Complaint #: 186850 Based on interviews and medical record review (MR) and other pertinent facility documentation on 6/4/25, it was determined that facility failed to thoroughly investigate an allegation of abuse for 1 of 4 residents (Resident #4). This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #4 was admitted with diagnoses including but not limited to: Visual Loss, Presence of Artificial Eye, Unspecified Hearing Loss, and Anxiety Disorder. A review of the Minimum Data Set (MDS), an assessment tool dated 3/30/25, revealed that Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #4 was cognitively intact, and was Supervision/Touch assistance with ADLs (Activities of Daily Living), independent with transfers and continent of bowel and bladder. During an interview with the Surveyor on 6/4/25 at 12:30 P.M., Resident #4 stated that they were not able to remember the date or the exact time but stated that sometime after supper that someone came in the room and pulled down their pants. Resident #4 stated the person cleaned him/her up, put a diaper on them, even though they don't wear diapers. Resident #4 further stated that the person then started to put a hospital gown on them, and after he/she began to cry, they then took the hospital gown off and put their clothes back on him/her. Resident #4 stated that they are unsure who the individual was, because they cannot see, and has hearing loss. Resident stated that they told their family member about the issue. During a telephone interview with Resident #4's family member on 6/4/25 at 1:06 P.M., the family member stated the incident was video recorded and occurred on 5/23/25, and started at 8:57 P.M., and lasted until 9:20 P.M. The family member stated that the Certified Nursing Aide #1 (CNA #1) went into Resident #4's room, and stated to the resident, let me change your diaper. The family member stated that CNA#1 then looked down Resident #4's pants, he then goes to get a towel and [NAME] coat. CNA #1 then wipes the resident with the towel, and the resident then yells that it's cold, the family member states that CNA#1 then throws the [NAME] coat on the resident. The family member further stated that Resident #4 began to yell what is this, I have my own pajamas, and I have to go to the bathroom,' CNA#1 then put Resident #4's clothes back on. The family member stated that another aide came into the room and told CNA#1, you're not supposed to do this for [resident], and she got the resident out of bed and took them to the bathroom. The facility provided a Reportable Event Record/Report dated 5/31/25. The summary and conclusion was included with the Reportable. The Administrator was not able to provide any statements regarding the incident. The Administrator verified that she conducted the investigation for the incident. Surveyor attempted to call CNA#1 on 6/4/25 at 2:30 P.M., there was no answer, and call was not returned. During an interview with the Licensed Practical Nurse (LPN) on 6/4/25 at 3:02 P.M., she stated that she was Resident #4's primary nurse on the night of the incident. The LPN stated that she heard Resident #4 yelling as she was passing by the room. She stated as she walked in the room, she observed CNA #1 providing care. She stated she then told CNA #1, you don't need to do anything for Resident #4, they are independent. LPN stated that to calm Resident #4 down, she allowed Resident #4 to feel her arm and hold on to her, because Resident #4 cannot see and did not have their hearing aids in their ears. She stated Resident #4 was yelling, I have to go to the bathroom. LPN denied being asked to write a statement. During an interview with the LPN/Infection Control Nurse (LPN/ICN) on 6/4/25 at 3:36 P.M., she stated that she was notified of the incident on 5/26/25, and she spoke to Resident #4's family member regarding the incident that occurred on 5/23/25. She stated the family member stated they had mentioned that she felt Resident #4 was inappropriately touched, and they wanted to provide videos of the incident. Stated that she watched the video of the care, stated that she did not see CNA #1 touch Resident #4 inappropriately, however, when CNA #1 pulled Resident #4 up in the bed, the resident did say ouch. Resident #4 allowed her to do a full skin assessment, and she did not see any bruising on Resident #4's skin. She further stated that she explained everything that was in the video to the Administrator. She denied writing a statement. During an interview with the Administrator on 6/4/25 at 4:10 P.M., she stated that during an investigation of abuse that involves a staff member, the staff member is immediately suspended pending the investigation. The investigator then speaks to the involved residents, staff, and family members to find out what happened. They would also speak to other alert and oriented residents on the alleged staff member's assignment. The Administrator stated she did not collect statements from other staff members that worked at the time of the incident, nor did she collect statements from other alert and oriented residents on the staff member's assignment. The administrator denied watching the video recording of the incident. A review of the facility's policy presented by the Administrator, titled Abuse. Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revision date of September 2022, , included but was not limited to the following: under the heading for Policy Statement, it states, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the heading, Investigating Allegations, it states: 1. All allegations are thoroughly investigated. The administrator initiates investigations .7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence .d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; .h. interviews staff members (on all shifts) who have contact with the resident during the period of the alleged incident .j. interviews other residents to whom the accused employee provides care or services; .l. thoroughly documents the investigation completely and thoroughly. N.J.A.C: 8:39-4.1 (a) 5, 12

Based on observation, interviews, and record review, it was determined that the facility failed to provide nail care to a resident who required extensive assistance from staff for Activities of Daily Living (ADL). This deficient practice was identified for 1 of 7 residents (Resident #13) reviewed for ADL care. The deficient practice was evidenced by the following: On 03/25/24 at 10:28 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed, with his/her right hand from middle finger to pinky finger closed into a fist and the index finger pointing out with an elongated thickened non-smooth nail. The surveyor was not able to observe the resident's right hand nails from the middle finger to pinky finger. Resident #13's left hand had long nails on the thumb, index finger and the pinky finger. The third and fourth fingernails had jagged appearance. The surveyor reviewed the medical records for Resident #13. A review of the admission Record face sheet reflected Resident #13 was admitted to the facility with diagnoses which included, but were not limited to, Cerebrovascular Disease ([CVA] conditions that affect blood flow to your brain), Right leg above knee amputation (removal of a limb), and Atherosclerotic heart disease (buildup of plaque in arteries causing reduced blood flow). A review of the most recent Quarterly Minimum Data Set (MDS) an assessment tool to facilitate resident care dated 03/13/24 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Section GG Functional Abilities and Goals reflected that the resident had an impairment on one side in the upper extremity. The MDS revealed that the resident required extensive assistance and was dependent on staff for most ADLs and personal hygiene. Section E Behavior indicated that the resident did not exhibit rejection of care. A review of the resident's Care Plan (CP) did not reflect the Resident had a ADL self-care performance deficit and required assistance with ADLs. On 03/26/24 at 01:26 PM, the surveyor interviewed Certified Nursing Aide (CNA) #1, who stated that if she sees a resident with long nails and the residents were alert then she would ask the resident if she could trim their nails. On 04/01/24 at 12:07 PM, the surveyor asked the resident how he/she feels about his/her nails being that long or if the staff cleans their nails during care. The resident stated I don't like them (nails) too long. They don't clean the nails when they provide care. My hand is now contracted before I was able to use the right hand. On 04/02/24 at 11:47 AM, the surveyor interviewed CNA #2 who stated she was familiar with Resident #13. She stated that the resident was total dependence with care. CNA #2 stated that she cleans the nails when she provides care. I cut/trim residents nails if they need to be cut. The surveyor asked the CNA if they keep a log for nail care and the CNA stated, No log. On 04/02/24 at 12:17 PM, the surveyor interviewed the 3rd floor Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that the CNA's are supposed to do basic nail care such as cutting and filing hand nails only. The UM/LPN stated, it was important to cut/trim nails because of an increased risk for infection, easy to scratch themselves or the staff, and for manipulations of utensils. The UM/LPN entered Resident #13's room with the surveyor. When asked about the resident's nail care, the UM/LPN stated, The resident has long nails and would benefit from having their nails cut and filed today. On 4/4/24 at 03:17 PM, the survey team met with LNHA, DON and Regional Nurse to present the above concerns. A review of the facility provided undated Position Title: Certified Nurse Aide document under responsibilities/ Accountabilities included: Bathes the resident in bed, tub or shower, combs hair, cleans and cuts fingernails and given shampoos. A review of the facility provided ADL Care policy revised on 09/2023 included: The level of assistance needed for any ADL activity will be included on the resident's plan of care. The care plan will describe potential distress triggers or behaviors as related to the completion of ADLs. A review of the facility provided Comprehensive Care Plan policy revised on 09/2023 included: The care planning process will include an assessment of the resident's strengths and needs and will incorporate the president's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlines by the comprehensive care plan, shall be culturally competent and trauma-informed. NJAC 8:39-27.2 (g)

Based on observation, interviews, record review and review of other relevant facility documentation, it was determined that the facility failed to obtain and carry out an order to discontinue a Peripheral Intravenous line (IV [In a vein]) and to maintain the site according to professional standards of practice. The deficient practice was identified for one of one residents (Resident #326) reviewed for IV therapy. The deficient practice was evidenced by the following: On 3/26/24 at 11:43 AM, the surveyor observed the resident's left forearm (region of the upper limb between the elbow and the wrist) with an IV line in place. The IV line was covered by a transparent dressing. The tape holding the dressing to the skin was peeling off. The surveyor noted the IV line was not dated or initialed. There were no medications or fluids infusing through the IV line during this observation. A review of the admission record (an admission summary) revealed that the Resident #326 was admitted to the facility with the follow diagnoses, which included but not limited to; Urinary tract infection (UTI [infection of any part of the urinary tract]), Fournier gangrene (a rare, life-threatening bacterial infection of your scrotum, penis or perineum [the area between your genitals and rectum]) and Type 2 Diabetes. Further review of Resident #326's admission record reflected that the resident was admitted to the facility with an IV access site. A review of the resident's admission Minimum Data Set (MDS), a tool used to facilitate the management of care, dated 3/12/24, revealed that the resident's Brief Interview for Mental Status (BIMS) score was 11 out of 15, which indicated the resident was moderately cognitively impaired. MDS section N and O reflected that the resident was on IV antibiotics within the past fourteen (14) days while at the facility. A review of the March 2024 Physician Orders (PO) revealed a PO dated 3/5/23 for the following: Ceftriaxone Sodium injection Solution Reconstituted 1 GM (gram). Use 100 ml intravenously one time a day for UTI for six (6) days. Further review of the PO did not reveal a PO to maintain or discontinue an IV line after the completion of IV antibiotics. Further review of the PO's did not reveal an order to assess or to discontinue the left forearm IV line. A review of the March 2024 Medication Administration Record (MAR) revealed that Resident #326 had received IV Ceftriaxone Sodium once a day for six (6) days from 3/6/2024 to 3/11/2024 for a UTI. The order was signed as given as ordered at 0630 (06:30 AM). Further review of the MAR and Treatment Administration Record (TAR) March 2024 did not reveal that the left foream IV line had been assessed or discontinued. A review of the Care Plan ([CP] a document that summarizes a person's health condition, specific care needs and health condition) did not reveal a focus for IV-line care or IV antibiotics. A review of the Physician Progress Note dated 3/18/24 entered and signed by an Infectious Disease (ID) Advance Practice Nurse (APN) revealed: Recommendation: 4. Can d/c (discontinue) PIV (peripheral IV) from ID standpoint .case and care plan reviewed and discussed with Dr. [name redacted] and nurse. On 3/28/24 at 11:28 AM the surveyor interviewed the resident's Registered Nurse (RN). The RN stated, the resident is not on antibiotics now and stated, I don't know when his/her IV was inserted. On 3/28/24 at 11:40 AM the surveyor interviewed the RN/ Charge Nurse (RN/CN). The RN/CN stated that the resident came in with the IV line from the hospital and further stated, I don't know when it was inserted in the hospital, but I have to check his/her hospital records and get back to you. The RN/CN then reviewed Resident #326's progress notes dated from 3/6/2024, in the presence of the surveyor and stated, It (the note) says PICC line (is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). The RN/CN reviewed the resident's paper chart/medical records from the hospital. The surveyor requested a copy of the Universal Transfer Sheet ([UTS] ensure that accurate communication of pertinent clinical patient care information is conveyed at the time of a transfer between healthcare facilities or programs). At 12:15 PM, the surveyor received and reviewed the copy of the UTS with the RN/CN which revealed: 17 IV Access which revealed the option for Saline lock (which is referred to IV line also) was checked off. At 12:48 PM, the RN/CN and the surveyor went to the resident's room to confirm the access site. The RN/CN acknowledged, It's an IV line and it was unacceptable that it was still there. During a follow up interview with the RN/CN in regard to the purpose of removing an IV line, the RN/CN stated Infection is definitely a major one. Infection can lead to causing other things like sepsis. The RN/CN further stated that any nurse can get PO to discontinue an IV line after the completion of antibiotics. The surveyor reviewed the CP with the RN/CN and asked if IV-line care or antibiotics should have been care planned for and RN/CN stated, it might be that they (the MDS coordinator) removed it since he/she (the resident) completed his/her IV antibiotics. On 3/28/24 at 01:01 PM, the surveyor interviewd the MDS coordinator, who acknowledged that the focus CP for IV-line care or antibiotics use was not there. On 3/28/24 at 02:17 PM, the surveyor interviewed the Director of Nursing (DON) in regard to her expectation of staff if a resident was admitted with an IV line. The DON stated, the IV line should be changed every 3 days but As a nurse, I will follow the policy. The DON also acknowledged that the IV line should have been care planned. On 4/02/24 at 09:48 AM, the DON provided the surveyor a timeline for Resident #326's IV line. A review of the time line revealed: Hospital records state PICC line, upon admission assessment, resident had IV peripheral (IVP) line to left forearm. Resident was receiving antibiotics from admission to 3/11/24. On 3/13/24, ID phyiscian assess resident and recommened IVP to be removed. No order was written for removal. Staff continued to maintian IVP and on 3/18, the ID physician recommended removing the line-no order was written. Order received on 3/28/24 (after surveyor inquiry) to remove the line and nurse removed with no issues. On 4/03/24 at 11:43 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that upon admission, the staff should document the kind of access the resident had and when it was inserted. She further stated it should all be documented in the admission assessments and also in progress notes. The ADON stated, the IV line is changed every 3 days to prevent infection and for Resident # 326, the IV line should have been removed after the completion of IV antibiotics. The ADON acknowledged that the CP should have been initiated for IV line and stated, No, it is not acceptable that the IV-line CP wasn't initiated. On 4/04/24 at 3:17 PM, the survey team met with the LNHA, DON and Regional Nurse to present the above concerns. No additional infomration was provided. A review of the facility's policy Catheter insertion and care with an effective date 8/1/2018, revealed: Policy: Peripheral IV dressings will be changed when needed to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 2. Change the dressing if it becomes dampl, loosened or visibly soiled and at least every 5 to 7 days. Change dressing and perform site care if signs and symptoms of site infection are present. A review of the facility plociy Comprehensive Care Plans policy, revised on 09/2023 revealed: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan 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. NJAC 8:39-25.2(c)5

