #4's Order Summary Report for active orders as of 7/28/23 revealed a 7/16/23 physician order (order) for Humalog 100 unit/milliliter (ml) and to inject two units subcutaneously three times a day for DM. Review of the Resident #4's 7/2023 MAR revealed the corresponding 7/16/23 order for Humalog 100 unit/ml and to inject two units subcutaneously three times a day for DM with the administration times of 7:30 AM, 11:00 AM, and 4:30 PM. During an interview on 7/28/23 at 11:03 AM, the LPN/Infection Preventionist (LPN/IP) stated that she expected nurses to maintain safety and infection control practices when administering medications to the residents. The LPN/IP further stated that nurses should not place a resident's insulin syringe on the overbed table and that the insulin would then be considered dirty. The LPN/IP explained the process of administering injections. The nurse would cleanse the insertion site with an alcohol wipe, allow the site to air dry, and then administer the injection as ordered. The LPN/IP added that the nurse should maintain the insulin syringe in their possession and not place it on the overbed table. During an interview on 7/28/23 at 12:04, the Director of Nursing (DON) stated the nurse should not place the resident's insulin pen on the overbed table. The DON further stated that the injection site needed to be cleansed with an alcohol pad prior to inserting the needle for infection control purposes. The DON added that the resident's skin may have bacteria and that failing to cleanse the insertion site may introduce bacteria into the resident's body. Review of the facility's undated Insulin Administration policy, instructed under the Steps in the Procedure (Insulin Injections via Syringe) section to 17. Clean the injection site with an alcohol wipe and allow to air dry. Review of the facility's undated Administering Medications policy, revealed under the Policy Interpretation and Implementation section that 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. NJAC 8:39-11.2(b) NJAC 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ00163657 Based on interviews, medical record review, and review of other permanent facility documents on 05/18/23 and 05/22/23, it was determined that the facility failed to: a.) transcribe a physician's order to monitor a resident's wander guard (a device that alarms the facility if the resident attempts to leave the building) for Resident #1 and b.) failed to implement a care plan interventions for a wander guard for Resident #2. The deficient practice was identified for 2 of 3 residents reviewed for elopement and was evidenced by the following: 1. According to the admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Dementia, unspecified severity, with other behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 04/16/23, indicated that Resident #1 was severely cognitively impaired. The MDS also indicated that Resident #1 was ambulatory, used a wander/elopement alarm, and wandered daily. Review of Resident #1's 11/08/22 DMN-Wandering Risk Scale assessment (an assessment tool used to provide an overview of resident's risk level for wandering) revealed that the resident scored a 10, which indicated the resident was at risk to wander. Review of Resident #1's Care Plan (CP) dated 06/15/22 showed under Focus: Resident #1 was at risk for elopement secondary to exit seeking, talks of leaving/going home, increased confusion/wandering at night, disoriented to place, and impaired safety awareness. The CP included an intervention, revised on 07/20/22, of WANDER ALERT: [every] shift. Review of Resident #1's Order Summary Report (OSR) for active orders as of 04/15/23, revealed a 07/17/22 physician order for WANDER GUARD TO LOWER EXTREMITY- PF [placement and function] OF DEVICE QS [every shift]. The OSR revealed a second physician order, dated 07/17/22, for SKIN CHECK QS [every shift] UNDER WANDER GUARD. Review of the resident's January 2023, February 2023, March 2023, and April 2023 eTARs did not include the aforementioned 07/17/22 physician orders. The surveyor reviewed Resident #1's electronic Progress Notes (PN) from 01/19/23 to 04/14/23. The PN revealed no documentation that a skin check under the wander guard was completed every shift per the physician's order. The PN also revealed no documentation that the wander guard had been checked for placement and function every shift per the physician's order. Review of Resident #1's OSR, order date range 01/01/23-05/31/23, revealed the following physician orders: 1. Physician order, dated 04/15/23, to Check function of wander guard using tester daily. 2. Physician order, dated 04/17/23, to Check placement of wander guard to right lower extremity every shift. 3. Physician order, dated 04/17/23, to Check skin check every shift under wander guard. Further review of the resident's April 2023 eTAR indicated that the aforementioned 04/15/23 and 04/17/23 wander guard orders had been transcribed. 