Complaint: 2600629, 2601350Based on interviews, medical records review, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., that the nurse saw Resident #1 around 3:10 P.M., well dressed with cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside. The nurse said okay, and documented that the physician was informed to get an out on pass order. Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct. The Director of Nursing (DON) and the writer were contacted. Due to a syncopal (loss of consciousness) episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the facility's undated REPORT OF INVESTIGATION revealed under 6. Conclusion of investigation: It was concluded that [Resident #1] who is alert and oriented BIMS 12 verbalized desire to go for a walk and sit outside for a while. Order for Out on Pass obtained and signed by [Resident #1] .During out on pass [they] walked away.Returned to facility later in the evening, safe. Body check done, no signs of injury. Wander guard was placed on [Resident #1] for extra safety. Care plan updated.During an interview on 8/29/2025 at 1:14 P.M., with the Licensed Nursing Home Administrator (LNHA) and DON, the surveyor asked if the elopement was reported to the NJDOH. The DON stated that after reviewing the incident they determined that reporting to the NJDOH was not necessary since they had a physician's order and an out on pass signed.A review of the medical record did not include a physician's order at the time of the incident for the resident to go out on pass unescorted. A review of the facility's policy titled ACCIDENTS/INCIDENTS INVESTIGATION PROCESS dated 6/05/25, revealed under REPORTABLE EVENTS that The results of all investigations will be reported to the administration of his or her designated representative and to other officials in accordance with State law, including the State Agencies, within 5 working days of the incident with appropriate corrective action taken as a result of the investigation.NJAC 8:39-9.4(f)

Complaint: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 08/29/2025 and 9/02/2025, it was determined that the facility failed to follow acceptable standards of nursing practice by a.) not documenting a physician's order for a resident (Resident #1) to leave the facility on pass (out on pass) and b.) not following a physician's order for a psychiatric consultation and psychological consultation for a resident (Resident #1) that was ordered at admission to the facility.This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45 Chapter 11, Nursing Board. The Nurse Practice Act for the State of New Jersey states; the practice of nursing as a Registered Professional Nurse is defined as diagnosing, and treating human response 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 restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist. 1. The surveyor reviewed the medical record for Resident #1. According to Resident #1's face sheet, the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., that the nurse saw Resident #1 around 3:10 P.M., well dressed with a cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside. The nurse said okay, and documented that the physician was informed to get an out on pass order. Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct. The Director of Nursing (DON) and the writer were contacted. Due to a syncopal (loss of consciousness) episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the physician's orders (PO) on 8/29/2025, did not include a PO for the Resident #1 to go out on pass at the time of the incident. During a telephone interview on 8/29/2025 at 12:36 P.M., the Registered Nurse/Nursing Supervisor (RN/NS) stated that he had called the physician that day and obtained an order for Resident #1 to go out on pass, but I forgot to put in the order and write the note. The RN/NS acknowledged it was important to document the order because it made everyone aware that the resident was allowed to go out on pass. During an interview on 8/29/2025 at 1:14 P.M., with the Licensed Nursing Home Administrator (LNHA) and the DON, the DON stated the RN/NS did not write the order, so I immediately did a one-to-one in-service with the [RN/NS] and other nursing staff. The DON also stated that she called the physician who confirmed that an order was obtained. The DON confirmed the nurse did not document the physician's order for Resident #1 to go out on pass. 2. The surveyor reviewed the medical record for Resident #1. According to Resident #1's face sheet, the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the physician's orders (PO) on 8/29/2025, for Resident #1, included a PO dated 5/30/2025, for a consultation (consult) for a psychiatry evaluation with [name redacted group]. A review of an additional PO dated 5/30/2025, included a psychology consult. A review of the medical record included a psychiatric consult that was completed almost three months later on 8/25/2025, after the resident eloped from the facility. A further review did not include that a psychology consult was obtained as ordered. During an interview on 9/2/2025 at 2:41 P.M., the DON stated that upon admission to the facility, there were certain consultations that were a standard order for all residents, which included the psychiatric and psychological consults. The DON stated the orders should have been for as needed psychiatric and psychological consults. The DON confirmed the PO's were not followed as written for Resident #1; that there was no psychological consult obtained, and the psychiatric consult was done on 8/25/2025. A review of the facility's policy titled Out on pass dated 7/1/2025, revealed under PROCEDURE: 6. Nursing Supervisor will notify Physician & obtain an order for Out on Pass with Responsible Party or independently if deemed appropriate. A review of the facility's policy titled DOCUMENTATION in the EMR dated 6/5/2025, revealed POLICY: It is the policy of this center to document all information related to the patients medical care in the Electronic Medical Record.NJAC 8:39- 27.1(a)

COMPLAINT #NJ185510 Based on interviews, record reviews, and review of other facility documentation, on 05/08/25 and 05/09/25, it was determined that the facility failed to provide a requested medical record for a discharged resident within 2 days of a written request. This deficient practice was identified for 1 of 3 residents, reviewed (Resident #6), and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the Resident Face Sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease, Dementia, Respiratory Disorder, and Chronic Pulmonary Obstructive Disease. The face sheet also revealed that a family member (FM) requesting the Resident's medical record was listed in the Contacts section as Primary, listed the FM's relationship to the resident, and under designation PHI: [protected health information] Full. According to the admission Minimum Data Set (MDS), an assessment tool dated 04/03/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated that Resident #6 was severely cognitively impaired. The surveyor reviewed a timeline provided by the facility Administrator (ADM) on 05/09/25 regarding a FM's written request for the medical record for Resident #6. According to the timeline, on 4/07/2025, the FM requested the medical records. The contracted provider of the medical record informed the facility ADM they required documentation demonstrating the requestor was the personal representative of the resident and had the authority to request the records. According to the timeline, the next communication was on 4/21/2025 at 5:03 pm from the ADM to the FM that supporting documentation was required. The facility did not follow up with the FM in a timely manner with this new request for information to ensure receipt of the medical record within 2 days of the 4/07/2025 request. The surveyor reviewed emails provided by the Administrator for review: -4/7/25 at 4:04 P.M.: Email sent from facility to the Contracted Provider containing the medical record request from the family. -4/7/25 at 4:21 P.M.: Email sent from the Contracted Provider to the facility advising that additional documentation was needed prior to approving the release of records. The current Medicaid Coordinator (MC), whose role was Medical Records personnel at the time of the FM request on 4/07/2025, was interviewed on 5/08/2025 at 4:37 PM. The MC stated she was aware the FM filed a request for the resident's medical record. The MC further stated she did not deal directly with the family regarding the medical record request but was copied on the emails regarding the request. On 05/08/25 at 5:08 P.M., the surveyor interviewed the Administrator (ADM), who stated that to obtain a resident's medical record, a form must be completed, and then the facility would send the request to [Contracted Provider Name]. The ADM further explained that this provider was the facility's legal consultant who reviewed each request and informed the facility if the person requesting was legally entitled to the information or if additional documentation was needed. According to the ADM, the request for the medical record was received from Resident #6's FM and was sent to the Contracted Provider for review on 04/07/25. The Administrator also stated that he received a response from the Contracted Provider on the same day, 04/07/25 and that the provider advised that additional documentation was needed prior to releasing the records. The Administrator stated that he informed the family of the need for additional documentation on 04/21/25 when he next returned to the facility. When the surveyor asked why the facility did not send the request for additional information to the family member sooner, the Administrator stated that he could have delegated the task to someone else but that he did not. N.J.A.C. 8:39-35.2(h)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a resident's activities of daily living (ADL) care in a dignified manner. This deficient practice was identified for 1 of 3 residents reviewed for activities of daily living (Resident #102), and was evidenced by the following: On 11/07/2024 at 10:58 AM, the surveyor observed Resident #102 in their private room accompanied by Certified Nursing Assistant (CNA #1), who assisted the resident transfer from a wheelchair to the bed. While laying in bed, the surveyor observed CNA #1 remove Resident #102 pants exposing the resident's lower body and their incontinence briefs. At that time, the surveyor left and asked the RN Supervisor-in-training (RN #1) to check on Resident #102. Upon returning to the room, Resident #102 was under the blankets and covered. When CNA #1 exited the room, the surveyor inquired how ADLs are to be performed in the room. CNA #1 acknowledged that the curtain was not pulled for privacy. RN #1 confirmed that all ADL care should be provided in the room with either the door shut or curtain pulled for privacy. The surveyor reviewed Resident #102's medical Record: A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/21/24 reflected the resident was admitted to the facility with diagnoses which included fracture of the humerus and ribs. The MDS also reflected that the resident brief interview for mental status (BIMS) score of 11 out of 15, which indicated that the resident had moderately impaired cognition. On 11/12/2024 at 12:19 PM, in the presence of the Licensed Nursing Home Administrator, Regional Nurse, the Director of Nursing (DON), acknowledged it was the expectation of staff to have the door closed or close the privacy curtain closed to ensure privacy and dignity to the residents. A review of the facility policy titled, Resident Rights, last reviewed June 11, 2024, revealed that: Resident's Rights include, but are not limited to the following: treated with respect, dignity [ .] NJAC 8:39-4.1(a)12

Complaint # NJ00176124 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain treatment records that were complete with staff signatures according to professional standards of clinical practice for Resident # 72, 1 of 24 residents reviewed for professional standards. The deficient practice was evidenced by the following: A review of Resident # 72's admission Record indicated Resident # 72 was admitted to the facility with diagnoses which included but were not limited to Quadriplegia (partial or total loss of function in all for limbs and the torso) and Peripheral Vascular Disease (a condition that occur when blood vessels outside the brain and heart narrow, reducing blood flow to organs and tissues). A Review of Resident #72's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 09/24/2024 revealed a Brief Interview for Mental Status score of 15/15, indicating Resident #72 was cognitively intact. A review of Resident #72's Treatment Administration Record (TAR) for the months of July 2024, August 2024, September 2024, and October 2024 revealed several blanks. For the treatment to the left 3rd toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 09/30/24 day shift For the treatment to the left great toe blanks were noted for: 07/04/24 day shift 07/08/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 09/30/24 day shift For the treatment to the right calf blanks were noted for: 07/04/24 day shift 07/08/24 day shift 07/13/24 day shift 07/14/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 10/04/24 day shift For the treatment to the right 3rd toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift For the treatment to the Right 4th toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift For the treatment to the right great toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 10/04/24 day shift For the treatment to the left lower leg blanks were noted for: 09/30/24 day shift For the treatment to the right buttock blanks were noted for: 09/30/24 day shift 10/04/23 day shift During an interview on 11/08/2024 at 09:56 AM with the surveyor, Resident #72 said they feel like when there are only 2 nurses on the floor their wound care doesn't get done. During an interview on 11/12/2024 at 12:19 PM with the surveyor, The Director of Nursing (DON) said when there are blanks on the TAR it means the nurse didn't sign it and you don't know if it was done. The DON also said there should not be any blanks on the TARS. A review of a facility provided policy last reviewed 06/04/2024 titled Documentation in the EMR revealed under section Purpose that, To maintain all information regarding the resident's care and treatment in an organized manner to ensure residents receives appropriate medical care with appropriate documentation. The also revealed under General information that, Documentation about treatments received will be located in the TAR. This will include the treatment ordered, frequency and location to administer treatment as well as the date/time administered and who performed the treatment. Any refusal should be documented accordingly, and MD should be informed. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that expired vaccines were removed from active inventory upon expiration. The deficient practice was identified in 1 of 2 medication rooms and was evidenced by the following: On [DATE] at 11:30 AM, in the presence of the Licensed Practical Nurse Unit Manager (LPNUM #1), the surveyor inspected the second floor medication room on the sub-acute unit. In the refrigerator, the surveyor observed a brown bag that had identification stickers which identified it as Covid-19 vaccines with an expiration date of [DATE]. Inside the bag were five (5) prefilled Intramuscular (IM) Moderna Covid 19 vaccine syringes with an expiration date of [DATE]. At this time, LPNUM #1 stated that the overnight shift is responsible for checking the expiration dates and confirmed that the bag should not be in refrigerator. On [DATE] at 1:40 PM during an interview with the surveyor, the Assistant Director of Nursing (ADON) confirmed that the Covid 19 vaccines were expired and should not have been in the refrigerator. On [DATE] at 11:12 AM, during an interview with the surveyor, the Infection Preventionist (IP) confirmed that the overnight staff are responsible for checking expiration dates in the medication rooms and that the Covid 19 vaccines should have been removed from the medication room. When asked why it is important to remove vaccines that are expired, the IP responded that vaccines might not be effective past that date. On [DATE] at 12:19 PM, in the presence of the Licensed Nursing Home Admistrator, Regional Nurse, Director of Nursing (DON), acknowledged that the expired vaccine in the medication room refrigerator. A review of the facility policy titled, Medication Storage, last reviewed [DATE], revealed under, Responsibility that: 1.[Licensed Nurse] Checks medication storage at least monthly to ensure all meds and supplies are checked for labels, expiration dates and to ensure the labels are legible. 2. Any meds that will be expiring should be removed before the expiration date. If pending expiration, it will determine if the supply will be completed before expiration date. NJAC-8:39-29.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary and comfortable environment that helped prevent the development and transmission of communicable diseases and infections. The deficient practice was evidenced by the following: On 11/06/24 at 10:58 AM, upon initial tour of the second-floor sub-acute unit, the surveyor observed room [ROOM NUMBER] with an Enhanced Barrier Precautions sign along the doorframe. The surveyor observed inside the room Personal Protective Equipment (PPE) Gown discarded in the resident's personal trash bin. On the same date and time, the surveyor observed room [ROOM NUMBER] with a Contact Precautions Sign along the doorframe. The surveyor observed inside the room a discarded Personal Protective Gown on the resident's floor. On 11/07/2024 at 11:13 AM, during an interview with the surveyor, Licensed Practical Nurse Unit Manager (LPNUM #1) stated that facility expectation was to bring a red biohazard disposable bag into the resident room and place all discarded PPE into the bag and throw it away in the soiled trash room. LPNUM #1 confirmed that PPE is not to be discarded in the resident trash bin or on the floor. On 11/12/24 at 10:22 AM, the surveyor observed in room [ROOM NUMBER] with an Enhanced Precautions Sign along the doorframe. The surveyor observed inside the room PPE discarded in the resident's personal trash bin. On 11/12/2024 at 10:26 AM, during an interview with the surveyor, Certified Nursing Assistant (CNA #1) stated that upon the start of their day, they receive report of residents with a change in status and any resident that is on enhanced barrier protection and/or contact precautions. CNA #1 confirmed that upon entering a room with a precaution sign, they are to bring a red trash bag and discard the PPE in that bag upon exiting the room then bring the bag to the soiled trash room. CNA #1 confirmed that PPE is not to be discarded in resident trash bin or on the floor. On 11/12/2024 at 11:12 AM, during an interview with the surveyor, the Infection Preventionist (IP) acknowledged that PPE disposal was to be in a red bag and brought to the trash room. The IP confirmed that PPE is not to be discarded in resident trash bin or on the floor. On 11/12/2024 at 12:19 PM, in the presence of the Licensed Nursing Home Administrator, Regional Nurse, Director of Nursing (DON), acknowledged that the PPE should not be discarded on the floor or in resident trash bins. A review of the facility document titled Infection Control Manual, last reviewed June 4, 2024, revealed under Isolation- Initiating Transmission Based Precautions that When transmission based precautions are implemented, the infection preventionist or designee shall: C. Ensure that appropriate linen barrel/hamper and waste container with appropriate liner are placed in or near the resident's room. A review of the facility document titled Infection Control Manual, last reviewed June 4, 2024, revealed under Personal Protective Equipment- Using Gown that After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. A review of the facility document titled Certified Nursing Assistant Job Description, revealed under safety and sanitation to follow established procedures in the use and disposal of personal protective equipment. A review of the facility document titled Licensed Practical Nurse Job Description, revealed under safety and sanitation to Ensure that CNAs and other nursing personnel follow established procedures in the use and disposal of personal protective equipment. NJAC 8:39-33.1(b)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 shower rooms. The deficient practice was evidenced by the following: On 11/06/2024 at 10:58 AM, the surveyor entered the shower room on the second floor and observed tiles on the floor and various hygienic products left in the whirlpool tub. On 11/07/2024 at 09:49 AM, the surveyor entered the shower room on the second floor and observed tiles picked up and placed on the window sill, and items remained in the whirlpool tub. On 11/07/2024 at 1:05 PM, the surveyor entered the shower room on the third floor and observed brown stains on the wall and floor tiles, an empty can of aftershave on the floor, a leaking shower head in a plastic bag, and a broken faucet. On top of the linen cart was one loose, blue incontinent pad and one open bag of incontinence briefs. On 11/08/2024 at 09:35 AM, the surveyor entered the shower room on the third floor and observed in the shower area a leaking shower head in a plastic bag with towels around it. Clothing on the shower bed and tissues on the floor under the shower bed. Trash in the trash can with no bag lining. On 11/08/2024 at 09:39 AM during an interview with the housekeeper (HK # 1), the surveyor asked who is responsible for cleaning the shower rooms. HK # 1 replied, Housekeeping is responsible for emptying the trash, mopping the floors, and cleaning the shower room. Certified Nurse Aides (CNAs) are responsible to clean up behind the residents after showering. On 11/08/2024 at 09:44 AM during an interview with the Director of Housekeeping (DOH), the surveyor asked what are the brown stains in the shower area on the third floor, who is responsible to clean the shower rooms, and do the residents use the shower area. The DOH replied, The staining in the shower area is caused by the harshness of the water. Housekeeping is responsible for cleaning the area. The area is difficult to maintain due to the water quality. The Regional Director of Housekeeping (RDOH) was notified yesterday for guidance on addressing the water stains. The RDOH brought in lime spray today to clean the area, and the stains have now been removed. The shower area is currently non-functional and has not been used for the resident showers in over a year. On 11/12/2024 at 12:27 PM during an interview with the Licensed Nursing Home Administrator (LNHA), the surveyor asked what are the brown stains in the shower area on the third floor. The LNHA replied, The staining in the shower area is due to the harshness of the water, and the shower area should have been cleaned. A review of a facility provided policy, with a review date of 06/04/2024, titled Environmental Services revealed under the section titled Procedure Bathroom and Toilets #4 that, Sanitation: Bathrooms are high-risk areas for pathogen transmission, so extra attention is needed. Toilets, sinks, and faucets should be sanitized with appropriate disinfectants. Shower Areas: Cleaning and disinfecting showers, bathtubs, and other wet areas to prevent mold and mildew buildup is essential. A review of a facility provided policy, with a review date of 06/04/2024, titled Environmental Services revealed under the section titled Environmental Cleaning Audits #11 that, Monitoring and Evaluation: Facilities should implement regular audits or inspections to assess the effectiveness of cleaning practices. These audits can be used to identify areas for improvement and ensure that standards are met. Feedback Loop: Providing ongoing feedback to housekeeping staff is crucial for continuous improvement and maintaining high standards of cleanliness. § 8:39-31.4 (a)

Based on observation, interview, and record review it was determined that the facility failed to provide a homelike and dignified dining experience to residents on 2 of 2 nursing units on 3 consecutive days. The deficient practice was evidenced by the following. The surveyor observed the lunchtime meal at the following locations and days/times: Second floor dining room - 8/28/23 at 12:00 PM; 8/29/23 at 12:17 PM; 8/30/23 at 11:57 AM. Third floor dining room - 8/28/23 at 11:45 AM; 8/29/23 at 12:19 PM; 8/30/23 at 12:00 PM. During each of the observations, staff served residents' meals on plastic trays. The trays remained in place throughout the residents' mealtime. Additionally, staff placed each plate dome lid upside down on residents' tables and used them as a trash container for wrappers and debris from the meal tray. The dome lids remained in place on the tables throughout the mealtime. On 8/30/23 at 12:02 PM the surveyor interviewed the Licensed Practical Nurse (LPN) who supervised the second floor dining room. The LPN stated it was the practice of the facility to leave meal plates on the plastic trays and to leave the dome lids on the table during the entire dining period. On 8/30/23 at 1:26 PM the surveyor told the Director of Nursing (DON) and the Administrator of observed concerns with dining practices that were not homelike or dignified. On 8/31/23 at 10:05 AM the DON stated to the surveyor leaving plates on plastic serving trays and using dome lids for trash was a dignity concern. On 9/6/23 the DON provided the surveyor with the facility Policy and Procedure for Meal Service, last reviewed 1/10/23. The document did not contain information for steps to set up the meal in a dignified and homelike manner. NJAC 8:39-4.1(a)12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #254 was admitted on [DATE]. The Comprehensive/5 Day MDS had an ARD of 8/16/23 which was completed late on 8/30/23. On 8/31/23 at 2:00 PM, a Validation Report was received from the Regional MDS Coordinator which confirmed the comprehensive assessment was completed late. On 8/31/23 at 2:05 PM, the survey team spoke to the Director of Nursing (DON) and the Administrator regarding late MDS submissions. The DON stated a new MDS Coordinator was hired, however, did not show up for work. A second was hired but has not yet started. The DON stated a Quality Assurance Performance Improvement (QAPI) was started in April 2023 for the timely completion of MDS assessments. The DON voluntarily provided information to the survey team regarding the facility's quarterly QAPI meetings and the MDS submission compliance rates. The surveyors reviewed the facility's QAPI for Timely MDS Completion/Transmission, reporting period April 2023 to July 2023; reviewed 7/28/23 and 8/23/23; next review date 9/29/23. The April 2023 compliance rate of 95.7% had dropped to 31.2% in July 2023. The DON provided the surveyors with the facility MDS policy on 8/31/23. Procedure #4 indicated the RN MDS Coordinator monitors the completion of the scheduled assessments including the Care Area assessments, signs and dates when the MDS is completed. NJAC 8:39-11.2(e) 3. On 08/28/23 at 11:26 AM, the surveyor observed Resident #89, awake, alert lying in bed, responding to the surveyor by nodding his head. The surveyor reviewed the medical records of Resident #89, which revealed the following: Resident #89 was admitted to the facility on [DATE] and readmitted with diagnoses that included but were not limited to Acute and Chronic Respiratory Failure and Dysphagia (difficulty in swallowing). The admission MDS (AMDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating that the resident's cognition is severely impaired. Resident #89 was observed to have an AMDS with an ARD of 3/22/2023 and was due to be submitted no later than 4/04/2023. The MDS was not submitted until 4/06/2023. 4. Resident #100 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus (increased sugar level) with diabetic chronic kidney disease. The AMDS, dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, indicating that the resident's cognition is intact. Resident #100 was observed to have an AMDS with an ARD of 7/24/2023 and was due to be submitted no later than 8/06/2023. The MDS was not submitted until 8/23/2023. Based on interview and record review, it was determined that the facility failed to complete quarterly and comprehensive Minimum Data Set (MDS) assessments in a timely manner for 5 of 23 residents reviewed (Resident #8, #39, #89, #100 and #254). The MDS is an assessment tool used to guide the resident's plan of care. This deficient practice was evidenced by the following: 1. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #8 which revealed the following. The annual MDS indicated an observation end date or assessment reference date (ARD) of 7/21/23. The status of the annual MDS was listed as in progress.The MDS should have been completed by the 14th day (8/4/23). The MDS was 26 days overdue on the day of the surveyor's record review (8/30/23). 2. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #39 which revealed the following. The quarterly MDS indicated an ARD of 7/21/23. The status of the quarterly MDS was listed as in progress. The MDS should have been completed by the 14th day (8/4/23). The MDS was 26 days overdue on the day of the surveyor's record review (8/30/23).