NJ #159787 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of foods served to the residents. This deficient practice was identified for 5 of 5 residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 04/05/24 for 1 of 3 nursing units (2nd Floor unit) tested for food temperatures and was evidenced by the following: On 03/27/24 at 10:51 AM, the surveyor met with five residents for a resident council meeting. Three out of five residents resided on the 3rd floor. Two out of five residents resided on the 4th floor. Five of five residents agreed that the food trays were not warm. On 04/05/24 at 11:14 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team. On 04/05/24 at 12:24 PM, the surveyor observed the lunch truck arrive to the 2nd floor. The Assistant Director of Nursing (ADON) met the food truck. A regular diet consistency tray (Resident #120) was removed and verified by the surveyor and the ADON. The tray was placed at the nurse's station. At 12:25 PM, the Unit Clerk called the kitchen and ordered a replacement tray for Resident #120. The nursing staff began delivering the resident's food trays. At 12:35 PM, the last tray was delivered. The surveyor tested the food temperatures on the reserved tray in the presence of the ADON. The temperatures were as follows: Roast Beef 3 oz & gravy 2 oz: 122.5 degrees F roasted potatoes 4 oz.: 121.0 degrees F Capri veg blend 1/2 cup:115.9 degrees F cream of tomato 6 oz: 144.0 degrees F fruit cup 1/2 cup (watermelon): 53.3 degrees F 1% milk 8oz: 54.3 degrees F On 04/05/24 at12:45 PM, the surveyor interviewed the Food Service Director (FSD), who stated that the lunch tray line was set up at approximately 10:55 AM-11:00 AM. He then stated that food temps were taken just prior to the first tray being pulled at approximately 11:00 AM to 11:10 AM. The FSD stated the 4th floor gets delivered first, then the 2nd floor and then the 3rd floor. The FSD provided the surveyor with the Service Line Checklist which revealed that at the time of service the temperaturyes were as follows: Roast Beef was 176 degrees F, roasted potatoes was 178 degrees F, Broc/Caulif (broccoli/cauliflower) was 178 degrees F, watermelon was 34 degrees f, and the tomato soup was 181 degrees F. On 04/05/24 at 01:52 PM, during a follow up interview with the FSD, in the presence of the survey team, he stated that the 2 cooks verify the food temperatures. He verified that yes, everything (in the kitchen) was functioning properly today. The surveyor reviewed the above mentioned temperatures observed on the 2nd floor with the FSD. He stated he takes temperatures of the food that has been on the truck the longest before the truck is ready to leave the kitchen, but he does not record it. The FSD stated that they use pellets (keeps hot food at safe temperatures) on their trays. He stated the purpose of taking the food temperatures were to ensure the food was palatable and consistent. On 04/05/24 at 02:56 PM, the above findings were presented to the Licensed Nursing Home Administrator, the Director of Nursing, and the Region Clinical Operations/Registered Nurse in the presence of the survey team. A review of the undated facility's policy Cold Food Policy revealed Policy: The kitchen will receive and deliver cold foods to residents at a temperature of 41 degrees Fahrenheit or lower. 6. Food will be delivered to residents at a temperature of 41 degrees or lower. A review of the undated facility's policy Hot Food Policy revealed Policy: All managers are responsible for training dietary staff on how to take and monitor food temperatures on a daily basis. For quality assurance. Food temperature will be monitored, and test tray temperature will be monitored. 7. The Food Service Director .will monitor test tray temperatures. NJAC 8:39-17.2(g);17.2 (a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure foods were provided in accordance with physician's orders and resident preferences identified in their plan of care. This deficient practice was identified for 2 of 4 residents reviewed for nutrition (Resident #114 and #120). This deficient practice was evidenced by the following: 1. On 3/27/24 at 10:57 AM, the surveyor observed Resident #114 seated in a wheelchair at a table in the dining area drinking water. On 3/28/24 at 12:18 PM, the surveyor observed the resident's lunch tray. The meal ticket indicated the tray items should have included four ounces (oz.) of red bean chili, a creamy peanut butter and jelly sandwich, a ½ cup of Fortified mashed potatoes, a ½ cup of green peas, one piece of cornbread, six oz. chicken orzo soup, one serving of a low-sugar house shake, ½ cup of fruit cup, one vanilla ice cream, a four oz. cranberry juice, eight oz. of whole milk and six oz. of tea. There was no evidence of a low-sugar house shake, the Fortified mashed potatoes and there was a chocolate ice cream (not vanilla) on initial observation. On 3/28/24 at 12:35 PM, the surveyor reviewed the meal ticket versus items on the lunch meal tray with the Licensed Practical Nurse (LPN)/Unit Manager (UM) who acknowledged there were no Fortified mashed potatoes (white rice was served), no low-sugar house shake and a chocolate ice cream instead of vanilla on the tray. On 4/1/24 at 12:15 PM, the surveyor observed the resident seated in the dining area. The surveyor observed his/her tray placed on the table and the LPN/UM sat next to the resident to assist. Prior to that, the surveyor observed an opened empty container of health shake in his/her room. Review of Resident #114's admission Record (an admission summary) reflected the resident had diagnoses which included but were not limited to; Alzheimer's Disease, malignant (cancer) . tumors, and cachexia (unintentional weight loss). Review of the residents admission Minimum Data Set (MDS), a tool to facilitate the management of care, dated 12/29/23 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated his/her cognition was severely impaired. It also reflected the resident received a therapeutic diet (a meal plan that is modified or tailored to fit the nutrition needs of a particular person). Review of the April 2024 Order Summary Report (OSR) reflected physician's orders (PO) for a four oz. Health Shake with lunch and dinner and Super Mashed with meals, both with a start date of 1/5/24. Review of the electronic Medication Administration Record's (eMAR) for January 2024 through April 2024, reflected the PO's noted above. Review of the Nutrition Care Plan initiated 12/27/23, reflected the above PO's as interventions. Review of the Registered Dietitian's (RD) initial evaluation dated 12/26/23, reflected that the resident enjoyed vanilla ice cream and it would be provided with lunch and dinner. Review of the RD's Nutrition Note dated 1/5/23, reflected that super mashed potatoes would be provided with lunch and dinner. On 3/28/24 at 12:35 PM, the surveyor interviewed the LPN/UM who acknowledged that the missing tray items on the lunch tray were nutritional interventions that were part of the resident's plan of care to promote weight gain. On 3/28/24 at 12:43 PM, the surveyor interviewed RD #1 and reviewed the items that were not provided on Resident #114's lunch tray. She acknowledged that the house shake and fortified foods were part of the resident's plan of care which provided extra nourishment to promote weight gain. She could not speak to why these items were not provided and that there should have been an employee in the kitchen that checked the tray for accuracy before delivery to the resident. On 3/28/24 at 1:16 PM, the surveyor interviewed the Food Service Director (FSD). He acknowledged that there were no low-sugar health shakes in the facility. On 4/05/24 at 12:45 PM, the surveyor interviewed Regional RD #2 (RRD) in the presence of the survey team. She stated that super mashed potatoes were one of the fortified foods available. And that these foods were nutritional interventions to promote weight gain or prevent weight loss because they were nutrient dense. The RRD further stated that this was part of the resident's individualized plan of care. She stated that there would have been a PO and there was accountability on the eMAR. She could not speak to which kitchen employee was responsible to ensure tray accuracy but acknowledged that someone should have been responsible. 2. On 03/25/24 at 11:23 AM, the surveyor observed Resident #120, who was groomed and offered no concerns. On 4/05/24 at 12:35 PM, the surveyor observed the residents lunch tray and reviewed the meal ticket versus items on the tray with the Assistant Director of Nursing (ADON). The meal ticket indicated the resident should have received two large portions of protein, however there was three oz. on the plate; there should have been a dinner roll, however a slice of bread was provided; eight oz. of whole milk should have been provided instead the resident received one percent milk; and there was supposed to be a four oz. juice and eight oz. of coffee on the tray, neither of which were provided. Review of resident #120's admission Record, reflected the resident had diagnoses that included but were not limited to; type 2 diabetes and Parkinson's Disease (a progressive disease of the nervous system). Review of the residents admission MDS dated [DATE], reflected a BIMS score of 15 out of 15 which indicated the resident had an intact cognition. It also reflected the resident was on a therapeutic diet. Review of the Nutrition Care Plan initiated 3/4/24, included the intervention Provide me with my food/beverage preferences as available. Review of the Registered Dietitian's (RD) initial evaluation dated 3/4/24, reflected that the resident had a history of unplanned weight loss and would be provided large protein portions at meals as per his/her preference. On 4/05/24 at 12:45 PM, the surveyor interviewed the FSD who stated that the cook or the caller position checked the meal trays to ensure accuracy and that if an item was not available, he should have been notified. He stated that if the meal ticket indicated coffee, whole milk and a dinner roll that is what should have been provided. The FSD then stated he was aware that the facility was out of whole milk. On 04/05/24 at 1:05 PM, the surveyor interviewed the RRD who stated she should have been notified if there was no whole milk available. She further stated that a protein portion was three oz. and if the meal ticket indicated two (2) portions, the resident should have received six oz. On 4/05/24 at 1:52 PM, the surveyor interviewed the FSD who stated that if a meal ticket indicated a large portion of protein, the resident should have received eight oz. He stated that one of the cooks should have checked the trays for accuracy today and could not state whether or not any employee ensured lunch tray accuracy for the lunch meal service. He acknowledged he had not assigned anyone this task. On 4/05/24 at 2:56 PM, the Licensed Nursing Home Administrator (LNHA) acknowledged the concerns regarding tray accuracy. On 4/08/24 at 11:30 AM, the LNHA stated there was no additional information to present for above mentioned concerns. Review of the undated facility policy Medical Nutrition Therapy Documentation included that medical nutrition therapy for each individual was the responsibility of the RD and the FSD. Review of the undated facility policy Therapeutic Diets included that all residents would be given foods based on their diet order which was prescribed by the physician. In addition, the policy included that the purpose of a therapeutic diet was to eliminate or decrease specific nutrients in the diet or provide food that a resident is able to consume. Review of the undated facility policy Fortified Foods and Supplements included Fortified foods and supplements will be given inn accordance with the orders of a physician or registered or licensed dietitian. In addition, the policy included that The supplement or fortified food item is then added to the resident's meal tray card ticket to be prepared, served and delivered accordingly. Review of the undated facility policy Dining and Food Preferences included Individual dining, food and beverage preferences will be identified, accommodated, and followed for all residents. It further included that all preferences will be added to the meal tray card ticket. Review of the undated facility policy Tray Accuracy included the following: - Each residents individual meal tray will be set up and made according to the resident's personal meal tray card ticket. All items described on this ticket will be present on the tray. The defined diet and the individual needs and food preferences will be present on the tray including likes and dislikes in accordance with the compliance guidelines. - All trays will be checked by the Dietary representative calling the tray line and setting up each tray. Each tray will then be checked by a Dietary management team member prior to being sent to the unit. - Once received on the unit, the healthcare professional will check the tray prior to serving it to the resident. Review of a signed and undated Cook job description included that the cook was responsible and accountable for following menus and special diet instructions. Review of a signed Dining Services Director job description dated 2/27/24, included the following responsibilities: - Prepare food for regular and therapeutic diets according to the planned menu and written doctor's orders. - Purchase food, supplies, and equipment, as required to meet the needs of the department. - Ensure that a stock of staple/non-staple food, supplies, equipment, etc., is maintained at adequate levels at all times to perform departmental functions. NJAC 8:39-17.4(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and other facility documentation, it was determined that the facility failed to complete weekly skin evaluations for 3 of 3 residents (Resident #5, #49 and #86) reviewed for pressure ulcers. This deficient practice was evidenced by the following: 1.On 03/25/24 at 11:10 AM, during initial tour of the 4th floor, the surveyor observed Resident #5 in bed. The surveyor attempted to interview the resident but he/she was unable to answer the surveyor's questions. A review of Resident #5's Electronic Medical Record (EMR) revealed the following: According to the admission Record, Resident #5 was admitted to the facility with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Epilepsy, (a brain condition that causes recurring seizures) Unspecified, Not Intractable, without Status Epilepticus. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/29/24, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 9 out of 15 which indicated that the resident was moderately cognitively impaired. Further review of the MDS, revealed the resident had one Stage 3 (full thickness tissue loss. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer. A review of the physician Order Summary Report (OSR) revealed an active physician's order (PO) for: Skin evaluation weekly every evening shift every Tue for Skin Evaluation. Complete COMS-Skin Only Evaluation (under Evaluation Tab). Report abnormal findings as per protocol. A review of the Treatment Administration Record (TAR) for January 2024 revealed that the above PO for Skin evaluation weekly was signed as completed for Eveni (evening) on 01/02/24, 01/16/24 and 01/23/24. The Eveni was left blank for 01/09/24 and 01/30/24. A review of the TAR for February 2024 revealed that the above PO for Skin evaluation weekly was signed as completed for Eveni on 02/06/24, 02/13/24 and 02/27/24. The Eveni was left blank for 02/20/24. A review of the TAR for March 2024 revealed that the above PO for Skin evaluation weekly was signed as completed for Eveni on 03/05/24, 03/12/24, 03/19/24, and 03/26/24. A review of the skin evaluations (under the Evaluations tab) revealed a N Adv - Skin Only Evaluation dated 2/19/2024. There were no other skin evaluations documented under the Evaluations tab for January, February, or March 2024. A review of the resident's Care Plan revealed a Focus: potential for pressure ulcer development r/t (related to) Disease process, impaired mobility, incontinence. Lt (left) buttocks-stage 3 02/29/2024 seen by Heritage wound care- resolved. Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown in [name redacted]. On 04/01/24 at 12:20 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who confirmed she was Resident #5's assigned nurse. She stated that skin assessments were usually done at least weekly on shower days. She then stated that the skin assessment should be documented under Evaluations in the EMR. On 04/02/24 at 09:42 AM, the surveyor interviewed the 4th floor LPN/Unit Manager (UM), who stated that resident's skin gets checked weekly and a skin check evaluation should be done in the EMR. He stated that skin evaluations were required if there was not a wound or if a wound was still there or if the wound was healing. The LPN/UM stated that the assessment was charted on the TAR and under the Evaluation tab. On 04/02/24 at 09:48 AM, the LPN/UM reviewed the EMR in the presence of the surveyor for Resident #5. He verified the above PO for weekly skin assessments. He confirmed that the 02/19/24 skin evaluation under the Evaluations tab was the only evaluation documented since 01/01/24. The LPN/UM confirmed no additional skin evaluations were completed since 2/19/2024. He stated the purpose of the evaluations was to check if skin was intact, to make sure the proper treatment was being done. He stated that the evaluations should be done even if a wound was already present because they still need to monitor the skin in addition to the wound to identify any new areas. He then stated that the Certified Nursing Assistant (CNA) would also identify new wounds. 2. On 03/27/24 at 11:33 AM, the surveyor observed Resident #49 sitting in a reclining chair in the common area on the 4th floor. The resident had their eyes closed. A review of Resident 49's EMR revealed the following: According to the admission Record, Resident #49 was admitted to the facility with diagnoses that included but were not limited to: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety and a Pressure Ulcer of Sacral Region, Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). The Quarterly MDS dated [DATE], indicated that the facility assessed the resident's cognitive status using a BIMS. The resident scored a 00 out of 15 which indicated that the resident was severely cognitively impaired. Further review of the MDS, revealed the resident had one Stage 3 pressure ulcer. A review of the physician OSR revealed an active PO for: Skin evaluation weekly every (Monday) on (11-7) evening shift every Mon for Skin Evaluation. Complete COMS-Skin Only Evaluation (under Evaluation Tab). Report abnormal findings as per protocol. A review of the TARs for January 2024 revealed that the above PO for skin evaluations weekly was signed as completed for Night on 01/08/24, 01/15/24 and 01/22/24 and 01/29/24. The Night was left blank for 01/01/24. A review of the TARs for February 2024 revealed that the above PO for skin evaluations weekly was signed as completed for Night on 02/05/24, 02/12/24, 02/19 /24 and 02/26/24. A review of the TARs for March 2024 revealed that the above PO for skin evaluations weekly was signed as completed for Night on 03/04/24, 03/11/24, and 03/25/24. The Night was left blank for 03/18/24. A review of the skin evaluations (under the Evaluations tab) revealed a N Adv - Skin Only Evaluation dated 2/19/2024. There were no other skin evaluations documented under the Evaluations tab for January, February, or March 2024. A review of the resident's Care Plan revealed a Focus: has a high risk for ulcer sacrum-pressure, rt (right) heel- pressure ulcer r/t Immobility, sacrum Date Initiated: 03/01/2022, Revision on: 03/22/2024. On 04/02/24 at 09:48 AM, the surveyor interviewed the 4th floor LPN/UM, who confirmed he was Resident #49's assigned nurse. He reviewed the EMR in the presence of the surveyor. He verified the above PO for weekly skin assessments. He then acknowledged that the only documented skin assessment under Evaluations from January to present was the N Adv - Skin Only Evaluation dated 02/19/2024. 3. On 03/25/24 at 11:17 AM, during the initial tour of the 3rd floor, Resident #86 was observed in a reclining chair in the activity area. A review of Resident 86's EMR revealed the following: According to the admission Record, Resident #86 was admitted to the facility with diagnoses that included but were not limited to: Pneumonia, Unspecified Organism (An infection of the air sacs in one or both the lungs) and Dysphagia, Oropharyngeal Phase (difficulty swallowing food or water). The Quarterly MDS dated [DATE], indicated that the facility assessed the resident's cognitive status using a BIMS. The resident scored a 00 out of 15 which indicated that the resident was severely cognitively impaired. Further review of the MDS, revealed the resident's skin was intact. A review of the physician OSR revealed an active PO for: Skin evaluation weekly every Monday on evening shift. Every evening shift every Mon for Skin Evaluation. Complete COMS-Skin Only Evaluation (under Evaluation Tab). Report abnormal findings as per protocol. A review of the TARs for January 2024 revealed that the above PO for Skin evaluations weekly was signed as completed for Eveni on 01/01/24, 01/08/24, 01/15/24 and 01/29/24. The Eveni was left blank for 01/22/24. A review of the TARs for February 2024 revealed that the above PO for Skin evaluations weekly was signed as completed for Eveni on 02/05/24, 02/12/24, 02/19/24 and 02/26/24. A review of the TARs for March 2024 revealed that the above PO for Skin evaluations weekly was signed as completed for Eveni on 03/04/24, 03/11/24, and 03/25/24. The Eveni was left blank for 03/18/24. A review of the skin evaluations (under the Evaluations tab) revealed a N Adv - Skin Only Evaluation dated 01/16/24, 01/30/24, 02/13/24, and 3/12/24. There were no other skin evaluations documented under the Evaluations tab for January, February, or March 2024. A review of the residents Care Plan revealed a Focus: has sacral pressure ulcer -resolved Rt lateral thigh-surgical-3/28/24 infection to rt thigh rt arm-skin tear-resolved 8/31/23 skin tear lt hand-resolved r/t Immobility Date Initiated: 08/29/2022 Revision on: 03/28/2024. Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown. On 04/02/24 at 10:07 AM, the surveyor interviewed the CNA, who stated that if new skin break down was identified, she would call the nurse in to see it. On 04/02/24 at 10:25 AM, the surveyor interviewed the 2nd floor Desk Nurse/Registered Nurse (DN/RN), who stated that skin assessment were done weekly in the evening and that it should be documented under the skin assessment under Evaluations tab. She stated the assessments should be signed off on the TAR as being completed and then document skin assessments. The DN/RN stated it (documentation) should be done regardless of skin breakdown or not. The DN/RN stated the purpose was to know if a wound was improving, if there was development of a wound, and to make sure there was nothing present that wasn't there before. On 04/02/24 at 10:30 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that skin assessments were done weekly by the nurses. She then stated that the CNA's would notify the nurse if anything new comes up. The ADON stated that the assessment was documented on the Medication Administration Record (MAR) or TAR. She further stated that the skin assessment would be done weekly usually with the resident's shower and if anything, abnormal was found a skin evaluation would be done. On 04/03/24 at 12:17 PM, the surveyor interviewed the Regional Clinical Operations/Registered Nurse (RCO/RN) who state that skin should be assessed on admission, readmission, weekly and as needed. She stated that it (the skin assessment) should be documented in the EMR under the Evaluations tab. The RCO/RN stated that every resident should have a weekly skin assessment regardless of skin breakdown or not. She stated the purpose was to monitor skin abnormalities and to make sure interventions were put in place. At that time, the RCO/RN reviewed the facility provided OSR for Resident #5 and #49. She confirmed that the Complete COMS-Skin Only Evaluation (under Evaluation Tab) should be completed weekly as ordered. She reviewed the TARS and stated that if nurses are signing the TAR, they were acknowledging that the skin assessment was completed on skin assessment COMS tab. She further stated if they (nurses) don't sign it, it was not completed. If it is not documented, it is not done. She then reviewed the Evaluations tab in the EMR in the presence of the surveyor and verified that there was only a skin assessment documented on 02/19/24. On 04/03/24 at 12:45 PM, the surveyor made the Licensed Nursing Home Administrator, the DON and the RCO/RN were made aware of the above findings for Residents #5, #49, and #86. No additional information was provided. A review of the facility's policy Pressure Ulcer Prevention & Management Policy revised 9/2023, revealed Policy: It is the policy of this facility to assess all resident upon admission; readmission and quarterly thereafter for risk factors associated with Pressure Ulcer development and the necessary precautions to prevent formation. Appropriate interventions will be utilized to prevent pressure ulcer development and to promote healing when pressure ulcer are present. Procedure: 1. All residents will be assessed on admission, re-admission, if noted with significant change in condition, and quarterly thereafter for the risk of PRESSURE ULCER formation using the BRADEN SCALE. 3. THE SKIN ONLY EVAL will be completed by the licensed nurse weekly to determine effectiveness of treatment. NJAC 8:39-25.2 (c), 27.1(e)

Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) staff followed a Physician Orders (PO) for the administration of an insulin medication for 1 of 1 resident (Resident #96) reviewed for the management of insulin, b.) medications were observed as accurately and timely administered to one (1) of five (5) residents, (Resident #54) reviewed for medication administration, and c.) to ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automated medication dispensing system (AMDS) located on the 2nd floor nursing unit. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A.) On 03/26/24 11:49 AM, Resident #96 was observed in the room. The resident was in bed and watching television. The resident was alert and verbalized no issues or concerns to the surveyor. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to the following: diabetes mellitus (DM) type 2(the pancreas does not make enough insulin), cerebral infarction due to occlusion(blockage which prevents blood flow to the brain), and occlusion and stenosis of left carotid artery (narrowing of the blood vessel that prevents blood flow). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident's Brief Interview for Mental Status (BIMS) was 13 out of 15, which indicated that the resident's cognition was intact. A review of the Order Summary Report (OSR) revealed a PO dated 2/16/24, for insulin Glargine subcutaneous (under the skin) solution 100 unit/ml (insulin Glargine) inject 14 unit subcutaneously in the evening for DM Hold if BS (blood sugar) is less than 100. A review of the February 2024 electronic Medication Administration Record (eMAR) revealed the above PO for the insulin Glargine had been signed as administered as ordered from 2/16/24 to 2/29/24 at 2000 (08:00 PM). Further review of the eMAR, did not reveal documentation that a blood sugar was obtained prior to the administration of medication. A review of the March 2024 eMAR revealed the above PO for the insulin Glargine had been signed as administered as ordered from 3/1/24 to 3/25/24 at 2000. Further review of the eMAR did not reveal documentation that a blood sugar was obtained prior to the administration of medication. On 3/26/24 at 12:40PM, the surveyor interviewed the Assisted Director of Nursing (ADON). The ADON informed the surveyor that she was the nurse taking care of the resident. The ADON stated that the blood sugar should have been obtained first and then given if the blood sugar was above the parameters or held according to the parameters. She further stated that if the insulin was held it should be documented in the supplemental section of the eMAR. At that time, the ADON reviewed Resident #96's March 2024 eMAR in the presence of the surveyor for the order dated 2/16/24, for insulin Glargine subcutaneous solution 100 unit/ml (insulin Glargine) inject 14 unit subcutaneously in the evening for DM (diabetes mellitus) Hold if BS is less than 100. The ADON confirmed she was unable to verify that the blood sugar had been obtained prior to the administration of the evening insulin. On 3/26/24 at 12:56 PM, the surveyor interviewed the Registered Nurse (RN)/Unit Manager (UM,) in the presence of the ADON, in reference to the insulin parameters. The RN/UM reviewed the March 2024 eMAR, for the order dated 2/16/24, for insulin Glargine subcutaneous solution 100 unit/ml (insulin Glargine) inject 14 unit subcutaneously in the evening for DM Hold if BS is less than 100. She acknowledged that the blood sugars were not documented on the eMAR. She then reviewed the weights and vital sign section of the eMAR which revealed one blood sugar obtained on 3/25/24 at 20:15 (08:15 PM) which was 229. She further acknowledged that the blood sugars should have been obtained and documented on the eMAR. The RN/UM stated the purpose of the parameters on insulin was to monitor for hypoglycemia (low blood sugar). On 3/27/24 at 2:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Regional Clinical Nurse. There was no additional information provided. On 03/28/24 at 11:10AM, during a follow up interview with the RN/UM and in the presence of the surveyor, the RN/UM reviewed the February 2024 eMAR and acknowledged that the BS was not documented for the order for the insulin Glargine subcutaneous solution 100 unit/ml (insulin Glargine) inject 14 unit subcutaneously in the evening for DM Hold if BS is less than 100. B). On 4/03/24 at 10:48 AM, the surveyor was touring the 4th floor nursing unit and noted Resident #54 in bed with his/her head slump down. The surveyor knocked on the door and greeted the resident. The resident picked up their head and said hello. At that time, the surveyor noted a medication cup that was turned over on their overbed table that contained 4 tablets. At that time, the surveyor called the Registered Nurse/Unit Manager (RN/UM) into the resident's room, who acknowledged that there was a medication cup that contained four (4) tablets on the resident's overbed table. The RN/UM stated that he doesn't know how the medication were left on the overbed table and stated it was the nurse's responsibility to assure that medication was not left unattended and to assure that all medication is consumed by the resident. The RN/UM identified the 4 tablets as being a Multivitamin with minerals (a supplement), Coreg (blood pressure/heart medication), Eliquis (heart medication and blood thinner), and Lasix (a water pill). The RN/UM also acknowledged that he was the nurse that administered the resident's medication that morning and that he assured that the resident consumed all their medications. The RN/UM was unable to answered how the medication ended up on the resident's overbed table. The surveyor reviewed the medical record for Resident #54 The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), acute pulmonary edema (shortness of breath, cough, decreased exercise tolerance and chest pain), adjustment disorder with depression (excessive reaction to stress that involve negative thoughts, strong emotions and changes in behaviors) and hypertension (a condition in which the force of blood against the artery walls is to high). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/12/24, reflected that the resident had a brief interview for mental status (BIMS) score of 8 out of 15, indicating that the resident is moderately impaired. A review of the active interdisciplinary care plan revealed that there was no focus area that indicated that the resident could self-administer their medications. A review of the April 2024 Order Summary Report (OSR) and the Electric Medication Administration Record (e-MAR) revealed the following physician's orders (PO): 1. Carvedilol (Coreg) oral tablet 3.125 milligrams (mg) dated 1/5/24, give 1 tablet by mouth every 12 hours for dysfunction of left ventricle of the heart. Give with food to reduce risk of orthostatic hypotension. Advise resident to arise slowly to reduce possibility of following and hold for Systolic blood pressure (SBP) less than 100. The eMAR also revealed that Coreg had an administration time of 0900 (9:00AM) and 2100 (9:00 PM) that showed that the medication was signed off as being given at 0900 on 4/3/24. 2. Eliquis oral tablet 2.5 mg (Apixaban) dated 1/5/24, give 1 tablet by mouth two times a day for DVT (Deep Vein Thrombosis) prophylaxis. Monitor for bruising, dark urine and black tarry stools. The eMAR also revealed that Eliquis had an administration time of 0900 (9:00AM) and 1700 (5:00 PM) that showed that the medication was signed off as being given at 0900 on 4/3/24. 3. Multivitamins-Minerals tablet dated 1/5/24, give 1 tablet by mouth one time a day for supplement. The eMAR also revealed that Multivitamins had an administration time of 0900 (9:00AM) and was signed off as being given on 4/3/24. 4. Lasix Oral Tablet 20 MG (Furosemide) dated 3/24/24, give 1 tablet by mouth in the morning for congestive heart failure (CHF). The eMAR revealed that Lasix had an administration time of 0900 (9:00AM) and was signed off as being given on 4/3/24. On 04/03/24 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON) who acknowledge that medications should never be left unattended and that a nurse should assure that the resident consumed their medication. On 4/05/24 at 2:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator and the Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Medication Administration dated 09/30/23, which was provided by the DON included the following: 15. Observe resident consumption of medication. C). On 4/02/24 at 10:20 AM, the surveyor inspected the 2nd floor medication room which contained the facility's AMDS machine. The surveyor interviewed the second floor Registered Nurse/Desk Nurse (RN/DN) who stated that the AMDS counts were checked once a day between the 7-3 (7AM-3PM) shift and the 3-11(3PM-11PM) shift. She showed the surveyor the AMDS April 2024 daily count narcotic back-up sheet. The sheet revealed that the narcotic count was performed on 4/1/24. The surveyor requested the daily count narcotic back-up sheets for March and February 2024. The RN/DN stated that the DON had the daily count sheets from March and February. On 4/02/24 at 10:30 AM, the surveyor reviewed the facility's DEA 222 forms and asked the DON if she could provide the surveyor with signed off logs showing that narcotics were being accounted for in the facility's AMDS. On 4/02/24 at 12:15 PM, the surveyor went to the License Nursing Home Administrator (LNHA) office where the DON was seated. The surveyor requested the facility daily count narcotic back-up sheets. The DON was only able to show that the AMDS narcotic counts were performed on 3/28/24 and 3/29/24. The DON was unable to provide any accountability and narcotic counts for the AMDS machine prior to 3/28/24. At that time, the surveyor interviewed the LNHA who stated that the facility just created a new form on 4/1/24 for daily counts of narcotics and controlled substances in the AMDS machine. On 4/8/24 at 9:00AM, the surveyor interviewed the DON who stated that it's important to perform a daily inventory counts for controlled substances which includes narcotic because it assures accountability, and that medication is not being diverted. On 4/05/24 at 2:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator and the Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for BLOOD GLUCOSE MONITORING reviewed on 10/2023, revealed the following: 1.Check physician's order for blood glucose testing frequency and coverage if needed. 10. Monitor resident for signs of hypo-or hyper-glycemia. 11. Record findings in the Medication Administration Record. Report any abnormal findings to the MD. A review of the facility's policy for Controlled Substances Policy dated 08/31/23, which was provided by the DON included the following: Accounting for Back-up stock Controlled Substances. 1. Back-up Controlled Substances will be counted daily by incoming and outgoing unit manager/nurse supervisor/designee for accuracy of number of doses currently on hand. 2. An immediate investigation will be initiated to resolve any discrepancy. The DON and the Administrator will be notified of all unresolves discrepancies immediately. A review of the facility's policy for CUBEX Station Medication Policies and Procedures that was undated which was provided by the DON included the following: J. Discrepancy Reporting and Documentation 9. A narcotic activities report will be printed daily according to established facility procedures that will track access of medications from the CUBEX station for E-Kit/Starter doses purposes. The report will include the name of the patient, nurse's name, prescriber name, medication, dose, quantity, date, and time of removal. The reports representing these activities will be retained per Federal Regulations for ten (10) years at the facility and pharmacy. NJAC 8:39-11.2 (b), 29.2 (d) (n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and pertinent facility documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 3/25/24 at 09:00 AM, the survey team entered the facility and was made aware by the Licensed Nursing Home Administrator (LNHA) that the facility was licensed for 180 beds and the facility census was 123 (the number of residents who currently resided at the facility). On 03/25/24 at 10:10 AM, the surveyor toured the kitchen with the facility's Food Service Director (FSD) and the Regional FSD. During the initial tour, the surveyor was escorted to a storage room which contained the emergency water and food supply. In the presence of the surveyor and the facility's FSD, the regional FSD stated that he had 22 cases of emergency water which contained 6 gallons of water per case. He stated that there was a total of 132 gallons of emergency water in the facility available in the event of an emergency. The surveyor inquired how much water should he have based on today's census, and he stated that there should be a water supply of 1 gallon per resident for 3 days. He further stated that he had to throw some water out because it had expired, and that he had already placed an order to replenish the water that was discarded. He informed the surveyor that the previously ordered emergency water supply would be delivered to the facility on [DATE]. The surveyor requested an invoice that showed that the emergency water supply had been ordered prior to surveyor inquiry. On 03/26/24 at 09:36 AM, in the presence of the survey team and the senior corporate FSD. The regional FSD provided the surveyor with an invoice order dated 3/25/24 from [name redacted]and an invoice from [name redacted] dated 03/27/24. Review of both invoices did not reveal that water had been ordered. The surveyor inquired again about the emergency water supply that was observed on 3/25/24. The regional food service director acknowledged that the emergency water supply that was in the facility on 03/25/24 was not enough based on the resident census of 123. The regional FSD also stated that the first time he saw the emergency water supply was with the surveyor on 03/25/24. On 03/26/24 at 10:11 AM, in the presence of the survey team, the surveyor interviewed LNHA. The surveyor inquired about the invoice dated 03/27/24 from [name redacted]. The LNHA clarified that the invoice date of 3/27/24 was the delivery date. She confirmed that an order was placed on 03/25/24 at 12:25pm by phone and was scheduled to be delivered on 03/27/24. She also acknowledged that she approved the purchase order for additional emergency items. On 03/27/24 at 02:07 PM, in the presence of the survey team, the surveyor interviewed the facility's FSD. The facility's FSD stated that he had knowledge of emergency preparedness. He stated that the purpose of the emergency water and food supply was so that if there was a situation that the facility was unable to obtain food and water, the facility had a supply of emergency food and water in storage at the facility. The FSD stated that the facility was required to have 1 gallon of water per resident for three days. He stated that he was responsible for ensuring that there was enough food and water for emergency use. On 03/27/24 at 09:04 AM, the LNHA provided the surveyor with invoices from the contracted vendor [name redacted] that additional water had been delivered for the emergency water supply. On 03/27/24 at -2:30 PM, the surveyor presented the above concerns to the LNHA, Director of Nursing (DON) and the Regional Clinical Nurse in the presence of the survey team. The LNHA stated that it was the responsibility of the facility's FSD to ensure that the emergency supply is sufficient based on the census. She further stated that she and the regional FSD were responsible for approving food orders and that there was no delay in approval or delivery. She stated, I get emails regarding food ordering and orders come to my phone if I am not here. She stated that if there was an emergency, the requirement was that the facility had 1 gallon of water per resident for 3 days in storage. There was no additional information provided to the surveyor. Review of an undated facility policy VENETIAN EMERGENCY WATER POLICY AND PROCEDURE under PROCEDURE revealed the following: - The Venetian will have 3 gallons of water per resident for 3 days time according to current census. - If more water is needed, our contracted vendor will deliver water within 24 hours or sooner in case of an emergency. Review of an undated facility policy EMERGENCY AND DISASTER PLANNING POLICY, included under PROCEDURE revealed the following: 2. The Food Service Director will be responsible for ensuring 3-day emergency supply (as per emergency supplies list attached) is located in the facility with Inventory List, noting expiration date of items. 