2. According to the admission Record, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Dementia, unspecified severity, without behavioral disturbance and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], included the resident had a Brief Interview for Mental Status score of 3, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was ambulatory and used a wander/elopement alarm, daily. Review of Resident #2's 11/09/22 DMN-Wandering Risk Scale assessment revealed that the resident scored an 11 which indicated the resident was high risk to wander. Review of Resident #2's CP, revised on 11/14/22, showed under Focus that The resident is an elopement risk/wanderer. Disoriented to place, resident wanders aimlessly. The CP included interventions, initiated on 10/05/22, of WANDER ALERT- WANDERGUARD and check device placement and function each shift. Review of Resident #2's OSR, order date range 01/01/23-05/31/23, revealed the following physician orders: 1. Physician order, dated 04/17/23, to Check function of wander guard using tester daily. 2. Physician order, dated 04/17/23, to Check placement of wander guard to right lower extremity every shift. 3. Physician order, dated 04/18/23, to Wander guard to lower extremity- right #OOFDB9. The OSR did not include a physician order for the aforementioned 10/05/22 CP interventions of wander alert- wanderguard and check device for placement and function each shift. Review of Resident #2's January 2023, February 2023, March 2023, and April 2023 eTARs did not include a physician order for the aforementioned 10/05/22 CP interventions of wander alert- wanderguard and check device for placement and function each shift. Further review of the resident's April 2023 eTAR indicated that the aforementioned 04/17/23 and 04/18/23 wander guard orders had been transcribed. The surveyor reviewed Resident #2's electronic PN from 01/24/23 to 04/16/23. The PN revealed no documentation that the resident's wander guard was present and being checked for placement and function every shift per the CP. During a telephone interview with the surveyor on 05/22/23 at 10:42 AM, Licensed Practical Nurse (LPN) #1 stated that Resident #1 had increased confusion during the evening shift and would wander the unit. LPN #1 stated that a physician order was required for a wander guard and that the nurses were responsible for documenting the function and placement. LPN#1 further stated the wander guard checks were documented on the resident's TAR. LPN #1 added that the wander guard orders were on the eTAR to notify the nurse on duty to check the resident's skin for possible skin breakdown under the wander guard and the placement and function of the wander guard. During an interview with the surveyor on 05/22/23 at 10:42 AM, LPN #2 stated a physician's order was required for a wander guard and that the nurses were responsible for checking the wander guard for placement and function. LPN #2 further stated that the wander guard orders were documented on the eTAR. LPN #2 added that the eTAR alerted the nurse to check the resident's wander guard to make sure that it was present and functioning properly. During an interview with the surveyor on 05/22/23 at 12:31 PM, the Director of Nursing (DON) stated Resident #1 had a wander guard and that it was checked daily by the nurse. The DON added that residents with wander guards should have a physician's order to check for placement, function, and skin integrity under the wander guard. The DON further stated that the wander guard orders were documented on the TAR and that the nurses were responsible for checking for the function and placement. The surveyor requested Resident #1 and #2 missing wander guard documentation for January 2023, February 2023, March 2023, and April 2023; the DON stated she would look into it and follow up with the surveyor. During a follow-up interview with the surveyors on 05/22/22 at 3:03 PM, in the presence of the License Nursing Home Administrator (LNHA), [NAME] President of Clinical, Senior Director of Plant Operations, and Regional Director of Operations (RDO), the DON stated she was still looking for the requested documentation. The DON stated the facility had recently transitioned from paper charts to the electronic medical record (EMR) and that the nurses may have been documenting the wander guard checks on paper. The surveyor questioned the monthly recapitulation (recap) process for residents' physician orders; the DON stated that the nurse would check the physician orders documented on the paper physician order sheet against the physician orders documented EMR. The DON added that Resident #1 had a Physician's Order for the wander guard. The nurse did not check off the additional documentation box, which would have transcribed the Physician's Order onto the resident's TAR. When questioned about the transition, the RDO stated the nurses who struggled with the electronic medical record would continue the documentation on paper. The RDO added that they would have to review the medical records in storage and will email the requested documents to the surveyor. Review of the 05/23/23 email, sent at 7:50 AM by the LNHA, stated no additional documentation for Resident #1. The email included Resident #2s PN from 01/10/23 to 01/23/23 which revealed that the resident's wander guard was in place and checked for function. The email revealed no additional documentation that Resident #2's wander guard was in place and being checked for function from 01/24/23 to 04/16/23. Review of the facility's Wander Management and Elopement Prevention policy, updated April 2023, revealed that When implementing a wander management system device, the staff will implement routine checks for placement and functionality. a. Wander management system devices will be checked for placement each shift by nursing staff. b. Wander management system devices will be checked for functionality daily by nursing staff. Review of the facility's undated Safety and Supervision of Residents policy revealed that implementing interventions to reduce accident risks and hazards shall include, but not limited to the following: a. communicating specific interventions to all relevant staff, d. ensuring that interventions are implemented; and e. documenting interventions. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure staffing ratios were met for 17 of 42 shifts. This deficient practice had the potential to affect all residents and was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. 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 CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and 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 CNA and perform CNA duties. 1. A review of posted facility staffing ratios from 06/19/21 through 07/02/21 revealed the following for the day shifts: On 06/20/21, the staff to resident ratio was posted as 1 CNA to 9 residents on the day shift. On 06/21/21, the staff to resident ratio was posted as 1 CNA to 11.1 residents on the day shift. On 06/28/21, the staff to resident ratio was posted as 1 CNA to 9.1 residents on the day shift. 2. A review of posted facility staffing ratios from 06/19/21 through 07/02/2021 revealed the following for the evening shifts: On 06/19/21, the staff to resident ratio was posted as 1 CNA to 12.6 residents on the evening shift. On 06/20/21, the staff to resident ratio was posted as 1 CNA to 10.5 residents on the evening shift. On 06/22/21, the staff to resident ratio was posted as 1 CNA to 10.7 residents on the evening shift. On 06/27/21, the staff to resident ratio was posted as 1 CNA to 12.6 residents on the evening shift. 3. A review of posted facility staffing ratios from 06/19/2021 through 07/02/2021 revealed the following for the night shifts. On 06/19/21, the staff to resident ratio was posted as 1 CNA to 21 residents on the night shift. On 06/20/21, the staff to resident ratio was posted as 1 CNA to 15.8 residents on the night shift. On 06/21/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 06/22/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 06/23/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 06/27/21, the staff to resident ratio was posted as 1 CNA to 15.8 residents on the night shift. On 06/28/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 06/29/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 06/30/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. On 07/01/21, the staff to resident ratio was posted as 1 CNA to 15.5 residents on the night shift. During an interview with the Administrator (ADM), Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 07/01/21 at 2:38 PM, in the presence of the survey team, the ADM stated that with Covid, staffing was difficult. Normally the facility would hold CNA classes at the facility. They formed a partnership with [NAME] County Tech. The first CNA graduating class was coming into work with them on 07/06/2021, and all students coming in are going to be vaccinated. Then they will have another CNA class graduating in August and in September. They also train TNAs (Temporary Nurse Aides) at [NAME] County Tech. They feel that this partnership will help with staffing; and the ADM feels lucky that they formed this partnership. The DON stated that they currently have nine TNAs. They also have used nurses as CNAs, and they are hiring nurses. The ADON stated that there were eight applications for nurses; and she was willing to take new nurses and train them. The DON further stated that they have brought TNAs in and they have not worked out, as they found out that this environment is not for them. The ADON further stated that she had interviews set up for 3 or 4 nurses next week, and was also calling the RN/LPN schools to make them aware that they needed help. The ADM stated that [NAME] County Tech was starting up an LPN program and that they also wanted to be partners with that program. NJAC 8:39-5.1(a)

Based on observation and review of facility provided documentation on 07/01/21, in the presence of facility management, it was determined that the facility failed to maintain 2 of 2 dryers completely free from lint. The deficient practice was evidenced by the following: During the building tour at 11:02 AM, in the presence of the Maintenance Director, the surveyor observed that the enclosed room behind the two commercial dryers in the main laundry had a heavy accumulation of lint on top of the upper burn chambers. This was the area where there was the gas-fired exposed tubular assembly with an open flame. The surveyor observed on the floor behind the two dryers had an approximately 1/8 of an inch build up of lint. A review of the facility's Preventive Maintenance log entitled, Clean behind Dryers, reflected that the facility cleans behind the dryers weekly and that the area was cleaned on the following dates in June: 06/02/21, 06/09/21, 06/15/21, 06/22/21 and 06/28/21. The Administrator was notified of the findings at the life safety code exit conference on 07/01/21. NJAC 8;39-31.2(e)