Complaint# NJ00172367 Based on interviews, record review, and review of other pertinent facility documentation on 06/12/24, it was determined that the facility failed to maintain a complete Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #3), and was evidenced by the following: According to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Dementia, Transient Cerebral Ischemic Attack, Muscle Weakness A review of the Resident #3's Progress Notes (PN) revealed that on 03/21/2024 at 12:53 A.M, Registered Nurse (RN) documented that Resident #3 needed to be sent out to the hospital for an injury near the right eye area. A further review of the Resident #3's PN, dated 03/21/2024 at 5:53A.M. and documented by LPN, revealed as follows: Return from E.R. 4:10am via stretcher accompanied by 2 EMT from Atlantic ambulance BP 136/76, pulse 78, respiration 19 and Pulse oximeter 97% on room air. sutures to right eyebrow intact no complaint pain needs attended.'' A review of Resident #3's MR revealed no NJUTF for the 03/21/2024 transfer to the hospital. During an interview with the surveyor on 06/12/24 at 4:30 P.M. the Director of Nursing (DON) stated she was unable to locate the 03/21/2024 NJUTF for Resident #3. A review of the facility's undated policy titled, Transfers (Hospital or another facility). Revealed under Policy Statement A patient transfer form is to be completed at the time of transfer to hospital or another facility. NJAC 8:39-35.2 (d) 12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility provided documents it was determined that the facility failed to provide a physically impaired resident a specialized call bell according to the resident's limitation and preference. This deficient practice was identified for Resident #1, one (1) of two (2) residents reviewed for the limited range of motion, and was evidenced by the following: On 10/13/23 at 11:47 AM, during the courtesy meeting with the facility's Volunteer Advocate (VA), the VA informed the survey team that she was the one who recommended to the facility for the resident to have a specialized call bell due to the resident's limitations to upper extremities as per resident's preference. The surveyor reviewed Resident #1's medical records. The admission Record (or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts communication between the brain and the body. MS causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), other muscle spasm, and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 9/20/23, Section C Cognitive Patterns had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which reflected that the resident's cognitive status was moderately impaired. The qMDS also reflected in Section G Functional Status, G0400 Functional Limitation in Range of Motion that the resident was coded 1 (one) for the limitation that interfered with daily functions on the upper extremity and 2 (two) for lower extremities limitations. A review of the personalized care plan with a focus that the resident had a limited ADL (activities of daily living) function, physical mobility r/t (related to) contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), MS, and weakness that was initiated on 7/04/18 and was revised on 8/11/23. The limited ADL care plan's interventions/tasks did not include information about the specialized call bell. Further review of the care plan showed that the resident had a focus care plan for at risk for falls r/t gait/balance problems, a diagnosis of MS that was initiated on 7/04/18 and was revised on 10/12/23. The interventions/tasks included call the light is within reach, encourage the resident to use it for assistance as needed, and needs a prompt response to all requests for assistance that was created on 7/04/18 and revised on 10/03/22. The personalized care plan interventions did not specify where to put the call bell according to the resident's limitations and preferences. In addition, the resident had a care plan focus that the resident has MS/quadriplegia and spends most of their time in bed and depends on staff for solid and liquid administration that was initiated on 3/28/23 and revised on 9/24/23. The IDCP (Interdisciplinary Care Planning)- Team Conference for quarterly assessment dated [DATE] and was locked (closed) on 10/07/23. The information included that the resident was dependent on staff for solid and fluid administration and that the resident requires total care for all aspects of care self-feeding, hygiene, dressing, toileting, and all mobility require total assist. In addition, it included that the resident could follow short cues to participate in tasks and was currently on PT/OT (Physical Therapy/Occupational Therapy) services. A review of the electronic Progress Notes (PN) dated 10/02/23 by the Social Worker (SW) showed that the resident was issued a last cover date of 10/06/23 because the resident met the goals for Skilled PT and OT and that the resident could not sign the NOMNC (Notice of Medicare Non-Coverage; is a notice that indicates when your care is set to end from a skilled nursing facility (SNF) example skilled PT and OT) due to MS. On 10/17/23 at 8:49 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) in the 200-wing nursing station. LPN#1 informed the surveyor that LPN#2 was the assigned nurse of Resident # 1. On 10/17/23 at 8:51 AM, the surveyor interviewed LPN#2. LPN#2 informed the surveyor that she was a per diem nurse and assigned nurse of Resident # 1. The surveyor asked the LPN to go with the surveyor inside the resident's room. In the resident's room, the surveyor and the LPN both observed the flat call bell attached/pinned to the left part of the head bed approximately (two) 2 inches away from the pillow where the head of the resident was. The specialized call bell was placed where the resident was unable to use the call bell. The surveyor observed the resident with bilateral hands/arms limitations. On that same date and time, the surveyor asked LPN#2 if that was where the call bell should be and the LPN stated that definitely not, and the LPN took it and placed it just above the xiphoid process (xiphoid process is a small extension of bone just below the sternum) and grabbed the residents hands to be able to touch the call bell. The surveyor then asked the LPN should the call bell was there, and the LPN stated yes and that the resident could use it with the resident's hand. At this time the resident said it should be under the resident's chin. Then, the surveyor observed the LPN went outside the room and took a towel before entering the resident's room again. On 10/17/23 at 8:53 AM, the surveyor interviewed the assigned Certified Nursing Assistant (CNA) of the resident. The CNA informed the surveyor that he was the regular CNA in the 200 wing, worked 7-3 and 3-11 shifts, and had been working in the facility for 24 years. He further stated that he was assigned to the resident and he was familiar with the resident. At that same time, the CNA stated that the resident's specialized call bell should be placed in the resident's chest so the resident could reach it with their hand. He further stated that, lately the resident was not able to use the call bell and the CNA was unable to state how long and why. The surveyor asked the CNA how he knew that it should be placed in the resident's chest and who educated him about the proper placement of the resident's call bell, and the CNA stated that he just knew. The CNA was unable to state who informed him that it should be in the resident's chest. On 10/17/23 at 9:48 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and [NAME] President of Clinical Services (VPoCS) of the above findings. On 10/17/23 at 11:00 AM, the surveyor interviewed the Rehab Director/OT (RD/OT) in the presence of the survey team. The RD/OT acknowledged that he knew Resident #1 and that he recently treated and discharged (d/c) the resident from Skilled OT. The RD/OT informed the surveyor that the resident was d/c with no significant changes, and remained in total care with ADLs except for the left hand/extremity have some movement. On that same date and time, the surveyor asked about the resident's specialized call bell. The RD/OT claimed he called it a pancake call bell the way it looked, flat and circular. He stated that the pancake call bell should be placed on the left breast area of the resident. The surveyor asked the RD/OT if education was provided to the staff regarding the proper use of the pancake call bell and who provided the call bell. The RD/OT stated that he discussed with the Registered Nurse Unit Manager (RN/UM) verbally how to use it. The surveyor then asked how other nurses and CNAs were educated, and he stated that he did not talk to nurses and CNAs. The RD/OT further stated that generally, it should be nurses who document for care plan for the use of the call bell. On 10/17/23 at 11:55 AM, the surveyor interviewed the RN/UM in the presence of the survey team. The RN/UM informed the surveyor that when she was promoted as a UM beginning of May 2023, that was the same time she observed that the resident had the specialized call bell. The RN/UM stated that she was not sure who provided the call bell. She further stated that it was the VA who recommended the specialized call bell since the resident had limitations on both hands/arms. The RN/UM stated that the call bell should be placed under the left breast. She further stated that it was her and the RD/OT who assessed the resident that the resident can use their left hand in using the specialized call bell. On that same date and time, the surveyor asked the RN/UM if education was provided to the staff including the aides on the proper placement of the specialized call bell, the UM stated that just verbal instructions to the aides in the morning shift. The surveyor then asked how about other shifts, 3-11 and 11-7, the UM stated that she told the nurses in the morning, and that they do shift reports, and probably the nurses notified other staff. The RN/UM acknowledged that in-service or education should have been provided to all staff and all shifts on the proper placement of the call bell. In addition, the surveyor also asked if should it be in the care plan. The UM stated that it should be documented in the care plan the proper placement of the call bell. She further stated that the preference of the resident should be consider on where to put the specialized call bell and it should be in the care plan interventions. The RN/UM informed the surveyor that the resident was cognitively intact, not confused, and had no unusual behavior. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), DON, and VPoCS, and notified of the above findings. On 10/18/23 at 12:00 PM, the surveyor reviewed the typewritten explanation that was provided by the LNHA included that the staff education and care plan was updated about the pancake call bell after the surveyor's inquiry. Included in the typewritten explanation also was that the maintenance provided a call bell at the request of the Ombudsman on 6/14/23. The pancake bell was on the premises and supplied on 6/15/23. A review of the updated care plan showed an intervention/task dated 10/17/23 for a geri call within reach Patient prefers under the chin. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and the team could proceed with decision making. NJAC 8:39- 4.1 (a), 12

Based on interview, record review, and other pertinent facility documentation, it was determined that the facility failed to a) notify in advance and in writing of a resident's new roommate change for a cognitively impaired resident in accordance with federal and state regulations. This deficient practice was identified for one (1) of three (3) residents reviewed for room change (Resident #81) and was evidenced by the following: On 10/17/23 at 10:07 AM, the surveyor interviewed the Director of Social Services (DSS) who stated the process for a resident's room change were discussed during the morning clinical meeting with the Interdisciplinary team. The team was comprised of the Certified Nursing Assistant (CNA) to the resident, Social Services, the Licensed Practical Nurse (LPN) or the Registered Nurse (RN) assigned to the resident, the Infection Preventionist (IP), the Director of Nursing (DON), and the Licensed Nursing Home Administrator (LNHA). The conversation involved discussing the resident's personality differences, comfort. We also wanted the resident in the room to be comfortable along with the new resident who was going to be moved into the room. At that time, the DSS stated that the conversation was not documented anywhere. The team meetings were documented but not our conversations. We did document the notification to the family and guardian [as applicable]. At that time, the DSS informed the surveyor that she recalled the Resident who was being moved into Resident #81's room was documented as the aggressor but did not see the report before it was sent to the State Agency. As the social worker I thought it was ok to move the resident into Resident 81's room. When I placed the resident in the room, I did not think the new roommate to be was the aggressor. I effectuated the room changes [05/02/23] after a team conversation to determine the room change. At that time, the DSS stated that she had notified the guardian of the Resident who was being moved into Resident #81's room. At that time, the DSS stated that she had not provided a written notification to Resident #81's family. The surveyor reviewed Resident #81's medical record. A review of the resident's admission Record (an admission summary) reflected that Resident #81 was admitted to the facility with diagnoses that included vascular dementia (problems with reasoning, planning, judgement, memory, and other thought process caused by impaired blood flow to the brain) without behavioral disturbance, depressive episodes, and personal history of transient ischemic attack (stroke that lasts a few minutes) and cerebral infarction (a result of decreased blood flow to the brain) without residual deficits. According to the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate management of care dated, 9/12/23, Resident #81 was documented as having a Brief Interview for Mental Status score of two out of 15, indicating that the resident had a severely impaired cognition. A review if the Census (total number of residents) list reflected Resident #81 had been in the room since 8/06/22. There was no documentation that Resident #81 was notified of a new roommate, or their representative was notified in writing. On 10/18/23 at 12:32 PM, during a meeting with the surveyors, the [NAME] President of Clinical Services (VPoCS) and the LNHA, the surveyor discussed the concern regarding the missing written notification of a new roommate for Resident #81. On 10/19/23 at 11:52 AM, during a meeting with the surveyors, the DON, the LNHA, and the RN/IP/Interim LNHA, the VPoCS stated the SSD was educated on the process of roommate notifications. At that time, the RN/IP/Interim LNHA stated that they did not have a facility policy on room changes. N.J.A.C. 8:39-4.1(a)(13)

Based on observation, interview, and review of pertinent facility documentation it was identified that the facility failed to provide residents with a clean, safe, comfortable, and home like environment. This deficient practice was identified in one (1) of two (2) dining areas where morning activities for the English-speaking residents were also held. A review of the Material Safe Data Sheet for [brand name redacted] under Section 7: Handling and Storage included the following: Provide good ventilation. Do not use in confined spaces without adequate ventilation and/or respirator. Avoid contact with skin and eyes. Do not eat, drink, or smoke when using the product. Methods of Clean-up: Small spillages: Absorb with sand or other inert absorbent. Large spillages: Dam and absorb. Collect spillage in containers, seal securely and deliver for disposal according to local regulations. Wear necessary protective equipment. Storage: Keep separate from food, feedstuffs, fertilizers and other sensitive material. Store in closed original container at temperatures between 5°Cand 30°C/ 40°F and 86°F. Protect from freezing and direct sunlight. On 10/06/23 at 01:20 PM, the surveyors observed Resident #95 walking the hallway adjacent to the dining area without assistance. The resident was cognitively impaired and conversant. At that time, the surveyor walked with Resident #95 towards the Recreation/Activities Director's (R/AD) office. The Activity Director (AD) stepped outside her room and assisted the resident towards their wing. On 10/11/23 at 10:28 AM, the surveyor met with the AD in the main dining room to commence the meeting with the resident council president and representatives. At that time, the AD stated that the resident council meeting was always held in the main dining room. The main dining room had two entrance and exit doors from the hallway and across the entrance/exit doors was the entrance to the kitchen. At that time, the surveyor observed a heavy-duty flatbed dolly cart with handles and wheels, a hand truck, a fan, a mop, a palette of wood flooring, and multiple gallons of vinyl flooring adhesive (construction materials) next to one of the entrances/exit doors in which one of the resident council representatives (Resident #50) entered from. Resident#50 parked their mechanical sit and stand lift (a mechanical medical device that promotes movement from seated to a standing position) next to the palette of construction materials. At that time, the resident council member(s) who did not want to be identified stated that the floor construction where we had our resident council meeting was new. They were unsure exactly when. On 10/11/23 at 12:16 PM, the surveyor observed residents in the dining area waiting for lunch to be served. The construction materials were still in the corner of the dining area next to the entrance/exit and adjacent to a dining table where residents were seated. On 10/11/23 at 01:09 PM, the surveyor met with the Facility Maintenance Director (FMD) and walked into the dining area together. The FMD confirmed observing the construction material with visible seepage from the vinyl glue adhesive gallon container. The FMD informed the surveyors that he did not put the construction materials into the dining area. I just noticed it was there. The FMD stated that the facility had a contractor who did not report to him. At that time, the FMD stated that the facility did not have space to put the construction materials. The Administrator had hired the contractor and reported to the administrator directly. The FMD stated he was in -charge of water, the hood in the kitchen, painting, temperature, and water testing. The materials purchased by the FMD were not in bulk and could be kept downstairs. On 10/11/23 at 01:25 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and discussed the concern regarding the construction materials and the visible seepage from the vinyl glue adhesive gallon container stored inside the dining area where residents ate and had activities. At that time, the LNHA stated it did not occur to him that it was a problem. The LNHA stated yes, the area is a resident area, yes, he did see the residents in the area, and yes, food was served there. The LNHA confirmed he had knowledge that he had wandering residents living in the facility and yes, it can be a hazard. At that time, the LNHA stated that it did not occur to him that it was a problem. The LNHA informed the surveyors that he would move the construction materials from the dining area. On 10/13/23 at 10:19 AM, the surveyor observed the dining area was cleared of the construction materials. At that time, during the meeting with the survey team, the LNHA stated he was ultimately responsible for the construction. He did not see that it was a contradiction to a homelike or safety environment. On 10/13/23 at 11:28 AM, during a meeting with the surveyors, the [NAME] President of Clinical Services (VPoCS), Director of Nursing (DON), Registered Nurse (RN)/Infection Preventionist (IP), and the LNHA, the surveyor discussed the concern regarding safety, homelike environment (similar to those found in a private residence or apartment) and storing construction materials in an area where confused wandering residents, residents that required assistance with daily living, and all the residents who had access to dining area. On 10/16/23 at 12:06 PM, during a meeting with the surveyors, the VPoCS, and the DON, the LNHA stated the supplies were not a danger, a resident would have to use a crowbar to open the vinyl adhesive glue gallon containers. The LNHA did not discuss the palette of wood, the heavy-duty flatbed dolly cart with handles and wheels, the hand truck, the fan stored next to the entrance/exit of the dining area and the decrease in dignity for the residents who used the dining/activities area. At that time, the LNHA stated we moved it immediately. Based on the regulations it was not against homelike environment. It was appropriate to keep it there for a few days. It was a big process to remove the palette. It took 45 minutes to remove from the dining area. It was there for a short period of time. At that time, the LNHA informed the surveyors that the facility did not have a Policy and Procedure for homelike environment. A review of the undated/unsigned facility provided job description for the facility Maintenance Director under position summary included. The Maintenance Director follows established safety rules and policies and procedures of the maintenance department, keeps required records and submits them to the administrator and director of property management when required and cooperates with other employees and department heads. Under responsibilities/accountabilities included performs overall supervision of the maintenance department including hands on performance of maintenance and repair work. Concerns his/ herself with safety of all facility residents in order to minimize the potential for fire and accidents. Also ensures that facility adheres to the legal, safety, health, fire, and sanitation codes by being familiar with his/ her role in carrying out the facilities fire, safety, disaster plans and by being familiar with current MSDS. A review of the undated/unsigned facility provided job description for the Administrator (LNHA) included the following: Position Summary The administrator is responsible for planning and is accountable for all activities and department of the facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The administrator administers directs and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. Responsibilities 2. Interprets personal practices within policy guidelines and recommends changes as necessary; 5. Super intense physical operations of the facility; 9. Concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. Also, ensures that the facility adheres to the legal safety health fire and sanitation codes by being familiar with his/her role in carrying out the facilities fire safety disaster plans and by being familiar with the current MSDS. NJAC 8:39-31.4(a)(f)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of nine (9) newly hired staff reviewed, (Staff #1, #4, and #6) and was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed nine randomly selected new employee files for license verification which revealed the following: Staff #1, a Certified Nursing Assistant (CNA), hired 7/06/23, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. Staff #4, a Speech Therapist, hired 01/01/23, did not have a New Jersey Division Consumer Affairs license verification printout for license verification. There was no documented evidence that Staff #4's license was verified. Staff #6, a CNA, hired 3/21/23, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. On 10/18/23 at 11:59 AM, the surveyor interviewed the Human Resources Director (HRD) regarding the process for license verification. The HRD stated that she would go online and verify the employee's license. The HRD confirmed that Staff #1 and #6 did not have a date on their license verification printout. The HRD confirmed that Staff #4 did not have a license verification printout in their employee file. On 10/18/23 at 01:02 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Clinical Services (VPoCS) the concern that three newly hired employees did not have documented evidence that their licenses were verified prior to their date of hire. On 10/19/23 at 10:59 AM, in the presence of the survey team, LNHA and DON, the VPoCS stated that the HRD now knows how to print the date on the printout. The surveyor asked if licensed employees should have their licenses verified prior to hire and that if the date should be on it. The VPoCS confirmed that they should be. A review of the undated facility provided policy titled, New Hire And Onboarding Process included the following: Prior to a start date: Valid NJ State License (RN, LPN, C.N.A., etc.) A review of the facility provided policy titled, Prohibition of Resident Abuse & Neglect dated 5/18/22, included the following: Employee and Volunteer Screening 2. Inquiry of State Nurse Aide Registry for CNA applicants 3. Inquiry of licensing authorities for all licensed/certified positions N.J.A.C. 8:39-43.15(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaints # NJ00158985, NJ00156816 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for three (3) of 21 residents, (Resident #26, Resident #208, Resident #209) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set 3.0 Public Reports page last modified October.20.2023, included that the MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of the source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. 1. On 10/18/23 at 12:17 PM, the surveyor observed and interview Resident #26. The surveyor observed the resident had jagged teeth and brown discoloration when he/she smiled. The resident stated that there was no pain at this time. The surveyor asked if the resident had seen a dentist or had been offered since he/she was admitted . The resident stated no, neither. On 10/16/23 at 11:46 AM, surveyor interviewed the assigned aide of the resident, Certified Nursing Assistant (CNA). The CNA stated that Resident #26 was a set-up for morning (AM) care including care of resident's teeth. The aide further stated that the resident did not have a complete set of teeth and had some broken teeth. On 10/10/23 at 9:45 AM, the surveyor reviewed Resident #26's electronic medical record (eMR). A review of Resident #26's admission Record (AR; or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high. Blood glucose is your main source of energy and comes mainly from the food you eat), moderate protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function ), need for assistance with personal care (the range of services put in place to support an individual with personal hygiene and toileting, along with dressing and maintaining your personal appearance.). The Order Summary Report dated 8/25/23 through 10/10/23 revealed that there was not an order for a dental consultation. A review of the Nutrition Assessment, dated 8/29/23, #12, Teeth /Dentures, letter J, indicated broken or carious teeth? Was answered Yes. A review of the Comprehensive Minimum Data Set (CMDS), dated [DATE], revealed the resident had Brief Interview for Mental Status (BIMS), score of five out of 15 which reflected that the resident had a severe cognitive impairment. It further revealed under. -section L, Oral/Dental status none of the above were present. -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance, (helper does less then half the effort.) A review of the resident's personalized Care Plan (CP), dated 8/24/23, revealed a focus resident has an ADL self-care performance deficit related to (r/t) activity intolerance and impaired balance. date initiated 8/29/23, revision date of 10/07/202. The individualized care plan did not reflect a focus for teeth impairment and care. There was no documentation that Resident #26 was offered and refused dental care services. 2. On 10/10/23 at 10:02 AM, the surveyor reviewed Resident #208's closed medical record. A review of Resident #208's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified severe protein-calorie malnutrition, cognitive communication deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). A review of the Quarterly MDS (QMDS), dated [DATE] revealed: -section L, Oral/Dental status as left blank -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was left blank - section G, Functional Status was coded as 3 (Extensive Assistance, resident involved in activity, staff provided support) self-performance and 2 (one-person physical assist) Support Further review of the QMDS, dated [DATE], revealed the resident had BIMS) score of four out of 15 which reflected that the resident had a severe cognitive impairment. In addition: -section L, Oral/Dental status was left blank -section G, Functional Status was coded as 3 (Extensive Assistance, resident involved in activity, staff provided support) self-performance and 2 (one-person physical assist) Support -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was left blank The resident's personalized CP, dated 8/31/21, revealed a focus resident has oral/dental health problems (oral laceration) r/t refuses assist with dental care. Poor oral hygiene. date initiated 10/14/2022, revision date of 01/02/2023. There was no documentation that Resident #208 was offered and refused dental care services. 3. On 10/10/23 at 10:20 AM, the surveyor reviewed Resident #209's closed medical record. Resident #209's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, unspecified protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), vitamin B deficiency, Vitamin D deficiency. A review of the Nursing admission assessment, dated 5/05/2022 revealed section #12 Teeth and Dentures; a) own teeth? No, b) partial upper (blank) c) partial lower (blank) d) full upper (blank) e) full lower (blank) f) has dentures but does not wear them (blank) A review of the Order Summary Report, dated 5/11/22 through 8/01/22 revealed that there was an order for a dental consult, initiated on 5/05/2022. A review of the Nutrition Assessment, dated 5/10/2022, revealed in the assessment and plan section; resident has been put on list to see the dentist as resident doesn't wear them due to poor fit. It also revealed #12 Dentures answered as #5 edentulous (lacking teeth). A review of a Social Worker progress note (PN), date 5/12/2022, labeled as 72-hour meeting revealed resident was on a diet of; no added salt (NAS) pureed texture and thin liquids. It did not reflect the residents oral standing of having dentures but not using because of poor fit. A review of the CMDS dated [DATE], revealed the resident had BIMS score of four out of 15 which reflected that the resident had a severe cognitive impairment. It further revealed under. -section L, Oral/Dental status none of the above were present. -Section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance, (helper does less than half the effort.) A review of the resident's personalized CP, dated 5/05/22, revealed a focus Resident does not wear dentures due to poor fit. Resident receives consistency modifications. Eats fairly with acceptable BMI (body mass index [BMI] is a measure of body fat based on height and weight that applies to adult men and women) on admit. date initiated 5/18/22, revision date of 5/18/2022. There was no documentation that the resident declined dental services. Surveyor requested MDS policy 10/12/2023. The facility was unable to provide a policy. The VPOCS stated, they refer to the RAI manual by CMS guidelines. A review of the Dental Services policy, dated 1/2018, revealed; statement; To ensure a resident's diet is appropriate, optimal hydration and nutritional status are maintained and risk of choking is avoided. Speech therapy (via screen) and dietary (via alert) must be notified of the following circumstances: -Missing/ broken dentures -Recent extractions -Refusal to wear dentures -New dentures If a resident's dentures are lost or damaged, they must be referred to a dentist within 3 days for services. If a referral does not occur within 3 days, supportive documentation of what was done to ensure the resident could still eat and drink adequately and the extenuating circumstances behind the delay of services will be noted. A review of the policy Interdisciplinary Care Planning Protocol revealed; #3. Activities and Dietary provide an overview of their assessment of resident needs and problems. #8. Problems established by the team with the resident/ family input MUST be specific and individualized. On 10/19/23 at 11:36 AM, the surveyor interviewed the [NAME] President of Clinical Services (VPoCS) who stated, the MDS coordinator was unavailable and out on personal leave and she could answer surveyor's question regarding coding. She stated coding of the MDS was based on what is found in the record and Interdisciplinary Care Plan (IDCP) note. The IDCP should be a synopsis of the MDS. NJAC 8:39-33.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; and b.) ensure an individualized comprehensive care plan interventions were developed and implemented to a Stage 1 pressure injury wound; and c.) ensure an individualized comprehensive care plan with interventions were developed and implemented in a timely manner after a skin impairment occurred for one (1) of three (3) residents reviewed for PU (Resident #81). This deficient practice was evidenced by the following: On 10/16/23 at 10:00 AM, the surveyor observed Resident #81's assigned Licensed Practical Nurse (LPN #1) perform a wound treatment. Prior to handwashing (HW), LPN #1 pulled the lever on the paper towel dispenser downward and upward multiple times to dispense the paper towel. LPN #1 then performed HW for 20 seconds. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. LPN #1 donned (put on) gloves and proceeded to wipe the top of the treatment cart with a disinfectant wipe. LPN #1 then wiped the bedside table with a new disinfectant wipe. She doffed (took off) her gloves. LPN #1 performed HW for 20 seconds. She then used her elbow to move the lever downward and upward to dispense the paper towel from the towel dispenser. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. She put a blue disposable barrier sheet on the bedside table, gathered the supplies needed for the treatment and placed them on top of the barrier sheet. At 10:16 AM, LPN #1 dispensed the paper towel from the dispenser then performed HW for 20 seconds. After the she dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. LPN #1 donned a new pair of gloves and removed the dressing that was on Resident #81's sacrum. She doffed her gloves. After LPN #1 dispensed the paper towel with her hand, she performed HW for 20 seconds. After LPN #1 dried her hands with the paper towel, she turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. At 10:22 AM, the Certified Nursing Assistant (CNA) doffed her gloves and performed HW for 20 seconds which was mostly under the flow of water. She then dried her hands with a paper towel that she had dispensed prior to HW. Afterward, she used her right hand to dispense more paper towels by pushing the lever downward and upward. She then dried her hands with the additional paper towel and then used the used wet paper towel to turn off the faucet. She did not use a clean dry paper towel to turn off the faucet. She then donned gloves and continued to hold the resident. At 10:24 AM, LPN #1 donned a new pair of gloves and then wiped Resident #81's sacral wound with a 4 X 4 gauze dressing that was moistened with normal saline solution. She then patted dry the wound with a dry 4 X 4 gauze dressing. LPN #1 then used a cotton tipped applicator to place medihoney paste (medication used on acute and chronic wounds and supports the removal of necrotic tissue and aids in wound healing) on the wound and then used a second applicator to place additional medihoney paste on the wound. LPN #1 applied a border gauze dressing over the wound. LPN #1 did not change her gloves or perform HW after she cleansed the wound prior to applying the medication and dressing. She doffed her gloves and performed HW for 20 seconds. After drying her hands, LPN #1 used the used wet paper towel to turn off the faucet. She did not use a clean dry paper towel to turn off the faucet. At 10:26 AM, after removing the used supplies from the bedside table and placing them in the garbage, LPN #1 performed HW and again turned off the faucet with the used wet paper towel. She did not use a clean dry paper towel to turn off the faucet. She then signed off the treatment as being performed in the computer. At 10:29 AM, the surveyor asked LPN #1 if she was finished with the wound treatment. LPN #1 stated yes. LPN #1 had not wiped the used bedside table with a disinfectant wipe. The surveyor then asked if she would wipe the bedside table at the end of a wound treatment. LPN #1 stated that she did not usually wipe the bedside table after because the barrier sheet was there. The surveyor then asked if she always used the used wet paper towel to turn off the faucet. LPN #1 stated that she usually used the wet paper towel and that she was probably not supposed to use it. She added that she was supposed to use a clean one. She then confirmed that she had done it wrong and that she was supposed to use a clean one. She added that she just had an inservice. The surveyor then asked LPN #1 if she should have changed her gloves after cleaning the wound and before applying the medication and dressing. LPN #1 stated the she did not usually change her gloves between cleaning the wound and applying the medication. At 10:46 AM, the surveyor interviewed the CNA regarding her HW. The CNA stated that she does it inside the sink under the water. A review of Resident #81's admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), hypertension (high blood pressure) and cerebral infarction (circumscribed focus or area of brain tissue that dies as a result of localized hypoxia/ischemia due to cessation of blood flow). A review of Resident #81's Significant Change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/05/23, indicated a Brief Interview for Mental Status (BIMS) score of 02 out of 15, which reflected that the resident's cognition was severely impaired. Further review of Section M-Skin Conditions indicated that Resident #81 had 1 Stage 2 pressure ulcer. A review of Resident #81's entry MDS dated [DATE], indicated that Resident #81 was readmitted to the facility after an unplanned discharge to the hospital. A review of Resident #81's Discharge Return Anticipated MDS dated [DATE], indicated that the resident had an unplanned discharge to an acute hospital. Further review of Section M-Skin Conditions indicated that Resident #81 did not have an unhealed pressure ulcer/injury. A review of Resident #81's Quarterly MDS dated [DATE], Section M-Skin Conditions indicated that Resident #81 did not have an unhealed pressure ulcer/injury. Section M1200 Skin and Ulcer/Injury Treatments indicated that a pressure reducing device for bed was being utilized. A review of the facility provided Order Summary Report, dated 10/17/23 included the following orders: 1. Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to sacral wound topically every day shift for wound healing clean sacrum w/ (with) NSS (normal saline solution), pat dry, apply layer of medihoney to sacral wound bed and cover with border dressing. 2. Turn every two hours while in bed every shift for relief of pressure Turn every two hours while in bed with a start date of 10/05/23. A review of Resident #81's individualized care plan (CP) included the following: 1. At risk for: Potential for altered skin integrity related to: disease process with an initiated date of 6/15/2023 and a revision on 8/04/2023. The interventions included: Consult wound care prn (as needed) and follow MD (physician) orders Date Initiated: 10/10/2023 Revision on: 10/10/2023 Monitor for bruising daily with am (morning) care and PRN Date Initiated: 6/15/2023 Instruct staff/family on fragile skin. Date Initiated: 6/15/2023 2. Impaired Skin Integrity R/T (related to) Poor nutritional status Moisture/Incontinence, Immobility/CVA (cerebrovascular accident or stroke, which is damage to the brain from interruption of its blood supply) with an initiated date of 10/14/2023 and a revision on 10/14/2023. The interventions included: Encourage nutrition and hydration Date Initiated: 10/14/2023 Keep skin clean and dry Date Initiated: 10/14/2023 Monitor for signs of infection Date Initiated: 10/14/2023 Perform necessary wound care as per MD's ordered Date Initiated: 10/14/2023 Provide pressure reduction mattress. Date Initiated: 10/14/2023 Wound care consult in place to treat and evaluate wound Date Initiated: 10/14/2023 A review of the Braden Scale for Predicting Pressure Sore Risk, dated 9/22/23 indicated a score of 16 and that Resident #81 was at risk. A review of the Skin Observation Tools dated 9/22/23 and 9/29/23 indicated that Resident #81 had an observation of the Coccyx that had a stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area) redness with a measurement of 3 cm length and 3 cm width. A review of the Skin Observation Tools dated 10/03/23 indicated that Resident #81 had an observation of the sacrum with a type of pressure which measured 3 cm length and 2 cm width but did not indicate the stage. A review of the Skin Observation Tools dated 10/04/23 indicated that Resident #81 had an observation of the sacrum with a type of pressure that measured 3 cm length, 2.3 cm width and 0.2 cm depth and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). A review of the September 2023 CNA Task documentation, that was provided by the facility, did not include any intervention of turning or applying a skin protectant cream. A review of the October 2023 CNA Task documentation, that was provided by the facility, included an intervention of roll left and right q (every) shift. The intervention was started on 10/05/23. There was no documented evidence that the CP was updated with any additional interventions to prevent Resident #81's redness from becoming a Stage II pressure ulcer when the resident was readmitted to the facility on [DATE]. There was no documented evidence that the CP for the skin impairment was initiated in a timely manner when Resident #81 was found to have the impairment on 10/04/23. There was no documented evidence that Resident #81 was being turned from 9/22/23 to 10/05/23. On 10/16/23 at 10:55 AM, the surveyor interviewed the Unit Manager (UM) of the 200 wing unit, regarding the process of HW and wound treatment. The UM stated that after the person washes their hands for 20 seconds, they would dry their hands with a paper towel and throw it in the garbage. The UM stated that the person should take another paper towel to turn off the water. The surveyor asked the UM if the hand washing part was outside the flow of water. The UM stated that it was outside the flow of water. The surveyor asked the UM if a nurse should change gloves and perform hand hygiene after the wound is cleaned and before applying medication. The UM stated that after the wound is cleaned, the nurse should remove the gloves, wash their hands and put on clean gloves before medication is placed. The surveyor asked the UM if the bedside table should be cleaned at the end of the treatment. The UM stated that the bedside table should be washed at the end because you do not know what fell on table. She added that the resident is going to use the table after, so you would make sure it is clean. On 10/17/23 at 10:08 AM, the surveyor interviewed the assigned CNA regarding the care of Resident #81. The CNA stated that she did everything for the resident. She added that she would put the resident back to bed after lunch and that she would reposition the resident when the resident was in bed. The surveyor asked the CNA if Resident #81 had a pressure ulcer. The CNA stated that the resident had a small opening and that it was getting smaller. The surveyor asked the CNA if she documented the care of the resident. The CNA stated that she would document on the laptop. On 10/17/23 at 10:27 AM, the surveyor interviewed the assigned LPN #2 regarding the process for preventing pressure ulcers and CP. LPN #2 stated that for person at risk for pressure ulcer, the resident would be turned every couple hours. The surveyor asked what the process was if a resident was a readmission to the facility and had redness on their skin. LPN #2 stated that all residents have a general assessment when they come to the facility. She added that a skin check, full body check, is performed and if there is redness it is documented on the skin observation tool. She then stated that she would also document it in a progress note. The surveyor asked if a CP with interventions would be initiated. LPN #2 stated that of course it would be but that she did not do anything with the CP. She stated that she believed it was the UM that did the CP. On 10/17/23 at 10:38 AM, the surveyor interviewed the UM regarding the process related to a resident's skin when there was redness noted. The UM stated that when a nurse checked the skin and there was redness, the nurse would contact the physician and get an order for a skin barrier and measure the redness and document it. She added that there would be a CP for risk of skin breakdown and interventions may include turning when in bed and a cushion for the wheelchair. The UM stated that she would do the CP and that also the MDS coordinator and Director of Nursing (DON). On that same date and time, the UM added that anyone that has redness there would be an order for turning every 2 hours. The surveyor asked about Resident #81's CP. The UM stated that the resident had an order for turning but that she just did not update the CP. The surveyor asked the UM if the order to turn every 2 hours should have been done prior to 10/05/23. The UM stated that it should have been ordered the first day the redness was found (9/22/23). The surveyor asked the UM how the tasks on the CNA documentation are put in the system. The UM did not know and stated that she would have to check with the Director of Nursing (DON). On 10/17/23 at 11:53 AM, the surveyor interviewed the DON regarding the process of CP for a resident's skin. The DON stated that it was done by the interdisciplinary team. She stated that if someone was at risk for a pressure ulcer that there would be a CP with preventative interventions that might include turning, positioning, air mattress and heel pads. The surveyor asked what the expectation would be if a resident had redness. The DON stated that the expectation would be that they would be turned and repositioned and that with each incontinent change, a barrier cream would be applied. The surveyor asked if those interventions would be listed on the CP. The DON stated yes. At that same time, the surveyor asked about the documentation of the CP and the CNAs. The DON stated that the nursing staff put in interventions. She added that if you put an intervention in the CP, it gives you an option to put it in the tasks for the CNA documentation. She added that it is not an automatic entry but that it has to be prompted by individual that is adding to the CP. The DON stated that not everything was always on the CP and that some were standards of practice like the barrier cream. The surveyor asked if the barrier cream was an order and if it was documented anywhere. The DON stated that it was not an order and that it was not documented anywhere. Furthermore, the surveyor asked the DON about the process of the wound treatment and HW. The DON stated that the HW process of lathering was mostly outside the flow of water, but that if you did not have enough lather that you could add a little water. She stated that after you dried your hands, you would take another paper towel to turn off the faucet. The DON stated that after cleaning the wound the nurse should change gloves before placing medication. On that same date and time, the surveyor notified the DON about the concern of Resident #81's CP that there were no interventions to prevent an impairment. The DON stated that interventions were being done and that they just were not documented. She added that Resident #81 was being turned and position, had barrier cream and had an air mattress. She then stated that the wound was getting better. On 10/17/23 at 01:40 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Administrator in Training/Registered Nurse/Infection Preventionist (AIT/RN/IP) and [NAME] President of Clinical Services (VPoCS) the concerns that Resident #81 did not update the at risk CP to include interventions to prevent a Stage I to develop into a Stage II, the actual impairment of skin integrity CP was not initiated at the time of the impairment and the infection control issues that were observed during the wound treatment. On 10/19/23 at 11:28 AM, in the presence of the survey team, LNHA, AIT/RN/IP and VPoCS, the DON stated that she educated the nurse on the wound treatment and HW. She added that the nurse should have used a clean towel, changed her gloves after cleaning and wiped the bedside table. The surveyor asked if the facility had a response regarding the CP and if Resident #81's should have been updated. The AIT/RN/IP stated that the staff would be inserviced on the proper CP and timely updating. The surveyor then asked how often the CP should be updated. The DON stated as needed and quarterly. The LNHA stated that any change that warrants the CP to be changed. A review of the undated facility provided policy titled, Wound Care Protocol included the following: 1. Use disposable towel to establish a clean field on resident's over-bed table. 2 .Wash and dry your hands thoroughly following standards of practice . 4. Put on gloves . 5. Apply treatments and dress wound as indicated. 6. Discard disposable items into the designated container. 7. Remove gloves and wash hands following standards of practice. A review of the undated facility provided policy titled, Handwashing/Hand Hygiene included the following: Washing Hands Procedure 2. Wet hands with warm (not hot) running water. 3. Apply soap and vigorously rub hands together, creating friction to all surfaces, for at least twenty (20) seconds. 4. Rinse hands thoroughly under running water 5. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. A review of the undated facility provided policy titled, Pressure Ulcer Prevention, included the following: The Nursing Department's goal is to ensure that a resident does not develop pressure ulcers unless clinically unavoidable and provide care to: Promote the prevention of pressure ulcer development; Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcers The licensed nurse on admission will complete a comprehensive skin assessment within 2 hours, initiating interventions based upon the resident's risk level and risk factors. Interventions will be documented on the care plan . The Certified Nursing Assistant will reposition residents according to their needs and based on their ability to reposition themselves to promote circulation and prevent as much as possible skin breakdown/or to aid in the healing of any skin breakdown . A review of the undated facility provided policy titled, Interdisciplinary Care Planning Protocol, included the following: Interdisciplinary Care Planning 2. Nursing provides overview of medical and nursing care regimes. Nursing Assistants must provide input especially related to ADL (activities of daily living), skin, weights, and safety needs . 7. CAA Summary triggers are reviewed by the team to decide whether or not to proceed with care planning for each triggered area. 9. Problems established by the team with resident/family input MUST be specific and individualized. N.J.A.C. 8:39-27.1

Based on observation, interviews, record review and review of other pertinent facility provided documentation, the facility failed to implement and document in the resident's care plan a new intervention after each fall in order to prevent any additional falls for one (1) of five (5) residents reviewed for falls (Resident #22). This deficient practice was evidenced by the following: On 10/10/23 at 12:12 PM, the surveyor observed resident #22 in their room, seated in a wheelchair eating lunch. Resident #22 did not want to be bothered at this time. The surveyor reviewed Resident #22's medical records. The admission Record (or face sheet; an admission summary) reflected that Resident #22 was admitted to the facility with diagnoses that included but not limited to asthma (a chronic condition that inflames and narrows the airways in the lungs), atherosclerosis heart disease (or hardening of the arteries -- is the leading cause of heart attacks, strokes, and peripheral vascular disease.), unspecified systolic (congestive) heart failure (a specific type of heart failure that occurs in the heart's left ventricle). A review of the facility Incident/Accident Report dated 3/02/23 indicated that the resident had an unwitnessed fall. The investigation documentation revealed the fall was with injury and the resident was transferred to acute care for further evaluation. Further review of the facility Incident/Accident Report dated 5/20/23 indicated that the resident had another unwitnessed fall. The investigation documentation revealed there were no injuries noted. The Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/21/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which reflected a severely impaired cognition. The Fall Risk Evaluation (an assessment tool) reflected that anytime there was a total score of 10 or greater, the resident should be considered at HIGH RISK for potential falls. It also indicated that a prevention practice should be initiated immediately and recorded on the resident's care plan. A review of the resident's fall risk assessment score dated 3/04/23 revealed the resident score of 14. Further review of the resident's fall risk assessment score dated 4/21/23 revealed the resident score of 14. Upon review of the resident's care plan (CP) which included that the resident at risk for falls related to (r/t) disease process, date initiated: 7/21/2023 and was revised on: 8/04/2023. The CP was not updated or revised to include new interventions for fall incidents that happened on 3/02/23 to prevent further fall on 5/20/23. During Interview on 10/16/23 at 11:30 AM with the Director of Nursing (DON) she stated, a CP should have been initiated immediately following the investigation of the fall and interventions should have been adjusted with the second fall. The DON and facility management were unable to provide a fall policy upon surveyor request. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other pertinent provided facility documents, it was determined that the facility failed to ensure that tracheostomy (trach) care and services were provided according to the standard of clinical practice for one (1) of one (1) resident (Resident #18) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's admission Record (or face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dependence on supplemental oxygen, gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) status, hypoxic ischemic encephalopathy (a type of brain damage), dysphagia unspecified (a disorder characterized by difficulty in swallowing), chronic obstructive pulmonary disease unspecified (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and anoxic brain damage not elsewhere classified (caused by a complete lack of oxygen to the brain, which results in the death of brain cells due to oxygen deprivation). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care with an assessment reference date (ARD) of 9/04/23 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 00 which indicated that the resident's cognitive status was severely impaired. The qMDS also showed that the resident had trach care for the last 14 days. A review of the October 2023 orders showed that there was an order to change the tracheostomy tube inner cannula daily on days one time a day with a start date of 6/13/2023. Further review of the above 6/13/23 order showed that it was signed by nurses daily. The order for the inner cannula did not include the size. On 10/11/23 at 11:01 AM, the surveyor observed the Licensed Practical Nurse (LPN) performed handwashing inside the resident's room, introduced himself to the resident, and explained that he will be doing trach care. The resident was at the geri chair at this time, then the LPN left the room and read the order in the electronic treatment administration record (eTAR) in his treatment cart as follows: change tracheostomy tube inner cannula daily on days one time a day. The LPN informed the surveyor that the order was to change the inner cannula daily and that he does it every day. On that same date and time, the LPN performed handwashing inside the resident's toilet room, donned gloves, and placed a blue liner on top of the table without disinfecting the table first. The garbage container inside the toilet room was full. LPN then removed gloves, performed handwashing, dried his hands with a paper towel, and discarded the used paper towel on top of the full garbage slightly pressing the garbage. The LPN then took the supplies from the treatment cart that was outside of the resident's room and opened the NSS bottle, packets of gauze, and trach mask on top of the blue liner. The LPN opened the trach kit and put the white liner on top of the blue liner. The LPN accidentally dropped the paper cover of gauze inside the sterile kit container and stated to the surveyor that he had to discard it and get another sterile trach kit. The LPN discarded the first sterile trach kit and performed handwashing, dried his both hands with a paper towel, and slowly placed directly the used paper towel on top of the garbage that was full to prevent it from spilling. After discarding the first sterile trach kit, the LPN opened another sterile kit. The LPN opened the inner cannula container. The LPN informed the surveyor that he would change the inner cannula with this (showing opening the inner cannula). The surveyor asked the LPN what was the size order for the inner cannula for the resident. The LPN asked the surveyor where he could find that information in the inner cannula container. He further stated Is it in the expiration date? The LPN was unable to state the complete order and what size of the inner cannula. At that time, the LPN informed the surveyor that he always changed the resident's inner cannula and he knew that it was the same inner cannula even though he was not aware of the size of the inner cannula. He further stated that it was the Respiratory Therapist who provided the supplies for trach care of the resident that included the inner cannula. The surveyor asked the LPN, as a standard of practice, if should there be an order for what size to use for the resident's inner cannula. The LPN had no response. On 10/11/23 at 11:34 AM, the surveyor immediately interviewed the [NAME] President of Clinical Services (VPoCS) regarding the inner cannula order and what should be included. The VPoCS informed the surveyor in the presence of another surveyor that there should be an order for the size of the cannula. This time the surveyor notified the VPoCS of the above findings. The VPoCS further stated that she will talk to the LPN right now. On 10/11/23 at 12:25 PM, the Director of Nursing (DON) in the presence of the survey team confirmed to the surveyor that the order for inner cannula size should be part of the resident's order as a standard of practice. On 10/13/23 at 9:22 AM, the surveyor interviewed the LPN regarding the trach care observation on 10/11/23. The surveyor asked the LPN why he did not disinfect the table prior to putting the blue liner and treatment supplies? The LPN stated I could but since I put another sterile liner on top of the blue chux (excellent absorbency, comfort, and moisture control pad), he thinks that would be fine not to disinfect the table. The surveyor asked what the Infection Preventionist (IP) education provided to him and other staff about disinfecting frequently touched surfaces, does he include the table as frequently touched surfaces? The LPN stated that he did not consider the resident's table as frequently touched surface because the resident was a total care and did not get out of bed to be able to reach the table and touch it. The surveyor then asked the LPN how about the Certified Nursing Assistants (CNAs) who take care of the resident do they not use the table or touch the table when providing care, or how about visitors and other facility staff who enter the room? On that same date and time, the LPN acknowledged that the CNAs use at times the table for providing care, that the resident received visitors, and that the resident's responsible party visits almost every day. In addition, he indicated that other staff entered the room as well. The LPN also stated that he can not remember the education provided to him about disinfecting tables, maybe he had but can not remember because there was a lot of education provided already. Furthermore, the LPN acknowledged that the garbage receptacle of the resident inside the toilet room at that time was full. On 10/13/23 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), and VPoCS. The surveyor notified the facility management of the above findings. A review of the undated facility's Tracheostomy Care Policy that was provided by the AiT/RN/IPN included in the procedure guidelines to check the physician's order and to remove gloves and discard them into the appropriate receptacle. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and survey team could proceed with decision-making. NJAC 8:39-25.2(b),(c)4

Based on observation, interview, and record review, it was determined that the facility failed to: a) consistently monitor the resident's vital signs (VS) and dialysis access site and b) complete the Hemodialysis Communication Record (HCR) according to the facility's policy and standard of clinical practice. This deficient practice was observed for one (1) of one (1) resident reviewed. The deficient practice was evidenced by the following: On 10/06/23 at 9:48 AM, the surveyor observed that Resident #60 was not in their room. The Unit Clerk stated that the resident was at the dialysis center. On 10/10/23 11:48 AM, the surveyor observed the resident in bed asleep. The surveyor reviewed the hybrid medical records (a combination of paper, scanned, and computer generated record) of Resident #60. The admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life, dependence on renal dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions) and chronic combined systolic and diastolic heart failure (abnormalities of hemodynamic compression pump performance). A review of the Annual Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 9/05/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 8 out of 15 which indicated that the resident's cognitive status was moderately impaired. The Physician Order Set (POS), dated 8/11/2023 revealed an order that resident #60 dialysis days were on a Monday, Wednesday, and Friday (M, W, F). The dialysis days order was discontinued (d/c) on 10/08/2023. On 10/10/23 at 9:20 AM, the surveyor reviewed the Dialysis Communication Log (a binder on the unit which contains a resident's HCR forms) of Resident #60. The surveyor reviewed the communication book documents from 9/12/22 through and including 10/06/23. The facility provided the documentation that was scanned into the computer from the Dialysis log. (The resident was discharged from dialysis on 10/07/23 and started on hospice services on 10/09/23.) The facility also provided a manual progress notes as part of dialysis communication. There were missing information in the provided manually written progress notes as part of dialysis communication as follows: -signature of sending nurse to dialysis, communication of pre dialysis, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), pre dialysis weight, signs, and symptoms (s/s) of resident or implanted device, medications given, and body weight. -communications from the dialysis center VS, and post dialysis vitals, post dialysis weight, new orders for labs, medications, diet order, and signature of dialysis nurse. According to the provided Dialysis Communication Record Policy that was provided to the surveyor, the HCR forms must be utilized as communication record between the facility and the dialysis center. On 10/11/23 at 9:31 AM, the surveyor interviewed the Director of Nursing (DON). The DON confirmed that the communication between the facility and the dialysis center documentation should be completed upon the residents return to the facility. The DON also stated that the HCR form that was provided to the surveyor with the facilities Dialysis Communication Book policy was not being used for this resident since 9/22/22. The LNHA provided the surveyor with the facility policy titled Dialysis Communication Book Policy, updated 5/18/2022. During review, it revealed: Policy: It is the policy of this facility to maintain an ongoing communication between the dialysis center and [facility] regarding the resident's care and progress. Procedure: 2. The book will be initiated from the facility to include but not limited to the following: a. Residents name b. Vital signs prior to leaving. c. medication changes since last visit d. lab work and results since last visit e. any notes or comments 3. Upon return from dialysis treatment, the dialysis center will provide the following: a. weight at start/ending weight. b. fluid removed. c. Blood Pressure (BP) at start / ending BP. d. notes /comments: (i.e.) medications, labs, any unusual occurrences Attached to the facilities Communication Book Policy was a [facility] Dialysis Communication Record it was in grid format to include residents' name / room # /Extension of the nurses station / date / VS prior to leaving the facility/ Medications changes since last visit / lab work since last visit / any notes or comments. N.J.A.C. 8:39-2.7(a)

Based on interviews and review of pertinent facility documentation, it was determined that the facility allowed one (1) of one (1) Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days. This deficient practice was identified during new hire employee review. This deficient practice was evidenced by the following: On 10/18/23 at 9:16 AM, the surveyor reviewed the facility provided new hire employee files. The review included the following: The NA had a date of hire (doh) 5/11/23. The NA completed a Certified Nurses Aide (CNA) Program on 4/14/23. The NA passed the Skills Evaluation on 4/17/23. There was no documented evidence that the NA was licensed as a Certified Nursing Assistant. On 10/18/23 at 11:13 AM, the surveyor interviewed the Human Resources Director (HRD) and the Director of Nursing (DON) regarding the NA. The HRD stated that the NA was under the 190 days after her skills test. She added that when a NA came from the school that the school told us that the NA could work for 190 days after the skills test. The HRD stated that the NA was going to take her test to become a licensed CNA at the end of the month and that if the NA does not pass the test she would no longer be employed at the facility. She added that this would be the third time that she would be taking the test. The surveyor asked the HRD if she could provide the survey team the reference that she was using that indicated the timeframe was 190 and not 120 days. The surveyor reviewed the facility provided staffing schedule for that day (10/18/23) and the NA was listed on the schedule as working on the 100 wing unit with a CNA. The NA had provided direct resident care past the allotted 120 days. On 10/18/23 at 01:02 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Clinical Services (VPoCS) the concern that the NA was working after the specified 120 days. The surveyor asked if the VPoCS could locate a signed job description for the NA in the NA's employee file. The VPoCS confirmed that the NA did not have a signed job description in the employee's file. The surveyor requested the facility's job description for NA. A review of the facility provided NA job description included the following: Education & Qualifications .Be employed for less than 120 days and is currently enrolled in an approved nurse aide in long term care facilities training course and scheduled to complete the competency evaluation program (skills and written/oral examinations) within 120 days of employment. Or been employed for no more than 120 days, completed the required training and has been granted a conditional certificate by the Department while awaiting clearance from the criminal background. On 10/19/23 at 11:51 AM, in the presence of the survey team, DON, VPoCS, the LNHA stated that he had spoken to the HRD and that he thought it was a mistake from when COVID-19 was and the timeframes were different. The surveyor asked the LNHA if the NA should have been working after 120 days. The LNHA stated that the NA should not have been working. He added that the NA was offered another position until the NA obtained the license but that she declined and she was terminated. The facility did not provide a reference. The facility did not have a policy regarding NA's. N.J.A.C. 8:39-43.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for two (2) of 21 residents, (Resident #26, Resident #209) reviewed for dental care services, and was evidenced by the following: 1. On 10/18/23 at 12:17, PM the surveyor observed the resident had jagged teeth and brown discoloration when Resident #26 smiled. The resident stated that there was not any pain at this time. The surveyor asked the resident if he/she had seen a dentist or had been offered since the resident was admitted . The resident stated no, neither. On 10/16/23 at 11:46 AM, surveyor interviewed the Certified Nursing assistant (CNA). The CNA informed the surveyor that Resident #26 was a set-up for morning (AM) care including care for resident's teeth. She further stated that the resident had no complete set of teeth and with some broken teeth. On 10/10/23 at 9:45 AM, the surveyor reviewed Resident #26's electronic medical record (eMR). Resident #26's admission Record (AR; or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Type 2 Diabetes (the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high), moderate protein-calorie malnutrition (PCM; refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), need for assistance with personal care (the range of services put in place to support an individual with personal hygiene and toileting, along with dressing and maintaining your personal appearance). A review of the Order Summary Report (OSR), dated 8/25/23 through 10/10/23 revealed that there was not an order for a dental consultation. A review of the Nutrition Assessment, dated 8/29/23, #12, Teeth /Dentures, letter J, indicated broken or carious teeth? Was answered Yes. A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 8/30/2023, Section C Cognitive Patterns had Brief Interview for Mental Status (BIMS) score of five out of 15 with indicated that the resident's cognitive status was severely impaired. The CMDS also included the following: -section L, Oral/Dental status none of the above were present. -section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance, (helper does less than half the effort.) A review of the resident's personalized Care Plan (CP), dated 8/24/23, revealed a focus resident has an ADL self-care performance deficit related to (r/t) activity intolerance and impaired balance, date initiated 8/29/23, revision date of 10/07/2023. The individualized CP did not reflect a focus and interventions for current status of the resident's teeth. Further review of the resident's medical record showed that there was no documentation that the resident was offered and declined dental services. 2. On 10/10/23 at 10:20 AM, the surveyor reviewed Resident #209's closed medical record. Resident #209's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, unspecified protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), vitamin B deficiency, vitamin D deficiency. A review of the Nursing admission Assessment (NAA) dated 5/05/2022 revealed section #12 Teeth and Dentures. a) own teeth? No, b) partial upper (blank) c) partial lower (blank) d) full upper (blank) e) full lower (blank) f) has dentures but does not wear them (blank) Further review of the above NAA showed that assessment was incomplete and with multiple blanks in the areas of assessment. On 10/10/2023 a review of the OSR, dated 5/11/22 through 8/01/22 revealed that there was an order for a dental consult, initiated on 5/05/2022. A review of the Nutrition Assessment, dated 5/10/2022, revealed in the assessment and plan section; resident has been put on list to see the dentist as resident does not wear them due to poor fit. It also revealed #12 Dentures answered as #5 edentulous (lacking teeth). A review of a Social Worker progress note (PN), date 5/12/2022, labeled as 72-hour meeting revealed resident was on a diet of no added salt (NAS) pureed texture and thin liquids. It did not reflect the residents oral standing of having dentures but not using because of poor fit. A review of the CMDS, dated [DATE], revealed the resident had BIMS score of four out of 15 which reflected that the resident's cognitive status was severely impaired. The CMDS included the following: -section L, Oral/Dental status none of the above were present. -Section GG, Functional abilities, and Goals, Oral Hygiene admission performance was coded 3, meaning, Partial to moderate assistance The resident's personalized CP, dated 5/05/22, revealed a focus Resident does not wear dentures due to poor fit. Resident receives consistency modifications. Eats fairly with acceptable BMI (Body mass index is a value derived from the mass and height of a person) on admit. date initiated 5/18/22, revision date of 5/18/2022. Further review of the resident's medical record showed that there was no documentation that the resident was offered and declined dental services. On 10/19/23 at 11:36 AM, the surveyor interviewed the [NAME] President of Clinical Services (VPoCS) who stated, the MDS coordinator was unavailable and out on personal leave. The VPoCS stated that she could answer question regarding MDS coding. She further stated that the coding of the MDS is based on what is found in the record and Interdisciplinary Care Plan (IDCP) note. The IDCP should be a synopsis of the MDS. A review of the Visiting Dental Associates signed contract with facility, dated 5/05/2001, revealed under the facility agrees to section #3, --obtain a physician's order for dental care and consent from patients sponsor before instructing the consultant to render any and all dental services. The facility was unable to provide a policy regarding MDS. The VPoCS stated, they refer to the RAI (Resident Assessment Instrument/Minimum Data Set (RAI/MDS) is a comprehensive assessment and care planning process used by the nursing home industry since 1990 as a requirement for nursing home participation in the Medicare and Medicaid programs) manual by CMS guidelines. A review of the Dental Services policy, dated 01/2018, included that, to ensure a resident's diet is appropriate, optimal hydration and nutritional status are maintained and risk of choking is avoided. Speech therapy (via screen) and dietary (via alert) must be notified of the following circumstances: -Missing/ broken dentures -Recent extractions -Refusal to wear dentures -New dentures If a resident's dentures are lost or damaged, they must be referred to a dentist within three (3) days for services. If a referral does not occur within three (3) days, supportive documentation of what was done to ensure the resident could still eat and drink adequately and the extenuating circumstances behind the delay of services will be noted. A review of the policy Interdisciplinary Care Planning Protocol revealed. #3. Activities and Dietary provide an overview of their assessment of resident needs and problems. #8. Problems established by the team with the resident/ family input MUST be specific and individualized. NJAC 8:39-33.2(d)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently identified and implemented for one (1) of six (6) residents (Resident #8) reviewed for dietary preferences. This deficient practice was evidenced as follows: On 10/06/23 at 11:04 AM, the surveyor observed Resident #8 inside their room with a Certified Nursing Assistant providing care. On 10/11/23 at 9:04 AM, the surveyor observed the resident seated on a specialized air mattress, covered with a blanket, and with water on top of a tray table in front of the resident. The resident stated that the resident had a concern with food because the resident was not being provided with a menu in advance to choose what the resident likes to eat. The resident further stated that the resident was not provided with an option to choose their meals. On that same date and time, the surveyor asked the resident if the resident informed the facility management and if the Dietician was aware of the resident's concern with regard to the resident's preferences and menu options. The resident responded that the resident informed the Dietician and the Social Worker about the resident's concerns on a few occasions and during the care plan meeting. The resident further stated that he/she was told in the meeting which the resident can not remember when, and that there was nothing that they (facility management) could do about it because it was a corporate decision on what to order and what to bring in the facility. The surveyor then asked the resident if he/she did not like the food that was being served and, if was there an alternative that the resident could choose and ask for. The resident stated that yes there was an alternative but it was all the same every day. The resident did not have a copy of the select menu inside the room and no posted menu. In addition, the resident informed the surveyor that he/she used to receive a select menu to choose from weekly and that the resident was unable to remember when he/she stopped receiving the weekly select menu. The surveyor reviewed the resident's medical record as follows: The admission Record (or face sheet; and admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes mellitus without complications (a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels), neuromuscular dysfunction of bladder unspecified (lack bladder control due to a brain, spinal cord or nerve problem), and depression unspecified. The most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 8/09/23, Section C Cognitive Patterns had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of the Progress Notes (PN), Nutrition/Dietary Note a Quarterly Nutrition Note, dated 6/15/22 showed that the Dietitian documented that the resident had a copy of the menu with alternate in their room and utilized this to inform staff of desired alternate meals. On 10/16/23 at 10:55 AM, the surveyor interviewed the Dietitian in the presence of the survey team and the Licensed Nursing Home Administration (LNHA). The Dietitian informed the surveyor that select menus with alternate menus were being distributed weekly on a Sunday. The Dietitian further stated, that in addition to the select menu, there is always an available menu that the resident can choose from. On 10/16/23 at 11:16 AM, the two surveyors, LNHA and Dietitian went to the resident's room. The Dietitian asked the resident about the menu and if the resident got it on Sunday. The resident responded that he/she had not gotten the menu. The Dietitian asked the resident if the resident was sure about the menu, and the resident responded I will know if got one. The resident asked when the alternate has to be ordered and the Dietitian stated that it has to be ordered at least two hours prior. The Dietitian then asked the resident if it was okay for the facility management to go on to the resident's personal things and belongings to verify if the menu was provided to the resident. The Dietitian searched the resident's table in front of the resident while the resident was lying on the bed and the Dietitian did not find a copy of the menu. The LNHA searched the resident's drawers and did not find a copy of the menu. At this time, the Dietitian asked the resident if there were other concerns the resident wanted to tell the facility management, and the resident stated that she did not like the food that the resident was getting and that was why the resident wanted to have an option to choose from ahead of time and to get a copy of select menu and other menu options. On 10/16/23 at 12:05 PM, the survey team met with the [NAME] President of Clinical Services (VPoCS), Director of Nursing (DON), and LNHA, the surveyor notified the facility management of the above findings. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information. NJAC - 17.4(a)1,(c),(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) appropriate use of personal protective equipment (PPE) for two (2) of three (3) staff observed during meal observation and b) linen carts were maintained and cleaned for proper storage of clean supplies for four (4) out of five (5) linen carts according to facility policy and Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: According to the CDC, Appendix D - Linen and laundry management, last reviewed May 4, 2023, Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Each floor/ward should have a designated room for sorting and storing clean linens. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least once daily) cleaned with a neutral detergent and warm water solution. 1. On 10/06/23 at 10:39 AM, the surveyor toured the 100 wing. In rooms 101 through 116, both the surveyor and Licensed Practical Nurse #1 (LPN#1) observed linen cart #3 with a dirty cover. The surveyor asked LPN#1 about linen cart #3 and the LPN stated that linen cart #3 was considered a clean linen cart of linens, blankets, and gowns. The surveyor asked what was the dried brownish discoloration on the linen cart. The LPN stated that she did not know what the brownish discoloration was. The LPN further stated that it looked like something had spilled over the linen cart cover and extended inside the cart. On that same date and time, LPN#1 informed the surveyor that the linen cart should have been cleaned and she would ask the housekeeping to clean it and wash again everything that was inside the cart. On 10/06/23 at 11:00 AM, the surveyor observed linen cart #5 parked next to the Registered Nurse's (RN) treatment cart in the 100 wing in rooms 120 through 136. The RN informed the surveyor that linen cart #5 was being used by staff to get clean linens, blankets, and gowns. The RN confirmed that there was a brownish-discolored spill that dried up outside the linen cart cover. The RN further stated that it looked like it had been there for a couple of days and should have been cleaned. At that same time, both the surveyor and the RN observed linen cart #7 with the same unidentified brownish-colored spill over the linen cart cover. A few steps away was a clean linen cart #8. On 10/06/23 at 11:08 AM, both the surveyor and LPN#2 in 100 wing in the area from rooms 107 through 116 observed linen cart #4 parked in front of room [ROOM NUMBER] with brownish substances on the cover of the linen cart which was confirmed by LPN#2. LPN#2 stated that he did not know what was the brown substance and there was wear and tear on the back of the cover, and that it should have been cleaned. On 10/13/23 at 10:25 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility had no policy with regard to the environment and storage of linens and care of the linen carts. On 10/16/23 at 12:05 PM, the survey team met with the [NAME] President of Clinical Services (VPoCS), the Director of Nursing (DON), and LNHA. The LNHA stated that the Certified Nursing Assistant (CNA) was responsible for basic cleaning and thorough cleaning of the linen carts was the housekeeping. The surveyor asked who was responsible for following up and checking if the linen cart cleaning was done. The LNHA stated that it was the Unit Manager, DON, Housekeeping Director, and LNHA who made sure that it was clean. The surveyor asked if there was accountability for cleaning the linen carts and the LNHA stated that there was no checklist just spot-checking. The facility management acknowledged that the linen carts should have been cleaned. 2. On 10/13/23 at 12:21 PM, the surveyor observed the main dining with 19 residents, two Dietary Staff, and the Activity Director (AD). Dietary Aide #1 (DA#1) and DA#2 were both serving hot and cold drinks to the residents. Both DA #1 and #2 were wearing gloves while serving drinks. The surveyor asked the AD if it was appropriate for two staff to serve drinks with gloves, and the AD responded that it was okay because the activity team also uses gloves while serving during coffee time. The surveyor asked the AD who were the two staff with gloves in use while serving drinks. On 10/13/23 at 12:24 PM, both the surveyor and the DON went to the main dining room and observed DA#1 and DA#2 with gloves while serving drinks to the residents. The surveyor asked the DON if it was appropriate for the two Dietary staff with gloves while serving drinks in the dining area for lunch to the residents. The AD explained to the DON that they were doing the same thing (with gloves ) even the coffee time with recreation, the DON then stated I think it was okay because I have seen that too. On 10/13/23 at 12:27 PM, the surveyor observed five residents in the 200 wing small dining area during lunch. The surveyor interviewed a CNA who informed the surveyor that she assisted in serving lunch earlier. The surveyor asked if she wore gloves when serving lunch to the resident, and at this time LPN#3 joined the interview. Both the CNA and LPN#3 stated No we don't wear gloves, because of infection control and cross-contamination. On 10/13/23 at 12:32 PM, the surveyor asked the VPoCS in the presence of the survey team if it was appropriate for DA#1 and #2 to use gloves when serving drinks to the residents. The VPoCS stated no due to infection control. The surveyor notified the VPoCS of the above findings. On 10/16/23 at 12:05 PM, the survey team met with the VPoCS, and LNHA and were made aware of the above findings. A review of the facility's Bare Hand Contact with Food and Use of Plastic Gloves Policies and Procedures dated 5/10/23 that was provided by the VPoCS included that gloves hands are considered a food contact surface that can get contaminated or soiled. If used, single-use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. A review of the undated facility's Housekeeping Policy that was provided by the Administrator in Training/Registered Nurse/Infection Preventionist Nurse included that it is the policy of this facility to provide and maintain a safe, clean, orderly, and homelike environment for residents. Procedures: all equipment and environmental surfaces shall be clean to sight and touch. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information. NJAC 8:39-19.4 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) for three (3) of three (3) staff in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised [DATE]) included ii. The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated [DATE] and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated [DATE], effective date on [DATE] Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available. On [DATE] at 8:57 AM, the survey team entered the facility and met with the Receptionist who instructed the surveyors about the COVID-19 screening. Later on, an employee introduced herself to the survey team as the facility's Administrator in Training and a Registered Nurse (AiT/RN). The AiT/RN provided a business card that included her name with the title of Administrator. On [DATE] at 9:54 AM, the surveyor met with the AiT/RN and the Director of Nursing (DON). The facility management informed the surveyor that it was the full time Licensed Practical Nurse (LPN) who was the facility's designated Infection Preventionist Nurse who attended the QAPI meetings and was responsible for the facility's infection control. The surveyor asked for a copy of the LPN/IPN's resume, signed job description, and certificate of completion for infection control. A review of the license verification site in New Jersey (NJ) revealed that LPN/IPN had an expired license in another state and a pending reinstatement of LPN license in NJ. A review of the NJ license verification for Administrators in NJ showed that the AiT/RN had no current Licensed Nursing Home Administrator (LNHA) license in NJ. On [DATE] at 11:58 AM, the surveyor followed up with the DON the documents that were asked during the Entrance Conference which included the LPN/IPN's resume, signed job description, and certificate of completion for IP. The DON stated that she wanted to correct herself because the LPN/IPN had a clerical assistant job and not functioning as a nurse. The DON clarified that the LPN/IPN was not the IPN of the facility. The DON further stated that the facility's IPN was the AiT/RN (AiT/RN/IPN). The DON informed the surveyor that the LPN will eventually be the LPN/IPN once the NJ license is available. The surveyor asked for the employee files of the unlicensed LPN (previously identified by facility as LPN/IPN) and the AiT/RN/IPN. On that same date and time, the DON informed the surveyor that since the DON started working in the facility, it was the AiT/RN/IPN who was the designated IP (Infection Preventionist). The surveyor asked the DON for a timeline of who was the designated IP of the facility from [DATE] up to [DATE] and the DON stated that she would get back to the surveyor. The surveyor also asked the DON if the facility complied with the regulation with regard to IP requirements, and the DON responded that she had to get back to the surveyor. On [DATE] at 12:26 PM, the surveyor interviewed the Human Resource Director (HRD) who also claimed that she was the Staffing Coordinator of the facility. The HRD informed the surveyor that her responsibilities were the hiring process, payroll, central supply, receptionist, staff nursing, and helping other departments with guidance. At that same time, the surveyor asked the HRD who was the facility's IP, the HRD responded that it was the Corporate Registered Nurse (CRN) before, then the DON, and now it was the AiT/RN/IPN. The surveyor asked for CRN's employee files, and the HRD stated that she had to ask for them from corporate office. The HRD further stated that the unlicensed PN (uPN; who was also identified by the facility management as the LPN/IPN) was the assistant of the DON who does paperwork and keeps files together. On [DATE] at 12:59 PM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) in the presence of the survey team who informed the surveyor that she had been working in the facility for nine years as a full-time 7-3 shift nurse in 200 Wing, and at times works in 3-11 shift. LPN#1 stated that it was the uPN who was the designated IP of the facility. LPN#1 further stated that the uPN was responsible for infection control education, and competencies. LPN#1 informed the surveyor that a month ago in the office of the uPN, they (staff) had competency done. She further stated that the uPN was the facility's Assistant Director of Nursing (ADON) and that usually the ADON was also the IP. LPN#1 indicated that the uPN did not do patient care. On that same date and time, the surveyor asked LPN#1 if the AiT/RN/IPN was also the IP. LPN#1 stated that the AiT/RN/IPN was not the facility's designated IP and was not involved in infection control education and training. On [DATE] at 01:29 PM, the two surveyors interviewed the uPN. The uPN informed the surveyors that her job descriptions included as an assistant to the DON, doing audits, answering questions on the floor/unit/wing, a lot of copying for the DON, and helping the AiT/RN/IPN providing training in infection control. She further stated that she does not do patient care. The surveyor asked the uPN if she was the ADON and she responded Not technically. She further stated that the AiT/RN/IPN was the designated IP. A review of the signed Job description of AiT/RN/IPN for the job title of RN on [DATE] did not include the designated job title for IPN. A review of the provided List of Employees that were hired since the last recertification by the AiT/RN/IPN included the following information: uPN was hired on [DATE] as the ADON AiT/RN/IPN was hired on [DATE] as an Administrator DON was hired on [DATE] as a DON. CRN was hired on [DATE] as Regional Director of Nursing On [DATE] at 01:45 PM, the surveyors interviewed the AiT/RN/IPN. The AiT/RN/IPN informed the surveyors that her title was a Registered Nurse waiting for a reciprocity for Administrator. She further stated that she was a licensed Administrator in another state and that she was the acting IP of the facility. On that same date and time, the surveyor asked the AiT/RN/IPN, if she was not the Administrator of the facility, why she signed the offer letter of the uPN to be the facility's ADON on [DATE] wherein she signed her name with a title of Administrator. The AiT/RN/IPN stated that she did not know why the facility LNHA did not sign the offer letter. She further stated that she did not realized the offer letter that she signed had a title of an Administrator in her name. Furthermore, the surveyor asked the AiT/RN/IPN why the employee files that were provided to the surveyor showed that she (AiT/RN/IPN) had no signed job description for being an IP and that the signed job description in the file was for an RN. The AiT/RN/IPN stated that technically she was the designated IP of the facility and the CRN was covering IP prior to her (AiT/RN/IPN) assuming the position of an IP. On [DATE] at 9:22 AM, the surveyor interviewed LPN#2 regarding the IPN of the facility. LPN#2 informed the surveyor that it had been the practice of the facility that the ADON was the designated IP and at this time it was the uPN that was the designated IP. LPN#2 further stated that the uPN provided education, in-service, and competencies about infection control that included handwashing and the use of PPE (personal protective equipment). On that same date and time, the surveyor asked about the CRN and the AiT/RN/IPN as an IP. LPN#2 stated that to be honest, she was seldom here, not even once a week, the CRN probably did one or couple of education and it was always the ADON. LPN#2 also stated that the AiT/RN/IPN was not the designated IP because she was the Administrator. He further stated that AiT/RN does not deal with us nurses because she is the administrator. The surveyor then asked who was the LNHA, LPN#2 stated that he was also their Administrator. The surveyor then asked what the AiT/RN did, and LPN#2 responded that he did not know. On [DATE] at 9:37 AM, the surveyor interviewed the Wound Nurse (WN). The surveyor asked the WN what was the job responsibility of the AiT/RN at the facility and she stated that the AiT/RN was the Administrator of the facility. On [DATE] at 10:33 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and [NAME] President of Clinical Services (VPoCS). The surveyor notified the facility management of the above findings and concerns regarding the Infection Preventionist role from [DATE] through [DATE]. On [DATE] at 11:47 AM, the survey team met with the Volunteer Advocate (VA). According to the VA, the AiT/RN/IPN was the facility's Administrator, and the LNHA whom the surveyors were talking about was the facility's Regional LNHA. The VA stated that she discussed her concerns and questions with the AiT/RN/IPN because the AiT/RN/IPN was introduced to her as the facility's Administrator and that she had a business card with the AiT/RN/IPN as an Administrator. On [DATE] at 12:05 PM, the survey team met with the VPoCS, DON, and LNHA. The LNHA stated that the facility staff was used to having an ADON as the facility practice before as the IP, but since the facility's bed number, we are not required to have an ADON anymore. The LNHA further stated that the CRN fills in if there will be no IP which was why it was the CRN the IP of the facility from last year. The facility management acknowledged that the CRN was the designated IP from [DATE] until the AiT/RN/IPN came in [DATE]. On [DATE] at 9:34 AM, the surveyors interviewed the DON regarding staff education and who was responsible. The DON stated, I am, I do everything here. She further stated that the uPN tracks the in-service. The DON informed the surveyors that the uPN was the administrative assistant to the AiT/RN/IPN and DON. On that same date and time, the DON informed the surveyor that in [DATE] there was no ADON and it was the CRN covered as the IP. The DON stated that when there was a vacancy in the facility management, it was the corporate people who covered for the vacant position. She further stated that the CRN oriented the DON and the DON covered for an IP when the DON started in the facility until [DATE]. The DON also stated that from [DATE] through [DATE] it was the CRN who was the IP, and when the AiT/RN/IPN started on [DATE], the AiT/RN/IPN was the designated IP up to this time. A review of the Position Title: Infection Control Coordinator with a revision date of 6/01 that was provided by the DON included the following information: Department: Nursing Reports to: DON Position Summary: The Infection Control Coordinator assists and supports the translation of the nursing philosophy of the facility into nursing practice by participating in the planning, implementation, and evaluation of the nursing care delivery system. In addition, he/she provides residents and personnel with established guidelines to follow in the prevention and spread of contagious, infectious, or communicable diseases. Responsibilities/Accountabilities: Coordinates regular in-services on infection control practice at least quarterly; Assumes responsibility for detecting and reworking nosocomial infections on a systematic and current basis; Conducts rounds throughout the nursing facility to assure compliance with State, Federal, and [another name of the facility was entered]; a report on findings will be submitted to the DON and to the LNHA; Maintains active involvement in facility Quality Improvement Policy; Performs other duties as requested. Specific Educational/Vocational Requirements: The Infection Control Coordinator must be a graduate of an accredited School of Nursing with current registered nurse licensure by the NJ State Board of Nursing. Essential Job Functions: Location of Job Conditions: Outside 0%, Inside 100%. On [DATE] at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information. NJAC 8:39-19.1(b)

Based on interview and review of facility provided documents, it was determined that the facility failed to ensure that all Certified Nursing Assistant (CNA) received the mandated 12-hours annual competency training as required. This deficient practice was identified in five (5) of five (5) CNAs reviewed and was evidenced by the following: On 10/17/23 at 02:25 PM, the surveyor asked the Director of Nursing (DON) for the mandated education and annual competency training of five (5) randomly chosen CNA. On 10/18/23 at 9:16 AM, the Human Resource Director provided the requested mandatory education and annual competency training documents that included the following: CNA #1 was hired 01/02/1999; total of eight hours of education CNA #2 was hired 09/24/2021; total of eight hours of education CNA #3 was hired 04/01/2007; total of eight hours of education CNA #4 was hired 03/24/2016; total of 6.5 hours of education CAN #5 was hired 12/29/2022; total of eight hours of education Further review of the above documents showed that the five CNAs did not have mandated 12-hours annual competency training as required. On 10/18/23 at 11:30 AM, the Director of Nursing (DON) and the unlicensed Practical Nurse/Staff Educator informed the survey team that they (facility management) could not find documentation that the 12 hours of competencies were completed. In addition, the DON stated that she reviewed the in-service training book and that information documented on the Continuing Education Record did not meet the 12-hour requirements. NJAC 8:39-43.10

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident: a) on 6/23/23 that resulted in a nose fracture for Resident #27 and b) Resident 208. This deficient practice was identified for two (2) of six (6) residents reviewed for accident and was evidenced by the following: 1. On 10/10/23 at 11:44 AM, the surveyor observed Resident #27 sitting in their room and could not be interviewed as the resident spoke in [dialect redacted]. At that time, the activities/translator was at the activities area, attending to other [dialect redacted] speaking residents. On 10/10/23 at 12:47 PM, the surveyor observed the resident was not in the room and found the Certified Nursing Assistant (CNA) in the room instead. In the presence of the surveyor and Licensed Practical Nurse (LPN), the CNA stated that she was waiting for the resident to call her from the bathroom. At that time, the LPN stated that the resident was obsessed with their bowels. The door to the bathroom was closed. The LPN stated that the resident had a mechanical sit to stand lift (a mechanical medical device that promotes movement from seated to a standing position). The surveyor reviewed the medical record for Resident #27 The admission Record (AR; or facesheet; an admission summary) reflected that the resident had been admitted with diagnoses which included hemiplegia and hemiparesis (weakness or the inability to move on one side of the body) following cerebral brain infarction, affecting non-dominant side, type 2 diabetes mellitus without complications ((a disease of inadequate control of blood levels of glucose), unspecified dementia (impairment of memory loss and judgment), with unspecified severity without behavioral disturbance, and benign prostatic hyperplasia (enlarged prostate, symptoms include difficulty and sudden urge to urinate) without urinary tract symptoms and unspecified depressive disorder. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated 8/02/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) out of 15, which indicated the resident had a moderate impaired cognition and needed/wanted an interpreter to communicate with a doctor or healthcare staff. Further review of the qMDS developed by the facility to identify the resident's needs and implemented care interventions revealed that Resident #27 required extensive assistance (resident involved in activity; staff provide weight-bearing support) with two person assistance for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and toilet use (how the resident uses toilet room). The individualized Care Plan (CP) revealed a focus that included, Resident #27 had an actual fall on 6/23/23, related to impaired gait and mobility, paralysis, and weakness. The interventions included: A referral to an Ear Nose and Throat (ENT) Orthopedist. The resident was offered toileting before meals, at bedtime and as needed since the resident frequently attempted to get out of bed to go to the bathroom initiated on 6/23/23 and revised on 10/10/23. The resident frequently attempted to get out of bed to go to the bathroom and was on early up, the resident was offered toileting before meals, at bedtime and as needed initiated on 6/23/2023, and revised on: 10/10/2023. A review of the Progress Note for Resident #27, created on 6/23/23 at 10:49 AM, by the LPN, documented the following: Resident #27's roommate had called this nurse (LPN) and said the resident was on the floor, the resident was wheeling the chair and fell forward. The resident was on the floor, lying on their right side, bleeding from the nose, resident alert, saying get me up .walnut size bump over the right eyebrow, resident was able to move all extremities except the stroke arm, dark purple bruising over bridge of nose, updated daughter. The resident was sent out via 911 to the hospital for evaluation . A review of the Risk Management Report dated 6/23/23 at 11:46 AM, reflected the following: Incident description by the nurse: the resident's roommate called for help. The resident was on the floor [NAME] down on the right side, blood coming from nose, resident self-propelling forward and fell forward. Incident description by the resident: I fell frontways. Immediate action description: Resident was in a sitting position, nose and face cleansed. The bridge of the nose was purplish, and bleeding continued. The physician was informed. The resident was sent to the emergency room for possible nasal fracture. Level of pain was blank. Mental status was blank. Injuries report post incident: No injuries observed post incident Predisposing environmental factors was blank. Predisposing physiological factors was blank. Predisposing situation factors was blank. Witness was blank. Family member and physician were notified. Notes: On 6/26/23, team note review, the resident had not had a fall in greater than ten months, it appears the toileting schedule had worked. The incident although not witnessed the roommate with BIMS of 15 and the resident were able to state what had happened. A review of the Consultation note dated 7/21/23 indicated the report was a follow up for the resident's nasal fracture from a fall four weeks ago. The resident's septum was ok, and no significant deformity. No intervention was required. A review of the electronic Medical Record, Assessment tab, under Interdisciplinary Team Conference (group of health care professionals working together to set goals and make decisions) reflected the team met on the following dates: -1/31/23 -5/2/23 -8/7/23 There was no documented meeting after Resident #27's fall on 6/23/23 that resulted in a nose fracture. A review of a facility provided unsigned and undated document indicated the Resident fell on 6/29/23 in which the resident and sustained a fractured nose. The resident was sent to the hospital for evaluation and returned to the facility. The resident was in their room self-propelling, leaned forward and fell forward. Roommate did not see [Resident #27] fall. The resident preferred to stay in their room and do their own activity. Was seen by ENT 7/21/23 as follow up. Healing well no congestion, will heal on own. On 10/12/23 at 11:23 AM, during a meeting with the surveyors, Registered Nurse (RN)/ Infection Preventionist (IP), and the Director of Nursing (DON), the [NAME] President of Clinical Services (VPoCS) stated that incidents of falls and risk management were discussed during the morning meeting with the team. At that time, the DON explained their process for investigating incidents and accidents. The team reviewed the particulars of the incident and accidents with or without a witness statement from the resident. When an injury occurred from an incident or an accident the rehabilitation department (therapy) was involved to conduct a screening. A medical work up was conducted, and a member of the facility communicated with the medical doctor. The results of the screen and evaluation were documented on the notes section of the risk management report (RMR; also known as the Accident/Incident Report). The witness/staff statements were also uploaded into the electronic Medical Record (eMR). The DON stated the process could be a lot tighter. On 10/12/23 at 01:06 PM, in the presence of two surveyors, the DON stated there was not a need for a witness statement from the resident since she documented what she learned from the resident and the roommate. The DON could not explain while utilizing the RMR, the root cause of the fall, why the resident was leaning forward, where the resident was propelling to, and exactly where in the room the resident fell. At that time, the DON did not have a signed witness statement(s). The DON stated she would ask the LPN who documented on the PN to see what she recalled. On 10/13/23 at 11:28 AM, during a meeting with the surveyors, and the VPoCS, the DON stated the incident was not reported to the State Agency because the fall was witnessed by the roommate. At that time, the DON stated she obtained a signed statement from the nurse yesterday [after surveyor inquiry] about the fall that occurred on 6/23/23. The DON learned the resident fell on the right-side foot of the bed and the roommate with a BIMS of 15 (cognitively intact) informed the same nurse that the roommate saw the resident fall. The nurse had mistakenly entered the incorrect information and checked unwitnessed fall on the RMR. The DON was unable to explain from the statement and the report why the resident fell forward or where the resident was propelling to and the discrepancies from the investigation between the unwitnessed summary on the RMR and the witnessed signed statement provided that day. 2. The surveyor reviewed the medical records of Resident #208. A review of the the facility provided investigations showed incomplete investigations and missing witness statements for the following dates: -Un-witnessed fall 01/14/2022 -Un-witnessed fall 01/26/2022 -Un-witnessed fall 01/30/2022 -Un-witnessed fall 06/04/2022 -Bruise of unknown origin 06/18/2022 -Bruise of unknown origin 11/17/2022 -Un-witnessed fall 08/22/2022 -Un-witnessed fall 09/24/2022 -Injury of mouth from unknown origin 10/14/2022 -Un-witnessed fall 10/29/2022 -Un-witnessed fall 11/05/2022 -Un-witnessed fall 11/16/2022 -Un-witnessed fall 12/25/2022 -Un-witnessed fall 02/09/2023 Resident #208's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, chronic atrial fibrillation, unspecified lack of coordination, cognitive communication deficit. A review of Resident #208's comprehensive MDS (cMDS) dated [DATE], reflected that the resident had a BIMS score of four out of 15, which indicated the resident had a severely impaired cognition status. Further review of the cMDS developed by the facility to identify the resident's needs and implemented care interventions revealed that Resident #208 required extensive assistance (resident involved in activity; staff provide weight-bearing support) with two person assistance for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and toilet use (how the resident uses toilet room). The individualized CP revealed a focus that included, Resident #208, revealed resident was high risk for falls, initiated on 8/05/2021 and revised on 3/19/2023. A review of the undated facility policy provided Incident/Occurrence Investigation policy included the following: Policy Statement 1. All incidences of alleged abuse, mistreatment, or neglect of a resident by staff, other residents, visitors, etc. will be investigated. 4. The results of investigations that indicates that abuse, neglect, or mistreatment has occurred, or cannot be conclusively ruled out, will be reported to the DOH utilizing standard reporting procedures. Procedure: 1. Following an occurrence or notification or a complaint the RN Manager or RN Supervisor will submit to the DON - Nursing/Designee a copy of the Accident/Incident report [RMR] with staff statements. If Social Services is notified regarding a complaint or occurrence, the DON - Nursing/Designee and Administrator will be promptly advised. If event occurs on the weekend the RNM or RN Supervisor will initiate an investigation and will advise the Administrator on Duty that an that an investigation is underway. 5. Administrator, DON- Nursing/Designee will meet to review the summary of the investigation and make a decision if an event is reportable to the DOH. The Medical Director or Director of Social Services may be asked to participate in the decision making process depending on the type of event that has occurred. A file with an investigation summary will be kept in all occurrences or complaints that meet criteria for requiring an investigation. On 10/16/23 at 12:06 PM, during a meeting with the survey team, the VPoCS, the DON and LNHA informed the surveyors that all the staff were educated along with the Interdisciplinary team about the risk management documentation and the expectation was to thoroughly document the record, collect witness statements, and root cause analysis would be completed at the time of investigation. The LNHA stated that his lawyer did not want him to acknowledge the investigation was incomplete. At that time, the VPoCS stated we have identified the need to update the process as identified by the surveyors. The issue regarding thorough documentation was incorporated within the Quality Assurance Performance for Improvement (QAPI). Our process is for continued improvement. NJAC-8.39-4.1(a)5

