Based on observation and interview it was determined that the facility failed to dispose of refuse in a manner to maintain a sanitary environment and prevent potential pests. The deficient practice was evidenced by the following: On 5/4/25 at 7:05 AM, the surveyor observed the dumpster area with the Food Service Director (FSD) and observed the garbage dumpster door was open and filled with garbage bags and the recycling dumpster was also open. The area adjacent to the dumpster had various debris, pallets, old garbage cans and various debris including various plastic, paper, and pallets were strewn in the wooded area behind the dumpster. The FSD stated the dumpsters should be closed and the area should not look like that and proceeded to close the dumpster doors. On 5/5/25 at 10:42 AM, the surveyor informed the Regional Licensed Nursing Home Administrator (RLNHA) and the Licensed Nursing Home Administrator (LNHA) of the debris and refuse outside of the open dumpsters and showed the pictures taken on 5/4/25. The RLNHA stated that he was not aware and it would be taken care of. NJAC 8:39-19.7(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: LAW, [NAME] Complaint NJ # 173967 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) incontinence care, and b) nail care. This deficient practice was identified for 5 of 5 residents reviewed for ADL care (Resident #14 , #30, #31, #15 and Resident #33). Findings included: On 5/4/25 at 6:30 AM, Surveyor #1 assisted with a random Certified Nursing Aide (CNA) performed an incontinence care tour. The South Wing had a strong urine odor. 1. At 6:35 AM, Surveyor #1 noted the strong smell of urine and entered Resident #14's room. Surveyor #1 observed the 11:00 PM to 7:00 AM Certified Nurse Aide (CNA) assessed the resident for incontinence. Resident #14 was observed wearing an incontinence brief with a rolled up towel between the incontinence brief and the residents skin and the brief and the towel were saturated with urine. A review of the admission Record (AR; an admission summary) revealed Resident #14 had been admitted with diagnoses which included but were not limited to; hemiplegia (a neurological condition characterized by paralysis of one side of the body) and left hand contractures. A review of the quarterly Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 4/10/25, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 09 out of 15 indicating moderately impaired cognition. The MDS further documented that Resident #14 was dependent on staff for toileting. A review of the Individual Comprehensive Care Plan (ICCP) included a Focus area dated 1/27/23, bladder incontinence with interventions that included but were not limited to; incontinence brief use, change every 2 hours and as needed; and wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. 2. Surveyor #1 then entered Resident #30's room and observed Resident#30 on a low bed. Upon inquiry, the resident informed the surveyor that they were last changed last night. The surveyor asked a random CNA to assist with a care tour. Resident # 30 was wearing two incontinence briefs. The briefs were yellow stained and saturated with urine. The CNA confirmed that she had not provided incontinence care to the resident this morning. The admission Summary for Resident # 30 revealed the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia and hemiparesis, angina and unspecified glaucoma. The Annual Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 4/3/25 reflected that Resident # 30 had a BIMS Score (Brief Interview for Mental Status) of 15 out of 15 which indicted intact cognition. Section GG of the MDS which addressed Functional Abilities revealed Resident # 30 was dependent on staff for toileting. The Individual Comprehensive Care Plan (ICCP) included a focus initiated 3/29/23 had a Focus area for bladder incontinence related to poor control due to cerebro-vascular accident (stroke) with hemiparesis. The goal was for Resident #30 to be continent at day time through the review date. The interventions were to check Resident every 3 to 4 times per shift and as required for incontinence. Uses large disposable briefs. 05/09/25 5:43 PM, a On 5/8/25 at 12:04 PM, the surveyor interviewed Resident #30. They confirmed that after care the staff always used two incontinence briefs. Resident #30 informed the surveyor that they did not request to have two incontinence briefs. On 05/08/25 at 5:43 PM, during a telephone interview with the CNA who cared for the Resident during the 11:00 PM- 7 :00 AM shift on 5/4/25, the CNA confirmed that Resident # 30 was wearing two incontinence briefs. The CNA stated that the two briefs were applied by the prior shift, she did no have the time to check the resident during the night. 3. Resident #31 was in their room and informed the surveyor that they were soiled. A random CNA provided care and the surveyor observed that Resident #31 also had two incontinence briefs on which were both saturated with urine. On 05/08/25 at 5:58 PM, during a telephone interview with the CNA she acknowledged that she did not have the time to change and check the resident in the morning, she had to care for a difficult resident. She stated that the second brief was applied by the 3:00 PM -11:00 PM shift as a cushion to protect the bed. On 05/09/25 at 8:42 AM, the surveyor interviewed Resident #31 in their room, and they stated that usually the CNAs placed two briefs on because they urinated a lot. When inquired if they authorized two incontinence briefs, they stated, No. The admission Summary for Resident #31 revealed the resident was admitted to the facility with diagnoses which included, but were not limited to; Vascular Dementia, major depressive disorder and muscle weakness. The admission MDS assessment dated [DATE], reflected that Resident #31 had severe cognitive impairment. Resident # 31 scored 04 out of 15 on the BIMS. A review of Section GG which addressed Functional Abilities, Resident # 31 was coded as being dependent on staff for toileting. 4. The surveyor continued the care tour and entered Resident #15's Room. Resident #15 could barely answered to the surveyor's questions. The surveyor observed a random CNA check the resident for incontinence. The Resident had a towel between the brief and the skin which were both saturated with urine. Resident #15 also had also a colostomy bag that was completely filled with stool. The CNA revealed that she placed the towel inside the resident's brief. On 5/6/25 at 4:30 PM, during a telephone interview with the CNA who cared for Resident #30 and #31, the CNA revealed that she had to care for a difficult resident who required mostly a 1:1 observation, she did not have time to change Resident #30 in the morning. When inquired regarding the two incontinent briefs observed on Resident #31 the CNA stated that the facility did not have enough sheet, the second brief was used as a barrier to prevent the sheet from being wet. On 5/6/25 at 5:30 PM, CNA #2 returned the phone call and confirmed that she cared for Resident #15 and Residednt #33 and placed the towel inside their briefs. When asked to provide the rationale for placing the towel inside the brief, she stated both residents requested the towel. On 5/07/25 at 10:12 AM, Surveyor #2 interviewed the 7:00 AM to 3:00 PM CNA who directly cared for Resident #14. The CNA stated the process was to provide incontinence care at least every two hours or more as needed. She stated to only use one incontinent brief and never anything rolled in the brief. On 5/07/25 at 10:25 AM, during an interview with Surveyor #2, Resident #14 stated staff helped with incontinence care and they sometimes rolled a towel in the incontinence brief. Resident #14 stated they did not want to say anything else because they did not want to get anyone in trouble. On 5/7/25 at 1:19 PM the above concerns were discussed with the Director of nursing in the presence of the LNHA and the survey team. The DON stated that she interviewed the CNAs, and the CNA informed her that the residents were heavy wetters they confirmed that they placed the towels inside their briefs. 5. On 5/4/25 at 7:45 AM, Surveyor #3 observed Resident #33 in their bed. Surveyor #3 followed the Licensed Practical Nurse (LPN #1) to Resident #33's room for blood sugar check. Surveyor #3 observed the resident had long jagged and dark colored fingernails on both hands. On 5/5/25 at 1:05 PM, Surveyor #3 observed Resident #33 eating lunch in their bed. Resident #33 stated that they were washed up earlier (received morning care earlier). Surveyor #3 observed Resident #33's long jagged and dark colored fingernails on both hands. On 5/7/25 at 11:38 AM, Surveyor #3 reviewed the electronic medical records for Resident #33. A review of the AR revealed Resident #33 had been admitted with diagnoses which included but were not limited to; hemiplegia (a neurological condition characterized by paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following Cerebral infarction (also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting let dominant side and need for assistance with personal care. A review of an admission MDS, dated [DATE], included but was not limited to; a BIMS score of 11 out of 15 indicating Resident #33 had moderately impaired cognition. The MDS further documented that Resident #33 had impairment (functional limitation in range of motion) on their one (1) side of the body and was dependent on staff for personal hygiene. A review of the ICCP did not reveal a care plan with a focus area regarding providing Activities of Daily Living (ADLs) care. On 5/8/25 at 10:24 AM, Surveyor #3 observed Resident #33's long jagged and dark colored fingernails. Resident #33 stated my nails look like this because I am going through my bag. Resident #33 stated they (the staff) usually checked my nails, but my normal (regular) person was not here today. On 5/8/25 at 10:38 AM, during an interview with the Surveyor #3, the Licensed Practical Nurse (LPN) stated ICCP were initiated during admission and were updated with any changes in resident's condition during their stay. The LPN stated if resident requires assistance with ADL care like if a resident requires 1 person assist or if they are total care, if the resident was on isolation, their medications . etc. would be included in the care plan (CP). The LPN stated usually CNA would come and tell me if they provided a shower and/or hygiene care to the resident so I could go and check the resident myself. The LPN stated he did not always supervise the hygiene care but if the resident required 2 person assist then he would help the Certified Nurse Aide (CNA). The LPN stated it was important to provide the nail care because they (the residents) scratch themselves and poo (feces) gets stuck under their nails and residents could get infection. The LPN stated he was familiar with Resident #33 and the resident required assistance with their care. The LPN further stated the resident could take care of their right hand but not their left hand due to history of stroke. Surveyor #3 accompanied the LPN to Resident #33's room and the LPN acknowledged resident's nails looked dirty and long. On 5/8/25 at 11:09 AM, during an interview with Surveyor #3, the Registered Nurse/Unit Manager (RN/UM) on North Wing, stated CP were initiated to guide the staff regarding the resident's care and what was best for the patients. The RN/UM stated she was responsible to initiate the CP on admission and should have initiated the ADL focus area CP for Resident #33. The RN/UM stated nail care was a part of the morning care, and the CNAs would notify the assigned nurse or her (RN/UM) if the resident required their nails to be trimmed because the nurses or the RN/UM would cut resident's fingernails. The RN/UM stated it was important to provide nail care so they (the residents) did not scratch and get a skin tear, was uncomfortable to have ragged nails, they would look awful and for infection control. At 11:21 AM, in the presence of Surveyor #3, the RN/UM reviewed Resident #33's ICCP and confirmed that there was no ADL focus area CP initiated. After Surveyor #3's inquiry, the RN/UM stated she would initiate and update resident's CP. In the presence of Surveyor #3 and the RN/UM, the LPN stated the resident's nails were dirty and long. On 5/8/25 at 1:19 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON. Surveyor #3 presented above mentioned concerns with the administration. On 05/09/25 at 12:56 PM, the DON responded that the staff used the double incontinence briefs because they had to watch a resident who required close supervision and provided no additional information. A review of the facility provided Job Descriptions for Licensed Practical Nurse included but not limited to: Position Summary - Must maintain the highest standards in caring and servicing the needs of the residents . In section Responsibilities/Accountabilities: Takes an active role in direct resident assessment and care; Assesses each resident daily and implements a change in the course of action as needed; Ensure the residents and .receive the highest quality of service in a caring and compassionate atmosphere promoting dignity and respect which recognizes the individuals' needs and rights. A review of the facility provided policy, Activities of Daily Living (ADLs), updated 10/2024, included but was not limited to; Care and services . for the following activities of daily living: . 1. grooming . 3. toileting . Policy Explanation: . 3. a resident unable to carry out activities of daily living will receive . services to maintain good nutrition, grooming, and personal and oral hygiene. 5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. A review of the facility provided policy, Comprehensive Care Plans, updated 10/2024, included but not limited to: Policy- It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that are identified in the resident's comprehensive assessment. In section Policy Explanation and Compliance Guidelines: 3a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. NJAC 8:39-11.2 (e), 27.1(a), 27.2 (g)(h)

Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure; a) Peritoneal Dialysis (PD - a procedure using the lining of the abdomen to filter out waste products from the blood) supplies were not stored directly on the floor in the room to avoid possible contamination; b) facility staff were trained and received competencies in PD; and c) staff were documenting the administration of PD. This deficient practice was identified for 1 of 1 resident (Resident #229) reviewed for PD and was evidenced as follows: A review of the admission Record (an admission summary) revealed that Resident #229 was admitted with diagnoses which included but were not limited to; End Stage Renal Disease, dependence of renal dialysis, and pneumonia. A review of the admission Minimum Data Set (MDS) a tool used to facilitate care, dated 4/30/25, included a Brief Interview for Mental Status (BIMS) of 03 out of 15 which indicated severely impaired cognition. The MDS further documented that Resident #229 had been admitted with being on PD. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 5/1/25, for the need for peritoneal dialysis with Interventions which included but were not limited to; obtain vital signs and weight per protocol, and to observe/document/report any signs of infection, edema, bleeding, renal insufficiency. A review of the Order Summary Report included the following physician orders: -dated 5/1/25, beginning on 5/1/25 at 8 PM, PD using 1.5/6 L (liter) bag on Sundays, Tuesdays, Thursdays, and Saturdays and add 6,000 units/6 ml (milliliters) of heparin to PD bag. -dated 5/1/25, beginning 5/1/25 at 8 PM, PD using 2.5/6 L bag on Mondays, Wednesdays, and Fridays and add 6,000 units/6 ml (milliliters) of heparin to PD bag. -dated 5/1/25, pre and post dialysis weight. 1. On 5/4/25 at 8:45 AM, during the tour of the facility, the surveyor observed a box of opened PD supplies in direct contact with the floor in Resident #229's room. On 5/4/25 at 8:54 AM, the surveyor accompanied the North Unit Registered Nurse Unit Manager (RNUM) to the resident's room. The RNUM acknowledged the open box of PD supplies in direct contact with the floor and stated they should not be placed directly on the floor because of infection control purposes. The RNUM further stated that the nursing staff were trained on performing PD. 2) On 5/6/25 at 10:07 AM, the Director of Nursing (DON) provided the surveyor with a Patient Record of Trained Caregiver Form with a different resident name and dated 1/8/24. The form included 11 staff names and the signature of the trainer from a different dialysis company then the one used by Resident #229. At that time, the DON stated that the company Resident #229 used for PD had conducted an in-service for the staff recently. She stated she would be the person responsible to ensure staff training was done. The DON stated that upon surveyor inquiry, she also realized the nursing staff was not documenting the administration of the PD in Resident #229's Medication Administration Record (MAR). The DON further stated that PD supplies should not be in direct contact with the floor for infection control reasons. On 5/6/27 at 12:56 PM, the DON provided the General Training Checklist (GTC) from the other dialysis facility which had been filled out for nine of the 11 staff members on the list. The GTCs were all dated 1/8/24. The GTC noted that the checklist was used to verify training for the staff members who were in attendance of the session. It further revealed that the general training would be provided initially and annually . per the home dialysis care agreement. It again noted that the knowledge check list and training were not for a care partner (someone not medically trained and would be available at home to assist the resident). The GTC included documented competencies. At that time, the DON also provided two In-Service Sign in Sheets, one dated 4/30/25 and the second 3/3/25. The in-services were conducted by Resident #229's dialysis company; contained staff members who did not receive the initial training; and included the content which was a Cheat Sheet for Patients. There were no initial competencies included to ensure staff were properly trained to administer PD. 3) On 5/6/25 at 12:56 PM, the DON had also provided a CCPD (Continuous Cycling PD) Home Record sheet. The sheet had areas to document the following: date; weight before and after; blood pressure before and after; pulse before and after; temperature before and after; 1.5% or 2.5% columns; initial drain; and UF. The following information was not documented or missing: None of the dates included the year. -5/1 had no post pulse; no documentation of the physician ordered heparin; and no nurse staff signature. -5/2 had no pre weight; pre blood pressure; pre pulse; pre temperature; and no nurse staff signature. -5/3 had no initial drain; UF; and no nurse staff signature. -5/4 had no post weight; post blood pressure; post pulse; post temperature; initial drain; UF; and no nurse staff signature. -5/5 had no pre weight; pre blood pressure; pre pulse; pre temperature; and no nurse staff signature. -5/6 had no post weight; pre blood pressure; pre pulse; pre temperature; initial drain; and no nurse staff signature. At that time, the DON acknowledged that there were no staff signatures and there was missing information on the sheet. She acknowledged the two in-services from 2025 were not competencies and that there were no annual competencies from any of the initial training from 1/8/2024. On 5/07/25 at 8:17 AM, the Licensed Nursing Home Administrator (LNHA) stated that the nurses should have documented when PD was administered at the time they administered the treatment. The LNHA had provided Incident Reports dated 5/6/25 from the nurses who had supposedly administered the PD. The LNHA further stated that it was not the process to provide an incident statement after the administration of PD treatment. A review of the facility provided policy, Storage of Peritoneal Dialysis Supplies, reviewed 1/6/25, included but was not limited to; . supplies will be stored in a manner that maintains sterility . and to minimize the risk of infection. A review of the facility provided policy, Peritoneal Dialysis Services in Skilled Nursing Facilities, revised April 2024, and was from Resident #229's dialysis facility not the dialysis facility who conducted the initial training, included but was not limited to; Purpose: to provide compliance . in administering PD to patients in Skilled Nursing Facilities (SNFs). Policy: applies to SNFs providing PD services. Definitions: Caregiver . independent contractor . that has completed the . training and verification of competency. 3. A SNF Quality Checklist will be completed prior and signed by a representative of [name redacted dialysis facility] . 7. A trained, licensed RN or Licensed Practical Nurse (LPN) . must be onsite at the SNF and overseeing all treatments/exchanges at the SNF for the duration of the treatments/exchanges. 10. [name redacted dialysis facility] will provide initial and ongoing training to SNF licensed nurses . only [name redacted dialysis facility] trained Caregivers . who have completed . training program may be involved in the dialysis care of patients. 10. b. One or more SNF licensed nurses . will be verified as competent to oversee PD treatment each time a new patient is admitted . Each designated SNF caregiver must have a completed skills check list signed off by a [name redacted] PD RN. 10. c. The SNF must keep an update list of PD trained licensed nurses . to verify that a PD competent licensed nurses is on site at all times while a PD patient is admitted . The SNF needs to notify [name redacted] if further competency training is needed to verify an adequate number of . nurses are competent to oversee PD treatments. NJAC 8:39-2.10(a); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. On 5/4/25 at 8:09 AM, 2 surveyors observed 2 nurses administered 25 doses of medication to 3 residents and there were 2 errors which resulted in a medication error rate of 8%. The deficient practice was evidenced by the following: On 5/4/25 at 8:09 AM Surveyor #1 observed the Registered Nurse (RN ) on the South Wing, administered the following medications to Resident #15: Pantoprazole 40 mg 1 tab medication to treat Gastroeosophageal reflex. Dutasteride 0.5 mg 1 tab medication to treat benign prostatic hyperplasia Metropolol 25 mg 1 tab,medication to treat hypertension Miralax 17 gm, medication to treat constipation. Verapamil 120 mg 1 tab medication to treat hypertension. Apixiban, 5 mg, ( not administered). medication to treat blood clot. The RN poured 5 milliliters ( ml) of the Miralax powder into a medication cup, then she added only 15 ml of water, stirred it and gave it to the resident. 1/2 of the medication was left in the medication cup. The physician order was to administer Miralax 17 gm. According to the manufacturer specification the RN was to use the measuring cap to the indicated line (usually the top of the white section) to measure the Miralax. The RN used a measuring cup filled the measuring cup to 5 milliliter (ml) then added 15 ml of water stirred the powder and gave it to the resident. Prior to administer the Miralax, the surveyor asked the RN to check if it was the right dose. The RN informed the surveyor that was the correct dose to administer. The resident told the RN that the medication tasted like chalk. The Resident returned the cup with half of the medication which the nurse discarded in the receptacle bin. A review of the medication specification revealed that the Miralax was to be administered in 4 ounces of water. (Error #1) 2. On 5/4/25 at 8:09 AM, the RN did not administer Apixiban, a blood thinner ordered to be administered twice daily. At 10:30 AM, the surveyor returned to the medication cart and inquired regarding the Apixiban that was not administered. The RN informed the surveyor that the medication was not available. On 5/4/25 at 12:30 PM, the surveyor reviewed the Progress notes and the physician order sheet, There was no documented evidence that the physician was notified of the omission of the medication. The nurse informed the surveyor again that the Apixiban was still not available. On 5/5/25 at 9:30 AM, the surveyor observed a Licensed Practical Nurse (LPN ) on the medication cart. Upon inquiry, the LPN informed the surveyor that the medication was not available on the 3:00 PM- 11:00 AM shift and she informed the Director of Nursing who called the pharmacy and the medication was delivered late last night. However there was no documented evidence that the physician was called or an order was obtained to administer the medication upon delivery from the pharmacy. The resident missed two doses of the medication. A review of the Bingo cart delivered around 10:30 PM on 5/4/25 from the pharmacy was intact. (Error #2) On 5/6/25 at 12:30 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the medication pass errors observed. On 5/5/25 at 12:50 PM, in the presence of the survey team, the DON stated that the RN would not be administering medications until she was re-educated on proper administration of medications. A review of the RN's file revealed that the nurse missed several steps during the medication Pass administration dated 6/20/24. The nurse failed to lock the medication cart, failed to administer medication in a timely manner and failed to sign medications immediately after administration. A review of the facility's policy titled, Medication Administration last revised 10/2024, included the following: Policy: Medications are administered by licenses nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: Procedure #11(a) Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Procedure #14. Administer medication as ordered in accordance with manufacturer specifications. a.) Provide appropriate amount of food and fluid. A review of the Registered Nurse Responsibilities /accountabilities revealed the following: The RN must have knowledge of medications, their proper dosage and expected results. NJAC 8:39-29.2 (d)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to consistently follow medication hold parameters according to the physician's order. This deficient practice was identified for 1 of 3 residents reviewed for medications (Resident #1). The deficient practice was evidenced by the following: On 5/6/25 at 11:05 AM, the surveyor observed Resident #1 sitting in their bed. The Certified Nurse Aide (CNA) was present in resident's room. On 5/7/25 at 11:53 AM, the surveyor reviewed Resident #1's electric medical records (EMR) which revealed the following: The admission Record (AR; admission summary) revealed that Resident #1 had diagnoses which included but were not limited to: hypertension (high blood pressure), dementia and type 2 diabetes. A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated 3/22/25, revealed that Resident #1 had a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe impaired cognition. Normal Score: 00-15. A review of the Order Summary Report (OSR) reflected that Resident #1 had 2 separate Physician Orders (PO) dated 11/13/24 for a medication as follow: -Clonidine HCl Oral Tablet 0.1 Milligram (mg) - Give 1 tablet by mouth three times a day every Monday, Wednesday and Friday for hypertension on Dialysis days. Hold for Systolic Blood pressure (SBP) of 130 and below. -Clonidine HCl Oral tablet 0.1 mg - Give 1 tablet by mouth three times a day every Tuesday, Thursday, Saturday, and Sunday for hypertension on non-dialysis days. Hold for SBP of 130 and below. The corresponding PO was transcribed into the March 2025 through May 2025 electronic Medication Administration Record (eMAR). Further review of the March - May 2025 eMARs for Resident #1 revealed that nurses signed and reflected a checkmark which means that the medication was administered when the medication should have been held for a SBP of 130 and below according to the PO, for the following dates and times: Date Time SBP 3/15/25 2 PM 128/81 3/23/25 2 PM 125/70 3/27/25 6 AM 130/78 3/29/25 2 PM 98/30 4/1/25 6 AM 130/70 4/5/25 6 AM 128/76 4/9/25 5 PM 113/48 4/15/25 6 AM 105/75 4/23/25 8 AM 130/60 4/23/25 5 PM 128/64 4/23/25 10 PM 128/64 4/24/25 6 AM 127/63 5/3/25 2 PM 124/70 5/7/25 5 PM 130/66 On 5/8/25 at 11:26 AM, during an interview with the surveyor , the Licensed Practical Nurse (LPN) confirmed that Clonidine was prescribed to treat hypertension, and licensed staff were to hold Clonidine if the systolic blood pressure was 130 or below. The LPN further stated that Clonidine can cause a sudden drop in blood pressure and staff must follow the physician's order. On 5/8/25 at 11:37 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM) who confirmed that staff were to follow the physician's order and administered Clonidine within the parameter set forth by the physician. The RNUM stated if the blood pressure was low Clonidine can cause dizziness which could lead to falls. The surveyor reviewed the Medication Administration Record (MAR) with the RN/UM and we both verified that licensed staff had been administered Clonidine outside the parameter sets forth by the physician. On 5/8/25 at 1:19 PM, in the presence of the survey team, the surveyor shared the above concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON. The DON confirmed that the medication should not have been administered. The nurses were to follow the physician's order. A review of the Job Descriptions for Licensed