**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 2 residents (Residents #339) reviewed for timing of assessments and was evidenced by the following: This deficient practice was evidenced by the following: On 2/21/25 a review of the electronic health record (EHR) reflected that Resident #339 was admitted to the facility on [DATE]. The Comprehensive admission MDS was noted to be in progress. On 2/21/25 at 12:45 PM, the surveyor interviewed the MDS Coordinator, who stated the MDS assessment on a new admission was due within 14 days of admission. She further stated that she was working on this MDS now and that it should've been done the day before yesterday (2/19/25). A review of facility provided MDS Policy reviewed 10/2024 included: Policy: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS (Centers For Medicare and Medicaid) regulations and requirements. Purpose: 1. To outline the procedure of identifying and addressing residents' strengths and needs through the RAI (Resident Assessment Instrument) process 2. To provide information on the resident's condition 3. To facilitate development of a comprehensive care plan. 4. To ensure care delivery that enhances the resident's quality of life. 5. To help achieve the highest and practical level of self sufficiency. Procedure: MDS Department 1. Schedules Minimum Data Set (MDS) and Care Plan Meeting in accordance to existing regulations governing RAI process. 3. Assures the completeness and accuracy of the information in the MDS. 5. Coordinates, signs and certifies the completion of the MDS. 6. Submits MDS data in required format to CMS. 8. Reviews and corrects errors with the MDS Coordinator. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-17, the Comprehensive admission assessment must be completed no later than the admission date + 13 calendar days. NJAC 8:39-11.2 (e)

Based on interview, review of medical records and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete and electronically transmit the Minimum Data Set (MDS), an assessment tool, within 14 days of the resident's discharge. This deficient practice was identified for 1 of 1 resident, (Resident # 83) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 2/18/25, the surveyor reviewed the MDS history in the electronic medical record (EMR), which revealed that Resident #83 was discharged on 12/2/2024. The surveyor was unable to locate a discharge MDS in Resident #83's EMR. On 2/18/25, the surveyor interviewed the MDS Coordinator, who stated the discharge MDS on Resident #83 should've been completed within 14 days of the discharge date . She also stated, I'm not sure what happened. On 2/25/25, after surveyor inquiry, the surveyor noted the discharge MDS was completed on 2/19/2025 and was transmitted on 02/20/2025 (completion was due by 12/16/2024 and transmission was due by 12/30/2024). A review of facility provided MDS Policy reviewed 10/2024 revealed: Policy: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements. Purpose: 2. To provide information on the resident's condition Procedure: MDS Department 1. Schedules Minimum Data Set (MDS) and Care Plan Meeting in accordance to existing regulations governing RAI (Resident Assessment Instrument) process. 3. Assures the completeness and accuracy of the information in the MDS. 5. Coordinates, signs and certifies the completion of the MDS. 6. Submits MDS data in required format to CMS (Centers for Medicare and Medicaid Services). According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-19, the discharge return-not anticipated assessment must be completed no later than the discharge date + 14 calendar days with the transmission date no later than MDS completion date +14 days. NJAC 8:39-11.2 (e) 3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 00179151 Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 31 residents reviewed (Resident #5, Resident #43, and Resident #53) for MDS accuracy. This deficient practice was evidenced by the following: 1. On 2/19/25 at 11:33 AM, the surveyor observed Resident #5, in a wheelchair, in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. On 2/19/25 at 02:43 PM, the surveyor observed Resident #5, out of bed, in a wheelchair in the bedroom, yelling out for help. On 02/19/25 at 02:46 PM, the surveyor observed Resident #5, in a wheelchair in the 3rd floor dining room yelling help continually. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), major depressive disorder (depression), and type 2 diabetes (high blood sugar). A review of the Medication Administration Record (MAR) for January 2025 revealed documentation under behavior monitoring (screaming continuously) that indicated that screaming occured multiple times daily on all shifts during the look back period of 1/18/25 - 1/24/25 except for 1/19/25. A review of the comprehensive significant change MDS, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating moderate cognitive impairment. Further review revealed, Section E of the MDS, question E022C, was coded 0, indicating no behavior symptoms exhibited during the look back period of 7 days. On 2/21/25 at 10:44 AM, the surveyor interviewed the MDS Coordinator, who when asked about the behavior coding, stated Resident #5 was not yelling during the lookback period. After reviewing the MAR, she stated she was going to modify the MDS to correct it. 2. On 2/14/25 at 10:49 AM, the surveyor observed Resident #43 in bed. The resident verbalized current smoking status and stated that the facility holds the cigarettes and lighter. On 2/18/25 at 2:00 PM, the surveyor observed Resident #43 in a wheelchair, getting onto the elevator on 2nd floor. The resident stated they were going out to smoke after getting cigarettes and lighter from the receptionist. A review of Resident #43's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; orthopedic aftercare following surgical amputation (removal of a limb), type 2 diabetes (high blood sugar), and major depressive disorder (depression) A review of the individual comprehensive care plan (ICCP) revealed a focus area of independent smoking, dated 8/14/22, with interventions including resident will follow the smoking policy, resident will be free of injury associated with smoking, complete smoking assessment upon admission, quarterly and as needed, and education to be provided to the resident regarding health complications related to smoking. A review of smoking evaluations completed 2/22/24, 5/21/24, 7/26/24, and 10/24/24 all indicate Resident #43 was safe to smoke unsupervised. A review of the annual comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed Section J, question J1300, was coded 0, indicating no current tobacco use. On 2/21/25 at 10:44 AM, the surveyor interviewed the MDS Coordinator, who stated that Resident #43 was a smoker, the smoking assessment was overlooked when the MDS was completed. She further stated that she modified the MDS to correct it. 3. On 2/14/25 at 11:26 AM, the surveyor observed Resident #53 in bed. The resident stated, I'm in a pile of poop. The call bell was noted to be on and was answered by a certified nurse assistant (CNA) in about 3 minutes. On 2/18/25 at 01:06 PM, the surveyor observed Resident #53 in a wheelchair in the hallway. The resident stated they had therapy today and it was good. The resident was dressed and appeared neat and clean. On 2/19/25 at 9:47 AM, the surveyor observed Resident #53 lying in bed. The resident stated they were tired today and further stated that the staff helps them when needed within a reasonable time. On 2/20/25 at 9:44 AM, the surveyor observed Resident #53 lying in bed with their eyes closed, no odors noted. A review of Resident #53's admission record reflected the resident had diagnoses that included but were not limited to; surgical aftercare following surgery on the genitourinary system (kidneys, bladder, etc), major depressive disorder (depression), and epilepsy (seizures). A review of the IDCP (interdisciplinary care plan) summary dated 1/7/25, reflected the resident required partial/moderate assistance with toileting hygiene and personal hygiene and supervision or touching assistance with toilet transfer. A review of the ICCP revealed a focus area of ADL (activities of daily living) self care performance deficit related to osteoporosis (loss of bone density resulting in weaker bones) and history of fractures (broken bones) dated 8/12/23. Interventions included praise all efforts at self care, encourage participation to the fullest extent possible with each interaction, and encourage to use call bell for assistance. The ICCP also included a focus area of bladder incontinence related to the disease process dated 8/12/23 which included interventions of staff to check frequently for incontinence and for staff to wash, rinse, and dry perineum. A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS of 15 out of 15, indicating intact cognition. Further review revealed Section GG, questions GG0130B, GG130I, GG0170F all coded as independent. On 2/21/25 at 10:44 AM, the surveyor interviewed the MDS Coordinator, who stated section GG is a little different, and that when she interviewed the CNA and the staff, they indicated the resident was independent. When surveyor showed her the IDCP Summary dated 1/7/25 and the task sheet for toileting hygiene which had many codes of 4, indicating supervision or touching assistance and a few codes of 3, indicating partial or moderate assistance needed during the 7 day look back period, she stated that she had seen that, but her interviews said the resident was independent. Review of MDS Policy Reviewed 10/2024 included: Policy: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS (Center for Medicare and Medicaid) regulations and requirements. Purpose: 1. To outline the procedure of identifying and addressing residents' strengths and needs through the RAI (Resident Assessment Instrument) process 2. To provide information on the resident's condition 3. To facilitate development of a comprehensive care plan. 4. To ensure care delivery that enhances the resident's quality of life. 5. To help achieve the highest and practical level of self sufficiency. Procedure: MDS Department 1. Schedules Minimum Data Set (MDS) and Care Plan Meeting in accordance to existing regulations governing RAI process. 3. Assures the completeness and accuracy of the information in the MDS. 5. Coordinates, signs and certifies the completion of the MDS. 6. Submits MDS data in required format to CMS. 8. Reviews and corrects errors with the MDS Coordinator. N.J.A.C 8:39-11.1

Complaint #: NJ 00179151 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every thirty days from April 2024 through January 2025 for 1 of 34 residents, (Resident #5) reviewed for physician visits. This deficient practice was evidenced by the following: On 2/19/25 at 11:33 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was noted with their head down and eyes closed. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), major depressive disorder (depression), and type 2 diabetes (high blood sugar). A review of the comprehensive significant change Minimum Data Set (MDS), an assessment tool dated 1/24/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating moderate cognitive impairment. A review of the electronic medical record (EMR) revealed a progress note from Resident #5's attending physician on 4/15/24. No further attending physician notes were found in the EMR by the surveyor. On 2/25/25 at 02:08 PM, the Director of Nursing (DON) provided physician visits for Resident #5 handwritten on paper dated 8/10/24, 9/29/24, 11/23/24. When the DON was asked if this was all the visits, he stated yes. When asked what the requirement was, he stated the regulation is every 30 days for long term care. On 2/25/25 at 02:22 PM, the Licensed Nursing Home Administrator (LNHA) provided additional physician visits for Resident #5 handwritten on paper dated 7/11/24, 12/15/24, and 2/16/25. Addition review of the EMR and handwritten physician notes did not reveal a progress note from the attending physician for May 2024, June 2024, October 2024, and January 2025. A review of facility provided policy Physician visits included: Policy: It is the policy and procedure of this facility that the Attending Physician must make visits in accordance with applicable state and federal regulations. Procedure: 1. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admissions, and then at least every sixty (60) days thereafter. NJAC 8:39-23.2 (d) reveals: A physician or advanced practice nurse shall visit each resident at least every 30 days unless the medical record contains an explicit justification for not doing so. Following the initial visit, alternate 30-day visits may be delegated by a physician to a New Jersey licensed physician assistant, in accordance with facility policies. N.J.A.C, 8:39-23.2 (d)

Complaint #: NJ 00179151 Based on observations, interviews, review of the medical record and review of other facility documentation, it was determined that the facility failed to ensure adequate indication for a resident with behaviors prior to the administration of an antipsychotic medication (Seroquel). This deficient practice was identified for 1 of 6 residents (Resident #5) reviewed for unnecessary medications and was evidenced by the following: On 2/14/25 at 12:13 PM, the surveyor observed Resident #5 in a wheelchair with raised footrests in the 3rd floor dining room ready for lunch. On 2/19/25 at 9:55 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 10:28 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 11:33 AM, the surveyor observed Resident #5 in a wheelchair in the day room on the 2nd floor. The resident was sitting with their head down and eyes closed. On 2/19/25 at 12:28 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated regarding Resident #5 and the behavior of screaming, that they (the resident) are out of bed all day. They used to refuse to get out of bed. We have really encouraged them to be out of bed. We encourage activities. If the 2nd floor can't keep them occupied, then they go to the third floor. The team has spent much time on this and this is a big dilemma for the team. This resident is definitely a challenge. I don't have a very good answer. He further stated the team has put a lot of thought into this, it comes up in meetings all the time. On 2/19/25 at 02:43 PM, the surveyor observed Resident #5 in a wheelchair in the bedroom, yelling out for help. On 02/19/25 at 02:46 PM, the surveyor observed Resident #5 in a wheelchair in 3rd floor dining room yelling help continually. On 2/20/25 at 9:39 AM, the surveyor observed Resident #5 in the 2nd floor day room, sitting quietly in a wheelchair, an I love Lucy trivia was going on in the activity room. On 2/20/25 at 12:19 PM, the surveyor observed Resident #5 in 2nd floor dayroom, sitting quietly in a wheelchair. A review of Resident #5's admission record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), major depressive disorder (depression), and type 2 diabetes (high blood sugar). A review of the physician's orders revealed an order for Seroquel 50 mg at bedtime for mood disorder dated 12/19/24. An additional order, dated 1/6/25, was noted for Seroquel 50 mg at bedtime for schizophrenia. A review of the psychiatric progress note dated 12/19/24, revealed a recommendation for Seroquel for mood disorder. The following was also recommended on 12/19/24: Always consider supportive and individualized non-pharmacologic interventions, inc: redirection, support/reassurance, comfort measures, reduced environmental stimulation, expression of feelings, family involvement. Treat medical issues including pain, UTI, constipation, infection, physical issues, positioning, toileting. Encourage participation in activities, social engagement as tolerated and as possible for psychosocial wellbeing. A review of the Medication Administration Record (MAR) for January and February 2025 revealed documentation under behavior monitoring (screaming continuously) multiple times daily and throughout all shifts. A review of the comprehensive significant change Minimum Data Set (MDS), an assessment tool, dated 1/24/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating moderate cognitive impairment. A further review revealed Section N indicated the use of an antipsychotic and an appropriate indication for the use. A review of the individual comprehensive care plan (ICCP) revealed focus areas of use of psych medication for diagnosis of mood disorder and behavior problem of screaming and yelling with interventions including to inform resident and family members of indication for medication and side effects, administer medications as ordered, intervene as necessary to protect the rights and safety of others, and to offer gentle reminders. Further review of the medical records did not reveal a diagnosis of schizophrenia. On 2/25/25 at 10:30 AM, the surveyor spoke with the certified consultant pharmacist who stated that in January she had noted to clarify diagnosis for the use of Seroquel as mood disorder is not an approved diagnosis for Seroquel. Review of facility provided policy 1.0 Psychotropic Drug Use, revised 10/1/24 which included: Policy: When clinically appropriate, the facility staff will initiate non-medication approaches to care to assist in the treatment of alteration of the customer's behavior as behavioral redirection, environmental alterations, etc. Procedure: A. Each customer receiving an antipsychotic medication for organic mental disorders (now referred to as dementia, Alzheimer's disease, or other cognitive disorders by DSM-IV) is observed for: 1. Episodes of the behavioral symptoms being treated and/or manifestations of the disordered thought process. 