Based on interviews, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner. This deficient practice was identified for three (3) of six (6) residents reviewed for physician visits, Residents #1, #8, and #18. This deficient practice was evidenced by the following: 1. On 10/17/23 at 8:51 AM, the surveyor and the Licensed Practical Nurse both observed Resident #1 lying on the bed. The surveyor reviewed Resident #1's medical records. The admission Record (AR; or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (or MS; resulting nerve damage disrupts communication between the brain and the body. MS causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), other muscle spasm, and quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). According to the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 9/20/23, Section C Cognitive Patterns had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which reflected that the resident's cognitive status was moderately impaired. A review of Resident #1's PN showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN revealed that there was no Physician Note after 6/30/23. 2. On 10/06/23 at 11:04 AM, the surveyor observed Resident #8 inside their room with a Certified Nursing Assistant providing care. The surveyor reviewed the resident's medical record as follows: The AR showed that the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis, type 2 diabetes mellitus without complications (a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels), neuromuscular dysfunction of bladder unspecified (lack bladder control due to a brain, spinal cord or nerve problem), and depression unspecified. The qMDS with an ARD of 8/09/23 had a BIMS score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) 3. On 10/06/23 at 10:37 AM, the surveyor observed Resident #18 seated in a geri chair (a specialized seating solution designed specifically for seniors and individuals with limited mobility) in their room eyes open, nonverbal, with a trach (an incision in the windpipe made to relieve an obstruction to breathing) and oxygen (O2) in use. The surveyor reviewed the medical records of Resident #18. The resident's AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to dependence on supplemental oxygen, gastrostomy (a tube inserted through the belly that brings nutrition directly to the stomach) status, hypoxic ischemic encephalopathy (a type of brain damage), dysphagia unspecified (a disorder characterized by difficulty in swallowing), chronic obstructive pulmonary disease unspecified (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), and anoxic brain damage not elsewhere classified (caused by a complete lack of oxygen to the brain, which results in the death of brain cells due to oxygen deprivation). The most recent qMDS with an ARD of 9/04/23 revealed that the resident had a BIMS score of 00 which indicated that the resident's cognitive status was severely impaired. A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS) and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x3 months. The VPoCS stated that it was an expectation that the face to face visit notes of the physician then will be every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, then the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyors that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months notes of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and entered the notes late. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy and that the facility followed the regulations. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. NJAC 8:39-23.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/10/12 at 01:45 PM, during an interview with the surveyors, the AiT/RN/IPN stated that she was waiting for her reciprocity from another state, and was the acting RN/IP (also the AiT/RN/IPN) since April of 2023. At that time, the RN/IP explained the process for the Pneumococcal (PNA) Vaccination for the facility to the surveyors. She stated that upon admission the resident should have been offered the PNA vaccine, if there was no history the resident should have been offered the PNA vaccine and administered if they wanted it. Ideally it should be re-offered quarterly or biennially. At that time, the RN/IP stated that the surveillance was conducted by running a report on the [electronic medical record (eMR)/brand redacted] as to who needed or wanted the PNA vaccine. At that time, the surveyors had asked the RN/IP if she had run the report. The IP stated that she did not recall but should have as part of the surveillance to ensure better resident outcomes. At that time, the RN/IP stated that the facility protocol was dependent on the physician's order and what was available at the pharmacy. The surveyor reviewed the medical records for Resident #13. The resident's AR reflected that Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) without behavioral disturbance, dysthymic disorder (chronic low level depression), chronic atrial fibrillation (a longstanding irregular heart rhythm), and vascular syndrome of brain in cerebrovascular diseases (condition that affects the blood vessels in the brain). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The MDS record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #13's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's Care Plan (CP) and Order Summary Report (OSR) did not indicate the resident was care planned or had an active order for immunizations. 3. The surveyor reviewed the medical record for Resident #95. The resident's AR reflected that Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia without behavioral disturbances, bipolar disorder (a mental health condition that causes unusual shifts in mood ranging from extreme high to lows), type 2 diabetes mellitus (high blood sugar), and chronic kidney disease, stage 2 ( the damage to the kidneys was still mild). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #95's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. 4. The surveyor reviewed the medical record for Resident #28. The resident's AR reflected that Resident #28 was admitted to the facility with diagnoses that included but were not limited to unspecified dementia with other behavioral disturbance, chronic diastolic (congestive) heart failure (heart does not pump enough blood to the body), hypertension (high blood pressure), cardiac pacemaker, and iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells). According to the qMDS dated [DATE] with a BIMS score of three (3) out of 15, indicating that the resident had a severely impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, indicated yes. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] A review of the Resident #28's eMR under Immunizations record did not indicate a record for Pneumococcal vaccination indicated the resident received Pneumovax/PPSV23 on 01/01/15. A review of the Resident #28's eMR under Immunizations record did not indicate a subsequent offer or declination of an offer for the PNA vaccine. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. A review of the Resident #28's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. 5. The surveyor reviewed the medical record for Resident #30. The resident's AR reflected that Resident #30 was admitted to the facility with diagnoses that included but were not limited to dementia without behavioral disturbances, bipolar disorder (a mental health condition that causes unusual shifts in mood ranging from extreme high to lows), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism). According to the qMDS dated [DATE] with a BIMS score of 12 out of 15, indicating that the resident had moderately impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was marked yes. The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #30's eMR under Immunizations record revealed a recorded Pneumovax Dose one (1) given on 3/29/2021. It did not indicate that the subsequent Pneumococcal vaccine was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. 6. The surveyor reviewed the medical record for Resident #85. The resident's AR reflected that Resident #85 was admitted to the facility with diagnoses that included but were not limited to depression (serious medical illness that negatively affects how you feel, the way you think and how you act.), anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and other schizoaffective disorder (relating to, characterized by, or exhibiting symptoms of both schizophrenia and a mood disorder (such as major depression or bipolar disorder). According to the comprehensive MDS dated [DATE] with a BIMS score of eight (8) out of 15, indicating that the resident had moderately impaired cognition. Further review of the qMDS section O. 0300 Pneumococcal Vaccine revealed the following: A. Resident's PNA vaccination up to date, was blank, [not assessed/no information]. B. If not received, state reason: 1. for not eligible, [blank] 2. offered and declined, [blank] 3. not offered, [blank] The MDS record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. The record did not reflect any actions taken for assessment of eligibility for the PNA vaccination, that it was offered and declined or that it was not offered. A review of the Resident #85's eMR under Immunizations record did not indicate a record for Pneumococcal Vaccination or that it was offered and declined. A review of the resident's CP and OSR did not indicate the resident was care planned or had an active order for immunizations. On 10/12/23 at 12:31 PM, during a follow-up interview with the surveyors, the RN/IP stated that the facility had a Group A Streptococcal (GAS) disease outbreak from 5/23 to 8/23 and the facility has been cleared since by the State Agency. At that time, the RN/IP stated that she had a working relationship with the Medical Director (MD) who was not comfortable to administer the PNA vaccines to the residents at that time of the GAS disease outbreak. The MD and the RN/IP did not document this discussion on the eMR of the residents who did not receive the PNA vaccines. The RN/IP also stated that se did not want to risk exposure to the resident by administering the PNA vaccine. The RN/IP did not provide documentation regarding the guidelines used for the decision to not offer the administration of the appropriate PNA vaccination based on the CDC's guidelines. At that same time, the RN/IP informed the surveyors that she followed the CDC guidelines for the PNA vaccination. Furthermore, the RN/IP stated that she would revisit the consent. If it was not uploaded into the eMR the resident or resident representative was not given the consent form. Moving forward we will revisit the offering of the PNA vaccine quarterly and update tracking of the consent, vaccinations. She further stated that the concern would be included into the Quality Assurance Performance for Improvement (QAPI). A review of the RN/IP surveillance report revealed Resident (#13, #95, and #85) were without consent forms. On 10/16/23 at 10:03 AM, during a meeting with the survey team, RN/IP, the DON, LNHA, and the VPoCS, the surveyor discussed the concern regarding the missing consent forms (proof of offer and/or declination), the surveillance of who needed PNA vaccination Resident (#13, #95, and #85), the surveillance of who needed the subsequent dose, Resident #28 and #30 and the concern regarding the facility policy. On 10/16/23 at 12:05 PM, the survey team met with the VPoCS, DON, and LNHA. The DON stated that we (facility management) went around and offered PNA vaccination to all residents and informed the family. The LNHA stated that a QAPI (Quality Assurance and Performance Improvement) plan and tracking was started after surveyor's inquiry. A review of the facility provided policy Pneumococcal Vaccination, dated 5/18/23 included the following: It is the policy of this facility to provide vaccination against Pneumococcal Disease for all residents who are [AGE] years of age or older in accordance with the Recommendations of the Advisory Committee for an Immunization Practices and the Centers for Disease Control, unless such vaccination is medically contraindicated or the resident has refused the vaccine. Under, procedure included, The the facility will provide the provisions of Pneumococcal vaccinations for all residents [AGE] years of age or older, who have not been previously immunized prior to admission unless the resident refuses offer of the vaccine, or the vaccine is medically contraindicated. Pneumococcal Vaccinations will be recorded in the resident medical record under immunizations, or it will be documented that the resident did not receive the vaccine due to medical contraindication or refusal. NJAC 8:39-19.4 (a) (i) Based on interviews, record review, and review of other pertinent provided facility documents, it was determined that the facility failed to: a) identify residents in need of, offer a Pneumococcal vaccine for four (4) of six (6) residents, (Residents #13, #82, #84, and 95), and offer the subsequent Pneumococcal vaccine for two (2) of six (6) residents, (Residents #28 and #30) and b) follow the facility Pneumococcal vaccine policy in accordance with the Advisory Committee on Immunization Practices and the CDC (Centers for Disease Control and Prevention) guidelines. This deficient practice was evidenced by the following: Reference: A review of the CDC guidelines for Pneumococcal vaccination included: Age 65 years or older who have: -Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive Pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23. 1. On 10/06/23 at 10:44 AM, the surveyor observed Resident #82 inside their room seated in a wheelchair while watching television. The resident stated that there was no concern with care. The surveyor reviewed the medical records of Resident #82. The admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), essential hypertension (occurs when abnormally high blood pressure that's not the result of a medical condition), type two diabetes mellitus without complication (It is characterized by high levels of sugar in the blood. Type 2 diabetes is also called type 2 diabetes mellitus and adult-onset diabetes), and adjustment disorder with mixed anxiety and depressed mood (Feeling both anxious and depressed). A review of Resident #82's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) 7/26/23, Section C Cognitive Patterns with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which reflected that the resident's cognitive status was moderately impaired. Section O Special Treatments, Procedures, and Programs included that the resident's pneumonia vaccine was not assessed and there was no information. The immunization record in the electronic medical record showed that the resident consent was refused. Further review of the medical records showed that there was no pneumonia vaccine consent documentation that the resident declined the vaccine. On 10/13/23 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified the facility management of the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to a.) store foods in a manner intended to prevent the spread of food borne illness and b.) maintain a clean storage for food and cooking utensils as evidenced by the following: On 10/06/23 at 9:44 AM, the surveyor toured the kitchen with the Food Service Director (FSD), observed the following: 1. In the freezer the surveyor found; one opened box of carrots without an open and a use by date. The interior bag holding the carrots was opened and unlabeled. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 2. In the freezer the surveyor found; one opened box of chopped celery. The exterior of the box was unlabeled. The interior bag was unlabeled, wide open to the elements with large ice crystals. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. 3. In the freezer the surveyor found; one opened box of chicken tenders that was unlabeled. Inside the box was an interior bag of chicken tenders that was opened and unlabeled. Also, inside the chicken tender box was a bag labeled garlic bread. There was not a label or date on the garlic bread. The FSD stated, that the exterior of the box should be labeled with the open and used by date. He also stated, the interior bag once opened should be labeled and dated. Surveyor and FSD continued the kitchen tour, and the surveyor observed the following: 1. The tilt skillet was observed to have white slimy substance covering most of the surface area. The FSD stated, it had not been used since he was hired a week prior. The surveyor asked the FSD to wipe it with a paper towel. The sediment was removable with a dry paper towel indicating it had not been cleaned after previous use. 2. Convection oven: was covered with thick baked on brown streaks and sediment. FSD acknowledged it was not cleaned. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. 3. The oven/stovetop range catch tray was covered with sediment, burnt on food and white congealed substance. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. 4. Microwave: the interior was not clean with sediment on all the walls, door and top. The FSD did not have a cleaning schedule in place and was unable to provide an accountability chart for staff. 5. Toaster crumb tray was not clean and had thick built-up sediment that was burnt on. The FSD did not have a cleaning schedule in place and was unable to provide an accountability chart for staff. 6. Utility refrigerator gasket seals were covered with black discoloration that was filled with sediment within the ridges of the seal. The FSD stated, it should be cleaned daily but did not know when the tray was last cleaned and was unable to provide an accountability chart for staff. On 10/10/23 at 9:40 AM, the surveyor toured the kitchen for second time with the FSD. Surveyor observed in the walk-in freezer an opened box of minute steaks, the box was dated 9/27. The inside bag was wide open, not dated, and the meat was exposed. The FSD had no response to why the meat was not sealed and open to the elements. The FSD was unsure of what the date of 9/27 meant, (i.e., received, opened, or expired). He did state, I was in the freezer all weekend. A review of the facility's Food Storage Procedure, undated, given to surveyor by LNHA on 10/13 at 10:12 AM included the following: 1. Food services, or other designated staff, will maintain clean food storage areas at all times. 5. All foods stored in the refrigerator or freezer will be covered, labeled, and dated . 8. Uncooked and raw animal products and fish will be stored separately and below fruits, vegetables and other ready to eat foods. A review of the policy Labeling and Dating Procedure in the Dietary Department review date 4/17/2023, included the following: Procedure: 1. Food items, as appropriate, will be labeled and dated by dietary staff using the facility labeling system, and the Food Service Director / designee will oversee labeling and dining. Label System Process: 1. Received Date 2. Pulled Date 3. Opened date; a) Food items will be labeled with an open date once the individual item is opened for use. A review of the Food Service Manager Position Summary dated revised 6/01, revealed: 2. Adheres to all the sanitary regulations governing handling and serving of food. 5. Develops, revises, and adapts work techniques and methods for more efficient operation of unit and for training employees. On 10/13/23 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator, Director Of Nursing, Administrator in Training/Registered Nurse/Infection Prevetionist Nurse, and [NAME] President of Clinical Services, and the facility management were made aware of the above findings and concerns. NJAC 8:39-17.2(g)

Based on observations, interviews, review of medical records, and review of facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure: a) accurate documentation of the needed information in the Nurse Staffing Report, b) minimum State staffing requirements were met for 14 of 14 day shifts and on 3 of 14 overnight shifts reviewed, c) physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes (PN) at least once every sixty days in a timely manner, d) that nurse aides received the minimum required number of in-service hours, and e) LNHA and Medical Director attended the QAPI (Quality Assurance and Performance Improvement) meeting routinely necessary to provide for the needs of residents. This failure had the potential to affect all 105 residents who currently live in the facility. The evidence was as follows: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, 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. On 10/06/23 at 9:54 AM, the survey team met with the Administrator in Training/Registered Nurse (AiT/RN) and the Director of Nursing (DON) during the Entrance Conference. The facility management confirmed that the Licensed Nursing Home Administrator (LNHA) will be coming in later and will proceed with the Entrance Conference meeting without the LNHA. On that same date and time, the surveyor provided a copy of a blank Nurse Staffing Report to the facility management to be used to fill out information for the weeks of 10/17/23-10/23/23, 10/24/23-10/30/23, 01/01/23-01/07/23, and 12/25/2022-01/07/2023. The surveyor also notified the facility management to submit the Nurse Staffing Report as soon as possible to the surveyor and to send it via email in order for the NJ Department of Health to run the provided reports to determine compliance with NJ mandated staffing law. On 10/11/23 at 9:51 AM, the survey team met with DON and the LNHA. The surveyor notified the facility management of concerns regarding the requested documents that were asked by the surveyor during the Entrance Conference on 10/06/23. The surveyor mentioned that the requested documents were asked also yesterday (10/10/23) and followed up by the surveyor to the DON, AiT/RN which included the Nurse Staffing Report. On 10/12/23 at 8:33 AM, the surveyor reviewed the provided Nurse Staffing Report via email (scanned documents) and showed that on the week of 01/01/23-01/07/23, the LNHA who signed the Nurse Staffing Report did not include the census on each day. The surveyor immediately notified the LNHA to review the submitted document and advised them to follow the directions on how to accurately fill out the form. On 10/19/23 at 9:08 AM, the surveyor in the presence of the survey team notified the DON of the concern regarding the submitted revised Nurse Staffing Report because there were discrepancies in the previously submitted reports (included NAs and TNAs) and new reports (did not include the previously counted NAs and TNAs), the missing census on 01/01/23-01/07/23, and multiple non-legible numbers. The surveyor notified the DON that the facility had to follow the correct and accurate way of submitting the Nurse Staffing Report and that the TNAs (temporary nursing assistants) and the NAs (non-certified nursing assistants) must not be counted as CNAs. On 10/19/23 at 9:26 AM, the surveyor in the presence of the survey team notified the LNHA of the above concerns regarding the submitted Nurse Staffing Report. The LNHA stated that he thought that during the time of the pandemic, the TNAs and CNAs could be counted as CNAs which was why the facility added them to the CNAs ratio. The surveyor referred the LNHA again to the website NJ Portal where the instructions and how to properly submit an accurate report. The LNHA stated that it was fine and that he would just check and revise the submitted forms. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN (also the Infection Preventionist Nurse of the facility according to the LNHA and DON), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified of the above findings and concerns. On 10/19/23 at 01:32 PM, the Human Resource Director (HRD) submitted via email the revised Nurse Staffing Report that was signed by the LNHA. 2. As per the Nurse Staffing Report completed by the facility for the two (2) weeks of staffing prior to survey from 9/17/2023 to 9/30/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 3 of 14 overnight shifts as follows: -09-17-23 had 7 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/18/23 had 8 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/19/23 had 7 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/20/23 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs. -09/20/23 had 6 total staff for 101 residents on the overnight shift, required at least 7 total staff. -09/21/23 had 9 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/22/23 had 10 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/23/23 had 9 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/24/23 had 8 CNAs for 100 residents on the day shift, required at least 12 CNAs. -09/25/23 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/26/23 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/26/23 had 7 total staff for 107 residents on the overnight shift, required at least 8 total staff. -09/27/23 had 11 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/28/23 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -09/29/23 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -09/30/23 had 9 CNAs for 106 residents on the day shift, required at least 13 CNAs. -09/30/23 had 7 total staff for 106 residents on the overnight shift, required at least 8 total staff. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), DON, and VPoCS. The LNHA acknowledged that there was a concern with short staffing. On 10/18/23 at 9:54 AM, the surveyor interviewed the Staffing Coordinator (SC) regarding staffing. The SC acknowledged that the facility was aware of the number of CNAs required but did not always have the required number of CNAs. 3. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN of Resident #1 revealed that there was no Physician Note after 6/30/23. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the LNHA, AiT/RN/IPN, DON, VPoCS and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x 3 months. The VPoCS stated that it was an expectation that the MD visits and notes then every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyors that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months note of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and entered the notes late. On that same date and time, the surveyor asked the LNHA if he was aware that the MD did not have PN documented in the timely manner, and the LNHA stated that now he knew. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy and that the facility followed the regulations. 4. The surveyor reviewed five (5) randomly chosen nurse aides' for their mandatory in services and showed the following information: CNA #1 was hired 01/02/1999 CNA #2 was hired 09/24/2021 CNA #3 was hired 04/01/2007 CNA #4 was hired 03/24/2016 CAN #5 was hired 12/29/2022 The facility could not provide the in services completed from the CNAs' hiring date to their anniversary date for CNAs#1, #2, #3, #4, and #5. On 10/18/23 at 11:30 AM, the DON and the unlicensed Practical Nurse Staff Educator informed the team that they (facility management) could not find documentation that the 12 hours of competencies were completed. In addition, the DON stated that she reviewed the in-service training book and that information documented on the Continuing Education Record did not meet the 12-hour requirements. 5. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON during the Entrance Conference. The facility management confirmed that the LNHA will be coming in later time and will proceed with the Entrance Conference meeting without the LNHA. At this time, the surveyor asked for a copy of the last three quarters' QAPI sign-in sheets, policy, and procedure. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated 4/20/23=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated 8/08/23=MD and LNHA did not attend the meeting QAPI dated 9/26/23=LNHA did not attend the meeting A review of the QAPI Program Plan that was provided by the AiT/RN/IPN revealed that the QAPI Plan was adopted on 11/01/19 and signed by the previous LNHA, MD, previous DON, previous ADON/IPN, and QAPI Coordinator that included the following: Governance & Leadership: The Administration assures the QAPI plan is reviewed on an annual basis by the QAPI team and approved by the governing body .The facility QAA Committee meets a minimum of quarterly and functions under the direction of the QAPI team. The QAPI team monitors data monthly from QAA findings and identifies areas for improvement to assure the achievement of the highest level of quality throughout the organization. QAPI Framework: The Administrator, DON, Infection Control and Prevention Officer, medical director, and three additional staff from the QAPI team. The QAPI coordinator is responsible for identifying projects, planning meetings, and document activities. Responsibility and Accountability: The administrator and/or QAPI coordinator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our organization. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and VPoCS. The surveyor asked the LNHA if he was aware of the missing physician's visit notes, and the LNHA stated that he was not aware not until the surveyor's inquiry. The surveyor also asked the LNHA if he was aware that the MD was not also present during the last three quarters' QAPI meeting, the LNHA stated I am very aware now. On that same date and time, the LNHA confirmed that they (the facility) knew now that the governing body should be in the QAPI meeting as well. The LNHA acknowledged that the governing body was not present in the QAPI meeting. A review of the Administrator's signed job description included the following: Position Summary: The Administrator is responsible for planning and is accountable for all activities and departments of the facility subject to rules and regulations promulgated by government agencies to ensure proper healthcare services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. Responsibilities/Accountabilities: Meet with licensing authorities as required and accompany them throughout any survey of the facility; superintend physical operation of the facility; oversee and guide department managers in the development and use of departmental policies and procedures; conduct committee meetings such as Quality Assurance, Infection Control, Pharmaceutical Services, and Safety Committee. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. NJAC 8:39-23.2(d); NJAC 8:39-25.2(a)(b); NJAC 8:39-27.1(a); NJAC 8:39-33.1(a)(b)

Based on the interview, record review, and review of other pertinent facility documentation it was determined that the facility Medical Director (MD) failed to provide clinical oversight and guidance regarding resident care policies and procedures that affect resident care, medical care, and resident quality of life related to a) required physician visits and notes, b) attends mandatory quarterly QAPI (Quality Assurance and Performance Improvement) meetings, and c) minimum State staffing requirements were met. This failure had the potential to affect all 105 residents who currently live in the facility. This deficient practice was evidenced by the following: 1. A review of Resident #1's Progress Notes (PN) showed that the Physician Note's most recent documentation was a late entry on 7/23/23 for a date of service of 6/30/23. The following were other Physician Notes documented in the PN: 4/20/23 For date of 3/01/23 (late entry on 4/20/23) For date of 01/06/23 (late entry on 01/31/23) For date of 11/16/22 (late entry on 12/23/22) For date of 9/22/22 (late entry on 10/25/22) Further review of the above PN of Resident #1 revealed that there was no Physician Note after 6/30/23. A review of Resident #8's PN showed that the most recent documented Physician Note was on 9/08/23. The following were other Physician Notes documented in the PN: 6/27/23 5/11/23 For date of 4/03/23 (late entry on 4/13/23) For 02/01/23 (late entry on 02/06/23) 01/20/23 For 01/04/23 (late entry on 01/14/23) For 12/13/22 (late entry on 12/15/22) A review of Resident #18's PN showed that the most recent documented Physician Note was for 7/28/23 as a late entry on 8/14/23. The following were other Physician Notes documented in the PN: For 6/02/23 (late entry on 6/03/23) For 4/26/23 (late entry on 4/28/23) For 3/01/23 (late entry on 3/28/23) For 01/03/23 (late entry on 02/10/23) For 10/19/22 (late entry on 11/08/22) On 10/17/23 at 12:51 PM, the survey team met with the Licensed Nursing Home (LNHA), Administrator in Training/Registered Nurse/Infection Preventionist Nurse (AiT/RN/IPN), Director of Nursing (DON), [NAME] President of Clinical Services (VPoCS) and were notified of the above findings. At that same time, the surveyor asked the facility management about the facility's policy and practice regarding physician visits. The DON informed the surveyors that the physician visits should be within 48-72 hours upon admission, the following month, monthly x 3 months. The VPoCS then stated that it was an expectation that there would be a face-to-face visit and notes every two months minimally if there is a Nurse Practitioner (NP). Then the surveyor asked the facility management if the facility had an NP, then the DON and the LNHA stated that the facility did not have an NP. The VPoCS then stated that it would be monthly physician visits and notes at least because there was no NP in the building. The facility management informed the surveyors that the resident's doctor was also the facility's Medical Director (MD), who also takes care of all residents in the facility. On 10/17/23 at 01:48 PM, the surveyor interviewed the MD in the presence of the survey team. The MD informed the surveyor that she started working at the facility in 2005 and she probably has 99% of residents in her care, that I come in every day, and this was her main facility. The MD stated Sometimes it's my fault I'm behind, with notes. She further stated that she does see all residents and addresses the problem. The MD acknowledged that she missed some notes. On 10/19/23 at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and the VPoCS. The VPoCS informed the surveyor that the MD was educated regarding the missing documentation of the physician. The VPoCS stated that the facility complied with the every two months notes of the MD. The surveyor notified again the facility of the above missing notes. At this time, the AiT/RN/IPN reviewed the electronic medical records for the physician's PN and confirmed that there were missing notes and that the physician documented PN and the PN were entered late. The facility management acknowledged that the facility did not comply with the required visit notes. At this time, the surveyor asked for the facility's policy and procedure with regard to physician visits and notes. The VPoCS stated that the facility did not have a policy with regard to physician visits. The VPoCS further stated that instead they (facility management) follows the regulations as guidance about physician visits. A review of the provided typewritten responses for the concerns that were discussed on 10/17/23 that were provided by the LNHA included that the MD Visits missing in documentation were acknowledged by the MD and that the facility had no MD Visit policy. 2. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON during the Entrance Conference. The surveyor asked for a copy of the last three quarters' QAPI sign-in sheets, policy, and procedure. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated 4/20/23=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated 8/08/23=MD and LNHA did not attend the meeting QAPI dated 9/26/23=LNHA did not attend the meeting On 10/17/23 at 01:48 PM, the surveyor interviewed the MD in the presence of the survey team. The surveyor asked the MD if she attended quarterly meetings in the facility, and the MD stated If I'm available I attend the meeting. The surveyor then asked the MD if she was not able to attend if she sent someone to represent her in the meeting, and the MD responded that she did not send someone to represent her in the quarterly QAPI meeting. On that same date and time, the surveyor asked the MD who was in charge of Infection Control in the facility and who attended the QAPI that reports for Infection Control. The MD stated that I think usually ADON is in charge, of the Infection Control and who attended the QAPI meeting. The MD further stated that at this moment she was not sure who was Infection Preventionist of the facility was. At this time, the surveyor asked the MD who discussed vaccinations in the QAPI meeting, and the MD responded Frankly I don't remember who reported it. The MD stated that she would go to the facility tomorrow to verify the QAPI sign-in sheets. On 10/18/23 at 10:37 AM, the survey team met with the MD. The MD verified the sign-in sheets for QAPI in the presence of the survey team and the MD confirmed that her signature was on the 9/26/23 QAPI meeting and not on 4/20/23 and the 8/08/23 QAPI sign-in sheets. The surveyor asked the doctor if she knew why she was not present on the dates of 4/20/23 and 8/03/23 and the doctor had no response. On that same date and time, the surveyor asked the MD how often the QAPI meetings were and what was the expectation with regard to her attendance. The MD stated that when the AiT/RN/IPN came in as the new administrator in April 2023, the big classic quarterly meetings were changed to more frequent meetings because there was so much stuff to go over and things had changed with the meeting. The MD further stated that she was not sure how and when the frequent meeting. She further stated that the quarterly QAPI meeting used to be a set date one Thursday in certain month not sure how it was set up the date. The MD informed the surveyors that the facility was working toward arranging the set schedule for QAPI meetings. At this time, the surveyor asked the MD if the AiT/RN/IPN was the administrator who was the LNHA. The MD stated that the LNHA whom the surveyor was referring to was the Regional LNHA. The MD further stated that the LNHA whom the survey team was referring to was not at the facility every day and the AiT/RN/IPN was the one who was at the facility every day. 3. On 10/06/23 at 9:54 AM, the survey team met with the AiT/RN/IPN and the DON. The facility management confirmed that the census (counts all residents in a facility) was 105 plus one bed hold. On 10/11/23 at 9:10 AM, the surveyor interviewed Certified Nursing Assistant #1 (CNA#1) who informed the surveyor that he's been working at the facility as a regular floater for the 7-3 shift and at times at 3-11 shift with no regular wing assignment, been at the facility for 10 years. Then CNA#2 joined the interview and both stated they were aware of the NJ (New Jersey) mandated staffing law of a 1:8 ratio (one CNA to eight residents). Both CNAs informed the surveyor that the mandated staff-to-resident ratio was not always being followed. At this time, CNA#1 informed the surveyor that he had 10 residents on his assignment today at 100 wing. CNA#1 stated that the usual ratio in the 7-3 shift was around nine to ten residents per CNA. He further stated that on a worse day with calls out can reach up to 11 per piece per CNA. Furthermore, the surveyor asked both CNAs if they were able to finish their assignments, and CNA#2 stated that they still take care of the resident but it takes time for them to finish their assignments. The surveyor asked the CNAs if they notified their management about their concerns with staffing and CNA#1 stated that they (facility management) were aware. The surveyor then asked CNAs what was the facility management responded to their concern, CNA#2 stated that the facility management told them that they were doing something about it but they did not know what was the plan. A review of the 100 Wing 7-3 shift Assignments that were provided by the AiT/RN/IPN for date 10/06/23 showed the following: Census: 46 residents Nurses: Licensed Practical Nurse #1 (LPN#1), LPN#2 CNAs: CNA#3 with nine (9) residents, CNA#4 with nine residents, CNA#5 with nine residents, CNA#6 with 10 residents, CNA#7 with nine residents A review of the 100 Wing 7-3 shift Assignments that were provided by the LNHA for date 10/11/23 showed the following: Census: 47 residents CNAs: CNA#3 with nine residents, CNA#4 with nine residents, CNA#6 with 10 residents, CNA#2 with nine residents, CNA#1 with 10 residents Further review of the above 10/06/23 and 10/11/23 assignments revealed that the NJ mandated law ratio for 1:8 was not followed. On 10/17/23 at 12:51 PM, the survey team met with the LNHA, AiT/RN/IPN, DON, and VPoCS. The LNHA acknowledged that there was a concern with short staffing. On 10/18/23 at 9:54 AM the surveyor interviewed the Staffing Coordinator (SC) regarding staffing. The SC acknowledged that the facility was aware of the number of CNAs required but did not always have the required number of CNAs. On 10/18/23 at 10:37 AM, the survey team met with the MD. The surveyor asked the MD if staffing issues were discussed during the QAPI meeting. The MD stated I am not sure about staffing being discussed in the QAPI. Then the MD asked the surveyor if there was an issue with staffing at the facility. The MD also asked the survey team if the facility management notified the surveyor that there was a problem with staffing. At this time, the surveyor notified the MD of the above findings, and that the facility management acknowledged the concern. On 10/18/23 at 11:03 AM, the surveyor asked the DON in the presence of the survey team for a copy of the MD policy and signed job description of the MD and she stated that she would get back to the surveyor. On the same date and time, the DON informed the surveyor that the MD was not an employee of the facility and was only a contracted service MD which was why the facility had no signed job description and policy. A review of the facility's Medical Director Agreement that was provided by the LNHA showed in Section II Obligations of Medical Director 2.3 (a) To attend and participate in quarterly Quality Improvement Committee, Infection Control, Pharmacy, and Therapeutics meetings as scheduled. This was signed by the previous Administrator. On 10/19/23 at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information and that the survey team could proceed with decision making. N.J.A.C 8:39-23.1, 2, 3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documentation, the facility failed to have: a) the Medical Director (MD) present for two out of three Quality Assurance and Performance Improvement (QAPI) meetings, b) the Licensed Nursing Home Administrator (LNHA) present for three out of three QAPI meetings, and c) set QAPI meeting schedule. This failure had the potential to affect all 105 residents who currently live in the facility. The deficient practice was evidenced by the following: On [DATE] at 8:57 AM, the survey team entered the facility and met with the Receptionist who instructed the surveyors to use the touchless thermometer attached to a wall to check the surveyors' temperature, log in the binder temperature, and answer the COVID-19 screening questions. Later on, an employee introduced herself to the survey team as the facility's Administrator in Training and a Registered Nurse (AiT/RN). The AiT/RN provided a business card that included her name with the title of Administrator. On [DATE] at 9:54 AM, the survey team met with the AiT/RN and the Director of Nursing (DON). The facility management confirmed that the census (counts all residents in a facility) was 105 plus one bed hold. The surveyor asked for a copy of the last three quarters' sign-in sheet for QAPI, policy, and procedure. The facility management informed the surveyor that it was the Licensed Practical Nurse (LPN) who was the facility's designated Infection Preventionist Nurse who attended the QAPI meeting and was responsible for the facility's infection control. The surveyor asked for a copy of the LPN/IPN's resume, signed job description, and certificate of completion for infection control. A review of the