Practical Nurse revealed the following: The Licensed Practical Nurse must adhere to all facility policies and procedures. Responsibilities/Accountabilities: The Licensed Practical Nurse will dispense medication and performs treatments, as requested, and in accordance with policies and procedures. A review of the facility policy titled Medication Administration policy revised 10/24 included under Policy Statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Under section Policy Explanation and Compliance Guidelines: 8.) Obtain and record . When applicable, hold medication for those vital signs outside the physician's prescribed parameters. NJAC 8:39-11.2(b), 27.1 (a), 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 173967 REPEAT DEFICIENCY Based on observation and interview, it was determined that the facility failed to ensure the environment and common areas were maintained in a clean, homelike and sanitary manner. The deficient practice occurred on 2 of 2 resident units (North and South) and in the main dining room/activity room and was evidenced by the following: On 5/4/25 at 7:15 AM, the surveyor entered the main dining room and observed the wall air condition unit was missing molding around it, there were visible rips in the wall paper in several areas, the ceiling was cracked, the vents in the dining room were soiled with debris, the window air conditioning unit had debris inside the vent, and several chairs were visibly worn through the paint and at 7:19 AM, the surveyor interviewed the Infection Preventionist Licensed Practical Nurse who confirmed that the dining room was used daily. On 5/4/25 at 7:26 AM upon entering the North, Sub-Acute Unit, the surveyor observed a ceiling light fixture with a broken cover and then observed the following on the North Sub-Acute Unit: -room [ROOM NUMBER], Resident in bed and the six-drawer dresser was visibly broken as the drawer was not straight, the wall above the dresser had scuffed areas, the floor was soiled and there was a hole in the wall. At 7:31 AM, the Certified Nurse Aide (CNA #1) entered and confirmed the surveyor's observations. - room [ROOM NUMBER], Window bed had a broken bottom area on the nightstand, the bedside table was chipped on the edges, and the base was soiled; the Door bed nightstand was missing a handle on the bottom drawer. -room [ROOM NUMBER], foam was protruding through the wall by the window. -The adjacent shower room had a storage cabinet with worn through and chipped areas, the metal molding by the toilet area was visibly lifted. The shower area had what appeared to be screws with rust like stained areas and rust stained areas by the grab bar. The door to the shower room was broken and missing wood in areas and visibly chipped and rough in appearance. -room [ROOM NUMBER], the door to the room was had broken/chipped wood on the outside and the bedside curtain was soiled. On 5/4/25 at 7:52 AM, the surveyor observed the smoking area courtyard. The door used by the residents to access the courtyard had gaps by the seal and open areas to the courtyard were visible through the holes. The exterior of the door appeared rotted and broken and had a hole in it. On 5/5/25 at 8:37 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility was in the process of transferring to a new owner. On 5/5/25 at 10:30 AM, the surveyor proceeded to tour the facility with the facility management company Regional LNHA (RLNHA #1) and the current LNHA. The surveyor reviewed the concerns regarding the dining room which was presently being utilized by residents for an activity. The surveyor proceeded to tour the North Sub-Acute Unit with the RLNHA and LNHA and observed the same concerns as observed by the surveyor on 5/4/25 for room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] and the additional concerns as following: -room [ROOM NUMBER] both bedside curtains were visibly soiled. -room [ROOM NUMBER], the window air conditioner was soiled, the sitting chair had chipped areas on the arm rests, was worn through and the dresser was broken. -room [ROOM NUMBER] W area by window air conditioner was not sealed and open to the outside. Resident #39 was in the window bed and the surveyor asked if the resident had any concerns with insects. The resident stated, creepy crawlies, yes, and they (facility) knew about it. The top of the cabinet in the was missing trim, and there was a crack in the ceiling. The hallway vents outside of room [ROOM NUMBER], were soiled with visible debris and the light covers appeared dusty. -room [ROOM NUMBER], closet door appeared stuck and was soiled on the outside. closet door stuck, soiled outside -room [ROOM NUMBER], chip on the room door and the inside of the air conditioner had visible debris. -room [ROOM NUMBER], the inside of the air conditioner unit had visible debris. -room [ROOM NUMBER], the inside of the air conditioner unit had visible debris. -room [ROOM NUMBER] had no air conditioner in the window and the room felt very warm. Resident #280 was the only resident in the room and the surveyor asked Resident #280 if they were comfortable, and the resident stated they were hot. The LNHA stated she was not aware there was no air conditioner in the room and the resident had just been admitted . On 5/5/25 at 11:20 AM, the surveyor toured the South Unit with the RLNHA and LNHA and observed the following: -Resident # 37's room had a broken nightstand drawer that could not fully close and was crooked. The surveyor asked Resident #37 about the drawer and the resident stated it has been like that for 1 ½ years. -room [ROOM NUMBER], the inside of the air conditioner unit was visibly soiled with debris. -room [ROOM NUMBER], had a broken air conditioner unit cover. -room [ROOM NUMBER], the door to the room was visible chipped and missing pieces. -Room # 40, there was no screen in the window. -Room # 39, the door had visibly worn areas, and the window air conditioner unit was filled with debris. - Room # 42, room entry door with missing wood chips. - Room # 44, there were two air conditioner units, and both were filled with debris inside, the tray table was soiled with debris on the base. -Room # 45, the air conditioner was soiled inside and out with debris, the wallpaper was ripped, and the tray table was visible worn. -Room # 49, the air conditioner was soiled with debris, and the wallpaper was ripped. -Room # 51, the door was broken, the air conditioner unit was broken, the bedside table was chipped, and the bed curtain was soiled. -Room # 55 Door bed, the bedside curtain was soiled. -Room # 56, the window blinds were broken. -Room # 58, the air conditioner was soiled with debris inside and the dresser drawer was broken. -Room # 60, the air conditioner unit was soiled with debris. -room [ROOM NUMBER], the 6-drawer dresser was missing a drawer, and the wallpaper was ripped. On 5/5/25 at 11:59 AM, the surveyor observed a visibly soiled Sit to Stand, and a visibly soiled mechanical sling lift in the hallway. Both the RLNHA and LNHA confirmed the surveyor observations during the tour. The RLNHA stated that he was part of the management company. The RLNHA informed the surveyor that the blinds were going to be replaced, and the management company wanted to renovate the building. When the surveyor asked both the RLNHA and LNHA, who had previously informed the surveyor that was employed at the facility for seven months, regarding the identified issues on 5/4/25 and 5/5/25 with overall cleanliness and disrepair, and why they have not been addressed? Neither had a response. NJAC 8:39-31.4(a)

Based on observation, interview and document review it was determined that the facility failed to store all potentially hazardous foods at appropriate temperatures and maintain the kitchen environment and equipment in a clean and sanitary manner to limit the potential for food borne illness. The deficient practice was evidenced by the following: On 05/04/25 at 6:29 AM, the surveyor completed a brief initial tour of the kitchen with the [NAME] and observed the following: 1. The can opener affixed to the metal table had embedded debris on the base, blade and metal shavings were visibly embedded in the debris and the insert on the base of the can opener. 2. The refrigerated sandwich preparation refrigerator contained a thermometer next to metal food containers with a reading of 60 degrees Fahrenheit (F) with a metal pan of sandwiches on top of and next to various containers including, but not limited to; metal containers labeled Tuna, 5/2-5/4; Swiss Cheese 4/27-5/3; Turkey 5/3-5/9. The surveyor asked the [NAME] to check the temperatures of the food items and the cook placed a thermometer in the egg salad which read 42.6 F, then the turkey which was 41.7 F, then again in the egg salad which read 43.2 F, then into the tuna which was 41.4 F, and the last time into the egg salad which read 44.1 F. The Food Service Director (FSD) joined the tour, and the surveyor asked what the appropriate temperature was for cold food. The FSD stated 40 F or below, and 42 F or 43 F was okay. When asked if the temperatures were monitored, the FSD provided a blank temperature log HACCP (hazardous analysis critical control point- for food safety)/Safety-Serving Line Temperature Log with Cold Food/Salad - 38 F. 3. Fifty insulated burgundy tray lids that were used to cover the meals during transport were visibly worn on the edges and had a rough appearance. 4. The floor area behind and underneath the stove had visible debris strewn about and the wall was also soiled, and oven racks were stored behind the stove on the floor. 5. The black three-tiered cart next to the tray line was visibly soiled throughout. 6. The fan inside the walk-in refrigerator was visibly soiled with debris. On 5/6/25 at 12:13 PM, a follow-up kitchen tour was conducted with the FSD, and the following was observed: 1. The surveyor observed the Three Compartment Sink Log for May 6 was blank and the kitchen staff was washing and sanitizing metal pans in the three-compartment sink. The surveyor asked for the reading of the sanitizer solution and the FSD placed the strip in the sanitizer of the three-compartment sink and the strip did not change color, remained the orange of the strip. The FSD placed a second strip in the sanitizer solution to test it and again, it did not register and remained orange. The surveyor asked if that was okay and the FSD stated, no, not appropriate, he may have added water to the solution. The surveyor asked if the level was supposed to be documented on the Log and the FSD stated it was supposed to be written down. 2. The surveyor approached the lunch meal preparation, and the tray line was in progress. There was a pungent sewage odor next to the tray line and the surveyor observed fluid pouring out of a pipe under a sink next to the tray line. A staff informed the surveyor that the grease trap was overflowing and that was what was pouring onto the floor. On 5/7/25 at 8:02 AM, the Licensed Nursing Home Administrator provided the surveyor with the following policies: The Monitoring of Cooler/Freezer Temperatures, Undated revealed: It is the policy of the facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day .2. Thermometers shall be placed inside each cooler/freezer and calibrated at least once per week. 3. All refrigerated storage must be maintained at or below 41 F, the supervisor will be notified immediately for corrective action. B. Internal temperature readings of all perishables of potentially hazardous food shall be taken and discarded if not in an acceptable range. The Manual Can Opener Policy, Undated revealed: Procedure: 4 Kitchen staff will inspect can opener blade, clean and sanitize after each usage. The Manual Warfewashing-3Compartment Sink policy, Undated revealed: To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans and other utensils using a 3 compartment sink in accordance with current standards for food safety. 7. Sanitizing solutions shall be tested by a test kit or other device that accurately measures the concentration in MG/L (milligrams per liter). Testing will occur periodically but not limited to a. When sink is initially filled. NJAC 8:39-17.2(g)

Based on the interview and review of medical records, it was determined that the facility failed to consistently treat resident personal finances and resident mail in a respectful and accountable manner. This deficient practice was observed for one (1) of the 20 residents reviewed (Resident #17). This was evidenced by the following: On 12/01/23 at 12:00 PM, the surveyor requested a line list of the facility's Personal Needs Account (PNA) and the surety bond account information. On 12/06/23 at 9:07 AM, the surveyor observed Resident #17 in bed getting ready to be washed and bathed by his/her assigned hospice aid. The surveyor reviewed the medical records of Resident #17. Resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to cerebral vascular accident (CVA) (a brain attack, an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body, hemiplegia indicates partial or total paralysis instead), peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 6/02/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 15 of 15 which reflected that the resident's cognitive status was intact. A review of the quarterly statement dated 7/01/2023 through 9/29/2023 for Resident #17 revealed an account balance of $7109.72. The surveyor reviewed the PNA line list with balances as of 12/01/2023, provided by the Licensed Nursing Home Administrator (LNHA), and showed that the resident had a balance of $7246.51. A review of the provided documents by the Revenue Cycle Manager (RCM) included the resident's most recent account statement which revealed a clothing deduction on 12/11/23 of $4847.35. After the clothing deduction, the account balance was $2399.16 for Resident #17. On 12/12/23 at 08:50 AM, the surveyor interviewed the Social Worker (SW) who was responsible for checking if the resident received items purchased for them by the facility. The SW stated, Everyone can receive a package for them, nursing, central supply, and activities. The surveyor asked if those departments had access to the receipts for the items purchased. The SW stated, no, only I have access. The surveyor asked if any items had been received yet for such a large ($4847.35) purchase. The SW responded, I am not sure. On 12/12/23 at 9:00 AM the surveyor reviewed an itemized bill, dated 11/28/2023 provided by the SW. The bill included 62 items in total. The items consisted of clothing, personal lift chair, and a television. On 12/12/23 at 9:15 AM, the surveyor and the SW went to the resident's room to check if the product that was ordered worth $4847.35 was delivered and received by the resident. Both the surveyor and the SW did not find the item that was purchased for the resident. The surveyor then asked the SW who was responsible and accountable for the resident's mail and order processing, and the SW responded, I guess I am the one that should check it. On 12/12/23 at 9:48 AM, the surveyor and the Director of Nursing (DON) went to the storage to locate Resident #17's missing mail and purchased items. On that same date at 9:52 AM, the surveyor and the DON entered the storage room with the Central Supply Department head (CSD). The CSD stated the invoice was attached to the box. The CSD further stated, I do not handle personal packages. The CSD indicated that the packing slip for personal items was left in the recreation mailbox and they handled the boxes. On that same date and time, the surveyor asked how two large boxes were put in the central supply department. The CSD stated, The packing slip said blankets and I thought it was from a supply vendor. When I saw it was for a resident, I brought it to the SW's attention. The Recreation Director (RD) and/or SW look to check the receipt of the products. I don't know the process of what they do with it. I just know it is not for me to deal with it. The surveyor asked when the packages were delivered and moved to the basement? The CSD stated, he was unsure of the delivery date. The surveyor asked how long the residents' mail was locked up in central supply. The CSD stated he was not sure. On 12/12/23 at 10:18 AM, the surveyor interviewed the Regional Infection Preventionist Nurse (RIPN) who stated, The process when a package is delivered it is received at the front desk the activities pick up and delivers to the resident. if it is a large package with furniture or something that needs to be built or hung maintenance will build it in the basement, inspect it to see if it is working then install it in the resident's room. The receipt should come with the delivery, follow up in the clinical meeting each dept head would be asked if there has been a delivery for the resident. A review of the policy Personal Privacy- Residential Mail original date 1/2012, Reviewed 11/2017, 9/2022, 9/2023 the Policy indicated, It is the practice of this facility to respect our residents' right to personal privacy, including the right to privacy in his or her oral (that is, spoken) written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than the postal service. Under the section Policy Explanation and Compliance Guidelines it further indicated. 1. A facility designee will receive the mail, letters, packages, and other materials addressed to current residents in the facility. 2. The facility designee will refer to the resident mail disposition form when sorting resident mail, letters, packages, and other materials delivered to the facility for the resident. a.) All resident mail, letters, and packages will be distributed promptly by the facility designee to alert the oriented residents. 4. The Social Services Director /designee will maintain a Resident Mail Disposition (RMD) of all current residents of the facility. RMD will be reviewed quarterly as needed. On 12/13/23 at 01:00 PM, the survey team discussed their concerns with the LNHA, RIPN, and the DON. The facility management stated they had no new comments or items to provide to the survey team. NJAC 8:39-4.1 (a)(12)(15)

Complaint #NJ00165614 #NJ00165821 Based on interviews, a review of medical records (MR), and other facility documentation, it was determined that the facility failed to report an allegation of neglect to the New Jersey Department of Health (NJDOH) in the required timeframe for one (1) of two (2) sampled residents, (Resident #17). This deficient practice was evidenced by the following: On 12/02/23 at 10:00 AM, the surveyor asked the Licensed Nursing home Administrator (LNHA) for a copy of Resident #17's Incident/Accident and Reportable (I/A & R) reports for the last eight (8) months, and the LNHA stated that he will get back to the surveyor. A review of the Complaint/incident investigative report revealed an allegation of neglect; Complaint # NJ00165614 reflected an alleged event date on 7/07/23 at 01:45 PM and intake receive date of 7/11/23 at 4:23 PM from the supervising Emergency medical technician (EMT) listed as source other healthcare provider. The facility reported an allegation of neglect reflected an alleged event date of 7/07/23 and an intake receive date of 7/20/23 at 10:25 AM after the resident was readmitted to the facility from the hospital and complaint #NJ00165614 was known to the facility. A review of the reportable event record report provided by the LNHA on 12/02/23 revealed the event date 7/07/23, called in marked yes date of 7/13/23 at 9:50 AM. It also included a fax submission date of 7/19/23 at 4:41 PM to the complaint department of NJDOH. Further review of the reportable event record report provided by the LNHA on 12/02/23 revealed an event dated 7/07/23. The investigation report revealed that the resident was found to have drainage on his/her pillowcase. Upon further inspection by the nurse, the resident was found to have a laceration above his/her right ear with an infestation of maggots (fly larvae) that occupied the wound. The resident had complaints of right-sided head pain. The resident was taken by a medical transport team with EMTs to an acute care hospital and was admitted from 7/07/23-7/11/23. The surveyor reviewed the medical records of Resident #17. Resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral vascular accident (CVA) (a brain attack, is an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body, hemiplegia indicates partial or total paralysis instead), peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 6/02/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which reflected that the resident's cognitive status was intact. On 12/12/23 at 11:18 AM, during an interview with the LNHA about the process of handling I/A & R and grievances the LNHA stated, The staff would initiate the incident form and it would be given to the Unit manager, the Director Of Nursing (DON) or the LNHA, abuse and neglect would fall under me. He further explained, An injury of unknown origin should be reported within two (2) hours to the NJDOH. The investigation should be reported within 24 hours and at the conclusion. At that time, the surveyor asked, why it was not reported within the timeframe per the regulation. The LNHA stated, They did not find it to be neglect, but they reported it on 7/20/23 to air on the side of caution. The surveyor asked, did you know where the laceration came from or was it an injury of unknown origin? The LNHA stated, We didn't know where the head trauma was from, we logically assumed it was a scratch from the resident himself. The surveyor proceeded to ask, if it was unknown origin, should it have been called in within the 2-hour time frame? The LNHA responded, Yes. The surveyor reviewed the investigation report. The Ombudsman's office was notified of the incident on 7/19/23 via fax. On 12/13/23 at 10:21 AM, the survey team met with the new DON, Assistant Director of Nursing (ADON), Regional Infection Preventionist Nurse (RIPN), facility Infection Preventionist Nurse (IPN), and the LNHA. The surveyor notified the facility management of the above findings that the facility did not report the incident of unknown origin in a timely manner. A review of the Incidents/Accident Reporting policy dated original 01/2012 and REV (reviewed) dates of 2/14, 5/2019, 9/2020, 9/2022, 9/2023, provided by the LNHA included that the policy explanation and compliance guidelines revealed #4, In case of incidents or injury of unknown etiology, an investigative report of injury of unknown origin and investigative report for skin tear/bruise of unknown etiology are completed as needed. A review of the Abuse, Neglect and Exploitation policy dated original 01/2012, REV 11/2017, 11/2019, 9/2021, 9/2022, and 9/2023 provided by the LNHA included the following: ~The section of the policy labeled definitions reads; Neglect means failure of the facility, its employees, or service providers to provided goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. ~The section of the policy labeled policy explanation and compliance guidelines reads; #2) The administrator/designee is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with the state law. #3) the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. ~The section of the policy labeled identification of abuse, neglect and exploitation reads; B. Possible indicators of abuse include but are not limited to #8) failure to provide care needs such as feeding, bathing, dressing, turning, and positioning. ~The section of the policy labeled VII Reporting / Response reads; A. #1) Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a.) immediately, but not later than (2) two hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b.) not later than (24) twenty-four hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The administrator will follow up with government agencies, during business hours to confirm the initial report was received, and to report the results of the investigation when final with in (5) five working day of the incident, as required by state agencies. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility IPN, ADON, and new DON for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-13.4(c)(2)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASARR) to include all psychiatric diagnoses to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of (2) two residents (Resident #18) reviewed for level II PASARR and was evidenced by the following: On 12/01/23 at 10:41 AM, during the initial tour, the surveyor observed Resident #18 laying in bed, alert, awake, covered with a bed sheet from chest to toe, and floor mats that were placed on both sides of the bed. The surveyor reviewed the medical record for Resident #18. According to Resident #18 admission Record (or Face Sheet, an admission summary) the resident was admitted to the facility with the diagnoses that included but were not limited to fibromyalgia, systemic lupus erythematosus (SLE; an autoimmune disease, in which the immune system attacks its own tissues such as joints, skin, brain, lungs, kidneys, and blood vessel), major depressive disorder, anxiety disorder, unspecified psychosis, and other seizures. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 9/22/23, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. A review of the admission MDS, dated [DATE], reflected the resident had little interest or pleasure in doing things, was feeling down/depressed, had trouble falling asleep, had poor appetite, felt badly about self, had trouble concentrating, such as reading the newspaper or watching television, moved and spoke slowly or opposite and was fidgety, or restless. The resident had Patient Health Questionnaire-9 score of 17, which indicated the resident had moderately severe depression. The surveyor reviewed the PASARR level one (1) Screen dated 4/12/23, does the individual have diagnoses or evidence of major mental illness to the following disorders: schizophrenia, schizoaffective, mood (bipolar and major depressive type), paranoid, delusional, panic, or other severe anxiety disorder; somatoform or paranoid disorder, personality disorder; atypical psychosis or other psychiatric disorder not otherwise specified) or another mental disorder that may lead to chronic disability? According to the question asked, the facility SW documented on the form that the resident did not have any psychiatric diagnoses. A review of an office visit progress note dated 7/06/22, revealed the resident saw a psychiatrist and had taken Prozac (used to treat depression), Klonopin (used to treat anxiety), and Seroquel (Quetiapine, used to treat psychosis). A review of the Psychiatric Progress Note dated 9/05/23, revealed the resident was diagnosed with the following: depression, anxiety, insomnia, mood disorder not otherwise specified, seizure, SLE and hypertension. On 12/12/23 at 01:36 PM, the surveyor interviewed the Director of Social Services (DSS) who stated that she encouraged hospitals to complete the PASARR level 1 prior to admission to the facility and in the event, the resident was admitted without it, she then created one for the resident. The DSS also stated she never updated the PASARR level 1. At that time, the DSS explained that she checked the PASARR for accuracy of name, social security, date of birth , demographics, and for mental illness (MI). Based on the answers on section 2, we determine the result [positive/negative screen]. The DSS stated that for section 2, she answered the MI against the resident's diagnosis. At that time, the DSS stated that there was no process or flag to update the PASARR. The DSS also stated I am not sure if there is a process to update the PASARR. I do not know when and if I have to update the PASARR. On 12/13/23 at 11:26 AM, the surveyor and the new Director of Nursing (DON) reviewed the record for the resident. At that time the new DON stated that section 2 was answered by the DSS inaccurately and that the resident should have been a positive screen for MI as opposed to negative screen. At that time, the DON could not determine if the resident should have been referred to the appropriate state-designated authority for level II PASARR evaluation and determination. At that time, the new DON could not explain if the facility had a process or procedure for the DSS to follow. The DON stated she would get back to the surveyor after investigating the concern. On 12/14/23 at 9:54 AM, in the presence of the survey team, the Infection Preventionist Nurse (IPN), the Regional IPN (RIPN), the License Nursing Home Administrator, the Maintenance Department Director, the Regional Director of Environmental Services, and the Assistant Director of Nursing (ADON), and the DON stated she sat down with the DSS and went over the PASARR for the resident. The DON stated that the DSS acknowledged that the PASARR for Resident #18 was inaccurate. The DON stated the DSS did not have a process that she followed and the DSS was unable to state why. At that time, the DON stated that they had created a process yesterday for the DSS to follow. The DON further stated that I sat with the DSS and we updated Resident #18's PASARR and she referred the resident to the appropriate state-designated authority for level II PASARR evaluation and determination. We initiated a Quality Assurance Performance for Improvement (QAPI) with the objective to follow the correct process and create an accurate PASARR. A review of the facility's Coordination with PASARR Program, dated on 9/20/23 revealed under Policy Explanation and Compliance Guideline 1 All applicants to this facility will be screened for serious mental disorder or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review. NJAC 8:39-11.2(i), 27.1(a)