Complaint # NJ00155894 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered Care Plan (CP) to address the needs for a resident with Diabetes, Epilepsy (a disorder that causes seizures), and that required oxygen (Resident #104), 1 of 24 residents reviewed for CP. This deficient practice was evidenced by the following: According to the admission Record, Resident #104 was admitted to the facility in May of 2022, with diagnoses that included but were not limited to: traumatic subdural hemorrhage (caused by a blow to the head or fall, causing bleeding inside the brain), Epilepsy, dependence on supplemental oxygen, and Type 2 Diabetes Mellitus. A review of the admission Minimum Data Set (MDS), an assessment tool dated 5/10/22, revealed a Brief Interview for Mental Status of 00 indicating severe cognitive impairment. Further review of the MDS revealed the resident was total dependence for activities of daily living, had an Active Diagnoses of Diabetes Mellitus, Seizure Disorder or Epilepsy, Respiratory Failure, and dependence of supplemental oxygen. A review of the physician order summary report for May 2022 revealed a physician's order for OXY* Oxygen inhalation (via nasal cannula @-2 lpm (liters per minute)) every shift check every shift; Keppra Tablet 500 MG (milligrams) (levETIRAcetam) give 1 tablet via G-tube two times a day for seizures; HumaLOG Solution 100 unit/ML (milliliters) (Insulin Glargine) inject as per sliding scale . subcutaneously every 6 hours for dm (diabetes); Lantus Solution 100 unit/ML (Insulin Glargine) inject 10 unit subcutaneously at bedtime for dm. A review of the facility provided CP initiated 05/07/22, revealed a Focus for Resident #104; at risk for falls r/t (related to) impaired safety awareness, impaired mobility. Combative behavior. Hx (history) of repeated falls w/ subdural hematoma .Date Initiated: 05/07/2022. Further review of the CP, did not reveal a Focus for epilepsy, Type 2 Diabetes, or supplemental oxygen use. On 08/31/23 at 1:21 PM, during an interview with the surveyors, the Licensed Practical Nurse (LPN) stated that the purpose of the CP was to know what the resident's goals were and what the resident was capable of doing. She then stated that the focus of the CP was guided toward the resident's diagnoses. The surveyor asked the LPN if she would expect to see a CP for a resident with diagnoses of Diabetes, Epilepsy, and oxygen use, she stated, yes, they should all be on the CP. On 09/01/23 at 9:28 AM, during a meeting with the surveyor, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated that the purpose of the CP was to actually meet the needs of the patient and to makes sure the interdisciplinary team, the patient and the responsible party were on same page. The DON stated that it would include the MDS and medical diagnoses. The surveyor asked the DON and the ADON, if they would expect to see a CP for a resident with diagnoses of Diabetes, Epilepsy, and oxygen use, they both stated, yes they should. The surveyor asked the DON and the ADON to review the facility provided CP, for resident #107, for Diabetes, Epilepsy, and/or oxygen use. The DON stated, sad to say, I cannot find those 3 items. They both confirmed that all 3 of the above items should have been addressed on the CP. A review of the facility's policy Comprehensive Care Plan with a last review date of 2/1/23, revealed: Policy Statement: A. A comprehensive care plan for each resident shall be developed and initiated on admission at this facility utilizing and interdisciplinary team approach. The comprehensive care plan will be individualized, defining the problems/needs identified from each discipline's assessment, attainable goals, and interventions. B. The resident's initial comprehensive care plan shall be completed by all disciplines within 14 days of admission. Purpose: A. To provide a system for all disciplines involved to direct resident care to: Identify and assess each resident's problems/needs. Develop, document, and implement a coordinated plan of care. Evaluate the effectiveness of the plan of care and modify plan as needed. N.J.A.C 8:39-11.2 (d) (e) (1) (2) (3)

Based on observation, interview, and record review it was determined that the facility failed to ensure a physician's order for oxygen therapy was complete and thorough for 1 (#254) of 1 resident reviewed for respiratory services. The deficient practice was evidenced by the following: On 8/29/23 at 9:30 AM, the surveyor observed resident #254 in his/her room awake, alert, and oriented in bed. The oxygen concentrator was turned off and had no tubing or nasal cannula attached. The water reservoir was dated 8/26/23. On 08/30/23 at 11:53 AM, the surveyor interviewed the resident. The resident was pleasant and interviewable. The oxygen concentrator at the bedside was turned off and had no tubing or nasal cannula attached. On 08/30/23 12:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident. The surveyor asked the LPN to review the oxygen order with her in the Electronic Health Record (EHR). The LPN showed the surveyor the order which read Oxygen Inhalation (via nasal cannula @ 2 lpm [liters per minute]) every shift check every shift, Start Date 08/26/2023 0700. The LPN confirmed the order was incomplete since it did not indicate whether the oxygen was to be used continuously or as needed (prn). A review of the hybrid Medical Record revealed the following information. The August 2023 Order Summary included an order for oxygen therapy as follows. - OXY* Oxygen Inhalation (via nasal cannula @ 2 lpm) every shift check every shift, Start Date 08/26/2023 0700. The respiratory Care Plan initiated on 8/28/23, included an intervention for oxygen settings O2 via nasal cannula @ 2 lpm. On 8/30/23 at 1:30 PM, the surveyor interviewed the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Infection Preventionist (IP) regarding the incomplete oxygen order. On 08/31/23 at 10:00 AM, the DON confirmed the oxygen order was incomplete. A new oxygen order was received from the physician on 8/30/23 for 2 lpm as needed for low oxygen level. On 8/31/23 the DON provided the surveyor with the facility Oxygen Administration Policy and Procedure with a reviewed date of 10/29/22. The policy reflected that if a resident is using oxygen, the frequency and duration of the treatment should be recorded in the resident's medical record. NJAC 8:39-27.1(a)

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 on 8/30/23, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 31 opportunities, and six (6) errors were observed which calculated to a medication administration error rate of 19.3%. This deficient practice was identified for two (2) of five (5) residents, (Resident #56 and #83), that were administered medications by one (1) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. On 8/30/23 at 8:00 AM, during the morning medication pass, the surveyor observed the Licensed Practical Nurse (LPN #1) obtaining a blood pressure (BP) for Resident #56. The LPN#1 placed the BP cuff on the resident's right leg below the knee. The LPN #1 stated that this was the best way to obtain the BP because the resident was very thin. The LPN#1 then stated that she received an error indication on the digital BP machine, the surveyor observed her reposition the BP cuff on the same area and immediately restarted the BP machine. The LNP#1 then stated that she had obtained a BP of 187/147 and a heart rate (HR) of 63. The LPN#1 added that the resident's BP was usually high and would check the BP again later. After removing the BP cuff, the LPN#1 asked the resident if he/she wanted the Iron pill and the resident shook their head in the yes direction. The LNP#1 explained to the surveyor that the resident did not always like the Iron pill because it turned the applesauce black and would refuse to take it. On 8/30/23 at 8:07 AM, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 20 milligram (MG) tablet of Famotidine (Pepcid) (a medication used to treat excess stomach acid), one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to slow the HR and lower the BP), one (1) 150 MG capsule of Polysaccharide-Iron Complex (Ferrex)(a medication used to treat iron deficiency), one (1) 500 MG tablet of Ascorbic Acid (Vitamin C)(a supplement) and two (2) 325 MG tablets of Acetaminophen (Tylenol)(a medication used for pain relief) for Resident #56. On 8/30/23 at 8:14 AM, the surveyor observed the LPN #1 crush four (4) of the five (5) medications together in a pouch and then poured the crushed medications into a 30 milliliter (ML) medication cup with applesauce. The LPN#1 then opened the Ferrex capsule and mixed the contents into the medication cup that had the four (4) medications and filled the medication cup with applesauce. The applesauce then turned a black color. On 8/30/23 at 8:16 AM, the surveyor observed the LPN#1 approach the resident to administer the five (5) medications in the applesauce and the resident was shaking their head in the no direction. The LPN #1 explained that the applesauce contained the resident's medication and that it was important to take the medications. The LPN#1 scooped a spoonful of the applesauce and administered the spoonful to the resident. The resident took the spoonful and shook their head in the no direction repeatedly. The LPN#1 explained again the importance and told the resident there was just another spoonful left. The LPN#1 was unable to administer the remaining applesauce containing the medications. Upon returning to the medication cart, the LPN#1 discarded the remaining applesauce and stated that the resident had swallowed more than half of the applesauce, so she felt that the resident had received the medications. The LPN#1 then indicated on the electronic administration record (EMAR) that the resident had received the five (5) medications. At that time, the LPN#1 was unable to verify that the complete dose of each of the five (5) medications was received. The LPN#1 stated that she should have used less applesauce. (ERROR #1, #2, #3, #4, #5) The surveyor reviewed the medical record for Resident #56. A review of the resident's admission Record (AR) revealed diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (HTN)(high blood pressure), severe protein-calorie malnutrition and gastro-esophageal reflux disease (acid reflux). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 7/14/2023, reflected the resident had a brief interview for mental status (BIMS) score of three (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed physician orders (PO) for the following: Famotidine tablet 20 MG, give 1 tablet by mouth in the morning for acid indigestion with a start date 1/13/23. Metoprolol Tartrate oral tablet 100 MG, give one tablet by mouth two times a day for HTN-give with food hold if systolic BP less than 110 millimeter of mercury (mmhg) and HR less than 60 with a start date of 7/25/23. Polysaccharide Iron Complex capsule 150 MG, give 1 capsule by mouth one time a day for deficiency with a start date of 1/13/23. Ascorbic Acid tablet 500 MG, give 1 tablet by mouth one time a day for supplement with a start date of 1/13/23. Acetaminophen tablet 325 MG, give 2 tablet by mouth every 6 hours as needed for pain with a start date of 2/24/23. A review of the EMAR revealed consistency with the above POs. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that when the nurses had to crush medications that they should be crushed individually. The UM/LPN also stated that if crushed medications were all mixed in the same applesauce or pudding then the resident had to take the entire contents. The UM/LPN added stated that if the resident refused to finish the applesauce or pudding that contained all the medications then there was no way to know how much of the medications that the resident received. The UM/LPN stated that a BP of 187/147 had not sounded accurate and would retake the BP to be sure. The UM/LPN added that if the BP of 187/147 was a true reading than the physician should be called. The UM/LPN added that she would not administer any medication if she had not thought the BP was accurate. On 8/31/23 09:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that the nurses should not crush all the medications together because if the resident were to refuse to take all the applesauce or pudding that the medications were mixed in then there would be no way to determine which medication the resident had not received. The IP added that if a resident took some of the crushed medication there was no way to determine the actual dose received. The IP added that the nurse would have to document that the medication was refused because the whole dose would not have been administered and the physician should be notified. The IP also stated that the nurses should try to figure out why the resident was refusing medications and put interventions in place such as changing the medication if the taste were an issue or possibly changing the time. The IP then stated that crushing medications required a physician's order and usually would populate in the EMAR to crush the medications so that all the nurses were aware. In addition, the IP stated that a BP of 187/147 had not sounded accurate and would recommend retaking the BP and if the BP was accurate than the physician should be called. On 8/31/23 at 11:30 AM, the IP provided the surveyor with an example of an unsampled residents electronic record that indicated Special Instructions: crush meds per resident request to explain how there was a section to populate that indicated that the resident took their medications crushed. A review of Resident #56's electronic record had not indicated special instructions. In addition, the IP provided the surveyor with a Medication Pass Audit Tool dated 5/2/23 for LPN #1 completed by the Consultant Pharmacist (CP) which revealed that there were areas indicating a No, which meant that the technique was not performed appropriately, which included for the Technique Assessment: Medications via Gastric Tube that Administers each medication individually. was not performed correctly and there was a handwritten note that this was discussed. On 8/31/23 at 2:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, ADON and IP to review the medication observation results. The IP stated that when a medication pass audit was performed if there were indications that proper procedures were not followed then another observation and in servicing would be followed up. The DON stated that she would check if there were any other medication observations performed for LPN #1. On 9/1/23 at 8:58 AM, the DON provided the surveyor with an In-service on medication pass dated 5/10/23 completed by the ADON and signed by LPN #1 was performed and a Competency Validation: Medication Pass was completed by the ADON on 7/26/23 that indicated the LPN#1 Meets Standard for all the Performance Criteria. In addition, the DON provided a Medication Observation Form dated 6/9/23 for LPN #1 completed by the provider pharmacy which revealed that there was zero (0) % error rate. On 9/1/23 at 9:38 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the consultant for the facility for approximately a year. The CP stated that she had performed medication observations with the nurses and verified that she used a Medication Pass Audit Tool but was unable to speak to the actual form that she had completed for LPN#1. The CP stated that she would add to the form Discussed tips & tricks for med pass observation by Department of Health (DOH), etc. because as she performed the medication observation, she would review different areas to help the nurses understand what the correct procedure that should be done during the medication pass. The CP stated that medications should be crushed separately unless there was a PO and the reason for crushing the medications separately was because if a resident refused to finish the vehicle that the medications were mixed in then the nurse would have no way of knowing the actual dose the resident received. The CP added that if a resident was refusing a medication or was unable to receive the entire dose then the physician should be notified, and the nurses should review the possible reason the resident was refusing to possibly make a change. The CP added that the completed Medication Pass Audit Tool was left with the DON and if there were issues, she would review them, and the DON would decide the next step. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that The EMAR is the form onto which all medication orders are transcribed from physician electronic orders, from which medications are poured and administered and on which medication doses are documented. In addition, the policy reflected, Obtains orders for crushing of medications as appropriate/necessary as per manufacturer's directions and crushes medications individually prior to administration. Also, Administers full dose of medication to resident via correct route. 2. On 8/30/23 at 8:20 AM, during the morning medication pass, the surveyor observed the LPN #1 preparing six (6) medications which included a Lidocaine 5 % patch for Resident #83. The LPN#1 removed a Lidocaine 5% patch from the medication cart and stated that the patch was a house stock medication, meaning that the facility provided the medication and was an over the counter (OTC) medication. On 8/30/23 at 8:35 AM, the surveyor observed the LPN#1 apply the Lidocaine 5% patch to the resident's right shoulder. On 8/30/23 at 8:41 AM, upon returning to the medication cart, the surveyor with the LNP#1 reviewed the EMAR regarding the Lidocaine PO. The surveyor asked the LPN#1 if the PO on the EMAR for Aspercreme (Lidocaine) Patch 4% was the same as the Lidocaine 5% patch that she had applied to the resident's right shoulder. The LPN#1 stated that she thought the Lidocaine was a house stock medication and thought she was correct. The LPN#1 then looked in the medication cart and removed the box that she had taken the Lidocaine 5% patch from. The surveyor with the LPN#1 observed a label on the Lidocaine 5% patch box which revealed the name of an unsampled resident. The LPN#1 stated that the Lidocaine patch that she had removed was from the unsampled resident's box of Lidocaine 5% and thought there was another box that contained the house stock Lidocaine 4% patches. The LPN#1 looked through the medication cart and was unable to find a box containing Lidocaine 4% patches. The LPN#1 stated that she would have to call the physician. (ERROR #6) The surveyor reviewed the medical record for Resident #83. A review of the AR revealed that the resident had diagnoses which included adhesive capsulitis of unspecified shoulder (frozen shoulder). A review of the admission MDS, an assessment tool used to facilitate the management of care with an assessment reference date of 6/23/2023, reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report revealed a PO dated 8/23/23 with for Aspercreme Lidocaine Patch 4% (Lidocaine), apply to Right shoulder topically one time a day for pain apply for 12 hours then remove. A review of the EMAR revealed a PO with a start date of 8/24/23 for Aspercreme Lidocaine Patch 4% (Lidocaine), apply to Right shoulder topically one time a day for pain apply for 12 hours then remove. On 8/30/23 at 12:11 PM, the DON provided the surveyor with the facility Over the Counter (OTC) List. The DON explained that the list indicated which medications the provider pharmacy would know not to send to the facility if there was a PO and the facility would provide. A review of the OTC List reflected for Lidocaine/Asper 4% that the provider pharmacy Do NOT Send and that the facility provided that medication. On 8/30/23 at 12:13 PM, the DON stated that a med error report for Resident #86 was done. The DON acknowledged that Aspercreme (Lidocaine) 4% was a house stock medication and was ordered for Resident #83 and that the LPN#1 had administered Lidocaine 5% that was obtained from an unsampled resident's prescription. The DON added that the physician was notified. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that Assures the 5 rights: Compares the medication name, strength, route and dosage schedule on the medication administration record against the prescription label, Always check three times prior to administration of medication. NJAC 8:39-11.2(b), 27.1(a), 29.2(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 01:33 PM, ADON/RN (Nurse #1) told the surveyors she was ready to do the treatment pass. The treatment cart was right outside the resident's room, and there was a computer on top of the treatment cart. The Nurse #1 read the following treatment: Mupirocin External Ointment 2 % (Mupirocin) Apply to sacrum topically every day shift for wound care clean with NSS, apply santyl, bactroban (mupirocin), pack with gauze, cover with foam dressing AND Apply to sacrum topically as needed for wound care for 30 Days clean with NSS, apply santyl, bactroban (mupirocin), pack with gauze, cover with foam dressing. On [DATE] at 01:37 PM, the Nurse #1 squeezed Santyl into the two (2) medicine cups and one (1) medicine cup for Bactroban cream, then checked the order from the computer. On [DATE] at 01:47 PM, the Nurse #1 entered the resident's room, put on gloves, and put the treatment supplies on the overbed table. Nurse #1 returned to the treatment cart to get the two medicine cups that contained Bactroban and Santyl in each cup outside the resident's room. The Nurse #1 returned to the resident's room but left one medicine cup with Santyl on top of the treatment cart outside. The surveyor got the attention of the Nurse #1 regarding the medication left on top of the treatment cart. The Nurse #1 stated that she forgot but did not comment further. NJAC: 8:39-29.4 (a) (h) (d) Based on observation, interview, and record review, it was determined that the facility failed to (a). properly label, store and dispose of medications in two (2) of five (5) medication carts inspected, b). failed to secure two (2) of two (2) narcotic lock boxes in 2 of 2 medication refrigerators inspected, and c). failed to secure medications in one (1) of five (5) and in one (1) of four (4) treatment carts observed. This deficient practice was evidenced by the following: a). On [DATE] at 11:10 AM, the surveyor inspected the 3rd floor medication cart A in the presence of Licensed Practical Nurse (LPN#1). The surveyor observed an unopened and undated bottle of Xalatan eye drops (medication for pressure in the eyes), an opened bottle of Xalatan eye drops with an opened date of [DATE] with an expiration date of [DATE], and an opened bottle of Dorzolamide eye drops (pressure in the eyes) with an opened date of [DATE] and was expired. The surveyor interviewed LPN#1 who stated that both Xalatan and Dorzolamide were outdated and should have been removed from the medication cart. LPN#1 also stated that a bottle of unopened and undated Xalatan eye drops should have been stored in the medication refrigerator. On [DATE] at 11:20 AM, the surveyor inspected the 3rd floor medication cart B in the presence of LPN#2. The surveyor observed an opened and undated bottle of LPS (protein supplement) solution. The surveyor reviewed the manufacturer's instructions on the bottle of LPS in the presence of LPN#2. After reviewing the manufacturer's instructions, LPN#2 stated that once opened a bottle of LPS solution have a 60-day expiration date. LPN#2 acknowledge that the bottle of LPS solution was undated and that when bottle was opened it should have been dated. A review of the Manufacturer's Specifications for the following medications revealed the following: 1. Xalatan eye drops once opened have an expiration date of 42-days. 2. Dorzolamide eye drops once opened have an expiration date of 28-days. 3. LPS solution once opened have an expiration date of 60-days. 4. Unopened Xalatan eye drops should have been stored in a refrigerator. b). On [DATE] at 11:25 AM, the surveyor inspected the 3rd floor medication room refrigerator in the presence of LPN#2. The surveyor observed a narcotic lock box that contained five syringes of Ativan (medication of anxiety) 0.5 mg topical gels. The narcotic box was affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#2 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. On [DATE] at 11:35 AM, the surveyor inspected the 2nd floor medication room refrigerator in the presence of LPN#3. The surveyor observed a narcotic lock box that contained twenty-six (26) capsules of Marinol (appetite stimulant) 2.5 mg capsules. The narcotic box was observed affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#3 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. c). On [DATE] at 11:35 AM, the surveyor while conducting initial tour observed a 2nd floor medication cart outside of room [ROOM NUMBER], that was left unattended and contained an unused insulin syringe, glucose test strips, blood glucose monitor and a vial of Humalog insulin that were left unsecured on top of the medication cart. The surveyor observed no residents in the vicinity of the medication cart. The surveyor waited for the nurse to returned to the cart which was approximately 4-minutes after the medication cart was observed. The surveyor interviewed LPN#4 who acknowledge that it was her medication cart. She further acknowledges that she left the cart unattended with medications and medical supplies left in an unsecured area. LPN#2 also stated that it's the facility policy when a medication cart is left unattended that all medications and medical supplies should be left in a lock and secured area. On [DATE] at 1:00 PM, the surveyor discussed the above concerns with the Administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Medication Storage that was dated [DATE] and provided by the DON that included the following: 2. Any meds that will be expiring should be removed before expiration date. If pending expiration, will determine if supply will be completed before expiration date. A review of the facility's policy for Controlled Medications Accountability and storage that was dated [DATE] and provided by the DON included the following: Narcotic ordered for residents are stored in a locked narcotic box of the medication cart. If the narcotic medication is to be refrigerated, the narcotic is stored in the locked box within the refrigerator. The refrigerator has a lock on the door as well. A review of the facility's policy for Medication Administration and Documentation Policies, Procedures and Information that was dated [DATE] and provided by the DON included the following: 6. The medication cart must be locked when out of nurse's view.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 8/30/23 at 11:25 AM, the surveyor inspected the 3rd floor medication room refrigerator in the presence of Licensed Practical Nurse (LPN#1). The surveyor observed a narcotic lock box that contained five syringes of Ativan (medication of anxiety) 0.5 mg topical gels for Resident #88. The surveyor observed the narcotic box was affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#2 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included hypertension (elevated blood pressure), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activity), and mood disorder (general emotional state or mood is distorted or inconsistent and interferes with your ability to function). A review of the Order Summary (OS) (physician's order) dated 3/8/23 revealed a physician order (PO) for Ativan 0.5mg, apply to the inner wrist topically every 8 hours as needed for severe agitation. A further review of the PO revealed that the medication was discontinued on 3/23/23. A review of the March 2023 electronic Medication Administration Record (eMAR) revealed an order dated 3/8/23, for Ativan 0.5mg (Lorazepam), apply to inner wrist topically every 8 hours as needed for severe agitation with a discontinued date of 3/23/23. On 3/30/23 at 12:30 PM, the surveyor inspected the 3rd floor medication room refrigerator narcotic box in the presence of LPN#1. LPN#1 acknowledge that the Ativan gel was discontinued and should be remove from active medication and will be destroyed per facility policy. b). On 8/30/23 at 11:35 AM, the surveyor inspected the 2nd floor medication room refrigerator in the presence of LPN#2. The surveyor observed a narcotic lock box that contained twenty-six (26) capsules of Marinol (appetite stimulant) 2.5 mg capsules for Resident #64. The narcotic box was observed affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#2 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included hypertension (elevated blood pressure), metabolic encephalopathy (chemical imbalance of the brain), and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition). A review of the Order Summary Report (OSR) (physician's order) dated 7/17/23 revealed PO for Marinol (Dronabinol) 2.5mg, give 1 capsule by mouth two times a day for appetite stimulant. A review of the August 2023 eMAR revealed an order dated 07/17/23, for Marinol (Dronabinol) 2.5mg, give 1 capsule by mouth two times a day for appetite stimulant with a discontinued date of 8/18/23. A review of a Progress Note dated 8/18/23 at 5:10 PM revealed that Resident #64 was discharged home. On 3/30/23 at 12:30 PM, the surveyor inspected the 2nd floor medication room refrigerator narcotic box in the presence of LPN#2. LPN#2 acknowledge that the Marinol 2.5 mg belonged to Resident #64 and that the resident was discharged from the facility. The surveyor observed LPN#2 place the Marinol back in the narcotic box and then lock the box. LPN#2 stated that she will destroy the medication during shift change because she will need another nurse to witness the destruction. On 8/31/23 at 1:00 PM, the surveyor discussed the above concerns with the Administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Controlled Medications Accountability and storage that was dated 01/07/23 and was provided by the DON included the following: Narcotic ordered for residents are stored in a locked narcotic box of the medication cart. If the narcotic medication is to be refrigerated, the narcotic is stored in the locked box within the refrigerator. The refrigerator has a lock on the door as well. A review of the facility's policy Medication Storage that was dated 05/26/23 and was provided by the DON included the following: 4. Any discontinued medications should be removed from the refrigerator, med room or med cart and returned to pharmacy or discarded no later than 14 days. A review of the facility's policy Discarding and Destroying Medications that was undated and was provided by the DON revealed the following: 5 (c). Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by a resident. NJAC 8:39-11.2 (b), 29.2(a), 29.2 (d), 29.3(a)(5), 29.4(g) Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately obtain a blood pressure and accurately document the site, b.) accurately document the refusal of medications, d.) dispose of medications in a safe manner, c.) clarify and accurately administer a medication (Midodrine) according to a physician's order and d.) remove and dispose of controlled substances from active inventory when discontinued from March of 2023 until surveyor inquiry. The deficient practices occurred for two (2) of seven (7) residents, (Resident #56 and #75) reviewed for medication management and for two (2) of two (2) medication refrigerators inspected. 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. This deficiency was evidenced by the following: 1. On 8/30/23 at 8:00 AM, during the morning medication pass, the surveyor observed the Licensed Practical Nurse (LPN #1) obtaining a blood pressure (BP) for Resident #56. The LPN#1 placed the BP cuff on the resident's right leg below the knee. The LPN #1 stated that this was the best way to obtain the BP because the resident was very thin. The LNP#1 then stated that she received an error indication on the digital BP machine, the surveyor observed her reposition the BP cuff on the same area and immediately restarted the BP machine. The LNP#1 then stated that she had obtained a BP of 187/147 and a heart rate (HR) of 63. The LPN#1 added that the resident's BP was usually high and would check the BP again later. After removing the BP cuff, the LPN#1 asked the resident if he/she wanted the Iron pill and the resident shook their head in the yes direction. The LNP#1 explained to the surveyor that the resident did not always like the Iron pill because it turned the applesauce black and would refuse to take it. On 8/30/23 at 8:07 AM, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), for Resident #56. On 8/30/23 at 8:16 AM, upon returning to the medication cart, the LPN #1 indicated on the EMAR the BP of 187/147 was obtained in the sitting position to the right arm. The LPN#1 stated she had not seen another way to enter the site the BP was taken. The surveyor reviewed the medical record for Resident #56. A review of the resident's admission Record (AR) revealed diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (HTN)(high blood pressure). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 7/14/2023, reflected the resident had a brief interview for mental status (BIMS) score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed physician orders (PO) dated 7/25/23 for Metoprolol Tartrate oral tablet 100 MG, give one tablet by mouth two times a day for HTN-give with food hold if systolic BP less than 110 millimeter of mercury (mmhg) and HR less than 60. A review of the vital sign recordings for BP for August 2023 had the following dates which indicated the site for the BP was other; 8/3/23 at 7:14 PM, 8/4/23 at 8:43 AM, and 8/8/23 at 8:01 AM. All other entries for the site of the BP were to the right or left arm. A review of the August EMAR reflected the above PO and revealed that the vital sign recordings for 8/4/23 and 8/8/23 were entered by LPN#1. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that she was familiar with Resident #56 but had not taken a BP on the resident's leg. The UM/LPN could not speak to if that was the correct method because she had not taken the BP that way. The UM/LPN stated that a BP of 187/147 had not sounded accurate and would retake the BP to be sure. The UM/LPN added that when she would retake the BP that she would change the arm in order to get an accurate reading. The UM/LPN also stated that she used her own digital BP machine because there was only one BP machine on the unit and there were two nurses who would be administering medications at the same time, so it was easier to use her own. At that time, the UM/LPN was unable to locate the facility BP machine that was on the unit. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that a BP of 187/147 had not sounded accurate and would recommend retaking the BP and if the BP was accurate than the physician should be called. The IP explained that if an error or inaccurate reading of a BP was obtained then the nurse should retake the BP. The IP further explained that retaking a BP would mean changing the site such as going from right to left arm or if the same site was going to be used again then the nurse would have to wait at least five (5) minutes because retaking the BP on the same site could give an inaccurate reading. The IP stated that she would prefer the nurses using the facility BP machines because they were calibrated and remained in the facility. The IP further stated that when nurses used their own BP machines there was the possibility that they were not always calibrated and accurate. The IP also stated that she knew there was one BP machine on each unit and that there were additional BP machines that were being purchased. On 8/31/23 at 11:30 AM, the IP provided the surveyor with a Medication Pass Audit Tool dated 5/2/23 for LPN #1 completed by the Consultant Pharmacist (CP) which revealed that there were areas indicating a No, which meant that a technique was not performed appropriately. On 8/31/23 at 2:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, ADON and IP. The IP stated that when a medication pass audit was performed if there were indications that proper procedures were not followed then another observation and in servicing would be followed up. The DON stated that she would check if there were any other medication observations performed for LPN #1. On 9/1/23 at 8:58 AM, the DON provided the surveyor with an In-service on medication pass dated 5/10/23 completed by the ADON and signed by LPN #1 was performed and a Competency Validation: Medication Pass was completed by the ADON on 7/26/23 that indicated the LPN#1 Meets Standard for all the Performance Criteria. In addition, the DON provided a Medication Observation Form dated 6/9/23 for LPN #1 completed by the provider pharmacy which revealed that there was zero (0) % error rate. On 9/1/23 at 9:38 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the consultant for the facility for approximately a year. The CP stated that she had performed medication observations with the nurses and verified that she used a Medication Pass Audit Tool but was unable to speak to the actual form that she had completed for LPN#1. The CP stated that she would add to the form Discussed tips & tricks for med pass observation by Department of Health (DOH), etc. because as she performed the medication observation, she would review different areas to help the nurses understand what the correct procedure that should be done during the medication pass. The CP added that the completed Medication Pass Audit Tool was left with the DON and if there were issues, she would review them, and the DON would decide the next step. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that It is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner. In addition, The EMAR is the form onto which all medication orders are transcribed from physician electronic orders, from which medications are poured and administered and on which medication doses are documented. A review of the facility policy dated as reviewed 3/1/23 for Vital Signs provided by the DON reflected that Vital signs are documented in the medical records. Vital signs can be taken manually or obtained electronically. Physician's or Nurse Practitioner's should be notified about changes in vital signs including any symptoms identified, in accordance with parameters ordered. 2. On 8/30/23 at 8:05 AM, during the morning medication pass, the LPN#1 asked the resident if he/she wanted the Iron pill and the resident shook their head in the yes direction. The LNP#1 explained to the surveyor that the resident did not always like the Iron pill because it turned the applesauce black and would refuse to take it. On 8/30/23 at 8:07 AM, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 20 milligram (MG) tablet of Famotidine (Pepcid) (a medication used to treat excess stomach acid), one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), one (1) 150 MG capsule of Polysaccharide-Iron Complex (Ferrex)(a medication used to treat iron deficiency), one (1) 500 MG tablet of Ascorbic Acid (Vitamin C)(a supplement) and two (2) 325 MG tablets of Acetaminophen (Tylenol)(a medication used for pain relief) for Resident #56. On 8/30/23 at 8:14 AM, the surveyor observed the LPN #1 crush four (4) of the five (5) medications together in a pouch and then poured the crushed medications into a 30 milliliter (ML) medication cup with applesauce. The LPN#1 then opened the Ferrex capsule and mixed the contents into the medication cup that had the four (4) medications and filled the medication cup with applesauce. The applesauce then turned a black color. On 8/30/23 at 8:16 AM, the surveyor observed the LPN#1 approach the resident to administer the five (5) medications in the applesauce and the resident was shaking their head in the no direction. The LPN #1 explained that the applesauce contained the resident's medication and that it was important to take the medications. The LPN#1 scooped a spoonful of the applesauce and administered the spoonful to the resident. The resident took the spoonful and shook their head in the no direction repeatedly. The LPN#1 explained again the importance and told the resident there was just another spoonful left. The LPN#1 was unable to administer the remaining applesauce containing the medications. Upon returning to the medication cart, the LPN#1 discarded the remaining applesauce and stated that the resident had swallowed more than half of the applesauce, so she felt that the resident had received the medications. The LPN#1 then indicated on the electronic administration record (EMAR) that the resident had received the five (5) medications. The LPN#1 had not documented any refusal of medication by the resident. The surveyor reviewed the medical record for Resident #56. A review of the resident's admission Record (AR) revealed diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (HTN)(high blood pressure), severe protein-calorie malnutrition and gastro-esophageal reflux disease (acid reflux). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 7/14/2023, reflected the resident had a brief interview for mental status (BIMS) score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed physician orders (PO) for the following: Famotidine tablet 20 MG, give 1 tablet by mouth in the morning for acid indigestion with a start date 1/13/23. Metoprolol Tartrate oral tablet 100 MG, give one tablet by mouth two times a day for HTN-give with food hold if systolic BP less than 110 millimeter of mercury (mmhg) and HR less than 60 with a start date of 7/25/23. Polysaccharide Iron Complex capsule 150 MG, give 1 capsule by mouth one time a day for deficiency with a start date of 1/13/23. Ascorbic Acid tablet 500 MG, give 1 tablet by mouth one time a day for supplement with a start date of 1/13/23. Acetaminophen tablet 325 MG, give 2 tablet by mouth every 6 hours as needed for pain with a start date of 2/24/23. A review of the August 2023 EMAR revealed consistency with the above POs. In addition, the EMAR had not revealed any refusals by the resident for medications. A review of the resident's progress notes had not indicated that there were any refusals of medications. A review of the resident's Interdisciplinary Care Plan had not revealed that there was a Focus area for the resident refusing medications. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that she was familiar with Resident #56 and was unaware of any medication refusals. The UM/LPN stated that when a resident refused medications the physician would be notified and there would be documentation in the progress notes. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that the nurses would have to document that a medication was refused because the whole dose would not have been administered and the physician should be notified. The IP also stated that the nurses should try to figure out why the resident was refusing medications and put interventions in place such as changing the medication if the taste were an issue or possibly changing the time. In addition, the IP provided the surveyor with a Medication Pass Audit Tool dated 5/2/23 for LPN #1 completed by the Consultant Pharmacist (CP) which revealed that there were areas indicating a No, which meant that the technique was not performed appropriately. On 8/31/23 at 2:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, ADON and IP. The IP stated that when a medication pass audit was performed if there were indications that proper procedures were not followed then another observation and in servicing would be followed up. The DON stated that she would check if there were any other medication observations performed for LPN #1. On 9/1/23 at 8:58 AM, the DON provided the surveyor with an In-service on medication pass dated 5/10/23 completed by the ADON and signed by LPN #1 was performed and a Competency Validation: Medication Pass was completed by the ADON on 7/26/23 that indicated the LPN#1 Meets Standard for all the Performance Criteria. In addition, the DON provided a Medication Observation Form dated 6/9/23 for LPN #1 completed by the provider pharmacy which revealed that there was zero (0) % error rate. On 9/1/23 at 9:38 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the consultant for the facility for approximately a year. The CP stated that she had performed medication observations with the nurses and verified that she used a Medication Pass Audit Tool but was unable to speak to the actual form that she had completed for LPN#1. The CP stated that she would add to the form Discussed tips & tricks for med pass observation by Department of Health (DOH), etc. because as she performed the medication observation, she would review different areas to help the nurses understand what the correct procedure that should be done during the medication pass. The CP added that if a resident was refusing a medication or was unable to receive the entire dose then the physician should be notified, and the nurses should review the possible reason the resident was refusing to possibly make a change. The CP added that the completed Medication Pass Audit Tool was left with the DON and if there were issues, she would review them, and the DON would decide the next step. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that Documents administration of medication in the EMAR immediately following administration. Notes in EMAR medications not administered (i.e., refused, etc.) and identifies reason. The policy also reflected that Documents all held or refused medications on EMAR. Uses prudent professional judgement by informing Physician in a timely manner when medications held, refused, or otherwise unavailable for administration. 3. On 8/30/23 at 8:07 AM, during the morning medication pass, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 20 milligram (MG) tablet of Famotidine (Pepcid) (a medication used to treat excess stomach acid), one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), one (1) 150 MG capsule of Polysaccharide-Iron Complex (Ferrex)(a medication used to treat iron deficiency), one (1) 500 MG tablet of Ascorbic Acid (Vitamin C)(a supplement) and two (2) 325 MG tablets of Acetaminophen (Tylenol)(a medication used for pain relief) for Resident #56. On 8/30/23 at 8:14 AM, the surveyor observed the LPN #1 crush four (4) of the five (5) medications together in a pouch and then poured the crushed medications into a 30 milliliter (ML) medication cup with applesauce. The LPN#1 then opened the Ferrex capsule and mixed the contents into the medication cup that had the four (4) medications and filled the medication cup with applesauce. The applesauce then turned a black color. On 8/30/23 at 8:16 AM, the surveyor observed the LPN#1 approach the resident to administer the five (5) medications in the applesauce and the resident was shaking their head in the no direction. The LPN #1 explained that the applesauce contained the resident's medication and that it was important to take the medications. The LPN#1 scooped a spoonful of the applesauce and administered the spoonful to the resident. The resident took the spoonful and shook their head in the no direction repeatedly. The LPN#1 explained again the importance and told the resident there was just another spoonful left. The LPN#1 was unable to administer the remaining applesauce containing the medications. Upon returning to the medication cart, the LPN#1 discarded the remaining applesauce in the garbage that was attached to the medication cart. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that when any medication had to be disposed there was a medication disposal system on each medication cart. The UM/LPN added that if the medication were a controlled medication, then the DON or ADON would be given the controlled medication for a witnessed destruction. The surveyor with the UM/LPN looked in the medication cart that the UM/LPN was using and were unable to find the medication disposal system in that medication cart. The UM/LPN stated that she would have to get one for the cart. On 8/30/23 at 1:16 PM, the LPN#1 showed the surveyor that she had a medication disposal system on the medication cart that she was using. The LPN #1 stated that because the medications were crushed for Resident #56, she could throw them in the garbage that was attached to the medication cart. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that when the nurses had to dispose of a medication that was not a controlled medication then they would use the medication disposal system that was on each cart. The IP further explained that the safest method for medication disposal even if the medications were crushed was to use the medication disposal system. On 9/1/23 at 9:38 AM, the surveyor interviewed the CP via the telephone who stated that the nurses were to use the medication disposal system when a medication needed to be discarded. The CP added that even if the medication was crushed that the medication disposal system should be used and thought there was one on each medication cart. A review of the undated facility policy for Discarding and Destroying Medications provided by the DON reflected that Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. 4. On 8/28/23 at 11:42 AM the surveyor observed Resident #75 in bed, the surveyor attempted to interview the resident, but the resident was unable to answer any questions. The surveyor reviewed the medical record for Resident #75. A review of the resident's AR revealed diagnoses which included dementia, neurocognitive disorder with [NAME] bodies (a mental health disorder that primarily affect cognitive abilities), syncope and collapse and HTN. A review of the admission MDS, an assessment tool used to facilitate the management of care, with an assessment reference date of 8/30/2023, reflected the resident had a BIMS score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the August and September electronic medication records (EMAR) revealed a PO dated 8/23/23 for Midodrine Hydrochloride oral tablet 5 MG, give 5 MG by mouth every 8 hours (Q8H) as needed (PRN) for low BP, give if BP less than 110. There was no documentation that the medication was administered. A review of the vital sign recordings for the resident's BP for August 2023 had the following dates with BP recordings that had a BP less than 110; on 8/29/23 at 5:26 PM 82/52, on 8/30/23 at 7:47 PM 107/70 and on 9/1/23 at 10:40 AM 107/60. Further review of the August and September EMARs revealed a PO dated 8/24/23 for Metoprolol Tartrate (Lopressor) (a medication used to slow the heart rate and lower BP). oral tablet 25 MG, give 25 MG by mouth two times a day for HTN hold for systolic BP less than 110 or HR less than 60. There was documentation on 8/29/23 that the BP was 82/52 and on 8/30/23 the BP was 107/70 and the Lopressor medication was held. There was documentation on 9/1/23 that the Lopressor medication was held but no documentation of the BP results. On 9/5/23 at 11:23 AM, the surveyor interviewed LPN #2 who stated that she was the medication nurse for Resident #75. The LPN #2 stated that the resident had been readmitted at the end of August. The surveyor with the LPN#2 reviewed the EMAR regarding the PRN Midodrine and the LPN#2 stated that if the resident's BP was less than 110 then the Midodrine should have been administered. The LPN#2 stated that she had not administered the Midodrine because she had not had a BP less than 110 for the resident. The LPN#2 acknowledged that the PRN Midodrine had no documentation as being administered and also acknowledged that there was documentation of BP's less than 110. The LPN#2 also stated that the resident had no PO for a BP to be obtained every 8 hours (Q8H) and that a BP was obtained twice a day for the medication Lopressor. On 9/6/23 at 9:49 AM, the surveyor interviewed the DON who stated that she thought the PO for Midodrine was a PRN PO and was allowed to be administered three times within a 24-hour period and that a BP was not needed Q8H. On 9/6/23 at 10:05 AM, the surveyor further interviewed the DON. The surveyor with the DON reviewed the EMAR for Resident #75. The DON acknowledged that the Midodrine was not administered when the BP was less than 110. The DON also acknowledged that when the BP was taken for the Lopressor PO and was less than 110, the Lopressor was held but there was no indication to administer the PRN Midodrine. The DON acknowledged that the PO for PRN Midodrine should be clarified. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that It is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner. In addition, the policy reflected, Monitors vital signs when appropriate prior to medication administration. Administers med according to parameters ordered by physician (if any).

Infection Control Covid-19 Survey Based on observations, interviews, and the review of other pertinent facility documents on 11/18/2022 and 11/21/2022, it was determined that the facility failed to thoroughly screen all staff for Covid-19 signs and symptoms in accordance with the facility's policy titled Employee Screening for Symptoms of Covid 19 and the Centers for Disease Control and Prevention (CDC) guidelines. This deficient practice was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, showed .1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP [Health Care Provider] should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 . A review of the facility document titled Line List (a list of all Covid 19 positive staff and residents) reveals the first case of Covid 19 was on 11/3/2022 with a resident, and the most recent case was on 11/17/2022 with a resident. A review of the facility-provided screening logs for November 2022 revealed that from 11/3/2022 through 11/17/2022, during the hours of 10:00 p.m. to 5:00 a.m., only one staff was screened for all fifteen days. During an interview on 11/18/2022 at 1:30 p.m., the Receptionist stated that she screens everyone that enters during her working hours of 8 a.m. to 4 p.m. According to the Receptionist, there are per diem staff at the reception desk from 4 p.m. to 8 p.m. and on the weekends. During an interview on 11/21/2022 at 1:20 p.m., the Administrator was asked if all the screening logs for the dates requested by the Surveyor were emailed to the Surveyor, and the Administrator answered, yes. The Surveyor asked the Administrator to confirm if the records were complete, and the Administrator again replied, yes. The Surveyor told the Administrator that there were no screening logs for the overnight shift staff from 11/3/2022 through 11/17/2022. The Administrator stated that they (the kiosk screening company)shut the kiosk down and contacted the screening company to send us why they did not record the screenings late at night and to see if they (staff) didn't screen. During a second interview on 11/21/2022 at 4:00 p.m., When asked by the Surveyor for the other screening logs, the Administrator stated, I don't have anymore screening logs. According to the Administrator, everyone who came in at night for the last two weeks was not screened. He continued, I learned my lesson. I am the one who monitors the screening log, or I should have, I was not taught properly, but I will be now. A review of the facility policy titled Employee Screening for Symptoms of Covid 19 with an effective date of 3/6/2020 and last review date of 1/7/2022, under Policy: revealed the following: It is the policy of this facility to screen all employees prior to the start of duty for signs and symptoms of respiratory illness. The policy further reveals under Purpose: To protect our residents, families, and staff from Covid 19 by not allowing staff to work while ill. The policy also reveals under General Information: All Staff will be screened for an elevation in temperature and symptoms of respiratory illness prior to starting work. This screening will happen at the front door. Staff will be permitted to enter only through (the) front door. Entry will not be permitted through any other door. [ .] If the scan indicates a temperature reading above 100.4 degrees F, that person will be pulled from the line of people entering the facility AND referred to the nursing supervisor to come to the front door to complete an assessment of the employee. N.J.A.C: 8:39-19.4(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that facility failed to ensure: a.) staff provided consistent care regarding the use of a feeding tube declogger device (Device), and b.) staff consistently communicated, to pertinent staff, episodes of a clogged feeding tube (a plastic-type tube used to provide nutrition by bypassing chewing and swallowing) for a resident who received a tube feeding (enteral nutrition-liquid nutrients delivered through a feeding tube). This deficient practice was evidenced for 1 of 1 residents reviewed who received tube feedings (Resident #9) and was evidenced by the following: On 06/30/21 at 8:27 AM, the surveyor observed Resident #9 with his/her eyes open and lying in the bed, with the head of the bed elevated, and had a tube feeding infused via a pump located at the bedside. The surveyor observed that opposite of the lower portion of the resident's bed, adjacent to the opposite wall, was a nightstand. The top of the nightstand contained a navy-blue colored, U-shaped fuzzy fabric neck pillow, and adjacent to the neck pillow was a package that contained a Device. The surveyor further observed that the packaging for the Device was opened at one end with several inches of the Device exposed, sticking outside of the package, and was hanging off of the nightstand. During the observation, a Licensed Practical Nurse (LPN #1) entered Resident #9's room. At that time, the surveyor pointed to the Device on the nightstand and inquired to LPN #1 the purpose of the Device. The LPN #1 stated she was assigned to Resident #9 and the Device was used when the feeding tube became clogged. LPN #1 further stated that the Device was used when the resident did not get the water into the feeding tube in time. At 8:38 AM, LPN #1 exited the resident's room and left the Device on the nightstand. At 9:55 AM, the surveyor re-entered Resident #9's room and observed LPN #1 inside the resident's room and was holding a container in her hand. LPN #1 stated that she thought the water helped prevent the feeding tube from getting clogged. LPN #1 further stated that if the feeding tube became clogged, she would pull out the substance that caused the clog. LPN #1 then described the clog as a consistency that usually resembled wet dog or cat food and she looked at the Device and showed the surveyor that there were ridges on the Device. The surveyor inquired as to how far, and deep inside, would the Device need to be inserted into the residents feeding tube, and LPN #1 stated I try to not go too deep. The surveyor observed the Device was a plastic-type thin rod in appearance and approximately one foot in length and had corkscrew type ridges at one end. LPN #1 stated she did not document in the medication administration record (MAR), or in the progress notes when she used the Device. LPN #1 stated that she did not always see other progress notes that indicated as to when the Device was used, and if she observed a dirty Device in the room, she would assume it had been used for the resident. She stated the facility did not formally train her to use the device and that other nurses showed her how to use it. Review of Resident #9's medical record revealed the following information. The admission Record revealed the resident had diagnoses which included: cerebral infarction (Stroke), dysphagia following cerebral infarction (swallowing difficulty) and gastrostomy status (an opening into the stomach, made surgically, from the abdominal wall, made for the introduction of a artificial nutrition/tube feeding). The Quarterly Minimum Data Set, dated [DATE], revealed the resident had a gastric tube and received artificial