2. Adverse reactions and side effects 3. Appropriateness of drug selection and dosage C. Antipsychotics are not to be used if one (1) or more of the following is/are the only indication: 5. Anxiety 6. Depression w/o psychotic features 13. Agitated behaviors which do not represent a danger to the customer or others F. Each customer on an antipsychotic for organic mental syndrome with agitation or psychosis has a plan of action the includes dosage reduction and behavioral interventions unless clinically contraindicated as defined below. I. When psychotropic drugs are used outside the recommended dosage ranges of the federal interpretive guidelines, the physician or nursing staff (per physician explanation) documents the reason (i.e. maintenance or improvement of customer's functional status) for the higher dose and the absence of adverse drug reactions (ADRs). On 2/25/25 at 9:35 AM, the survey team met with the Director of Nursing and the Licensed Nursing Home Administrator (LNHA). The LNHA stated that the neurologist started the resident on the Seroquel, not us (the facility). Reference: A review of the manufacturer's specifications for Seroquel (quetiapine) under the black box warning reflected Warning: Increased Mortality In Elderly Patient with dementia related psychosis and suicidal thoughts and behaviors. Section 1 Indications and Usage included schizophrenia, bipolar disorder, and special considerations in treating pediatric schizophrenia and bipolar 1 disorder. Section 5.1 included, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death . Section 5.3 Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis . Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis. N.J.A.C. 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documentation, the facility failed to a.) ensure the required committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and b.) review of Antibiotic Stewardship (AS). This deficient practice was evidenced by the following: A review of the facility provided QAPI Meeting 3rd Quarter dated 10/17/24, did not reveal the Infection Preventionist (IP) signed in. A review of the facility provided QAPI Meeting 4rd Quarter dated 1/16/24, revealed the Infection Preventionist (IP) signed in. On 02/25/25 at 1:21 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) to review the facility's QAPI. The LNHA reviewed the QAPI sign in sheets dated 10/17/24 and verified he did not see where the IP had signed in. The surveyor asked the LNHA to show the AS Information that was reviewed with the committee. The LNHA reviewed the QAPI binder and was unable to locate the AS data, he acknowledged that the other departments information was in the binder. During that meeting, the LNHA verified the IP attended the 1/16/25 meeting, but the LNHA was unable to show the AS information that was reviewed. He stated that usually the AS was printed and reviewed at the meeting. He then added that the information could be pulled from the electronic medical record system for tracking. The surveyor made the LNHA aware of the AS binders tracking from July 2024 to present were printedon 2/17/25 by the [NAME] President of Nursing. A review of the facility's policy, Antibiotic Stewardship reviewed 9/3/24 revealed. Policy: It is the policy of [NAME] Post Acute Care to implement an Antibiotic Stewardship program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infection, at the same time reducing the possible adverse events associated with antibiotic use. The Core Elements of stewardship . tracking measures, reporting data .about antibiotic resistance and opportunities for improvement .5. Tracking, a. IP will be responsible for infection surveillance and MDRO (multi-drug resistant organisms) b. IP will collect and review data. 6. Reporting: a. IP and/or other members of the ASP team will review and report findings to facility staff and to QA committee. A review of the facility's policy, Quality Assurance and Performance Improvement reviewed 5/2024, revealed Policy: Our company is committed to developing, implementing, and maintaining an effective, comprehensive, date-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. g. iii. Several key options for identifying date collect, analyze, and apply the QAPI process are the following examples; .15. Antibiotics, 17. Infections rates, 18. Infection Control Compliance. NJAC 8:39-33.1(a)(b)

Based on observation, interview, and a review of facility documentation, it was determined that the facility failed to ensure laundry staff had the proper personal protection equipment (PPE) necessary to handle linens to prevent the spread of infection. This deficient practice was evidenced by the following: On 02/20/25 at 2:34 PM, the surveyor toured the laundry room with the Director of Nursing (DON), the Chief Nursing Officer (CNO) and the Director of Housekeeping (DH). The surveyor observed 3 dryers in use and clean linens, which included patient johnny coats (hospital gowns), folded on a table. The tour continued into to the washing machine side. The surveyor observed empty linen carts. The surveyor did not observe any PPE. The surveyor asked the DH the process for sorting dirty laundry. He stated staff sorted the laundry by wearing gloves and a patient gown. He explained staff came in from the dryer side with the gown. He took the surveyor back to the dryer side and showed the surveyor the short-sleeved hospital gown. He stated staff wore the gown and then put it in the laundry when they were done with it. The surveyor asked if that was acceptable protection? The DH responded yes but the CNO responded, no it is not, it should be a PPE gown. The CNO verified that the staff should be wearing a long-sleeved disposable PPE gown for protection. The DON, CNO, and DH all acknowledged there were no PPE gowns available on the dryer side or the washer side. On 2/21/25 at 1:09 PM, the surveyor made the Licensed Nursing Home Administrator, the DON, and the Administrator in Training aware of the above findings in the presence of the survey team. A review of the facility's policy Linen Handling for Nursing Personnel revised 9/20/24 revealed Policy: To ensure the safety of residents and staff the facility will ensure proper handling of linen. A review of the facility's undated policy Personnel Linen Handling for Residents on Isolation revealed Policy: To ensure the safety of residents and staff the facility will ensure proper handling of linen for residents on Isolation. Objectives: To prevent the spread of communicable and infectious diseases through laundry and linen handling .Procedures: 6. The laundry staff personnel will perform hand hygiene the donn (put on) PPE (personal protective equipment) (gown, gloves) to handle contaminated linen. NJAC 8:36-19.4 (a) (b) (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of facility documents, it was determined that the facility failed to maintain an ongoing review for their Antibiotic Stewardship (AS) Program. This deficient practice was evidenced by the following: On 2/20/25 at 1:54 PM, the surveyor interviewed the Chief Nursing Officer (CNO), who stated she was the acting Infection Preventionist (IP) since the last one had recently resigned. She stated she attended the quarterly Quality Assurance & Performance Improvement (QAPI) meeting and reports on infection control. The surveyor requested to review the AS. The CNO requested the Director of Nursing (DON) to join the meeting. At 2:19 PM, the DON joined the interview with 2 Antibiotic Stewardship binders, 2024 and 2025. The CNO stated the facility uses McGeer's Criteria (a set of guidelines used to define and diagnose healthcare associated infections (HIAs) in long-term care Facilities (LTCFs). The surveyor asked to be shown unsampled Resident #15's antibiotic tracking for January 2025. The DON and the CNO reviewed the 2025 binder and acknowledged the resident was not in book .The surveyor asked how are you tracking and ensuring staff are following McGreers, making sure proper tests were done before antibiotics were started, such as an xray or urine culture? The DON and CNO looked in the 2024 binder for December's AS binder and was unable to provide the evidence. The CNO stated that antibiotic monitoring was important because the main purpose was to prevent incorrect use of antibiotic use and resistance. Neither binder was given to the surveyor at that time for review at that time. On 2/21/25 at 10:38 AM, during a follow up meeting with the surveyor, the DON and the CNO, Resident #15's McGreers Criteria check list, dated 1/19/25, was reviewed which revealed the following under the Pneumonia box, All three criteria must be present. -An empty box next to Interpretation of a chest radiograph as demonstrating pneumonia or the presence of a new infiltrate. -An empty box next to At least one of the following respiratory sub-criteria. A check in the circle next to New or increased cough -An empty box next to At least one of the constitution Criteria No circles were checked -Medication/Antibiotics: Amox (amoxicillin) for URI (upper respiratory infection) X-ray neg (negative). -A check in No for Hospital Acquired Infection - A check in Yes for Met Surveillance Criteria -A check in No for reportable to DOH -Signed by Licensed Practical Nurse. At that time, the CNO stated on 1/19/25 cold symptoms started for Resident #15 and the doctor ordered the antibiotic and ordered an xray. She stated the nurse should have called the doctor and let them know that the resident did not meet the criteria for starting the antibiotic. She further explained that it would be discussed with the medical director if the doctor still wanted to start the antibiotic. She stated that there should be a progress note documenting the time out of antibiotics and what was done. The CNO verified a progress note was not done. On 2/25/25 at 12:48 PM, a review of the facility provided antibiotic stewardship binders for 2024 and 2025. The surveyor reviewed the book which revealed from July 2024 to present, all the data in book for each month was printed on 2/17/25 by the CNO, which was after survey started. On 2/25/25 at 1:05 PM, the surveyor interviewed the DON, who acknowledged the IP surveillance binder had not being updated. On 02/25/25 at 1:21 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) to review the facility's Quality Assurance and Performance Improvement (QAPI). The LNHA reviewed the QAPI sign in sheets for 10/17/24 and verified he did not see where the IP had signed in. The surveyor asked the LNHA to show the AS Information that was reviewed with the committee. The LNHA reviewed the QAPI binder and was unable to locate the AS data, he acknowledged that the other departments information was in the binder. During that meeting, the LNHA verified the IP attended the 1/16/25 meeting, but the LNHA was unable to show the AS information that was reviewed. He stated that usually the AS was printed and reviewed at the meeting. He then added the information could be pulled from the electronic medical record system for tracking. The surveyor made the LNHA aware of the AS binders tracking from July 2024 to present were printed 2/17/25 by the CNO. On 2/21/25 at 1:09 PM, the surveyor made the LNHA, the DON, and the Administrator in Training aware of the above findings in the presence of the survey team. A review of the facility's policy, Antibiotic Stewardship reviewed 9/3/24 revealed. Policy: It is the policy of [NAME] Post Acute Care to implement an Antibiotic Stewardship program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infection, at the same time reducing the possible adverse events associated with antibiotic use. The Core Elements of stewardship .at a minimum, include these basic elements: Leadership, accountability, drug expertise, action to implement recommended policies or practices, tracking measures, reporting data .about antibiotic resistance and opportunities for improvement .5. Tracking, a. IP will be responsible for infection surveillance and MDRO (multi-drug resistant organisms) b. IP will collect and review data. 6. Reporting: a. IP and/or other members of the ASP team will review and report findings to facility staff and to QA committee. NJAC 8:39-19.4 (d)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to have a designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) and physically worked onsite in the facility. This deficient practice was evidenced by the following: Reference: According to the NJ Executive Directive 21-012 (revised 12/22/22) included 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 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022, 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 2/14/25 at 10:13 AM, during entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the last IP resigned approximately 2 weeks ago. He stated that facility had an interim Regional Infection Control nurse. A review of the facility provided timeline of IP's revealed the following: IP #1 date of hire (DOH) was 10/16/23 to termination 2/23/24 IP #2 DOH 6/3/24 to termination 7/19/24 IP #3 DOH 8/19/24 to termination 10/11/24 IP #4 DOH 10/29/24 to termination 1/24/25 On 2/20/25 at 1:54 PM, the surveyor interviewed the Chief Nursing Officer (CNO), who stated she was the acting IP, since the last one had recently resigned. She stated she usually came to building 3 times a week for usually 8 hours each time and was in constant communication with the building. She acknowledged that IP's sole responsibility should be full time. She reviewed the above-mentioned IP timeline and acknowledged the multiple lapses the facility did not have a designated IP, with the longest lapse of 2/24/24 to 6/2/24. She added she was the covering IP during those times but was unable to show accountability for being in the building as the IP during those lapses. The CNO stated, I know we are not in compliance with IP. On 2/21/25 at 1:09 PM, during a meeting with the survey team, the surveyor made the LNHA, the DON, and the Administrator in Training aware of the above findings. A review of the facility's Infection Preventionist Job Description revealed Job Summary: the infection preventionist is responsible for the facility infection prevention and control program (IPCP0, which is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Essential Function: .Maintain current knowledge of federal state, and local regulations and ensure that the facility leader are informed of appropriate issues. Experience: Be qualified by education, training, experience, or certification in infection control. Must work at least part-time at the facility. NJAC 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00178967 Based on interviews and review of pertinent facility documents on 10/31/24, it was determined that the facility failed to report an alleged violation