Based on observation, interview, and review of medical records and facility documents, it was determined that the facility failed to update the resident's plan of care with new interventions. This deficient practice was identified for one (1) of 20 residents (Resident #17) reviewed for behaviors and assistance of daily living (ADL) and was evidenced by the following: On 12/06/23 at 9:07 AM, the surveyor observed Resident #17 in bed getting ready to be washed and bathed by his/her assigned hospice aid. The surveyor reviewed the medical records of Resident #17. Resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral vascular accident (CVA) (a brain attack, is an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body, hemiplegia indicates partial or total paralysis instead), peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care with assessment reference date (ARD) 6/02/23 showed that the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which reflected that the resident's cognitive status was intact. A review of the reportable event record report provided by the Licensed Nursing Home Administrator (LNHA) on 12/02/23 revealed an event dated 7/07/23. The investigation report revealed that the resident was found to have drainage on his/her pillowcase. Upon further inspection by the nurse, the resident was found to have a laceration above his/her right ear with an infestation of maggots (fly larvae) that occupied the wound. The resident had complaints of right-sided head pain. The resident was taken by medical transport to an acute care hospital and was admitted from 7/07/23-7/11/23. The facility's internal investigation concluded that the ADL care plan was updated with a new intervention involve the family in plan of care, reach out to [family member] via phone call 7/18/23 by the Director of Nursing (DON). The investigation also included that the resident had combativeness and refusal of care. A review of the resident's person-centered care plan (CP) revealed that a focus on Behavior was initiated on 02/10/2014 for abusive to staff. The revision dates were 7/09/2015, 12/15/2016, and 11/28/23. No new interventions were added. The last dated revision was on 02/07/2019 for interventions, which was refer to rehab department for proper use of dumbbells. There was not a new intervention for combativeness and refusal of care as stated in the Reportable Event Record/ Report investigation from the facility dated 7/11/2023. Further review of the above personalized CP showed that the original CP already had an intervention involve the family in plan of care as an intervention written on 2/10/2014. The Reportable Event Record/ Report investigation dated 7/11/2023 did not include statements by nursing on why the original plan of care intervention to involve the family in the plan of care was not being followed. Furthermore, the resident's person-centered CP revealed that a focus of ADL: Self-care deficit was initiated on 01/08/2016. Goal revealed Resident will have self-care needs met by staff x 90 days. The revision dates were 6/22/2022, 6/12/2023, 6/14/23 and 8/02/23. No new interventions were added to alter the outcome until 11/23/23. A review of the resident's person-centered CP revealed that a focus on Hospice was initiated on 7/13/2023. On 12/07/23 at 10:24 AM, during an interview with the contracted hospice nursing aid, she stated that she has a good rapport with the resident, and the resident allows her to bathe and wash the resident's hair. She further stated that the resident was not aggressive or combative with her. She indicated that the resident did have a scab on their right temporal, but it was healing nicely. On 12/07/23 at 11:41 AM, the surveyor interviewed the facility's Certified Nursing Assistant (CNA). The CNA stated, The resident is okay, he/she has never been disruptive and has never tried to hit me. The resident does refuse care at times. The CNA further stated You just have to walk away and leave him/her alone, tell the nurse on duty, and document it on the resident's ADL sheet that the resident refused care. On 12/14/23 at 12:52 PM, the surveyor interviewed the Regional Infection Preventionist Nurse (RIPN, who was the previous Director Of Nursing at the facility). The surveyor asked the RIPN what was the purpose of updating the CP. The RIPN stated, It is to reflect the up-to-date plan of care for a patient, for recurring or new interventions that were identified and possible interventions that were exhausted and not working. The Interdisciplinary Department Team is to ensure all the care needed by the resident is captured and at that point, it should be reflected in the care plan. During that time interventions should be reviewed on the care plan and altered and updated to reflect any identified concerns and new interventions should be put in place. A review of the Comprehensive Care Plan policy dated, 01/2012, 11/2017, 11/2019, 9/2021, 9/2022, and 9/2023 revealed Person Centered Care Plan definition means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. It is further revealed under the section Policy Explanation and Compliance Guidelines . #1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents' personal and cultural preferences in developing goals of care. Services provided or arranged by the facility as outlined in the comprehensive care plan, shall be culturally and trauma-informed. #5. The comprehensive CP (CCP) will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. #6. The CCP will include measurable objectives and timeframes to meet the residents' needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed. #7. The physician, other practitioner, or professional will inform the resident and /or resident representative of the risks and benefits of proposed care of treatment and treatment alternatives /options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident and or resident representative. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility Infection Preventionist Nurse, Assistant Director Of Nursing, and new Director Of Nursing for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-11.2 (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure residents were appropriately supervised and monitored to ensure safety specifically by failing to ensure a) a resident was properly and accurately assessed for risk of elopement, b) a wander guard (a bracelet or anklet that triggers alarms and can have the capability to lock monitored doors to prevent a resident from leaving a facility unattended) was in place according to risk for elopement, c) a care plan for wandering was created, and d) the Minimum Data Set (MDS; an assessment tool used to facilitate the management of care) was accurately coded for one (1) of two (2) residents reviewed for elopement (Resident #26). This deficient practice was evidenced by the following: On 12/01/23 at 11:40 AM, the surveyor observed Resident #26 ambulating the halls of the facility holding a bag in his/her hand. The resident went through the double doors at the end of the South unit and toward the front entrance of the building. A staff member asked Resident #26 if the resident needed help. The resident went with the staff member through the other set of double doors that led to the North unit. On 12/01/23 at 12:20 PM, the surveyor observed Resident #26 with a different staff member walking the hall of the North unit. The surveyor reviewed the medical records of Resident #26. Resident #26's admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident #26's Quarterly MDS (QMDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which reflected that the resident's cognition was severely impaired. Section E Behavior indicated that the resident wandered daily. Section P Restraints and Alarms indicated that a wander/elopement alarm was not being used. A review of Resident #26's December 2023 Medication Administration Record and Treatment Administration Record did not include an order related to a wander guard. Resident #26's Progress Notes included the following notes: Effective date: 9/22/2023 07:33 [Resident #26] is alert, with confusion, he/she wanders around the facility, no history of exit seeking, staff continue to monitor whereabouts, wander guard discontinued. Effective date: 11/03/2023 12:41 [Resident #26] noted to wanders around the hallway, no exit seeking noted for the past quarter, wanderguard discontinued, loves to collect things like utensils, empty containers, straws, spoons, have a [bag] he/she carries around with whatever he/she collects, staff continues to monitor for safety. A review of Resident #26's Discontinued Orders included an order created on 3/14/23 to check wander guard function every night shift for protocol which indicated the resident had a wander guard applied. Further review indicated the order was discontinued on 9/26/23. A review of Resident #26's quarterly Elopement Evaluation dated 9/18/23, the evaluation performed prior to the removal of the wander guard device, indicated a score of 0.0 that the resident was not at risk. However, the section for BIMS score was blank and the section for CAM score (Confusion Assessment Method, which identifies delirium) was left blank. Each of those sections if filled out properly could affect the score. Further review indicated that under Clinical Suggestions the following were checked: Apply identification bracelet; Apply personal safety alarm device(s); and Monitor location frequently. The evaluation/assessment was not correctly completed. The evaluation/assessment indicated that the resident should have an alarm device applied based on the answers to the questions listed in the evaluation. There was no elopement evaluation/assessment after 9/18/23 to indicate a safety alarm device was not needed and that the resident's wander guard should have been removed. Review of Resident #26's previous quarterly Elopement Evaluation dated 6/14/23, indicated a score of 0.0 and the sections for BIMS score and CAM score were left blank. The evaluation/assessment was not correctly completed. Review of Resident #26's admission Elopement Evaluation indicated a score of 2.0 which meant the resident was at risk for elopement. Further review indicated that under Clinical Suggestions the following were checked: Apply identification bracelet; Apply personal safety alarm device(s); Monitor location frequently; Document specific behaviors on the behavior log; and Notify staff of elopement risk. A review of Resident #26's active individualized care plan (CP) did not reflect a focused area that the resident wandered or was at risk for elopement. There was a focused area that the resident was unaware of safety needs. Dx. (diagnosis) Dementia. Further review indicated there was a resolved focused area that Resident #26 was an elopement risk r/t (related to) wandering and impaired safety awareness that was initiated on 3/14/2023 and was resolved/discontinued on 11/03/23. The resolved/discontinued interventions included the following: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.; Monitor location every frequently. Document wandering behavior and attempted diversional interventions.; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.; WANDER ALERT: Apply Wander guard alert band on the (L) ankle, Check for placement every shift and check for function every night. A review of Resident #26's QMDS dated [DATE], indicated that the Resident had a BIMS score of 6 out of 15, which indicated that the resident's cognition was severely impaired. Section P Restraints and Alarms indicated that a wander/elopement alarm was not used. The MDS was coded incorrectly. The resident had a wander guard at the time of this MDS. On 12/04/23 at 11:03 AM, the surveyor, via phone, interviewed Resident #26's representative who stated that Resident #26 was being taken care of at the facility. The resident's representative (RR) stated that Resident #26 was previously at another facility in a dementia unit and that the resident was transferred here. The RR stated that Resident #26 had dementia but that the resident was able to roam free at this facility and that the staff keep an eye on the resident. The surveyor asked the RR if Resident #26 seeked the exit. The RR stated that in the beginning Resident #26 wanted to go back to his/her house and that by walking he/she thinks that he/she was trying to get there. The RR added that when they visit, Resident #26 wanted to go outside for a walk and that they knew that the resident may not want to go back in [the facility]. On 12/05/23 at 10:58 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding the process for residents that wandered. The CNA stated that if a resident wandered, she would check on them to see where they were. She added that sometimes they may wander around the building to the north unit and that she would redirect them back to the south unit. She then stated that she thought that residents that wandered had a wander guard. The surveyor then asked the CNA about Resident #26. The CNA stated that the resident sometimes went around the building and that when she would look for the resident she would go to the south unit to find the resident. On 12/05/23 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding residents that wandered or were at risk for elopement. The LPN stated that if a resident ambulated then an ankle bracelet would be applied and it would alarm at the exits. She added that an assessment was done by the Unit Manager (UM) and the resident was monitored closely, kept in activities and they knew where they were all the time. The surveyor asked about Resident #26. The LPN stated that when Resident #26 was admitted that the resident had a wander guard alarm and that it was discontinued because the resident was not an exit seeker. The LPN added that the resident just walked around the building and that the resident did not say that he/she wanted to go home. The surveyor asked if the resident should have a CP for wandering and who was responsible for the CP. The LPN stated that she was not sure and that the UM would do the CP. On 12/05/23 at 11:09 AM, the surveyor interviewed the UM of South unit regarding the process for CP. The UM stated that she and the nurses did the CP and that anyone could update the CP. The surveyor asked if a resident wandered or was at risk for elopement if they would have a CP. The UM stated that there would be a CP for elopement and for wandering. The UM stated that they would evaluate if the resident would need a wander guard if exit seeking. On 12/05/23 at 11:14 AM, the surveyor interviewed the Receptionist regarding the process for residents who wandered or were at risk for elopement. The receptionist stated that when a resident that had a wander guard on would come near the exit door then the alarm would sound and the door would lock. The surveyor asked what would happen if a resident did not have a wander guard on. The receptionist stated that from 8 AM to 8 PM there was someone at the desk and that they would see the resident and redirect them away from the exit door On that same date and time, the surveyor observed that behind the desk were five (5) resident's pictures under a sign which read Patients with Wander guard. Resident #26's picture was listed under the Patients with Wander guard sign. There were three resident's pictures under a sign which read Wander but don't have Wander guard. The Receptionist stated that she had to move Resident #26's picture down to the section that had the Wander but don't have Wander guard sign. The surveyor asked why she had to move Resident #26's picture. The Receptionist stated that the staff just tell me what to do and that Resident #26 did not have the wander guard anymore. She added that she still watched for Resident #26. On 12/05/23 at 11:37 AM, the surveyor interviewed the UM of South unit regarding Resident #26 and the reason the wander guard was removed. The UM stated that Resident #26 wandered but that the resident did not exit seek and that the resident did not exit seek for the last quarter (3 months) so they discontinued the wander guard and the at risk for elopement CP. The surveyor asked if Resident #26 should have a CP for wandering. The UM stated that she did not see a CP for wandering. She added that she would consult with the interdisciplinary (IDCP) team to determine if the resident needed a CP for wandering and that if the resident needed that CP, she would put it. On 12/05/23 at 01:11 PM, the surveyor interviewed the UM of the South unit regarding the process for the elopement evaluation/assessment. The UM stated that Resident #26 was due for the quarterly elopement evaluation/assessment this month on 12/22/23 and that the resident would be reassessed then. The surveyor asked who performed the elopement evaluation/assessment. The UM stated that she and the nurses did them. At that same time, the surveyor asked how elopement evaluation/assessment was done. The UM stated that she would review with the nurses, interview staff and check the progress notes to see if there were any issues. The surveyor reviewed Resident #26's three elopement evaluation/assessments that were done with the UM and asked about the BIMS and CAM sections that were blank. The UM stated that the Social Worker (SW) did the BIMS score in a separate assessment. The surveyor asked if the BIMS score should be filled in on the elopement evaluation/assessment or should it be left blank. The UM stated that if the BIMS score was already done by the SW then it would be available to view in the computer system and that it could be put in the elopement evaluation/assessment. She added that if the BIMS score assessment was not done prior then she could not put it in the elopement evaluation/assessment. Furthermore, the surveyor asked the UM how the clinical suggestions were populated on the elopement evaluation/assessment. The UM stated that clinical interventions (suggestions) were populated from the questions that were answered. The surveyor then asked about the 9/18/23 elopement evaluation/assessment that had the clinical suggestion of apply personal safety alarm device. The UM stated that the wander guard was discontinued on 11/03/23. The surveyor asked the UM if there was another elopement evaluation/assessment done before the wander guard was discontinued and if a wanderguard should be discontinued if the elopement evaluation/assessment had the clinical suggestion of apply personal safety alarm device. The UM stated that the discontinuation of the wander guard would be supported by the progress note on 11/03/23 that said will continue to monitor for safety. The UM added that she was going to do the quarterly elopement evaluation/assessment in December and that they would decide then if the wander guard was needed or not. The surveyor then asked if the BIMS score was put in the elopement evaluation/assessment, would the BIMS score affect the at risk score. The UM stated that a low BIMS score would make the resident at risk because that meant the resident was confused. The surveyor asked what Resident #26's BIMS score was. The UM stated the latest score was 3 (cognition severely impaired). On 12/05/23 at 01:37 PM, in the presence of the Regional Infection Preventionist Nurse (RIPN), the surveyor interviewed the Acting Director of Nursing (acDON), who was the current acting DON, regarding the process for a resident that wandered. The acDON stated that an elopement assessment would be done and that a wander guard would be applied if fitting. The surveyor asked if the resident would have a CP. The acDON stated that if they wandered then they would have a CP and that if a wander guard was applied that would also be on the CP. At that same time, the surveyor asked how it was determined if a resident needed a wander guard. The acDON stated that if a resident wandered and was at risk for elopement then a wander guard would be applied. The RIPN stated that the evaluation was done on admission and quarterly. The surveyor asked if the BIMS and CAM should be filled out on the elopement assessment. The RIPN stated that ideally they would be put in if they were available. She added that they were a separate assessment. The surveyor asked if the BIMS score would affect the risk of elopement score. The RIPN stated that the BIMS score did affect the at risk for elopement score. The surveyor asked how the clinical suggestions were determined on the assessment. The RIPN stated that the clinical suggestions were triggered by the answers to the questions. The surveyor asked that if the elopement assessment had apply personal safety device (i.e. wander guard) then should the expectation be that a resident would have the safety device on. The RIP stated that it was a yes and no. She added that if the resident were exit seeking they would have the device but that if the resident was not exit seeking then they would not have a the device. The surveyor asked that if a resident wandered should they have a CP. The acDON and RIPN both stated definitely. On 12/06/23 at 11:15 AM, the surveyor interviewed the MDS Coordinator (MDSC) regarding the process for MDS. The MDSC stated that before the MDS is done, the admission nurse would do their own evaluation and assessments. She added that she would gather information from the different assessments and do the admission MDS. The MDSC stated that the same process for getting the information for the quarterly MDS was from nursing assessments and whatever documentation that was needed for look back period. The surveyor asked about the section for behavior and wandering. The MDSC stated that the SW did that section. The surveyor asked about the section for alarms. The MDSC stated that she got the information from the MAR/TAR. On 12/06/23 at 11:21 AM, the surveyor interviewed the Director of Social Services (DoSS) regarding the process for MDS. The DoSS stated that for the BIMS assessment she would interview the resident and ask questions like what year it was. She added that the resident could not answer then she would interview the family or get information from staff observation. The DoSS stated that for the behavior and wandering section she would assess the resident and observe if the resident wandered or exit seek. She added that she would also ask the family. The surveyor then asked about Resident #26. The DoSS stated that Resident #26 on admission when first arrived the resident was not wandering. The surveyor then asked about the June MDS and if it was coded correctly. The DoSS stated that she would have to get back with the answer. On 12/06/23 at 11:28 AM, the MDSC confirmed that Resident #26's MDS's were coded incorrectly in regards to the alarm section and that it was an oversight and that it was not accurately captured from the MAR/TAR. She confirmed that she modified the MDS's. On 12/06/23 at 11:33 AM, the DoSS confirmed that Resident #26's MDS's were coded incorrectly for the wandering section and were modified. On 12/07/23 11:09 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Regional Procurement (RP), Regional Clinical Operations (RCO), RIPN and Regional Food Services Director the concerns that Resident #26 was not properly and accurately assessed for the risk of elopement, the residents wander guard was removed without an accurate assessment, the resident did not have a CP for wandering and the MDS was not coded accurately. On 12/11/23 at 9:52 AM, in the presence of the survey team, the LNHA, Regional Director of Environmental Services, the RIPN stated that after the surveyor inquiry, the IDCP team reassessed Resident #26 for elopement risk and that Resident #26 scored 3 on the assessment (which meant the resident was at risk for elopement). She added that the IDCP team discussed with the resident's family the reassessment, the resident's history and for the resident's safety the wander guard was reapplied. At that same time, the RIPN stated that the MDS was reviewed and it was not coded correctly and that they modified the MDS on 12/06/23. The RIPN stated that Resident #26 was not assessed properly prior to removal of the wander guard. The surveyor asked if the BIMS and CAM sections of the assessment should have been filled out. The RIPN stated that assessments done prior to October 2023, should have been filled out. The surveyor asked if the wander guard should have been removed based on the assessment done before the removal. The RIPN stated that the wander guard should not have been removed. The surveyor asked if there should have been a CP for wandering. The RIPN stated that the resident should have had a wandering CP. A review of the facility provided policy titled, Elopements and Wandering Residents with a reviewed date of 9/2023, included the following: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. 2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks., implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers or designee will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the 24-hour staffing report that was posted was up to date and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/01/23 at 8:50 AM, the survey team entered the facility and observed the Nursing Home Resident Care Staffing Report (NHRCSR) was on a bulletin board outside the Licensed Nursing Home Administrator's (LNHA) office which was on the North unit side of the building. The location of the bulletin board was not visible to residents or their visitors that resided on the South unit since those residents and/or their visitors would not walk in that direction. The NHRCSR was dated 11/30/23. The NHRCSR for that day was not posted. On 12/01/23 at 01:46 PM, the surveyor observed that the NHRCSR that was posted was dated 11/30/23. The posting was the same posting that was observed that morning. On 12/04/23 at 8:50 AM, the surveyor observed the NHRCSR posted was dated 11/30/23. The NHRCSR had not been posted daily on Friday, Saturday or Sunday. The place that the NHRCSR was posted was not visible to any residents or their visitors that resided on the South unit since the bulletin board would not be passed on the way to the South unit. On 12/05/23 at 11:24 AM, the surveyor interviewed the Staffing Coordinator (SC) regarding the process for posting the NHRCSR. The SC stated that she posted the NHRCSR every day during the weekdays. She stated that she would post it on Friday and if there were any changes over the weekend that she would change it in the system on Monday. On that same date and time, the surveyor asked the SC if anyone posted the NHRCSR on the weekend days. The SC stated that nobody posted it on the weekend. The surveyor asked the SC what time of the day the NHRCSR was posted. The SC stated that tried to post it by 10 AM. At that same time, the surveyor asked the SC if she was working on 12/01/23 since the NHRCSR that was observed on 12/01/23 was dated 11/30/23. The SC stated that maybe she posted it late because she had callouts and was trying get people to come in. The surveyor then notified the SC that when the surveyors entered the facility on Monday 12/04/23 the posting that was observed was dated 11/30/23. The SC stated that she was not sure why. On 12/07/23 11:10 AM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Regional Procurement (RP), Regional Clinical Operations (RCO), RIPN and Regional Food Services Director the concerns that the staff posting was not in a prominent place and not up to date on a daily basis. The surveyor requested a facility policy on posting the staffing report. On 12/11/23 at 9:35 AM, in the presence of the survey team, LNHA, and Regional Director of Environmental Services, the RIPN stated that they investigated and put interventions because the posting was only on one side. She added the SC forgot to post the NHRCSR on 12/01/23, 12/02/23, 12/03/23 and 12/04/23. On 12/11/23 at 10:28 AM, the RIPN stated that the facility did not have a policy regarding posting the NHRCSR and that they followed the state regulation for posting and visible to residents and staff. N.J.A.C. 8:39-41.2 (a)(b)(c)

Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) the staff handled, stored, and processed linens and other supplies in a clean manner and to prevent possible contamination according to facility's policy and Centers for Disease Control and Prevention (CDC) guidelines, b) routine, ongoing, and systematic monitoring and tracking of facility's water management, and c) policy was reviewed and updated to reflect and address the need of the facility according to clinical standard of practice and CDC guidelines. This deficient practice was evidenced by the following: According to the CDC, Appendix D - Linen and laundry management, last reviewed May 4, 2023, Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Each floor/ward should have a designated room for sorting and storing clean linens. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least once daily) cleaned with a neutral detergent and warm water solution. According to the CDC, What Owners and Managers of Buildings and Healthcare Facilities Need to Know about Legionella Water Management Programs, Page last reviewed: April 30, 2018, included, How to Develop a Legionella Water Management Program Developing and maintaining a water management program is a multi-step process that requires continuous review. Below are steps to building an effective Legionella water management program: -Establish a water management program team -Identify areas where Legionella could grow and spread Identify where potentially hazardous conditions could occur in your building water systems, such as areas where water temperature could promote Legionella growth or where water flow might be low. -Decide where you need to apply control measures and how to monitor them -Make sure the program is running as designed and is effective Establish procedures, both initially and on an ongoing basis, to verify that your team is implementing the water management program as designed. -Document and communicate all activities on a continual basis. 1. On 12/12/23 at 11:36 AM, the surveyor toured the laundry area in the presence of the Director of Housekeeping (DH). The DH informed the surveyor that there was no in-house laundry at the facility since he started working less than a year ago and that they have an outsourced, third party that provides personal clothing and other laundry needs of the facility. The DH stated that the third-party laundry services' pick-up and return schedules were every Tuesday, Thursday, and Saturday. On that same date and time, the surveyor observed in the basement hallway area a three-tier rack of clean linen and fitted sheets that were not covered and not stored in a plastic bag. On top of the rack, approximately eight inches away from the ceiling were linens and fitted sheets, not stored in a plastic bag. Inside the three-tier rack, at the bottom part, there were linens and bed sheets not stored in a plastic bag. The DH stated that the linens, fitted sheets, and be sheets were considered clean and should have been covered, stored in a plastic bag, and not exposed. Upon entry to the Laundry room, there was a folding table for clean linens that were mixed with personal items that included a container of Aquaphor (a brand of over-the-counter (OTC) skincare ointments), a container of petroleum jelly (that helps skin and can ease inflammation and keep skin moist) and a container of ABHR (alcohol base hand rubbed). The DH stated that they (Aquaphor and petroleum jelly) were personal items of the person in charge of the laundry area and the table was considered clean and should not have personal items on top of the table that were being used for sorting out linens that were delivered. He further stated that the facility sorted out linens that were delivered because some of them had holes and were not appropriate sizes that the residents at the facility could use and that they were returned to the third-party vendor. At that time, there was a bin of sorted linens next to the folding table that was full and uncovered. In the same room (Laundry room), there was a three-tier rack of linens, towels, pillowcases, and fitted sheets that were not covered. Just above the three-tier rack of linens was an electric fan that was covered with grayish substances. The fitted sheets were not stored in a plastic bag. The DH stated that the electric fan should have been cleaned and the cover for the clean linens, towels, pillowcases, and fitted sheets should have been dropped down to cover from dust and maintain cleanliness. The DH stated that the grayish substances were accumulation and build-up of dust. He acknowledged that the housekeeper was responsible for making sure the room was clean. He further stated that the linens, towels, pillowcases, and fitted sheets were considered clean. On 12/13/23 at 10:21 AM, the survey team met with the new Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Infection Preventionist Nurse (RIPN), facility Infection Preventionist Nurse (IPN), and the Licensed Nursing Home Administrator (LNHA). The surveyor notified the facility management of the above findings with the laundry. On 12/14/23 at 9:54 AM, the survey team met with the LNHA, Regional Director of Environmental Services (RDEVS), MD, RIPN, new DON, and the facility IPN. The RDEVS stated that contamination was possible due to the accumulation of dust in the fan that could go to the clean linens inside the laundry room where the three-tier rack for clean linens was left open, some of the linens was not properly stored inside the bag as well as the one in the basement hallway where the linen cart that was left opened and unattended. 2. On 12/13/23 at 01:35 PM, the surveyor interviewed the Director of Maintenance (DM) in the presence of the survey team. The DM informed the surveyor that he had been working at the facility since August 2023. The surveyor asked the DM what was the facility process with regard to water management and Legionella (serious type of pneumonia caused by Legionella bacteria that people can get when they breathe in or swallow water contaminated with Legionella). The surveyor also asked the DM who was the designated person in charge of the facility's water management which included the surveillance for Legionella. The DM stated that he thought he was in charge of water management. The surveyor then asked the DM what was the facility's process, and the DM responded that he needed to get the facility's policy first before responding to the surveyor's inquiries, and the DM left. On 12/13/23 at 01:50 PM, the DM came back and informed the surveyor in the presence of another surveyor that he confirmed with the RIPN first before meeting the surveyor again that we do not test unless there was a confirmed case of Legionella. The surveyor asked the DM how he knew if there were confirmed cases of Legionella, and where to get that information. The DM then pulled the Legionella Surveillance Policy [reviewed 5/2023] and read #5 in the policy Primary prevention strategies: a. Diagnostic testing i. The facility shall use the McGeer criteria (are designed for Surveillance and are used for retrospectively counting true infections) when diagnosing pneumonia. The surveyor also asked where else the information on Legionella be available. The DM was not able to identify local health where the risk of Legionella and other opportunistic pathogens in the facility's water systems can be affected by the local water system. On that same date and time, the DM stated that the water temperature (temp) should be maintained above 140 degrees and circulated by visually checking the water temp gauge. The surveyor asked the DM if there was a log or accountability for monitoring the water temp, and the DM stated that he did not have a log and that there was no regular set scheduled for checking it. The surveyor asked about where in the facility water system he could check and monitor the temp, and DM said he did not know. The surveyor then asked if he did not know what to check and routinely monitor the water temp of the facility, how he knew that the facility complied with the facility's policy and procedure, and regulations with regard to water management, and the DM did not respond. Later on, the DM stated in the presence of another surveyor that he would go to the RIPN to get the information and education needed in order to comply with the requirement of water management and Legionella surveillance policy. The surveyor also asked the DM about the facility's policy #5 C. Physical Controls iii. nonpotable water systems shall be routinely cleaned and disinfected. The DM stated that the policy for non-potable water systems was not being followed because the facility had no non-potable water system. The surveyor then asked if the facility had no potable water system and why it was in the facility's policy. The DM stated that probably the policy was intended for the entire [company name of the facility] and not intended for the facility. The surveyor then asked should the policy be reflective of the facility's needs and specifications. The DM stated that he would get the information from the RIPN and update the policy. On 12/13/23 at 02:05 PM, the surveyor in the presence of another surveyor notified the LNHA, new DON, and the RIPN of the above findings and concerns with regard to water management and Legionella. The LNHA stated that DM was in charge of water management including Legionella. On 12/14/23 at 9:54 AM, the survey team met with the LNHA, RDEVS, MD, RIPN, new DON, and the facility IPN. The RDEVS stated that there was no log for cold temp as part of water management. The RDEVS further stated that the facility failed to keep a log, however visuals were done. The LNHA and RIPN acknowledged that there was a break in the system for water management, and accountability should have been done. The surveyor asked again about the non-potable water as part of the facility's policy, and the RIPN and RDEVS both stated that they would review again the policy. The RDEVS further stated that we failed to include what specific procedure to be done about Legionella and that the facility failed to include it in the water management plan. On 12/14/23 at 12:53 PM, the surveyor notified the RIPN in the presence of the survey team about the review of the provided documents of the LNHA for the timesheets of the maintenance staff and the dead leg (will have more stagnant water having more microbial growth because the water in the dead leg does not circulate) and less frequent area weekly flush records, daily air and water temps and aerator logs that showed that the following: A. Deadleg and Less Frequently Area weekly flush log: -was signed by Maintenance Staff (MS) on 8/23/23. The time sheet showed that the MS did not work on 8/23/23. -there was no weekly sheet for 10/25/23 B. Daily Air and Water Temps log: -March 2023-December 2023 =water temp (hot temp) [there was no log for cold temp] A review of the facility's Infection Prevention and Control Program Policy with a reviewed date of 5/19/23 that was provided by the RIPN included the Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program. A review of the facility's Legionella Surveillance Policy with a reviewed date of 5/2023 that was provided by the DM included primary prevention strategies: c. Physical controls: i. Cooling towers and potable water systems shall be routinely maintained iii. Non-potable water systems shall be routinely cleaned and disinfected . d. Temperature controls: i. Cold water shall be stored in distributed below 68 degrees Fahrenheit. ii. Hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit. A review of the undated Storing Clean Linen Policy that was provided by the RIPN included that all linen being brought to the floors must be bagged, never stack piles too high on shelves-it may be a hazard when moving, keep storage areas clean, neat, and sanitary at all times, and clean linen bins must be covered at all times and in a clean area upon delivery. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility IPN, ADON, and new DON for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-19.4 (a), 21.1(d)

Based on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the implementation of a comprehensive antibiotic stewardship program (ASP) in accordance with the facility's policy and procedure and the Centers for Disease Control and Prevention (CDC) guidance. This deficient practice was identified for one (1) of one (1) month antibiotic (ABT) log reviewed. This deficient practice was evidenced by the following: According to CDC, Core Elements of Antibiotic Stewardship for Nursing Homes, Page last reviewed: August 20, 2021, included, . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority.Antibiotic stewardship refers to a set of commitments and actions designed to 'optimize the treatment of infections while reducing the adverse events associated with antibiotic use'. CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use.Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors. Below are examples of antibiotic use and outcome measures.Process measures: Tracking how and why antibiotics are prescribed.Antibiotic use measures.Tracking how often and how many antibiotics are prescribed.Antibiotic outcome measures.Tracking the adverse outcomes . The surveyor reviewed the hybrid medical records (a combination of paper-based and electronic records that primarily involve tracking and storing a patient's health records in several formats and places) of Resident #22. A review of December 2023 current physician orders included an order dated 12/10/17 for a Cephalexin cap (capsule) 250 mg (milligram) to give 1 capsule orally one time a day for chronic UTI (Urinary Tract Infection) prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). A review of the ABT Log for November 2023 revealed Resident #22 was not included in the list of residents who received ABT for UTI and there was no tracking that the criteria was met for UTI ABT use. A review of the Physician Progress Notes (PPN) showed that on 11/06/23 Medicine Annual History and Physical of Physician #1 included in the documentation for a follow-up Uro (Urology) consult and follow-up use of Cephalexin. In addition, the 12/06/23 PPN also included the documentation of Physician #1 to follow up on Uro and Cephalexin. Further review of the hybrid medical records of Resident #22 revealed that there was no Uro Consult that was done and no documentation to justify the continued use of ABT Cephalexin. On 12/11/23 at 01:03 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for a copy of the most recent Urologist Consult of Resident # 22 and he stated that he will get back to the surveyor. On 12/12/23 at 9:27 AM, the surveyor reviewed the provided Uro Consult office visit reports that were provided by the Registered Nurse/Unit Manager (RN/UM) and revealed that the most recent Uro Consult visit notes from the Urologist was on 11/14/2019. On 12/12/23 at 9:37 AM, the surveyor called the primary physician's (Physician #2) office and the surveyor was informed by the receptionist that it was Physician #1 who was responsible for Physician #2's residents in the facility and that she would notify Physician #1 to call the surveyor for an interview regarding Resident #22. On 12/12/23 at 10:07 AM, Physician #1 informed the surveyor that she was responsible for the residents of Physician #2 at the facility including Resident #22. Physician #1 stated that she had been working with Physician #2 and had been going to the facility for about six to seven years now. During an interview of the surveyor with Physician #1 concerning Resident #22's ABT Cephalexin, Physician #1 stated that she did include in her PPN that the resident needed a Uro Consult with regard to the use of Cephalexin. She further stated that she documented that she spoke to the assigned nurse at that time about the Uro Consult needed. On that same date and time, Physician #1 stated that she was not aware that the last Urologist consult was back on 11/14/2019 and that the resident did not return to the Urologist. The surveyor asked Physician #1 if she was aware that it was after the surveyor's inquiry that the facility had contacted the previous Urologist and the resident's Responsible Party (RP) regarding the follow-up Uro Consult, and Physician #1 responded that she was not aware and was not notified by the facility. On 12/12/23 at 11:06 AM, Physician #1 called back and stated that the resident should be followed up with the Urologist regarding the continued use of ABT Cephalexin, and that was why she documented it in her PPN. On 12/12/23 at 11:47 AM, the surveyor interviewed the RN/UM in the presence of another surveyor in the North unit nursing station. The RN/UM informed the surveyor that she knew Resident # 22 who was on ABT Cephalexin for a long period for UTI. The RN/UM stated that according to the resident's RP, the resident should be on an antibiotic for UTI for life to prevent UTI as per the Urologist. She further stated that the information of RP was a verbal communication from the Urologist and there was no documentation about it. At that same time, the RN/UM acknowledged that the last Uro consult was on 11/2019 and that per facility practice and standard of practice, she should have called the Urologist to verify the resident's RP information that the resident should be on antibiotic for life since there was no documentation from Urologist about what the RP had said. The RN/UM further stated that she did not recall that she had called the Urologist about it. Furthermore, the RN/UM stated that she was not aware that Physician #1 had documented in her PPN about follow-up Uro Consult regarding continued use of ABT Cephalexin. The surveyor asked the RN/UM why it is important that the resident with ABT should be monitored, have a stopped date, and have justification for its use. The RN/UM stated that it was important because of the possible resistance to the ABT according to antibiotic stewardship. The surveyor asked the RN/UM then why the physician's notes for Uro follow-up for continued use of ABT were not followed if she knew the importance of the ABT stewardship program and policy, and why the facility did not follow up with the RP about the Uro Consult not until surveyor's inquiry, the RN/UM had no answer. On 12/12/23 at 12:37 PM, the surveyor in the presence of the survey team interviewed the Regional Infection Preventionist Nurse (RIPN). The RIPN verified the ABT Log for November 2023 and acknowledged that Resident #22 was not included in the list of residents on ABT for UTI even though the resident was using Cephalexin for prophylaxis for UTI. On 12/12/23 at 12:40 PM, the surveyor interviewed the facility's Infection Preventionist Nurse (IPN). The IPN stated that she was in charge of the ABT stewardship program of the facility. She further stated that she generated reports for ABT from the nurses' notes about signs and symptoms, physician progress notes about the diagnosis for use of ABT, and laboratory results to follow criteria for the use of ABT which were considered justification for continued use of ABT according to the facility's policy and procedure. On that same date and time, the surveyor asked the IPN if residents who were in ABT for prophylaxis were included on the ABT log, and the IPN responded yes. The IPN acknowledged that Resident #22 was on ABT for UTI prophylaxis. The surveyor then asked the IPN why the resident was not included on the November 2023 ABT Log and that the resident was not monitored and tracked, the IPN stated that it was overlooked. She further stated that the facility should have seen Physician #1's documentation about follow-up Uro Consult and Cephalexin use and that the facility should have followed up with the RP. On 12/14/23 at 9:54 AM, the survey team met with the LNHA, Regional Director for Environmental Services (RDEVS), Director of Maintenance (DM), RIPN, new Director of Nursing (DON), and facility IPN. The RIPN acknowledged that the Nurse practitioner (NP) had documented the resident's justification for continued use of ABT Keflex (also known as Cephalexin) after the surveyor's inquiry. At this time, the surveyor asked the facility management why was it important that all residents were reviewed for ABT stewardship. The RIPN stated that to ensure that the resident was not prescribed unnecessary medication, monitor possible side effects of chronic use of medications, and follow regulations for ABT stewardship. The RIPN also acknowledged that there was no tracking and monitoring as part of ABT stewardship for Resident #22 in the November 2023 ABT Log. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility IPN, Assistant Director Of Nursing, and the new DON for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-19.1(a), 19.4(d)

Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP), and physically worked onsite in the facility for one (1) of two (2) staff and b) must have time necessary and participate in required Quality Assessment and Assurance (QAA) committee for one (1) of three (3) QAPI quarters in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised 12/22/22) included ii. The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022 Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available. On 12/01/23 at 9:33 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and Infection Preventionist Nurse (IPN) during the Entrance Conference. The IPN informed the surveyor that she had been working at the facility for five years and assumed the position of an IPN in June or July 2023. On that same date and time, the facility management confirmed that the facility was not in a COVID outbreak and currently did not have an in-house COVID positive residents and staff. The surveyor reviewed the employee file of the IPN and showed the following: -Nursing Home Infection Preventionist Training Course (web-based) completed on 3/10/23 -The Infection Preventionist Job Description was signed on 6/01/23. Included major duties and responsibilities to participate in the facility's QAA committee (required to meet at least quarterly to identify issues and to develop and implement plans of action to correct identified deficiencies). A review of the last three-quarters QAPI (Quality Assurance and Performance Improvement (QAPI) is a data-driven and proactive approach to quality improvement where the QAA committee expected to attend) sign-in sheets showed that on the 3rd quarter, 10/25/23, the IPN did not attend the meeting. On 12/07/23 at 9:12 AM, the surveyor interviewed the Regional Infection Preventionist Nurse (RIPN) in the presence of the survey team regarding IP requirements. The surveyor asked who was the designated IP of the facility since the last recertification (02/06/23). The surveyor also asked for the timeline of the designated IP. The RIPN stated that she was the covering IP and the covering DON of the facility from February 2023 until the facility was able to hire a new DON and the IPN completed the training and examination for an IP position. The RIPN confirmed that the IPN assumed the position of IP on June 2023. She further stated that the designated IP from February 2023 through May 2023 was the RIPN and the IPN assumed the position of an IP from June 2023 through the present, and that there was no other designated IP except the RIPN and the IPN. At that same time, the surveyor asked the RIPN if she was aware of the regulation regarding IP hours and the requirement for an IP, and that the IP should be on-site, the RIPN stated yes. The surveyor then asked the RIPN if the facility complied with the IP requirements according to the facility's policy and regulations, and the RIPN stated no, and unfortunately, we tried to hire and no one fits the position, and that no applicants. She further stated that the IPN was required to attend the QAPI quarterly meetings. On 12/07/23 at 11:00 AM, the surveyors met with the LNHA, Regional Director of Procurement, Regional Clinical Operations, RIPN, and Regional Food Service Director. The surveyor notified the facility management of the above concerns regarding the designated IP role that the requirement was not met from February 2023 through May 2023 that the RIPN had confirmed. On 12/11/23 at 9:34 AM, the survey team met with the LNHA, Regional Director of Environmental Services (RDEVS), and RIPN. The RIPN stated that around February to March 2023, she asked the IPN to do the training for IP and the IPN completed it on 3/10/23. The RIPN further stated that the facility was trying to get a replacement because the IPN was still a full-time nurse in the subacute unit and wanted to have a replacement first before the IPN assumed the position on 6/01/23. In addition, the RIPN stated that the facility did not have a designated IP in-house at the facility from February 2023 through May 2023. On 12/14/23 at 9:54 AM, the survey team met with the LNHA, RDEVS, Maintenance Director, RIPN, new Director Of Nursing (DON), and IPN. The LNHA stated that he acknowledged the concern of the surveyor regarding the IPN did not attend the quarterly meeting on 10/225/23. A review of the facility's Infection Preventionist Policy with an original date of 9/2023 that was provided by the RIPN included the facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program to include the antibiotic stewardship program. The IP must be employed at least part-time and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP. The facility, based upon the facility assessment, will determine if the individual functioning as the IP should be dedicated solely to the IPCP. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA. The IP will physically work onsite in the facility. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, IPN, ADON, and the new DON for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in 11 out of 17 resident rooms and one (1) of one (1) shower room observed during environmental rounds. This deficient practice was evidenced by the following: On 12/05/23 at 10:39 AM, the surveyor observed the wound care treatment of Resident # 39 that was done by the Licensed Practical Nurse (LPN) and was assisted by the Registered Nurse/Unit Manager (RN/UM). The LPN performed handwashing inside the toilet room, the toilet room was adjoined (a toilet room that is accessed from and used exclusively by the occupants of two adjacent sleeping units) and the toilet tissue paper holder dispenser was broken. The two rooms with the adjoined toilet were for rooms [ROOM NUMBERS]. Resident #39 was in room [ROOM NUMBER]. After the wound treatment, the LPN went outside the resident's room to throw the garbage inside the soiled room which was in front of the resident's room. Inside the soiled room was a sink where the LPN performed handwashing. Separated by a wall was a shower room with a shower vent that had an accumulation of grayish substances. On 12/06/23 at 9:21 AM, the surveyor and the RN/UM went to 17 resident rooms for environmental rounds of the South unit and revealed the following concerns for 11 resident rooms: room [ROOM NUMBER]=toilet room had one of two toilet tissue dispensers broken. The RN/UM stated it should been fixed, not sure when it was broken and she will let housekeeping know about it. room [ROOM NUMBER]=black phone on top of the overhead light. Resident#6 stated that the black phone was broken. The resident was unable to remember when the broken phone was on top of the overhead light, and the resident claimed that it was been a while. room [ROOM NUMBER]=with an adjoined toilet room with room [ROOM NUMBER], the toilet seat had a commode chair (designed to act as a second toilet seat). Both the surveyor and the RN/UM observed the commode chair with brownish substances around the area. The RN/UM stated that the brownish substance was rust and not feces. room [ROOM NUMBER]=with an adjoined toilet room with room [ROOM NUMBER], the toilet room had two broken toilet tissue holders. Resident#12 in room [ROOM NUMBER]W's ceiling had scattered brownish substances that extended into the resident's closet upper door. Resident #12 stated that the broken tissue holder and the brownish substances in the ceiling had been there since the resident moved into the room. The RN/UM stated that Resident#12 was cognitively intact. During an interview with the RN/UM, the RN/UM stated that I don't know why the ceiling had brownish substances and was not sure what was that and indicated that it should have been cleaned. Shower Room (south unit)=the exhaust (or vent) in the shower area was observed with an accumulation of grayish substances in the presence of the RN/UM and the Porter. This was the second time that the surveyor observed the vent with accumulation of grayish substances. The [NAME] stated that he was responsible for cleaning the shower room daily including the vent which was noted with grayish substances which he claimed were dust. The [NAME] further stated that the look of it, it had been there a week. The surveyor asked the [NAME] if he was responsible for cleaning the shower room including the vent daily why there was an accumulation of dust for a week and the [NAME] had no answer. room [ROOM NUMBER]=with an adjoined toilet room with room [ROOM NUMBER], the tissue holder dispenser was broken. room [ROOM NUMBER]=the RN/UM informed the surveyor that the room had been empty (which means that no resident was occupying the room) for a week now. The toilet room had scattered papers and tissues and the garbage receptacle with tissues. The surveyor asked the RN/UM if the room had been empty for a week, and why the toilet room was not clean. The RN/UM stated, I don't know. room [ROOM NUMBER]=with an adjoined toilet room with room [ROOM NUMBER], the toilet tissue dispenser was broken, and the call light system (rectangular box) connected to the call bell string was not properly installed to the wall. The RN/UM stated that it should fixed to the wall and probably it was due to too much pulling of the string when it was being used. On 12/11/23 at 9:34 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Environmental Services (RDEVS), and Regional Infection Preventionist Nurse (RIPN). The RDEVS stated that there were broken toilet tissue dispensers and there was a non-functional toilet tissue dispenser due to the wrong size of toilet paper. The RDEVS further stated that the toilet commode found in one of the residents' adjoined toilet rooms that were rusty was immediately replaced. He also stated that in room [ROOM NUMBER], the call bell that was loose from the wall was fixed and now stable. In addition, the RDEVS informed the surveyor that the housekeeping checklist was revised to add the toilet dispenser as part of the responsibility and accountability for checking the environment. On that same date and time, the RDEVS acknowledged that the shower room in the South wing unit vent was cleaned after the surveyor's inquiry. The RDEVS and the facility management acknowledged the above findings and concerns of the surveyor. At that same time, the surveyor asked the facility management what happened and why the above findings happened if the facility had a checklist on what to do. The RDEVS stated that it was missed, and the housekeeper should have reported all broken equipment and supplies on a day-to-day basis. A review of Resident #12's medical records showed that the resident was moved to room [ROOM NUMBER]W on 01/27/21 and currently remained in the same room. room [ROOM NUMBER]W was the room with scattered brownish substances in the ceiling and closet door. A review of the undated facility's Resident Room Cleaning Policy that was provided by the LNHA included that the purpose was to provide a detailed description of the steps that are to be completed daily in the cleaning of a resident room. Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit and control the spread of infection and bacteria, and maintain the outward appearance of the facility. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility's IPN, acting Director of Nursing (also known as the Assistant Director of Nursing), and new Director of Nursing for an Exit Conference. The facility management did not provide additional information and did not refute findings. NJAC 8:39-31.2 (e), 31.4(a)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00164563 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a) evaluate and complete an assessment for a newly identified pressure ulcer/injury (PU) for one (1) of two (2) residents reviewed for pressure ulcer/injury (Resident #299) according to standards of clinical practice and facility's policy and procedure, b) accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of two (2) residents reviewed for PU (Resident #299), c) update the individualized care plan (CP) for one (1) of two (2) residents reviewed for PU (Resident #299), d) clarify multiple treatments for PU for one (1) of two (2) residents reviewed for PU (Resident #299), e) ensure all incident reports were in the computer system in order to track and trend, and f) maintain infection control practices to reduce the risk of infection during a PU treatment for one (1) of two (2) residents reviewed for PU (Resident #39). This deficient practice was evidenced by the following: 1) On 12/01/23 at 12:48 PM, the surveyor reviewed the closed medical record of Resident #299. Resident #299's admission Record (AR or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; acute cystitis with hematuria (an infection that only affects your bladder with blood in the urine), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and muscle weakness. A review of the Universal Transfer Form (UTF) dated 4/20/23 from the hospital to the facility indicated under skin condition that the resident had a wound and the site was stg (stage) 2 to penis. A review of Resident #299's readmission evaluation indicated that the resident had Moisture Associated Skin Damage (MASD) on the sacrum. There was no documentation to acknowledge that the UTF was reviewed or that the documented stg 2 penile wound that was documented on the UTF was not observed by the admission nurse. A review of Resident #299's Skin Evaluation dated 5/18/23 indicated the resident had the following new skin issues: deep tissue injury (DTI; purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right heel; DTI to the left heel and other skin issue to the penile opening. There were no measurements of the wounds. A review of the Resident #299's Skin Evaluation dated 5/22/23 indicated the resident had the DTI to both heels and that the other skin issue was traumatic wound to penis urethral meatus. This assessment included the measurements. Review of the CP included the focus area of at risk for skin integrity alteration r/t (related to) fragile skin and refusing care at times with an initiated date of 10/12/2021 included the following interventions: Apply house lotion to moisturize skin; apply protective skin barrier; Monitor s/s (signs and symptoms) of infection such as (redness, delayed healing, fever, pain, tenderness, warmth, excessive drainage or swelling), notify MD (medical doctor); skin evaluation weekly. There was no update to the CP to include a focus area of actual skin impairment for the two heel DTIs and penile wound or scrotal excoriation. A review of Resident #299's Discharge Return Anticipated MDS, dated [DATE], indicated the Brief Interview for Mental Status (BIMS) question was left blank. The Cognitive Skills for Daily Decision Making was coded 1-modified independence (some difficulty in new situations only). Further review of Section M-Skin Conditions indicated that Resident #299 did not have any PU. A review of Resident #299's Discharge Return Anticipated MDS, dated [DATE], indicated the resident had two (2) unstageable DTI and that one (1) of the two (2) was present upon admission/entry or reentry. The MDS was coded incorrectly. On 12/05/23 at 9:00 AM, the surveyor asked the Regional Director of Operations for any incidents and investigations that Resident #299 had since the last recertification survey. On 12/05/23 at 10:37 AM, the Regional Infection Preventionist Nurse (RIPN) provided the surveyor one incident report that was in the facility's risk management section of their computer system. Review of the incident provided was for a fall. An incident report for the three wounds and later scrotal excoriation was not provided. A review of Resident #299's Braden Scale for Predicting Pressure Ulcer Risk dated 4/21/2023 indicated on readmission the score was 15.0 which indicated the resident was at risk. On 12/11/23 at 10:30 AM, the surveyor asked the RIPN if Resident #299 had any other incidents or investigations. The RIPN stated that she believed that the incident provided for the fall was the only one but that she would double check. On 12/11/23 at 10:58 AM, the RIPN confirmed that there were no other incidents or investigation for Resident #299 for the year 2023. On 12/11/23 at 11:27 AM, the surveyor interviewed, via phone, the Registered Nurse (RN) who performed the readmission skin assessment. The surveyor asked the RN if the process was to review the information on the UTF. The RN stated that she looked at the UTF. The surveyor asked the RN if a skin assessment was done for residents that were readmitted . The RN stated that a head to toe assessment was done with a Certified Nursing Assistant which included the perineal area. She added that she would document what she saw. The surveyor asked the RN about the skin assessment that she performed on Resident #299. The RN stated that she did not remember. On 12/11/23 at 11:43 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1) regarding the admission assessment. LPN #1 stated that she could do the admission or readmission assessment and that a registered nurse would double check the assessment. She stated that she would perform a head to toe assessment of the skin and then after that the residents would have a weekly skin assessment done. On that same date and time, the surveyor asked LPN #1 if she reviewed the UTF. The LPN stated that she would review the UTF and that she would observe the resident for any wound. She then added that if there was a wound she would measure it and refer to the wound physician. The LPN further stated that she could not depend on what was written on the UTF because she had observed a wound in the past that was not listed on the UTF. At this time, the surveyor asked LPN #1 what the process was for a new wound. The LPN stated that if a wound developed, she would notify the UM, assess the wound with measurements, find the cause and see what could be done for the wound. The surveyor asked if an incident report would be done. The LPN stated that an incident report would be done since it was a change of condition. She added that the wound would be investigated and the previous shifts would be interviewed. The surveyor asked the LPN if she had taken care of Resident #299. The LPN stated that she was not sure. On 12/11/23 at 12:49 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) on South unit regarding the readmission process. The UM stated that the nurse would perform a readmission assessment that included a skin check. The surveyor asked if the nurse would review the UTF and verify what was written on the UTF. The UM stated that the nurse would look at the UTF. The surveyor asked the UM what the process was for a new wound or DTI. The UM stated that the wound or DTI would be referred to the wound physician who visited the facility every Monday. She then stated that an incident report and investigation would be done. The surveyor asked the UM if the CP would be updated. The UM stated that the CP would be updated as soon as the incident report was reviewed and that it should be updated within two to three days. She added that the nurse, herself and the wound nurse would update the CP. On 12/12/23 at 9:28 AM, the surveyor interviewed the RN/UM regarding Resident #299's wound and DTI's. The UM stated that Resident #299 developed the wound/DTIs during his/her stay at the facility. She stated that according to the electronic medical record, the resident went to the hospital with acute cystitis and hematuria on 4/18/23 and returned to the facility a few days later and had sacral MASD according to the readmission assessment. On that same date and time, the RN/UM stated that on 5/18/23 it was noted that the resident had bilateral heel discoloration that was a DTI and a penile opening that was caused from the catheter. The UM stated that on 5/22/23 the wound physician noted that it was a trauma wound to the penis. The surveyor asked if there was an incident report. The UM stated that there was an investigation that was done on paper and that it was in the nursing office. The surveyor asked the UM the reason why it was not in the risk management section of the facility's computer system like other incident reports. The UM stated that it should have been in the risk management section. At this time, the surveyor asked the RN/UM about the UTF that had listed a stg 2 wound to the penis. The UM stated that the nurse should verify the information listed. She added that she did not know what happened that day. The surveyor asked the UM about the MDS and if it was coded correctly. The UM stated that the MDS should have the two DTI and that none were present on readmission. On 12/12/23 at 9:53 AM, the surveyor asked the acting Director of Nursing (acDON) where incident reports were located. The acDON stated that the incident reports were in the computer system and that everything should be in the computer. On 12/12/23 at 10:18 AM, the RN/UM provided the surveyor a folder with an investigation for Resident #299's bilateral heel DTIs. There was no investigation for the penile wound or the scrotal excoriation. On 12/12/23 at 10:19 AM, in the presence of another surveyor, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and the RIPN the reason some of the incident reports were on paper and some were in the computer system. The RIPN stated that the PU ones were hybrid (on paper). The surveyor asked the RIPN how the facility would track and trend the PUs if they were not in the computer system. The RIPN stated that it was something that they needed to look into and improve. Furthermore, the surveyor asked the RIPN the reason the PU incident report was not provided to the surveyor when the surveyor asked multiple times and that it was only provided after the surveyor inquired about the resident. The RIPN stated that she did not ask the RN/UM. The surveyor asked what the purpose of the risk management was. The RIPN stated to monitor and fully investigate to ensure abuse or neglect was ruled out. She added also to track and trend. The RIPN stated that it should be in a central location and easily accessible to all staff. A review of Resident #299's December 2023 MAR/TAR (Medication Administration Record/Treatment Administration Record) included the following: Cleanse with NSS (normal saline solution) and apply Bactroban Ointment (is a topical (for the skin) antibiotic used to treat infections of the skin) to penile tip two times a day for redness for 14 Days which was ordered on 5/19/23. The order was discontinued on 5/22/23 and replaced with the following order: Mupirocin External Ointment 2 % (Mupirocin) apply to penis urethral meatus topically every day shift for wound care cleanse penis with dakins solution 0.0125% pat to dry apply bactroban cover with dry dressing which was ordered on 5/23/23. Further review included an order to cleanse penile opening with NSS and apply povidoine ointment two times a day for infection for 14 Days that was ordered on 5/17/23 and was continued until the resident went to the hospital on 5/26/23. This order should not have been administered at the same time as the order for Bactroban and Mupirocin were administered. Lastly there was an order to cleanse scrotal area with NSS and apply dakins sol two times a day for excoriation for 14 Days which was ordered on 5/22/23. There was no documentation or assessment performed for this new skin alteration. On 12/12/23 at 12:02 PM, the surveyor interviewed the RIPN regarding Resident #299's CP. The RIPN stated that the CP should have been updated to reflect the wounds. On 12/13/23 at 9:49 AM, the surveyor interviewed the RN/UM regarding the skin assessment dated [DATE] and if it should include measurements. The UM stated that it should have had measurements. The surveyor asked if the penile wound should have had an incident report. The UM stated that it was her understanding the penile wound was from trauma and that if we knew the cause then they would not do an incident report. The UM added that only if the origin was unknown. The surveyor asked the UM about the scrotal excoriation. The UM confirmed that there was not a skin assessment done and it should have been. The surveyor asked the UM about the multiple orders for the penile wound treatment (tx). The UM stated that the orders should have been clarified. On 12/13/23 at 10:01 AM, the surveyor interviewed the Wound Nurse (WN) regarding the process for a new wound or DTI. The WN stated that the primary nurse would perform a skin evaluation and an incident report. The surveyor asked the WN if the measurement section should be filled out on the assessment. The WN stated that the measurements should be filled out. The surveyor asked the WN if an assessment should be done for excoriation. The WN stated that there should be an assessment and incident report. The surveyor asked the WN if there should have been multiple orders for the tx of Resident #299's penile wound. The WN stated that the original tx should have been discontinued (d/c) when the other tx was ordered. On 12/13/23 at 10:37 AM, in the presence of the survey team, the surveyor notified the LNHA, new Director of Nursing (nDON), acDON, RIPN and facility IPN the concerns that Resident #299 had a UTF that indicated the resident had a stg 2 penile wound, there was no update to the CP, the MDS was coded incorrectly, there were two different treatments for the penile wound, the skin assessment did not have measurements and there was no skin assessment for the scrotal excoriation. On 12/13/23 at 10:38 AM, the RIPN stated that one of the treatments should have been d/c. On 12/14/23 at 11:43 AM, in the presence of the survey team, the LNHA, nDON, IPN, Director of Maintenance, and Regional Director of Environmental Services, the RIPN responded with the following regarding the concerns. RIPN stated that according to the nurse's assessment there was no penile stg 2 wound. She added that she interviewed that nurse and that nurse stated that she did not see that. The RIPN stated that if there was inconsistency that there should have been documentation that it was not noted. The RIPN stated that the documentation description was poor to determine if an actual incident report was required for the penile wound and that for MASD one was not done. The RIPN stated that the MDS was coded incorrectly. The RIPN stated that the assessment should have had measurements whenever there was a skin alteration. She added that the entire form should be completed. The RIPN stated that a skin assessment should have been done for the scrotal excoriation and the CP should have been updated. On that same date and time, the RIPN stated that the incident reports should be in one place and in the computer system. The RIPN stated that the original order should have been d/c when the new order was written. She added that the nurses should have questioned the multiple order and gotten clarification. A review of the facility provided policy titled, Skin Assessment Policy with a rev (reviewed) date of 9/2023 included the following: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer prevention and for the promotion of healing of various skin conditions, including pressure ulcers . Policy Explanation and Complete Guidelines 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after newly identified pressure ulcer . 7. Documentation of skin assessment: a. Include the date and time of the assessment, your name, and position title. b., Document observations (i.e. skin conditions, how the resident tolerated the procedure, etc.) c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate. A review of the facility provided policy titled, Comprehensive Care Plan dated 9/2023, included the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered CP for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines 1. The care planning process will include an assessment of the resident's strengths and needs . 2 .Other factors identified by the interdisciplinary team .will also be addressed in the plan of care . 3. The comprehensive CP will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . 5. The comprehensive CP will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The policy did not include information regarding updating the CP with a change in a resident's condition. A review of the facility provided policy titled Incident/Accident Reporting with a reviewed date of 9/2023, included the following: Policy: The facility shall ensure that systems are in place whereby resident incidents and accidents are reported, their causes identified when possible and timely interventions are established to reduce the probability of a repeated incident. Policy Explanation and Compliance Guidelines: 1. It is the responsibility of the licensed nurse who first witnessed the incident/accident to initiate and complete the Risk Management forms its entirety utilizing input from the staff present at the time of the incident/accident . 8. The UM brings all completed incident/accident reports to the morning meeting/team huddles for review by the Interdisciplinary Team. Interventions agreed upon are documented. CPs are updated, as needed. 9. A conclusion or summary of the investigation is completed by the IDCP team for all incidents/accidents. 2. On 12/01/23 at 10:48 AM, the surveyor observed Resident #39 seated in a recliner wheelchair, well dressed, there was an air mattress on the bed, and the feeding tube hung on the pole was off. On 12/04/23 at 8:38 AM, the RIPN provided a list of residents with in-house (facility-acquired) wounds on 12/01/23 that included Resident # 39. The surveyor reviewed the medical records of Resident #39. The AR revealed that the resident was admitted to the facility with medical diagnoses that included but were not limited to; hypothyroidism (hypothyroidism's deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), contracture left knee (stiffen and become rigid so the knee can no longer move the way it used to), encounter for attention to gastrostomy (is the creation of an artificial external opening into the stomach for nutritional support or gastric decompression). The quarterly MDS with an assessment reference date (ARD) of 11/12/23, Section C Cognitive Patterns showed skills for daily decision-making were severely impaired. Section M Skin Conditions revealed that the resident had a stage four, present on admission pressure ulcer. On 12/05/23 at 10:39 AM, the surveyor observed the wound care tx of Resident # 39 that was done by LPN #2 assisted by the RN/UM. LPN #2 informed the surveyor that the resident was cognitively impaired, and required total assistance with adls (activities of daily living), the resident was pre-medicated with Tylenol two tablets before wound treatment for pain management. The surveyor observed the feeding tube was off and the resident had bilateral blue heel pads in use while in bed. The LPN introduced herself to the resident and informed the resident that the surveyor will observe the wound tx. LPN #2 then performed handwashing inside the toilet room, went to the tx cart outside the resident's room donned (put on) gloves, took the disinfecting wipes, disinfected the table inside the resident's room, doffed off (removed) gloves, and performed handwashing. LPN took the wound care supplies inside the tx cart, medihoney (aids and supports autolytic debridement and a moist wound healing environment in acute and chronic wounds and burns) tube container, three skin prep (forms a barrier between the patient's skin and adhesives to help preserve skin integrity and prevent insult or injury during removal of tapes and films), one pack of 4 x 4 gauze, two 30 milliliters (mls) medicine cup with Dakin's solution (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns), two tongue depressor and two blue chux (or chucks; a kind of ultra-absorbent incontinence products that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect). LPN #2 put the two blue chux on top of the dry table inside the resident's room and placed the gathered supplies from the tx cart in the blue chux. LPN returned to the tx cart to get the border gauze 6 x 6, wrote the date signed the border gauze, and then placed it on top of the table. The LPN did not read tx orders before starting the wound care tx and while preparing the wound care supplies. LPN then donned a new pair of gloves without performing hand hygiene. LPN removed the old dressing to the sacral area. The surveyor observed an old dressing with brownish discoloration to the gauze, LPN stated that was a serosanguineous discharge (a normal drainage of fluid from a wound or incision site after surgery) and the dressing was brownish due to medihoney medication. There was no smell and the peri-wound was observed with MASD (Moisture-associated skin damage is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection). LPN# 2 stated that MASD was present in the peri-wound and that the sacral pressure wound was stage four. LPN described the wound bed with areas of eschar (dead tissue that sheds or falls off from the skin), yellow sloughed (refers to the yellow/white material in the wound bed; it is usually wet but can be dry, and generally has a soft texture), and some epithelial (appears pink or pearly white and wrinkles when touched) and granulation (Appears red and moist). LPN also stated that the wound doctor came in yesterday, comes every week [once a week] did some debridement to the wound area, and changed the orders. LPN #2 removed gloves and performed handwashing, donned gloves, cleansed the wound bed with the use of 4 x 4 gauze that the LPN soaked inside the 30 mls container of Dakin solution and used the same gloves that were used in cleaning the sacral wound bed and the same gloves used in getting a new 4 x 4 gauze inside the pack that the gloves touched the surrounding area inside and outside the gauze pack x 4 times. LPN stated that the white area in the peri-wound was the z guard medicated cream that was d/c by the wound doctor and changed to skin prep. LPN doffed off gloves and performed handwashing, donned new gloves used skin prep to apply to peri-wound x 2, took the tongue depressor to apply the medihoney to the sacral wound bed, and covered the wound bed with 4 x 4 gauze covered with border gauze. LPN #2 asked the RN/UM to get another border gauze. The RN/UM doffed off gloves and did not perform hand hygiene went to the tx cart. The surveyor observed the RN/UM from a slightly open door, open enough that the surveyor was able to see the RN/UM get another border gauze by opening the tx cart with keys that were from the LPN's uniform pocket. RN/UM took a pair of new blue gloves from her uniform pocket and donned gloves without performing hand hygiene, went inside the resident's room, and handed the border gauze to the LPN. LPN used the border gauze to cover the wound, and LPN doffed off gloves. Later on, the RN/UM doffed off gloves, performed handwashing for 28 seconds, and scrubbed both hands under the stream of running water. Afterward, LPN #2 performed handwashing, took the extra 4 x 4 gauze pack and box of gloves outside the resident's room, and returned the used supplies on top of the tx cart. LPN then disinfected the table, took the garbage outside the room to the soiled room, and performed hand washing. At this time, LPN #2 stated that she was done and will sign off on the tx. She indicated that she read the order for wound treatment to the sacral area before the surveyor observed the wound tx. The LPN then put back the 4 x 4 gauze pack inside the tx cart. On 12/05/23 at 11:20 AM, near the Nursing Station where the medication (med) cart of LPN #2 was parked, the LPN read the order for the sacral wound and signed off the electronic TAR. During the interview, the LPN informed the surveyor that the sacral wound was deteriorating and that it was an unavoidable wound due to the resident's comorbidity, diagnosis, and history of healed pressure ulcers. She further stated that the resident was on supplements like protein and vitamins to promote wound healing and was on preventative tx prior to the wound development. On that same date and time, the surveyor asked who provided her education for infection control including hand hygiene and personal protective equipment (PPE) use, and LPN #2 stated it was the IPN. The LPN stated that handwashing should be done before and after donning and doffing and when gloves are visibly soiled. The surveyor notified the LPN of the above concerns regarding hand hygiene not performed before and after donning doffing off gloves and the concern regarding the 4 x 4 gauze pack. The LPN acknowledged that she should have performed hand hygiene before donning and doffing gloves and that the 4 x 4 gauze pack should have been thrown out. On 12/05/23 at 11:29 AM, the surveyor interviewed the RIPN and IPN regarding hand hygiene and infection control. The IPN stated that it was an expectation that staff when they come out of the resident's room, aftercare, passing tray, before and after donning/doffing PPEs including gloves, hand hygiene should be performed. She further stated that staff should not be stocking gloves inside their pockets and they can not put back the 4 x 4 gauze inside the tx cart due to infection control and contamination. The IPN indicated that when the staff had multiple back and forth from one area to another, there should be hand hygiene, for example, the LPN with supplies to the room and then to tx cart with keys in their pocket, hand hygiene should have been done. On 12/05/23 at 12:36 PM, the surveyor interviewed the RN/UM. The RN/UM stated that it was that IPN who does education regarding infection control hand hygiene, and PPE use. The RN/UM further stated that hand hygiene should be done before and after gloves use. She stated that hand washing which was scrubbing of both hands should be at least 20 seconds and done outside the running water and not under the stream of running water. The surveyor then asked why the RN/UM did not follow the education and practice for hand hygiene if she knew that gloves should not be stored inside the uniform pocket, scrubbing of hands outside the stream of running water, and perform hand hygiene after each glove use that included donning and doffing with direct contact with the resident's environment bed frame, bed, resident's body, privacy curtain when she removed her used gloves 2 x to get supplies from tx cart. the RN/UM stated that because she was hurrying up. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, IPN, acDON, and nDON for an Exit Conference and there was no additional information provided by the facility management. N.J.A.C. 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 ensure that the facility failed to maintain the necessary respiratory care and services of residents who were receiving oxygen, according to the standard of practice, specifically a) that a resident received oxygen as ordered for three (3) of five (5) residents reviewed for respiratory care (Resident #11, #56, and #90) and b) oxygen and respiratory equipment were stored in accordance with facility policy and infection control measures for three (3) of five (5) residents reviewed for respiratory care (Resident #11, #65 and #90). This deficient practice was evidenced by the following: According to the National Library of Medicine, Oxygen-induced hypercapnia: physiological mechanism and clinical implications Abstract Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. 