4. The Food Service Director will maintain Inventory Check List monthly to check that all documentation is completed correctly, and all stock is accounted for. NJAC 8:39-31.6 (n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set, an assessment tool used to facility the management of care, to identify that the resident was on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN), who was assigned to Resident # 107. The LPN stated that the resident went out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. Review of the admission Record reflected that Resident #107 was admitted to the facility with diagnoses which included, but were not limited to, end stage renal (kidney) disease (ESRD). Review of the admission Minimum Data Set (MDS), dated [DATE], did not reflect that Resident #107 received dialysis. Review of the Order Summary Report (OSR) which reflected active physician orders as of 09/21/22 revealed that the resident received hemodialysis on Monday, Wednesday, Friday at 10:30 AM. On 09/23/22 at 10:45 AM, the surveyor interviewed the Regional MDS Coordinator who stated that the admission MDS dated [DATE] was a comprehensive assessment that was not coded accurately according to the resident's status and she did not know how the Registered Nurse (RN) completing the admission MDS did not accurately code that Resident #107 was receiving hemodialysis. She stated that it would be important to make sure the MDS was coded properly to assure that a complete accurate comprehensive assessment was done in order to paint a picture of the resident. She further stated an accurate assessment would assure that a CP was completed accurately with interventions, and it would also be important for payment purposes. She sadded that the purpose of the MDS was to assure that residents received an accurate assessment that was reflective of the resident's status at the time of the assessment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 reflects under Section O, Special Treatments, Procedures, and Programs, the directions to check all of the following treatments, procedures, and programs that were performed during the last 14 days while a resident of the facility and while not a resident of the facility. Section O0100J Dialysis, reflects to Code peritoneal or renal dialysis which occurs at the nursing home or at another facility . NJAC 8:39 - 11.2 (e)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 1 of 4 residents (Resident #58) reviewed for pain. This deficient practice was evidenced by the following: On 09/16/22 at 10:03 AM, the surveyor observed Resident #58 in bed with the head of the bed elevated. When interviewed at that time, Resident #58 stated that he/she was always in pain. According to the admission Record, Resident #58 was admitted with diagnoses that included, but were not limited to, aftercare following explantation (revision) of knee joint prosthesis, infection, and inflammatory reaction due to internal left knee, and pain in the left knee. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/03/22, revealed staff identified Resident #58 as cognitively intact, with range of motion impairment on one side of the lower extremity (hip, knee, ankle, foot) and the resident received scheduled pain medication and as needed pain medications for occasional moderate pain. Review of the Pain Assessment (3.0), dated 07/27/22, reflected that resident was assessed for pain. The assessment reflected that the resident had frequent pain over the last five days which made it hard to sleep at night and limited the resident's day-to-day activities because of the pain. The resident's pain intensity was severe over the last two days voicing complaints of pain (e.g., that hurts, ouch, stop) and exhibiting facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth, or jaw). Review of the Order Recap Report for orders as of 07/01/22 - 08/31/22 revealed a 07/27/22 physician order (PO) for Acetaminophen Tablet 325 mg (milligram), give two tablets every six hours as needed for mild pain and a 07/29/22 PO for Percocet Tablet 5-325 mg, give one tablet every six hours as needed for moderate to severe pain. Review of the July 2022 Medication Administration Record (MAR) revealed the resident received the Acetaminophen on 07/28/22 at 10:21 PM and 07/31/22 at 10:48 AM. The MAR further revealed that the resident received the Percocet on 07/29/22 at 1:20 AM. Review of the August 2022 MAR revealed the resident received the Acetaminophen on 08/04/22 at 2:34 PM, 08/05/22 at 0:45 AM, 08/12/22 at 9:53 AM and 08/27/22 at 11:06 AM. The MAR further revealed that the resident received the Percocet on 08/02/22 at 9:47 PM, 08/03/22 at 9:15 PM, 08/04/22 at 9:31 PM, 08/05/22 at 9:05 PM, 08/07/22 at 4:36 AM and 11:26 PM, 08/08/22 at 6:43 AM and 10:30 PM, 08/10/22 at 10:33 PM, 08/12/22 at 9:31 PM, 08/14/22 at 9:44 PM, 08/16/22 at 5:29 AM and 4:29 PM, 08/17/22 at 5:46 AM, 12:35 PM and 10:01 PM, 08/18/22 at 8:01 PM, 08/19/22 at 10:33 PM, 08/20/22 at 8:53 PM, 08/21/22 at 8:51 PM, 08/22/22 at 2:31 PM, 08/23/22 at 1:42 PM and 8:30 PM, 08/24/22 at 10:35 PM, 08/26/22 at 11:53 AM and 08/29/22 at 8:53 PM. Review of the September 2022 MAR revealed the resident received the Acetaminophen on 09/13/22 at 5:04 PM. The MAR further revealed that the resident received the Percocet on 09/01/22 at 1:53 PM, 09/02/22 at 9:52 PM, 09/03/22 at 10:39 PM, 09/04/22 at 8:51 PM, 09/05/22 at 8:36 PM, 09/06/22 at 12:29 PM and 10:40 PM, 09/08/22 at 10:47 PM, 09/09/22 at 10:50 PM, 09/11/22 at 7:19 PM, 09/12/22 at 11:29 PM, 09/14/22 at 10:08 PM, 09/15/22 at 10:51 PM and 09/16/22 at 10:41 PM. Review of the 07/27/22 20:05 (8:25 PM) COMS-Clinical admission Evaluation progress note reflected that Resident #58 had Vocal complaints of pain of the left knee. Review of the Care Plan (CP), initiated 07/28/22, did not include a focus with interventions for pain. During an interview with the surveyor on 09/21/22 at 12:45 PM, the Registered Nurse Charge Nurse (RNCN) reviewed Resident #58's CP with the surveyor. The RNCN stated that we initiate a CP for each resident on the date of admission. The RNCN confirmed there was no focus in the CP for pain. She stated that she was responsible for the CP and always included pain, fall and skin focus areas for each new admission. The RNCN indicated that pain should definitely have been care planned for Resident #58, as he/she had a left knee surgical incision. During an interview on 09/29/22 at 9:09 AM, the Director of Nursing (DON) stated that any discipline in the Interdisciplinary (IDC) Team can update the care plan including nurses. If a resident comes into the facility during the evening or night shift, the evening or night supervisor will review/update the resident's care plan. Thereafter, when a member of the IDC team completed an assessment or a change in resident status, they would update the CP. The DON stated, I know there have been inconsistencies in CPs. But we are trying. Review of the facility's Baseline Care Plan policy, with a revision date of 11/2020, reflected that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The policy further reflected that the facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of resident's admission and meets the requirements of comprehensive care plans. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently document in the Medication Administration Record (MAR). This deficient practice was identified for 1 of 5 residents (Resident #58) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the admission Record, resident was admitted to the facility with diagnoses which included, but were not limited to, aftercare following explantation (revision) of knee joint prosthesis, infection and inflammatory reaction due to internal left knee, Pemphigus (blistering of the skin and the inside of the mouth, nose, throat, eyes, and genitals), anxiety disorder, and hypertension. Review of the Order Recap Report for Order Date: 07/01/22-08/31/22, the July 2022 and August 2022 MARs for Resident #58 revealed that there was no documentation to indicate that the medications were administered and/or procedures were completed as ordered: - 07/28/22 Day Shift. Heparin Lock Flush 10 unit/ml (unit/milliliter) (a medication used to keep IV catheters open and flowing freely). Use 5 ml intravenously (administer into a vein) every day shift for IV patency. Flush PICC (a type of IV catheter, a long thin tube inserted in a vein of the arm, leg, or neck) after IV medication administration. Order dated 07/27/22. - 07/28/22 Day Shift. Sodium Chloride Flush Solution 0.9% (used to clean out an IV catheter). Use 10 ml intravenously every day shift for IV patency. Flush PICC before and after IV medication administration. Order dated 07/27/22. - 07/31/22 Day Shift. Heparin Lock Flush 10 unit/ml. Use 5 ml intravenously every day shift for IV patency. Flush PICC after IV medication administration. Order dated 07/27/22. - 07/31/22 Day Shift. IV tubing change each day shift. Order dated 07/27/22. - 07/31/22 Day Shift. Sodium Chloride Flush Solution 0.9%. Use 10 ml intravenously every day shift for IV patency. Flush PICC before and after IV medication administration. Order dated 07/27/22. - 07/31/22 Day Shift. Evaluate for COVID-19 signs/symptoms every shift, BP (blood pressure), HR (heart rate), RR (respiratory rate), Temp (temperature), SPO2 (percentage of oxygen in the blood), Pain every day and evening shift for COVID-19 screening. Order dated 07/27/22. - 07/31/22 Day Shift. Evaluate for cough, SOB (shortness of breath), chills, headache, myalgia (muscle pain), sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting diarrhea, pneumonia, ARDS (Acute Respiratory Distress Syndrome) every shift for COVID-19 other signs/symptoms screening. If Yes, evaluate further and notify MD, Infection Preventionist. Order dated 07/27/22. - 07/31/22 Day Shift. May combine all crushable medications at one time mixed in (applesauce, pudding, etc.). every shift. Order dated 07/27/22. - 07/31/22 Day Shift. Resident is on Trazadone (an antidepressant medication) for difficulty sleeping every shift. Monitor for side effects: sedation, increased/decreased appetite, sleeplessness, GI discomfort, tremors, falls, memory impairment, ataxia (drunk walk), hangover effect, daytime drowsiness, sedation Document in progress notes and notify MD. Order dated 07/29/22. - 07/31/22 Day Shift. Resident is on Trazadone for difficulty sleeping every shift. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 07/31/22 Day Shift. Resident is on Xanax for anxiety every shift. Monitor for side effects: fall, dry mouth, constipation, urinary retention, drowsiness/lethargy, confusion, increased anxiety, agitation, restlessness, hallucinations. Document in progress notes and notify MD. Order dated 07/29/22. - 07/31/22 Day Shift. Resident is on Xanax for anxiety. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/06/22 Evening Shift. Evaluate for COVID-19 signs/symptoms every shift, BP, HR, RR, Temp, SPO2, Pain every day and evening shift for COVID-19 screening. Order dated 07/27/22. - 08/07/22 2200 (10:00 PM) Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutanously every 8 hours for DVT Prophylaxis. Order dated 07/27/22. - 08/09/22 1400 (2:00 PM) Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutanously every 8 hours for DVT Prophylaxis. Order dated 07/27/22. - 08/09/22 at 1400 (2:00 PM) Active Liquid Protein Sugar Free one time a day for supplement, give 30 ml by mouth. Order dated 07/30/22. - 08/09/22 at 1400 (2:00 PM) Multiple Vitamins-Minerals Tablet. Give one tablet one time a day for Supplement. Order dated 08/03/22. - 08/10/22 Evening Shift. Evaluate for COVID-19 signs/symptoms every shift, BP, HR, RR, Temp, SPO2, Pain every day and evening shift for COVID-19 screening. Order dated 07/27/22. - 08/11/22 at 1400 (2:00 PM) Active Liquid Protein Sugar Free one time a day for supplement, give 30 ml by mouth. Order dated 07/30/22. - 08/11/22 at 1300 (1:00 PM) Benzonatate Capsule 100 mg (milligram). Give one capsule by mouth three times a day for cough. Order dated 07/29/22. - 08/11/22 at 1400 (2:00 PM) Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutanously every 8 hours for DVT Prophylaxis. Order dated 07/27/22. - 08/11/22 at 1400 (2:00 PM) Multiple Vitamins-Minerals Tablet. Give one tablet one time a day for Supplement. Order dated 08/03/22. - 08/11/22 Day Shift. Resident is on Trazadone for difficulty sleeping. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/11/22 at 1200 (noon). Hydroxyzine HCL Tablet 25 mg. Give one tablet by mouth every 6 hours for itchy skin. Order dated 07/27/22. - 08/15/22 Evening Shift. Evaluate for COVID-19 signs/symptoms every shift, BP, HR, RR, Temp, SPO2, Pain every day and evening shift for COVID-19 screening. Order dated 07/27/22. - 08/22/22 Evening Shift. Calamine Lotion. Apply to affected areas topically every day and evening shift related to Pemphigus. Order dated 08/18/22. - 08/22/22 Evening Shift. Evaluate for cough, SOB, Chills, Headache, myalgia, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting diarrhea, pneumonia, ARDS every shift for COVID-19 other signs/symptoms screening. If Yes, evaluate further and notify MD, Infection Preventionist. Order dated 07/27/22. - 08/22/22 at 2200 (10:00 PM). Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutaneously every eight hours for DVT (type of blood clot) prophylaxis. Order dated 07/27/22. - 08/22/22 Evening Shift. May combine all crushable medications at one time mixed in (applesauce, pudding, etc.). every shift. Order dated 07/27/22. - 08/22/22 Evening Shift. Resident is on Trazadone for difficulty sleeping every shift. Monitor for side effects: sedation, increased/decreased appetite, sleeplessness, GI discomfort, tremors, falls, memory impairment, ataxia (drunk walk), hangover effect, daytime drowsiness, sedation Document in progress notes and notify MD. Order dated 07/29/22. - 08/22/22 Evening Shift. Resident is on Trazadone for difficulty sleeping. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/22/22 Evening Shift. Resident is on Xanax for anxiety. Monitor for side effects: fall, dry mouth, constipation, urinary retention, drowsiness/lethargy, confusion, increased anxiety, agitation, restlessness, hallucinations. Document in progress notes and notify MD. Order dated 07/29/22. - 08/22/22 Evening Shift. Resident is on Xanax for anxiety every shift. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/27/22 Night Shift. 24 hour chart check on the 11:00 PM-7:00 AM shift every night shift. Order dated 07/27/22. - 08/27/22 at 2100 (9:00 PM) Trazodone HCL Tablet. Give 75 mg by mouth at bedtime related to anxiety disorder. Order dated 07/29/22. - 08/27/22 at 2100 (9:00 PM) Simvastatin Tablet 40 mg. Give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol). Order dated 07/27/22. - 08/27/22 Evening Shift. Calamine Lotion. Apply to affected areas topically every day and evening shift related to Pemphigus. Order dated 08/18/22. - 08/27/22 at 2100 (9:00 PM) Carvedilol Tablet 6.25 mg. Give one tablet by mouth every 12 hours for hypertension (high blood pressure). Order dated 07/29/22. - 08/27/22 at 2100 (9:00 PM) Gabapentin Capsule 300 mg. Give one capsule by mouth every 12 hours for neuropathic pain (caused by damage or injury to the nerves). Order dated 07/27/22. - 08/27/22 Evening Shift. Evaluate for cough, SOB, Chills, Headache, myalgia, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting diarrhea, pneumonia, ARDS every shift for COVID-19 other signs/symptoms screening. If Yes, evaluate further and notify MD, Infection Preventionist. Order dated 07/27/22. - 08/27/22 Night Shift. Evaluate for cough, SOB, Chills, Headache, myalgia, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting diarrhea, pneumonia, ARDS every shift for COVID-19 other signs/symptoms screening. If Yes, evaluate further and notify MD, Infection Preventionist. Order dated 07/27/22. - 08/27/22 at 2200 (10:00 PM). Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutaneously every 8 hours for DVT prophylaxis. Order dated 07/27/22. - 08/27/22 Evening Shift. May combine all crushable medications at one time mixed in (applesauce, pudding, etc.) every shift. Order dated 07/27/22. - 08/27/22 Night Shift. May combine all crushable meds at one time mixed in (applesauce, pudding, etc.) every shift. Order dated 07/27/22. - 08/27/22 Evening Shift. Resident is on Trazadone for difficulty sleeping every shift. Monitor for side effects: sedation, increased/decreased appetite, sleeplessness, GI discomfort, tremors, falls, memory impairment, ataxia (drunk walk), hangover effect, daytime drowsiness, sedation document in progress notes and notify MD. Order dated 07/29/22. - 08/27/22 Night Shift. Resident is on Trazadone for difficulty sleeping every shift. Monitor for side effects: sedation, increased/decreased appetite, sleeplessness, GI discomfort, tremors, falls, memory impairment, ataxia (drunk walk), hangover effect, daytime drowsiness, sedation document in progress notes and notify MD. Order dated 07/29/22. - 08/27/22 Evening Shift. Resident is on Trazadone for difficulty sleeping. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/27/22 Night Shift. Resident is on Trazadone for difficulty sleeping. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/27/22 Evening Shift. Resident is on Xanax for anxiety. Monitor for side effects: fall, dry mouth, constipation, urinary retention, drowsiness/lethargy, confusion, increased anxiety, agitation, restlessness, hallucinations. Document in progress notes and notify MD. Order dated 07/29/22. - 08/27/22 Night Shift. Resident is on Xanax for anxiety. Monitor for side effects: fall, dry mouth, constipation, urinary retention, drowsiness/lethargy, confusion, increased anxiety, agitation, restlessness, hallucinations. Document in progress notes and notify MD. Order dated 07/29/22. - 08/27/22 Evening Shift. Resident is on Xanax for anxiety. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/27/22 Night Shift. Resident is on Xanax for anxiety. Observe resident for target behavior of (describe) and indicate number of occurrences throughout shift. Order dated 07/29/22. - 08/28/22 Day Shift. Heparin Lock Flush Solution 10 unit/ml. Use 5 ml intravenously every day shift for IV patency. Flush PICC after IV medication administration. Order dated 07/27/22. - 08/28/22 Day Shift. IV tubing change daily every day shift. Order dated 07/27/22. - 08/28/22 at 6:30 AM. Pantoprazole Sodium Tablet Delayed Release 40 mg. Give one tablet by mouth one time a day for GI prophylaxis (GERD). Order dated 07/27/22. - 08/28/22 Day Shift. Sodium Chloride Flush Solution 0.9%. Use 10 ml intravenously every day shift for IV patency. Flush PICC before and after IV medication administration. Order dated 07/27/22. - 08/28/22 at 6:00 AM. Heparin Sodium Solution 5000 unit/ml. Inject 5000 unit subcutaneously every eight hours for DVT prophylaxis. Order dated 07/27/22. - 08/28/22 at 0000 (midnight). Hydroxyzine HCL Tablet 25 mg. Give one tablet by mouth every 6 hours for itchy skin. Order dated 07/27/22. - 08/28/22 at 6:00 AM. Hydroxyzine HCL Tablet 25 mg. Give one tablet by mouth every 6 hours for itchy skin. Order dated 07/27/22. - 08/30/22 at 1800 (6:00 PM). Hydroxyzine HCL Tablet 25 mg. Give one tablet by mouth every 6 hours for itchy skin. Order dated 07/27/22. - 08/30/22 at 1800 (6:00 PM) Bethanechol Chloride Tablet 5 mg. Give one tablet by mouth one time a day for urinary retention. Order dated 07/27/22. During an interview with the surveyor on 09/23/22 at 11:58 AM, Licensed Practical Nurse #4 stated that the process was to administer a medication and then sign that the medication was administered in the Electronic Medical Record (EMR), because if the medication was not signed, it was not given. During an interview with the surveyor on 09/28/22 at 11:14 AM, the Director of Nursing stated that she expected the nurse to sign the EMR once an order was administered because if the EMR was not signed, it was not done. Review of the facility's Medication Administration policy, revised 11/2020, reflected to sign the MAR after the medication was administered. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff delivered meal trays to the correct residents. This deficient practice was identified for 2 of 2 residents observed during lunch meal services (Resident #34 and #36) and was evidenced by the following: On 09/19/22 at 12:27 PM, the surveyor observed Resident #36 lying in bed with his/her lunch meal tray on the overbed table. Resident #36 stated they had finished their partially eaten lunch and needed assistance to bring the Styrofoam cup filled with water closer. On 09/19/22 at 12:29 PM, the surveyor observed Resident #36's roommate, Resident #34, walking around in the room. Resident #34 used a walker and walked towards the meal tray on the overbed table. The surveyor tried to get the attention of Resident #34, but the resident did not acknowledge the surveyor. At that time, the surveyor observed the meal ticket for Resident #34 was for Resident #36. On 09/19/22 at 12:49 PM, the surveyor brought the Assistant Director of Nursing (ADON) into the room the residents shared. The ADON confirmed the identity of both Resident #34 and Resident #36. The surveyor showed the ADON the meal ticket that was on the meal tray for Resident #36 which reflected Resident #34's name and therapeutic diet of regular dysphagia (swallowing difficulties) advance diet (food of nearly regular textures but still needs to be moist and should be in bite-size pieces for swallowing). The surveyor then showed the ADON the meal ticket that was still on the meal tray for Resident #34 which reflected Resident #36's name and therapeutic diet of regular dysphagia mechanical soft diet (foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew and swallow). At that time, the ADON acknowledged that the meal trays were switched. The ADON stated the nurses and Certified Nursing Assistants (CNAs) were responsible for passing out the meal trays. She further stated both Residents #34 and #36 were able to feed themselves. The ADON asked Resident #36 how he/she felt. Resident #36 stated he/she felt fine, but they just wanted the water closer to them, but no one came into the room to assist them. The surveyor observed Resident #34 who was still walking around in the room. On 09/19/22 at 1:05 PM, the ADON went around asking the staff who delivered the trays to the roommates, but no one knew. The ADON stated she would look at the recorded camera to confirm who passed the lunch meal trays. When asked about the process for passing meal trays, the ADON stated that staff should confirm with the name on the door and ask the resident their names. She further stated, if the resident was not able to identify themselves, then the staff would confirm the resident by the room number on the door. On 09/19/22 at 1:11 PM, the surveyor interviewed License Practical Nurse (LPN #6) who stated that usually the CNAs passed out the meal trays to the residents and that staff were required to check the tickets prior to giving the trays to the residents. She explained it was important for staff to read the meal ticket to assure that the right consistency of food was provided to the right resident, because if a resident was given the wrong diet, the resident could choke on the food or have an allergic reaction. On 09/19/22 at approximately 1:14 PM, LPN #7 stated she was on orientation but that the facility had educated her on the importance of reading the meal ticket. LPN #7 stated that it was important to read the meal ticket because some residents had swallowing problems and they were on a special diet. She further stated that if a resident was given the wrong tray, it could be harmful to them because they could choke or get an obstruction from the wrong consistency of food. On 09/19/22 at 1:16 PM, Registered Dietitian (RD #1) stated she did dietary assessments on residents during mealtimes and assisted with passing out the meal trays to the residents if the nursing staff needed help. RD #1 stated that if residents received the incorrect therapeutic diet, they are at risk for food allergies, chewing and swallowing concerns, and aspiration (when food, liquid, or some other material enter the airway or lungs). RD #1 stated there was a difference between the two textured diets but that the speech therapist would know the actual textures and what residents could or could not have. On 09/19/22 at 1:22 PM, the surveyor interviewed RD #2 who stated that the CNAs, nurses and sometimes the RDs were responsible for passing out the meal trays. RD #2 stated that the process for passing the trays was to check the name label and the room number to make sure it matched the name on the room door. She further stated that prior to passing the meal tray to the resident, staff should check the meal ticket to make sure it matched the meal on the tray. RD #2 emphasized I would check the name on the menu, the name on the door and ask the resident their name. She explained it was important to give the right tray to the right resident, so the resident doesn't choke or have an allergic reaction. On 09/19/22 at 1:25 PM, the surveyor interviewed CNA #3 who stated prior to passing out the meal tray, they should look for the resident's name, room number and which bed either bed 1 or bed 2. CNA #3 stated that they also look to assure the resident received the correct diet because if the resident received the wrong type of food or liquid they could choke. On 09/19/22 at 1:26 PM, RD #1 reviewed Resident #36's chart in the Electronic Medical Record (EMR) with the surveyor which revealed on 08/09/22 that the resident was upgraded from a pureed diet (all the foods have a soft, pudding-like consistency) to the mechanical soft diet. A review of the September 2022 Order Summary Report for Resident #36 reflected a regular diet dysphagia mechanical soft textured, thin [liquid] consistency diet. A review of the September 2022 Order Summary Report for Resident #34 reflected a regular diet dysphagia advanced textured, thin [liquid] consistency diet. On 09/20/22 at 10:01 AM, the ADON confirmed a Regional Dietary Staff (RDS) member delivered the meal trays to the roommates. The surveyor interviewed the ADON again regarding the process of checking the meal trays prior to passing them. The ADON stated the nurses and dietitians were responsible for checking the accuracy of the meal tray verses the physician's order (PO). She further stated all staff was trained for checking the meal ticket prior to passing the meal trays to the residents. On 09/20/22 at 10:19 AM, in the presence of the survey team, the RDS member who identified himself as a Food Service Director (FDS) for another facility stated he used to be the FSD for this facility two years ago. The RDS/FDS confirmed he was responsible for delivering the wrong meal trays to Resident #34 and Resident #36. He stated everything had changed since he left and he got confused because they used to use the kitchenettes on the floor. The RDS/FDS explained he was following the meal trucks from the kitchen to the floors to assure all meal trays were being delivered. He further explained since it was all hands-on deck he picked up the meal trays and accidentally delivered the wrong tray to the wrong resident. The RDS/FDS acknowledged he should have engaged the residents and confirmed it was the correct resident prior to passing out the meal tray. He concluded passing out the wrong tray placed the residents at risk for choking, aspiration, or an allergic reaction. On 09/20/22 at 10:35 AM, in the presence of the survey team, the Speech Language Pathologist (SLP) stated the regular dysphagia advance and regular mechanical soft diets were similar. She stated the only difference on the meal tickets from 09/19/22 for both residents were the pureed bread and cake for the mechanical soft diet. The SLP explained Resident #36 was on a dysphagia mechanical soft diet, but he/she was evaluated and cleared to be upgraded to a dysphagia advance diet, but due to dental issues, it was Resident #36's preference to remain on the mechanical soft diet. The SLP stated since Resident #36 could have upgraded to the same diet as Resident #34, the resident was not at risk for choking or aspiration and did not feel that the meal was unsafe. On 09/23/22 at 8:47 AM, the Director of Nursing (DON) stated the importance of delivering the meal trays to the right resident was to make sure the residents received the correct diet. She stated that if the consistency or diet was incorrect, the residents were at risk for aspiration. The DON stated the process for passing meal trays were nursing and the dietitians were responsible to check the meal ticket during meal pass to ensure the accuracy of the meal tray. She acknowledged that staff should ensure they delivered the right meal tray to the right residents. A review of the in-service Meal Pass/Tray Delivery dated 04/14/22, provided by the Licensed Nursing Home Administrator (LNHA) included 1. Identify each resident. Check the diet card against the items on the tray for accuracy and food preferences .5. Check identity of resident. A review of the facility's policy, Serving A Meal revised 11/2019, included check to be sure everything is included on the meal tray that is required by the diet card, and the resident's preference NJAC 8:39-17.4(a)(1); NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag (urine collection bag) was stored in a way to prevent the spread of infection. This deficient practice was identified for 1 of 3 residents reviewed for the use of indwelling urinary catheters (Resident #56) and was evidenced by the following: According to the admission Record, Resident #56 had diagnoses that included, but were not limited to: encounter for attention to other openings of urinary tract. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/29/2022 , revealed the resident had a Brief Interview for Mental Status (BIMS) of 15/15 which indicated that the resident was cognitively intact. Further review of the MDS revealed the resident had a urinary indwelling catheter. On 09/16/22 at 11:00 AM, the surveyor observed Resident #56's drainage bag hanging from the bed in a privacy bag and the catheter piece used to empty the bag touched the floor. On 09/19/22 at 12:14 PM and on 09/21/22 at 9:09 AM, the surveyor observed Resident #56's drainage bag not attached to the bed with the drainage bag lying directly on the floor. Review of Resident #56's September 2022 Physician Order Summary included an order for a Foley Catheter (indwelling catheter) #20 French for diagnosis of bladder cancer, dated 07/22/22. During an interview with the surveyor on 09/22/22 at 11:13 AM, the Certified Nursing Assistant (CNA #1) stated that a drainage bag should be attached to the resident's bed, should be in a privacy bag and not lying directly on the floor. During an interview with the surveyor on 09/22/22 at 1:09 PM, the Licensed Practical Nurse (LPN #1) stated that a drainage bag should never be directly on the floor because of bacteria. During an interview with the surveyor on 09/27/22 at 12:20 PM, the Registered Nurse Charge Nurse (RNCN) stated that a drainage bag should be kept below the level of the bladder, stored in a privacy bag, and should not have touched the floor for infection control reasons. During an interview with the surveyor on 09/27/22 at 12:44 PM, the Director of Nursing (DON) stated that the drainage bag should be attached to the bed and the drainage bag should not have touched the floor because of infection control reasons. A review of the facility's Indwelling Catheter, Appropriate Use of policy, dated 09/2020, indicated that indwelling catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications which include but not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding. NJAC 8:39 - 19.4 (a)(5)

2.) According to the Electronic Pharmacist Information Consultant (EPIC) report dated 09/12/22, the CP made three (3) recommendations for Resident #583 as follows: a. Flomax (a medication used by men to treat the symptoms of an enlarged prostate) should be administered 30 minutes after a meal. Swallow the capsules whole with a drink of water; do not crush, open or chew. b. Flomax must be swallowed whole. Do not crush, chew or open. If this medication cannot be changed, please obtain a physician's order of may open capsule. c. Resident is taking Flomax and requires it to be administered via gastrostomy tube (g-tube: a tube inserted through the abdomen that brings nutrition directly to the stomach). Since Flomax is not recommended to be given this way, consider having the order changed to an alternative Benign Prostatic Hyperplasia (BPH: enlarged prostate gland) medication, such as Rapaflo, which can be opened or given via tube. A further review of the EPIC report reflected the nursing signature, and the date and time was left blank. According to the Consultant Pharmacist Evaluation report dated 09/16/22, the Pharmacy Consultant (PC) noted the same Flomax recommendation from the EPIC report dated 09/12/22 for Resident #583, which revealed the recommendation was still not addressed. A review of the September 2022 OSR reflected Flomax capsule 0.4 mg (Tamsulosin [generic name for Flomax]) Give one (1) capsule via G-Tube in the evening for BPH. A review of the September 2022 MAR revealed the nurses administered the daily Flomax via G-tube. A review of the Physician's Orders sheet reflected that the PC's Flomax recommendation was not addressed during the 24-hour chart check. On 09/23/22 at 10:10 AM, the Assistant Director of Nursing (ADON) stated the nursing staff was responsible for following up with the PC's recommendations once it was received. The ADON further explained the staff nurse and/or supervisor would follow up with the PC's recommendations and notified the primary care physician (PCP); and once the staff reviewed the recommendations, then they would make comments on it, then sign and date it to acknowledge the PC's recommendations were reviewed. The ADON stated to ensure that the recommendations were followed up, the night shift (11:00 PM to 7:00 AM) nurse conducted the 24-hour chart check. She further stated the 24-hour chart check ensured orders and recommendations were completed. On 09/23/22 at 11:38 AM, the Director of Nursing (DON), provided the PC's monthly report for August of 2022 for the third floor. The DON stated that the ADON was still working on the PC's recommendations for September of 2022 and would provide it later. On 09/27/22 at 8:43 AM, the DON stated once the staff nurse received the PC's recommendation, they were to review it. She further stated that once the PC completed her monthly MRR, a few days later, the PC would send her final report via email. The DON stated within a few days of receiving the final report, the nurses should follow up with the recommendations from the PC to the PCP. A review of the September 2002 CPMR dated 09/16/22 with a printed date 09/21/22 revealed the following: - Resident is taking Flomax and requires it to administered via g-tube. Since Flomax is not recommended to the given this way, consider having the order changed to an alternative BPH medication, such as Rapaflo, such can be opened or given via tube. Action Taken: Foley (thin, flexible tube placed in your bladder to drain urine) inserted. A further review of the MAR reflected after surveyor inquiry regarding the missed PC's recommendations from 09/12/22 and 09/16/22, the Flomax medication was discontinued. On 09/27/22 at 9:24 AM, the surveyor interviewed the PC via telephone in the presence of the survey team. The PC stated her role included reviewing resident's charts for labs, the timing of medications, interactions, and contraindication between medications, conduct unit inspections, medication administration pass and in-service the nurses. The PC stated the EPIC report was done within 24 to 48 hours of admission and then reviewed again either by herself or the EPIC department if she does the admission review. The PC further stated the nurses should follow up with the PCP and sign the EPIC report to acknowledge the recommendations were reviewed and then place the form in the resident's chart. The surveyor continued to interview the PC regarding what the process was if any recommendations were not addressed? She stated if a recommendation were not addressed, she would have brought it to the nurse's attention to follow up and then placed it on the monthly report again. She further stated her monthly reports were emailed to the DON and ADON, but the EPIC reports were sent via fax. The PC explained her recommendation was to get a PCP order for an alternative BPH medication or get an order that stated, may open capsule. The PC emphasized they always followed the recommendations according to the manufacturer's guidelines which for Flomax was not to open or crush it. During a follow up interview with the surveyor on 09/28/22 at 9:24 AM, the ADON stated once the nursing staff received any PC recommendations, they should inform the PCP that day. Then once it was reviewed, the nurse should have signed and dated the form. The surveyor and ADON reviewed the EPIC report dated 09/12/22 together and the ADON acknowledged the nursing signature and date line was left blank and should have been addressed that day. The surveyor continued to interview the ADON on 09/28/22 at 9:28 AM, who stated that once she received the CPMR that was when she reviewed all the PC's recommendations. She stated she received September's report sometime last week and explained they were given 24 to 48 hours to review the entire packet. The ADON stated the PCP was notified on 09/23/22, and that the Flomax was discontinued on 09/24/22. The ADON clarified the rationale for foley inserted was that Resident #583 had a foley catheter and no longer needed the BPH medication for urinary retention. The ADON concluded that staff was educated on following up on PC recommendations and would provide it. On 09/28/22 at 9:34 AM, LPN #3 who identified herself as a night shift nurse, stated when they received a recommendation, they called the PCP to inform them of the recommendation. She stated the nurse should address each recommendation by going through each one and then initial the completed ones. LPN #3 stated once all the recommendations were completed, then the nurse would sign and date it and place the report in the resident's chart. LPN #3 stated if the recommendations were not completed, then the form should have been flagged in the chart and the nurse should have informed the next shift. The surveyor and LPN #3 reviewed Resident #583's EPIC report together and she further stated that if the recommendation was not addressed, then during the 24-hour chart check, which was done by the night nurses, should have been picked it up. LPN #3 confirmed that it was not addressed, but stated she never cared for Resident #583 and was unaware the EPIC was not addressed. LPN #3 emphasized any shift nurse could have picked up that the recommendation was not addressed. On 09/28/22 at 11:55 AM, the DON, in the presence of the survey team, stated the staff nurses were supposed to address the PC recommendations as soon as they received them. She stated if a staff nurse needed assistance with addressing the recommendations, then they should inform a supervisor. She further stated the nurses received the EPIC report and the ADON received the CPMR. She stated the nurses were educated on following up with PC recommendations which was done by the ADON. The DON acknowledged that the EPIC report from 09/12/22 and PC follow up recommendation from 09/16/22 for Resident #583 were not addressed and could have also been picked up during the 24-hour chart check review. A review of the additional information the PC provided via email on 09/29/22 at 11:26 AM, on her rationale for the Flomax recommendation revealed, we always use manufacturer's package insert as primary reference for our recommendations. She attached the Tamsulosin [generic name for Flomax] package insert which indicated that the capsule should not be opened to be administered via tube. The facility was unable to provide any education regarding addressing the PC recommendations until after surveyor inquiry. A review of the facility's policy, Pharmacy Consultant Services, dated 3/2020, included use outside resources to furnish pharmacy services for each resident .and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. NJAC 8:39-29.3 (a) (b) Based on interview and record review, it was determined that the facility failed to a) identify that medications were not scheduled to accommodate a resident's dialysis schedule during the monthly CP medication review and b.) act on or respond to recommendations made by the Consultant Pharmacist (CP) in a timely manner . This deficient practice was identified for 2 of 6 residents reviewed for medication regimen review (MRR) (Residents #107 and #583) and was evidenced by the following: 1.) On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN #2) who was outside in the hallway and indicated that she was providing care for Resident #107 today who was out to dialysis. The surveyor was unable to interview the resident currently. The LPN #2 stated that the resident goes out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. The LPN #2 further stated that the resident had an AV shunt (a surgical anastomosis, arteriovenous shunt a U-shaped plastic tube inserted between an artery and a vein used for filtering blood in dialysis) in the left upper arm. The admission Record reflected that Resident #107 was admitted to the facility with diagnoses which included, but were not limited to, diabetes mellitus (DM) type 2, end stage renal disease (ESRD), and Crohn's disease. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/31/22, indicated that Resident #107 had moderate cognitive impairment and required extensive care of two staff members for transfers and extensive care of one staff member for washing, dressing, toilet use and personal hygiene. The MDS did not reflect that the resident received dialysis. The surveyor reviewed the Order Summary Report (OSR) which reflected active physician orders as of 09/21/22. -According to OSR, dated 09/19/22, the resident received hemodialysis on Monday, Wednesday, Friday at 10:30 am. -According to the OSR, dated 08/25/22, there was an order written for Type of access: (CVC (central venous catheter)- AV Fistula - AV Graft (arteriovenous graft) Location: (indicate site/location) Schedule: M-W-F At 5am There was no specification as to what the access site was, where it was or when it was to be monitored The surveyor reviewed the Medication Administration Records (MAR) dated 08/01/22-08/31/22 and 09/01/22-9/30/22 which revealed the following medications were plotted on the electronic medical record (EMR). -Insulin Glargine 100 units/ml solution. Inject 10 units subcutaneously one time a day for DM (Diabetes Mellitus) at 9:00 AM, and was not given on 08/26/22, 08/29/22, 09/07/22, 09/09/22, 09/12/22, 09/19/22 and 9/21/22 because the resident was out at dialysis. There was no documentation that the physician (MD) was notified on the specific dates that the insulin was not administered. -Dicyclomine HCL capsule 10 mg give 1 capsule by mouth two times a day for IBS (irritable bowel syndrome). At 10:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, 09/12/22 and 09/21/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific date that the Dicyclomine HCL was not administered. -Metoprolol Tartrate 100mg give 1 tablet by mouth two times a day for hypertension. At 10:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, and 09/12/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that the Metoprolol Tartrate was not administered. -Voriconazole 200 mg give every 12 hours by mouth. At 9:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, 09/12/22, 09/19/22 and 09/21/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Voriconazole was not administered. -Insulin Lispro Solution 100 units/ml Inject three units subcutaneously before meals. At 7:30 AM, the medication was not given and accuchecks blood sugars were not performed on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/14/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was not in the facility and was out at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that insulin was not administered, and blood sugars were not done. -Reglan 5 mg Give 1 tablet by mouth before meals for GERD (Gastroesophageal reflux disease). At 7:30 AM, the medication was not given on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Reglan was not administered. -Sevelamer Carbonate 800 mg give 2 tablets by mouth 3 times a day for hypocalcemia (low calcium). At 8:00 AM, the medication was not given 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Sevelamer Carbonate was not administered. - Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale (blood sugar testing results): if 200 - 249 = one units; 250 - 299 = two units; 300 - 349 = three units; 350 - 399 = four units; 400 - 449 = five units; <70 or >449 Call MD, subcutaneously before meals and at bedtime for Type 2 DM. At 7:30 AM, accucheck blood sugars were not done for sliding scale on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that accucheck blood sugars were not done. The facility provided an email from the transportation company that transported the resident to and from the dialysis center and according to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by ambulance company at on 09/02/22 at 05:23 AM and brought back to the facility at 10:41 AM. According to the MAR dated 09/01/22-09/30/22 the nurse documented that the resident received the following medications but was not in the facility at those times. - The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 09:00 AM that indicated that Insulin Glargine 100 UNIT/ML Solution Inject 10 unit was injected subcutaneously when the resident was at dialysis at that time. The Medication Administration Audit Report (MAAR) reflected that the resident received that 09:00 AM insulin at 14:23 (02:23 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 09:00 AM indicating that Voriconazole Tablet 200 MG was administered at 09:00 AM when the resident was not in the facility at this time and was at dialysis. Upon review of the MAAR, it reflected that the nurse gave the Voriconazole at 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 07:30 AM which indicated that Insulin Lispro Solution 100 UNIT/ML three unit subcutaneously was administered when the resident was not in the facility and was at dialysis. The MAAR reflected that the nurse administered the Lispro insulin at 14:20 (02:20 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 07:30 AM which indicated that Reglan 5 mg was given when the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered Reglan 5 mg 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 08:00 AM, which indicated that Sevelamer Carbonate Tablet 800 MG two tablets were administered when the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered the medication at 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 07:30 AM, which indicated that the nurse took the resident's blood sugar. The blood sugar documented on the MAR was 295 and according to the sliding scale the resident received two units of insulin. The surveyor reviewed the MAAR which reflected that the 07:30 AM insulin was not administered until 14:20 (02:20 PM). Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if 200 - 249 = 1 units. 250 - 299 = 2 units. 300 - 349 = 3 units. 350 - 399 = 4 units. 400 - 449 = 5 units <70 or >449 Call MD, subcutaneously before meals and at bedtime for Type 2 DM According to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by ambulance company on 09/05/22 at 05:21 AM and brought back to the facility at 09:59 AM. According to the documentation in the MAR dated 09/01/22-09/30/22 the resident received the following medications when the resident was not in the facility at those times. -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received Insulin Glargine 10 units subcutaneously. The MAAR indicated that the nurse administered the medication outside of the timeframe at 14:01 (02:01 PM). -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that the resident received Metoprolol Tartrate 100 mg. The MAAR indicated that the nurse administered the medication outside of the timeframe at 14:01 (02:01 PM). -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received the medication Voriconazole 200 mg. The MAAR reflected that the nurse administered the medication outside of the time frame at 11:23 AM. According to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by ambulance company at on 09/14/22 at 04:54 AM, and brought back to the facility at 10:23 AM. According to the documentation in the MAR dated 09/01/22-09/30/22 the resident received the following medications when the resident was not in the facility at those times. -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received Insulin Glargine 10 units subcutaneously. The MAAR indicated that the nurse administered the medication outside of the timeframe at 13:13 (01:13 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that Dicyclomine 10 mg was administered. The MAAR reflected that the nurse administered the medication outside of the timeframe at 13:14 PM (01:14 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that Metoprolol Tartrate 100 mg was administered. The MAAR reflected that the nurse administered medication outside of the timeframe at 13:23 PM (01:23 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse signature slotted at 07:30 AM, which indicated that Reglan 5 mg was given when he resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered Reglan 5 mg 13:13 (01:13 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 08:00 AM, which indicated that Sevelamer Carbonate Tablet 800 MG two tablets were administered when the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered the medication at 13:13 (01:13 PM). On 09/22/22 at 9:32 AM, the surveyor interviewed Resident #107 with family present. The resident explained to the surveyor that he/she was picked up for dialysis around 4:30 AM and returned to the facility approximately 11:00 AM on Monday, Wednesday, and Friday. The Resident stated that he/she had a dialysis access site catheter in his/her left chest. Resident #107 could not explain when their medications were given. On 09/22/22 at 10:10 AM, the surveyor interviewed LPN #2 who has been employed in the facility for 2 years and stated she was familiar with the dialysis process. She stated that any resident admitted to the facility on dialysis, transportation was set up for the resident to receive dialysis at the dialysis center. She stated that there was a communication book set up and a communication sheet was utilized to facilitate communication between the dialysis center and the facility. She stated the communication sheet was sent out with the resident to dialysis. The surveyor asked the LPN what type of access site the resident had for dialysis and the nurse stated that the resident had an AV fistula in the left arm. The surveyor then explained to the nurse that the resident told the surveyor he/she had a catheter in the left chest wall that was utilized for dialysis. The nurse then replied, Oh yeah, it is in the left side of the chest, I was wrong, I am sorry. She then stated that there was a doctor's order to monitor the access site, but we do that automatically when the resident returns from dialysis to make sure there is no bleeding. We usually check off on the Treatment Administration Record (TAR) that we are monitoring the resident access site. The surveyor reviewed the physician orders and TAR in the presence of LPN #1, and she stated, We should have had an order to monitor Resident # 107's access site. I was not aware the resident did not have an order to monitor the site. I do not remember signing the TAR that the resident's access site was being monitored. LPN #2 also stated that she worked on Friday 09/02/22 and cared for Resident #107. When LPN #2 reviewed the MAR with the surveyor, she stated that she must have made a mistake and did not mean to sign the MAR that she administered the resident's medications when the resident was out to dialysis. The surveyor questioned LPN #2 on how she was able to obtain a blood sugar via accucheck for Resident #107 and administer insulin using the sliding scale when the resident was not present in the facility and LPN #2 could not explain to the surveyor how she documented a blood sugar and gave insulin to the resident when the resident was not in the facility. She stated that it must have been a mistake. On 09/22/22 at 10:43 AM, the surveyor interviewed the Registered Nurse/Assistant Director of Nursing/Unit Manager (RN/ADON/UM) for the 3rd floor RN/ADON/UM. She stated that medications should not be slotted out to be given at a time that the resident was at dialysis. She further added that it would be important to assure that a resident was receiving all the medications the MD ordered so that there was not a delay in care or a decline in the resident health. It all has a trickling effect. She confirmed that there were issues regarding Resident #107's medications being slotted at a time that the resident was at dialysis and that the nurses should have notified the MD to get the medication times changes and that the resident did not receive medications when he/she was at dialysis. On 09/22/22 at 11:35 AM, the surveyor interviewed the LPN #3 who stated that she was a float nurse and was not assigned to a specific unit. She reviewed the MAR with the surveyor and stated that her signature on the MAR on 09/19/22 reflected that she cared for Resident #107 that day. She stated that she did administer medication to Resident #107 because she documented as such on the MAR. LPN #3 stated that she documented on the MAR that medications were not administered because the resident was out to dialysis. She revealed that she did not give the resident Insulin, Metoprolol Tartrate, Voriconazole, Insulin Lispro, Reglan, and Sevelamer. She admitted that she did not call the MD that the resident did not receive the insulin or any other medication that she did not administer. The LPN stated that she did not receive any education or competencies on what do when a scheduled medication was to be given when a resident was out to dialysis. The LPN stated that it would have been important to call the MD about the medication times to make sure the resident got his/her medications. She also added that when a resident did not get their medication according to physician's orders that the resident could have health complications. On 09/27/22 at 09:25 AM, the surveyor conducted a telephone interview with the Pharmacy Consultant (PC) for the facility since 2016. She stated that her job responsibilities included resident chart review, unit medication storage inspection, medication pass, in-services, and quarterly meeting (QAPI-Quality Assurance and Performance Improvement). She stated that she performed chart review, reviewed labs, checked timing of the medications, interactions, contraindications, allergies, reviewed admissions, new consults, medication changes and nursing and physician recommendations. The PC stated that if she had any recommendation for the facility that the recommendations were sent via email to the DON and some of the Corporation nurses. She stated that when she reviewed residents' charts that were on dialysis, she would review medications and make sure medications were administered according to the dialysis schedule. She stated that it was important to make sure a resident got their medication correctly so that they were not getting their medication too closely together. She stated that medications should be scheduled for dialysis days and non-dialysis days. She added that the medication schedule should accommodate dialysis because you do not want to administer medications out of the window (timeframe that a medication could be administered), or if medications must be held. The MD needs to be made aware so that the medications could be scheduled correctly. She stated that if a dose of medication was missed because the resident was out to dialysis then the physician needed to be notified to find out what time the medication could be given. She further added that the nurse needed to document and make the physician aware and should not attempt to use their own judgement whether to give medications or not. She stated that when the nurse noticed that the residents' medications were scheduled during the time the resident was out to dialysis, they should have called the MD and got the medication times adjusted according to the dialysis schedule. The surveyor reviewed the Consultant Pharmacist's Monthly Report (CPMR) dated 09/15/22 which indicated that the PC reviewed Resident #107's medications and there were no recommendations that the resident's medication times were not scheduled to accommodate the dialysis schedule or that medications were not administered to the resident when the resident was out to dialysis. On 09/28/22 at 10:19 AM, the surveyor telephone interviewed the PC who explained to the surveyor that she was not sure why she did not make any recommendations to adjust Resident #107's medication times according to the dialysis schedule and would have to review this and get back to the surveyor with the information. On 09/28/22 at 11:42 AM, the surveyor interviewed Registered Nurse (RN) who was employed for the facility since 2019. The RN stated that she worked on 09/05/22 and documented on the MAR that she administered 10 units of insulin to Resident #107 at 9:00 AM. I gave the resident the insulin because she came back around 10:00 AM and it was in the scheduled timeframe to give it. She stated that she signed the medication out at 14:01 because she did not have time to sign the medication out at the time that she gave it. She stated that she knows that she is supposed to sign the medication out right after she administered it but did not because she was busy and is always interrupted and doesn't always get time. The RN also admitted to administering the insulin out of the timeframe on 09/14/22 at 9:00 AM but was not sure why. I'm not sure why I did not get the medication times adjusted according to the resident's dialysis days or call the doctor. On 09/29/22 at 10:14 AM, the surveyor interviewed the PC who admitted that she failed to identify that the resident's medication times were not adjusted according to the resident's dialysis time. She stated that the nursing department should have adjusted the times according to the dialysis center and that she should have identified this medication discrepancy during her monthly review on 09/15/22. She stated that she would investigate this and that when further reviewed the residents medical record and that the resident did not experience any untoward effects and that the resident recent A1C (shows how well blood sugar levels have been controlled) was 5.1 (normal reading). The form titled Consultant Pharmacist Responsibilities and dated 09/30/22 indicated that the Pharmacy Consultant was responsible to perform monthly reviews of the drug regimen of each resident with reports of any irregularities, ongoing assessment of all areas of pharmaceutical services and staff performance with recommendations and plans for implementation.