of abuse and its subsequent findings to the New Jersey Department of Health state agency and follow their facility policy on Abuse, Neglect and Mistreatment of Residents for a resident (Resident #1). The deficient practice was evidenced by the following: According to Resident #1's admission Record (AR), Resident was admitted to the facility with diagnoses of that included but not limited to the following: Cerebral Infarction, Metabolic Encephalopathy, Hypertension, Respiratory Failure, and Glaucoma. According to Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of each resident's functional capabilities, dated [DATE], revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 12 which indicated Resident's cognition was moderately impaired. Resident #1's MDS further showed Section GG- Functional Abilities which reflected the Resident required assistance and was dependent on staff for completion of her/his Activities of Daily Living (ADLs). Review of the written email [electronic mail] received by the Director of Nursing (DON) from Resident #1's family member [daughter] dated 10/23/2024 at 7:35 PM [evening] which according to the daughter, the Resident had been restrained or tied up after the Resident mentioned her/his leg pain again to the daughter. Resident's daughter stated, I asked why she [Resident] thought they hurt and understand she had been restrained or tied up as she said! I asked why again, and she [Resident] said so she would not hurt herself. Review of the email response of the DON to the Resident's daughter dated 10/24/2024 at 6:23 PM [evening], showed .our policy and procedure is to initiate an investigation with any claim/allegation, which we have already started since you sent your concerns to us. We are conducting an investigation and will reach out to you once we conclude. Review of the document provided by the facility titled INCIDENT SUMMARY (IS) with Date of Incident: 10/24/24 and under Incident: On October 23, 2024, [daughter's name] emailed the Director of Nursing that her mother told her during a facetime call that she was physically restrained by having her legs tied up. [Facility's Name] is a restraint-free facility, therefore this claimed precipitated an investigation which was initiated immediately by the Director of Nursing. The IS showed under Conclusion: .based on the evidence found by the IDT [interdisciplinary team] using resident and staff statements, interviews, facility policies, and nursing assessment, the team concluded no restraints had been applied to [Resident's name]. The team can safely conclude that no restraints had been used on [Resident's name], as per her daughter [Resident's daughter name] claim via email. However, upon review of [Resident's name] orders and care plan, she uses TED stockings which accounts for the tightness [Resident's name] reported feeling on her legs to her daughter [name]. According to [Resident's name]'s order the TED stockings are applied each morning and removed prior to bedtime. Based on these findings the team is able to rule out any abuse or neglect. In the IS, under Interventions, one of which .Office of the Long-Term Care Ombudsman made aware. There was no documented evidence that the allegation was reported to the New Jersey Department of Health (NJDOH). In an interview of the surveyor with the DON and Licensed Nursing Home Administrator (LNHA) on 11/01/24 via the telephone, DON stated notification of the allegation to Ombudsman was sent electronically and representative from Ombudsman office had been frequently visiting the Resident and was ongoing. LNHA stated we tried to reach out to resident's daughter [name] but she declined care conference. Review of the facility's Policy and Procedure titled: ABUSE, NEGLECT AND MISTREATMENT OF RESIDENTS POLICY, under Procedure: 1. All incidents of abuse (actual or suspected) will be reported immediately to the Administrator/Designee 3. The Adminstrator/Designee will notify the Department of Health within one (1) business day . NJAC 8:39-4.1(a) (5)(6) NJAC 8:39-9.4(f);Appx.B

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ00146686 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 08/02/23 and 08/03/23, it was determined that facility staff failed to consistently document in the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the residents. In addition, the facility staff failed to follow the facility's policy titled Activities of Daily Living for 4 of 4 residents (Resident #1, #2, #4, and #5) reviewed for documentation. The deficient practice was evidenced by the following: 1. On 08/02/23 at 09:47 AM, the surveyor observed Resident #1 in their bed with their family member at their bedside. Resident #1 did not respond to the surveyor's greeting. A family member was interviewed at this time, and revealed they visited the facility every day. They also indicated that the facility staff cared for resident 's ADL needs in a timely manner. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's Disease, Unspecified Sequelae of Cerebral Infarction (disrupted blood flow to the brain), Muscle Weakness, and Dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/18/23 indicated that Resident #1 had short term and long-term memory problems. The MDS also indicated the resident required between extensive and total assistance from staff for ADLs. The 06/12/23 care plan indicated a focus, [Resident #1] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Cognitive deficits, Disease process Alzheimer's. The surveyor reviewed the Documentation Survey Report (DSR), an ADL record documented by the Certified Nursing Assistants (CNA) during their assigned shifts for July 2023. The DSR revealed the following: The DSR forms had assigned ADL care tasks which included but were not limited to Bladder Continence, Bed Mobility, Bowel Continence, Daily Skin Observation with Care, Dressing, Locomotion, Oral Care, Personal Hygiene, Preventative Skin Care, Toilet Use, and Transferring. Review of Resident #1's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff was blank. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shift on 07/16/23 and 07/30/23. Evening shift on 07/02/23, 07/12/23, 07/18/23, 07/25/23, 07/26/23, and 07/30/23. Night shifts on 07/01/23 thru 07/19/23, 07/21/23, and 07/23/23 thru 07/31/23. 2. On 08/02/23 at 10:05 AM, the surveyor observed Resident #2 in bed wearing a hospital gown. The surveyor attempted to interview Resident #2 at this time, but the resident did not answer the surveyor's questions. According to the AR, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Unspecified Dementia, Peripheral Vascular Disease (narrowed blood vessels and reduced blood flow to extremities), and Primary Generalized Arthritis. The quarterly MDS dated [DATE] indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1 out of a possible 15 which indicated that the resident had severely impaired cognition. The MDS also indicated that Resident #2 required between extensive and total assistance from staff for ADLs. The care plan indicated, [Resident #2] is dependent on staff for [his/her] ADL care needs due to cognitive deficit, pain due to OA [Osteoarthritis]. The surveyor reviewed the DSR during the CNA's assigned shifts for July 2023. The DSR revealed the following: The DSR form had assigned ADL care tasks which included but were not limited to Bladder Continence, Bed Mobility, Bowel Continence, Daily Skin Observation with Care, Dressing, Locomotion, Oral Care, Personal Hygiene, Preventative Skin Care, Toilet Use, and Transferring. Review of Resident #2's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff was blank. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shift: 07/16/23 and 07/30/23. Evening shift: 07/02/23, 07/08/23, 07/25/23, and 07/30/23. Night shift: 07/01/23 thru 07/19/23, 07/21/23, and 07/23/23 thru 07/31/23. 3. The surveyor reviewed the closed medical record for Resident #4. According to the AR, Resident #4 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to Alzheimer's Disease, End Stage Renal Disease (kidney failure), and Cerebral Ischemia (impaired blood flow to the brain). According to the admission MDS dated [DATE], Resident #4 had a BIMS score of 14 out of a possible 15 which indicated that their cognition was intact. The MDS also indicated that the resident required between supervisory and extensive assistance from staff for ADLs. The 11/19/21 care plan indicated focuses for, The resident has a self-care performance deficit and The resident has limited physical mobility. The surveyor reviewed the DSR during the CNA's assigned shifts for November 2021. The DSR revealed the following: The DSR form had assigned ADL care tasks which included but were not limited to Bed Mobility, Dressing, Locomotion, Personal Hygiene, Toilet Use, and Transferring. Review of Resident #4's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shift: 11/20/21 and 11/24/21. Evening shift: 11/20/21, 11/22/21, 11/24,21, 11/26/21-11/28/21. Night shift: 11/26/21. The surveyor reviewed the DSR during the CNA's assigned shifts for December 2021. The DSR revealed the following: The DSR form had assigned ADL care tasks which included but were not limited to Bed Mobility, Dressing, Locomotion, Personal Hygiene, Toilet Use, and Transferring. Review of Resident #4's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff was blank. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shift: 12/12/21. Evening shift: 12/5/21 thru 12/7/21, 12/10/21, 12/11/21, 12/13/21, and 12/15/21. Night shift: 12/3/21, 12/5/21, 12/11/21, 12/14/21, and 12/16/21. 4. The surveyor reviewed the closed medical record for Resident # 5. According to the AR, Resident #5 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Altered Mental Status, Dementia, and Chronic Kidney Disease. According to the 07/01/21 admission Assessment, Resident #5 required substantial assistance or was dependent with activities of daily living including self-care, dressing, and transfers. The 07/01/21 Baseline Care Plan indicated that Resident #5 had a self-care performance deficit. The surveyor reviewed the DSR during the CNA's assigned shifts for July 2021. The DSR revealed the following: The DSR form had assigned ADL care tasks which included but were not limited to Bed Mobility, Dressing, Locomotion, Personal Hygiene, Toilet Use, and Transferring. Review of Resident #5's ADL record included an area for the CNAs to document the Resident's self-performance and support provided by staff was blank. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts: Day shift: 7/01/21. Evening shift: 7/09/21. During an interview with the surveyor on 08/02/23 at 11:27 AM, CNA #1 stated that she was expected to document ADL care on the POC [point of care] (documentation system). CNA #1 stated that the documentation was mandatory and that it had to be done every shift. CNA #1 stated that the purpose of documenting was to take credit for the care that she provided. During an interview with the surveyor on 08/02/23 at 2:02 PM, the Licensed Practical Nurse (LPN #1) stated that the CNAs should document ADL care in the POC every shift and that their aim was 100% documentation every shift every day. During an interview with the surveyor on 08/03/23 at 10:20 AM, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that staff have enough time to provide high quality ADL care to residents. The LPN/UM stated that the CNAs document in the POC and that they should document every day and every shift. The LPN/UM stated that he was responsible to ensure that the documentation was completed over all the shifts. The LPN/UM stated that he did not know why ADL care was not documented every shift. During an interview with the surveyor on 08/03/23 at 1:05 PM, the Licensed Nursing Home Administrator stated that he expected that ADL documentation by CNAs would be 100% and that night shift documentation in particular was a, weakness. The facility policy, Activities of Daily Living, with a revised date of 10/22 indicated under the Policy section, The activities of daily living will be entered onto [the Electronic Health Record] Point of Care Module every shift by the assigned nursing assistant. NJAC 8:39-35.2 (d)(6).

Based on observation, interview, and review of other pertinent documentation, it was determined that the facility failed to ensure a.) staff adhered to standards of infection control practices for the appropriate disposal of a soiled incontinence brief and b.) practiced appropriate hand hygiene in accordance with the Centers for Disease Control (CDC). This deficient practice was identified for (1) one staff member on one (1) of three (3) units. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 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. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. On 1/23/23 at 12:26 PM, the surveyor observed an agency Certified Nursing Assistant (CNA) rendering incontinence care to Resident # 32. The CNA placed the soiled incontinence brief onto the floor. She then picked up the soiled brief from the floor and placed it into an unlined open trash bin. The CNA then removed a clear plastic bag from her pocket and placed it over the unlined open trash bin and flipped the trash bin upside down and emptied the contents into the clear plastic bag. She then tied the plastic bag, removed gloves and walked into the bathroom. At that same time, the surveyor observed the CNA perform hand. She turned the facet on, wet her hands, applied soap and lathered for 20 seconds. She then proceeded to dry her hands but was unable due to the automatic paper towel dispenser was jammed. She then walked over to the roommate of Resident # 32 and removed one absorbent wipe from the package and dried her hands. She then picked up the plastic bag which contained the soiled incontinence brief from the floor and left the room. She did not perform hand hygiene after leaving Resident # 32's room. At that same time, the surveyor interviewed the CNA who did not wish to speak to the surveyor. On 1/24/23 at 10:36 AM, the surveyor interviewed the Infection Control Preventionist who stated that the soiled incontinence brief should never have been placed on the floor. She explained the process that the soiled brief should have been placed into a lined trash bin and then tied and placed into the proper disposable receptacle bin outside of the room. Review of the facility's Incontinent Care policy with a review date of 2/2022, included to remove all soiled items and place them in plastic bags. Soiled linen or briefs are to be properly disposed of in the waste bin. Review of the facility's Waste Bins policy with a review date of 3/2022, included that it is the policy and procedure of the facility to provide proper waste bins to discard trash in a sanitary manner in the resident rooms Doff [remove] gloves appropriately and conduct proper hand hygiene. Review of the facility's Handwashing/Hand Hygiene policy dated 1/2/23, included that the purpose of this policy procedure is to provide guidelines for effective handwashing and hand hygiene techniques that will aid in the prevention of the transmission of infections .dry hands with a paper towel and discard. On 1/26/23 at 12:53 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the above observations and findings. On 1/27/23 at 1:35 PM, the LNHA stated that one to one counseling was done with the agency CNA and he began a building wide hand washing in-service audit to ensure all paper towels dispenser are full in the building. NJAC 8:39-19.4 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/18/23 at 12:07 PM, the surveyor observed Resident #83 in bed awake lying comfortably watching tv. Review of Resident #83's medical record revealed the following information: Review of the resident's admission Record revealed that Resident #83 had diagnoses that included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque that cause blocking blood flow to the heart), and type 2 diabetes mellitus (too much blood sugar stays in the blood stream). Review of the resident's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 8 out of 15, which indicated that the resident had moderate cognitive deficit. Review of electronic Order Summary Report (OSR) included a physician's order (PO) for Cleanse sacral wound with NSS [normal saline solution], apply medihoney and cover with a DSD [dry sterile dressing] daily every day shift. Review of the January 2023 electronic Treatment Administration Record (eTAR) reflected the above corresponding PO's. Review of resident's Wound Evaluation & Management Summary report's from the wound care management company on 1/19/23, 1/12/23, and 1/05/23 revealed under Focused Wound Exam (Site 1): Non - Pressure wound sacral full thickness, and Etiology (quality) Moisture Associated Skin Damage. Review of the resident's CCP did not reflect the treatment to sacral wound for Resident #83. On 1/26/23 at 10:26 AM, the surveyor discussed the concern with the DON who acknowledged that there was no care plan initiated for the sacral wound. The DON stated that the care plan should have been added. No further information was provided. On 01/26/23 at 10:34 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the care plan should have been initiated by the nurse who entered the physician's order and as soon as the resident started the treatment. The RN/UM further stated that in the event he/she could not do so they would be responsible to notify the nurse supervisor. Review of undated facility policy Wound Care, reflected in the procedure that: 19. Update skin breakdown care plan with skin impairment. 