1. On 12/01/23 at 11:40 AM, during the initial tour, the surveyor observed Resident #11 in bed with the Oxygen (O2) concentrator (a medical device used for delivering oxygen) on and set between 5 and 6 liters per minute (LPM). The O2 tubing was dated, strewn over the garbage can and the nasal cannula (NC; an O2 delivery system that is placed directly in the resident's nose) was inside the resident's nostrils. The resident was awake and conversant. On 12/04/23 at 12:06 PM, the surveyor observed the resident lying in bed asleep. The O2 concentrator was on and set to 5 LPM. The O2 tubing was strewn over the garbage can and the floor. The NC was inside the resident's nostril. The surveyor reviewed the medical record for Resident #11. According to the admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD; restrictive breathing affecting lung capacity), chronic respiratory failure, unspecified whether with hypoxia (low levels of O2 in body tissues, causing confusion, bluish skin, and changes in breathing and heart rate) or hypercapnia (too much carbon dioxide (CO2) in your blood). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 8/24/23, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. The active Order Summary Report (OSR) revealed a physician order (PO) for O2 continuous inhalation at 4 LPM via NC every shift for shortness of breath (SOB). A review of the ongoing Care Plan (CP) reflected a focus that included, the resident's required O2 therapy related to respiratory illness and COPD which was initiated on 01/03/23. Further review of the CP included an intervention dated 01/03/23, that the resident required an O2 setting at 4 LPM. On 12/04/23 at 01:26 PM, the surveyor in the presence of the Licensed Practical Nurse/Wound Nurse (LPN/WN) observed the resident lying in bed, asleep, wearing the NC that was connected to the O2 concentrator. The O2 concentrator was on and set to 5 LPM. The O2 tubing was over the garbage can and partly on the floor. The surveyor and the LPN/WN exited the resident's room to discuss the observations and review the electronic Medical Record (eMR). On 12/04/23 at 01:30 PM, during an interview with the surveyor, the LPN/WN confirmed the resident's O2 order was for 4 LPM. The LPN/WN further stated that too much O2 was not good for the lungs and acknowledged that it could prove to be dangerous for a resident with COPD. The LPN/WN informed the surveyor that she would assess the resident and adjust the O2 saturation level according to the PO. At that time, the LPN/WN stated that the O2 tubing should not have been over the garbage can and on the floor because of contamination and against infection control. Furthermore, the LPN/WN informed the surveyor that she would obtain new tubing for the resident. On 12/05/23 at 11:05 AM, during an interview with the surveyor, and the Regional Infection Preventionist Nurse (RIPN), the Infection Preventionist Nurse (IPN) stated the O2 tubing should not have been on the garbage can and the floor to avoid contamination. The O2 tubing depending on the length should have been stored in a bag, when either used or not used. A review of the O2 Saturation for the resident reflected the following: 12/05/2023 11:41 99.0% O2 via NC 12/05/2023 06:09 97.0% O2 via NC 12/04/2023 21:12 98.0% O2 via NC 12/04/2023 12:58 99.0% O2 via NC 12/04/2023 00:49 97.0% O2 via NC 12/03/2023 18:42 97.0% O2 via NC 12/03/2023 14:49 96.0% O2 via NC 12/03/2023 08:01 96.0% O2 via NC 12/02/2023 23:25 95.0% O2 via NC 12/02/2023 15:09 96.0% O2 via NC 12/02/2023 03:20 96.0% Room Air 12/01/2023 18:31 96.0% O2 via NC On 12/05/23 at 11:47 AM, the surveyor, in the presence of the Registered Nurse/Unit Manager (RN/UM) entered the room and observed the resident lying in bed, asleep wearing the NC that was connected to the O2 concentrator. The O2 concentrator was on and set to 6 LPM. The O2 tubing was over the garbage can and partly on the floor. The surveyor and the RN/UM exited the resident's room to discuss the observations and review the eMR. At that time, the RN/UM confirmed the PO should have been followed and the O2 tubing should not have been on the garbage can and not touching the floor. 2. On 12/01/23 at 10:32 AM, during the initial tour, the surveyor observed Resident #65's room. The resident had an O2 concentrator in the room switched off, the tubing was connected to the O2 concentrator, and strewn over personal care items that included a brush, band-aid, lens wipes, topical tonic, and an aerosol deodorant spray. The NC was in the container, not in a storage bag next to the aerosol deodorant spray. At 10:33 AM, the Certified Nursing Assistant (CNA) was observed walking into the room and informed the surveyor the resident was in the activity room. The surveyor reviewed the medical record for Resident #65. According to the AR, the resident was admitted to the facility with a diagnosis that included, malignant neoplasm (cancerous tumor) of the bone and prostate, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (is a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder), and anemia (is a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). The qMDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. A review of the active OSR revealed a PO for O2 2 LPM via NC as needed for SOB which was initiated on 5/04/23. On 12/05/23 at 11:05 AM, during an interview with the surveyor, and the RIPN, the IPN stated the O2 tubing should have been dated and stored in a bag to prevent contamination. On 12/07/23 at 11:00 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the RIPN, the Regional Procurement (RP), the Regional Clinical Operations (RCO), and the Regional Food Service Director (RFSD) were made aware of the concerns regarding the failure to administer the O2 as ordered for Resident #11 and the failure to ensure proper storage of respiratory equipment for Resident #11 and #65. On 12/11/23 at 9:35 AM, in the presence of the survey team, the LNHA, the Regional Director of Environment Services (RDEVS), and the RCO, the RIPN stated the RN/UM on 12/04/23, changed the tubing, corrected the saturation, educated the resident, assessed the resident whose O2 saturation was between 95 to 98 and learned from the resident that they had adjusted their own O2 level. On that same date and time, the RIPN stated that after Resident #11 was assessed yesterday, the RN/UM spoke with the physician and obtained an order of 4.5 LPM which was to the resident's comfort level. At that time, the RIPN confirmed that the O2 saturation was monitored every shift but was not identified by staff, it was missed. The RIPN acknowledged the CP should have been updated. Furthermore, the RIPN stated a facility-wide education was given regarding proper storage of respiratory equipment since all staff on all shifts were responsible to ensure infection control practices were maintained when observed. All staff that entered the resident's rooms (Resident #11 and #65) should have seen it and acted upon identification. 3. On 12/01/23 at 10:28 AM, the surveyor observed Resident #56 in bed with O2 ongoing at 1.5 LPM via NC that was attached to an O2 concentrator. Resident #56 stated that he/she had been to the hospital because he/she had not been breathing well. The surveyor asked Resident #56 what setting the O2 was that he/she used. Resident #56 stated that it was supposed to be 2 LPM. On 12/04/23 at 12:27 PM, the surveyor observed Resident #56 laying in bed with O2 via NC at 1.5 LPM. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypercapnia (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient with an increase in partial pressure of carbon dioxide (PaCO2) above 45 mmHg), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose). Resident # 56's OSR included the following order: 02 inhalation at _2_ LPM via NC every shift for SOB Maintain SpO2 (Oxygen saturation (SpO2) is a measurement of how much O2 blood is carrying as a percentage of the maximum it can carry) at or greater than 90 % with O2 inhalation. The order had a start date of 7/25/23. On 12/05/23 at 12:46 PM, the surveyor observed Resident #56 seated in bed eating lunch. Resident #56 has O2 via NC at 1.5 LPM. On 12/05/23 at 12:53 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the process for O2. The LPN stated that upon admission she would get a report if the resident needed O2 and then get an order from the physician for how many LPM. The LPN further stated that she would bring the concentrator into the resident's room, do an assessment and if the order is 2 LPM then the concentrator should be on 2 LPM. On that same date and time, the surveyor asked how often the LPM was assessed to make sure the concentrator was in the correct setting. The LPN stated that she would check it every time she went into the room and at least one time per shift. The surveyor asked where the NC was stored went not in use. The LPN further stated that it should be in a plastic bag and that it should not be hanging over something. At that same time, the surveyor asked the LPN to observe Resident #56's O2 setting. The LPN confirmed that the setting was under 2 LPM and then changed the setting to 2 LPM. On 12/06/23 at 01:00 PM, the surveyor interviewed the RN/UM regarding the process for O2. The RN/UM stated that each shift the LPM should be checked to see that it was set correctly. The UM stated that the concentrator or tank would be set according to the order. She added that on the concentrator you would need to bend over to see the ball at eye level. At that time, the surveyor showed the RN/UM the pictures of the setting that was at 1.5 LPM. The RN/UM stated that she would have maintenance check the concentrator that maybe the ball was dropping. The surveyor and RN/UM then went to Resident #56's concentrator and observed that it was still set at 2 LPM from when the LPN had changed the setting earlier. The RN/UM then stated that there probably was not something wrong with the concentrator but that she still would have them look at it. 4. On 12/01/23 at 11:15 AM, the surveyor observed Resident #90 sleeping in bed with O2 via NC at 4 LPM on a concentrator. The O2 tubing that was attached to the concentrator was not dated to indicate when it was last changed. The surveyor observed Resident #90's wheelchair which had a portable O2 tank on the back. The NC tubing was not dated and the tubing was just hanging over the portable O2 tank, it was not stored in a plastic bag. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia (a condition where there is not enough oxygen in a person's blood), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction) and hypertension (a condition in which the force of the blood against the artery walls is too high). Resident # 90's OSR included the following orders: O2 inhalation at 2 LPM via NC every shift for SOB Maintain SpO2 at or greater than 90 % with O2 inhalation. The order had a start date of 10/14/23. O2 inhalation at 2 LPM via NC as needed for SOB for three months Maintain SpO2 at or greater than 90 % with O2 inhalation every shift. The order had a start date of 11/14/23 and an end date of 02/14/23. On 12/05/23 at 12:53 PM, the surveyor interviewed the LPN regarding the process for O2. The LPN stated that upon admission she would get a report if the resident needed O2 and then get an order from the physician for how many LPM. She further stated that she would bring the concentrator into the resident's room, do an assessment and if the order is 2 LPM then the concentrator should be on 2 LPM. On that same date and time, the surveyor asked how often the LPM was assessed to make sure the concentrator was in the correct setting. The LPN stated that she would check it every time she went into the room and at least one time per shift. The surveyor asked where the NC was stored went not in use. The LPN stated that it should be in a plastic bag and that it should not be hanging over something. On 12/06/23 at 10:27 AM, the surveyor observed Resident #90 seated in a wheelchair in the hallway. The surveyor then observed the IPN push Resident #90 into the resident's room so the LPN could administer medication to the resident. The surveyor observed Resident #90 had O2 NC tubing attached to a portable O2 tank that was on the back of the resident's wheelchair. The surveyor observed the O2 setting dial and it was positioned on 0. The IPN and LPN confirmed that Resident #90's O2 was not flowing and that the setting was at 0 which meant there was no O2 flowing out of the O2 tank and through the tubing. At this time, the IPN told the LPN that she had to check the O2 tank that the O2 was on. The surveyor asked who had put the resident in the wheelchair. The LPN stated that the CNA placed the resident in the wheelchair. The surveyor asked the LPN what the O2 should have been set on. The LPN stated that the order was for 2 LPM and then turned the knob on the portable O2 tank. On 12/06/23 at 01:00 PM, the surveyor interviewed the RN/UM regarding the process for O2. The UM stated that the CNA was not supposed to touch the O2. The UM stated that each shift the LPM should be checked to see that it was set correctly. The UM stated that the concentrator or tank would be set according to the order. She added that on the concentrator you would need to bend over to see the ball at eye level. The UM stated that the tubing was changed weekly and dated and that when it was not in use it should be stored in a plastic bag. At this time, the surveyor showed the RN/UM the picture of the tubing hanging over the O2 tank. The UM stated that the tubing should not be hanging over and that it should be dated. On 12/07/23 at 11:11 AM, in the presence of the survey team, the surveyor notified the LNHA, RP, RCO, RIPN, and RFSD of the concern that Resident #56's O2 setting was at 1.5 LPM instead of the ordered 2 LPM. In addition, the surveyor notified the facility management that Resident #90's tubing was not dated, was not in a plastic bag, and that the portable O2 was not turned on. On 12/11/23 at 10:07 AM, in the presence of the survey team, the LNHA, and the RDEVS, the RIPN stated that the LPM should be checked every shift. The RIPN further stated that the tubing should have been in a plastic bag and the O2 should have been on 2 LPM. The RIPN stated that the CNA should get the nurse to reapply equipment when they got the resident out of bed. A review of the facility's Oxygen Administration policy, revised on 9/12/23, indicated O2 is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. Under policy explanation and compliance guidelines reflected the resident's CP shall identify the interventions for O2 therapy based upon the resident's assessment and orders. Keep delivery devices covered in plastic bags when not in use. NJAC 8:39-27.1(a)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure a) that Temporary Nurse Aides (TNA) were enrolled in school prior to 5/11/23 and completed their Certified Nurse Aide (CNA) certification by 9/11/23 as mandated by Centers for Medicare and Medicaid Services (CMS) and New Jersey Department of Health (NJDOH) in order to continue to work after 5/11/23 for two (2) of two (2) non-certified NAs reviewed that were previously working as TNAs; and b) verification that the non-certified Nurse Aides were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program and validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, for two (2) of two (2) non-certified NAs that were previously working as TNAs; and c) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs. This deficient practice was evidenced by the following: Reference: CMS Center for Clinical Standards and Quality/Quality, Safety& Oversight Group (QSO) Memorandum (memo) QSO-21-17-NH, with an updated date of 5/10/2021 included the following regarding TNAs: Additionally, CMS waived the requirements that prohibit a nursing home from using any individual working in the facility as a nurse aide for more than four months unless they complete certain requirements (per 42 CFR §483.35(d)(1)). While this waiver has been in effect, many nurse aides have been able to work longer than four months to support facilities' staffing needs. However, nursing homes and nurse aides have raised concerns about what will happen when the waiver ends. For example, CMS has received questions on whether these individuals will need to leave the nursing home immediately when the waiver ends, if they have not completed the requirements for certification in the last four months. Though this waiver is not being terminated at this time, we are advising stakeholders that the four-month regulatory timeframe will be reinstated when the blanket waiver ends and will start at that time. In other words, nurse aides will have the full four month period starting from the end of the blanket waiver to successfully complete the required training and certification, regardless of the amount of time worked during the time the waiver was in effect. However, though nurse aides will have up to four months from the end of the blanket waiver to complete the required training and certification, we strongly encourage states and nurse aides to explore ways to complete all the training and certification requirements as soon as possible. Reference: CMS QSO memo QSO-22-15-NH & NLTC & LSC, with an updated date of 8/29/2022 included the following regarding TNAs: CMS waived the requirements which require that a SNF and NF may not employ anyone for longer than four months unless they met the training and certification requirements under §483.35(d). CMS previously provided information related to nurse aides working under this blanket waiver in CMS memorandum QSO-21-17-NH. This memo provides additional information as well on the modification of this waiver below. We remind states that all nurse aides, including those hired under the above blanket waiver at 42 CFR §483.35(d), must complete a state approved Nurse Aide Competency Evaluation Program (NATCEP) to become a certified nurse aide. State approved NATCEPs must have a curriculum that includes training in the areas defined at 42 CFR §483.152(b), such as respecting residents' rights, basic nursing skills, personal care skills, and caring of cognitively impaired residents. Additionally, the requirements at 42 CFR §483.154(b)(i) and (ii) requires these nurse aides pass a written or oral exam, and demonstrate skills learned. Lastly, we note that CMS did not waive the requirement that the individual employed as a nurse aide be competent to provide nursing and nursing related services at 42 CFR §483.35(d)(1)(i), and that requirement must continue to be met. Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. At that time, all Temporary Nurse Aides (TNAs) hired prior to the end of the PHE and who have enrolled in a NATCEP program and completed the first 16 hours of training prior to May 11, 2023, must complete the NATCEP and pass the nurse aide written exam and the clinical skills competency exam by September 10, 2023. Nurse aides hired after the end of the PHE will have four months to complete a NATCEP program and pass the exams, as required by N.J.A.C. 8:39-43.1. The New Jersey Department of Health issues this memorandum to update facilities on the interpretation of the CMS guidance, P.L. 2021, c. 326, c. 368 and Executive Directive (ED) 20-004 (Revised July 6, 2022). Facilities are advised as follows: I. TNAs A. Individuals who are working as TNAs must pass the nurse-aide written or oral exam and the State-approved clinical skills competency exam by May 11, 2023, or the end of the federal PHE, whichever comes first. B. If a TNA does not pass the exams by the end of the federal PHE, the TNA may not work after May 11, 2023, unless the TNA meets the requirements of Paragraph C below. C. In order to work beyond May 11, 2023, TNAs must, by May 11, 2023: 1. Be enrolled in a NATCEP CNA training program, and 2. Have completed the first 16 hours of training, and 3. Be working in a facility before May 11, 2023. 4. Note that the TNA only has until September 10, 2023 to complete the NATCEP program and pass the exams. II. Nurse Aides Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing. On 12/01/23 at 12:52 PM, the surveyor asked the Regional Infection Preventionist Nurse (RIPN) for the facility's NA policy. The RIPN stated that the facility did not have a specific policy for NAs and that they follow the NJDOH guideline. On 12/04/23 at 10:31 AM, the surveyor reviewed the facility provided list of employees that were NAs. Review of the list indicated the following: NA #1 had a date of hire (doh) of 3/02/2022. NA #2 had a doh of 3/16/2022. Review of the facility provided schedule for 12/02/2023 listed NA #1 and NA #2 scheduled to work the 3-11 shift. The two NAs would be past the 120 day employment and would also be past the TNA waiver that mandated TNAs be certified by 9/11/23. On 12/04/23 at 11:02 AM, the surveyor requested the RIPN provide the surveyor the two NAs employee files. At 11:48 AM, the surveyor requested the two NAs employee files from the Licensed Nursing Home Administrator (LNHA). At 12:34 PM, the surveyor requested again the two NAs employee files from the LNHA. At 12:40 PM, in the presence of another surveyor, the surveyor interviewed the Regional Director of Human Resources (RDHR). The RDHR stated that she supported several buildings and that she kept the HR portion of new hire employees in her office. The surveyor asked where the two NA files were that the surveyor had requested. The RDHR stated that she had given them to the nursing office. At 12:48 PM, the LNHA stated that he had dropped a copy of the two NAs files in the conference room. At 12:55 PM, the surveyor reviewed the copies of documents that were provided. The complete employee files that the facility had were not provided. At 12:58 PM, the surveyor requested from the LNHA the documented evidence that the NAs completed Module 1/16 hours of the CNA program and their competencies. On 12/05/23 at 8:50 AM, the surveyor requested the full and complete employee file for the two NAs from the Director of Operations who was the designee for the LNHA who was not at the facility at the time. The employee files were provided. A review of the facility provided employee files included the following: NA #1: An application for employment for CNA dated 02/11/2022; TNA 8 hour training certificate of Completion (requirement for someone to work as a TNA during the PHE without the required CNA training) dated 12/12/2021; background check with a reported date of 02/14/2022; a payment receipt dated 6/16/2023 for CNA course which did not include when the course started; a job description for NA dated 3/2/2022. There was a personnel change form dated 9/22/23 which indicated the employee was a hospitality aid and changed to a NA with an effective date of change of 9/23/23. There was no documentation that NA #1 was enrolled in the NATCEP program by 5/11/2023. There was no verification that NA #1 had the required Module 1/16 hours of CNA program completed. NA #2: An application for employment for CNA dated 02/21/2022; background check with a reported date of 02/22/2022; an undated letter that stated that NA #2 was enrolled in a NATCEP program that started on 6/14/2023 and ended 8/19/2023; a job description for NA dated 3/16/2022. There was no documented evidence that NA #2 had the TNA 8 hour training certificate of Completion in the file. There was a personnel change form dated 9/22/23 which indicated the employee was a hospitality aid and changed to a NA with an effective date of change of 9/23/23. There was a personnel change form dated 3/30/23 which indicated the employee was a TNA with an effective date of change of 4/2/23 for a rate change. There was no documentation that NA #1 was enrolled in the NATCEP program by 5/11/2023. There was no verification that NA #1 had the required Module 1/16 hours of CNA program completed. On 12/12/23 at 9:56 AM, the surveyor interviewed RDHR regarding hiring TNAs and NAs. The RDHR stated that right now she did not hire TNAs. She stated that to hire a NA the person would have to be enrolled in school when she hired them. She added that she would get documentation that they are in school usually an enrollment letter. The surveyor asked if there was a certain amount of time that they had to pass the exam by. The RDHR stated that she thought it was 120 days from the completion of the course. The surveyor asked what needed to be verified if they were to work with residents if they were in school. The RDHR stated that she would defer that to nursing. She added that she knew they needed to be in school and that they have documentation they are in school. On that same date and time, the surveyor asked about the process for TNAs. The RDHR stated that TNAs were able to work during the PHE after they completed an online course and had a certificate. She added that she did not do much here with TNAs. The surveyor asked what was supposed to be done with the TNAs when the waiver for TNAs was ended. The RDHR stated that TNAs had to go to school and not sure what else. The surveyor asked if there was a time limit. The RDHR stated that she believed there was. She stated that the facility did not have any TNAs anymore. The surveyor asked if the facility had any current employees that were TNAs. The RDHR stated that maybe they did and that she would have to check. She added that the TNAs would have either left the facility or changed to a NA and then on to a CNA. At this time, the surveyor asked if the files that were provided were complete. The RDHR stated that the HR portion was complete. The surveyor asked if the TNA certificate and the Module 1/16 hours would be in the file. The RDHR stated that it should all be in there. On 12/12/23 at 10:35 AM, in the presence of the LNHA and acting Director of Nursing (acDON), the surveyor interviewed the RIPN regarding NA #2's TNA certificate. The RIPN stated that there was a separate binder for the TNA certificates to track who needed to switch over. She added that there was a memo in April that facilities could no longer use TNAs and that the facility sent them to school to get their certification but that some did not get their certification. The RIPN provided NA #2's TNA certificate that was dated 11/27/21. The surveyor asked when the TNAs should have been certified by. The RIPN stated that by 9/10/23 should have completed the program and passed the exam. The RIPN stated that they had to be enrolled in school and complete 16 hours to continue working here while completing the training and testing. She added that once they finished the skills, they had 120 days to complete the written test. At this time, the surveyor asked about the process for a NA. The RIPN stated that if they hired a NA, they would ask for proof of skills test and enrollment in school and if completed school they have 120 days from when they passed the skills exam. The surveyor asked who was responsible to verify the 16 hours was completed. The RIPN stated that the RDHR and staffing coordinator would verify and it would be reviewed by the DON. The acDON stated that she and the Staffing Coordinator worked with that. The surveyor asked if the documentation should be in the HR file. The acDON stated that it should be in the file. On 12/12/23 at 11:00 AM, the RIPN looked in the facility binders for the verification documentation that the TNAs/NAs had Module 1/16 hours. The RIPN confirmed that she could not find the documentation in any of the binders. On 12/12/23 at 12:12 PM, the surveyor reviewed the employee files with the RIPN. The RIPN stated that NA #1 was a TNA and converted to a NA when she went to school in June. She added that she passed the skills test on 9/15/23. The surveyor asked if there should be documentation that the NA completed Module 1/16 hours. The RIPN stated that it should be verified with a document that is dated that she completed 16 hrs. and it should be available in the HR file. On 12/12/23 at 12:22 PM, the RIPN confirmed that NA #2 had an undated form that she went to school from 6/14/23 to 8/19/23 and passed the skills test on 9/16/23. The RIPN confirmed that there was no verification documentation for Module 1/16 hours and that she was not certified by 9/11/23. On 12/12/23 at 12:28 PM, the surveyor asked the RIPN if the change in title to NA should have been done prior to 9/22/23. The RIPN stated yes and that the title given previously to the TNAs was hospitality aid because the Staffing Coordinator did not understand the correct title. On 12/12/23 at 02:01 PM, the RIPN stated that the existing TNAs had until 9/10/23 to complete the NATCEP program and pass the exams according to the 4/21/23 memo. She added that for the two NAs since they belonged to that category as of September 10 and they did not pass the written exam they were converted to NAs on 9/22/23. She added that according to their qualifications they completed the school after September 10 and they are still within the 120 days to pass the written exam. At that time, the surveyor asked that if they were to qualify to be changed to NAs then should they have had written verification of completion of Module 1/16 hours. The RIPN stated yes. The surveyor requested a blank TNA job description. A review of the facility provided TNA job description included the following: .Must be willing to apply and complete the CNA certification program before expiration of the NJ DOH Nurse Aide Certification waiver program . NA #1 and NA #2 did not have a signed TNA job description in their file. On 12/13/23 at 10:36 AM, in the presence of the survey team, the surveyor notified the LNHA, new Director of Nursing (nDON), acDON, RIPN and IPN the concerns that the two NAs who were TNAs worked past the 5/11/23 date with out being enrolled in school and that they were not certified by 9/11/23 and that even though they were not allowed to work after 9/11/23 that if they were allowed to be NAs that there was no verification that they completed their Module 1/16 hour. On 12/13/23 at 11:40 AM, the surveyor requested the schedules and assignment sheets for the NAs that worked before and after the 5/11/23 deadline. A review of the schedules and unit assignments from before 5/11/23 included the following: NA #1 worked 5/02/23 3-11 shift on the North Wing and had an independent assignment (Assignment 3). NA #2 worked 02/20/23 7-3 shift on the North Wing and had an independent assignment (Assignment 2). NA #1 and NA #2 were working as TNAs. On 12/13/23 at 12:27 PM, the RIPN stated that originally NA #1 and NA #2 were hired as TNAs. She added that when the memo was received they reviewed it and they were transitioned into a school. On 12/14/23 at 10:23 AM, in the presence of the survey team, LNHA, nDON, IPN, Director of Maintenance and Regional Director of Environmental Services, the RIPN stated that they were waiting for the actual school transcripts. The surveyor asked if the facility should have had that verification and documentation in the HR file. The RIPN stated that it should have been. The surveyor asked that if the NAs were TNAs when the memo was received, did the TNAs do what was required according to the memo to continue to work after 5/11/23. The RIPN stated that it was not done and that it should have been done. The surveyor asked if the NAs that were TNAs should have been certified by 9/11/23. The RIPN stated that they should have been. The RIPN stated that moving forward they would review credentials and ensure verification prior to hire. The facility did not have a policy regarding TNAs or NAs. N.J.A.C. 8:39-43.1