facility provided QAPI sign-in sheets showed the following information: QAPI 2023 1st Quarter dated [DATE]=MD and LNHA did not attend the meeting QAPI Q2 (2nd Quarter) dated [DATE]=MD and LNHA did not attend the meeting QAPI dated [DATE]=LNHA and LPN/IPN did not attend the meeting A review of the license verification site in New Jersey (NJ) revealed that LPN/IPN had an expired license in another state and a pending reinstatement of LPN license in NJ. A review of the NJ license verification for Administrators in NJ showed that the AiT/RN had no current LNHA license in NJ. On [DATE] at 11:58 AM, the surveyor followed up with the DON the documents that were asked during the Entrance Conference which included the LPN/IPN's resume, signed job description, and certificate of completion for IP. The DON stated that she wanted to correct the LPN/IPN had a clerical assistant job and not functioning as a nurse. The DON further stated that the facility's IPN was the AiT/RN (AiT/RN/IPN). The DON informed the surveyor that the LPN will eventually be the LPN/IPN once the NJ license is available. On [DATE] at 12:32 PM, the survey team met with the Director of Rehab/Occupational Therapist (DoR/OT). The surveyor asked the DoR/OT about the QAPI meetings. The DoR/OT informed the surveyors that he attended QAPI meetings. The DoR/OT was unable to state how often the QAPI meeting was, who attended the meetings, and how he knew the next QAPI meeting schedule. The DoR/OT stated to the surveyor that the surveyor should check the records. Later on, the DoR/OT stated that all department heads attend QAPI meetings. Then the surveyor asked who else besides the department heads attended the meeting and DoR/OT asked the surveyor to check the QAPI sheet. On [DATE] at 10:37 AM, the survey team met with the MD. The MD verified the sign-in sheets for QAPI in the presence of the survey team and the MD confirmed that her signature was on the [DATE] QAPI meeting and not on [DATE] and the [DATE] QAPI sign-in sheets. The surveyor asked the MD if she knew why she was not present on the dates of [DATE] and [DATE] and the doctor had no response. On that same date and time, the surveyor asked the MD how often the QAPI meetings were and what was the expectation with regard to her attendance. The MD stated that when the AiT/RN/IPN came in as the new administrator in [DATE], the big classic quarterly meetings were changed to more frequent meetings because there was so much stuff to go over and things had changed with the meeting. The MD further stated that she was not sure how and when the frequent meetings, used to be set date on Thursdays in the month not sure how it was set up the date. The MD informed the surveyors that the facility was working toward arranging the set schedule for QAPI meetings. On [DATE] at 9:39 AM, the surveyor met with the LNHA for a QAPI interview in the presence of the survey team. The surveyor asked the LNHA how often the QAPI meetings, and the LNHA responded that it was used to be quarterly then recently four months ago it was done monthly. He further stated that it was consistently quarterly every Thursday before, but the LNHA was unable to state when every Thursday. The LNHA was unable also to state when every month the scheduled QAPI meetings. The LNHA indicated that the QAPI meeting was being announced in the morning meeting when the next QAPI meeting, not written, communication of the schedule was verbal. The surveyor asked the LNHA if the MD attended morning meetings, and the LNHA stated No. The surveyor then asked the LNHA how will the MD know the schedule meetings for QAPI if the MD does not attend morning meetings, and the LNHA had no response. On that same date and time, the LNHA confirmed after checking the provided last three-quarters sign-in sheets for QAPI meetings, and LNHA stated that he was not in the meeting on [DATE], [DATE], and [DATE]. Furthermore, the surveyor asked the LNHA who the key person must be present during QAPI meetings, the LNHA stated that it was the DON, LNHA, and I am not 100% sure if the MD and maybe the Infection Preventionist. The surveyor notified the LNHA of the above concerns. On [DATE] at 10:49 AM, the survey team met with the LNHA, DON, AiT/RN/IPN, and VPoCS. The surveyor asked the LNHA if he was aware of the missing and late physician's visit notes, and the LNHA responded that not until the surveyor's inquiry. The surveyor also asked the LNHA if he was aware that the MD was not also present during the last three quarters' QAPI meeting, the LNHA stated I am very aware now. On that same date and time, the LNHA confirmed that they (the facility) knew now that the governing body should be in the QAPI meeting as well. The LNHA acknowledged that the governing body was not present in the QAPI meeting. A review of the QAPI Program Plan that was provided by the AiT/RN/IPN revealed that the QAPI Plan was adopted on [DATE] and signed by the previous LNHA, MD, previous DON, previous ADON/IPN, and QAPI Coordinator that included the following: Governance & Leadership: The Administration assures the QAPI plan is reviewed on an annual basis by the QAPI team and approved by the governing body .The facility QAA Committee meets a minimum of quarterly and functions under the direction of the QAPI team. The QAPI team monitors data monthly from QAA findings and identifies areas for improvement to assure the achievement of the highest level of quality throughout the organization. QAPI Framework: The Administrator, DON, Infection Control and Prevention Officer, medical director, and three additional staff from the QAPI team. The QAPI coordinator is responsible for identifying projects, planning meetings, and document activities. Responsibility and Accountability: The administrator and/or QAPI coordinator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our organization. On [DATE] at 12:55 PM, the survey team met with the LNHA, DON, and VPoCS and the facility management stated that there was no additional information. NJAC 8:39-33.1 (a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined the facility failed to ensure 1 (200 Hall) of 4 medication carts and 1 (100/200 Hall) of 2 treatment carts observed were locked when unattended to limit access to only authorized personnel. Findings included: On [DATE] at 3:26 PM, there was a treatment cart inside the nurses' station on the 200 Hall. The treatment cart had the locking mechanism sticking out, indicating the cart was unlocked. The nurses' station was a half-circle shape with a walkway through the station. There were no doors on either end of the nurses' station to prevent access to the treatment cart. Directly across from the nurses' station there were two medication carts parked against the dining room wall. The medication cart on the right had the locking mechanism sticking out, indicating the cart was unlocked. There were five residents in wheelchairs in the dining room. Licensed Practical Nurse (LPN) #3 was sitting at the nurses' station with her back towards the treatment cart. The following was observed on [DATE], after the initial observation at 3:26 PM: - At 3:30 PM, LPN #3 left the nurses' station, leaving the unlocked treatment and medication carts out of view. - At 3:33 PM, one staff member walked by the unlocked medication cart and a resident translator approached the nurses' station to review the assignment sheet for the hall. One resident in a wheelchair wheeled themselves to the dining room and passed the unlocked medication cart. - At 3:34 PM, LPN #3 returned to the nurses' station. When asked who was assigned the medication cart on the right, LPN #3 stated the cart was assigned to Registered Nurse (RN) #5. LPN #3 then walked to the medication cart on the left and did not acknowledge the unlocked medication cart to her right. LPN #3 then went to the supply room, located directly behind the nurses' station, and left the unlocked treatment and medication carts out of view. - At 3:36 PM, another staff member walked by the unlocked medication cart. - At 3:38 PM, LPN #3 left the supply room and went back to the medication cart on the left, still not acknowledging the unlocked medication cart to her right. At the same time, a resident using a walker walked by the unlocked medication and treatment carts. - At 3:44 PM, Certified Nursing Assistant (CNA) #4 walked by the unlocked treatment and medication carts. - From 3:26 PM to 3:44 PM, the door to the medication room behind the nurses' station had been shut. The door was solid and had no window. - At 3:46 PM, RN #5 came out of the medication room and went to the unlocked medication cart. The RN immediately locked the cart. During an interview at this time, RN #5 stated the medication cart should be locked at all times, but she was cleaning expired and discontinued medications out of the cart and that was why the cart was unlocked. On [DATE] at 3:56 PM, RN #5 was sitting at the nurses' station with her back turned towards the treatment cart that had been left unlocked since 3:26 PM. The surveyor brought RN #5's attention to the unlocked treatment cart. RN #5 stated she was responsible for the treatment cart and stated it should be locked at all times. The RN stated she was cleaning out all of the carts and that was why both the medication cart and treatment cart had been left unlocked. RN #5 stated while she was in the medication room, she did not have either cart in her view, since the door was shut. RN #5 opened the second drawer of the treatment cart. The drawer contents included scissors, wound treatment gel, ammonium lactate cream 12% (for dry, itchy skin), diclofenac sodium topical gel 1% (nonsteroidal anti-inflammatory cream), miconazole cream (antifungal cream), and numerous other types of treatments. During an interview on [DATE] at 10:33 AM, the Administrator stated the facility did not have a policy regarding medication storage. He stated the facility used the State Operations Manual (SOM) for their policy and guidance. During an interview on [DATE] at 12:25 PM, the Director of Nursing (DON) stated if a medication or treatment cart was left unattended, staff should ensure the carts were locked and the computer screen was shut down. During an interview on [DATE] at 12:44 PM, the Administrator stated if a medication or treatment cart was left unattended, staff should ensure the cart was locked. New Jersey Administrative Code § 8:39-29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility document review, and facility policy review, it was determined the facility failed to: - Ensure staff wore appropriate personal protective equipment (PPE) when transmission-based precautions (TBP) were required, - Ensure staff removed PPE (gloves) prior to exiting one resident room and entering another, and - Ensure linens were handled and transported in a manner to decrease the potential for the transmission of infection. This had the potential to affect all residents. Findings included: 1. Review of a facility policy titled, Precaution Procedure, reviewed on 05/18/2022, revealed under Contact Precautions, Staff PPE - Gowns, gloves, mask, goggles. The review further revealed under Droplet Precautions, All Staff PPE - Gown, gloves, mask (preferably N95 respirator) for employee and eye goggles. Review of the Resident COVID-19 Vaccination Log, revised 02/28/2023, indicated the resident in bed 133W was not vaccinated against COVID-19. Review of the List of Residents on TBP [transmission-based precautions], received from the Director of Nursing (DON) on 03/03/2023, revealed both residents in room [ROOM NUMBER] were on the list. The list indicated the room was on droplet isolation precautions for the resident in bed 133W. On 03/02/2023 at 3:16 PM, room [ROOM NUMBER] had a PPE bin located outside of the residents' room. The door to room [ROOM NUMBER] had a Contact Isolation sign and a Droplet Isolation sign on it. Occupational Therapist (OT) #2 was in room [ROOM NUMBER]'s bathroom and wore a surgical mask and gloves. OT #2 came out of the bathroom and Licensed Practical Nurse (LPN) #1 entered room [ROOM NUMBER] wearing a surgical mask and spoke to OT #2. LPN #1 then exited room [ROOM NUMBER]. During an interview at this time, LPN #1 stated he did not know why the resident was on TBP and would have to review the resident's chart. LPN #1 stated he should have worn gloves, a gown, and a mask before entering the room. He stated, There's no excuse for why he did not wear the required PPE. LPN #1 stated room [ROOM NUMBER] was a yellow zone, which meant staff should wear full PPE. During the interview with LPN #1, OT #2 removed their gloves, placed them in the trash, and exited the resident's room. During an interview on 03/02/2023 at 3:22 PM, OT #2 stated a resident in room [ROOM NUMBER] had diarrhea and that was why there were TBP signs on room [ROOM NUMBER]'s door. OT #2 stated she had gloves on while in the room and was in the bathroom to clean the toilet seat that had diarrhea on it. OT #2 stated she should have put a gown on before entering the room. During an interview on 03/03/2023 at 12:25 PM, the Director of Nursing (DON) stated residents that were newly admitted and were not vaccinated were assigned a yellow zone for ten days. The DON stated the yellow zone was to identify a resident on TBP. The DON stated in the yellow zone, staff were to wear an N95 respirator mask, gown, and gloves before entering a resident's room. The DON stated if there was a droplet isolation sign and a contact isolation sign, staff should wear a gown, gloves, a face shield or goggles, and an N95 respirator if the resident was not vaccinated. During an interview on 03/03/2023 at 12:02 PM, the Infection Preventionist (IP) stated if a newly admitted resident was not vaccinated, the resident went into a yellow zone and was on TBP for ten days. The IP stated staff going into a yellow zone had to wear a gown, N95 respirator, gloves, and goggles. The IP stated if the resident was on contact and droplet isolation, staff would wear blue disposable gowns, an N95 respirator, a face shield or goggles, and gloves. The IP stated a regular surgical mask and gloves were not appropriate PPE to wear if the resident was on droplet precautions and staff should have been wearing an N95 respirator. During an interview on 03/03/2023 at 12:44 PM, the Administrator stated if there was a contact isolation sign and a droplet isolation sign on a resident's door, facility staff should wear a gown, gloves, face shield, and an N95 respirator. 2. On 03/02/2023 at 3:36 PM, Certified Nursing Assistant (CNA) #4 was observed on the 200 Hall. The CNA retrieved a washcloth off the clean linen cart parked outside of room [ROOM NUMBER] and dropped the washcloth on the floor. CNA #4 picked the washcloth up off the floor and placed it back on the linen cart. On 03/02/2023 at 3:40 PM, CNA #4 was observed coming out of room [ROOM NUMBER] wearing gloves. The CNA grabbed two bed sheets off the linen cart. One of the sheets fell to the floor. CNA #4 kept one clean sheet in one hand and with the other hand retrieved the sheet from the floor. The CNA placed the clean sheet on top of the clean linen cart, entered room [ROOM NUMBER], and placed the sheet on a resident's bed. CNA #4 did not remove his gloves before exiting room [ROOM NUMBER] and entering room [ROOM NUMBER]. At 3:43 PM, CNA #4 exited room [ROOM NUMBER], wearing the same gloves. The CNA then removed the gloves in the hallway and disposed of them. During an interview on 03/02/2023 at 3:48 PM, CNA #4 stated he should have put the washcloth and the sheet that fell on the floor into the dirty linen bin and should not have used them. The CNA further stated he should have removed his gloves before exiting room [ROOM NUMBER], getting linens, and going into room [ROOM NUMBER]. During an interview on 03/03/2023 at 12:25 PM, the Director of Nursing (DON) stated if staff dropped clean linen on the floor, the linen should be put in the dirty linen container to be washed. The DON stated if staff wore gloves in a resident's room, they should remove the gloves before leaving the room and should not wear the gloves in the hall or go into another resident's room. During an interview on 03/03/2023 at 12:02 PM, the Infection Preventionist (IP) stated if staff dropped clean linen on the floor, they should not use the linen. The IP stated, You don't use linen that falls on the floor. It is a clear infection prevention violation. During an interview on 03/03/2023 8:51 AM, the Housekeeping and Laundry Supervisor stated if staff dropped clean linen on the floor, the linen should be put in the soiled linen bin and taken to the laundry room to be washed. During an interview on 03/03/2023 at 10:33 AM, the Administrator stated the facility did not have a policy regarding linen storage or transportation of linen. He stated the facility used the State Operations Manual (SOM) and the Centers for Disease Control and Prevention (CDC) as their policy and guidance. During an interview on 03/03/2023 at 12:44 PM, the Administrator stated if staff dropped clean linen on the floor, the staff should dispose of the linen in the dirty linen cart. The Administrator stated if staff wore gloves in a resident's room, the staff should remove the gloves before leaving the resident's room. New Jersey Administrative Code § 8:39-19.4(a)1-6 New Jersey Administrative Code § 8:39-27.2(j)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ157128, NJ157438, NJ16028, NJ160661 Based on interviews, medical records review, and review of other pertinent facility documentation on 1/19/2023, 1/20/2023, 1/23/2023, and 1/24/2023, it was determined that the facility failed to follow standards of clinical practice and failed to document the administration of treatments as ordered by the Physician for 2 of 17 residents (Resident #2 & #3). The facility also failed to follow its policy titled Medication Administration. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a Registered Professional Nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being and executing a medical regime as prescribed by a licensed or otherwise legally authorized Physician or Dentist. A review of Resident #2's Electronic Medical Records (EMRs) was as follows: 1. According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation and Malignant Neoplasm of Unspecified Par of Right Bronchus or Lung. According to the Minimum Data Set (MDS), an assessment tool dated 12/5/2022, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs). A review of Resident #2's Order Summary Report (OSR) revealed the following Physician Orders (POs): A&D Ointment (Vitamins A&D). Apply to right ear topically one time a day for Stage 1. Cleanse ear with normal saline, apply A&D, and cover O2 (oxygen) tubing with gauze daily; order date 12/01/2022. Bacitracin Ointment 500 UNIT/GM (gram). Apply to right thumb topically everyday shift for Skin Tear. Cleanse right thumb with normal saline; apply Bacitracin and a dry protective dressing daily, order date 12/01/2022. Bipap on at bedtime, off in am. Bipap 8cm (centimeters) H20 (water). Full face mask. Preset settings on [the] machine. Apply Mask and turn on machine @ (at) HS (bedtime) at bedtime and remove per schedule, order date 12/02/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to left ear topically one time a day for Stage II left ear. Cleanse ear with normal saline, apply ointment, and cover O2 (oxygen) tubing with gauze daily; order date 12/01/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to sacrum topically every day and evening shift for Unstageable Sacrum. Cleanse [the] area with normal saline and apply [the] cream to the surrounding area. Use with Silvadene order, order date 12/01/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to sacrum topically every day and evening shift for Unstageable Sacrum. Apply Calmoseptine to peri-wound after cleanse with NSS (normal saline solution), Medihoney to wound bed BID (twice a day), order date 12/11/2022. Foley Catheter Care q (every) shift and PRN (as needed) for wound healing, order date 12/01/2022. Medihoney Wound/Burn Dressing Gel (Wound Dressings). Apply to sacrum topically every day and evening shift for stage 2 pressure ulcer, order date 12/09/2022. Record Urinary Output for Amount, Color, Clarity, and Presence of Sediment every shift. Monitor for kinks in tubing and leakage and ensure drainage bag/leg bag is below the height of the bladder every shift, order date 12/01/2022. Silvadene Cream 1% (percent) (Silver sulfadiazine). Apply to Unstageable sacrum topically every day and evening shift for Unstageable sacrum. Cleanse area with normal saline, apply Silvadene cream to open areas, and cover with an abdominal pad (Surrounding skin Calmoseptine), order date 12/01/2022. Skin Prep Spray Miscellaneous (Ostomy Supplies). Apply to Right foot 5th toe topically one time a day for Stage 1. Cleanse right foot 5th toe daily with normal saline, apply skin prep, and place gauze between toes; order date 12/01/2022. A review of Resident #2's Treatment Administration Record (TAR) dated 12/1/2022-12/31/2022 revealed the above-aforementioned POs were not documented on the following dates: A&D Ointment (Vitamins A&D). Apply to right ear topically one time a day for Stage 1. Cleanse ear with normal saline, apply A&D, and cover O2 (oxygen) tubing with gauze daily on the day shift on 12/3/2022 and 12/14/2022. Bacitracin Ointment 500 UNIT/GM (gram). Apply to right thumb topically everyday shift for Skin Tear. Cleanse right thumb with normal saline, apply Bacitracin and a dry protective dressing daily on the day shift on 12/3/2022 and 12/14/2022. Bipap on at bedtime, off in am. Bipap 8cm (centimeters) H20 (water). Full face mask. Preset settings on [the] machine. Apply Mask and turn on machine @ HS at bedtime and remove per schedule to apply at 9:00 p.m. on 12/3/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to left ear topically one time a day for Stage II left ear. Cleanse ear with normal saline, apply ointment, and cover O2 (oxygen) tubing with gauze daily on the day shift on 12/3/2022 and 12/14/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to sacrum topically every day and evening shift for Unstageable Sacrum. Cleanse [the] area with normal saline and apply [the] cream to surrounding area. Use with Silvadene order on the day shift on 12/3/2022, on the evening shift on 12/1/2022, and on 12/3/2022. Calmoseptine Ointment 0.44-20.6% (Menthol-Zinc Oxide). Apply to sacrum topically every day and evening shift for Unstageable Sacrum. Apply Calmoseptine to peri-wound after cleanse with NSS (normal saline solution), Medihoney to wound bed BID (twice a day) on the day shift on 12/14/2022. Foley Catheter Care q (every) shift and PRN (as needed) for wound healing on the day shift on 12/3/2022 and 12/14/2022; on the evening shift on 12/3/2022. Medihoney Wound/Burn Dressing Gel (Wound Dressings). Apply to sacrum topically every day and evening shift for stage 2 pressure ulcer on the day shift on 12/14/2022 and 12/18/2022; on the evening shift on 12/17/2022. Record Urinary Output for Amount, Color, Clarity, and Presence of Sediment every shift. Monitor for kinks in tubing and leakage and ensure drainage bag/leg bag is below the height of the bladder every shift on the day shifts on 12/3/2022, 12/10/2022, 12/11/2022, and 12/14/2022; on the evening shift on 12/3/2022; on the night shift on 12/6/2022, 12/10/2022 and 12/14/2022. Silvadene Cream 1% (percent) (Silver sulfadiazine). Apply to Unstageable sacrum topically every day and evening shift for Unstageable sacrum. Cleanse area with normal saline, apply Silvadene cream to open areas, and cover with an abdominal pad (Surrounding skin Calmoseptine) on the day shift on 12/1/2022 and the evening shift on 12/3/2022. Skin Prep Spray Miscellaneous (Ostomy Supplies). Apply to Right foot 5th toe topically one time a day for Stage 1. Cleanse right foot and 5th toe daily with normal saline, apply skin prep, and place gauze between toes on the day shift on 12/3/2022, 12/14/2022, and 12/18/2022. 2. According to the AR, Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Gastrostomy Status, Unspecified Anemia, Unspecified Protein-Calorie Malnutrition, Other Acute Kidney Failure and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. According to the MDS, an assessment tool dated 10/20/2022, Resident #3 had a BIMS score of 3/15, which indicated the Resident had severely impaired cognition. The MDS also showed Resident #3 was totally dependent with most ADLs. A review of Resident #3's OSR revealed the following POs: Administer 200ML (Milliliter) of Free Water Flush Q6H (every 6 hours) every shift, order date 11/03/2022. Every shift, Keep HOB (head of bed) elevated 45 degrees during PEG (Percutaneous Endoscopic Gastrostomy) feedings and 30 min [minutes] prior to every shift, order date 11/03/2022. Maintain abdominal binder around the abdomen to secure PEG tube every shift; order date 11/03/2022. Monitor PICC (Peripherally Inserted Central Catheter) site integrity Q (every) shift, Notify MD/NP (Medical Doctor/Nurse Practitioner) if s/s (signs/symptoms) of infection or dislodgement every shift. Notify MD if s/s of infection or dislodgment [dislodgement], order date 11/03/2022. A review of Resident #3's TAR dated 11/1/2022-11/30/2022 revealed the above-aforementioned POs were not documented on the following dates: on the day shift on 11/6/2022 and 11/7/2022, on the evening shift on 11/4/2022 and the night shift on 11/5/2022. During an interview on 1/23/2023 at 1:22 p.m., when the Surveyor showed the Unit Manager/Registered Nurse (RN) the blank spaces on Resident #2's TAR, she replied, yes, if it (TAR) is not documented, it means it is not done. It [The blank space] means the treatment or medication was not done. During an interview on 1/23/2023 at 1:40 p.m., the Director of Nursing (DON) stated, What is expected [is] everything [medication/treatment] would be done as ordered and signed for when it is completed. You can presume, if not documented, the med [medication]/treatment is not done During an interview on 1/23/2023 at 2:15 p.m., the DON stated, we [facility] follow the Standards of Practice for treatment administration, and there is no specific policy on Documentation. The RN who cared for Resident #3 was unavailable for an interview at the time of the survey. A review of the facility policy titled Medication Administration with a reviewed date 5/18/2022 revealed the following: Under Non-binding general guidelines included A. Medications will be administered according to times of administration determined by the facility's Pharmacy Committee. 1. The facility's Pharmacy Committee and/or physician's direction may determine if specific medications should be administered at specific times B. Medication administration pass may begin sixty (60) minutes before the scheduled times of administration but may not exceed sixty (60) minutes after the scheduled times of administration .4. Medications administered outside the prescribed timeframe requires physician notification and documentation in the medical record in the Interdisciplinary Progress Notes and/or on the MAR (Medication Administration Record), stating the reason for change of time and physician response N.J.A.C.: 8.39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 22 residents (Resident #67) reviewed and was evidenced by the following: On 6/21/22 at 11:00 AM, the surveyor observed Resident #67 walking in hallway independently, with no need for an assistive device. Resident #67 called the surveyor Mommy while passing by. The resident was wearing a Wanderguard on the left ankle. The surveyor observed that the resident wore this alarm device on all survey days. Resident #67 then sat in a chair in the dayroom near the surveyor and began talking to the surveyor in Spanish. On 6/23/22 at 11:26 AM, the surveyor observed Resident # 67 pacing around the dayroom. The resident spoke to the surveyor in Spanish. When the surveyor stated that she only spoke English, the resident stated, I want to get out of here. Then Resident #67 continued pacing, pointing to empty chairs in the room and saying something in Spanish. He/she also pointed and spoke to another resident in the room, who did not respond. On 6/23/22 at 11:35 AM, the surveyor observed Resident #67 return to the dayroom and continued pacing, pointing, speaking to no one in Spanish. On 6/23/22 at 11:45 AM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN#1), who stated that the staff try to observe Resident #67 from a distance. LPN #1 continued, indicating that Resident #67 would get agitated if the staff touched the resident. LPN #1 stated that they had to send the resident out of the facility a few times. He explained that they try to let Resident #67 just walk through the hallways and observe to make sure he/she doesn't bother any other residents. LPN #1 also stated that the resident's significant other visits frequently and then Resident #67 calms down. The resident's significant other had told the staff that Resident #67 is very confused and sometimes just blurts out word salad. LPN #1 stated that staff don't always understand his/her Spanish dialect. On 6/23/22 at 12:17 PM, the surveyor observed the resident refusing to eat, despite encouragement from two staff members. Resident #67 continued pacing in the dayroom and attempted twice to sit on the floor. Staff members offered the resident a chair, but he/she refused. Eventually, a Certified Nursing Assistant (CNA) was able to assist Resident #67 to a table. On 6/24/22 at 12:11 PM, the surveyor observed a CNA feeding Resident #67 while she stood next to him/her. The CNA explained that she had to stand . that if she sat, Resident #67 would become combative and swing at her. The resident sat calmly and ate well. The CNA did sit toward the end of the meal. Resident # 67 was not aggressive at that time. On 6/27/22 at 11:49 AM, the surveyor observed Resident #67 seated at a table in the dayroom, speaking loudly in Spanish and gesticulating with his hand. A staff member set up the lunch tray for Resident #67 and the resident began eating a sandwich independently and remained quiet while eating. The resident's roommate was seated at the same table and both residents remained calm throughout the meal. On 6/27/22 at 12:58 PM, the surveyor observed Resident #67 make two attempts to open the dayroom door to the outside. One staff member stated that the door alarm would make the resident stop trying to open the door. After the second try, Resident #67 stopped attempting to open the door. On 6/28/22 at 10:45 AM, the surveyor observed Resident #67 pacing through the hallway. The resident occasionally stepped into another resident's room, then came right out. LPN #1 stated that the resident was more manageable when sitting. Resident #67 stated to the surveyor, I want food. The surveyor reported this to LPN #1 and the Licensed Nursing Home Administrator (LNHA), who arranged to have a sandwich brought to Resident #67. On 6/29/22 at 10:47 AM, two surveyors interviewed LPN #2 regarding behaviors displayed by Resident #67. The LPN stated that she was an agency nurse and had worked at the facility for one year. She stated that she knew Resident #67 well and that the resident Hit me. Threw things at me. Spit at me. Grabbed me and kicked me. There have been so many incidents. [He/she] has opened the door in the dayroom .so much going on. The LPN concluded that she sometimes asks people from the kitchen who speak Spanish to calm the resident down. On 6/29/22 at 10:50 AM, two surveyors observed Resident #67 approach the nurse's station crying and speaking in Spanish. LPN #3 redirected the resident. LPN #2 spoke softly to Resident #67, who then calmed the resident down. LPN #2 redirected the resident to the dayroom, where he/she calmly ate lunch. On 6/29/22 at 10:55 AM, two surveyors interviewed LPN #3 who stated that she had worked at the facility for almost three years and knew the resident well. LPN #3 stated that the resident can get extremely aggressive. They changed [him/her] from Xanax to Ativan, so we can give . the Ativan Gel .We needed a way to calm [him/her]. If [he/she] was not willing to take the medication by mouth. [His/her] meds were tweaked a little bit and [he/she] shows some improvement. The surveyor reviewed the hybrid medical record of Resident #67. According to the admission Record, Resident #67 was admitted a few months prior to the survey with diagnoses that included, but was not limited to unspecified psychosis not due to a substance or known physiological condition, dementia with behavioral disturbance, other specified depressive episodes, restlessness and agitation and generalized anxiety disorder. Review of the Significant Change Minimum Data Set (MDS), an assessment tool dated 5/27/22, indicated that Resident #67 had a Brief Interview for Mental Status score of 3 out of 15, which indicated that the resident's cognition was severely impaired. The MDS further indicated that Resident #67 displayed no behaviors including rejection of care, wandering, hallucinations or delusions. Section E of the MDS also reflected that Resident #67 displayed no physical or verbal symptoms directed toward self or others. Progress notes from nursing, physician, psychiatrist and the social worker (SW) revealed the following information regarding the resident's behaviors: A review of the Behavior Note dated 5/5/22, revealed the Resident was observed by the unit secretary in the day room waving over [his/her] head a wooden ornament. Nursing staff attempted to intervene, [he/she] broke the wooden statue while acting as if [he/she] was hitting something. When the nurse attempted to retrieve the object [he/she] began to fight against her. [He/she] kicked the nurse in the leg and then hit her with [his/her] hand. She was able to retrieve the wooden object without further incident but .continues to act aggressively while in the day room, staff attempts to redirect failed. PRN [as needed] Xanax given by medication nurse. Will monitor for effectiveness. A review of the Psychiatry note dated 5/17/22, revealed At times patient get very aggressive. Hit staff, difficult to redirect . A review of the Behavior Note dated 5/20/22, revealed that Resident #67 got very angry and combative when he/she tried to get out of the exit door and would not listen to the staff who tried to hold him/her away from the door. Then the resident started swinging at the staff. Resident #67 started to reach for something to throw at the staff. Resident #67 was kicking the chairs and wall. The staff was unable to calm the resident. Nurse was able to give him Xanax 0.25 mg po [by mouth] and then the resident made a fist attempting to hit the nurse. The MD [doctor] was made aware and ordered to send the resident to the hospital. 911 was called. While Resident #67 was on the stretcher the resident was attempting to removed his/her straps. POA .was made aware of the transfer and also the spouse. The hospital was called for report. The resident was transferred to the psychiatric emergency room. Resident was sent out for a behavioral evaluation. A review of the Health Status Note dated 5/21/2022, revealed at 7:00 PM. Resident started getting agitated. [He/she] stood up from [his/her] bed and open the window in the room .CNA called and with RN tried to calm resident. Redirected back to bed, but [he/she] kept going back to the window. [He/she] walk out to hallway, appear agitated and angry. Speaking in Spanish. [He/she] became very angry and combative and would not listen to the staff who are trying to hold [him/her] away from the window. [He/she] was swinging [his/her] arms, kicking and banging the tables and chairs. Unable to calm [him/her] down. Attempt made to give [him/her] Xanax, but [he/she] refused. significant other was called and returned to building. [He/she] calmed down and they were able to administer Xanax, which was effective. A review of the Behavior Note dated 5/22/2022, revealed Resident noted with increasing anxiety and pacing while speaking Spanish. [He/she] had episodes of crying and yelling. Xanax 0.25 administered. continued pacing but stopped crying and yelling. Resident was redirected several times as [he/she] kept entering other rooms other than [his/hers]. [Spouse] visited at 4 pm. No behavior noted with [spouse] present. A review of the Psychiatry Progress Note dated 5/23/22, revealed Pt. [patient] was sent out due to combative behavior . A review of the Physicians note Late Entry dated 5/23/2022, revealed follow up acute visit .Resident was very combative & aggressive, attempting to physically hit staff, not redirectable. Calm and pleasant now. tolerating increased depakote, awaiting psych eval. A review of the Health status note dated 5/24/2022, revealed C/O [complaining of] restlessness & agitation towards staff, seen crying & walking barefoot down halls. A review of the Social Services Note dated 5/27/2022, revealed Reached out to pt's [patient's] Guardian to explore the possibility of alternative, appropriate LTC ]long term care] placement. Pt. is primary Spanish speaking, communication board in place and staff/girlfriend translation available; however pt may benefit from more Spanish speaking community. Pt. also followed by psychiatry and MD, recent medication adjustments r/t behaviors in place. Team will continue to re-direct as needed and continue to invite to daily programs and offer sensory items, tasks that pt appears to enjoy. Awaiting f/u from Guardian. A review of the resident's Care Plan initiated on 4/27/22 and revised on 6/29/22 reflected a focus area for behavior problems including agitation, throwing objects, hitting and yelling related to dementia with behavioral disturbances and psychosis. Interventions included: 1. Administer medications as ordered. Monitor for side effects and effectiveness. 2. Assist resident with coping mechanisms, Encourage resident to express feelings appropriately. Provide non-verbal language barrier cue cards for self-expression. 3. Educate resident's family and caregivers regarding coping and interactive strategies. 4. Intervene to protect rights and safety of others. Approach in a calm manner. Remove from situation and take to alternate location, 5. Monitor behavior episodes and determine underlying cause. Consider location, day, time, persons involved and situations. Document behavior and underlying causes. 6. Provide a program of activities that is of interest and accommodates residents status. 