3. On 1/18/23 at 11:18 AM, the surveyor observed Resident #109 lying in bed, alert and oriented watching tv, with a call bell within reach. Review of Resident #109's medical record revealed the following information: Review of the resident's admission Record revealed that Resident #109 had diagnoses that included but were not limited to urinary tract infection (a condition in which bacteria invade the urinary tract), type 2 diabetes mellitus (too much blood sugar stays in the blood stream), and chronic kidney disease. Review of the resident's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. Review of the OSR indicated a PO dated 10/15/22, for Cephalexin capsule 250 milligram (mg) one time a day for a urinary tract infection (UTI). Review of the January 2023 electronic Medication Administration Record (eMAR) reflected the above corresponding PO's. Review of the resident's CCP did not reflect the use of antibiotic therapy for Resident #109 On 1/26/23 at 10:23 AM, the surveyor discussed the concern with the DON who acknowledged that there was no care plan initiated for the resident upon receiving antibiotic therapy. No further information was provided. Based on observation, interview and record review it was determined that the facility failed to a.) develop a comprehensive, person-centered care plan to address dementia care for Resident #16, b.) develop a comprehensive, person-centered care plan to address a sacral pressure ulcer for Resident #83, c.) develop a comprehensive, person-centered care plan to address the use of an antibiotic for Resident #109 and d.) develop a comprehensive, person-centered care plan to address pain management for Resident #122. This deficient practice was identified for 4 of 29 residents reviewed for comprehensive care plans and was evidenced by the following: 1. On 1/20/23 at 12:25 PM, the surveyor observed Resident #16 in the dining room in a recliner. The resident was alert but did not respond to the surveyor's inquiries. A review of the resident's medical record reflected the following: Review of the residents admission Record (an admission summary) reflected that he/she was admitted with diagnoses that included but not limited to unspecified dementia. Review of the residents admission Minimum Data Set (MDS), a tool to facilitate the management of care, dated 5/24/22 reflected that he/she had a diagnosis of dementia with a Brief Interview for Mental Status (BIMS) score of 00 which indicated a severe cognitive impairment. In addition, in the Care Area Assessment (CAA) of the MDS, it reflected that dementia/cognitive loss was coded as an actual problem and indicated goals for the resident to maintain his/her current level of functioning and to minimize risks related dementia/cognitive loss. Review of the residents Comprehensive Care Plan (CCP) did not reflect or address dementia and cognitive loss for Resident #16. On 1/25/23 at 10:48 AM, the surveyor interviewed the Registered Nurse (RN) MDS Coordinator (RN MDS) in the presence of the survey team. He stated that it was the interdisciplinary team members who were responsible to ensure that the residents needs were addressed in the comprehensive care plan. He further stated that he was responsible to coordinate and oversee that each discipline accurately and comprehensively developed the residents care plan to address his/her individual needs. The RN MDS also stated that if an area was triggered in the CAA's, it should have been addressed in the resident's comprehensive care plan. On 1/25/23 at 11:11 AM, the surveyor and the RN MDS reviewed the electronic medical record for Resident #16 in the presence of the survey team. He acknowledged that the admission MDS indicated that the resident had a diagnosis of dementia and cognitive loss. He stated that the person who completed that section (section I) should have initiated and ensured there was a care plan for dementia/cognitive loss. He further acknowledged that dementia/cognitive loss was not addressed in Resident #16's comprehensive care plan. The RN MDS stated that this is a problem. On 1/26/23 at 12:28 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. He stated that it was the nurses responsibility to develop the resident's comprehensive care plan and that he was ultimately responsible, that would be me to oversee and ensure that the resident care plans are complete and comprehensive. On 1/27/23 at 1:34 PM, the surveyors met with the DON and the Licensed Nursing Home Administrator (LNHA) for responses to previously shared surveyor concerns. At that time, the DON stated that a care plan for dementia/cognitive loss should have been initiated on the baseline care plan and then the personalized comprehensive care plan for Resident #16. Review of the facility policy Dementia Care dated 3/2022, included that It is the policy of this facility to provide appropriate care for those residents with dementia or similar cognitive impairments. It also reflected that Staff should follow the resident's plan of care. 4. On 1/18/23 at 10:45 AM, the surveyor observed Resident #122 sitting in wheelchair next to bed. The resident was stated they had a history of pain and had been on pain medication prior to being admitted . Resident #122 added that the facility had to figure everything out. During the interview, the resident denied having pain and shows no sign/symptoms of discomfort. A review of the resident's medical record reflected the following: Review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to surgical aftercare, abdominal hernia, and osteoporosis. Review of Resident #122's admission MDS, dated [DATE], reflected that the resident was cognitively intact and had received as needed pain medication in the last five days. The MDS revealed that the resident had frequent pain which made it hard to sleep at night and had to limit his/her day-to-day activities because of pain. Review of Resident #122's 1/8/23 CAA Triggers Summary (Care Area Assessment) (care areas triggered by MDS response) revealed that Pain was triggered and that it was addressed in the CP. Review of the residents OSR revealed a PO, dated 1/7/23, for Hydrocodone-Acetaminophen (pain medication) 10-325 milligrams (mg) and to administer one tablet every four hours as needed for intractable pain. This order was discontinued on 1/8/23. The OSR revealed additional POs, dated 1/8/23, 1/11/23 and 1/12/23 for Hydrocodone-Acetaminophen 10-325 mg and to administer one tablet every four hours as needed for severe pain. Review of Resident #122's January 2023 Medication Administration Record revealed the resident was administered Hydrocodone-Acetaminophen 10-325 mgs on: -1/7/23 for a pain level of 6 out of 10. -1/8/23 at 7:29 AM for a pain level of 7 out of 10 and at 6:06 PM for a pain level of 8. -1/9/23 at 9:12 AM for a pain level of 7 out of 10 and at 5:30 PM for a pain level of 8. -1/10/23 at 5:00 AM for a pain level of 8 out of 10, at 11:15 AM for a pain level of 8 out of 10, and at 5:10 PM for a pain level of 8 out of 10. -1/11/23 at 5:25 AM for a pain level of 6 out of 10, at 9:38 AM for a pain level of 7 out of 10, and at 4:45 PM for a pain level of 8 out of 10. -1/12/23 at 8:19 AM for a pain level of 7 out of 10 and at 4:42 PM for a pain level of 8 out of 10. -1/13/23 at 2:06 AM for a pain level of 6 out of 10, at 9:44 AM for a pain level of 7 out of 10, and at 1:51 PM for a pain level of 7 out of 10. -1/14/23 at 5:55 AM for a pain level of 8 out of 10 and at 11:30 AM for a pain level of 6 out of 10. -1/15/23 for a pain level of 8 out of 10. -1/16/23 for a pain level of 7 out of 10. -1/17/23 at 4:38 AM for a pain level of 5 out of 10, at 4:18 PM for a pain level of 8 out of 10, and at 11:27 PM for a pain level of 8 out of 10. -1/18/23 at 1:01 PM for a pain level of 7 out of 10 and at 8:22 PM for a pain level of 8 out of 10. -1/19/23 at 3:00 AM for a pain level of 8 out of 10, at 2:34 PM for a pain level of 7 out of 10, and at 10:57 PM for a pain level of 7 out of 10. -1/20/23 at 8:50 AM for a pain level of 7 out of 10 and at 5:59 PM for a pain level of 8 out of 10. -1/21/23 at 8:48 PM for a pain level of 8 out of 10. -1/22/23 at 10:10 AM for a pain level of 8 out of 10 and at 5:16 PM for a pain level of 8 out of 10. -1/23/23 at 5:00 AM for a pain level of 7 out of 10, at 5:13 PM for a pain level of 8 out of 10, and at 9:31 PM for a pain level of 8 out of 10. Review of the residents CCP did not reflect or address pain for Resident #122. On 01/25/23 at 10:48 AM, the surveyor interviewed the RN MDS who stated the completion of the CCP was an interdisciplinary team effort. The RN MDS added that CPs were entered by the discipline of each department and the care areas triggered by the MDS should be addressed in the CCP. The RN MDS reviewed Resident #122's MDS and CCP, in the presence of the surveyor, and confirmed that pain was not addressed. The RN MDS added that pain should have been addressed in the resident's CCP. On 01/25/23 at 11:02 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN UM) who stated that the UM's reviewed and revised the CCP as needed. The RN UM added that it was the responsibility of the interdisciplinary team to make sure the CCP addressed all of the resident's needs. On 01/26/23 at 12:27 PM, the surveyor interviewed the DON who stated that he expected Resident #122's CCP to address the resident's pain. Review of the facility's Comprehensive Care Plan policy, revised 02/2022, included that the CCP would be resident centered having the individual resident as the focus of control. Each discipline would be responsible for the initiation and ongoing follow up for the care plans as related to their area of expertise. The policy indicated the CCP would address resident goals, actual and potential problems, needs, strengths, and preferences. NJAC 8:39-11.2 (e)(2)

2. On 1/20/23 at 12:14 PM, the surveyor observed Resident #90 lying in bed awake. He/she was not verbally responsive and was not able to maintain eye contact with the surveyor. On the left side of the resident's bed, the surveyor observed a urinary catheter (flexible tube inserted into the bladder and used to drain urine into a bag) drainage bag in a privacy bag that was hung on the left side of the bed. The surveyor reviewed the medical record for Resident #90 which revealed the following: A review of the admission Record (an admission summary) reflected diagnoses that included but not limited to Autistic Disorder, Aphasia (loss of ability to understand or express speech), and Functional Quadriplegia (complete immobility). A review of the 11/10/22, Significant Change in Status Assessment Minimum Data Set (SCSA/MDS), an assessment tool used to facilitate the management of care, indicated that the resident's cognition was severely impaired. It also reflected that the resident had an indwelling catheter. A review of Urology Report of Consultation form dated 1/17/23 reflected a diagnosis of Urinary Retention (difficulty urinating and completely emptying the bladder) with a recommendation to flush the suprapubic (SP) tube daily with 50 cc (cubic centimeter) of sterile water. A review of the Order Summary Report with an order date of 1/17/23 and the resident's January 2022 electronic medication administration record (eMAR), reflected a physician's order to flush S/P (suprapubic) tube with 60 cc normal saline daily to keep patent every day shift for flushes/patency. On 1/25/23 at 1:14 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that when a resident returned to the facility from a consultation, he would review the consultation report form for the procedure that was done during resident's consultation and any orders or recommendations. He also stated that after reviewing the consultation form, he would call the resident's Attending Physician (AP) to communicate the consult's recommendation. The UM/LPN stated that if the AP agreed with the recommendations, he would carry out and transcribe the AP orders into the EMAR via the orders tab on the resident's electronic medical records (EMR). Furthermore, he stated that he would document his conversation with the AP and include their responses and orders in the resident's EMR in the Progress Notes section. During the interview, the surveyor inquired to the UM/LPN about Resident #90's Urology appointment. The UM/LPN stated that the resident's last Urology appointment was on 1/17/23. The UM/LPN reviewed and read the resident's Urology Report of Consultation dated 1/17/23 in the presence of the surveyor. He acknowledged that the Urology consult's recommendation was to flush the SP tube daily with 50cc of sterile water. He informed the surveyor that after he reviewed the consult form, he called the resident's AP and communicated to him the above recommendations. He stated that the AP gave him an order and ok to follow the Urology consultant's recommendation. The surveyor asked the UM/LPN why the Urology consult's recommendation and the AP order for the SP tube flushes were different and inconsistent. The UM/LPN acknowledged the discrepancies. On the same day at 1:29 PM, the UM/LPN called the Urology office and spoke to the LPN staff in the Urology office, in the presence of the surveyor. The UM/LPN asked the LPN to clarify the Urology SP tube flushes recommendations on 1/17/23 for Resident #90. The LPN acknowledged to the UM/LPN and the surveyor that the recommendation was to flush the SP tube daily with 50cc of sterile water. On the same day at 1:33 PM, the UM/LPN acknowledged that the way he carried out and transcribed the AP's order was wrong. He acknowledged that he entered 60 cc instead of 50 cc in the EMR, not according to Urology recommendation and AP's order, stating It was a mistake. On 1/26/23 at 11:19 AM, the surveyor interviewed the LPN in the Urology office via phone call, in the presence of the survey team. The LPN acknowledged that she spoke to the UM/LPN and the surveyor in which she clarified the Urology consult recommendation to flush the SP tube with 50cc daily with sterile water was clarified. When the surveyor asked the LPN when the SP tube flush was clarified, she acknowledged that it was clarified on 1/25/23, after the surveyor's inquiry. On the same day at 12:59 PM, the surveyor informed the DON and LNHA of the above concerns, in the presence of the survey team. The surveyor showed the 1/17/23 Urology Report of Consultation form. The DON read the written Urology recommendation and confirmed that the recommendation was to flush the SP tube with 50cc with sterile water daily. On 1/30/23 at 1:08 PM, the DON and LNHA met with the survey team. The DON stated that when the resident returned from a consultation with recommendations, the receiving nurse in the facility should call the resident's AP to communicate the recommendations. He further stated that the nurse should document in the resident's electronic progress notes and include whether the AP agreed or disagreed with the recommendations. During the interview, the DON stated that if the nurse was in doubt and had questions about the recommendations, the nurse should have called the consultant for clarification and document this in the progress notes. On 1/31/23 at 1:50 PM, the survey team met with the LNHA and DON. There was no further information provided. The facility's policy Consult and Order with a revised date of 3/2022, included to follow through and carry out all consults and orders as needed a nd deemed necessary by the residents primary care physician. NJAC 8:39-11.2(b) Based on observation, interview, and record review, it was determined that the facility failed to a.) follow physician orders for Dilantin and Keppra (anti-epileptic medications used to control seizures) levels every three months since 8/9/2021 for Resident #13. This deficient practice was identified for 1 of 28 residents (Resident # 13) reviewed for physician orders; b.) act upon the Urology Consultation's recommnedation according to professional standards of clinical practice for Resident #90. This deficient practice was evidenced for 1 of 2 residents (Resident #90) reviewed for catheters. 