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to a) develop and evaluate policy and procedure for the implementation of pharmaceutical services consistent with state and federal requirements and reflect current standards of practice for dispensing; disposing of narcotic medications within the electronic back-up machine (EBM) upon the departure of the previous Medical Director, and b) maintain a system of record keeping of the DEA Form 222 that ensured an accurate inventory and reconciliation of controlled dangerous substance (narcotics medications, with high potential for abuse and are tracked with detail) observed during medication storage inspection. This deficient practice was evidenced by the following: 21 CFR 1301.52 Termination of registration; transfer of registration; distribution upon discontinuance of business. (a) Except as provided in paragraph (b) of this section, the registration of any person, and any modifications of that registration, shall terminate, without any further action by the Administration, if and when such person dies, ceases legal existence, discontinues business or professional practice, or surrenders a registration. Any registrant who ceases legal existence or discontinues business or professional practice shall notify the Administrator promptly of such fact . (b) No registration or any authority conferred thereby shall be assigned or otherwise transferred except upon such conditions as the Administration may specifically designate and then only pursuant to written consent. Any person seeking authority to transfer a registration shall submit a written request, providing full details regarding the proposed transfer of registration, to the Deputy Assistant Administrator, Office of Diversion Control, Drug Enforcement Administration. See the Table of DEA Mailing Addresses in § 1321.01 of this chapter for the current mailing address. 21CFR 1305.18 Return of unused DEA Forms 222. If the registration of any purchaser terminates (because the purchaser dies, ceases legal existence, discontinues business or professional practice, or changes the name or address as shown on the purchaser's registration) or is suspended or revoked under § 1301.36 of this chapter for all Schedule I and II controlled substances for which the purchaser is registered, the purchaser must return all unused DEA Forms 222 to the Registration Section 1. On 12/07/23 at 11:44 AM, during an interview with the surveyor, the Regional Infection Preventionist Nurse (RIPN) stated we do not have narcotic back-up medications. The new DEA Form 222 (a federal requisition form), of the new Medical Director (MD) were just received. We do not have back up. On 12/11/23 at 12:18 PM, in the presence of the Registered Nurse/Unit Manager (RN/UM) and the RIPN, the surveyor inspected the EBM. During the inspection, the surveyor learned that narcotics were still available in the facility. The cycle count reflected the following narcotics were in stock for dispensing: -Acetaminophen-Codeine (is a combination medicine made up of codeine (an opioid medication) and acetaminophen (a non-opioid medication) and is used to relieve pain) 325 milligram (mg) 30 mg tablet, quantity of 15 -Dilaudid (narcotic analgesics) 2 mg tablet, quantity of 26 -Diazepam (Valium; anxiolytic and sedative that can treat anxiety, muscle spasms, and seizures) 5 mg tablet, quantity of 1 -Fentanyl (narcotic that can treat severe pain) 25 microgram (mcg) patch, quantity of 4 -Fentanyl 50 mcg patch, quantity of 3 -Lyrica (medication that treats nerve pain by calming overactive nerve) 50 mg (Pregabalin) capsule, quantity of 18 -Oxycodone (It can treat moderate to severe pain) 10 mg tablet, quantity of 24 A review of the facility provided; Controlled Substance Report dated 12/01/23 to 12/12/23 reflected the following: -Oxycodone 10 mg tablet, 1 tablet was removed on 12/04/23 by Facility staff (FS) #1 and FS #2 on 12/04/23 for a resident. -Oxycodone/ Acetaminophen 10 mg /325 mg tablet, 23 tablets were removed on 12/01/23 by the pharmacy provider representative (PPR) and RN/UM [same quantity was reflected on the destruction request form dated 12/06/23]. -Morphine Sulfate 10 mg/0.5 milliliter (ml), two ml was removed on 12/01/23 by the PPR and the RN/UM [quantity of 12 was reflected on the destruction request form dated 12/06/23]. A review of the facility provided; Controlled Substance Report dated 11/01/23 to 11/30/23 reflected the following: -Morphine sulfate 30 mg tablet, one tablet was removed on 11/04/23 by FS #3 and FS #4 for a resident, six tablets were removed on 11/30/23 by FS #5 and FS #6 not for a resident, discrepancy not stated and not resolved [quantity of 26 was reflected on the destruction request form dated 12/06/23]. -Oxycodone immediate release 5 mg tablet, one tablet was removed on 11/04/23, by FS #3 and FS #5 for a resident. Two tablets were removed on 11/11/23 by FS #8 and FS #9 for a resident. -Diazepam 5 mg tablet, one tablet was removed on 11/16/23 by FS #10 and FS #11 for a resident. One tablet was removed on 11/16/23 by FS #12 and FS #5 for a resident. -Oxycodone 10 mg tablet, one tablet was removed on 11/12/23, by FS #5 and FS #12 for a resident. -Fentanyl 12 mcg, two was removed on 11/29/23 by FS #5 and FS #6 [same quantity was reflected on the destruction request form dated 12/06/23]. Lyrica 50 mg, 18 were removed on 11/30/23 by FS #5 and FS #6 [same quantity was reflected on the destruction request form dated 12/06/23]. A review of the facility provided; Controlled Substance Report dated 10/01/23 to 10/30/23 reflected the following: - Morphine sulfate 30 mg tablet, [did not reflect a removal for return or usage}. -Oxycodone Immediate Release 5 mg one tablet was removed on 10/15/23 by FS #13 and FS #14 for a resident. one tablet was removed on 10/16/23 by FS #14 and FS #13 for a resident. one tablet was removed on 10/20/23 by FS #6 and FS #14 for a resident. one tablet was removed on 10/23/23 by FS #12 and FS #6 for a resident. one tablet was removed on 10/27,23 by FS #1 and FS #7 for a resident. one tablet was removed on 10/29/23 by FS #14 and FS #11 for a resident. one tablet was removed on 10/29/23 by FS #2 and FS #9 for a resident. A review of the Controlled Substance report for December 2023, November 2023, and October 2023, revealed the facility continued to use the narcotic medication located within the EBM after the previous MD resigned. On 12/12/23 at 10:33 AM, during an interview with the surveyor, the Registered Nurse/ Account Manager for [name redacted pharmacy] stated that he had not taken any narcotic orders from the facility for the EBM since the new MD started. They were waiting for the new DEA Form 222 that would reflect the current MD's DEA registration number. On 12/13/23 at 10:21 AM, in the presence of the survey team, the Infection Preventionist Nurse (IPN), the RIPN, Licensed Nursing Home Administrator (LNHA), the Assistant Director of Nursing (ADON), and the new Director of Nursing (DON), were made aware of the concerns regarding the failure of the facility to develop and evaluate policy and procedures for the implementation of pharmaceutical services consistent with state and federal requirements and reflect current standards of practice for dispensing; and disposing of narcotic medications upon the departure of the previous medical director and the missing DEA -222 Forms. On 12/13/23 at 10:58 AM, during an interview with the surveyor, the RIPN stated that we have not replenished our narcotic back-up medication for the EBM since the previous MD left in June 2023. On that same date and time, the RIPN stated that they were told by the provider pharmacy representative verbally that they were able to use the left-over narcotic medication in the EBM that was ordered under the previous MD's DEA license. The RIPN stated that the narcotic medications in the EBM were owned by the facility. At that time, the RIPN stated we did not inquire with the Consultant Pharmacist in June 2023. We decided to follow the guidance from the pharmacy provider who dispensed the medication to us. When the RIPN was asked who was ultimately responsible for the narcotic medication in the EBM, the RIPN stated the MD. At that time, the surveyor asked if the facility had followed their policy and procedures. The RIPN stated that she was unaware of the policy and procedures or if there was a process for the narcotics in the EBM when there was a change of MD or when an MD resigned. At that time, the RIPN confirmed that the facility did not notify the DEA of the fact that the previous MD had left or requested for guidance regarding the narcotics within the EBM prior to surveyor inquiry. Furthermore, the Director of Nursing (DON) stated that stat orders (immediate/emergency) were available for the facility from the provider pharmacy which could be delivered within two to four hours when needed. At that same time, the RIPN informed the surveyor that the DEA Form-222 were mailed back to the DEA but did not have proof that the documents were mailed or when they were mailed. The RIPN stated she was unsure of who the previous DON was at that time. On 12/13/23 at 12:01 PM, the DON stated that they had reached out to the New Jersey Drug Control Unit (NJDCU) on 12/11/23, by email and called the Controlled Dangerous Substance department to inquire regarding the event of a change of medical director, can the facility continue to dispense, administer narcotics left in the EBM from the previous MD after surveyor inquiry. At that time, the surveyor reviewed the NJDCU auto response email which reflected the facility's inquiry would receive a response in approximately two weeks. A review of the letter sent by the pharmacy provider's Compliance Officer dated 12/12/23, included guidance that reflected .the facility can continue to utilize their stock being that they have a valid CDS [Controlled Dangerous Substance, license] and DEA [Drug Enforcement Administration, registration number] under the new MD . A review of the previous MD's resignation letter revealed a date of 6/01/23. A review of the new MD's employee file revealed a contract signed on 6/19/23. A review of the CDS license revealed the valid dates were from 9/28/23 to 10/31/24. A review of the DEA registration number revealed an issue date of 11/06/23. The review of the previous MD's resignation against the date of hire of the new MD, the date of issuance of the CDS and DEA registration, revealed a gap of an authorized practitioner in the facility while the Controlled Dangerous Substance was maintained in the facility's EBM machine. A review of the standard form contract between the facility and the MD, under section 11.1 Disclosure of Confidential Information and Reports indicated: All property and supplies used by physician in the performance of its services hereunder; and all patient records charts, Facility equipment and Facility furnishings shall remain the sole property of Facility . On 12/14/23 at 9:54 AM, in the presence of the survey team, the IPN, the RIPN, the LNHA, the Maintenance Department Director (MDD), the Regional Director of Environmental Services (RDEVS), the Regional Clinical Operations, the RIPN stated there was no document of transfer of registration, no Power of Attorney on file, no letter was sent to the DEA for the change of the MD by the facility or the previous MD prior to surveyor inquiry. The RIPN acknowledged that there should have been communication with the DEA when the previous MD had resigned. At that time, the RIPN stated she found the DEA Form 222 that was locked in the previous DON's office. She further stated that she voided the forms, emailed CDS, and asked CDS where to mail the unused DEA Form 222. At that time, the RIPN stated she failed to account for the DEA Form 222. The RIPN further stated that the policy should have included a process for when there was a change of MD. On 12/14/23 at 12:42 PM, the surveyor and RIPN reviewed the recovered DEA Form 222s together. Upon review the forms, DEA Form number 220289218 could not be located. The RIPN could not identify if the form was used, lost, or stolen. At that time, the RIPN stated there was no process to identify, reconcile, account for the DEA Form 222 against diversion. The RIPN confirmed she was unable to account for the missing DEA Form 222. There is no current process to track, used and received DEA Form 222. A review of the facility provided; Controlled Substance Policy reviewed 8/2022, included the following: Policy: It is the policy of this facility to promote safe high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines 1. The Director of Nursing (DON) as designated by the facility will be responsible for ensuring that facility's compliance with the terms of the policy. Orders for Back-Up Controlled Substances 4. The DON will maintain a copy of the DEA Form 222. copy will be kept in the backup stock-controlled substance binder. The facility policy did not reflect a policy and procedure regarding a change of MD and a process for the narcotic in the EBM and a process to maintain a system of record keeping of the DEA Form 222 that ensured an accurate inventory and reconciliation of controlled dangerous substance. NJAC 29.7(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure a) that a consistent coordination/communication was provided between facility staff and hospice staff to meet the resident's needs b) that a recommendation made by hospice was acted upon on a timely manner (Resident #11), and c) an order was transcribed in accordance with standards of practice (Resident #65). This deficient practice was identified for two (2) of two (2) residents reviewed for hospice and end of life care. This deficient practice was evidenced by the following: 1. On 12/01/23 at 11:40 AM, during the initial tour, the surveyor observed Resident #11 in bed with the Oxygen (O2) concentrator on and set between 5 and 6 liters per minute (LPM). The resident was awake and conversant. The surveyor reviewed the medical record for Resident #11. According to the admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD; restrictive breathing affecting lung capacity), chronic respiratory failure, unspecified whether with hypoxia (low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate) or hypercapnia (too much carbon dioxide (CO2) in your blood). A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 8/24/23, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. A review of the active Order Summary Report (OSR) revealed a physician order (PO) for Hospice evaluation and treatment with [name redacted] with a start date of 01/27/23. A review of the Care Plan (CP) included a focus that the resident has new order for [name redacted] hospice, initiated on 02/14/23. At that time, the CP did not indicate an intervention or goals for the new orders. A review of the resident's weekly skin assessments reflected the following: -9/19/23, no skin issues; General Note: scratch marks on bilateral arms and abdomen . -9/26/23, no skin issues; General Note: scratch marks on bilateral arms and abdomen . -10/03/23, no skin issues -10/10/23, no skin issues -10/17/23, no skin issues -10/24/23, no skin issues -10/10/23, no skin issues -11/07/23, no skin issues -11/14/23, no skin issues A review of the Progress Note (PN) reflected the following: -10/10/23 at 13:05 no new skin issues -10/10/23 at 14:35 scratch marks on to abdomen and back. On 12/07/23 at 12:05 PM, the surveyor requested for the hospice communication record from the Registered Nurse /Unit Manager (RN/UM). At that time, the RN/UM could not locate the communication record from [name redacted] hospice within the hybrid medical record (a combination of paper-based and electronic health record that primarily involves tracking and storing a patient's health records in several formats and places). The RN/UM stated she would continue to look for it and contact the resident's Hospice Nurse (HN). On 12/12/23 at 11:15 AM, during an interview with the surveyor, the RN/UM stated the HN did not leave progress notes but had a communication record (CR) sign in sheet. This CR is where the communication with the nurses were documented. At that time, the RN/UM presented the communication record, [name redacted] Hospice recommendation sheets that she found in the resident's adjunct medical record. The CR reflected visits from [name redacted] hospice on the following dates: 7/19/23, 8/02/23, 8/16/23, 8/23/23, 8/30/23, 9/06/23, 9/13/23, 9/20/23, 9/27/23, 10/03/23, 10/18/23, 10/25/23, 11/01/23, 11/08/23, 11/15/23, 11/22/23, 11/29/23, 12/05/23, and 12/12 23. Within this time frame the surveyor received two documents (9/27/23 and 10/18/23) of hospice recommendation sheet for the resident. At that time, the RN/UM stated she had a conversation with the HN on 12/07/23, and on 12/12/23 regarding the missing progress notes/recommendation sheet record. The RN/UM stated that the HN documented on their own proprietary electronic system, which the facility had no access to review. The HN then sent their internal interdisciplinary team notes after surveyor inquiry to the facility. 2. A review of the CR for the resident reflected a recommendation made by hospice on 9/27/23 that indicated the resident had a left fungal rash. The specific location was not reflected on the hospice CR. Further review of the record reflected that on 10/25/23 the fungal rash clearing. A review of the PN from 9/12/23 to 10/10/23 did not reflect a documentation by any nurse regarding the recommendation from hospice for the resident's left fungal rash. At that time, the surveyor and the RN/UM reviewed the hospice recommendation (HR) dated 9/27/23, which indicated consider start Nystatin powder (used to treat some types of fungus infections of the skin) 100,000 units per gram, sprinkle medication to affected areas (inner thighs, under stomach and side of right hip two times a day for seven (7) days. Further review of the HR revealed the recommendation was reviewed with Licensed Practical Nurse (LPN #1) on the same date. At that time, the surveyor and the RN/UM reviewed the hybrid medical record for the resident which reflected the order was not transcribed until 10/10/23. At 11:39 AM, during an interview with the surveyor, in the presence of the RN/UM, LPN#1 whose name was reflected on the HR stated that he receives orders from the HN and is transcribed to an order on the same day. The hospice recommendation should be completed on the same day it is recommended, the HR is usually given to me but if I am doing something the paper is left here. I can not say why it was not carried out [transcribed] on the same day. At 11:56 AM, the RN/UM clarified that when a recommendation was made by hospice, we contact the physician and obtain an order. The RN/UM stated the Nystatin order was a duplicate since the resident was already on an Anti-fungal from 7/14/23. At that time, the RN/UM obtained the Antifungal powder and reviewed with the surveyor. The bottle reflected an active ingredient of Miconazole 2 %, The RN/UM confirmed the ingredients were not the same as the hospice recommendation of Nystatin powder 100,000 units per gram. At that time, the RN/UM stated the communication between the facility and [name redacted] hospice needed improvement. I will discuss this concern with the HN, the facility nurses and inform the Director of Nursing (DON). On 12/12/23 at 01:33 PM, during an interview with the surveyor, LPN #2 stated the skin evaluations were conducted weekly and logged in the electronic Medical Record (eMR). The surveyor and LPN#2 reviewed the skin evaluations which were marked as no skin issues. The LPN #2 stated when a resident had a rash the skin evaluation should not have been marked as no skin issues and should have indicated the resident had a skin issue/a rash. 3. On 12/1/23 at 10:32 AM, during the initial tour, the surveyor observed Resident #65's room. The resident had an O2 concentrator in the room switched off, the tubing was connected to the O2 concentrator. At 10:33 AM, the Certified Nursing Assistant (CNA) was observed walking into the room and informed the surveyor the resident was in the activity room. The surveyor reviewed the medical record for Resident #65. According to the AR, the resident was admitted to the facility with diagnosis that included, malignant neoplasm (cancerous tumor) of the bone and prostate, bipolar disorder, schizoaffective disorder, and anemia. A review of the qMDS, dated [DATE], reflected a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. A review of the active OSR revealed an order for [name redacted] hospice care ordered on 8/07/23. A review of the CP reflected the resident was admitted to the facility under [name redacted] hospice #2 care. A review of the resident's weekly skin assessments reflected the following: -9/19/23, no skin issues -10/17/23, no skin issues -11/01/23, no skin issues -11/20/23, no skin issues On 12/07/23 at 12:05 PM, the surveyor and the RN/UM reviewed the [name redacted] hospice CR within the resident's hybrid medical chart. On 12/12/23 at 12:27 PM, during an interview with the surveyor, the RN/UM confirmed the recommendation for the antifungal cream was transcribed as Hydrocortisone cream (a corticosteroid not belonging to an antifungal class of medication). The surveyor asked the RN/UM if that was the correct drug, the RN/UM stated no, the order should have been clarified with the doctor. A review of the PN did not reflect a documented clarification note for the Antifungal cream recommendation from the resident's hospice provider. The PN did not reflect a communication with the prescriber regarding the Antifungal cream. A review of the electronic Treatment Administration Record for October 2023 and November 2023 reflected the resident received administration for the Hydrocortisone from 10/26/23 to 11/24/23. At that time, the surveyor and the RN/UM reviewed the order entry for the hydrocortisone that reflected the order was created on 10/25/23, revised on 11/07/23, and discontinued on 11/24/23. At that time, the RN/UM informed the surveyor that she would assess the resident, inform the doctor, contact hospice, the family, and the DON. We will have to educate all the nurses. On 12/13/23 at 9:16 AM, during an interview with the surveyor, the LPN/Wound Nurse (LPN/WN) was asked regarding the order that she had revised for the resident. The LPN/WN stated that the Hydrocortisone was a house stock medication and that it was an antifungal medication. The nurse also stated that antifungal was a classification for a drug and not a name of a medication. The LPN/WN acknowledged that the recommendation of the Antifungal cream should have been clarified since it was a type of medication as opposed to a name of a medication. On 12/13/23 at 10:21 AM, in the presence of the survey team, the Infection Preventionist Nurse (IPN), the Regional IP Nurse (RIPN), Licensed Nursing Home Administrator (LNHA), the Assistant Director of Nursing (ADON), and the new DON (nDON), were made aware of the concerns regarding the failure of the facility to ensure consistent collaboration and communication occurred between hospice and the facility staff. The facility skin evaluations did not indicate Resident #11 and 65 had a skin issue while the hospice recommendation identified the rash and recommended a treatment for each resident. The facility did not act upon the recommendation made for Resident #11 on 9/27/23, in a timely manner and was later acted upon on 10/10/23. The concern regarding Resident #65's order that was not transcribed in accordance with professional standards of practice. On 12/14/23 at 9:54 AM, in the presence of the survey team, the IPN, the LNHA, the Maintenance Department Director (MDD), the Regional Director of Environmental Services (RDEVS), the ADON, and the nDON, the RIPN stated a medication incident report form was created for Resident #11 regarding the order that was not acted upon on a timely manner. At that time, the RIPN stated that she had spoken with LPN#3 who had originally created the order for Resident #65. The RIPN stated that LPN #3 had failed to document that the physician assistant had changed the order from Antifungal cream to Hydrocortisone cream. Furthermore, the RIPN confirmed that there were discrepancies with the skin evaluations documented for the residents. The RIPN further acknowledged that the transcription of Resident #65's order was not in accordance with standards of practice. A review of the facility's Coordination of Hospice Services, revised on 9/2023 included the following: Policy; It is the policy of this facility to provide and or arrange for Hospice services in order to protect resident's rights to a dignified existence, self-determination, and communication with, and access to persons and services inside and outside the facility. Procedure: 2. The facility will utilize A systematic approach for recognition, assessment, treatment, and monitoring of Hospice care. 3. The facility and Hospice will coordinate plan of care and will implement interventions in accordance with the resident's needs, goals and recognize standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible 5. The facility will communicate with Hospice and identify communicate, follow, and document all interventions put into place by Hospice and the facility. NJAC 8:39-27.1(a)

Based on interview and review of pertinent facility documentation, the facility failed to have: a) the Director of Nursing (DON) present for two (2) of three (3) Quality Assurance and Performance Improvement (QAPI) meetings and b) the Infection Preventionist Nurse (IPN) present for one (1) of three (3) QAPI meetings. The deficient practice was evidenced by the following: On 12/13/23 at 11:04 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team for an interview regarding the facility's QAPI program. The LNHA informed the survey team that the facility had a quarterly meeting and the key people to attend were the Medical Director, Infection Preventionist, LNHA, DON, Social Worker, Minimum Data Set (MDS) Coordinator, Dietary, and Housekeeping. On that same date and time, the LNHA reviewed the last three quarters' sign-in sheets for QAPI and the LNHA acknowledged that there was no IPN who attended that 3rd quarter QAPI meeting on 10/25/23. The LNHA also acknowledged that there was no DON who attended the 2nd quarter QAPI meeting on 7/26/23. In addition, the LNHA acknowledged that at the 1st quarter QAPI meeting on 4/26/23, there was no DON who attended the meeting because the previous DON (pDON) who signed for DON at that time did not have a qualification for a DON and according to the resume, she (pDON) was the Assistant Director of Nursing (ADON) from February 2023 through June 30, 2023. On 12/14/23 at 9:54 AM, the survey team met with the LNHA, Regional Director of Environmental Services, Maintenance Director, Regional Infection Preventionist Nurse (RIPN), new DON, and the facility Infection Preventionist Nurse (IPN). The LNHA acknowledged the above findings of the surveyor regarding the key people who were not present during the quarterly QAPI meetings which were the DON and the IPN. A review of the facility's Quality Assurance and Performance Improvement Policy with a review date of 11/2022 that was provided by the LNHA included that the QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, Board Member, or other individual in a leadership role; and iv. The Infection Preventionist b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI Program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, IPN, ADON, and new DON for an Exit Conference and there was no additional information provided by the facility management. NJAC 8:39-33.1 (a) (b)