7. Reach out to resident's friend to alleviate agitation. On 6/29/22 at 12:31 PM, the surveyor interviewed the MDS Coordinator regarding the resident's Significant Change MDS, dated [DATE]. She stated that the significant change was due to improvements in all activities of daily living. Therefore, the resident experienced a significant improvement. She stated that the social worker was new and completed sections C (Cognitive Patterns), D (Mood), E (Behavior) and Q (Participation in Assessment and Goal Setting) of the MDS. The MDS Coordinator stated that she closes the MDS and each person completing their section signs off themselves. I was the one closing it. On 6/29/22 at 12:45 PM, the surveyor interviewed the social worker who stated she began working at the facility on 5/9/22. The social worker stated that she was familiar with Resident # 67 and that the resident wanders a lot and has confusion. She further stated they have been looking for a dementia unit to place Resident #67, where the resident would be better off. She had made referrals to other facilities. The social worker stated that she was familiar with the MDS and that she had been working the field of Long Term Care for about 8 months and had worked with children before working with the elderly. The social worker confirmed that she completed sections C, D, E and Q in the MDS. She stated that she uses interaction from residents, feedback from nurses and sees Psychologist's notes. She also refers to Progress notes and looks at nurse's notes. She told the surveyor that she was not aware of physical behavior of the resident. She stated, I know [he/she] hallucinates. Psych put in notes about hallucinating. She claimed she was not aware of the resident pushing others or physical abuse to staff. The social worker stated that the [spouse] thinks the behaviors are because the staff doesn't understand the resident. On 6/29/22 at 12:54 PM, the Regional Case Manager entered the room while the surveyor was interviewing the social worker. In the presence of the social worker, the surveyor mentioned the discrepancies between the coding of behaviors in the MDS, dated [DATE], and the behaviors described by the staff members. The Regional Case Manager acknowledged that there were errors in the MDS for Resident # 67. She then stated, We can reevaluate and amend whatever we need to. On 6/30/33 at 9:17 AM, the LNHA provided a copy of the revision made to the resident's Significant Change MDS of 5/27/22. The assessment was revised on 6/29/22 at 5:44 PM by the Regional Case Manager and included the following changes in Section E: 1. Physical Behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Response: Behavior of this type occurred 1 to 3 days. 2. Verbal Behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others). Response: Behavior of this type occurred 1 to 3 days. 3. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Response: Behavior of this type occurred 4-6 days. 4. How does the resident's current behavior status, care rejection, or wandering compare to prior assessment? Response: Worse According to a review of the Resident Assessment Instrument (RAI) Manual for proper coding of the MDS - Section E - Behaviors the intent of the MDS assessment is to, identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. The RAI Manual further indicated steps for coding - E0200 - Behavioral Symptom- Presence & Frequency (cont.) Steps for Assessment 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period. Coding Instructions - Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Use this code if the symptom has never been exhibited or if it previously has been exhibited but has been absent in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on any one of those days. Code 2, behavior of this type occurred 4-6 days, but less than daily: if the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occur on any of those days. Code 3, behavior of this type occurred daily: if the behavior was exhibited daily, regardless of the number or severity of episodes that occur on any of those days. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a.) medications were administered according to physician orders for 1 of 4 residents (Resident#16) observed during medication administration pass and b.) staff label the Intravenous Fluid (IVF) medication that was administered to 1 of 1 resident (Resident#57) according to the standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 06/23/22 at 9:05 AM, the surveyor observed a Licensed Practical Nurse (LPN#1) preparing to administer medications for Resident #16. The surveyor observed LPN #1 placed all medications that were plotted for 9 AM in a medication administration cup except for an Acidophilus capsule (a medication that balances potentially harmful bacteria that can otherwise flourish in the gut due to illness or antibiotics). On that same date and time, the surveyor observed LPN #1 double-checked each medication that she placed in the medication cup, but LPN #1 failed to recognize that the Acidophilus capsule was omitted. The surveyor then observed LPN #1 administering all the medications inside the medication cup to Resident #16. The surveyor stopped LPN#1 prior to signing off the electronic Medication Administration Record (eMAR) and asked LPN #1 if she could open the bottle of Acidophilus capsules. At that time, the surveyor interviewed LPN #1 who stated after identifying the contents of the Acidophilus bottle that she failed to administer the medication to Resident #16. The surveyor reviewed the medical records of Resident#16. The admission Record for Resident #16 indicated that the resident was admitted to the facility with diagnoses that included, but were not limited to: Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior), multiple sclerosis (is a chronic, autoimmune disease that attacks the brain, spinal cord, and optic nerves), overactive bladder, and type II diabetes. The June 2022 eMAR revealed an order for an Acidophilus capsule dated 6/2/22 with a direction of 1 capsule by mouth two times daily for a supplement with a slotted time of 10:00 AM and 5:00 PM (10:00, 17:00). On 6/27/22 at 1:00 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and there was no additional information provided by the facility. A review of the facility's policy for Medication Administration that was dated 5/18/22 provided by the LNHA indicated the following: A. Licensed nursing professionals will administer medications according to times of administration determined by the facility's Pharmacy Committee. 2. On 6/20/22 at 10:15 AM, the surveyor observed Resident #57 lying with the head of the bed elevated. The resident was alert and responded to the surveyor appropriately. On 6/23/22 at 8:34 AM, the surveyor observed the resident seated in their bed with 45% (45 percent) Normal Saline Solution (NSS) IVF infusing via a manual dial tube (where it showed the milliliters per hour to be infused) that was between 60 and 80. The manual dial tube had an increment of 20. The IVF was hung on a pole. There was approximately less than 100 milliliters left in the 1000 milliliters IVF bag. There was no label attached to the IVF to identify the resident's name and the information about the IVF. At that same time, the resident informed the surveyor that the IVF was hung by a nurse yesterday (6/22/22) and was unable to remember the exact time when the IVF was hung. The resident was not sure how many IVF bags will be infused. The resident further stated that the IVF was ordered by a physician because the resident's laboratory results were not within normal limits. On 6/23/22 at 8:38 AM, two surveyors and LPN#2 entered the resident's room. LPN#2 checked the IVF of the resident. Both the surveyors and the LPN#2 did not see a label on the IVF. No label can be found in the surrounding of the resident's room. Afterward, both surveyors and LPN#2 left the resident's room. During an interview with the surveyor, LPN#2 informed the surveyors that the physician ordered an IVF because of elevated potassium level and for hydration. LPN#2 stated that there should have been an IVF label attached to the IV bag that included the resident's name, medication name, mls/hr (milliliters per hour), the date the IV was hung, and the signature of the nurse who hung the IV bag to notify another nurse of the IVF when being checked during nursing rounds to make sure it was the right medication according to the physician's order. LPN#2 confirmed to both surveyors that there was no IVF label at that time. On that same date and time, the surveyor asked LPN#2 what the ordered mls/hr for the resident's IVF was. LPN#2 stated, I have to check the order first. Then, LPN#2 checked the eMAR and stated that the order was 75 mls/hr. LPN#2 further stated that the 3-11 nurse on 6/22/22 who started the IVF should have put the IVF label. He indicated that the facility had one kind of IV tubing that had 20 increment manual dial for mls/hr and at the time both the surveyors and LPN#2 observed the IVF tubing it was on a higher level between 60 and 80 which reflected 75 mls/hr. The surveyor reviewed the resident's medical records: The admission summary reflected that the resident was admitted to the facility with diagnoses that included essential hypertension (elevated blood pressure), dysphagia (difficulty swallowing), and malignant neoplasm (are cancerous tumors) of unspecified kidney, except renal pelvis. According to the 5/19/22 admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care indicated that the resident's Brief Interview for Mental Status score of 15 out of 15 which indicated that the resident's cognition was intact. There was a physician order dated 6/22/22 to start IVF ½ (45%) NSS at 75 ml/hr for one 1 liter (1000 milliliters) every shift for dehydration d/c (discontinue) when completed. The above corresponding physician order was transcribed onto the June 2022 eMAR. On 6/28/22 at 11:37 AM, the surveyor interviewed via phone conference the Registered Nurse (RN) in the presence of the survey team. The RN informed the surveyor that she was an agency nurse assigned to Resident #57 on 6/22/22 of the 3-11 shift. The RN stated that she was the one who administered and initiated the IVF to the resident that was taken from the IV medication backup supplies. She further stated that as per facility practice, when administering an IVF, there should be a label attached to the IV bag to identify the medication, mls/hr, when it was hung, and the resident's name. She stated that it is important to have a label in the IV bag because it helps to double-check the order of the resident. At the same time, the surveyor asked the RN why there was no label on the resident's IVF bag on 6/23/22. The RN stated, I don't know what actually happened. The RN acknowledged that there should have a label. On 6/28/22 at 11:48 AM, the surveyor followed up with the LNHA on the facility policy concerning IV medication and accountability for IV backup meds. The LNHA informed the surveyor that there was no facility policy and accountability for IV backup meds. On 6/28/22 at 2:03 PM, the survey team met with the LNHA, DON, [NAME] President for Operations (VPO), VP for Clinicals (VPC), and Regional Administrator and were made aware of the above concerns. On 7/1/22 at 10:43 AM, the survey team met with the LNHA. The LNHA informed the surveyors that there will be no additional information. NJ 8:39-11.2 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/21/22 at 11:29 AM, the surveyor observed that Resident #87 was seated in a recliner wheelchair with a hoyer lift (is a patient lift used by caregivers to safely transfer a patient) pad beneath the chair and with a right hand limitation. The resident was not wearing an adaptive device or a right hand splint. On 6/21/22 at 11:30 AM, the surveyor interviewed the Certified Nursing Aide (CNA). The CNA informed the surveyor that she has been working in the facility for 27 years as a regular aide on the 3-11 shift. The CNA stated that she also worked the 7-3 shift and takes care of Resident #87. She further stated that she was the regular aide for Resident #87 on the 3-11 shift. Furthermore, the CNA informed the surveyor that Resident #87 was cognitively intact, had no behavioral issues, and denied pain. The CNA stated that the resident required total assistance with activities of daily living (ADL), a feeder, non-ambulatory, with limitation to the right hand which was not something new to the resident. She further stated that the resident does not use an adaptive device for their right hand limitation. On 6/21/22 at 11:55 AM, two surveyors observed the resident in their room. The resident was not wearing a right hand splint. The surveyor interviewed the resident who stated that he/she does not use a splint. The resident can not remember the last time he/she had worn a splint and denied refusing a splint before. The resident further stated that the right hand limitation was not something new and denied complaints of pain. A short time later, the Licensed Nursing Home Administrator (LNHA) came inside the resident's room and delivered the resident's lunch tray. The surveyor reviewed the medical record for Resident #87. A review of the Face sheet (admission record) indicated the resident was admitted to the facility with diagnoses that included but were not limited to multiple sclerosis (MS) (a chronic, autoimmune disease that attacks the brain, spinal cord, and optic nerves) and quadriplegia (paralysis from the neck down, including the trunk, legs, and arms). A review of the 4/06/22, Annual Minimum Data Set (AMDS), an assessment tool used to facilitate care management, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which reflected that the resident's cognition was moderately impaired. The MDS indicated that the resident had limited ROM to one side of the upper and two sides of the lower body extremities. The AMDS did not indicate that the resident was in the Restorative Nursing Program (RNP). A review of the June 2022, Order Summary Report included a physician order dated 4/28/22 for R (right) palm guard on at all times, except for self-care and bathing and remove every shift and check skin integrity every shift for contracture. The order for the right palm guard was transcribed to the electronic Treatment Administration Record (eTAR) for June 2022 and signed by nurses as administered or applied. The personalized care plan focus for splint/guard/cast location: palm guard right hand was revised on 4/21/22. The care plan interventions created and revised on 3/11/22 included applying right hand palm guard on all times except for self-care/hygiene per MD (medical doctor) order, monitor signs and symptoms of discomfort every shift, and refer to Rehab as necessary. Further review of the March through June 2022 hybrid medical records showed that there was no further documentation that indicate that the resident declined the use of the right palm guard, complained of pain and that Rehab was notified of any concern with regard to the use of right hand palm guard. The 3/11/22 Multidisciplinary Therapy Screen (MTS) signed by the Occupational Therapist/Lead (OTR/L) included Pt (patient) referred for OT intervention for R hand contracture. Pt presents with claw hand presentation of R hand gently contracted distal IP (interphalangeal) joints toward palm. No sign of skin breakdown. Pt reported no pain. Trialed R palm guard, to which Pt reported no pain and reported comfort with palm guard. Pt expressed interest and agreed to recommendation to wear at all times, except for care. Communicated with unit manager and assigned CNA. Orders placed. Checked in-with no redness or skin irritation noted. The 6/6/22 MTS signed by OTR/L included Pt presents at usual level of function upon re-admission from hospital. Pt R palm guard fits well with no s/s (signs/symptoms) or irritation. Pt requires assist with self feeding and total care for bed mobility and adls. Pt is a hoyer lift transfer. Pt is at usual level of function and no skilled PT/OT (Physical Therapy/Occupational Therapy) recc (recommended) at this time. On 6/23/22 at 11:20 AM, the surveyor interviewed Licensed Practical Nurse#1 (LPN#1) in the presence of the CNA. LPN#1 informed the surveyor that she was not sure if the resident should have a right hand splint and stated the CNA can answer for that. Both the surveyor, CNA, and LPN#1 went inside the resident's room and observed Resident #87 seated on a wheelchair with no right hand splint in use. After leaving the resident's room, LPN#1 checked the eTAR and stated that the resident should have the right palm guard as ordered at all times except during care. On that same date and time, the CNA stated that since she worked 3-11 shifts and few of 7-3 shifts, she did not see the splint. The CNA confirmed that on 6/21/22 when the surveyor interviewed the CNA that day, there was no splint in use and that she did not see it even on 3-11 shifts. Then, the CNA went to the resident's room to look for the splint. Afterward, the CNA informed both the surveyor and LPN#1 that there was no splint in the resident's room that she can find. On 6/23/22 at 11:38 AM, the surveyor in the presence of the survey team interviewed the OTR/L. The OTR/L informed the surveyor that once the resident was discharged from Skilled Rehab, the responsible therapist will do a splint trial, if tolerated, the therapist will train the assigned nurse and the CNA, then provide an order for the splint. He further stated that the care plan for the splint was initiated by him and was updated quarterly during MDS review by me and/or nursing. On that same date and time, the OTR/L stated I don't know where nursing document accountability for splint use and application. According to the OTR/L, I do the quarterly screen, I interview the nurse and staff about the splint use, and assess. He further stated that Resident#87 has a right palm guard for gentle contraction and comfort and that the resident was tolerating it. At that time, the surveyor informed the OTR/L of the above observations and concerns that the right palm guard was not in use during the surveyor's observations. The surveyor asked the OTR/L to check what happened and where was the right palm guard. The OTR/L stated that he will get back to the surveyor. On 6/23/22 at 12:07 PM, the surveyor met with the OTR/L in the presence of the survey team. The OTR/L informed the surveyor that upon checking with nursing, the splint was found. The surveyor asked the OTR/L where did they see the splint and the OTR/L stated I don't know, they just told me that it was found. Furthermore, the OTR/L stated that as per nursing, and the CNA, the resident was refusing the splint at times due to pain. Then the surveyor asked the OTR/L when the resident refused the splint, should the staff document the refusal, where should the documentation be written, and if he received a report of pain due to the use of the splint? The OTR/L stated that it should be documented in the electronic medical records, I did not receive a report about pain with the use of a splint, and the splint was appropriate from the last rehab screen. During an interview of two surveyors on 6/23/22 at 1:22 PM, LPN#1 informed the surveyors that the right hand splint was found under the resident's bed by the CNA. On 6/23/22 at 1:23 PM, the surveyors interviewed the CNA. The CNA informed the surveyors that the right hand splint was found inside the resident's bottom drawer covered by the resident's personal belongings. The CNA stated that it was the first time that she saw the splint. During an interview of the surveyors on 6/27/22 at 10:48 AM, LPN#2 informed the surveyors that she worked on 6/21/22 on the day that the surveyor did not observe the resident wearing a right hand palm guard on multiple occasions on that date. She further stated, I don't know what happened or why it was not with the resident at that time. The surveyor asked LPN#2 why the CNA did not know about the right palm guard, LPN#2 had no answer. On that same date and time, the surveyor asked LPN#2 when the resident refused the splint where should it be documented, and if the resident had refused the use of the splint. LPN#2 stated that refusal should be documented in the eTAR. She further stated yes that it was being refused at times. Then the surveyor asked LPN#2 did she document the refusal and LPN#2 did not answer. On 6/28/22 at 01:01 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON informed the surveyor that the facility used to have a Restorative Aide (RA) and since the RA was on medical leave, there was no replacement. The DON stated that the responsibility of the RA was now transferred to the assigned CNA. The surveyor asked the DON if the assigned CNA was educated and trained in the restorative program which included splinting. The DON stated that the CNAs were trained but there was no documentation that the CNA signed the education and training. On 6/28/22 at 2:03 PM, the survey team met with the LNHA, DON, and the three regional directors and were all made aware of the above concerns. A review of the facility Restorative Nursing Program Policy revised 7/21, provided by the LNHA included Restoration and maintenance of optimal independence shall be integral to the care provided to all residents. Restorative programs shall be individualized and designed to restore and/or maintain functions which have been lost or reduced by illness, injury or inactivity. Procedure: 5. All residents shall be assessed for restorative nursing care within twenty-four (24) hours of admission and upon discharge from any rehabilitation therapy program. 6. Resident shall be placed in a restorative program appropriate to his or her needs. A description of the restorative care to be provided will be inputted as a task into the POC system. 7. All restorative services shall be appropriately documented as having been provided in the Point of Care system. On 6/29/22 at 2:26 PM, the survey team met with the LNHA, DON, Regional [NAME] President for Operations (VPO), [NAME] President for Clinicals (VPC), and Regional DON. The surveyor asked the facility if they have additional information about the surveyor's concerns, the LNHA stated that there was no additional information. NJAC 8:39-27.2(m) Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for an adaptative device for 2 of 3 residents (Resident #2 and R #87) reviewed. This deficient practice was evidenced by the following: 1. On 6/21/22 at 11:16 AM, the surveyor observed Resident # 2 in bed sleeping. The head of the bed was elevated approx. 30 degrees. The television was in use. A hospice recreation aide entered the room to play music for the resident. There was no Aspen collar in use. On 6/23/22 at 11:01 AM, the surveyor observed Resident # 2 in bed awake and fully dressed. The resident's bedside table was observed with a half pint (240 ml's) of regular milk, 4 ounces (oz) of orange juice, and 12 oz (ounces) of water in a white Styrofoam cup with a lid and a straw. There was no Aspen collar in use. On 6/23/22 at 11:45 AM, the surveyor interviewed the resident's assigned Certified Nursing Aide (CNA) who stated that the hospice aide takes care of the resident usually every morning but if the hospice aide wasn't there then she would care for the resident. The CNA stated in the beginning she had a collar, but I don't know what happened to it. I don't know if it was discontinued. I don't know. I haven't seen it. On 6/23/22 at 12:15 PM, the surveyor interviewed the director of rehab who could not speak to the collar for resident #2 and stated he would look into it. He further stated that the resident was on hospice care, and he doesn't get involved with residents who are on hospice. On 6/23/22 at 12:13 PM, the surveyor reviewed the plan of care book on the unit which revealed an Adaptive Devices/splint/braces/ETC-100 wing list (a list with the names of the residents who utilize adaptive devices/splints/braces). The surveyor, in the presence of the CNA reviewed the adaptive devices list which was dated 10/11/20. The CNA acknowledged that the list was outdated. On that same date and time, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated, we don't have a restorative aide right now. He confirmed that the physician's order for the Aspen collar was active but not transcribed onto the medication or treatment administration record for accountability of the Aspen collar. The LPN further stated I don't know what happened. I don't know why it wasn't transcribed or why the resident isn't wearing the collar. On 6/24/22 at 10:54 AM, the surveyor observed Resident # 2 awake in bed fully dressed watching TV. The resident answered hello when the surveyor greeted him/her. There was no Aspen collar in use. The surveyor reviewed the medical record for Resident #2. A review of the resident's admission Record reflected that the resident was admitted to the facility on [DATE], with diagnoses which included but were not limited to unspecified displaced fracture of seventh cervical vertebra, subsequent encounter for fracture with routine healing, fracture of unspecified part of right clavicle, subsequent encounter for fracture with routine healing, unspecified dementia with behavioral disturbance, other specified depressive episodes, and other chronic pain. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/18/22, reflected that the resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15 which indicated that the resident's cognitive skills for daily decision making was severely impaired. Review of the Medication Review Report (MRR) revealed a physician's order (PO) dated 3/7/22, for Aspen collar on at all times, dx [diagnoses] cervical fracture at all times for cervical fracture. Review of the March, April, May, and June 2022, electronic Medication, and Treatment Administration Records (eMAR/eTAR) did not indicate that the above corresponding PO was transcribed onto the eMAR/eTAR's. On 6/28/22 at 2:03 PM, the surveyor met with the administrative team and discussed the above observations and concern. On 6/29/22 at 9:55 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) who stated that the resident was on hospice services and was no longer using the Aspen collar. The LNHA could not speak to a physician's order for discontinuing the Aspen collar. The LNHA further stated that the resident was refusing and removing the Aspen collar, but it wasn't documented since the resident's admission. She further acknowledged that the adaptive device wasn't care planned. On 6/30/22 at 1:55 PM, in the presence of the survey team, the LNHA stated that the resident was refusing to wear the Aspen collar, but staff did not document the refusals of the collar. There was no additional information provided.

Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate care and services of urinary catheter for 1 of 2 residents (Resident#57) reviewed for urinary catheters. This deficient practice was evidenced by the following: On 6/20/22 at 10:15 AM, the surveyor observed Resident #57 lying with the head of the bed elevated. There was a urinary catheter bag hung on the left side below the level of the bladder, and off the floor with a privacy bag. The resident was alert and responded to the surveyor appropriately. The surveyor reviewed the resident's medical records: The admission summary reflected that the resident was admitted to the facility with diagnoses that included essential hypertension (elevated blood pressure), other retention of urine, presence of urogenital implants (artificial material in urinary organs or genitals), and malignant neoplasm (are cancerous tumors) of unspecified kidney, except renal pelvis. According to the 5/19/22, admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care indicated that the resident's Brief Interview for Mental Status score of 15 out of 15 which indicated that the resident's cognition was intact. The AMDS indicated that the resident had an indwelling (or urinary) catheter. There was an a physician order dated 5/22/22, that foley inserted initially. Other physician orders included an order dated 5/27/22, to record urinary output for amount, color, clarity, and presence of sediment q (every) shift. The above corresponding physician order was transcribed onto the June 2022 electronic Treatment Administration Record (eTAR). Further review of the June 2022 eTAR showed the following dates with missing urinary output, color, clarity, and presence of sediment documented and did not follow the above physician's order: Day (7-3 shift): 6/3, 6/6, 6/6, 6/12, and 6/19/22 Evening (3-11 shift): 6/14 and 6/16/22 Night (11-7 shift): 6/2, 6/3, 6/12, 6/14, 6/15, and 6/19/22 Review of the personalized care plan did not include information about the care of urinary catheter. On 6/28/22 at 12:43 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) about the urinary catheter concerns. The LPN stated that it was better to speak with the Director of Nursing (DON) concerning the care plan and missing logs in the eTAR according to the physician's order. The LPN further stated, just ask the DON. On 6/28/22 at 1:01 PM, the surveyor in the presence of the survey team, interviewed the DON who stated that the Unit Manager (UM) used to do the care plans, but now it was the desk nurse (DN) who does care plans and care plan was being updated with the help of the DON, MDS Coordinator, Infection Preventionist Nurse (IPN), and the Regional. The DON further stated that a urinary catheter care plan should be initiated immediately upon admission in the baseline care plan, quarterly, and updated when there is a change. The surveyor asked the DON if the urinary catheter should have been included in Resident#57's care plan and the DON stated absolutely. On that same date and time, the surveyor asked the DON should there be an order and accountability for urinary catheter care? The DON stated it should be in the eMAR (electronic Medication Administration Record) or eTAR. The surveyor informed the DON of the above concerns regarding the urinary catheter care plan and physician orders not being followed concerning urinary catheter care. On 6/28/22 at 2:03 PM, the survey team met with the LNHA, DON, [NAME] President for Operations (VPO), VP for Clinicals (VPC), and Regional Administrator and were made aware of the above concerns. On 6/29/22 at 9:50 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA). The LNHA provided a copy of the indwelling catheter for the Neurogenic bladder (when a problem in the brain, spinal cord, or central nervous system makes you lose control of your bladder) care plan date initiated on 6/28/22. The surveyor asked the LNHA why the indwelling catheter care plan was initiated after the surveyor's inquiry, and the LNHA stated that she will get back to the surveyor. On 6/29/22 at 2:26 PM, the survey team met with the LNHA, DON, VPO, VPC, and Regional DON. The LNHA stated, I reviewed the case and there was inconsistencies with the urinary catheter documentation and omission. The LNHA further stated that it was because on 5/10/22, the UM quit and the care plan was not done in a timely fashion. A review of the undated facility's Foley Care Policy that was provided by the LNHA included Policy Statement: It is the policy of [name redacted] that an indwelling Foley catheter will be maintained thru Catheter Care as per medical staff order, every shift or as directed by the medical staff Catheter Care Protocol: 9. Measure drainage at end of each 8 hour tour of duty, unless more frequent measurements have been ordered, or large volumes of urine are collected. Empty into clean container and discard. 10. Assess urine output every shift for amount, color, odor, sediment or resident complaints .11. Maintain output record unless otherwise indicated 15. Change catheter as ordered by the physician, based on assessment of the resident. Bedside drainage bags are to be replaced at least every 30 days when the Foley catheter is changed, or more often as warranted. Leg bags are to be changed each night with a new bedside drainage bag. On 7/1/22 at 10:43 AM, the survey team met with the LNHA. The LNHA informed the surveyors that there will be no additional information. NJ 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) identify and address clinically significant weight losses until surveyor inquiry, b.) obtain and assess weights in a timely manner (readmission weights, reweights, and weekly weights), c.) ensure care planned nutrition interventions were implemented, d.) perform consistent meal consumption monitoring, e.) use industry standard parameters to calculate caloric needs. This was identified for 2 of 6 residents (Resident #77 and Resident #80) reviewed for nutrition. This deficient practice was evidenced as follows: Resource referenced: Review of the Nutrition Care Manual from the Academy of Nutrition and Dietetics: Anthropometric Measurements reflected the following: To effectively use weight in the assessment of a client/patient's nutritional status, it is important to obtain accurate measurements. The significance of the percentage of weight change depends on the length of time in which the weight change occurred, as well as whether the weight loss was intentional or unintentional. Assessing Percentage of Weight Change: Interpretation, Percentage of Weight Change as follows: Time Frame Significant Weight Loss Severe Weight Loss 1 week 1-2% >2% 1 month 5% >5% 3 months 7.5% >7.5% 6 months 10% >10%. 1. On 6/20/22 at 9:49 AM, the surveyor observed the Resident #77 in his/her room. The resident was seated in a wheelchair. The surveyor reviewed the medical record for Resident #77. Review of the residents admission Record (an admission summary) reflected that the resident had diagnoses that included but were not limited to: Hypertension and a Vitamin D deficiency. Review of the residents Quarterly Minimum Data Set (MDS) dated [DATE], a tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected an intact cognition. Review of the resident's nutrition care plan dated 12/9/18, reflected that the resident had a history of weight loss, frequently changed his/her food preferences and had a desire for weight maintenance. It also reflected a goal to maintain present weight (a numerical weight value was not included in the care plan goal) plus or minus three pounds which was revised on 5/3/22 (4/25/22 the resident's weight was 132.2 lbs.). In addition, it reflected that the resident's meal intake should be monitored and recorded for each meal. It also reflected to provide an ice cream at lunch per the resident's request. Review of the resident's physician Order Summary Report for June 2022 reflected a physician's order dated 11/5/21 to obtain a weight every Monday, once a week for monitoring. The surveyor reviewed the residents' weights in the electronic medical record (EMR). Weights documented were as follows: - 12/6/21 135.8 lbs. - 12/20/21 140 lbs. - 12/27/21 136.5 lbs. - 1/10/22 137 lbs. - 1/17/22 140 lbs. - 1/24/22 135.5 lbs. - 1/31/22 135 lbs. - 2/7/22 134 lbs. - 2/14/22 134.5 lbs. - 2/21/22 132.8 lbs. - 3/7/22 132.6 lbs. - 3/14/22 133 lbs. - 3/21/22 131.8 lbs. - 4/11/22 131 lbs. - 4/25/22 132.2 lbs. - 5/9/22 129 lbs. - 5/23/22 130 lbs. - 5/30/22: 124.5 lbs. [no evidence of a reweight] The 5/30/22, weight reflected a severe weight loss of 4.3% x 1 week. - 6/6/22: 125.9 lbs. - 6/13/22: 120 lbs. [no evidence of a reweight] The 6/13/22, weight reflected a severe weight loss 4.7% x one week, a severe weight loss of 7% x 1 month (4 weeks) and a severe weight loss of 11.7% x 6 months. -There was no evidence for a weekly weight on 6/20/22 - 6/27/22: 118 pounds (lbs.) Review of the Registered Dietitian's (RD) progress notes (PN) did not reflect documented evidence that she identified or addressed the above noted severe weight losses. Review of an RD PN dated 6/10/22, indicated that changes to weight are not significant 30/180 days, however the resident is clearly on a downward trend. In addition, her PN reflected Willing to have half egg salad sandwich added to lunch tray as the resident claims to enjoy it. The resident remains at risk for weight loss . On 6/27/22 at 12:32 PM, the surveyor observed the resident in his/her room during lunch. The resident stated that he/she did not eat too much for lunch. Upon surveyor inquiry the resident stated that he/she did not receive a half or whole egg salad sandwich nor an ice cream on the lunch tray but would have liked to. The meal ticket did not indicate to provide these items at lunch. Review of a copy of the resident's lunch meal ticket for 6/27/22, provided to the surveyor by the RD at 1:11 PM that day, did not reflect provision of half an egg salad sandwich nor ice cream to be provided with the lunch meal. On 6/28/22 at 11:17 AM, the surveyor interviewed the interim FSD (IFSD) and the RD in the presence of a second surveyor. The RD stated that the kitchen had no production sheets. She stated that the [NAME] prepared meals and menu items according to the likes and dislikes noted on the resident's meal tickets. The RD stated that the food/beverage items a resident should receive daily should appear on the right side of the meal ticket. On 6/28/22 at 11:25 AM, the surveyor interviewed Resident #77's Licensed Practical Nurse #1 (LPN#1) in the presence of a second surveyor. LPN #1 stated that monthly weights were obtained by the 8th of the month. She stated that a weight should be obtained on admission and readmission but could speak to more frequent weights after that unless there was a physician's order such as when a resident is on a diuretic prescription. She stated that Resident #77 had a physician's order to be weighed on Monday's. LPN #1 stated that weights were recorded in the eMAR. She also stated that if a resident had a weight loss, they would be placed on weekly weights for four weeks. LPN #1 also stated that the RD would indicate on the weight worksheets if a resident required a reweight or weekly weights. She showed the worksheets to the surveyors and provided a copy. Review of the weight worksheet titled Resident Weights for June 2022 revealed Resident #77 had a weight of 125.4 lbs. for the month of June. There was an indication to obtain a reweight however it was blank. LPN #1 also stated that there were meal monitoring accountability books that the Certified Nurse Aides (CNAs) recorded each resident's meal consumption as a percentage. She further stated that the CNAs also verbally communicate if a resident was eating poorly or not eating. She could not speak to what staff member was responsible to review the meal accountability books to ensure that they were completed and to identify any trends/changes in resident intake, however her expectation was that the RD did so. She provided the books for the surveyors to review. Review of the Meal Acceptance worksheets revealed Resident #77 had varied meal consumption for breakfast at lunch ranging from 25-50% from 6/1/22 through 6/27/22. There was no documented evidence of the resident's consumption for the dinner meal from 6/1/22 through 6/27/22. On 6/28/22 at 12:24 PM, the surveyor observed the resident in his/her room at lunch. The resident stated they could not eat and showed the surveyor a copy of the menu which indicated the meal should have consisted of Southern fried chicken, mashed potatoes with gravy, Harvard beets, watermelon cubes, whole milk and coffee. The resident removed the lid from her lunch tray and showed the surveyor that he/she received a plate of cheese tortellini with broccoli, which was untouched. The resident also showed the surveyor that this was the alternate meal on the menu. The resident did not have milk on the tray nor the watermelon cubes, half an egg salad sandwich or ice cream. There was a fresh sliced orange which was indicated on the meal ticket. She stated that she was supposed to get milk at every meal. The resident stated that a previous Food Service Director (FSD) used to visit regularly and go over the menus with him/her and further stated that no one from the kitchen had done this since the FSD left. The Licensed Nursing Home Administrator (LNHA) provided the surveyor with a timeline of FSDs employment status