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 1/18/23 at 12:46 PM, the surveyor observed Resident # 13 in bed awake watching television. The surveyor reviewed the medical records of Resident #13. Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to Epilepsy, Unspecified. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/30/22, reflected the resident had a brief interview for mental status (BIMS) score of 99. Further review of the MDS indicated that the resident's cognitive skills for daily decision making was moderately impaired. Review of the electronic Order Summary Report indicated a physician's order (PO) dated 8/9/2021, for Dilantin and Keppra level's every three months. Further review of the electronic Order Summary Report reflected a PO dated 8/10/21, for Dilantin Infatabs tablet chewable 50 mg (milligrams), give 4 (four) tablets by mouth in the afternoon for seizures (4 tabs = 200 mg), and a PO dated 1/23/21, for Dilantin capsule 100 mg, give 2 (two) capsules by mouth at bedtime for seizures, and a PO dated 1/24/21, for Keppra 1000 mg, give one tablet by mouth every 12 hours for seizures. Review of the January 2023 electronic Medication Administration Record (eMAR) reflected the above corresponding PO's. Review of the resident's comprehensive care plans reflected a focus area for actual seizure risk related to seizure's initiated on 1/18/23. Interventions implemented on 1/18/23 reflected to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Give medications as ordered by doctor. Review of the electronic and paper chart for Resident # 13 revealed a Keppra level dated 2/11/22, which indicated a normal lab value of 23.5 ug/ml (microgram per milliliter). The normal value for Keppra level is 6.0 to 46.0 ug/ml. Further review of the electronic and paper chart revealed a Keppra level dated 5/11/22, which indicated a normal lab value of 31.4 ug/ml. There were no Dilantin levels obtained as ordered by the physician and the Keppra levels were not obtained every three months as ordered by the physician on 8/9/2021. On 1/24/23 at 9:34 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Dilantin and Keppra levels were not done because we changed labs and didn't get done. He stated the Dilantin and Keppra levels were done yesterday 1/23/23, and the nurse practitioner (NP) discontinued the order for labs every three months for the Dilantin and Keppra. Review of the 1/23/23, Dilantin level indicated a level of 57 ug/ml which was an elevated level. A normal Dilantin level is 6 to 46 ug/ml. Review of the 1/23/23, Keppra level indicated a level of 14.6 ug/ml which was within normal limits. Review of the electronic Progress Notes (ePN) dated 1/24/23 timed at 8:30 AM and documented by the Nurse Practitioner (NP). The ePN indicated that the NP spoke with the resident's primary care physician (PCP) and discussed the Dilantin/Keppra levels for every three months. The PCP ordered to discontinue the Dilantin/Keppra levels every three months. There was no additional information provided. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to a.) consistently monitor fluid restriction instructions in accordance with the physician's order and professional standards of care and b.) carry out a dietitian recommendation for 1 of 2 residents (Resident #71) reviewed for dialysis care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 01/19/23 01:35 PM, the surveyor observed Resident #71 in bed asleep wearing his/her own clothes. According to the admission Record (an admission summary), the resident was readmitted with diagnoses that included but were not limited to End Stage Renal Disease (condition in which the kidney stops working), diabetes mellitus (too much blood sugar stays in the blood stream), and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/23/22, Resident #71 revealed a BIMS score of 99 out of 15, which indicated that the resident had severe cognitive impairment and had no behavioral issues. Review of Resident #71's Care Plan (CP) initiated on 9/18/19, revealed that Resident #71 was at risk for altered fluid balance related to hemodialysis (a treatment to filter wastes and water from your blood). The CP further revealed an intervention that was initiated on 10/01/21, for fluid restriction of 1200 milliliter (ml) per day. Review of Resident #71's 12/06/21 Order Summary Report, revealed a physician's order dated 9/02/22, for Fluid Restriction 1200 ml per day. The order indicated that nursing had 360 ml per day and dietary had 840 ml per day. The order further instructed: Fluid restriction 1200 ml/day Nsg 360 ml (180 7-3; 120 3-11; 60 11-7) every shift for fluid restriction for Nursing 360 (180/120/60); Dietary 840 ml (360/240/240). Review of Resident #71's November 2022 Electronic Medication Administration Record (eMAR) reflected the above 9/02/22 order for 1200 ml Fluid Restriction per day. The order was also specified on the [DATE] ml per shift for nursing (180 7-3; 120 3-11; 60 11-7). The November 2022 MAR reflected that nurse administered fluids outside the physician ordered fluid restriction parameters as follows: 11/02/22: the nurse administered 120 ml on night shift. 11/05/22: the nurse administered 180 ml on evening shift. 11/09/22: the nurse administered 120 ml on night shift. 11/12/22: the nurse administered 180 ml on evening shift. 11/14/22: the nurse administered 180 ml on evening shift. 11/15/22: the nurse administered 180 ml on evening shift. 11/16/22: the nurse administered 120 ml on night shift. 11/17/22: the nurse administered 180 ml on evening shift. 11/20/22: the nurse administered 180 ml on evening shift. 11/22/22: the nurse administered 240 ml on day shift. 11/23/22: the nurse administered 180 ml on evening shift and 180 ml on night shift. 11/30/22: the nurse administered 120 ml on night shift. The December 2022 MAR reflected that nurse administered fluids outside the physician ordered fluid restriction parameters as follows: 12/01/22: the nurse administered 240 ml on day shift. 12/03/22: the nurse administered 240 ml on day shift and 240 ml on evening shift. 12/08/22: the nurse administered 180 ml on evening shift. 12/10/22: the nurse administered 180 ml on evening shift. 12/13/22: the nurse administered 300 ml on day shift. 12/15/22: the nurse administered 240 ml on day shift. 12/18/22: the nurse administered 360 ml on day shift. 12/19/22: the nurse administered 180 ml on evening shift. 12/21/22: the nurse administered 180 ml on evening shift and 180 ml on night shift. 12/23/22: the nurse administered 180 ml on evening shift. 12/24/22: the nurse administered 180 ml on evening shift. 12/29/22: the nurse administered 240 ml on night shift. The January 2023 MAR reflected that nurse administered fluids outside the physician ordered fluid restriction parameters as follows: 1/01/23: the nurse administered 180 ml on evening shift. 1/05/23: the nurse administered 280 ml on day shift and 280 ml on evening shift. 1/07/23: the nurse administered 360 ml on evening shift. 1/14/23: the nurse administered 120 ml on night shift. 1/15/23: the nurse administered 180 ml on evening shift. 1/16/23: the nurse administered 120 ml on night shift. 1/20/23: the nurse administered 240 ml on day shift. Nursing was to administer 360 ml per day. During an interview with the Licensed Practical Nurse (LPN) on 1/25/23 at 1:18 PM, the LPN stated Resident #71 was on a fluid restriction of 1200 ml, and it was broken down every shift and it was documented in the MAR at the end of each nurse's shift. The LPN further stated that the resident was unable get fluid by him/herself because the resident was bed bound and that fluids were given by nursing. During an interview with the Director of Nursing (DON) on 1/26/23 at 10:13 AM, the DON stated that the staff were inconsistent with giving fluids to the resident and the staff should follow the physician order correctly. The DON further stated that the dietitian should be involved with the fluid restriction so that the nurse would not give fluids more than the amount recommended by the physician. Review of Resident #71's 12/29/22 Dietitian Alert Sheet (DAS) revealed under Description of Problem: Weight gain with handwritten notation of Significant wt. gain + 16.1 #/+10.9 % x 6 mo and on Recommendation with handwritten notations of: 1. change fluid restrictions to 1000 ml/day: Nursing = 280 ml (120/120/40) Dietary 720 (240/240/240). Review of Resident #71's December 2022 Order Summary Report revealed that the DAS recommendations were not addressed to decrease the fluid restriction to 1000 ml per day. During an interview with the Registered Nurse/Unit Manager (RN/UM) on 01/23/23 at 11:58 AM, the RN/UM stated that if there' was a flagged up recommendation in a residents chart it meant that there was an order recommendation and the physician needed to be called, and if the physician approved the recommendation, she would carry out the order. The RN/UM further stated that the dietitian recommendation was not carried out until today after surveyor inquiry. During an interview with the Dietitian on 01/23/23 at 12:16 PM, she stated that the resident had fluid retention due to a significant weight gain of 10% within 6 months. The dietitian further stated that she wrote a recommendation to change the fluid restriction to 1000 ml per day then flagged it in the chart but failed to follow up with the nurses. During an interview with the Licensed Nursing Home Administrator on 01/27/23 at 01:42 PM, who stated that the expectation was that the nutritional recommendation should have been carried out. Review of the facility's undated policy Fluid Restriction included that Guidelines 4. Nursing will document fluid given during med pass and residents compliance with fluid restriction. Review of the facility's undated policy Nutrition Documentation, included under Follow-Up: Any changes to resident nutritional and dietary needs will be conducted through the RD. NJAC 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 provide pharmaceutical services in accordance with professional standards a.)accurately document the administration of a controlled medication for Resident #11; and b.) ensure that a resident was administered all their medications for Resident #11. This deficient practice was identified for one (1) of three (3) residents, Resident #11 and one (1) of two (2) nurses during medication observation pass; and failed to c.) maintain the availability of two topical analgesic medications (Diclofenac 1% gel and Biofreeze 4% gel ) for (1) one of (6) six residents interviewed during resident council, Resident #103. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 1/26/22 at 9:05 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) in the room of Resident #11. The surveyor observed LPN #1 checking the resident's identification bracelet and informing Resident #11 that she will be administering the resident's medications. The surveyor observed that the resident just finished eating breakfast. On 1/26/23 at 9:05 AM, the surveyor observed the LPN #1 preparing to administer sixteen (16) medications to Resident #11 which included Alprazolam (Xanax) 0.25 mg tablet (medication for Anxiety). The surveyor observed LPN #1 remove a bingo card (medication administration system) from the narcotic locked box that contained a card for Alprazolam 0.25 mg tablets. The surveyor observed the card containing 28 tablets and after LPN #1 removed one tablet the card there were 27 remaining tablets. The surveyor then observed LPN #1 sign off the Narcotic logbook count down sheet which then indicated that they were only 5 tablets remaining in the bingo card. After administering Resident #11's medications the surveyor asked LPN #1 if she can show him the resident's Alprazolam bingo card and count down sheet. It was revealed that Resident #11 had two bingo cards of Alprazolam 0.25 mg tablets. LPN #1 removed one tablet from a new card that was received from the pharmacy and signed off on a count down sheet for a bingo card that contained 6 remaining tablets. After realizing that she logged off the wrong count down sheet, LPN #1 called over the unit manager and explained to her that she logged off the wrong count down sheet. The surveyor observed both LPN #1 and the unit manager correct the count down sheets and checked the count on both cards which revealed that they were no missing tablets. The surveyor reviewed the medical record for Resident #11. A review of the admission Record (an admission summary) revealed diagnoses which included but were not limited to Spinal Stenosis (abnormal narrowing of the spinal canal), Chronic Pain Syndrome (persistent pain that last weeks to years) and Vitamin Deficiency (condition with a long-term lack of vitamins). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/6/23, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the January 2023 Order Summary Report (OSR) reflected a physician's order (PO) with a start date of 7/1/22 for Alprazolam Tablet 0.25 mg give 1 tablet by mouth every 12 hours for anxiety A review of the January 2023 Electronic Medication Administration Record (EMAR) revealed a PO with an order date of 7/1/22 for Alprazolam Tablet 0.25 mg give 1 tablet by mouth every 12 hours for anxiety. The EMAR indicated that Alprazolam was to be administered at 8:00 AM (0800) and 8:00 PM (2000). On 1/26/23 at 11:45 AM, the surveyor interviewed LPN#1 in the presence of the surveyor team. LPN #1 stated that it was her responsibility to log on the correct count down sheet when she removed any narcotic medication to ensure that the counts match. She acknowledged that she failed to do so prior to administering the medication to Resident #11. 2. On 1/26/23 at 9:05 AM, the surveyor observed the LPN #1 preparing to administer sixteen (16) medications to Resident #11 which included Glycolax (MiraLAX) Powder (medication used for constipation). The surveyor observed LPN #1 measure a capful of powder that was equivalent to 17 grams, the surveyor then observed LPN #1 add the powder into a cup and then added eight (8) ounces of water. LPN#1 was then observed mixing the contents with a straw. The surveyor observed LPN #1 administer Resident #11's medications. After the resident took all their medications the surveyor observed LPN#1 discard the cup that contained the Glycolax powder into the resident's garbage with around 30 ml's of solution remaining in the cup. The surveyor did not observe LPN#1 encourage the resident to drink the remaining contents of their medication. A review of the January 2023 OSR reflected a PO with a start date of 7/1/22 for Glycolax Powder (Polyethylene Glycol 3350) give 17 grams by mouth one time a day for constipation (in liquid) 8 oz of water. A review of the January 2023 EMAR revealed a PO dated 7/1/22 for Glycolax Powder (Polyethylene Glycol 3350) give 17 grams by mouth one time a day for constipation (in liquid) 8 oz of water. The EMAR indicated that Glycolax Powder was to be administered at 9:00 AM (0900). On 1/26/23 at 11:45 AM, the surveyor interviewed LPN #1 in the presence of the surveyor team. LPN #1 stated that she thought that the resident took all their medication and that she never bothered checking the cup to make sure the resident consumed all their medication. On 1/27/23 at 1:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the surveyors concerns from medication administration. No further information was provided. 