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to complete weekly weights and consistently monitor a resident with a history of weight loss. This deficient practice was identified for 1 of 6 residents (Resident #15) reviewed for nutrition and was evidenced by the following: On 09/19/22 at 12:37 PM, the surveyor observed Resident #15 sitting up in bed with a lunch tray positioned on the overbed table. The resident was pleasantly confused and was observed feeding self without difficulty. The surveyor observed that the resident ate approximately 25% of the lunch meal. When interviewed, the resident stated the meal was alright and that he/she did not want anything else to eat. According to the admission Record, Resident #15 was admitted with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems), muscle weakness, and need for assistance with personal care. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/03/22, revealed the resident had a Brief Interview for Mental Status of 08 indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident had a weight loss but was not on a physician-prescribed weight-loss regimen. Review of the Resident #15's Nutrition Note, (NN) dated 06/09/22, reflected that the resident's monthly weight was 165.5 lbs which indicated an 8% weight loss in one month. The NN further reflected that Weekly weight warranted to monitor weight trends given significant wt [weight] loss . Will continue to follow weekly weights and po [by mouth] intakes. Review of Resident #15's Order Summary Report (OSR) for order date range 06/01/22-06/30/22, revealed a 06/09/22 physician order (order) for Weekly weights x 4 every day shift every Monday for significant wt [weight] loss until 07/04/22. Review of Resident #15's Weight and Vital Summary report (weight report), contained within the Electronic Health Record (EHR), revealed the following: On 05/09/22, the resident weighed 179.2 lbs. On 06/08/22, the resident weighed 165.5 lbs. with a notification under Warnings: -Comparison Weight 05/09/22, 179.2 lbs, -7.6%, -13.7 lb.] On 06/10/22, the resident weighed 165 lbs. On 07/12/22, the resident weighed 164.5 lbs. The weight report did not include weights documented for the following Mondays: 06/13/22, 06/20/22, 06/27/22 and 07/04/22. During an interview with the surveyor on 09/29/22 at 11:30 AM, the Registered Dietician (RD) stated that Resident #15's weight loss was discussed with the Unit Manager (UM) at the care conference. The RD added that nursing would report the resident's weight loss to the physician and an order would be obtained for any new interventions. The RD stated that the resident was on a downward trend and that she was monitoring his/her eating which had stabilized in July 2022. The RD added that the resident's meal intakes had improved to 75% or more. When questioned about weekly weights ordered on 06/09/22, the RD review Resident #15 electronic medical record (EMR), in the presence of the surveyor and stated an order for weekly weights was inputted on 06/09/22 and was due to start on 06/13/22. The RD added that she did not see the weekly weights in the medical record, and they had not been completed. RD stated that she repeatedly reinforced to nursing that the resident's weekly weights needed to be completed but they still did not complete them. The RD was unable to provide any documentation that she informed nursing administration of the weekly weights not being completed. When questioned how she monitored the resident's weight loss trend, the RD stated she just monitored the resident's meal consumption. Review of Resident #15's June 2022 Documentation Survey Report v2, provided by the Director of Nursing (DON), revealed no documentation of the resident's meal consumption on the following: 06/10/22 at 9:00 AM and 1:00 PM 06/11/22 at 9:00 AM and 1:00 PM 06/12/22 at 6:00 PM 06/13/22 at 9:00 AM and 1:00 PM 06/15/22 at 9:00 AM and 1:00 PM 06/17/22 at 9:00 AM and 1:00 PM 06/18/22 at 9:00 AM, 1:00 PM and 6:00 PM 06/19/22 at 9:00 AM, 1:00 PM and 6:00 PM 06/21/22 at 9:00 AM and 1:00 PM 06/23/22 at 9:00 AM and 1:00 PM 06/24/22 at 9:00 AM, 1:00 PM and 6:00 PM 06/25/22 at 9:00 AM and 1:00 PM 06/26/22 at 9:00 AM, 1:00 PM and 6:00 PM 06/27/22 at 9:00 AM and 1:00 PM 06/30/22 at 9:00 AM and 1:00 PM Review of Resident #15's July 2022 Documentation Survey Report v2, provided by the Director of Nursing (DON), revealed no documentation of the resident's meal consumption on the following: 07/01/22 at 9:00 AM, 1:00 PM and 6:00 PM 07/02/22 at 9:00 AM, 1:00 PM and 6:00 PM 07/03/22 at 9:00 AM, 1:00 PM and 6:00 PM 07/04/22 at 9:00 AM, 1:00 PM and 6:00 PM During an interview with the surveyor on 09/29/22 at 12:11 PM, the Director of Nursing (DON) stated that all weights were reviewed monthly to identify any resident with significant weight loss or gain. Once identified, the team would review the resident's chart and meet with the RD. The DON stated they would try to identify why the resident was having weight loss and if there was any underlying cause to the weight loss. They would initiate weekly weights x4 to see the trend, a calorie count to see how much the resident was eating at meals and inform the physician to see if additional labs or an in-person assessment was needed. The DON further stated the resident would be placed on the weekly weight list, a physician order would be inputted into the EMR, which would alert the nurse to inform the CNA to weigh the resident. The RD would review the weekly weights, calorie counts, and make recommendations that would then be communicated to the nursing staff. The DON stated that she expected the RD to inform the charge nurse, UM and herself that weekly weights were not being completed. The DON stated that they would have add additional weekly weights and would have made sure they were completed. During an interview with the surveyor on 09/30/22 at 9:56 AM, the Licensed Practical Nurse/UM (LPN/UM) stated Resident #15 required extensive assist with activities of daily living but was able to feed self after staff setup of the meal tray. The LPN/UM stated the resident's meals were monitored every shift for all meals and the percentages consumed were documented in the EMR. The LPN/UM further stated the RD recommends weekly weights, the nurse confirms the order, which would then reflect on the administration record. The LPN/UM added that Resident #15's 06/09/22 order for weekly weights x4 order was inputted under order type as no documentation required. The LPN/UM added that the order was present, but the order type not being checked resulted in it not being carried over to the administration record for nursing to complete. The LPN/UM stated completing a resident's weekly weights was important to determine any additional weight loss and to look further into the cause. The LPN/UM further stated that he did not recall if the RD informed him that Resident #15's weekly weights were not being completed. Review of the facility's Weight Monitoring policy, revised on 11/2019, indicated that Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. The policy reflected that weights should be recorded at the time obtained and included, but not limited to, a suggested weight schedule of daily or weekly, if clinically indicated. The policy further indicated that Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) During the initial tour of the second-floor nursing unit on 09/16/22 at 12:19 PM, the surveyor observed Resident #120 asleep, seated in a wheelchair next to his/her bed. The resident wore a nasal cannula (NC) (oxygen tubing) that was connected to an oxygen concentrator (a medical device used for delivering oxygen) that was set at three liters per minute (L/min). On 09/19/22 at 10:15 AM, the surveyor observed Resident #120, who was seated in a wheelchair in his/her room and wore a NC that was connected to an oxygen concentrator that was set at three L/min. The resident was awake and alert and stated that they wore oxygen at all times. The resident also stated that they wore three L/min of oxygen all the time while at home as well. On 09/20/22 at 09:51 AM, the surveyor observed Resident #120, who was seated in a wheelchair in their room and wore a NC that was connected to an oxygen concentrator that was set at three L/min. On 09/21/22 at 10:10 AM, the surveyor observed Resident #120, who was seated in a wheelchair in their room and wore a NC that was connected to an oxygen concentrator that was set at three L/min. On 09/22/22 at 12:45 PM, the surveyor observed Resident #120, who was seated in a wheelchair in their room and wore a NC that was connected to an oxygen concentrator that was set at three L/min. According to the admission Record, Resident #120 was admitted to the facility with diagnoses that included, but were not limited to, chronic respiratory failure with hypoxia (a condition in which not enough oxygen passes from your lungs into your blood), unspecified asthma (a lung disorder which causes narrowing of the airways that causes shortness of breath, wheezing and cough), and dependence on supplemental oxygen. A review of the admission MDS, dated [DATE], revealed Resident #120 was cognitively intact, needed the assistance of one person for mobility and received respiratory treatments. A review of the Order Summary Report, dated 09/23/22, failed to include a physician order for the use of oxygen. A review of the CP, initiated on 08/29/22, failed to contain an entry for the use and care of oxygen. A review of the progress notes, dated 08/31/22 through 09/23/22, revealed documentation of oxygen levels that were administered to Resident #120, included the following: - On 09/05/22 at 05:32 AM, a Licensed Practical Nurse (LPN #4) documented the resident had continuous oxygen in place. - On 09/08/22 at 08:30 AM, the Nurse Practitioner (NP) documented the resident was on oxygen at three L/min nasal cannula. - On 09/12/22 at 06:47 AM, LPN #4 documented the resident had continuous oxygen maintained. - On 09/12/22 at 09:27 AM, the NP documented the resident was on oxygen at three L/min NC. - On 09/14/22 at 14:28 (2:28 PM), the NP documented the resident was on oxygen at three L/min NC. - On 09/14/22 at 18:56 (6:56 PM), LPN #2 documented the resident had oxygen via NC. - On 09/15/22 at 09:30 AM, the NP documented the resident was on oxygen three L/min NC. - On 09/18/22 at 06:55 AM, LPN #5 documented the resident was on oxygen at two L/min via NC. - On 09/22/22 at 15:43 (3:43 PM), LPN #2 documented the resident had oxygen via NC. - On 09/23/22 at 07:19 AM, LPN #5 documented oxygen continues on two L/min via NC. On 09/23/22 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #2) assigned to Resident #120. CNA #2 acknowledged the resident was on oxygen and that she got report from the nurse to let her know how much oxygen the resident wore. On 09/23/22 at 10:43 AM, the surveyor interviewed LPN #2 assigned to Resident #120. The surveyor accompanied LPN #2 into the resident's room and LPN #2 acknowledged that the resident was wearing oxygen three L/min via NC. LPN #2 stated that when oxygen was ordered by the physician that it appeared on the Treatment Administration Record (TAR) and that a resident's response to a treatment was required to be documented in the progress notes. LPN #2 stated the physician's order specified how much oxygen the resident was to receive. In the presence of the surveyor, LPN #2 reviewed the resident's Order Summary Report that contained active orders as of 09/23/22, and LPN #2 acknowledged that there was no order for oxygen. LPN #2 also reviewed the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 09/01/22-09/30/22 and acknowledged that oxygen was not documented. LPN #2 stated that the resident should have had an order for oxygen and that it was important to have an order to show how much oxygen should have been administered. LPN #2 reviewed the resident's CP and acknowledged that the resident did not have a CP for oxygen. LPN #2 stated that everyone should have had a CP because it was a document that listed the care provided to residents, and that oxygen should have been on the CP. On 09/23/22 at 10:54 AM, the surveyor interviewed the second-floor nursing unit Charge Nurse (CN) who stated that if a resident needed oxygen, a physician order should have been obtained and the nurse or CN would set up the oxygen for the resident. The CN stated the nurse would know a resident was on oxygen from the shift report and from the TAR and that it would have been documented on the 24-hour report for every nurse to review. In the presence of the surveyor, the CN reviewed Resident #120's Order Summary Report that contained active orders as of 09/23/22, and the CN acknowledged that there was no order for oxygen. The CN also reviewed the resident's MAR and TAR dated 09/01/22-09/30/22 and acknowledged that oxygen was not documented. The CN stated that if a resident was on oxygen an order should have been obtained and documented so that the resident was treated correctly. The CN reviewed Resident #120's CP and acknowledged oxygen was not on the CP. The CN stated that a CP contained actions pertinent to a resident's care and that oxygen should have been on Resident #120's CP so that the resident was treated correctly. On 09/29/22 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) and informed her of Resident #120's oxygen observations and interviews with staff. In the surveyor's presence, the DON reviewed the resident's Order Summary Report that contained active orders as of 09/23/22 and she acknowledged that there was no oxygen order. The DON stated that she was unsure how much oxygen the resident should have been on and that it was important to obtain a physician order for oxygen so that the resident was provided the correct amount of oxygen. The DON reviewed the resident's CP and acknowledged oxygen was not on the CP and that it should have been. The DON stated that the CP showed what interventions should have been used and that the CP was important because it provided the resident with the required care. The facility policy titled Tracheostomy Care and dated 11/2021 indicated that the facility would ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. The policy also indicated that the facility would provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and or suctioning. Tracheostomy care will be provided according to physician's orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risk for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include: Provide tracheostomy care as ordered per physician. According to the policy, based upon resident assessment, attending physician orders and professional standards of practice, the facility in collaboration with the resident/representatives will develop a care plan what includes appropriate interventions for respiratory care. Review of the facility policy, Oxygen Administration, revised 09/2021, revealed Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans .Policy Explanation and Compliance guidelines: 1. Oxygen is administered under orders of a physician .4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: A. type of oxygen delivery system. B. When to administer, such as continuous or intermittent and/or when to discontinue. C. Equipment setting for the prescribed flow rates. D. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. E. Monitoring for complications associated with the use of oxygen. Review of the facility policy, Comprehensive Care Plans, revised 09/2021, revealed Policy: It is the policy of the facility 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, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. N.J.A.C 8:39- 11.2 (d), 1, 2 NJAC 8:39-27.1(a) Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) document the size and type of resident's tracheostomy tube on the resident's Care Plan (CP) and b.) obtain a physician order for oxygen and include oxygen use and care on a CP. This deficient practice was identified for 2 of 3 residents (Residents #89 and #120) reviewed for respiratory care and was evidenced by the following: According to the admission Record reflected that the resident was admitted to the facility with the diagnoses which included, but were not limited to, Cerebral Infarction (stroke, Infarction refers to death of tissue), aphasia (comprehension and communication (reading, speaking, or writing)) disorder resulting from damage or injury to the specific area in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe for artificial airway), and hemiplegia (paralysis of one side of the body). The annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/26/22, reflected that the resident was nonverbal, had severe cognitive impairment, and required complete care with all aspects of activities of daily living (ADL). The MDS also reflected that the resident had a tracheostomy and required suctioning and oxygen. On 09/16/22 at 10:33 AM, during tour, the surveyor observed Resident #89 in bed with the head of bed up. The resident was observed with a tracheostomy tube (a breathing tube inserted into a tracheotomy). The resident was observed to be non-verbal and unable to be interviewed. On 09/28/22 at 09:06 AM, the surveyor observed that there was a tracheostomy tube attached to the resident's respiratory equipment at the bedside. The surveyor reviewed Resident #89's Care Plan (CP) which indicated that the resident had a tracheostomy related to (r/t) impaired breathing mechanics. There was no documentation on the resident's CP indicating the type or size of the tracheostomy tube. On 09/28/22 at 09:18 AM, the surveyor interviewed the Registered Nurse who stated that it would have been important to include the type and size of the tracheostomy in the resident CP. On 09/28/22 at 09:25 AM, the surveyor interviewed the Registered Nurse Assistant Director of Nursing who was acting Unit Manager of the 3rd floor who confirmed that the size and type of trach was not documented on the resident's CP and could not explain why it was missed. She stated that it would be important to have that documented on the CP to get a full picture of what was going on with the resident and so that all staff members could also know what medical conditions or equipment the resident had. On 09/28/22 at 10:03, the surveyor interviewed the Director of Nursing (DON) who stated that it would be important to know the size and type of resident's tracheostomy tube in case the trach tube came out the nurse would know what trach tube to replace it with. She added that it would also be important to have it documented in the CP so there was documentation regarding what size and type the tracheostomy tube was. The DON admitted that there was no CP intervention for the type and size trach tube the resident had. She stated that when the CP was reviewed that the interdisciplinary team should have identified that there was no documentation on the CP regarding the size or type of tracheostomy tube the resident had. On 09/29/22 at 10:52 AM, the surveyor telephone interviewed the Respiratory Therapist, in the presence of the survey team, who stated that the facility scheduled her to come to the facility once a week but would come in at additional times if the facility needed her. She also stated that she did not know that the size and type of tracheostomy tube was not documented on the resident's CP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor and manage a resident's pain consistent with professional standards of practice or develop a comprehensive person-centered care plan for 1 of 4 residents who exhibited signs and symptoms of pain, Resident # 55. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 09/16/22 at 10:37 AM during tour, the surveyor observed Resident #55 in bed with the head of bed (HOB) up and a wash basin was in his/her lap. The resident was non-verbal however, was able to communicate with facial gestures and hand signals. Resident #55 was pointing to their stomach area and making gestures that they felt nauseous. The surveyor observed a tube feeding Jevity 1.5 infusing at 60/cc hour. The surveyor notified the dietician who was standing in the hall and informed her that the resident was making gestures that she was not feeling well, and the dietician stated that she would get the nurse. The nurse came to the resident's room and stated that the resident was probably in pain and that she would provide the resident with pain medication. The admission Record reflected that Resident #55 was admitted to the facility with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD) and malignant neoplasm of the larynx. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/26/22, reflected that the resident was cognitively intact and required extensive to total assistance with all activities of daily living (ADLs). The MDS also reflected that the resident was not exhibiting pain. The surveyor reviewed Resident #55's Care Plan (CP) which did not reflect Resident #55 had complaints of pain, location of pain or interventions related to pain reduction or relief. The surveyor reviewed the physician Order Summary Report with active orders as of 09/19/22 which revealed the resident had the following orders: 1.) Order dated 08/11/22 for Acetaminophen liquid 160 mg/5 ml, give 20 ml via (by way of) g-tube (gastric tube- tube that is placed directly into the stomach for feeding) every 6 hours as needed for mild pain give 640 mg=20 ml, not to exceed 3 grams in 24 hours from all sources. 2.) Order dated 07/24/22 for Tramadol HCL tablet 50 mg, give 1 tablet via g-tube every 12 hours as needed for moderate to severe pain and monitor for respiratory depression, sedation, constipation while administering Tramadol. 