Based on interviews and review of other facility pertinent documents, the facility failed to have a designated licensed Director of Nursing (DON) on a full time basis to oversee the care of all residents in the facility with 114 licensed beds. This failure increased the risk that all residents would not be provided with appropriate and accurate care and assessments from March 1, 2023, through July 10, 2023. This deficient practice was evidenced by the following: On 12/01/23 at 9:33 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and the Infection Preventionist Nurse (IPN). The LNHA stated that the facility had 114 licensed beds. The ADON stated that she had been at the facility for three months. On that same date and time, the LNHA stated that there was no Director of Nursing (DON) at the moment and that the new DON will start on 12/11/23. The LNHA further stated that the previous DON #1 (DON#1) who had not been at the facility for a month had left. The surveyor asked for the DON timeline after 02/06/23 (the last recertification survey) up to present, and the LNHA stated that he will get back to the surveyor. On 12/05/23 at 10:08 AM, the surveyor interviewed the ADON. The ADON stated that she started on 9/04/23 as the ADON. She further stated that she was now the acting DON and that the new DON will start on Monday (12/11/23). The surveyor followed up on the timeline of the DON. On 12/05/23 at 12:36 PM, the surveyor in the presence of the survey team interviewed the Registered Nurse/Unit Manager (RN/UM) regarding the DON at the facility since the last recertification in February 2023. The RN/UM informed the surveyor that DON #2 was the previous DON for about three months. The RN/UM was unable to remember the timeframe of DON #2 as DON of the facility. She further stated that there was no covering DON for a month until the current ADON came. A review of the provided typewritten sequence of DON of the facility for 2023 that was provided by the Regional Infection Preventionist Nurse (RIPN) revealed the following: 02/09/23=RIPN was the covering DON. DON #2 in Training [RIPN stated that DON #2 was not the DON at this time]. 7/31/23=DON #2 resigned 7/31/23=RN/UM was interim DON 9/05/23=ADON interim DON. 10/09/23=DON #1. DON #1 was on vacation on 10/20/23, returned on 10/31/23, and was termed on 10/31/23. 10/31/23=ADON interim DON again. 12/11/23=DON #3, new DON expected start date 12/11/23. A review of the provided employee file of DON #2 revealed the following: -The resume showed that DON #2 had a total of five months of experience in a supervisory position in a Long Term Care Facility prior to assuming the position of ADON in the facility from February 2023 to June 30, 2023. The resume also included that DON #2 assumed the position of DON at the facility on 7/01/23. -Letter provided by the LNHA addressed to the Department of Health (DOH) dated 7/08/23 included that DON #2 assumed the role of DON and replaced the RIPN as DON. -Resignation letter of DON #2 dated 7/19/23 with an effective date after 7/31/23. On 12/06/23 at 10:47 AM, the surveyor in the presence of the survey team interviewed the RIPN. The surveyor asked the RIPN how often she stayed at the facility from the last recertification survey (02/06/23) and if the RIPN was at the facility Monday through Friday. The RIPN stated I visit twice a week, depending on what was happening at the facility. The RIPN confirmed that when she was the covering DON at the facility she was never at the facility Monday through Friday, from February through December this year (2023). On that same date and time, the surveyor asked the RIPN if she was the covering DON of the facility and why she was not on-site at the facility to cover for a full-time DON. The RIPN had no response. On 12/07/23 at 11:00 AM, the survey team met with the LNHA, Regional Procurement Director, Regional Clinical Operations, RIPN, and Regional Food Service Director. The surveyor notified the facility management of the above findings and concerns that there was no designated licensed DON on a full time basis to oversee the care of all residents from 02/09/23 through 6/30/23 as evidenced by the provided documents for DON #2 and interview of RIPN. A review of the provided Position Title: Director of Nursing Services (job description) included in the position summary that the essential functions of the job for a DON requires, and may be amended from time to time at the sole discretion of [facility's company name], to include, but are not limited to the following: -Must possess a valid RN license, in good standing in accordance with laws of this state, from an approved NJ (New Jersey) Nursing School of Nursing. A minimum of five (5) years of full-time or equivalent clinical experience is required and a minimum of two years of clinical experience in long-term care nursing with one year in a management/administrative or supervisor capacity is preferred. BSN (Bachelor of Science in Nursing) preferred. -Comply with standards of business conduct in accordance with federal, state, and local health and regulatory standards and guidelines, as applicable. Responsibilities/Accountabilities: -Completes daily rounds on the units to observe residents and to determine if nursing needs are being met; -Participates in the assessment of residents to be admitted by evaluating the level and amount of care required by prospective residents in relation to existing nursing capabilities . On 12/11/23 at 9:34 AM, the survey team met with the LNHA, Regional Director of Environmental Services (RDEVS), and RIPN. The RIPN stated that for the definition of designated fulltime DON, yes there was no DON here from February to July 2023. On that same date and time, the LNHA stated that the facility did not have a policy with regard to DON and that the facility followed the DON's job description. NJAC 8:39-25.1(a)

7. On 12/01/23 at 10:41 AM, during the initial tour, the surveyor observed Resident #18 lying in bed, alert, awake, covered with a bed sheet from chest to toes, and floor mats were placed on both sides of the bed. The surveyor reviewed the hybrid medical records of Resident #18. According to the resident's AR, Resident #18 was admitted to the facility with the diagnoses that included but were not limited to fibromyalgia, systemic lupus erythematosus (SLE; an autoimmune disease, in which the immune system attacks its own tissues such as joints, skin, brain, lungs, kidneys, and blood vessel), major depressive disorder, anxiety disorder, unspecified psychosis, and other seizures. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 8. On 12/01/23 at 11:40 AM, during the initial tour, the surveyor observed Resident #11 in bed with the Oxygen (O2) concentrator (a medical device that can help you breathe) on and set between 5 and 6 liters per minute (LPM). The surveyor reviewed the hybrid medical records of Resident #11. According to the AR, the resident was admitted to the facility with diagnoses that included COPD, chronic respiratory failure, unspecified whether with hypoxia (ow levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate) or hypercapnia (too much carbon dioxide (CO2) in your blood) A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 9. On 12/01/23 at 11:00 AM, the surveyor observed Resident # 76 wandering up and down the hallways, fitted with non-skid socks, and was well dressed. The surveyor reviewed the hybrid records of Resident #76. According to the AR, the resident was admitted to the facility with diagnoses that included, hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), hyperlipidemia, PVD, and dementia. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023 10. On 12/01/23 at 10:32 AM, during the initial tour, the surveyor observed Resident #65's room. At 10:33 AM, the CNA was observed walking into the room and informed the surveyor the resident was in the activity room. The surveyor reviewed the hybrid medical records of Resident #65. According to the AR, the resident was admitted to the facility with diagnoses that included, malignant neoplasm (cancerous tumor) of the bone and prostate, bipolar disorder, schizoaffective disorder, and anemia (low blood red blood cell or hemoglobin). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 11. On 12/01/23 at 11:19 AM, during initial tour, the surveyor observed the Resident #72's door was closed, enhanced barrier precaution sign on the door, personal protective equipment supply was outside the resident's door with ample supply. The surveyor reviewed the hybrid medical records of Resident #72. According to the AR, the resident was admitted to the facility with diagnoses that included, type 2 DM, hidradenitis suppurativa (a skin condition that causes skin abscesses and scarring), and methicillin resistant staphylococcus aureus infection (a type of infection that is resistant to many antibiotics). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 12. On 12/01/23 at 10:15 AM, during initial tour the surveyor observed the Resident #61 lying on a low positioned bed with a blanket covering their chest. The resident stated he/she attended dialysis three times a week and the schedule were mostly consistent and was accommodated when he/she arrived late. The resident informed the surveyor they were diabetic and had not experienced low blood sugar. The surveyor reviewed the hybrid medical records of Resident #61. According to the AR, the resident was admitted to the facility with diagnoses that included, end stage renal disease, type 2 DM, and PVD. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to provide oversight by a licensed Consultant Pharmacist (CP), to review the resident's medication regimen and medical record to identify and report irregularities for 17 out of 20 residents, (Residents #1, #11, #16, #17, #18, #24, #26, #38, #39, #43, #56, #61, #65, #72, #76, #87, and #90) reviewed during Medication Regimen Review (MRR), according to facility's policy and procedure. This deficient practice was evidenced by the following: 1. On 12/01/23 at 9:12 AM, the surveyor observed Resident #1 sitting on edge of bed eating breakfast and dressed appropriately. The surveyor reviewed the hybrid (a combination of paper-based and electronic medical records that primarily involves tracking and storing a patient's health records in several formats and places) medical records of Resident #1. Resident #1's admission Record (AR; or face sheet, an admission summary) reflected that that resident was a long-term care (LTC) resident at the facility and had diagnoses which included but were not limited to hereditary and idiopathic neuropathy (neuropathies are nervous system disorders that interfere with normal nerve function, whether motor or sensory), end stage renal disease (ESRD) (the final, permanent stage of chronic kidney disease), type 2 diabetes mellitus (DM) (characterized by high levels of sugar in the blood) , dependent on renal dialysis (dialysis is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to), unspecified dementia (unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety)( Dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities). A review of the resident's Consultant Pharmacist (CP) Evaluation (or MRR), a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 2. On 12/06/23 at 9:03 AM, the surveyor observed Resident #16 in bed, the surveyor noted a left upper extremity contracted. The resident had an air mattress in place and a left-hand roll, fingernails were trimmed and neat. The surveyor reviewed the hybrid medical records of Resident #16. Resident #16's AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to, spastic quadriplegic cerebral palsy (spastic quadriplegia cerebral palsy is a form of cerebral palsy that affects both arms and legs and often the torso and face), obstructive reflux uropathy (occurs due to obstructed urinary flow and can be either structural or functional) essential (primary) hypertension (systolic blood pressure (SBP) values of 130 mm Hg or more and/or diastolic blood pressure (DBP)). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 3. On 12/6/23 at 9:07 AM, the surveyor observed Resident #17 in bed getting ready to be washed and bathed by their assigned hospice aid. The surveyor reviewed the hybrid medical records of Resident #17. Resident's 17's AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; cerebral vascular accident (CVA) (a brain attack, is an interruption in the flow of blood to cells in the brain), hemiplegia and hemiparesis (hemiparesis indicates weakness on one side of the body, hemiplegia indicates partial or total paralysis instead), peripheral vascular disease (PVD; slow and progressive circulation disorder caused by narrowing, blockage or spasms) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 4. On 12/01/23 at 10:44 AM, the surveyor observed Resident #24 during transfer by two Certified Nursing Assistance (CNA). The surveyor reviewed the hybrid medical records of Resident #24. Resident #24's AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels), type 2 DM, hyperlipidemia (means you have too many lipids (fats) in your blood), atherosclerotic heart disease (develops when a sticky substance called plaque builds up inside your arteries), and essential primary hypertension. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/25/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 5. On 12/01/23 at 10:48 AM, the surveyor observed Resident #38 on edge of bed and during breakfast and there was a wheelchair (w/c) in the room. The surveyor reviewed the hybrid medical records of Resident #38. Resident #38's AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to chronic obstructive pulmonary disease, (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), morbid obesity (BMI 40 or higher, or if you're at least 100 pounds over your ideal body weight), obstructive sleep apnea (complete collapse of the airway or partial collapse with an associated decrease in oxygen), hyperlipidemia, and hypertension (type of high blood pressure that has no clearly identifiable cause). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 6. On 12/01/23 at 10:58 AM, the surveyor observed Resident #43 seated in a w/c inside their room watching tv. The surveyor reviewed the hybrid medical records of Resident #43. Resident #43's AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body), atherosclerotic heart disease, depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act), hypertensive (when the pressure in your blood vessels is too high (140/90 mmHg or higher), benign prostatic hyperplasia without lower urinary tract symptoms (Frequent or urgent need to pee, also called urination), hereditary and idiopathic neuropathy, and gastroesophageal reflux disease without esophagitis (GERD) (when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 13. On 12/01/23 at 11:40 AM, the surveyor observed Resident #26 ambulating the halls of the facility holding a bag in his/her hand. The surveyor reviewed the hybrid medical records of Resident #26. A review of Resident #26's AR indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; type 2 DM, COPD, and dementia. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/26/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was in July 2023 while CP #2 initial MRR was on 11/16/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 14. On 12/01/23 at 10:28 AM, the surveyor observed Resident # 56 in bed with O2 ongoing at 1.5 LPM via nasal cannula (NC) that was attached to an O2 concentrator. The surveyor reviewed the hybrid medical records of Resident #56. A review of Resident #56's AR indicated that the resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypercapnia (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient with an increase in partial pressure of carbon dioxide (PaCO2) above 45 mmHg), COPD, and type 2 DM. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the initial MRR was on 7/25/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was in July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 15. On 12/01/23 at 10:20 AM, the surveyor observed Resident #87 laying in bed with a blue splint on his/her right hand. The surveyor reviewed the hybrid medical records of Resident #87. A review of Resident #87's AR indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; dysphagia following cerebral infarction (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage following the pathologic process that results in an area of necrotic tissue in the brain or also known as stroke), gastrostomy (creation of an artificial external opening into the stomach for nutritional support or gastric decompression) and hypertension. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was in July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 16. On 12/01/23 11:15 AM, the surveyor observed Resident #90 sleeping in bed with O2 via NC at 4 LPM on concentrator. The surveyor reviewed the hybrid medical records of Resident #90. A review of Resident #90's AR that the resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia (condition where there is not enough oxygen in a person's blood), metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction) and hypertension. A review of the resident's CP Evaluation, a paper month-to-month report of CP #1 revealed that the last MRR date was on 7/24/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was in July 2023 while CP #2 initial MRR was on 11/17/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. 17. On 12/01/23 at 10:48 AM, the surveyor observed Resident #39 seated in a recliner wheelchair and well dressed. The resident's tube feeding (means of nourishment) was off while hung on a pole. The surveyor reviewed the hybrid medical records of Resident #39. Resident #39's AR reflected that that resident was a LTC resident at the facility and had diagnoses which included but were not limited to hypothyroidism unspecified (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism) and encounter for attention to gastrostomy (gastrostomy is the creation of an artificial external opening into the stomach for nutritional support example tube feeding). A review of the resident's Consultant Pharmacist (CP) Evaluation (or MRR), a paper month-to-month report of CP #1 revealed that the last MRR date was on 6/29/23. A review of the provided two binders for Pharmacy reviews showed that there were two different companies for CP. CP #1 last MRR was on July 2023 while CP #2 initial MRR was on 11/29/23. Further review of the hybrid medical records showed that there were no MRRs for August, September, and October 2023. On 12/06/23 at 9:01 AM, the surveyor interviewed the South unit Registered Nurse/Unit Manager (RN/UM) regarding CPs. The RN/UM informed the surveyor that the previous CP company had stopped service in mid-August 2023. The RN/UM stated that she was not sure about July 2023 because she was on vacation at that time. She further stated that she was unaware of the reason why the previous company of the previous CP #1 had terminated services in the facility because the facility management did not discuss why. On that same date and time, the RN/UM stated that the new company for CP #2 started last month (November 2023). Furthermore, the RN/UM confirmed that there was no covering CP during August, September, and October 2023 to do MRR. On 12/06/23 at 10:05 AM, the surveyor in the presence of the survey team asked the Licensed Nursing Home Administrator (LNHA) and the acting Director of Nursing (acDON) for the CPs contracts and timeline. At that same time, the LNHA confirmed after he reviewed the two binders for CPs MRRs that the last service of the previous CP was on 7/31/23 and the new CP's MRR start date was on November 2023. On that same date and time, the surveyor asked the LNHA why there were no CP services in August, September, and October 2023. The LNHA stated I don't know why there was a lapse, it will be the corporate office who knows the answer and coordinates all contracts because all contracts were coordinated by the corporate office. He further stated that he was aware that there was no CP at the facility for the last three months. On 12/06/23 at 10:21 AM, the surveyor in the presence of the survey team called CP #2 for an interview and the surveyor was unable to leave a message because the voicemail was full. On 12/06/23 at 10:22 AM, the surveyor in the presence of another surveyor called CP #1's company number, and the surveyor was able to speak to the CEO (chief executive officer (CEO) the highest-ranking executive in the company) who informed the surveyor that the CP services were terminated on 7/31/23 due to non-payment of the facility for approximately 14 months. On 12/06/23 at 10:28 AM, the LNHA provided a copy of the Agreement of the facility between the company of CP #2 that was signed by the Owner (CP #2 was also known as the owner) and the Chief Clinical Officer (CCO) of the facility on 11/16/23 that stipulated under Fees: Due Date: All payments are to be made in advance on the first of every month. On 12/06/23 at 10:32 AM, CP #2 called back and was interviewed by the surveyor in the presence of the survey team. CP #2 stated that she was also the owner of the consulting pharmacy and the pharmacist who came to the facility for MRR. She further stated that she started in November this year and per requirement, we come to the facility to review residents' medication records, and onsite visit requirements once a month. On 12/06/23 at 11:52 AM, the surveyor called and spoke to the CCO in the presence of the survey team. The CCO confirmed that there was no CP for the last 3 months (August, Sept, and October 2023) at the facility and that she was responsible for coordinating Consultant Pharmacist contracts of the facility. The CCO stated that the previous CP's company provided a three-day notice only to the facility when services were terminated which was why it took them months to be able to get another CP to be on board. She further stated that she tried multiple companies via phone communication and there was no email documentation of the inquiries to other companies. On 12/06/23 at 01:27 PM, the surveyor interviewed again CP #2 regarding communication with the facility's CCO regarding the start of service at the facility. CP #2 stated that it was the CCO who called her in September 2023 but she was unable to remember the exact date in September when she was asked by the CCO to be the facility's CP. CP #2 further stated that she informed the CCO that she would not be able to start until November 2023. At that same time, the surveyor asked CP #2 why was it important that the facility had a CP. CP #2 stated that it was important to have CP at the facility to make sure to review residents' medication records for the safety of the residents and compliance with the regulations. On 12/06/23 at 02:21 PM, CP #2 called back and stated that she wanted to make sure that the contract was ready and reviewed first prior to accepting the job at the facility. She further stated that she knew that there was a problem with the previous CP at the facility due to late payments. On 12/11/23 at 9:34 AM, the survey team met with the LNHA, Regional Director of Environmental Services (RDEVS), and Regional Infection Preventionist Nurse (RIPN). The surveyor asked the facility management if the CP services were part of the care of the residents and the RIPN responded yes and needed to be met. The RIPN further stated that the new CP started on 11/16/23. The facility management confirmed that there were no CP services in August, September, and October 2023. On 12/11/23 at 11:16 AM, the surveyor called and interviewed the CEO of the previous CP in the presence of the survey team regarding the facility-provided copy of an email dated 7/26/23 from the CEO regarding the termination of contract to the facility's company effective 7/31/23. The CEO stated that there were prior notifications provided to the company of the facility regarding late payments until final notification of termination of the contract was sent to the facility's regional office. A review of the previous CP contract with the facility that was provided by the LNHA was signed on 9/09/08 by the Facility/Covering Entity and the previous CP company's [NAME] President of Executive Services signed on 9/23/08 included in number 11 that it is agreed that [name of company] has the right to immediately terminate this contract if the facility does not abide by the reimbursement schedule agreed upon in this contract. On 12/14/23 at 01:37 PM, the LNHA stated that as per RIPN and his decision there was no additional information that the facility could provide and surveyors could proceed with decision-making. A review of the facility's Medication Regimen Review Policy with an original date of 9/2023 that was provided by the RIPN included that the drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. MRR or a Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. On 12/14/23 at 02:00 PM, the survey team met with the LNHA, RIPN, facility's IPN, acDON, and new DON for an Exit Conference. There was no additional information provided by the facility management. NJAC 8:39-29.3

Based on observation, interview, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a comprehensive care plan was developed for a resident who was receiving pain medication (Resident #18). This deficient practice was identified for 1 of 18 residents reviewed for care plans and was evidenced by the following: On 01/24/2023 at 11:30 AM, Resident #18 was observed awake and in bed. Resident #18 stated that the staff provided pain medication for the resident's pain. According to the admission Record, Resident #18 was admitted to the facility in 02/2013 with diagnoses which included but were not limited to; contracture of the left hand, mononeuropathy (nerve damage to brain or spinal cord ), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting the left non-dominant side. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/2/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 14 which indicated that the resident had intact cognition. An additional review of the MDS revealed that the resident was on a scheduled pain medication regimen. A review of Resident #18's Physician's Progress notes dated, 12/13/2022 at 8:52 PM, 12/20/2022 at 8:16 AM, 12/28/22 at 3:29 PM, 01/04/2023 at 8:01 PM, and 01/22/2023 at 7:18 PM, revealed that the resident had pain on and off of their entire body and was relieved with medication. A review of the resident's Order Summary Report which listed active physician's orders (PO) as of 1/27/2023 reflected the following POs: An order dated 11/03/2020, for Naproxen Sodium 220 milligrams (mg), 1 tablet orally every twelve hours for pain management; An order dated 12/15/2022, for Tramadol 50 mg, 1 tablet orally two times a day for pain management; An order dated 12/15/2022 for Tramadol 50 mg, 1 tablet every six hours as needed for pain (4-6); and An order dated 12/15/2022, for Morphine Sulfate Solution 20 mg per milliliter (ml) 0.25 ml by mouth every four hours as needed for pain (7-10) if tramadol is not effective. A review of the resident's December 2022, January 2023, and February 2023 Electronic Medication Administration Record (EMAR) reflected the above physician's orders. A review of Resident #18's care plans from the Electronic Medical Record (EMR) revealed there was no care plan developed for the resident's pain or pain medication. On 1/27/23, the Regional Infection Preventionist (IP) (who was covering for the Director of Nursing) provided an updated care plan for Resident #18 which was created on 1/27/23. The care plan included the resident was at risk for pain related to disease process, and interventions were added which included administering analgesics (medication to relieve pain) specify medication per orders, and to evaluate the effectiveness of pain interventions. During an interview with the surveyor on 02/02/23 at 10:20 AM Licensed Practical Nurse (LPN #1) stated Resident #18 was on pain management and should have a care plan for pain because the resident used pain medication. During an interview with the surveyor on 02/02/23 at 10:32 AM the Unit Manager (UM) stated that she was primarily responsible to complete resident care plans, but the nurses could also complete them. She stated care plans were reviewed quarterly unless there were any changes. The surveyor reviewed Resident #18's care plan, PO, and EMAR with the UM. She stated Resident #18 was on pain medication and confirmed that the care plan was initiated for pain on 01/27/23. The UM stated the pain care plan should have been initiated prior to 01/27/23. During an interview with the surveyor on 02/02/23 at 11:43 AM the Regional IP stated care plans were updated 48 hours after a change, reviewed quarterly, or when there was a change in condition. She stated the UM was responsible for updating care plans. The surveyor reviewed Resident #18's care plan and EMAR with the Regional IP. The Regional IP stated that pain and pain medication should have been on Resident #18's care plan. During a follow up interview with the surveyor on 02/03/23 at 12:34 PM, the Regional IP confirmed that Resident #18's care plan was not in place prior to surveyor inquiry and was completed by a regional Director of Nursing. A review of the facility's Comprehensive Care Plans policy, revised on 09/2022, included that it was the facility policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being. The comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: the attending physician, a registered nurse with responsibility for the resident. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. NJAC 8:39-11.2(e)