3. On 1/23/23 at 10:26 AM, the surveyor conducted the Resident Council meeting with six alert and oriented residents. Resident # 103 stated that two or three weeks ago the nurse was unable to apply an ointment used to relieve pain due to the medication was unavailable. On 1/26/23 at 11:49 AM, the surveyor in the presence of the second floor Licensed Practice Nurse (LPN #2) assigned to care for Resident # 103 inspected the second-floor medication cart and the treatment cart assigned to LPN #2. LPN #2 was unable to locate the as needed topical medications ordered for Resident # 103. At that same time, LPN #1 stated, I can order it from the pharmacy. Anyway, the resident doesn't ask for it. On that same date and time, the surveyor interviewed the second floor Registered Nurse Unit Manager (RN/UM) who stated that both as needed topical medications should be available and could not speak to why they weren't available. She further stated that the primary nurse was responsible for ensuring all active ordered medications were available. On that same date at 12:03 PM, the surveyor interviewed Resident # 103. The resident stated that his/her pain was under control and they were not in any pain. The surveyor reviewed the medical records for Resident # 103. Review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to type II diabetes, morbid obesity, and essential hypertension. Review of the quarterly MDS dated [DATE], reflected the resident had a BIMS score of 13 which indicated that the resident had an intact cognition. Review of section J for pain management reflected that the resident occasionally experienced pain and that the resident had experienced a numeric scale 06 the last five days of the assessment. Review of the electronic Order Summary Report indicated a PO dated 8/14/22, for Biofreeze Colorless gel 4% (Menthol Topical Analgesic) apply to bilateral knees topically every 6 hours as needed for pain management and a PO dated 11/28/22, for Diclofenac Sodium Gel 1 % apply to bilateral knees topically every 12 hours as needed for pain apply 4 grams to each knee. Review of the December 2022 and January 2023 electronic Medication Administration Record (eMAR) reflected the above corresponding PO's. Further review of the December 2022 eMAR indicated that the Diclofenac Sodium Gel 1 % was administered on 12/20/22 for a pain level of two (2). Further review of the December 2022 and January 2023 eMAR indicated that the Biofreeze Colorless gel 4% was not administered. On 1/27/23 at 1:35 PM, the survey team met with the LNHA and the DON and discussed the above observations and findings. The LNHA stated that both topical medications were over the counter (OTC) and should be available. He further stated that the medications were probably available from central supply but the nurse did not follow up with central supply and should have followed up with the doctor. On that same date and time, the DON stated, that both topical medications were house stock and should have been items available in central supply but weren't. A review of the central supply inventory list provided on 1/27/23, by the LNHA revealed that Biofreeze 4 oz was indicated on the central supply inventory list. Diclofenac 1% gel was not indicated on the inventory list. At that same time, the DON further stated that the topical medications came from the pharmacy at one point. The LNHA explained the process that the nurse(s) order from central supply and then central supply has to order from the company that the facility utilizes for all OTC medications. The LNHA could not speak to name of the company who provided the facility with the OTC medications. The DON and the LNHA stated that the provider pharmacy did not provide the facility with OTC medications. The DON further stated that it was ultimately his responsibility to ensure that all medications were available. There was no additional information provided to dispute the above findings. A review of the facility's policy for Controlled Substances Accountability dated 9/2022, and provided by the LNHA included to double check the count of the controlled medication whenever administering the drug; if there is a discrepancy, it should be investigated immediately. A review of the facility's policy for Medication Administration dated 3/2022, and provided by the LNHA included Medication Administration (General) .All medications administered. NJAC 8:39-11.2(b), 27.1(a), 29.2(d), 29.4(g)(h)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 1/26/23, the surveyor observed three (3) nurses administer medications to three (3) residents. There were 29 opportunities, and three (3) errors were observed, which calculated to a medication administration error rate of 10.34 %. This deficient practice was identified for two (2) of three (3) residents, (Resident #11 and #73), that were administered medications by two (2) of three (3) nurses. The deficient practice was evidenced by the following: On 1/26/22 at 9:05 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) in the room of Resident #11. The surveyor observed LPN #1 checking the resident's identification bracelet and informing Resident #11 that she will be administering the resident's medications. The surveyor observed that the resident just finished eating breakfast. On 1/26/23 at 9:05 AM, the surveyor observed the LPN #1 preparing to administer sixteen (16) medications to Resident #11 which included Gabapentin 400 mg (a medication that is used for nerve pain) and Vitamin D3 1000 (a supplement). The surveyor observed LPN #1 moving quickly, pulling out cards, indicating the medication name and it's use to the surveyor. The surveyor observed LPN #1 administer sixteen (16) medications to Resident #11 including Gabapentin 400 mg (Error #1) and Vitamin D3 1000 (Error #2). The surveyor reviewed the medical record for Resident #11. A review of the admission Record (an admission summary) revealed diagnoses which included Spinal Stenosis (abnormal narrowing of the spinal canal), Chronic Pain Syndrome(persistent pain that last weeks to years) and Vitamin Deficiency (condition with a long-term lack of vitamins). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 1/6/23, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. 1.A review of the January 2023 Order Summary Report (OSR) reflected a physician's order (PO) with a start date of 7/1/22 for Gabapentin Capsule 400 mg Give 1 capsule by mouth every 8 hours for mononeuropathy. A review of the January 2023 Electronic Medication Administration Record (EMAR) revealed a PO with an order date of 7/1/22 for Gabapentin Capsule Give 1 capsule by mouth every 8 hours for mononeuropathy. The EMAR indicated that Gabapentin was to be administered at 6:00 AM (0600), 2:00 PM (1400) and 10:00 PM (2200). A further review of the January 2023 EMAR revealed that LPN #1 did not sign off that Gabapentin was administered. The surveyor observed that the 6:00 AM dose was signed off by the overnight nurse (11-7). On 1/26/23 at 11:45 AM, the surveyor interviewed LPN #1 in the presence of the survey team who stated that she was told by the overnight nurse to administer, Resident #11's Gabapentin. She further stated that it was not a normal practice to give a medication three hours after the recommended time and stated that she should have not administered the Gabapentin with the 9 AM medications 2. A review of the January 2023 OSR reflected a PO with a start date of 7/1/22 for Vitamin D3 Tablet (cholecalciferol) Give 1 tablet by mouth one time a day for supplement. A further review of the PO revealed no strength for Vitamin D3. A review of the January 2023 EMAR revealed a PO dated of 7/1/22 for Vitamin D3 Tablet (cholecalciferol) Give 1 tablet by mouth one time a day for supplement. The EMAR indicated no strength for Vitamin D3. On 1/26/23 at 11:45 AM, the surveyor interviewed LPN #1 in the presence of the survey team regarding the fact that there was no strength documented for Vitamin D3 on the PO or EMAR. LPN #1 stated that she gave the 1000 units because it was the standard strength despite Vitamin D3 being available in multiple strengths. LPN #1 further stated that she should have clarified the order with the physician to make sure that the resident received the proper strength. 3. On 1/26/23 at 9:35 AM, during the medication administration observation, the surveyor observed LPN #2 in the room of Resident #73. The surveyor observed an empty food tray next to the resident. LPN #2 asked Resident #73 if the resident was ready to receive their medications. LPN #2 then identified the resident and checked their identification bracelet. The surveyor observed LPN #2 prepare to administer nine medications (9) to Resident #73 which included Topiramate 50 mg (medication for seizures). The surveyor observed LPN#2 prepare the medications for administration. The LPN #2 stated that the resident medications were crushed and administered with apple sauce. The surveyor observed LPN #2 crush Resident #73's medication and added apple sauce to the crushed medications which included Topiramate 50 mg (ERROR #3). The surveyor then observed LPN #2 administer the medications to Resident #73. The surveyor observed Resident #73 express a look of displeasure after consumption of the crushed medications in apple sauce. The resident asked LPN #2, what he/she just ate. LPN #2 stated it was apple sauce. The surveyor reviewed the medical records for Resident #73. A review of the admission Record revealed diagnoses which included Epileptic Seizures (condition in which the brain's electrical rhythms become imbalanced resulting in recurrent seizures) , Anxiety Disorder( mental health disorder that characterized by feeling of worry) and Major Depressive Disorder (Condition of Clinical Depression). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/18/22, reflected the resident had a BIMS score of 2 out of 15, indicating that the resident was severely cognitively impaired. A review of the January 2023 OSR reflected a PO with a start date of 11/24/21 for Topiramate Tablet 50 mg Give 1 tablet by mouth one time a day for Seizure. A review of the January 2023 OSR reflected a PO with a start date of 11/24/21 which revealed the following: May crush all meds permissible by manufacturer and administer together. A review of the January 2023 EMAR revealed a PO with an order date of 11/24/21 for Topiramate Tablet 50 mg Give 1 tablet by mouth one time a day for Seizure. The EMAR indicated that Topiramate was to be administered at 9:00 AM. A review of the Manufacturer's specifications revealed the following: Take Topamax (Topiramate) Tablets whole. Do not chew the tablets. They may leave a bitter taste. On 1/26/23 at 11:10 AM, the surveyor interviewed LPN #2 regarding crushing of Topiramate. LPN #2 looked up Topiramate on the computer and pointed out to the surveyor that Topiramate should not be crush and that a sprinkle formulation was available. On 1/27/23 at 1:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the surveyors concerns from medication administration. On 1/30/23 at 1:30 PM, the survey team met with the LNHA and DON who then responded to the surveyors concerns from 1/27/23. The LNHA stated that he spoke to LPN#1 who stated that she accidently administered Resident #11's Gabapentin 2 PM dose at 9AM. The LNHA also stated that he spoke with the 11-7 nurse who stated that she administered Resident #11's 6AM Gabapentin dose. The DON also stated that LPN #1 should have clarified the order for the Vitamin D3 strength with the physician. The facility also acknowledged that the manufacturer's specifications for Topiramate revealed that the medication should have been taken whole and not crushed. A review of the facility's policy for Medication Administration, dated 3/2022 and was provided by the LNHA included the following: Medication Timing 1. General Rule: For medications scheduled at the times designated by facility policy (i.e., BID at 9AM and 5PM), there is a two-hour window for administration. This is one hour before up to one hour after scheduled administration time. Medication Preparation Under 3 Crushing revealed the following: b. Refer to Do Not Crush list or drug reference if clarification needed. c. If a medication states do not crush-it should not be crushed unless physician order states that crushing the medication will not adversely affect the resident. Nursing should also monitor for adverse effects. d. If resident cannot swallow the medication-request the physician to change the order to alternative dosage form of the medication. Medication Administration (General) 1. Medication checked against MAR/eMAR before administering. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 4 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 1/27/23 at 11:25 AM, the surveyor inspected the 3rd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened and undated bottle of Morphine 20 mg/ml solution (medication for pain). The surveyor interviewed LPN #1 who stated that once a bottle of Morphine solution was opened that it should be dated because once opened it only had a 90-day expiration date. On 1/27/23 at 11:30 AM, the surveyor inspected the 3rd floor medication cart #2 in the presence of LPN #2. The surveyor observed an opened bottle of blood Glucose test strips (a product to test the blood sugar levels) that was not dated. The surveyor interviewed LPN #2 who stated that an opened bottle of blood Glucose test strips should have been dated. On 1/27/23 at 11:45 AM, the surveyor inspected the 2nd floor medication cart #2 in the presence of LPN #3. The surveyor observed an opened bottle of blood Glucose test strips that was opened and not dated. The surveyor interviewed LPN #3 who stated that an opened bottle of blood Glucose test strips should have been dated. On 1/27/23 at 12:00 PM, the surveyor inspected the 2nd floor medication cart #1 in the presence of LPN #4. The surveyor observed an unopened and undated vial of Lantus insulin (medication that controls blood sugar) inside the medication cart. The surveyor interviewed LPN #4 who stated that an unopened vial of Lantus insulin should have been stored in the medication refrigerator. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Morphine 20 mg/ml oral solution once opened had an expiration date of 90-days. 2. Blood Glucose Test strips once opened had an expiration date of 90-days. 3. Lantus Insulin once stored at room temperature had an expiration date of 28-days. 4. Unopened Lantus Insulin Vial should have been stored in a refrigerator. On 1/27/23 at 1:35 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no further information provided by the facility. 