from March till present. This reflected that the FSD the resident was referencing was no longer employed by the facility as of 6/6/22. The surveyor continued interviewing the resident who stated that he/she was losing weight and did not want to. The resident further stated that he/she was now 119 lbs. At that time a Dietary Aide / [NAME] (DA) brought the resident a plate of chicken with mashed potatoes and broccoli. The DA stated that the chicken was a boneless thigh, and the resident did not like dark meat chicken (this was indicated on the resident's meal ticket). She stated that she did not cook the meal, however, there was no white meat chicken available. The resident requested Harvard beets, however the DA stated there were no more beets available. The DA stated there was no selective menu for the resident, whereby the resident could select meals in advance. The resident stated that she had asked the RD for a selective menu, but it was never done. On 6/28/22 at 12:43 PM, the surveyor interviewed the IFSD in the presence of the DA regarding the recipe for Southern fried chicken. The IFSD provided the surveyor a recipe for oven fried chicken which he stated he used to prepare todays lunch for Southern fried chicken. Review of the recipe indicated Chicken breast as the main ingredient. At the bottom there was indication that chicken parts such as legs or thighs maybe used in place of breasts. The IFSD stated that if he knew in advance that a resident would only eat white meat chicken, he could have prepared chicken tenders which were white meat chicken. On 6/29/22 at 12:02 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. She stated that resident meal monitoring was assessed by the CNA's and recorded in accountability books. She stated that the CNA was responsible to record consumption for each meal daily. She stated that the RD reviewed the meal monitoring to monitor intake trends related to weight loss or gain. She stated that the RD utilized this information. She stated that weights were obtained for new and readmissions. She also stated that resident's weights were monitored monthly unless a resident had Congestive Heart Failure (CHF) [a chronic progressive condition that can affect fluid volume within the body] and then they would be weighed on Monday, Wednesday and Friday. She stated that only residents that were newly or readmitted to the subacute unit would be weighed weekly for four weeks. The DON stated that monthly weights were obtained by the 7th till the 10th of the month and recorded on the worksheet. She stated that then the Unit Managers (UM's) would review the weights and notify the RD if she needed to add interventions. She stated that if there was no UM then the charge nurse would be responsible. She stated that after weights were obtained, they were recorded in the EMR, and the hard copies were discarded. She stated that a reweight would be obtained if there was a five-pound discrepancy. She stated that the RD added to the worksheet if a resident required weekly weights (i.e., for a resident who was not eating well). She further stated that there would be a physician's order for weekly weights or more frequent weights for CHF monitoring. The DON also stated that nursing used the Dietary Alert Sheet to notify the RD of weight changes. On 6/29/22 at 1:09 PM, the surveyor interviewed the RD in the presence of the survey team. She stated that resident meal monitoring was done by the CNA's and daily consumption was recorded in an accountability logs. She stated that the DON delegated which staff member would be responsible to review the meal monitoring accountability logs to ensure completion and monitor for trends. The RD stated that she also reviewed these logs when she conducted nutritional documentation on residents. She stated that she used the information when a resident had a weight loss, a significant change or to monitor how newly admitted residents were eating. She further stated that she notified the DON if she observed omissions on the meal monitoring sheets. The RD stated that weights were taken on admission and readmission. She stated that monthly weight monitoring was completed by the 7th of the month and that any deviation of five lbs. from prior month required a reweight. She stated that a nurse would automatically reweigh the resident. The RD stated that she reviewed weights after they were entered into the EMR. She stated that nursing determined which residents required reweights and calculated weight changes and notified her via a communication tool titled, Dietary Alert Sheet. The RD stated that newly admitted residents should be weighed for four weeks after admission, and that the same process applied to readmissions on the subacute unit. She stated that on the long-term care unit, weekly weights for four weeks were not required for readmissions. The RD stated that there were physician's orders to obtain weights. She stated that weights were recorded under the Weights/Vitals tab of the EMR and sometimes in the eMAR. She stated that the DON designated who entered the weights into the EMR. She stated that if she finds weights were not recorded in the EMR she would enter them herself from the weight book. She stated that she would inquire if weights were not recorded and that it was part of her assessment. The RD stated that she documents for significant weight changes, quarterly reviews, and follow-ups. She stated that she followed-up on weekly weights. She stated that the purpose of weekly weight's was that if a resident was having continued weight loss there would be a need for added interventions. She further stated that she looked at weekly weight's and if she saw a decline she would intervene. She also stated that she typically reviewed the weekly weights after the four-week period, not necessarily week to week. She stated that she did not conduct weight meetings, but that weight losses were discussed in the facility's daily morning meetings, however no minutes were taken. She stated that she considered significant weight change 5% over one month and 10% over six months. She stated that a five lbs. weight change required a reweight to verify the change, and that nursing would notify her. She could not speak to any other parameters she would use when considering weight loss, she stated I don't have a set number. The RD stated that Resident #77 had a physician's order for weekly weights every Monday. She acknowledged there was no documented evidence to address the residents weight loss on 5/30/22. She stated that she was unaware if she needed to address a weight loss that occurred over a one-week period of time. The RD stated, I did not put a note. She acknowledged that she did not enter a progress note until 11 days later. The RD stated that she felt the weight loss was unavoidable since the resident was difficult and refused interventions. She stated that the resident had wanted to lose weight and at some point, wanted to maintain her weight. The RD could not speak to why there was no weekly weight entry for 6/20/22, and further stated, I wouldn't know because I did not look at it. She stated that if a resident was on weekly weight's she was not looking at the weights and that nursing would alert her if there was a change. She acknowledged that she documented the intervention to provide the resident with half an egg salad sandwich at lunch. The RD stated that she informed the kitchen in writing to add the sandwich to the resident's meal ticket but could not speak to why it was not done. She stated that the egg salad sandwich was an intervention for weight maintenance, even weight gain. The RD stated that she was notified yesterday that the resident was not receiving the sandwich. She stated that the goal she had for the resident on the nutrition care plan should have had a 90-day time frame and that she reviewed the goal quarterly. She stated that goals should be measurable to assess whether or not interventions were working or needed to be adjusted. The RD stated that nursing gave her a Dietary Alert Sheet for Resident #77 yesterday which indicated the resident had a five-pound weight change within one month, was 118 lbs. and had a poor appetite. She provided a copy to the surveyor which was dated 6/28/22. On 6/29/22 at 3:02 PM, the survey team met with the LNHA, DON, Regional DON, [NAME] President of Operations, [NAME] President of Clinical Services. The DON stated that nursing obtained weights, recorded the weights in the EMR and when there were significant weight changes nursing notified the RD. She stated that the RD did not review weights for significant weight changes. On 6/30/22 at 10:17 AM, the surveyor interviewed the resident after breakfast. Resident #77 stated that he/she had not eaten much. On 6/30/22 at 10:50 AM, the surveyor interviewed LPN #1 in the presence of a second surveyor. She stated that the UM left about four weeks ago. She stated that the UM typically reviewed the weight's but now I guess it's us who were responsible. LPN #1 stated responsibilities for weight monitoring were not discussed with her from management after the UM left. She stated that she did not know how to calculate significant weight changes and was unaware of what parameters were used to identify significant weight changes. She provided the surveyors with a copy of a communication tool used titled Dietary Alert Sheet which indicated that if a resident lost or gained five lbs. within a one month or two-month period of time, they should alert the RD. She stated that RD notified nursing when a resident required a reweight or needed to be placed on weekly weights. LPN #1 stated that she gave the RD a Dietary Alert sheet for Resident #77 yesterday since the residents weights have been declining and he/she was now 118 lbs. She stated that I see the weekly weight's because I enter them into the EMR, and I saw the resident was down to 118 lbs., so I had to notify the RD. She stated that the resident had a poor appetite and was prescribed very few medications. She stated that the resident was on a low dose diuretic and had no issues with edema, and that could not have contributed to weight loss. LPN #1 stated that the resident had a big weight loss and that we probably missed it. She further stated that we started a three-day calorie count today and the resident barely ate breakfast. On 6/30/22 at 12:16 PM in the presence of the survey team and the LNHA, the RD stated that she had no further responses related to the concerns addressed for Resident #77. She stated only that she entered a progress note on 6/29/22 and started a calorie count 6/30/22 after surveyor inquiry. 2. On 6/20/22 at 10:49 AM, the surveyor interviewed Resident #80 in the presence of his/her significant other. They both reported to the surveyor that the resident had lost weight. The surveyor reviewed the medical record for Resident #80. Review of the residents admission Record reflected that the resident had diagnoses that included but were not limited to dysphagia (difficulty swallowing), gastro-esophageal reflux disease, and cerebral infarction (stroke). Review of the residents Quarterly MDS dated [DATE], a tool to facilitate the management of care, reflected that the resident had a BIMS score of 13 out of 15, which reflected an intact cognition. Review of the resident's nutrition care plan dated 11/15/21, reflected that the resident had a significant weight loss prior to admission in the community and again within the first month of admission. It also reflected that the resident desired weight maintenance. In addition, on 6/5 it reflected that the resident's readmission weight was pending and was being seen by the Speech Language Pathologist (SLP) due to difficulty chewing. Interventions on the care plan included monitor weights, Monitor/report/record . significant weight loss: 3 lbs. in 1 week, > 5% in 1 month, >7.5% in 3 months, >10% in 6 months, and Provide, serve diet as ordered. Monitor intake and record each meal. Review of the resident's physician Order Summary Report for June 2022 reflected a physician's order to obtain a weekly weight every Monday dated 6/2/22. Review of the residents eMAR for June 2022 did not reflect documented evidence that a weekly weight was obtained for 6/6/22, 6/13/22 and 6/20/22. The surveyor reviewed the weight record in the EMR. Weights documented were as follows: -4/11/22 182.6 lbs. -5/2/22 176.4 lbs. -5/9/22 178.2 lbs. -5/16/22 173.2 lbs. -5/23/22 171.1 lbs. (reflected a severe weight loss of 6.3% x 1 month) There was no documented evidence for obtaining weights and weight monitoring after 5/23/22. Review of the RD PN's did not reflect documented evidence that she identified or addressed the above noted weight loss. Review of the RD initial assessment for Resident #80 dated 11/12/21, reflected the resident weighed 192 pounds and experienced weight loss prior to admission to the facility. It reflected that the resident had a CVA with left hemiparesis (paralysis). It reflected that the resident's meal consumption was 50% or less and was at risk for weight loss. The RD calculated the resident's caloric needs at 30 calories per kilogram of body weight at that time. Review of the RD PN dated 6/5/22, reflected that the resident was readmitted to the facility on [DATE] after a hospitalization and that a readmission weight was pending. It reflected that prior to being hospitalized the resident weighed 171 which showed that was significant from prior month, 7%. It reflected that the resident returned on a puree consistency, apparently had difficulty chewing chopped prior to being hospitalized . It also reflected that the resident was at risk for weight loss and would be weighed weekly. The RD calculated the resident's caloric needs at 25 calories per kilogram of body weight. On 6/28/22 at 11:00 AM, the surveyor interviewed LPN #2 who cared for Resident #80 in the presence of a second surveyor. He stated that meal monitoring was done by the CNAs and consumption was recorded in accountability books. LPN #2 also stated that CNAs would verbally report if a resident was not eating or was eating poorly. He could not speak to what staff member was assigned to review the accountability books, however he stated that he would expect that the RD would review and use the information. He showed the surveyor the meal monitoring accountability books and copies were made for Resident #80. Review of the Meal Acceptance worksheets revealed Resident #80 had varied meal consumption for all three meals on dates 6/2/22 through 6/21/22 most of which reflected 50 % or less of the meal consumed. There were omissions for the following: Breakfast 6/3/22, 6/7/22, and 6/10-6/13/22. Lunch 6/3/22, 6/7/22, and 6/10-6/13/22. Dinner 6/7/22, and 6/9-6/13/22. There was documentation of meal consumption for lunch and dinner on 6/21/22 during which time the resident was hospitalized . LPN #2 also stated that residents were weighed on admission and readmission and were then placed on weekly weights for four weeks. He stated that if a resident had CHF, they would be weighed three times a week on Monday, Wednesday and Friday. He also stated that if a resident was brittle, they may weigh them daily. LPN #2 stated there were physician's orders for weights, and further stated that served as a reminder to record the weights in the eMAR and then it auto populated to the Weights/Vital section of the EMR. He stated that the CNAs know who to weigh as it was indicated in the weight book. He could not speak to when a reweight was required but stated that the RD monitored resident weights and would let the staff know when a reweight needed to be done by indicating that on the weekly weight worksheets. Review of the weekly weight worksheets did not reflect documented evidence of a weekly weight obtained after 5/9/22. On 6/30/22 at 11:16 AM, the surveyor interviewed LPN #2 in the presence of a second surveyor. He stated that the RD reviewed the weights and that he did not calculate significant weight losses. He stated that if a resident lost three pounds in a week, he would notify the RD and the physician. LPN #2 stated that he notified the RD if a resident was refusing to be weighed or was eating poorly. He also stated that the subacute residents, which were the residents on his unit, were weighed weekly. Review of a typed document from the RD dated 6/30/22 and provided to the surveyor on 7/1/22 at 8:51 AM from the LNHA reflected the following: On 4/11/2022 the resident had a weight of 182.6 pounds, on 5/9/22 the resident weighed 178.2 lbs., that is a total weight loss of 2.41%. on 5/16/2022 the resident's weight 173.2 lbs. which is 5.1% weight loss from the weight of 4/11/2022. On 5/23 the resident's weight was 171.1 which was a loss of 6.3% from 4/11/22. The resident was not flagged for a significant weight loss as he/she did not have a 5% weight loss in a 30-day span. On the resident's readmission I wrote a note that mentioned a weight loss of 7% (technically was only 6.3%) but that loss was not experienced over a 30-day period. When I wrote the note it was not my intention to say that he/she experienced a significant change, rather I was giving a brief summary of his weight history. Review of an additional typed document from the RD dated 6/30/22 and provided to the surveyor on 7/1/22 at 8:51 AM from the LNHA reflected the following: Calculated caloric requirement: the resident is non ambulatory, and [his/her] BMI (Body Mass Index - determines an individual's fat level as weight in kilograms divided by height in meters squared; The National Institutes of Health (NIH) now defines normal weight, overweight, and obesity according to BMI rather than the traditional height/weight charts) is above a desirable range therefore in calculation [his/her] daily nutritional needs 25 calories / kilogram body weight was utilized on [his/her] readmission nutrition assessment. Review of the facility policy Diet Identification and Preference Ticket with a revised date of 12/6/21, included that tray tickets were used to properly identify each individuals prescribed diet, food preferences, dislikes .etc. It further reflected that FSD, or designee was responsible for keeping the tray ticket information up to date. Review of an undated policy provided by the facility titled Significant Weight Loss, included that the goal of medical nutrition therapy for significant unintended weight loss was to identify underlying causes and factors and intervene as appropriate to resolve the problem and stabilize the weight. It identified significant weight loss as 5% in 1 month, 7.5% in 3 months and 10% in 6 months. If further identified severe weight loss as >5% in 1 month, >7.5% in 3 months and >10% in 6 months. It reflected to reweigh the resident to assure an accurate weight. It reflected to review the resident's food intake records to estimate the average percentage of food/fluid intake in the past two to four weeks. It reflected to document the resident's estimated nutritional needs (calories, protein and fluid) versus estimated food/fluid intake (utilizing food intake records). The policy also reflected to interview the resident to identify possible causes and to determine appropriate nutrition interventions as well as to implement nutrition interventions based on the resident's food and beverage preferences. It reflected to place the resident on weekly weights for one month and to monitor the weights weekly. The policy further reflected to monitor and evaluate to assess the effectiveness of the intervention, alter interventions as needed and complete follow-up documentation as needed. Review of the facility policy Weights Policy dated 5/25/22, included that residents would be weighed within 24 hours upon admission, readmission and on a monthly basis. It reflected that weight deviations of five pounds from the previous month will be confirmed with a reweigh with nursing supervision. If confirmed a Dietary Alert Sheet will be initiated and forwarded to the RD. Weights will be recorded by nursing staff in the weight book and transcribed to the EMR. Review of an undated facility policy Recording Percent of Meal Consumption included that staff would document the percentage of each meal consumed for an individual on a daily basis and data would be recorded in the CNA accountability log. Review of an undated facility policy Interdisciplinary Care Planning Policy and Procedures included that individualized interdisciplinary interventions will be planned by each discipline to correct problems identified. It reflected that a minimum of quarterly each resident's progress will be evaluated and documented. It reflected that problems not resolved will be reevaluated and new interventions established as necessary. In the interim between quarterly assessments, any significant changes in a resident's condition will be reviewed by the interdisciplinary team. Since the care plan is a dynamic document, in the interim between quarterly reviews, the team must revise problems, goals, and interventions in response to changes in the needs of residents. The RD provided a typed document with a list of resources she used for clinical guidance which included the following: Nutrition Care of the Older Adult: A handbook for nutrition throughout the continuum of care, 3rd Edition. Academy of Nutrition and Dietetics. [NAME] - Diet and Nutrition Care Manual. Dietitian in Health Care Facilities - [NAME]. Essential Pocket Guide for Clinical Nutrition. The Diet Manual - A nutritional handbook training guide. Additional resources referenced: Review of the Nutrition Care Manual from the Academy of Nutrition and Dietetics: Body Mass Index (BMI) is a ratio of weight to height and is used as an estimate of body fat in the heal[TRUNCATED]

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide a documented clinical rationale for the reason that as needed (PRN) anti-anxiety medications, including Lorazepam (Ativan) Tablets and Cream, were prescribed for greater than 14 days. This deficient practice was identified for 1 of 5 residents (Resident #67), reviewed for unnecessary medications and was evidenced by the following: On 6/21/22 at 11:00 AM, the surveyor observed Resident #67 walking in hallway independently, with no need for an assistive device. Resident #67 called the surveyor Mommy while passing by. The resident was wearing a Wanderguard on the left ankle. The surveyor observed that the resident wore this alarm device on all survey days. Resident #67 then sat in a chair in the dayroom near the surveyor and began talking to the surveyor in Spanish. On 6/23/22 at 11:26 AM, the surveyor observed Resident # 67 pacing around the dayroom. The resident spoke to the surveyor in Spanish. When the surveyor stated that she only spoke English, the resident stated, I want to get out of here. Then Resident #67 continued pacing, pointing to empty chairs in the room and saying something in Spanish. He/she also pointed and spoke to another resident in the room, who did not respond. On 6/23/22 at 11:35 AM, the surveyor observed Resident #67 return to the dayroom and continued pacing, pointing, speaking to no one in Spanish. On 6/23/22 at 11:45 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1), who stated that the staff try to observe Resident #67 from a distance. LPN #1 further stated that Resident #67 would get agitated if the staff touched the resident. LPN #1 also stated that they had to send the resident out of the facility a few times. He explained that they try to let Resident #67 just walk through the hallways and observe to make sure he/she doesn't bother any other residents. LPN #1 also stated that the resident's significant other visits frequently and then Resident #67 calms down. LPN #1 stated that staff don't always understand his/her Spanish dialect. On 6/27/22 at 11:49 AM, the surveyor observed Resident #67 seated at a table in the dayroom, speaking loudly in Spanish and gesticulating with his hand. A staff member set up the lunch tray for Resident #67 and the resident began eating a sandwich independently and remained quiet while eating. The resident's roommate was seated at the same table and both residents remained calm throughout the meal. On 6/27/22 at 12:58 PM, the surveyor observed Resident #67 make two attempts to open the dayroom door to the outside. One staff member stated that the alarm would make the resident stop trying to open the door. After the second try, Resident #67 stopped attempting to open the door. On 6/28/22 at 10:45 AM, the surveyor observed Resident #67 pacing through the hallway. The resident occasionally stepped into another resident's room, then came right out. Resident #67 stated to the surveyor, I want food. The surveyor reported this to LPN #1 and the Licensed Nursing Home Administrator (LNHA), who arranged to have a sandwich brought to Resident #67. On 6/29/22 at 10:50 AM, two surveyors observed Resident #67 approach the nurse's station crying and speaking in Spanish. LPN #3 redirected the resident. LPN #2 spoke softly to Resident #67, who then calmed the resident down. LPN #2 redirected the resident to the dayroom, where he/she calmly ate lunch. The surveyor reviewed the hybrid medical record for Resident # 67. According to the admission Record, Resident #67 was admitted a few months prior to the survey with diagnoses that included, but was not limited to unspecified psychosis not due to a substance or known physiological condition, dementia with behavioral disturbance, other specified depressive episodes, restlessness and agitation and generalized anxiety disorder. Review of the Significant Change Minimum Data Set (MDS), an assessment tool dated 5/27/22, indicated that Resident #67 had a Brief Interview for Mental Status score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further indicated that Resident #67 displayed no behaviors including rejection of care, wandering, hallucinations or delusions. Section E of the MDS also reflected that Resident #67 displayed no physical or verbal symptoms directed towards self or others. A review of the resident's June 2022 Order Summary Report (OSR) included the following physician's orders for Lorazepam Tablets and Cream dated 5/26/22: 1. Lorazepam Tablet 0.5 MG Give 1 tablet by mouth (PO) every 12 hours as needed for increased anxiety/agitation, if initial dose is ineffective give this dose one hour after initial PRN dose if anxiety/agitation persists. Further review of the order revealed the order did not contain a 14-day duration. 2. Lorazepam Cream 0.5 mg/0.5 ml Apply 0.5 mg topically every 12 hours as needed if resident refuses or spits out PO dose. Maximum dose of all formulations is 2 mg/24 hours every 12 hours as needed for severe agitation/anxiety with refusal of PO dosing. Only use if resident refuses PO dosing, maximum dose/24 hours is 2 mg. Further review of the order revealed the order did not contain a 14-day duration. A review of the Consulting Pharmacist's (CP) Therapeutic Suggestions, dated 6/6/22, included that following statement: A duration must be specified for PRN psychoactive medications. First order is limited to only 14 days, but if rationale documented by prescriber to continue order, then next duration may be for longer, i.e. 30, 60, or 90 days. Please update order for Ativan per CMS regulations. The resident's physician who had ordered the Lorazepam cream and tablets for Resident #67 signed the CP suggestion form as Accepted on 6/6/22, with a hand-written notation next to the suggestion, As per Psychiatry Notes. A review of the Psychiatry Progress Note, written on 5/23/22 included the following plan for resident #67: Discontinue Xanax .Start Ativan 1 mg PO every 12 hours PRN x 14 Days .Ativan gel 0.5 mg apply topically every 12 hours PRN, only if refused PO Ativan x 14 days. The Psychiatrist indicated to stop the PRN medications in 14 days, the OSR did not indicate a stop date. Fourteen days past the original physician's order of 5/26/22 would reflect a stop date of 6/9/2022. The resident received 10 doses of either Lorazepam Tablets or Cream after the stop date suggested by the pharmacist and the psychiatrist as evidenced by the following: Review of the June 2022 electronic Medication Administration Reports (eMAR) reflected that Resident #67 received Lorazepam Tablet 0.5 mg by mouth on the following dates and times: - 6/17/22 at 1038 hours [10:38 AM] - 6/17/22 at 2018 hours [8:18 PM] - 6/20/22 at 1451 hours [2:51 PM] - 6/21/22 at 1138 hours [11:38 AM] - 6/22/22 at 1219 hours [12:19 PM] - 6/23/22 at 1949 hours [7:49 PM] - 6/24/22 at 1640 hours [4:40 PM] The eMAR for June 2022 indicated that Resident #67 received Lorazepam Cream 0.5 mg/0.5ml topically on the following dates and times: - 6/18/22 at 1654 hours [4:54 PM] - 6/19/22 at 1608 hours [4:08 PM] - 6/26/22 at 2006 hours [8:06 PM] On 6/29/22 at 10:47 AM, two surveyors interviewed LPN #2 who stated that she had worked at the facility for one year. When asked about the process for giving PRN psychotropic medication, LPN #2 stated, See that they (residents) display behaviors, such as anxiety, combative, etc. Follow the doctor's order. Check the last time they had the medication. Check the day the order began and if it is discontinued. On 6/29/22 at 10:55 AM, two surveyors interviewed LPN #3, who stated that she had been employed at the facility for three years. The LPN knew Resident #67 well and stated that the resident can get extremely aggressive. They changed .from Xanax to Ativan, so we can give .the Ativan Gel. LPN #3 explained that they needed a way to calm the resident if he/she was not willing to take medication by mouth. She stated that the resident's medications were tweaked a little bit and Resident #67 shows some improvement. She stated that the original dose of Ativan was decreased and the psychiatrist was following the resident. LPN #3 and the two surveyors observed the electronic Physicians Orders, which indicated that PRN Ativan tablets and cream were started on 5/26/22, and an end date indicating indefinite. The surveyors referred to the CP recommendation to reevaluate the PRN Ativan orders after 14 days, but could be continued for longer if the prescriber documents a reason to continue the medication. The surveyors also pointed out that the psychiatrist's note indicated Ativan x 14 days. LPN #3 stated that Resident #67 has a lot of behaviors .can be different each day we do the best we can to keep .all residents and the staff safe. When asked about what happens to the CP recommendations, LPN #3 stated that they were shared with the Director of Nursing (DON). It would have been sent to her and she shares them. On 6/29/22 at 11:06 AM, two surveyors interviewed the Nurse Practitioner (NP) regarding the Pharmacist recommendation to have a stop date on the PRN Ativan orders. The NP stated that the medication should be re-evaluated in 14 days but, We write 'indefinite' because of resident's continued behavior and because of recommendations from Psych to continue the medications. The nurses notes reflect the continued behaviors of the resident and the need to continue the Ativan. The NP stated that the MD wrote about several behavioral incidents in June. The surveyors brought to the NP's attention the psychiatry note indicating Ativan x 14 days. In response, the NP stated, Yes .should re-evaluate in 14 days and document resident's behavior and reason for continuing the medication past 14 days. Should have an end date and if need to continue should write a new start date. Understood. On 6/29/22 at 11:47 PM, the two surveyors interviewed the Medical Doctor (MD) who ordered the PRN Ativan for Resident #67. When asked about her reply to the CP recommendations to refer to the psychiatrist note. The MD stated, the note means that we co-manage the resident. She stated that Resident #67 has on-going problems and gets sent out. I go by the Psych assessment. We can re-evaluate, but I mostly follow the Psych recommendation. The surveyor pointed out that on the Ativan order, the stop date was Indefinite. The surveyor showed the physician the psychiatry evaluation, dated 5/23/22, with a recommendation for PRN Ativan x 14 days. The physician stated that they should re-evaluate the need to continue the Ativan in 14 days and put a stop date and if need to continue the medication, put a new start date. She stated that moving forward she would document the reason for continuing the PRN Ativan past the 14 days. She also stated that the CP gives her monthly notes. I go through them and address them. The MD concluded that the goal was to keep the resident safe. On 6/30/22 at 1:04 PM, the surveyor interviewed the DON who stated that she did not get the CP recommendations. Not the therapeutic suggestions. They go to the MD, who reviews suggestions, accepts or not. If she accepts then the nurse is supposed to follow up with the orders. In this case it refers to the psychiatry note. I think the nurse is supposed to say whatever is in the psychiatry note. Which referred to 14 days. The surveyor stated that the medications mentioned in the CP Therapeutic Suggestions for Resident #67 were given to the resident beyond 14 days of the original order. The DON replied, Right. On 6/30/22 at 9:17 AM, the LNHA provided an undated document entitled Pharmacy Consultant Therapeutic Suggestions Process which included the following statements: 1- After Consultant pharmacist monthly report is received the DON/Designee will review the Unit Inspection Report, Nursing Suggestions and Therapeutic Suggestions. 2- Verbal report will be given to Unit Manager/Nursing Designee with instructions to pay attention to certain suggestions. 3- The Therapeutic Suggestions are placed in the MD Binder on unit. The MD/designee will review and either accept or not accept the recommendations and will sign off. 4- The MD/designee will leave the completed form for the nurses who will then review and if the recommendations are accepted the nurse should carry through with recommended orders. 5- The unit Manager/Nurse Designee completes the Report and provides actions taken. This report is then returned to the DON/Designee. If there are any issues a discussion will take place and further action will be taken otherwise it is noted that suggestions are completed. The LNHA also presented a progress note for Resident #67 dated 6/29/22, which indicated that the behavioral health clinician, NP and MD agreed that Resident #67 should continue Lorazepam 0.5 mg tablets every 12 hours PRN for 14 more days and then re-evaluate. The note also indicated the Lorazepam gel and order for Lorazepam 0.5 mg po one hour post dose of Lorazepam if ineffective should be discontinued. The LNHA provided copies of the physician's orders which reflected these changes. NJAC 8:39-27.1(a), 29.3 (a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 1 of 4 medication carts and 1 of 2 medication refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 10:10 AM, the surveyor inspected the 200-nursing wing medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Novolog insulin (Diabetes) vial that had an opened date of [DATE] and an expiration date of [DATE]. At that time, the surveyor interviewed LPN #1 who acknowledge that the Novolog Insulin was expired and should have been removed from the medication cart on [DATE]. On [DATE] at 10:25 AM, the surveyor inspected the 100-unit medication room refrigerator in the presence of LPN #2. The surveyor observed an opened bottle of Lorazepam 2 mg/ml solution (anxiety medication) that was not dated but had a pharmacy label date of [DATE]. The surveyor also observed an opened Lorazepam 2 mg/ml single use IM vial that was dated [DATE] and was still in the medication refrigerator. The surveyor interviewed LPN #2 who stated that Lorazepam 2 mg/ml oral solution should have been dated when opened. LPN #2 also acknowledge that a single use Lorazepam vial should have been disposed once opened. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Novolog insulin vial once opened have an expiration date of 28-days 2. Lorazepam 2 mg/ml oral solution once opened have an expiration date of 90-days. On [DATE] at 1:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and no further information was provided by the facility. A review of the facility's policy for Labeling of Medication Containers that was dated [DATE] and was provided by the LNHA indicated the following: 3. Labels for individual resident medications include all necessary information, such as: h. The expiration date when applicable; and. A review of the facility's policy for Controlled that was undated and was provided by LNHA indicated the following: 8. Unless otherwise instructed by the Director of Nursing Services, when a resident refuses a non-unit dose medication or it is not given, or receives partial tablet or single dose ampules, or it is not given, the medication shall be destroyed, and may not be returned to the container. NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure foods were provided and prepared in a manner consistent with physician prescribed mechanically altered diets for 2 of 20 residents (Resident's #72 and #58) observed during a lunch meal. This deficient practice was evidenced by the following: On 6/21/22 at 12:11 PM, the surveyor observed the lunch tray for Resident #72 in the presence of a second surveyor. The meal ticket on the tray indicated the resident was on a Chopped diet. There were two chocolate chip cookies wrapped in a bag on the tray. At approximately the same time, the surveyors observed the lunch tray for Resident #58. The meal ticket indicated the resident was on a Puree diet. The pureed vegetables did not appear smooth and had unpureed particles. A review of Resident #72's Order Summary Report for June 2022, reflected that the resident had a diet order for a Chopped texture dated 5/19/21. A review of Resident #58's Order Summary Report for June 2022, reflected that the resident had a diet order for a Pureed texture dated 2/2/22. At 12:15 PM, the surveyor requested a sample tray for a Chopped and Pureed consistency diet from the Registered Dietitian (RD) in the presence of a second surveyor. Both surveyors joined the RD into the kitchen as the [NAME] prepared plates of the Chopped and Pureed lunch meal and the surveyor also asked for a sample of the Chopped and Pureed lunch desserts. At that time the Regional Licensed Nursing Home Administrator (LNHA) entered the kitchen. The surveyors immediately brought the samples to the conference room in the presence of the entire survey team. The survey team observed that there were two hard crisp chocolate chip cookies identified as the dessert for the Chopped diet. The survey team also observed that the pureed mixed vegetables which was not smooth and had particles of green bean, carrot and other fibrous pieces. At 12:45 PM, the surveyor interviewed the Speech Language Pathologist (SLP) in the presence of the survey team. After reviewing the samples, the SLP stated that Mechanically Altered diets are typically Chopped to bite size pieces, Ground or Pureed. She stated that Mechanical Soft diet were soft foods and that Chopped diets should indicate chopped as bite sized or ground. Then she assessed the sampled meals with the surveyor. She stated that a Mechanical Soft or Chopped diet should not receive hard textured cookies like these as she pointed to the cookies on the tray and stated that these are too hard. In addition, as she assessed the pureed vegetables, she stated that she would not be ok with the vegetables that were in the pureed food. The SLP stated that she would have expected the pureed vegetables to be smooth. She stated that she would expect the kitchen staff to have knowledge about the diet consistencies and what would and would not be allowed. In addition, she stated that she would expect the kitchen staff to ensure the trays were accurate before they were delivered to the residents. At 1:35 PM, the Regional LNHA, the LNHA, the RD and the SLP requested to meet with the survey team. The RD stated that the Regular diet and the Mechanical Soft diet are the same for the lunch meal that day. The RD stated that she reviewed and signed the facility menus for adequacy, accuracy and appropriateness and she bases this on the guidelines from the Diet Manual. The RD stated that the Mechanical Soft diet were soft foods and Chopped was specific to meats as bite sized or ground. She stated that the Mechanical Soft diet and the Chopped diets were interchangeable. The RD stated that on the Chopped diet the cookies should be soft. As she felt the cookies in the presence of the survey team, she stated that the cookies were not as soft as they could have been, they could have been better. She stated that the cookies were fresh baked and that they were cooked more than they should have been. The SLP acknowledged the same and stated that they were hard. The RD stated that the Pureed diet should be smooth. As the surveyor pointed out the particles in the pureed vegetables on the plate the RD responded, could have been pureed a little bit more. The SLP acknowledged the same. She stated that the Cooks prepare the meals, and it was the responsibility of the Food Service Director (FSD) to oversee the process for accuracy. The RD further stated that the FSD performed competencies on the Cooks for pureed food preparation. At 1:45 PM, the RD provided the surveyor with a copy of the Mechanical Soft Consistency policy used by the facility dated 2018. Under the title i.e., Chopped was handwritten. The RD acknowledged that she wrote that. She also provided the surveyor with a copy of the Puree Consistency policy from the same manual. On 6/23/22 at 12:22 PM, the LNHA informed the surveyor that she could not find the Cooks competencies for puree preparation. On 6/28/22 at 11:17 AM, the surveyor interviewed the interim FSD in the presence of a second surveyor. He stated that a pureed consistency should be smooth and pudding-like. He further stated that the pureed consistency should not have any particles or pieces in it. A review of the facility's Spring/Summer 2022 Menu for Week 3 - Tuesday dated 5/17/22 and signed by the RD, reflected the lunch meal served on 6/21/22. It indicated that the Mechanical Soft diet should have received 2 chocolate chip cookies for dessert which was the dessert the regular diet received. A review of the Mechanical Soft Consistency i.e., Chopped policy dated 2018, reflected that the purpose was To safely provide adequate nutrition and to facilitate eating for individuals with impaired chewing and/or swallowing ability. It also reflected that Mechanical Soft foods are easy to chew and soft in texture. It further reflected that foods with dry hard crusts should be limited/avoided. A review of the Puree Consistency i.e., Chopped policy dated 2018, reflected that the purpose was To safely provide adequate nutrition and to facilitate eating for individuals with impaired chewing and/or swallowing ability. It further reflected that Foods are pureed, homogeneous, and smooth; and have pudding-like consistency. It further reflected that when pureeing vegetables Avoid any foods that cannot be pureed to the appropriate texture i.e., smooth non-fibrous consistency. NJAC 8:39-17.2(a), 17.4(a)1,2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, and review of pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted guidelines for infection prevention and control. This deficient practice was identified for 1 of 5 staff members observed donning and doffing. The evidence was as follows: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/2/2022 included, HCP [Healthcare Personnel] must receive training on and demonstrate an understanding of when to use PPE, what PPE is necessary, how to properly don (put on), use and doff (remove) PPE in a manner to prevent self-contamination, how to properly dispose of or disinfect and maintain PPE, limitations of PPE. It further included that HCP should perform hand hygiene before putting on and removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process . Remove and discard gloves before leaving the patient room or care area, and discard gown in a dedicated container for waste or linen before leaving the patient room or care area. On 6/28/22 at 11:08 AM, the surveyor observed room [ROOM NUMBER] with signs for contact and droplet precautions and a stop sign which indicated please see the nurse before entering this room. At that same time, the surveyor observed the Director of Social Work (DSW) walk out of room [ROOM NUMBER] into the hallway wearing a blue disposable gown and remove the gown. The DSW then rolled the gown up and disposed the gown into a small open trash bin which was located in the hallway next in the to room [ROOM NUMBER]. On that same date and time, the surveyor interviewed the DSW who stated yeah, I should have doffed before coming out, but I forgot something. Yes, I was trained to remove PPE prior to coming out of the room. On 6/28/22 at 11:12 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that room [ROOM NUMBER] was a PUI [person under investigation] room and spoke to the process of donning and doffing. On 6/28/22 at 1:36 PM, the surveyor interviewed the Infection Preventionist (IP) who spoke to the process of donning and doffing and stated that the DSW should have removed the gown prior to coming out of the room. I will have to re-educate her. On 6/28/22 at 2:03 PM, the survey team met with the administrative staff and discussed the above observation and concern. On 6/29/22 at 9:50 AM, the Licensed Nursing Home Administrator stated that the DSW was re-educated on proper donning and doffing of PPE. Review of the facility's policy for contact precautions dated 5/18/22, included before exiting room, remove and discard gown and gloves and wash hands upon exiting room. Review of the facility's policy for droplet precautions dated 5/18/22, included before exiting room, remove and discard PPE and wash hands. NJAC: 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) maintain the necessary respiratory care and services for a resident who was receiving continuous oxygen for 2 of 3 residents (Resident#22 and #338) and b.) ensure that tracheostomy (a surgical opening through the neck into the windpipe providing an airway) care and services were provided according to the standard of practice for 1 of 1 resident (Resident#76) reviewed for tracheostomy care. This deficient practice was evidenced by the following: According to the U.S. CDC (Centers for Disease Control and Prevention) Guidelines for Preventing Health-Care-Associated Pneumonia, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee, dated 3/26/2004, included, III. Prevention of Transmission of Microorganisms .B. Prevention of Person-to-Person Transmission of Bacteria 1. Standard Precautions a. Hand hygiene: Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent (e.g., hand rub) if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn. Decontaminate hands as described previously before and after contact with a patient who has an endotracheal or tracheostomy tube in place, and before and after contact with any respiratory device that is used on the patient, whether or not gloves are worn. b. Gloving 1) Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient. 2) Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. 1. On 6/20/22 at 10:38 AM, the surveyor observed Resident # 22 lying in bed with 2 (two) LPM (liters per minute) oxygen with use nasal (nose) cannula not labeled or dated attached to the oxygen concentrator (type of medical device used for delivering oxygen to individuals) with humidified bottle (Oxygen humidifiers are commonly used, because the oxygen used is a dry and irritating gas that, if poorly humidified, causes lesions of the respiratory mucosa). On 6/27/22 at 11:14 AM, the surveyor interviewed the staff Licensed Practical Nurse#3 (LPN#3) who stated, if O2 tubing is not dated we are supposed to change it, but we prioritize med's and direct care is more important. The night shift signs the O2 tubing and humidification bottle changes on Wednesdays which is a generated task on the Medication Review Record (MAR). There is no respiratory therapist currently in the facility. On 6/28/22 11:39 AM, the surveyor interviewed, the Infection Prevention who stated, O2 tubing, and humidification bottle is changed on the 11 pm-7 am shift, there is no specific day the task is assigned. The tubing and humidifier bottle and nasal canula should be labeled and dated. The respiratory treatment tubing gets changed daily, mask gets rinsed, dried, and put in a bag and that is dated and labeled. On 6/28/22 at 1:00 PM, the surveyor interviewed, the Director of Nursing (DON) in the presence of another surveyor. The DON stated, the nurse on the 11 pm-7 am, Tuesday night going into Wednesday will change the tubing and humidification bottle and label and date it. The DON further described infection control practices for respiratory care, and further stated, the nurse changes the tubing weekly and label and date it, all equipment should have a tag stating the date, time, and nursing initials that changed it, nurses on every shift are responsible to make rounds on their residents checking the tubing for a label and date. The surveyor reviewed the medical records for resident #22. Review of the admission Record revealed a diagnosis of hemiplegia and hemiparesis following cerebral infarction, (Cerebral Infarction (Sequela) Hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis.) Chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), obesity (a complex disease involving an excessive amount of body fat), aphasia (loss of ability to understand or express speech, caused by brain damage.), dependence on supplemental oxygen (If there is not enough oxygen in your bloodstream to supply your tissues and cells, then you need supplemental oxygen to keep your organs and tissues healthy.) A review of the Annual Minimum Data Set (MDS) dated [DATE], reflected that the resident's Cognitive Skills for Daily Decision Making was severely impaired. A review of the Care Plan dated 6/24/2021, and revised on 6/10/2022, indicated a focus area was that the resident was on O2 therapy and Nebulizer therapy related to respiratory illness. A review of the June 2022 Order Summary Report (OSR) reflected a physician order (PO) dated 5/25/22 to change humidifier O2 bottle weekly, label with date and time every night shift Wednesday for infection control. A further review of the June 2022 Order Summary Report reflected a PO dated 5/24/22 change mask or cannula every Wednesday for infection purposes. The PO did not specify to label and date the cannula tubing. A review of the June 2022 electronic Medication Administration Record (eMAR) revealed change humidifier bottle weekly, label with date and time every night shift Wednesday for protocol/ infection control dated 5/25/22. The eMAR did not specify to label and date the nasal cannula tubing. 3. On 6/23/22 at 1:31 PM, the surveyor observed Resident #76 in a Geri chair recliner awake, however, did not respond verbally or make eye contact to the surveyor's inquiries. The resident had a tracheostomy tube and a tracheostomy (trach) mask attached to a humidifier that was set at 35%. The resident had no signs and symptoms of distress. On 6/27/22 at 9:16 AM, the surveyor reviewed the June 2022 eTAR which reflected a physician's order to change the tracheostomy tube inner cannula weekly one time a day, every Monday. A further review of the eTAR did not reflect a physician's order for trach care and suctioning. On 6/27/22 at 11:35 AM, the surveyor observed LPN#4 performed a treatment to change tracheostomy tube inner cannula in the presence of another surveyor. The resident was lying on a Geri chair recliner, awake but nonverbal with no eye contact, and with no signs and symptoms of distress. The surveyor observed a bedside table covered with a white linen cloth that was already set up with two trach supply kits, two unopened bottles of sterile saline water, several individual packs of sterile dressings (gauzes), a black marker, and tape. LPN#4 started by closing the resident's door for privacy which he then proceeded to perform appropriate hand hygiene and explained the procedure to the resident. The surveyor did not observe LPN#4 review the physician's orders prior to starting the procedure. Next, he donned (put on) a pair of sterile gloves using the sterile glove technique, but he tore his right glove in the process. He doffed (removed) the gloves and proceeded to apply new sterile gloves grasping the inside surface of the cuff of the glove. The surveyor did not observe LPN#4 performed hand hygiene after doffing the ripped gloves and before donning a new pair of sterile gloves. At that same time, the surveyor observed a nightstand drawer in the resident's room that was currently being utilized for the storage of the respiratory care and tracheostomy supplies, including tracheostomy inner cannula's. After the completion of the inner cannula change treatment, LPN#4 utilized paper towels to pick up the unopened sterile normal saline bottle, several unopened sterile dressings, black marker, and tape from the bedside table and transferred them to the top of the resident's nightstand drawer, where the trach supplies were stored. The surveyor did not observe LPN#4 performed hand hygiene. At approximately 12:17 PM, LPN#4 stated that he finished the procedure and informed the surveyor that he was done with the treatment. The surveyor asked LPN#4 if there was anything else he needed to do and he responded no, I'm done. The surveyors did not observe LPN#4 sign the eTAR for the inner cannula change. On that same date at 12:43 PM, the surveyors interviewed LPN#4 in the presence of the survey team. He stated that before performing the treatment, the physician's orders should have been reviewed. He acknowledged that he did not review the physician's order before performing the inner cannula change procedure. Furthermore, he stated that he should have read and reviewed the physician's order before performing the treatment to the resident. During the interview, he informed the surveyors that he realized that there was no physician's order for trach care and stated, I thought there was an order for tracheostomy care. He stated that there should have been a physician's order for trach care and stated, it was overlooked. He informed the surveyors that the physician's order for trach care was only obtained today. In that same interview, LPN#4 stated that he was supposed to sign the eTAR right after he performed the inner cannula change procedure. He acknowledged that he did not sign the eTAR after performing the procedure in the presence of the surveyors. At that same time, LPN#4 informed the surveyors that hand washing was required every time before donning and after doffing gloves. He stated that the resident's personal trach care supplies that were stored on top of the nightstand drawer were clean. He also referred to the bedside table as the dirty area after he used it to perform the treatment. He acknowledged that he took the unopened and unused supplies that were on the bedside table and transferred them to the resident's top nightstand drawer. He also acknowledged that the unused supplies were transferred using paper towels, without using gloves, and without performing hand washing afterwards. On 6/29/22 at 10:27 AM, the surveyor interviewed the Advanced Practice Nurse (APN) in the presence of another surveyor. She stated that residents with tracheostomies needed trach care and suctioning to ensure that they were receiving appropriate treatment and care. Furthermore, she acknowledged that trach care and suctioning orders required physician orders. However, the APN could not speak to why there was no physician orders for trach and suctioning for Resident #76 and stated, I don't know what happened. On that same date at 10:44 AM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN#1). She acknowledged that Resident #76 had multiple readmissions to the facility following hospitalizations on 6/1/22, 6/26/21, and 6/14/21. She also acknowledged that the trach care and suctioning required physician's orders. She confirmed that there was no physician's orders or documented evidence for trach care and suctioning in the eTAR since the resident's readmission to the facility since 6/14/21. The LPN#1 could not speak to why the trach care and suctioning were not ordered after each readmission. She informed the surveyors that the physician's orders for trach care and suctioning was obtained on 6/27/22. On that same date at 12:20 PM, the DON stated in the presence of the survey team that a resident with a tracheostomy should have physician's orders for trach care and suctioning PRN [as needed] upon admission to the facility. The DON could not speak to why there was no physician's orders for trach care and suctioning upon the resident's readmissions to the facility. On 7/1/22 at 10:43 AM, the survey team met with the administrative team. No further information was provided. The surveyor reviewed the hybrid medical record for Resident #76. Review of the electronic Progress Notes dated 6/2/22, reflected Physicians notes that documented medical diagnoses which included but were not limited to Chronic Respiratory Failure (a condition when the lungs have a hard time loading blood with oxygen or removing carbon dioxide), Hypoxic Encephalopathy (brain dysfunction caused by a lack of blood follow and oxygen to the brain) with Quadriplegia (paralysis of all four limbs), and Anoxic Brain Damage (harm to the brain due to a lack of oxygen). Review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/7/22 indicated that the cognitive skills for daily decision making for the resident was severely impairment. The assessment reflected that the resident was dependent on staff seven days a week for all care and required total dependence of one to two person assistance with care. Review of the electronic Progress Notes dated 6/26/21 and 6/1/22, reflected that the resident was readmitted to the facility. Review of the Universal Transfer Form (a form that communicates pertinent clinical patient care information at the time of a transfer between health care facilities) indicated that the resident was also readmitted to the facility following a hospitalization on 6/14/21. Review of the 6/14/21 through 6/26/22 eTARs, indicated no documented evidence of physician's orders and accountability for trach care and suctioning. Review of the 6/2/22, 6/4/22, 6/5/22, 6/7/22, 6/8/22, 6/9/22, 6/15/22, 6/18/22, 6/19/22, 6/20/22, 6/21/22, 6/23/22, and 6/25/22 electronic Skilled Charting reflected that the resident was provided with tracheostomy care. Furthermore, there was no documented evidence that an assessment was performed on how the resident tolerated the procedure after providing the tracheostomy care. Review of the electronic Progress Notes for June 2022 reflected no documented evidence that an assessment of how the resident tolerated the procedure after performing tracheostomy care on the above corresponding dates. Further review of the electronic Progress Notes reflected the following Health Status Notes: - 6/22/22 at 04:46 AM, indicated that the resident was suctioned. - 5/27/22 at 00:03 reflected sputum expectorating from inner canula, Suctioning applied. - 5/26/22 at 01:40 indicated that Trach was suctioned There was no evidence of a physician order for the suctioning of the tracheostomy. Review of the facility's Tracheostomy Suctioning form that was utilized and completed for staff competency reflected steps that included Verifies physician's order. The facility's Tracheostomy Care procedure guidelines reflected that the purpose of tracheostomy care was to maintain clean and patent tracheostomy. It also indicated that it should be done according to the physician's orders. The facility policy for Handwashing reflected to wash hands after removing gloves, after handling soiled tissues, and upon completion of duty. The facility policy and procedure for Tracheostomy Care, reviewed on 5/18/22 reflected that when concluding tracheostomy care, it was indicated to properly clean or dispose of all equipment, supplies, solutions, and trash. It was also specified to repeat the trach care procedure at least once every 8 hours and to document the resident's tolerance of the treatment. NJAC 8:39-25.2 (b), (c) 4 2. On 6/21/22 at 12:01 PM, the surveyor observed Resident# 338 laying in bed with 2 (two) LPM (liters per minute) oxygen with use nasal (nose) cannula attached to the oxygen concentrator (type of medical device used for delivering oxygen to individuals) with humidified tubing dated 6/21/22. The surveyor asked the resident how he/she was and the resident stated I am okay. On 6/23/22 at 8:34 AM, the surveyor observed the resident on 2 LPM oxygen via nasal cannula. The surveyor reviewed the medical record of Resident#338. According to the admission Summary, the resident was admitted to the facility with diagnoses that included dysphagia oropharyngeal phase (difficulty initiating a swallow) and dependence on supplemental oxygen. Review of the 5/25/22, Comprehensive Minimum Data Set (CMDS), revealed a BIMS score was 11 out of 15, which indicated that the resident's cognition was moderately impaired. The CMDS noted that the resident was on oxygen therapy. Review of the June 2022 OSR revealed an order dated 5/19/22, for oxygen at 3 L (three liters) via nasal cannula every shift for PNA (pneumonia=lung inflammation caused by bacterial or viral infection). The above order for oxygen was not transcribed to the June 2022 eMAR or electronic Treatment Administration Record (eTAR). Further review of the June 2022 OSR showed that there was no order for oxygen tubing change and care. Review of the personalized care plan revealed a focus area for oxygen therapy r/t [related to] respiratory illness which was initiated on 6/13/22. The care plan did not include interventions on how often the oxygen tubing would be changed. On 6/28/22 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the oxygen order should be followed. On 6/29/22 at 10:32 AM, the surveyor in the presence of another surveyor interviewed the Licensed Practical Nurse #1 (LPN#1) who stated that Resident#338 was cognitively impaired, required maximum assistance with activities of daily living (ADL), and was on continuous oxygen at 2 (two) LPM via nasal cannula. The LPN#1 further stated that there should be an order for oxygen and accountability for oxygen tubing change in the eMAR or eTAR signed by nurses. She also stated that the 11-7 shift nurse was responsible for changing the oxygen tubing once a week. A short time later, the surveyor asked the LPN#1 to go to the resident's room to show the surveyor how much oxygen the resident was receiving. In the resident's room, the LPN#1 checked the oxygen concentrator and showed it to the surveyor. The LPN#1 stated that the nasal cannula tubing date was 6/23/22 and that the resident was on 2 (two)LPM oxygen right now. The resident was stable and did not complain to the nurse. On that same date and time, the surveyor and the LPN#1 went back to the nursing station and reviewed the oxygen order for Resident#338. The LPN#1 then checked the eMAR and eTAR, and stated the order was for 3 (three) LPM. I thought the resident had it at 2 (two) LPM. She further stated that the order was not flagged, which was why the oxygen order was not transcribed to either the eMAR or eTAR. The LPN#1 indicated that there was no order for oxygen tubing change once a week and I'm fixing the order now. The LPN#1 stated that there was no negative effect on the resident and she showed the surveyor that nurses have been documenting the oxygen saturation in the medical record which indicated that the oxygen saturation was within normal limits. On 6/29/22 at 2:05 PM, the surveyor interviewed LPN#2 who stated that the resident was on continuous 2 (two) LPM via nasal cannula and when I came in today at 7 AM, as ordered. The surveyor informed LPN#2 of the 3 (three) LPM order. LPN#2 then stated, I thought the order was for 2 (two) LPM. On 6/29/22 at 02:26 PM, the survey team met with the LNHA, DON, [NAME] President for Operations (VPO), VP for Clinical's (VPC), and Regional DON and were made aware of the above concerns. On 7/01/22 at 10:43 AM, the survey team met with the LNHA. The LNHA informed the survey team that there was no additional information.

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during kitchen tours and was evidenced by the following: On 6/20/22 at 9:27 AM, the surveyor toured the kitchen with the Registered Dietician (RD). She stated that the Food Service Director (FSD) #1 was off for the day. The following was observed: 1. The handwashing sink near the kitchen entrance area was loose from the wall. The sink had a reddish/orange like substance and there was an accumulation of a white and black fuzzy substance. The area under the sink had an accumulation of black and white particles and there was an accumulation of still standing water. In addition, there were pieces of plastic, foil and paper on the floor. The RD stated that the floor looked like there was a lime substance and should have been cleaned. She further stated, obviously could do a little cleaning. In addition, the RD stated that I'm not sure how long it was not cleaned but need a cleaning. 2. The clear plastic ice scoop was inside a clear plastic ice scoop holder which was not covered and exposed to the environment. There was an accumulation of a black and white substance in the tube/water line of the ice machine. 3. The reach in freezer digital thermometer located on the outside of the unit read 11 degrees Fahrenheit (F). There were two internal thermometers, one read 18 degrees F and the other 29 degrees F. The RD stated, I don't know why the temperature was off. In addition, she stated that the temperatures were checked that morning and were fine. The RD further stated that the freezer temperature should be below 0 degrees F and that there were temperature logs that she would show the surveyor. 4. The reach in refrigerator digital thermometer located on the outside of the unit read 42 degrees F. There were two internal thermometers, one read 20 degrees F and the other 32 degrees F. 5. The hood above the cooking area had a brownish substance along one side. The RD stated that the kitchen staff cleans the area/hood once a week. At that time the surveyor requested documented evidence of a cleaning accountability system. 6. The glass inserts of the double stacked convection oven doors were covered with a brown substance which obscured visibility into the ovens. [NAME] #1 stated that the ovens were cleaned three months ago. The RD stated that the brownish substance on both glass doors were accumulation of debris and grease. The RD further stated that it should have been cleaned. 7. There was a storage room that the RD stated held kitchen cleaning materials and supplies. There was a sink with a leaking faucet and there was a brownish/greenish residue in the sink. The bottom of the sink had a heavy buildup of a fuzzy black and white substance. There were plastic containers and mop heads inside the floor sink that also had a buildup of a brownish substance. The RD stated that the faucet sink was probably not closed properly, and the RD tried to tighten the faucet. She stated that, I think I've gotten it worse, it won't turn off. The RD stated that the room should have been cleaned. 8. The walk-in freezer external thermometer read 30 degrees F. The RD stated that, I don't know why it's reading like that, and she stated that it should have been below 0 degrees F. The RD was unable to locate an internal thermometer. The Maintenance Director (MDir) joined the tour at 10:23 AM and confirmed that there was no internal thermometer in the walk-in freezer. In addition, [NAME] #1 confirmed that she too could not locate an internal thermometer in the walk-in freezer. [NAME] #1 stated that it was the cook's responsibility to check and record the temperatures of the refrigerators and freezers in the morning. She further stated that she had not gotten the chance to do so that morning because the kitchen was short staffed. In addition, [NAME] #1 stated that there was a binder that had all the refrigerator and freezer temperature monitoring logs. At that time, the Regional Licensed Nursing Home Administrator (LNHA) joined the tour. 9. There was a ceiling fan directly over a food prep table that had a heavy buildup of a fuzzy gray substance. There was an open container of kimchi (a Korean dish of spicy pickled cabbage) directly under the fan. The RD stated that the container should have been closed or covered. 10. There was a case of canned mixed vegetables stored directly on the floor in the storage room. 11. At 10:35 AM, the RD checked the temperatures of the reach-in freezer again in the presence of the surveyor. The external digital thermometer read 15 degrees F. The two internal thermometer's read 19 degrees F and 32 degrees F. In the presence of the RD, [NAME] #1 stated that she had not checked the temperatures that morning for any/all the freezers and refrigerators since the kitchen was short staffed. The RD provided the surveyor with copies of the kitchens Daily Freezer/Refrigerator Temperature Log's for the month of June 2022. It revealed that there were no temperatures recorded the mornings of June 9th, 16th and 20th for the following units: cook fridge, cook freezer, ice cream, beverage fridge, walk-in fridge, and walk-in freezer. 12. At 10:51 AM, the surveyor toured with the MDir to view the emergency water supply. There were crates of water that were stored directly on the floor with a heavy build up of a fuzzy grayish/brownish substance. On 6/21/22 at 11:08 AM, in the presence of two surveyors, the LNHA stated that when she started working at the facility in May 2022, she found that the kitchen was not clean and the previous FSD #2 was not competent. She stated that a new FSD #1 started about a week and a half ago. She stated that he had worked on the weekend and then resigned on 6/20/22 without notice. The LNHA acknowledged that there was no accountability system in place for kitchen sanitation. In addition, she stated that the RD would be overseeing the kitchen until the facility was able to replace the FSD position. On 6/27/22 at 9:34 AM, two surveyors conducted a second kitchen tour with the RD and an interim FSD. The following was observed: 13. The clear plastic ice scoop was inside a clear plastic ice scoop holder which was not covered and exposed to the environment. The interim FSD acknowledged that the scoop was exposed and showed the surveyors there was an attached cover to the scoop holder but was not properly placed. He stated that the ice scoop should have been covered. 14. The reach-in freezer external digital thermometer read 19 degrees F and the internal thermometer read 18 degrees F. Both the interim FSD and the RD stated that the temperature should have been below 0 degrees F. They also both stated that the unit had been opened. The surveyors requested that the unit remain closed for a bit to recheck. The RD announced to the kitchen employees not to open the unit. 15. The reach-in refrigerator external digital thermometer read 47 degrees F and the internal thermometer read 41 degrees F. The surveyors requested that the unit remain closed for a bit to recheck. The RD announced to the kitchen employees not to open the unit. 16. The walk-in refrigerator external thermometer read 41 degrees F and there were three internal thermometers. One read 30 degrees F, the second 32 degrees F, and the third read 40 degrees F. Both the RD and the interim FSD stated that staff should use the internal thermometers to monitor and record temperatures but could not speak to how the staff would know which internal thermometer to use. 17. In the walk-in refrigerator, there were two plastic containers of store bought raw (unpasteurized) eggs stored on the third shelf directly above fresh produce. There was one full container with 30 raw eggs and the second had 10 raw eggs. The RD and the interim FSD confirmed the raw eggs were not pasteurized. They both also acknowledged that raw eggs should be stored on a bottom shelf. The RD stated that the raw eggs should have been stored on the bottom shelf to prevent contamination. 18. The RD acknowledged that after 10 minutes the temperature of the reach-in freezer had not gone down and that the reach-in refrigerator temperatures went up. The reach-in freezers external digital temperature of the reach-in freezer read 19 degrees F and the internal thermometer read 20 degrees. The reach-in refrigerators external digital thermometer read 48 degrees F and then went up to 50 without opening the unit, and the internal thermometers read 39 degrees. The [NAME] President of Operations (VPO) joined the tour. He stated that the staff never use the external temperatures for monitoring and that the unit had been opened for use. At that time, the RD and interim FSD acknowledged and confirmed that it had not been opened and could not speak to why the temperatures of the freezer thermometers were reading above 0 degrees F. The RD, the interim FSD and the VPO stated that when a piece of equipment was not working that their facility process was to notify maintenance and log the concern in a maintenance log. They could not provide documented evidence that this was logged or that maintenance had been notified. In addition, they could not speak to why the process of monitoring and recording refrigerator and freezer temperatures using an internal thermometer was not indicated on the facility policy they provided. 19. Upon observation of the emergency food area, there were dented cans stored on the bottom shelf in the middle of the emergency food. There was a paper sign loosely placed on top that indicated dented cans. The interim FSD stated that the dented cans should have been stored in a separate area and stated that we will get it to a different place. 20. At 10:21 AM, two surveyors in the presence of the MDir and the VPO observed nine cases of water (four gallons in each) stored directly on the floor. When asked if the water could be stored directly on the floor? The VPO stated I don't know. The cased water supply had a heavy buildup of a fuzzy brownish substance. On 6/29/22 at 1:09 PM, in the presence of the survey team, the RD stated that she conducted kitchen sanitation audits on a monthly basis, and she then sent the reports via email to the LNHA. The surveyor requested copies of the reports from March 2022 till present, however the RD was unable to provide the audits. On 6/29/22 at 2:26 PM, the survey team met with the LNHA, the Regional Director of Nursing (DON), the DON, the VPO and the VP of Clinical Services to review the above concerns. At that time the LNHA stated that there were Performance Improvement (PI) reports for FSD #2 which she could provide to the surveyor. At that time, the administrative team was notified that the surveyor requested copies of the RDs monthly kitchen sanitation audits. On 6/30/22 at 9:52 AM, in the presence of the survey team, the LNHA was unable to provide Performance Improvement (PI) reports for the FSD #2, nor the RDs monthly kitchen sanitation audits. On 7/1/22 at 10:21 AM, the surveyor interviewed the LNHA in the presence of the survey team about the facility's Quality Assurance and Performance Improvement (QAPI) processes. The LNHA reported the list of topics that were reviewed by QAPI team at their quarterly meeting in April 2022. The LNHA did not report any topic related to the Food Service Department. At 10:37 AM, in the presence of the survey team, the DON joined the LNHA for an interview regarding QAPI topics for the April 2022 quarterly team meeting. There were no Food Service Department topics identified. A review of a timeline for FSDs provided by the LNHA revealed that the Regional LNHA, who was the previous LNHA toured the kitchen on 3/24/22, and found the state of the kitchen to be unacceptable. The findings were reviewed with FSD #2. On 4/4/22, the LNHA toured the kitchen again and found little to no progress in areas that were discussed. The LNHA gave FSD #2 a written warning to properly maintain the kitchen. On 4/15/22, the Kitchen was rounded again and found to be in the same state. On 6/6/22, the FSD #2 was terminated and on 6/7/22, FSD #1 began at the facility. Review of an additional document provided to the surveyor revealed the following: On 3/24/22 Administrator and Dietician did extensive kitchen rounds. We sent a list of items that needed to be rectified. The FSD was told to reply daily and let us know what items were still outstanding. He was told that we will be rounding weekly and expect that everything is completed by the next kitchen round. As of 4/4/22, FSD did not respond with any updates. On 4/4/22, Administrator and Dietician rounded the kitchen. Of the roughly 40 items on the list at least 33 were not addressed. Amongst these items were things that could have been rectified in 2 minutes or less. A review of the facility policy Equipment Temperature Monitoring with a revised date of 5/2018, reflected that the AM & PM cooks were responsible to record temperatures daily in the temperature logbook. It also reflected that refrigerator temperatures should be below 41 degrees F and freezers below 0 degrees F. In addition, it reflected that if a temperature was not within an acceptable range both the MDir and the FSD would be informed and would take the appropriate course of action. It did not indicate which thermometers should be used to monitor temperatures. A review of the facility policy Dry Food Storage with a revision date of 5/18/22, reflected that dry food should be stored in a clean, dry area free of contaminants and at a minimum of six inches above the floor. A review of an undated policy titled HACCP and Food Safety provided by the RD, reflected that Food and nutrition services staff will be well trained on food safety policies and procedures. Supervisors will monitor staff and correct any problems or concerns at the time they occur. It also reflected that staff would be aware of cross contamination, improper sanitation, and improper handling or cross contamination of ice. A review of the facility policy Cleaning Ice Scoops and Storage dated 5/18/22, reflected that the ice scoop would be stored beside or on top of the ice machine and would have a lid. A review of the facility policy Dented Cans dated 5/18/22, reflected that dented cans should be stored in a designated area for dented cans in the storeroom. NJAC 8:39-17.2(g)