nutrition and fluid via a tube feeding. Review of the on-going Care Plan dated 04/06/19, revealed a focus area that Resident #9 required a tube feeding due to dysphagia. The goal was to have the insertion site free of signs and symptoms of infection through the review date. Care Plan interventions, initiated 06/06/21, included: Monitor/document/report to doctor as needed aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation (removal), tube dysfunction or malfunction, abnormal laboratory values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. The Care Plan did not include documented interventions for the use of the Device. Review of a Nutrition Note completed by the Dietitian (RD), dated 03/03/21, revealed Resident #9 had a history of vomiting and gastrointestinal intolerance of the tube feeding and the tube feeding rate had been lowered to improve tolerance. Review of the Physician Orders (PO) for June 2021 through July 6, 2021 revealed Resident #9 received nutrition solely via tube feeding. There was no PO for use of the Device. Review of the June 2021 MAR, July 2021 MAR, and the June 2021 and July 2021 Treatment Administration Record (TAR) did not reflect documentation for the use of the Device. On 06/30/21 at 10:49 AM, the surveyor conducted a telephone interview with LPN #2. LPN #2 stated she had provided care for Resident #9 and was familiar with the resident's tube feeding. LPN #2 stated she was aware of the Device and had observed it in Resident #9's room. LPN #2 further stated that she thought the Device was used only once and then it should have been discarded, because if it was re-used it would be an infection control issue. LPN #2 stated she has not used the Device because when the resident was provided with ample water, along with properly crushed medications, the feeding tube should not become clogged. The surveyor attempted to contact the LPN who provided care to Resident #9 on the 11:00 PM to 7:00 AM shift on 06/29/21, but was unable to make contact. On 06/30/21 at 11:06 AM, the surveyor conducted a telephone interview with the resident's primary physician (MD). The surveyor inquired to the MD regarding the staff re-using the Device to unclog the resident's tube. The MD stated the staff would usually call him if the tube did not work and he would tell them to try the traditional method to de-clog a resident's tube which would be to flush the tube with saline, seltzer or ginger ale. The MD further stated that he was not familiar with the Device that was used by the facility to unclog Resident #9's feeding tube and he had not personally used it. The MD stated that he did not know how far the Device would be inserted into a feeding tube and that would be a nursing protocol. The MD further stated that if something was inserted into a resident's feeding tube and became stuck, a person's stomach could be perforated (ripped). He further stated it would depend on the skills of the nurse if they would be able to remove a clog from a feeding tube. On 06/30/21 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) regarding the protocol for removing a clog from a clogged feeding tube. The DON stated that first you would manually declog the tube and then you could use the Device. The DON further stated that the nurse should have checked the size of the resident's feeding tube and then selected the correct size of the Device that correlated with the size of the resident's feeding tube. The DON further stated that a PO was not required to use the Device and the Physician would be contacted only if the clog could not be cleared. The DON stated the nurses could read the directions for the Device which specified the length and color of the Device to use. The DON stated she will look for the protocol for use of the Device . On 06/30/21 at 12:18 PM, the DON while inside Resident #9's room, checked the size of Resident #9's feeding tube. The DON stated to the surveyor that the resident had a #16 gauge (width) feeding tube. The DON did not speak to the length of the feeding tube. On 07/06/21 at 9:05 AM, the surveyor observed Resident #9 in his/her room with LPN #1. The surveyor observed a soiled beige colored Device in the resident's trash can. The surveyor inquired to LPN #1 if the resident had a clogged feeding tube. She stated the Device must have been used on the overnight shift and acknowledged that the Device appeared as if it was used. The surveyor reviewed Resident #9's Progress Notes from 06/29/21 through 07/06/21. There was no documented evidence in the resident's Progress Notes regarding the use of the Device for Resident #9. On 07/07/21 at 10:51 AM, the surveyor interviewed the DON regarding any training completed with the staff to assess competencies for use of the Device. The DON stated there was no assessment of staff competencies regarding the use of the Device. On 07/07/21 at 12:14 PM, the surveyor interviewed the DON, in the presence of additional surveyors, regarding the selection of the correct size and for the use of the Device. The DON could not speak to the process for using the Device to remove a clog from a feeding tube per the manufacturers specifications. On 07/08/21 at 8:19 AM, the surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) who provided the surveyor with a Gastrostomy (stomach) Tube Feeding Skills Checklist for LPN #1 dated 05/10/21. The surveyor reviewed the document, in the presence of the RN/IP, and the RN/IP confirmed there was no competency or instructions on how to use the Device. On 07/08/21 at 9:13 AM, the surveyor interviewed the DON who stated if the resident's feeding tube repeatedly clogged, a multi-disciplinary approach would be required to assess the resident. The DON further stated that the nurses should sign in the resident's medical record and document when the Device was used. The DON stated that the nursing staff should communicate changes in the resident's feeding tube patency to the MD, Dietitian, and DON. The DON stated that she was unaware that the resident's feeding tube was clogging and she should have been notified because a root cause analysis would have been conducted to determine the cause of the consistent use of the Device. On 07/08/21 at 10:19 AM, the surveyor interviewed the RD regarding the use of the Device for Resident #9's feeding tube. The RD stated that she was not familiar with a Device used for Resident #9, and if the resident's feeding tube became clogged it was important she be made aware of it. The RD further stated that she would have needed to know about the feeding tube becoming clogged because there were many factors that could contribute to a resident's feeding tube becoming clogged. The RD stated that she would have needed to re-evaluate, and re-assess the resident's tube feeding formula, water flushes and also would have reviewed the resident's medication regimen to see if there were any interactions. The RD stated that she was always available to collaborate with the nursing staff regarding resident care and had access to the progress notes which she regularly reviewed for information about the status of the residents. The RD confirmed that she was not notified of any episodes of Resident #9's feeding tube becoming clogged. The RD stated if she was made aware she would have re-evaluated the resident's tube feeding regimen. Review of the Policy/Procedure: Enteral Feeding Tube Declogger, Original Issue Date: 2/2015, Revised 2/2020, revealed under Policy: Use Enteral Feeding Tube should be used as needed to maintain unimpeded flow of an enteral formula or medication. Enteral Feeding Tube will also be used to achieve patency of tube that has become clogged with semi-solid formula. Policy Interpretation and Implementation: Physician/RN/LPN may use Enteral Feeding Tube Declogger as needed if Enteral tube becomes clogged. Instructions: 1. Determine the size of the enteral feeding tube. 2. Select appropriate size declogger that corresponds to the size of the tube. 3. Turn enteral feeding pump to pause position and disconnect from enteral tube (if gravity pump, clamp the tubing). 4. Insert the declogger to reach the blockage and slowly rotate or move back and forth. 5. Repeat Step 4 until the stop disk of the declogger is reached without difficulty. 6. Flush tube with 30-60 ML of water. 7. Once clear, reconnect the delivery tube and restart the enteral feeding. 8. Discard declogger (single use) after procedure. 9. Notify physician if blockage in enteral tube was unable to be cleared. 10. Caution: If declogger becomes imbedded in the blockage and cannot be easily dislodged, the enteral feeding tube will need to be changed. Do not attempt to physically remove the declogger. Review of the Device User Instructions, dated 2019 revealed under Purpose: To maintain or achieve patency of gastric and/ or jejunostomy enteral tubes. Under Instructions: 1. Determine the size of the gastric or jejunostomy tube. Caution: Verify that the tube has not been modified, i.e. shortened. 2. Select appropriate size Device that corresponds to the size of the tube. 3. Turn enteral feeding pump to pause position and disconnect from enteral tube. 4. Insert the Device to reach the blockage and slowly rotated two times in a clockwise direction then reverse and rotate tow times in a counterclockwise direction while removing it. Do not attempt to force the Device through the entire blockage. 5. Repeat step 4 until the stop disk of the Device is reached without difficulty. 6. Flush tube with 30-60 cc'sof water. 7. Once clear, reconnect the delivery tube and restart the enteral feeding. 8. Discard Device and document results. NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient indication for use, or documented behavior monitoring for the use of psychoactive medication. This deficient practice was identified for 1 of 7 residents (Resident #27) reviewed for medication use. The deficient practice was evidenced by the following: On 06/30/21 at 10:07 AM, the surveyor observed Resident #27 inside the 3rd floor unit day room. Resident #27 observed the activity and proceeded to stand up and walk. The activity aide easily redirected the resident back to the table and there were no other behaviors observed by surveyor. On 07/01/21 at 8:31 AM, the surveyor observed Resident #27, quietly sitting, inside the 3rd floor unit day room. The surveyor observed staff offer the resident a selection of magazines or books. No behaviors were observed by the surveyor for Resident #27. On 07/06/21 at 8:19 AM, the surveyor observed Resident #27 in the 3rd floor unit day room. Resident #27 stood up and began to ambulate, staff intervened and easily redirected the resident. No other behaviors noted by the surveyor. Review of the admission Record revealed Resident #27 was admitted in 2015 with diagnoses that included but were not limited to dementia without behavioral disturbances, insomnia (trouble falling or staying asleep), heart failure, major depressive disorder, and a history of falling. Review of the quarterly Minimum Data Set (MDS - an assessment tool), dated 04/15/21, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severely impaired cognition. The MDS indicated the resident had no presence of the following problems or behaviors over the prior two weeks: little interest or pleasure doing things; feeling down, depressed, or hopeless; trouble falling or staying sleep; feeling tired or little energy; poor appetite or overeating; feels bad about self; trouble concentrating on things; moving or speaking slowly or being fidgety where people noticed; stating life isn't worth living, or being short-tempered or easily annoyed. The MDS indicated no physical, verbal, or other behaviors exhibited. The MDS further reflected that the resident had no behaviors of wandering. Review of the quarterly MDS, dated [DATE], revealed Resident #27 had a BIMS score of 06 which indicated severely impaired cognition. The MDS indicated the resident had no presence of the following problems or behaviors over the prior two weeks: little interest or pleasure doing things; feeling down, depressed, or hopeless; trouble falling or staying sleep; feeling tired or little energy; poor appetite or overeating; feels bad about self; trouble concentrating on things; moving or speaking slowly or being fidgety where people noticed; stating life isn't worth living, or being short-tempered or easily annoyed. The MDS indicated no physical, verbal, or other behaviors exhibited. The MDS further reflected that the resident had no behaviors of wandering. Review of the facility provided, Medication Management Assessment (MMA), dated 02/23/21 completed by the Psychiatric Mental Health Nurse Practitioner included diagnoses of insomnia, depressive disorder, Alzheimer's disease, and personal history of other specified conditions. The symptoms for the psychiatric evaluation were noted to be behavioral disturbances. The resident's social history indicated, Past Psychiatric Treatment psychotropics. Examination was that the resident was wandering frequently in the hallway and could be confrontational with others and difficult to redirect at times. The MMA revealed a recommendation for the medication, Depakote Sprinkles 125 mg (milligrams) by mouth once a day for behavioral agitation towards other residents. Review of the physician's order dated 02/23/21 revealed Depakote Sprinkles Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth one time a day for behavioral issues. Review of the facility provided, Psychiatric Initial Evaluation, completed by a different practitioner, dated 06/29/21, included but was not limited to, continue Depakote for mood disorder, dose reduction clinically contraindicated. The Psychiatric Initial Evaluation indicated that the resident was often seen trying to stand up and the team reported that the resident could have pacing behaviors. There was no documented follow-up on the Psychiatric Initial Evaluation for the resident's confrontational behaviors as documented in the 02/23/21 MMA assessment. Review of the Pharmacist Summary report, dated 06/22/21, revealed a recommendation to Please document target behavior for Depakote use for Resident #27. The facility was unable to produce documentation that supported the Pharmacist's recommendation was implemented. Review of the Care Plan for Resident #27 revealed an on-going focus date initiated, 10/01/20, that the resident was at risk for potential behavioral problems/alterations in mood due to history of depression. The goal was to have fewer episodes by next review date. An intervention included to monitor for s/s (signs and symptoms) depression, mood swings, change in behavior. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated March, April, May and June, 2021 revealed no documentation of behaviors. Review of the Clinical Assessments from 02/01/21 through 07/05/21, revealed there were no Psychotropic Monthly notes or summaries. On 07/07/21 at 8:25 AM, the Certified Nursing Assistant (CNA) stated Resident #27 required total care. The CNA stated the resident had behaviors that included standing up to walk without help and sometimes the resident did not understand. The CNA stated the resident would never hurt him/herself or anyone else. On 07/07/21 at 8:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) regarding any behaviors that Resident #27 exhibited. LPN #1 stated the behaviors exhibited were only restlessness and confusion and he/she walked around. LPN #1 stated the facility did not have any behavioral monitoring for the Resident #27. The surveyor inquired to LPN #1 why Resident #27 was on the medication, Depakote. LPN #1 stated that the resident was on Depakote for mood disorder. On 07/07/21 at 10:48 AM, LPN #1 stated any resident on Depakote should be monitored for behaviors such as agitation and the behaviors should be documented on the MAR. LPN #1, in the presence of the surveyor, reviewed the MAR for Resident #27. LPN #1 acknowledged there had been no documentation of behaviors and no orders to document or monitor the behaviors for Resident #27. LPN #1 stated Resident #27 should have behaviors monitored and documented to evaluate the effectiveness of the Depakote. On 07/07/21 at 10:53 AM, LPN #2 stated residents with mood disorders that required the use of Depakote should have their behaviors monitored and documented. LPN #2 stated the documentation was important to see if the medication was working or not, or if the medication could be reduced or needed to be increased. On 07/07/21 at 12:28 PM, the Director of Nursing (DON) stated residents on Depakote would see a psychiatrist, have a monthly psychotropic note, and the behaviors and medication would be noted on the resident's care plan. The DON stated the behavior monitoring would be documented on the monthly psychotropic note and behavior monitoring would be completed daily, and behaviors would also be documented in the progress notes (PN). The DON stated it was important to document behaviors to evaluate the effectiveness of the prescribed medication On 07/08/21 at 9:49 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility staff discussed residents who were on psychoactive medications at morning meetings, but did not review a written roster. The LNHA stated there were monthly meetings with the psychiatrist where they reviewed residents on psychotropics and determined if the medication could be reduced, the effectiveness of the medication, and the resident behaviors. On 07/08/21 at 10:46 AM, the LNHA acknowledged the last monthly psychiatric review meeting was held on 09/10/19. Review of the facility provided, Psychoactive Medication Protocol policy and procedure, reviewed 04/22/21, included but was not limited to the following: the purpose was to eliminate the use of unwarranted psychoactive medication and ensure orders for these medications are justified; and the policy that all residents who require psychoactive medications will have monthly assessments to evaluate the effectiveness of the medication and resident's response to the treatment. The facility was unable to produce any psychotropic monthly assessments for Resident #27 regarding the use of the psychoactive medication. NJAC 8:39-27.1(a)

Based on observation, interview, record review and document review, it was determined that the facility failed to: a.) utilize a single use de-clogging device per the manufacturer's instructions for use (IFU) and b.) perform hand hygiene (HH) in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and facility policy to aid in preventing infections. This deficient practice occurred for 1 out of 1 residents reviewed for a tube feeding (Resident #9), and during a medication pass observation. This deficient practice was evidenced by the following: a.) On 06/30/21 at 8:27 AM, the surveyor observed Resident #9 with his/her eyes open and lying in the bed, with the head of the bed elevated and a tube feeding (the delivery of nutrients through a feeding tube and directly into the stomach) was being infused via a pump located at the bedside. The surveyor observed that opposite of the lower portion of the resident's bed, adjacent to the opposite wall, was a nightstand. The top of the nightstand contained a navy-blue U-shaped fuzzy type fabric neck pillow, and adjacent to the neck pillow was a package that contained a tube feeding de-clogging device (Device). The packaging for the Device was open at one end and several inches of a beige colored portion of the device was exposed and was sticking outside of the package and was hanging off of the nightstand in the direction of the wall. During the observation, a licensed practical nurse (LPN #1) entered Resident #9's room. At that time, the surveyor pointed to the Device on the nightstand and inquired to LPN #1 the purpose of the Device. The LPN #1 stated she was assigned to Resident #9 and the Device was for Resident #9 and used when the feeding tube became clogged. LPN #1 further stated that the device was used when the resident did not get the water in the feeding tube in time. At 8:38 AM, LPN #1 exited the resident's room and she left the Device in the same location and partially opened on the nightstand. At 8:46 AM, the surveyor re-entered Resident #9's room with LPN #1. The Device was observed in the same location and partially opened on the nightstand. At 9:55 AM, the surveyor re-entered Resident #9's room with LPN #1. The Device was observed in the same location and partially opened on the nightstand. At that time, the surveyor interviewed LPN #1 regarding the Device. LPN #1 picked up the device, with her gloved hands, and showed it to the surveyor. The Device was protruding out of the opened end of the clear side of the approximately one-foot long packet and had a beige colored substance dispersed throughout the interior of the packet and affixed to the Device. LPN #1 stated that she did not use the Device today, but that when they (the nurses) used it, we put it back into the bag to be re-used. She stated that they tried to not touch it or have it touch the furniture. She confirmed the device was not labeled and dated and that it was used to pull out clogs that occurred inside of Resident #9's feeding tube. LPN #1 stated she tried to not let it get too dirty but stated they used and reused it and left it there. LPN #1 looked at the back of the package and stated there was no specific information regarding how many times the Device could be used. The surveyor inquired to LPN #1 regarding how many times the Device was used, and she stated that she did not know because there wasn't always documentation from the other nurses when it was used, because the staff didn't document the use of the Device. Review of the admission Record for Resident #9 revealed they had diagnoses which included Cerebral Infarction (Stroke), Dysphagia Following Cerebral Infarction (swallowing difficulty) and Gastrostomy Status (an opening into the stomach, made surgically, from the abdominal wall, made for the introduction of food). On 06/30/21 at 10:49 AM, the surveyor conducted a telephone interview with LPN #2. LPN #2 stated she had provided care for Resident #9 and was familiar with the resident's tube feeding. LPN #2 stated she was aware of the Device and had seen it in Resident #9's room and stated that she thought it was used once and then should be discarded, because if it was re-used it would be an infection issue. On 06/30/21 at 11:06 AM, the surveyor conducted a telephone interview with the primary physician (MD) for Resident #9 . The surveyor inquired to the MD regarding the staff re-using the Device to unclog the resident's tube. The MD stated if the Device was single use, you could not re-use it, and it would have to be discarded because it would be an infection risk for the resident. On 06/30/21 at 11:35 AM and 12:16 PM, the surveyor conducted an interview with the Director of Nursing (DON). The surveyor inquired as to how many times the Device could be used. She stated the Device was for single use only and stated they were supposed to throw it away after using it. The DON stated that the Device was single use and if it was re-used it could introduce and infection into the resident. On 07/06/21 at 9:37 AM, the surveyor interviewed the facility Registered Nurse/Infection Preventionist (RN/IP) about the use of the Device. The RN/IP stated the Device was a one time use piece of equipment and after the nurse utilized it, it should be discarded. This was because it could touch a surface and then it could re-introduce germs back into a person's environment and they would not want to reintroduce germs back into a resident's abdomen. On 07/07/21 at 10:43 AM, the surveyor accompanied LPN #1 to a storage room on the third floor which contained supplies, including the Device and stock of liquid tube feeding products. A box of assorted Devices was located on top of an un-used sink in the storage room. LPN #1 opened the box of clean Devices and the surveyor and LPN then observed a yellow colored device, partially opened and soiled inside of the package surrounding the Device with a beige colored material. LPN #1 looked at the Device and stated it was clearly used and and it was opened up inside of the box which contained clean Devices. LPN #1 stated she did not know where it came from because it was not there yesterday and that it should not have been there because they were just told yesterday that the Devices should not be re-used. b.) The surveyor observed the following during medication administration: On 06/30/21 at 8:23 AM, LPN #1 was observed at the medication cart on the 3rd floor. LPN #1 reached down with her bare right hand, touched the gray knob on the visibly soiled garbage can lid, and turned the knob to open the top of the garbage can. The debris was observed to be brownish in color and had dots and smears embedded on the top of the lid, and within proximity to the gray knob. LPN #1 did not perform hand hygiene before she started to prepare the resident's medications. The surveyor had observed an alcohol-based hand rub (ABHR) available on the top of the medication cart. LPN #1 next donned (put on) gloves, carried a medication cup that contained medication in applesauce with a spoon, a cup of water with a straw in it, and a bag that contained a vial of eye drops into the resident's room. While still wearing the gloves, LPN #1 picked up the spoon and administered the medication that was in the applesauce, into the resident's mouth. LPN #1 next used the same gloved hands and touched the straw to provide water to the resident. The LPN #1 then, while wearing the same gloves, disposed of the used medication cup, and then removed the eye drop vial from the bag to administer the medication to the resident. LPN #1 reached then over to touch the resident's face with the same gloved hand. At that time, the surveyor inquired to LPN #1 when it was appropriate to change gloves or use hand hygiene. LPN #1 stated she was never taught when to change gloves and pulled back from touching the resident's face. On 06/30/21 at 8:29 AM, LPN #1 removed the used gloves, walked to the medication cart outside the door of the room, which remained visible to the surveyor. LPN #1 then walked past the resident's bathroom sink and donned new gloves without performing any hand hygiene. An ABHR was available on top of the medication cart. LPN #1 then entered the resident's room, used her gloved left hand to pull the skin around the resident's right eye, instilled the eye drop, doffed (removed) her gloves, walked out past the resident's bathroom sink and to the medication cart located outside of the door of the room which remained visible to the surveyor. LPN #1 then donned new gloves without performing hand hygiene and LPN #1 entered the resident's room, used her gloved hand to pull the skin around the resident's left eye, and instilled the eye drop. On 06/30/21 at 8:31 AM, LPN #1 exited the resident's room, used the same gloved hand to turn the gray knob on the garbage can lid and removed her gloves. On 06/30/21 at 8:32 AM, LPN #1 stated hand hygiene should be done prior to going into and out of a resident's room while assisting the resident, giving medications, and when gloves are removed or changed. LPN #1 confirmed she had not used hand hygiene and stated it slipped my mind, and that the purpose of hand hygiene was not to contaminate anything. On 06/30/21 at 8:50 AM, the surveyor interviewed LPN #3 on the 3rd floor, stated handwashing or hand hygiene was done after contact with the resident and in between residents. LPN #2 stated the purpose was infection control and to avoid cross contamination. On 07/06/21 at 9:37 AM, the surveyor interviewed the RN/IP who stated that the appropriate procedure for hand hygiene was to turn on the water to the sink, apply soap, lather hands outside of the running water with friction for 20 to 30 seconds, rinse hands, dry hands with a paper towel, and then turn off the water to the sink with a new paper towel. The RN/IP further stated that the main purpose for hand hygiene was to prevent the spread of infection. Review of the facility provided, Hand Hygiene Competency Criterion Checklist, dated 5/5/21, revealed LPN #1 had been validated as correctly demonstrated how to perform hand hygiene. Review of the facility provided, Medication Pass Observation, dated 5/28/21 performed by the facility Pharmacy Consultants, included but was not limited to the following: 6. Hands washed using appropriate technique, and 12. Eye drop - washes hands before and after administration. The observation revealed LPN #1 was not competent and had to be educated to wash hands before all resident care. Review of the facility provided, Hand Washing, not dated, included but was not limited to: the policy to minimize transmission of infectious disease by frequent and correct handwashing techniques; process immediately or as soon as feasible after the removal of gloves, and before and after direct resident contact. Review of the facility provided, Eye Drop Administration, dated 10/91, included but was not limited to: 4. Hands must be washing in the sink or sanitized before and after administration of the eye drop. Review of the CDC, https://www.cdc.gov/handhygiene/providers/index.html, Hand Hygiene in Healthcare Settings, included but was not limited to when to perform hand hygiene as immediately before touching a patient; before moving from work on a soiled body part to a clean body site on the same patient; after touching a patient or the patient's immediate environment; after contact with contaminated surfaces; and immediately after glove removal. Review of the IFU for the [Device] dated 2019 revealed Single Use Only. The [Device], User Instructions, revealed Policy .The [Device] should be disposed of after a single use. Review of the facility Policy/Procedure: Enteral Feeding Tube Declogger, Original Issue Date: 2/2015 revealed under Instructions, #8, Discard declogger (single use) after procedure. NJAC 8:39-19.4(a)(1)(l)(n); 27.1(a)