2. On 1/26/23 at 11:49 AM, in the presence of the Licensed Practical Nurse (LPN #5), the surveyor inspected the Treatment Cart #2 on the second floor. In the top drawer the surveyor observed an unlabeled and undated 100 gram tube of Diclofenac (Voltaren) 1% gel (a medication used for arthritic pain) inside a clear plastic bag. At that same time, LPN #5 stated that she did not know who the Diclofenac 1% gel belonged to or where it came from. She further stated that it should have a label on it. On that same date and time, the surveyor interviewed the second floor Registered Nurse Unit Manager (RN/UM) who stated that the undated and unlabeled Diclofenac 1% gel should have a label on it. The RN/UM could not speak to who the gel belonged to or how long it has been in the treatment cart. On 1/27/23 at 1:35 PM, the surveyor discussed the above observation and findings with the LNHA and the DON. There was no additional information provided. A review of the facility's policy for Medication Labeling that was dated 3/2022 and provided by the LNHA included that the labels for individual drug containers must include the residents name and the expiration dates. A review of the facility's policy for Medication Storage dated 3/2022 and provided by the LNHA included that medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station. Medication must be stored separately from food and must be labeled. A review of the facility's policy for Medication Administration dated 3/2022 and provided by the LNHA included that the Organization of the Medication Cart .items that expire sooner than the printed expiration date after being opened or removed from refrigeration are dated (on the product itself, not just the outer container). NJAC: 8:39-29.4 (a) (h) (d)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of food and drink served to the residents. This deficient practice was identified by 6 of 6 residents, who during the 1/23/23 Resident Council group meeting stated that hot foods were received cold, and confirmed during the lunch time meal service on 1/27/23 on 1 of 3 nursing units (third floor) tested for food temperatures by two surveyors, and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. All six residents stated that hot foods were received cold at meals. On 1/27/23 at 11:44 AM in the presence of the survey team, the surveyor ensured that a state issued digital thermometer was calibrated (Calibration ensures that the thermometer is accurate and precise for the measurement of food temperatures) to the reading of 32 degrees Fahrenheit (F) via the ice bath method. On 1/27/23 at 12:21 PM, two surveyors observed the arrival of a closed food truck to the second floor. The surveyor and a Registered Nurse identified a regular consistency lunch tray that would be used for temperature testing. At 12:25 PM, the Director of Nursing (DON) closed the food truck door and stated that it belonged to the third floor. Both surveyors followed the DON who transported the food truck to the third floor. At 12:30 PM, the last food tray from the food truck was passed. At 12:31 PM, the surveyor obtained food and fluid temperatures in the presence of a second surveyor and the third floor Licensed Practical Nurse and Unit Manager (LPN/UM). The temperatures were as follows: Fish patty: 114.1 degrees F Broccoli: 104 degrees F White rice: 107 degrees F Black coffee: 144.6 degrees F Vanilla Health Shake 4 oz: 51 degrees F 4 oz Chocolate Ice Cream: 16.5 degrees F and the ice cream was soft to touch. Both the ceramic plate and the metal pellet (a metal plate that should be heated and placed below a ceramic plate to help retain heat in an effort to maintain hot food temperatures at meals) were not warm to the touch. This was acknowledged LPN/UM who touched both and stated that they were not even warm. On 1/18/23 at 10:52 AM, during the initial kitchen tour the Food Service Director (FSD) stated that the plate warmer was not working. On 1/27/23 at 10:15 AM, the survey team met with the facility's Volunteer Advocate who stated that he attended the resident council meetings on resident invitation and that lately there have been a lot of complaints related to food service, which included food temperatures. On 1/27/23 at 1:27 PM, the surveyor interviewed the FSD in the presence of the survey team. He acknowledged that the plate warmer was still not working and that the pellet warmer broke last night. He stated the kitchen was maintaining food temperatures by keeping hot foods in the steam table and that cold foods were iced down before the tray line service. The FSD further stated that test trays were conducted once a week. On 1/27/23 at 1:34 PM, the survey team met with the DON and Licensed Nursing Home Administrator (LNHA), at which time the surveyor reviewed the lunch test tray results. The LNHA stated that the facility was waiting for parts to fix the plate warmer and that the pellet warmer broke the night before. On 1/30/23 at 1:37 PM, the survey team met with the DON and LNHA, at which time the LNHA acknowledged that both the plate and pellet warmers had not yet been fixed and could not speak to how the FSD was able to ensure hot food temperatures would be maintained upon meal delivery to the residents. On 1/31/23 at 1:50 PM, the survey team met with the DON and LNHA, at which time no additional information was provided to the surveyor. The surveyor reviewed the 10/25/22, 11/29/22, and 12/29/22 Resident Council meeting minutes. The minutes did not address food temperatures. Review of the FS form Daily Food Temperature Log with a revised date of 3/2017, reflected that All hot food must be above 135 degrees F before service. All cold food must be below 41 degrees F before service .Danger zone - above 41 degrees F and below 135 degrees F. The FSD provided completed Test Tray forms for 12/6/22, 12/21/22 and 1/4/23. As previously indicated, the FSD stated that test trays were conducted once a week on interview. Review of the form indicated that soups, hot beverages, hot entrees, starch, vegetables and eggs should be above 135 degrees F and dessert, fruit, milk, cold beverages and potentially hazardous foods should be below 41 degrees F. The completed Test Tray form for 12/6/22, revealed a recorded temperature of 128 degrees F for Lasagna and 130 degrees F for coffee. Excellent was marked as the assessed overall quality. The completed Test Tray form for 12/21/22, revealed a recorded temperature of 120 degrees F for coffee. Excellent was marked as the assessed overall quality. The completed Test Tray form for 1/4/23, revealed a recorded temperature of 130 degrees F for pasta. Excellent was marked as the assessed overall quality. Review of the facility policy Test Meal/Tray Audit dated 4/2022, included that A test meal or tray audit will be conducted a minimum of once a quarter or more often as deemed necessary to ensure timely delivery, appetizing temperatures, and acceptable quality of all foods served. It also indicated that findings should be summarized, and a plan of correction should be developed for each problem noted. NJAC 8:39-17.4 (a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to consistently serve residents a nourishing snack when there was more than a 14-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 residents (Resident's #2, #27, #30, #46, #63 and #103) during resident council meeting and was evidenced by the following: On 1/23/23 at 10:26 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to attend the group meeting. Four of six residents stated that they did not receive a bedtime snack even when they asked. One resident stated that I didn't know they had snacks, so I didn't know to ask for it. On 1/25/23 at 9:31 AM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA) stated that he reviewed and provided copies to the surveyor of the snack accountabilities logs from the electronic medical record for Resident's #2, #27, #30, #46, #63 and #103. He acknowledged that there were holes in the documentation and that the facility started in services about documentation. On 1/27/23 at 10:03 AM, the surveyor interviewed the Food Service Director (FSD) who stated that the kitchen provided the three floors with bedtime snacks. He could not speak to an accountability system nursing used to document and ensure residents were served bedtime snacks. The FSD stated that he was aware that there could not be more than 16 hours between dinner and the breakfast meals, and that the facility was required to offer resident's a substantial snack at bedtime. The FSD stated that when he or his supervisor inspected the unit pantries in the morning that they have not found left over snacks, so he assumed they were distributed. On 1/27/23 at 10:09 AM, the surveyor interviewed the Registered Dietitian (RD) in the presence of the survey team. She stated that the facility-maintained snack logs but could not speak to where they were located or if she referred to them when conducting resident nutrition assessments. The RD could not speak to the allowable gap of time between the dinner and breakfast meals, whether or not snacks should have been served verse offered and/or if resident consumption should be accounted for. She then stated that by 8 PM residents should be offered a snack. On 1/31/23 at 1:50 PM, the survey team met with the DON and the LNHA and at that time no additional information was provided by the facility. The surveyor reviewed the 10/25/22, 11/29/22, and 12/29/22 Resident Council meeting minutes. The minutes did not address food bedtime snacks. Review of the undated facility Meal Times list reflected the following: First floor dinner was scheduled to arrive at 4:30 PM and breakfast at 7:45 AM, which yielded a 15 hour and 15-minute gap of time. Second floor dinner was scheduled to arrive at 5:10 PM and breakfast at 8:30 AM, which yielded a 15 hour and 20-minute gap of time. Third floor dinner was scheduled to arrive at 4:40 PM and breakfast at 8:00 AM, which yielded a 15 hour and 20-minute gap of time. Review of the Nutrition - Snacks logs with a 30 day look back period that was provided by the LNHA from the electronic medical record for Resident's #2, #27, #30, #46, #63 and #103 reflected the following: Resident #2 received a snack on 9 of 30 days, refused a snack on 2 of 30 days and on 1 of 30 days it reflected Resident Not Available. Resident #27 received a snack on 4 of 30 days and indicated No did not receive a snack on 10 of 30 days. Resident #30 received a snack on 4 of 30 days and indicated No did not receive a snack on 10 of 30 days. Resident #46 received a snack on 1 of 30 days, indicated No did not receive a snack on 10 of 30 days and on 1 of 30 days it reflected Not Applicable. Resident #63 received a snack on 1 of 30 days, refused a snack on 5 of 30 days and on 5 of 30 days it reflected Not Applicable. Resident #103 received a snack on 11 of 30 days, refused a snack on 1 of 30 days and on 1 of 30 days it reflected Not Applicable. Review of the facility policy Snacks with a review date of 2/2022, included the following: It is the policy and procedure of this facility to offer each resident an HS [bedtime] snack if applicable. If there are more than 14 hours between evening meal and breakfast the following day, a nourishing snack will be offered at bedtime. Ask the resident if they wish to have a snack. If not, document that the resident refused the snack. If yes, .Document that the resident was offered a snack and if the resident accepted the snack. NJAC 8:39-17.2 (f); 17.2 (f) 1

Based on interview and review of pertinent facility documents, it was determined that the facility failed to provide documentation to account for the Infection Control Preventionist attendance for 2 of 3 Quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings. This deficient practice was evidenced by the following: On 1/24/23 at 9:42 AM, the surveyor interviewed the Interim Infection Control Preventionist (ICP) in the presence of the survey team. The Interim ICP stated that she was responsible for the facility's infection prevention control program. She also stated that she had been coming in and out of the facility. However, she stated that she had been working full time in the facility, 50 hours per week for the past 3 weeks. She informed the surveyor that prior to her, the facility hired an ICP on 2 separate occasion and neither of which remained in the facility. During the interview, the surveyor asked the Interim ICP if she attended the Quarterly QAPI committee meetings. She stated that she had not attended the QAA meetings at the facility but was aware that the attendance of the ICP was a requirement. On 1/30/23 at 12:29 PM, the survey team met with the LNHA and DON. The DON stated that the QAA/QAPI team met weekly and quarterly. During the interview, the DON further stated that the ICP is supposed to attend the QAPI meetings. The DON and LNHA could not speak to whether an ICP had attended the QAPI meetings. The LNHA stated that the Interim ICP was at the facility on and off and they had some people in between. However, the LNHA and DON acknowledged that there was no documented evidence that the ICP attended the quarterly QAPI committee meetings on the three quarterly sign in sheets they provided to the surveyor. Review of the facility's QAPI Committee sign in sheets indicated that the Infection Control Coordinator as a member of the meeting as well as the LNHA, DON, and Medical Director in addition to other members which included department heads. Review of the completed QAPI Committee sign in sheets provided to the surveyor reflected that an ICP attended the 4/21/22 quarterly meeting, however there was no documented evidence that an ICP attended the quarterly meetings dated 7/21/22 and 11/17/22. Review of the facility policy Quality Assurance and Performance Improvement with a reviewed date of 2/2022, included Our leadership team, which consists of the administrator, director of nursing, and key department managers, is responsible for creating and sharing the focus of QAPI. NJAC 8:39-33.1 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review other facility documentation, it was determined that the facility failed to a.) ensure a care plan was developed timely for a resident who was receiving oxygen and b.) to ensure a fall intervention was implemented after a resident had a fall. This was identified for 2 of 21 residents reviewed for care plans (Resident #30 and #89). This deficient practice was evidenced by the following: 1. According to the admission Record, Resident #30 was admitted in 07/2020 with diagnosis which included but were not limited to; Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of Resident #30's admission Minimum Data Set (MDS), an assessment tool dated 07/16/20, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact. The MDS also revealed that the resident used oxygen. On 10/20/20 at 11:30 AM, the surveyor observed an oxygen concentrator connected to oxygen tubing in the resident's room. The resident was not in the room. On 10/21/20 at 9:05 AM, the surveyor observed the resident wearing oxygen via nasal cannula at 2 liters per minute. The resident stated that oxygen was used as needed since admission. The surveyor has the same observation on 10/21/20 at 1:01 PM. Review of the resident's vital signs documentation indicated that the resident used oxygen intermittently during the months of July 2020 to October 2020. On 10/21/20 at 2:19 PM, the surveyor reviewed the resident's care plan which did not include the resident's oxygen use. During an interview with the surveyor on 10/23/20 at 9:52 AM, the Registered Unit Manager (RN/UM) #1 stated that he or the MDS nurse create and update resident care plans and that oxygen would be on the resident's care plan. At that time, the surveyor asked to review the resident's care plan. RN/UM #1 showed the surveyor the care plan with an intervention for oxygen dated 10/22/20. The surveyor questioned the date, and the RN/UM stated he needed time to look at the care plan. During a follow up interview with the surveyor on 10/26/20 at 10:26 AM, RN/UM #1 stated he was unable to locate oxygen use on the care plan prior to 10/22/20. During an interview with the surveyor on 10/27/20 at 10:26 AM, the Director of Nursing (DON) stated that the oxygen should have been on the resident's care plan. 2. According the admission Record, Resident #89 was admitted to the facility in 12/2019 with diagnoses that included but were not limited to; epilepsy (seizure), down syndrome and impulse disorder. Review of the resident's Quarterly MDS, dated [DATE], revealed that the resident had a BIMS of 2 which indicated that the resident's cognition was severely impaired. Further review revealed that the resident required extensive to total care with activities of daily living (ADLS). On 10/20/20 at 11:38 AM, the surveyor observed the resident alone in his/her room, in a low chair. The resident was yelling and reaching over the side of the chair. A staff member then entered the resident's room. Review of the resident's fall care plan, initiated on 12/15/19, identified the resident as being at risk for falls related to unaware of safety needs, and impulse control and included a fall with no injury on 10/16/20. An intervention, dated 10/16/20, reflected to keep the resident in a supervised area when in wheelchair for monitoring. Review of the resident's Incident Report (IR), dated 10/16/20 at 3:22 PM, revealed that the resident was found sitting on the floor in the resident's room in front of the resident's chair. Additional review of the IR revealed, that the resident had behavioral problems and would get agitated when left alone. Staff to keep resident in a supervised area when in wheelchair. The surveyor observed Resident #89 in a low wheelchair alone in their room on the following dates and times: 10/21/20 at 11:27 AM; 10/22/20 at 12:15 PM; 10/22/20 at 12:24 PM; 10/22/20 at 1:00 PM; 10/22/20 at 1:47 PM; 10/23/20 at 11:30 AM; 10/23/20 at 1:04 PM During an interview with the surveyor on 10/22/20 at 1:54 PM, the Certified Nurses Aide (CNA) assigned to the resident stated Resident #89 was a fall risk, and was in a low chair due to the resident trying to get up. The CNA stated that the resident spends most of the time in the room watching TV and will verbalize when the resident wanted to come out of the room. During an interview with the surveyor on 10/22/20 at 2:09 PM, the RN assigned to the resident, RN #1, stated the resident was a fall risk, had a low chair and was unaware that the resident was to be in a supervised area when in the chair. During an interview with the surveyor on 10/23/20 at 9:35 AM, RN/UM #2 stated after a resident had a fall, IRs were reviewed during the morning falls meeting and care plans were updated with the new intervention. The staff were then verbally inserviced on the intervention. RN/UM #2 stated that staff sometimes bring Resident #89 out of the room and stated that the resident could be in his chair alone in his/her room to watch TV, and that the resident was checked on frequently. RN/UM #2 stated a supervised area was an area where the resident could be seen. During an interview with the surveyor on 10/23/20 at 10:33 AM, the DON stated that after a resident falls, IRs were reviewed the following day at the fall meeting and an intervention was put on the care plan. During a follow up interview with the surveyor on 10/27/20 at 10:26 AM, the DON stated that the resident should have been in a supervised area when in the chair. Review of a facility policy titled, Falls and Fall risk Managing, revised on 07/13/20, included that the staff will identify and implement relevant interventions to try to minimize serious consequences of falling and make updates to the resident's care plan accordingly. Review of a facility policy titled Care Plans-Comprehensive, revised on 07/08/20, included that the individualized comprehensive care plan included measurable objectives and time tables to meet the resident's medical, nursing, needs was developed for each resident. The comprehensive care plan was based on a thorough assessment that included, but was not limited to, the MDS. NJAC 8:39-11.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documents, it was determined the facility failed to remove an expired medication and maintain a clean, orderly medication cart for 2 of the 3 carts inspected. This deficient practice was evidenced by the following: On [DATE] at 12:27 PM, in the presence of the Unit Manager (UM), the surveyor inspected the second floor medication cart (Cart #2) and observed the following: in the first bin of the third drawer, there was one pink tablet and one green tablet which were unwrapped and unmarked. In the second bin of the third drawer, there were two orange tablets, one pink tablet, one yellow tablet, two white tablets, and one-half white table which were unwrapped and unmarked. When interviewed at that time, the UM stated the med cart drawers were cleaned before and after every shift and as needed for spills. The UM further stated loose medications were destroyed by the nurse using a drug destroyer and that the nurse checked expiration dates for safety to avoid an adverse reaction or complication. On [DATE] at 12:43 PM, in the presence of the UM and Registered Nurse Supervisor, the surveyor inspected the second floor medication cart (Cart #1) and observed the following: in the first bin of the second drawer, there was one unopened insulin needle, one pink pill, one white pill, one yellow pill, and two pink/dark pink capsules. All medications were unwrapped and unmarked. In the second bin of the second drawer, there was one tan pill, which was unwrapped and unmarked. The surveyor also observed a bottle of Deep Sea saline nasal spray, sealed, with an expiration date of 9/2020. The RN acknowledged the expired med and removed it from the cart. During an interview with the surveyor on [DATE] at 1:08 PM, the Licensed Practical Nurse (LPN) stated the medication carts were cleaned nightly. The LPN further stated she checked meds for expiration because they may not be effective if they were expired. During an interview with the surveyor on [DATE] at 10:27 AM, the Director of Nursing (DON) stated the nurses cleaned the med carts before and after each shift. The DON further stated the nurses check each cart to make sure the proper meds were available and not expired to prevent an adverse reaction. Review of the facility's undated Medication Storage in the Facility, Storage of Medications, undated, revealed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier and All medications dispensed by the pharmacy are stored in the container with the pharmacy label. The policy also included Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal if a current order exists. NJAC 8:39-29.4(a),(h)

Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 10/20/20 at 9:35 AM, during the initial tour of the kitchen, the surveyor who was accompanied by the Food Service Director (FSD), observed the following in the kitchen: In the dry storage room: 1. A 20-pound opened bag of [NAME] was not labeled with a received or opened date. 2. A 10-pound opened bag of Tri-Color Rotini was not labeled with a received or opened date. In the walk-in freezer: 1. An opened bag of potato skins was not labeled with a received or opened date. 2. A 10-pound opened undated box of precooked lasagna sheets in an opened plastic bag opened and not dated as to when the bag was opened. The FSD stated that all food that came into the building needed to be labeled with a received date. The FSD stated the unlabeled foods should have been labeled and he took full blame because he was the FSD. The FSD stated the AM and PM supervisors were responsible for labeling and dating the food in the kitchen and that all of the staff should also be checking the labels. During an interview with the surveyor on 10/23/20 at 10:41 AM, the FSD stated the protocol for the rice and the pasta would be 90 days from the open date and all frozen foods must be dated with a received date. On 10/26/20 at 12:35 PM, the Administrator and the Director of Nurses (DON) were made aware of the surveyor's findings. During a follow up interview with the surveyor on 10/27/20 at 10:26 AM, the Administrator and Corporate Chef stated the items should have been dated when they were opened because the facility had a protocol with used by dates. The Administrator stated that he understood that the labels were not on the items when they were opened and would not know how long the items were good for. Review of the Food Safety Requirements Policy and Procedure with an implementation date of 12/12/17, revealed, Procedure .4. proper labeling and dating of each item. Review of the undated Labeling and Dating System Protocol revealed bagged goods that are opened are good for 90 days. All food in freezer storage are good for 6 months. Review of the undated labeled Food Service Director Duties revealed the FSD ensures correct labeling and dating of all food products in kitchen. Review of the undated AM/PM [NAME] Supervisor Job Flow revealed the supervisors should perform a daily walk through to make sure all food items are labeled and dated properly NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the admission Record, Resident #50 was admitted in 02/2016 with diagnoses that included but were not limited to: gastrostomy (external tube that enters the stomach) and dysphagia (difficulty swallowing). Review of the resident's Quarterly MDS dated [DATE], included the resident's cognition was severely impaired. Further review of the MDS included the resident received a tube feeding (nutrition taken through a tube that goes directly into the stomach). Review of Resident #50's care plan, dated 04/23/2016, revealed the resident had an enteral feeding tube to meet nutritional needs and instructions to check for tube placement and gastric contents/residual volume per MD order. Review of Resident #50's Order Summary Report revealed an order for one can of Glucerna 1.5 five times a day for dysphagia via G-tube (feeding tube), dated 10/21/20, and an order for 300 ml (milliliters) free water every six hours, dated 09/08/20. Review of a progress note written by the Dietician on 10/19/20 at 4:19 PM, included the resident was NPO (nothing by mouth) and there were no reports of gastrointestinal concerns. On 10/23/2020 at 10:12 AM, the surveyor observed LPN #2 administer Resident #50's tube feeding. The LPN checked for residual, flushed the feeding tube using an undated, unlabeled gallon jug of water, and administered the tube feeding. When interviewed at that time, LPN #2 explained the process for administering a tube feeding which included checking for placement prior to checking for residual. The LPN further stated she did not check for placement prior to administering the tube feed. The LPN also acknowledged the gallon water jug was not labeled or dated and that she did not know how old the water was. During an interview with the surveyor on 10/23/2020 at 10:50 AM, the LPN/Unit Manager (LPN/UM) explained the process of tube feedings which included checking for placement prior to administering the feeding to make sure the food was going in the right place. The LPN/UM further stated the gallon water jugs came from the supply room and the nurse was responsible for labeling the jug with the room number, date, and nurse's initials. The LPN/UM stated the water jug was good for 24 hours and the date on the jug would tell the nurse if it was still good to avoid an infection. During an interview with the surveyor on 10/23/20 at 11:16 AM, the DON explained the process for tube feedings which included checking for placement prior to administering the tube feeding. During a follow up interview on 10/23/20 at 12:11 PM, the DON stated the facility used one bottle of water for each resident and it should have the date and resident's name on it. She also stated that once the jug was opened, it was good until the expiration date on the bottle. Review of the facility's Enteral Feedings-Safety Precautions policy, revised 11/2018, included Preventing aspiration, Check enteral tube placement prior to feeding or administration of medication. The facility was unable to provide a policy regarding the multi-use water jugs. NJAC 8:39-27.1(a) Based on observation, interview and medical record review, and review of other facility documentation, it was determined that the facility failed to: a.) transcribe orders to the electronic physician's orders and medication administration record (eMAR), for 2 of 3 residents reviewed for oxygen, (Resident #25 and #30); b.) check for placement of an enteral feeding tube prior to a bolus feed; and c.) label and date a resident specific multi-use gallon of water for an enteral tube flush for 1 of 2 residents (Resident #50) reviewed for tube feeding. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and 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. According to the admission Record, Resident #25 was admitted to the facility in 07/2020 with diagnosis which included but were not limited to; tracheostomy (tube inserted to opening in the neck to allow air to enter) and chronic respiratory failure. Review of the resident's admission Minimum Data Set (MDS), an assessment tool dated 7/29/2020, revealed that the resident had short and long term memory impairments. The MDS also indicated that the resident had a tracheostomy and used oxygen. Review of the resident's care plan, dated 07/11/20, revealed that the resident received humidified oxygen via tracheostomy. Further review of the medical record revealed that the resident was readmitted to the facility on [DATE]. On 10/20/20 at 12:40 PM, the surveyor observed the resident sleeping with humidified oxygen via tracheostomy. On 10/21/20 at 11:27 AM, and 10/22/20 at 10:23 AM, the surveyor had the same observation as above for Resident #25. Review of the electronic physician's orders, which included active orders as of 10/22/20, did not include an order that the resident was on oxygen. Review of the October 2020 eMAR and Electronic Treatment Administration Record (eTAR) did not include that the resident was on oxygen. During an interview with the surveyor on 10/22/20 at 12:21 PM, the Registered Nurse (RN) #1 assigned to Resident #25 stated that when residents with a tracheostomy were admitted to the facility, the facility nurse would receive report from the hospital with the amount of oxygen the resident was on and then would obtain a physician's order. During a follow up interview at 10/22/20 at 1:48 PM, RN #1 stated the resident was on 35% oxygen. At that time, the surveyor asked to see the order on the eMAR. RN #1 was unable to locate the order on the electronic physicians orders or the eMAR. During an interview with the surveyor on 10/23/20 at 9:43 AM, the RN Unit Manager (RN/UM) #2 stated that oxygen orders come from the hospital and would be on the eMAR or the eTAR. RN/UM #2 stated the resident was readmitted and that there must have been a glitch in the system. During an interview with the surveyor on 10/23/20 at 10:29 AM, the Director of Nursing (DON) stated that when residents were readmitted from the hospital with oxygen, an order was required and the oxygen order should be on the eMAR or the eTAR. On 10/27/2020 at 11:05 AM, the DON and RN #2 provided the surveyor with a 24-hour nursing report, dated 10/04/20, which read that the resident was readmitted on 35% oxygen. During at interview at that time, RN #2 stated she readmitted the resident to the facility, and obtained the physician's order for the resident's oxygen but forgot to transcribe the order to the electronic physician's orders and eMAR. 2. According to the admission Record, Resident #30 was admitted in 07/2020 with diagnosis which included but were not limited to; Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the admission MDS, dated [DATE], revealed that the resident had a BIMS of 15 which indicated that the resident's cognition was intact. The MDS also revealed that the resident used oxygen. On 10/20/20 at 11:30 AM, the surveyor observed an oxygen concentrator connected to oxygen tubing in the resident's room. The resident was not in the room. On 10/21/20 at 9:05 AM, the surveyor observed the resident wearing oxygen via nasal cannula at 2 liters per minute. The resident stated that oxygen was used as needed since admission. The surveyor had the same observation on 10/21/20 at 1:01 PM. Review of the resident's vital signs record revealed that the resident used oxygen intermittently from July to October 2020. Review of the resident's Order Summary Report for active orders as of 10/21/20 did not include an active physician's order for oxygen. Review of the resident's eMAR and Electronic Treatment Administration Records (eTAR) from July 2020 to 10/21/2020 did not include that the resident was on oxygen. During an interview with the surveyor on 10/22/20 at 1:06 PM, the Licensed Practical Nurse (LPN) #1 assigned to Resident #30, stated that a physician's order was required for oxygen use. At that time, the surveyor asked how much oxygen Resident #30 was on. LPN #1 reviewed the electronic physician's orders, eMAR and eTAR, and stated she was unable to locate the order for oxygen and would call the physician. During an interview with the surveyor on 10/23/20 9:52 AM, RN/UM #1 stated an order from the physician was required for oxygen use and the order was then transcribed to the eMAR or eTAR. During a interview with the surveyor on 10/27/20 at 11:00 AM, the DON handed the surveyor handwritten orders by the resident's physician dated 7/10/20. The orders included an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or oxygen saturation below 91%. The DON stated that the order for oxygen was never transcribed to the electronic medical record, and it should have been on the eMAR. Review of a facility policy, titled, Oxygen Safety revised 7/30/20, included, Oxygen is a medication that requires a Physician's order.