3.) Order dated 04/26/22 to observe and evaluate for signs and symptoms of pain every shift and notify the MD for unrelieved pain. 4.) Order dated 04/22/22 to observe and evaluate for signs and symptoms of pain one time a day on the last day of the month every month on the Pain Management Summary to evaluate effectiveness of routine and PRN (as needed) pain medication. The surveyor reviewed the Medication Administration Record (MAR) dated 07/01/22-07/31/22 which revealed the following documentation: The MAR indicated that Resident #55 received Acetaminophen liquid 160 mg/5 ml give 20 ml via (by way of) g-tube on 07/15/22 for a pain level of three indicating mild pain. The MAR further reflected the nurses documented on every shift (day, evening, and nights) indicated that the resident had no complaints of pain. There was no location of pain documented in the progress notes. The MAR reflected on 07/06/22, 07/11/22, 07/14/22, 07/16/22, 07/18/22, 07/20/22, and 07/21/22 there was documentation that Resident #55 received Tramadol HCL tablet 50 mg for moderate to severe pain. The MAR further reflected on 07/14/22, 07/16/22, 07/18/22, 07/20/22 and 07/21/22 that the nurses documented on every shift (day, evening, and nights) that the resident had no complaints of pain. There was no location of pain documented in the progress notes. The surveyor reviewed the MAR dated 08/01/22-08/31/22 which revealed the following documentation: The MAR indicated that Resident #55 received Acetaminophen liquid 160 mg/5 ml give 20 ml via (by way of) g-tube on 08/16/22, 08/23/22, 08/28/22 and 08/29/22 indicating mild pain. The MAR further reflected on 08/23/22, that the nurses documented on the MAR every shift (day, evening, and nights) that the resident had no complaints of pain. There was no location of pain documented in the progress notes. The MAR reflected on 08/08/22, 08/10/22, 08/11/22, 08/13/22, 08/16/22, 08/17/22, 08/18/22, 08/20/22, 08/23/22, 08/24/22, 08/25/22, 08/28/22 that there was documentation that Resident #55 received Tramadol HCL tablet 50 mg for moderate to severe pain. The MAR further reflected on 08/10/22, 08/11/22, 08/13/22, 08/17/22, 08/18/22, 08/20/22, 08/23/22,08/25/22 that the nurses documented on the MAR every shift (day, evening, and nights) that the resident had no complaints of pain. There was no location of pain documented in the progress notes. The surveyor reviewed the Medication Administration Record (MAR) dated 09/01/22-08/30/22 which revealed the following documentation: The MAR indicated that Resident #55 received Acetaminophen liquid 160 mg/5 ml give 20 ml via (by way of) g-tube on 09/03/22, 09/04/22, 09/06/22, 09/08/22 indicating mild pain. The MAR further reflected on 09/03/22, that the nurses documented on the MAR every shift (day, evening, and nights) that the resident had no complaints of pain. There was no location of pain documented in the progress notes. The MAR reflected on 09/01/22, 09/04/22, 09/05/22, 09/07/22, 09/08/22, 09/12/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22, 09/20/22, and 09/21/22 there was documentation that Resident #55 received Tramadol HCL tablet 50 mg for moderate to severe pain. The MAR further reflected on 09/07/22, 09/12/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22, 09/20/22, and 09/21/22 that the nurses documented on the MAR every shift (day, evening, and nights) that the resident had no complaints of pain. There was no location of pain documented in the progress notes. On 09/19/22 at 12:35 PM, the surveyor interviewed Resident #55's Certified Nursing Assistant (CNA) who stated that she had been employed in the facility since 2019. The CNA stated that Resident #55 was alert and oriented to person, place, and time. She also stated that the resident could communicate needs by one-word answers or hand gestures. The CNA added that Resident #55 required total care with all aspects of ADL's (activities of daily living) and was incontinent of bladder and bowel and wore protective undergarments/briefs. The CNA stated that the resident did not have any wounds or skin impairments. The CNA further added that the resident was NPO (nothing by mouth) and all nutritional and hydration needs were met via (by way of) peg tube (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach). She stated that the resident had frequent complaints of stomach pain, but the CNA did not know the causes. She added that if the resident complained of pain that she would let the nurse know so that the nurse could give pain medication. The CNA stated, Complaints of pain every day, twice a day on my shift but mostly every day. The CNA stated that the family was supportive. On 09/19/22 at 12:45 PM, the surveyor conducted a telephone interview with the responsible party (RP) who provided a history regarding Resident #55. The RP stated that the resident could verbally communicate however could not use their vocal cords and therefore only used gestures. The RP stated that there were no causes for abdominal pain but it might be due to the feeding tube needing to be changed, and that when the resident was home that they often complained of pain around the feeding tube. The RP further stated that the resident had taken pain medications occasionally while at home. On 09/21/22 at 11:23 AM, the surveyor interviewed the Registered Nurse (RN) who had been employed in the facility since 2019. She stated that she was a regular employee but that she floats around the facility and worked where the facility put her. She explained that if a resident was in pain, that the nurse would assess the resident and find out where the pain was located and the resident's level of pain (0-10) (0 being no pain and 10 being the worst pain/excruciating) and perform other measures to relieve pain such as repositioning. If alternative measures (repositioning) did not alleviate the pain she would have administered pain medication according to the level of pain. She stated that the nurses documented on the Medication Administration Record (MAR) the level of pain and what pain medications were administered and then 1/2 hour later would document if the pain medication was effective. She added that the nurse would also document in the nursing notes that the resident had complaints of pain, where the pain was, the type of pain medication given and the effectiveness of the pain medication. She further added that it would be important to document in the nurse's progress notes because the progress notes were a form of communication with other staff such as nurses, physicians and any persons who reviewed the chart. She stated the progress notes allowed all medical personnel to be able to know what was going on medically with a resident. She further stated that a CP for pain should have been developed because the resident had complaints of pain and the CP was important so that the staff could have reviewed the alternative interventions to relieve pain or developed interventions to relieve pain. She then added that Resident #55 had complaints of pain in her stomach all the time because she had cancer of the stomach. She stated that the resident was not on routine pain medication just prn (as needed). She stated that the medication that was given to Resident #55 was effective at managing his/her pain. The RN reviewed the MAR with the surveyor and stated that she did not know why some nurses documented that the resident was given pain medication on a specific day, but then also the same day documented that the resident did not complain of pain. On 09/21/22 at 11:42 AM, the surveyor interviewed the Registered Nurse/Assistant Director of Nursing/ Unit Manager (RN/ADON/UM) who stated that she was the covering the Nurse Manager position for the 3rd floor (RN/ADON/UM). She explained to the surveyor the process on how the facility managed a resident that had complaints of pain. She stated the following: -The nurse would evaluate the pain and develop therapeutic interventions such as position changes to manage a resident's pain prior to giving pain medications. -Evaluate the resident and if the resident was able to communicate, find out the level of pain (scale 0-10) and location of pain. -Documentation in progress notes to include location of the pain, consistency of pain, and level of pain the resident was experiencing. -Then the nurse would administer the pain medication and evaluate 10-15 minutes after the administration to make sure that the pain medication was effective or not. The RN/ADON/UM stated that the nurse should have documented the location of the pain in the electronic medical record (EMAR) which would then have populated onto the nurse's progress notes that should have included all the above information. She stated that pain assessments were done every shift in the EMAR and that the MD order did not have to be specific to include location. The RN/ADON/UM further stated it was important that a nursing progress note should have been written that related to where the resident was having the pain and what type of interventions were utilized that alleviated the pain. The RN/ADON/UM reviewed Resident #55's medical record with the surveyor, and she admitted that a Care Plan (CP) was not developed with interventions for Resident #55's pain. She stated that a CP should have been developed with interventions to help alleviate pain and that the CP would have been reviewed to make sure the interventions were adequate. She also stated that a location of the resident's pain was not documented in the progress notes up to this date for the month of September. On 09/21/22 at 12:13 PM, the surveyor interviewed the MDS Coordinator Licensed Practical Nurse MDS/LPN who stated that there was a 5 day look back period for pain and that according to the MDS dated [DATE] which had a look back period from 07/26/22 until 07/22/22, the resident did not receive any medication for pain. The MDS/LPN also reviewed Resident # 55's CP and confirmed that a CP was not developed for Resident # 55's complaints of stomach pain. On 09/30/22 at 8:26 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated she has been employed in the facility since 2015. She stated that if a resident complained about pain and was able to answer questions, the nurse would assess their level of pain according to a pain scale of 1 being low pain and 10 being the worst pain. The nurse would know what type of pain medication the resident would need according to whether the resident had severe pain or mild pain; either Tylenol or a stronger pain medication according to the level. LPN #1 added the nurse would find out the location of the pain, how long the resident had the pain and the onset of pain. She provided an example, If they complain of pain after therapy maybe they would need pain medicine before therapy to prevent pain. LPN #1 stated that depending how often the resident had pain, they may have needed routine pain medication. If they needed routine medication, then the physician would need to be notified and we would would have gotten a routine pain medication ordered. LPN #1 then stated that pain was monitored based on the documentation in the MAR and whether the pain medication was effective. She stated that if the resident had pain during your shift and was given pain medication, the nurse would be responsible to document in both places on the MAR; the first area on the MAR indicated that you gave pain medication, and the second area indicated if the resident had experienced pain during the shift. The nurse would also have documented in the progress note the level of pain, the location of pain, the duration of the pain, that pain medication was administered and if the pain medication was effective. She further confirmed that if a resident had complaints of pain a CP should have been developed with interventions that would include non-pharmacological and pharmacological interventions. On 09/30/22 at 8:38 AM, the surveyor interviewed LPN #2 who administered pain medications on 07/15/22. LPN #2 stated that if a resident complained of pain the nurse would document in the MAR that the resident complained of pain during that shift and what level of pain resident had 0 being no pain and 10 being the worst. LPN #2 then stated that pain medication type would depend on the level of pain the resident was experiencing. The nurse would document in the MAR if the pain medication was effective at relieving the resident's pain. She further revealed that if a resident complained of pain any time during the shift the nurse would have to document that the resident had pain in the MAR. She stated that she was not sure why she documented that Resident #55 did not have complaints of pain on 07/15/22 on day and evening shift, when she administered pain medication to the resident. According to the policy titled, Pain Management dated 11/2021, the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practices, the comprehensive person-centered care plan and the resident's goals and preferences. The policy also indicated that the staff were to identify key characteristics of pain to include duration, frequency, location, onset, pattern, and radiation. The interdisciplinary team and the resident collaborate to arrive at pertinent realistic and measurable goals for treatment. The Policy indicated that the facility was to revise pain management and plan of care as indicated. The facility policy titled, Reviewing and Revising Care Plan dated 11/2019, indicated that the purpose of this procedure was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The policy indicated that a person-centered comprehensive care plan will be developed in according with the facility policy and procedures and will be developed within 7 days after completion of comprehensive assessment, prepared by the interdisciplinary team. The policy also indicated that a comprehensive care plan will be reviewed, revised as necessary when a resident experiences a status change. The MDS Coordinator and Interdisciplinary team will discuss the residents condition and collaborate on intervention options. The team meeting discussion will be documented in the progress notes. Staff involved in the care of the resident will report resident response to new or modified interventions. NJAC 8:39- 27.1 (a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) coordinate medication administration times and accuchecks (blood sugar monitoring) with scheduled renal dialysis days, b.) identify and monitor the dialysis access site, c.) consistently maintain ongoing complete communication notes between the facility and the dialysis center, and d.) implement a person-centered care plan for a resident on renal dialysis. This deficient practice was identified for 1 of 4 residents (Resident #107) reviewed for dialysis and was evidenced by the following: On 09/16/22 at 10:25 AM during initial facility tour, Resident #107 was not in the room. The surveyor interviewed the Licensed Practical Nurse (LPN) who was outside in the hallway and indicated that she was assigned to Resident # 107 today however the resident was out to dialysis. The LPN stated that the resident went out to dialysis on Monday, Wednesday, and Friday from approximately 5:00 AM and returned to the facility at approximately 10:00 AM or 11:00 AM in the morning. The LPN further stated that the resident had an AV shunt ( a U-shaped plastic tube inserted between an artery and a vein used for filtering blood in dialysis) in the left upper arm. The admission Record reflected that Resident #107 was admitted to the facility with the diagnoses which included, but was not limited to, diabetes mellitus (DM) type 2, end stage renal (kidney) disease (ESRD), and Crohn's disease ( chronic inflammatory bowel disease). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/31/22, indicated that Resident #107 had moderate cognitive impairment and required extensive care of two staff members for transfers and extensive care of one staff member for washing, dressing, toilet use and personal hygiene. The MDS did not reflect that the resident received dialysis. The surveyor reviewed the Order Summary Report (OSR) which reflected active physician orders as of 09/21/22. -According to OSR dated 09/19/22 the resident received hemodialysis on Monday, Wednesday, Friday at 10:30 AM. -According to the OSR dated 08/25/22 there was an order written for Type of access: (CVC (central venous catheter)- AV Fistula - AV Graft (arteriovenous graft) Location: (indicate site/location) Schedule: M-W-F At 5:00 AM There was no specification as to what the access site was, where it was or when it was to be monitored The surveyor reviewed the Medication Administration Record (MAR) dated 08/01/22-08/31/22 and 09/01/22-9/30/22 which revealed the following medications were plotted on the electronic medical record (EMR). -Insulin Glargine 100 units/ml solution. Inject 10 units subcutaneously one time a day for DM (Diabetes Mellitus) at 9:00 AM, and was not given on 08/26/22, 08/29/22, 09/07/22, 09/09/22, 09/12/22, 09/19/22 and 9/21/22 because the resident was out at dialysis. There was no documentation that the physician (MD) was notified on the specific dates that the insulin was not administered. -Dicyclomine HCL capsule 10 mg give one capsule by mouth two times a day for IBS (irritable bowel syndrome). At 10:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, 09/12/22 and 09/21/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific date that the Dicyclomine HCL was not administered. -Metoprolol Tartrate 100 mg give one tablet by mouth two times a day for hypertension. At 10:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, and 09/12/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that the Metoprolol tartrate was not administered. -Voriconazole 200 mg give every 12 hours by mouth used to treat fungal infections. At 9:00 AM, the medication was not given on 08/29/22, 09/07/22, 09/09/22, 09/12/22, 09/19/22 and 09/21/22 because the resident was out of the facility at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Voriconazole was not administered. -Insulin Lispro Solution 100 units/ml Inject three units subcutaneously before meals. At 7:30 AM, the medication was not given and accuchecks blood sugars were not performed on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/14/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was not in the facility and was out at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that insulin was not administered, and blood sugars were not done. -Reglan 5 mg Give one tablet by mouth before meals for GERD (Gastroesophageal reflux disease). At 7:30 AM, the medication was not given on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Reglan was not administered. -Sevelamer Carbonate 800 mg give two tablets by mouth three times a day for hypocalcemia (Low calcium). At 8:00 AM, the medication was not given 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that Sevelamer Carbonate was not administered. - Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale (blood sugar testing results): if 200 - 249 = 1 units;250 - 299 = 2 units;300 - 349 = 3 units;350 - 399 = 4 units;400 - 449 = 5 units; <70 or >449 Call MD, subcutaneously before meals and at bedtime for Type 2 DM. At 7:30 AM, accucheck blood sugars were not done for sliding scale on 08/29/22, 08/31/22, 09/05/22, 09/07/22, 09/09/22, 09/12/22, 09/16/22, 09/19/22 and 09/21/22 because the resident was at dialysis. There was no documentation to reflect that the MD was notified on the specific dates that accucheck blood sugars were not done. The facility provided an email from the transportation company that transported the resident to and from the dialysis center and according to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by the ambulance company on 09/02/22 at 05:23 AM and brought back to the facility at 10:41 AM. According to the MAR dated 09/01/22-09/30/22, the nurse documented that the resident received the following medications; however, was not in the facility at those times. - The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 09:00 AM that indicated that Insulin Glargine 100 UNIT/ML Solution Inject 10 unit was injected subcutaneously; however, the resident was not in the facility and was at the dialysis center. The Medication Administration Audit Report (MAAR) reflected that the resident received that 09:00 AM insulin at 14:23 (02:23 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 09:00 AM indicating that Voriconazole Tablet 200 MG was administered at 09:00 am; however, the resident was not in the facility at this time and was at the dialysis center. Upon review of the MAAR, it reflected that the nurse gave the Voriconazole at 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse's signature slotted at 07:30 AM which indicated that Insulin Lispro Solution 100 UNIT/ML 3 unit subcutaneously was administered; however, the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered the Lispro insulin at 14:20 (02:20 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 07:30 AM which indicated that Reglan 5 mg was given; however, the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered Reglan 5 mg 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 08:00 AM, which indicated that Sevelamer Carbonate Tablet 800 MG 2 tablets was administered; however, the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered the medication at 14:19 (02:19 PM). -The surveyor reviewed the MAR dated 09/02/22, and there was a nurse signature slotted at 07:30 AM, which indicated that the nurse took the residents blood sugar. The blood sugar documented on the MAR was 295 and according to the sliding scale the resident received two units of insulin. The surveyor reviewed the MAAR which reflected that the 07:30 AM insulin was not administered until 14:20 (02:20 PM). Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale: if 200 - 249 = 1 units. 250 - 299 = 2 units. 300 - 349 = 3 units. 350 - 399 = 4 units. 400 - 449 = 5 units <70 or >449 Call MD, subcutaneously before meals and at bedtime for Type 2 DM According to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by the ambulance company on 09/05/22 at 05:21 AM and brought back to the facility at 09:59 AM. According to the documentation in the MAR dated 09/01/22-09/30/22 the resident received the following medications; however, was not in the facility at those times. -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received insulin Glargine 10 units subcutaneously; however, the MAAR indicated that the nurse administered the medication outside of the timeframe at 14:01 (02:01 PM). -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that the resident received Metoprolol Tartrate 100 mg; however, the MAAR indicated that the nurse administered the medication outside of the timeframe at 14:01 (02:01 PM). -The surveyor reviewed the MAR dated 09/05/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received the medication Voriconazole 200 mg. The MAAR reflected that the nurse administered the medication outside of the time frame at 11:23 AM. According to the ambulance transportation audit dated 09/22/22 at 10:28 PM, the resident was picked up by the ambulance company on 09/14/22 at 04:54 AM, and brought back to the facility at 10:23 AM. According to the documentation in the MAR dated 09/01/22-09/30/22 the resident received the following medications; however, was not in the facility at those times. -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 09:00 AM, which indicated that the resident received insulin Glargine 10 units subcutaneously; however, the MAAR indicated that the nurse administered the medication outside of the timeframe at 13:13 (01:13 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that Dicyclomine 10 mg was administered. The MAAR reflected that the nurse administered medication outside of the timeframe at 13:14 PM (01:14 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse's signature slotted at 10:00 AM, which indicated that Metoprolol Tartrate 100 mg was administered. The MAAR reflected that the nurse administered medication outside of the timeframe at 13:23 PM (01:23 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse signature slotted at 07:30 AM, which indicated that Reglan 5 mg was given; however, the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered Reglan 5 mg 13:13 (01:13 PM). -The surveyor reviewed the MAR dated 09/14/22, and there was a nurse signature slotted at 08:00 AM, which indicated that Sevelamer Carbonate Tablet 800 MG 2 tablets were administered; however, the resident was not in the facility and was at the dialysis center. The MAAR reflected that the nurse administered the medication at 13:13 (01:13 PM). On 09/22/22 at 9:32 AM, the surveyor interviewed Resident #107 with family present. The resident explained to the surveyor that he/she was picked up for dialysis around 4:30 AM and returned to the facility approximately 11:00 AM on Monday, Wednesday, and Friday. The Resident stated that she had a dialysis access site catheter in his/her left chest. Resident #107 could not explain when their medications were given. On 09/22/22 at 10:10 AM, the surveyor interviewed LPN #2 who had been employed in the facility for 2 years and stated that she was familiar with the dialysis process. She stated that any resident admitted to the facility on dialysis, transportation was set up for the resident to receive dialysis at the dialysis center. She stated that there was a communication book set up and a communication sheet was utilized to facilitate communication between the dialysis center and the facility. She stated the communication sheet was sent out with the resident to dialysis. The surveyor asked the LPN what type of access site the resident had for dialysis and the nurse stated that the resident had an AV fistula in the left arm. The surveyor then explained to the nurse that the resident told the surveyor he/she had a catheter in the left chest wall that was utilized for dialysis. The nurse then replied, Oh yeah, it is in the left side of the chest, I was wrong, I am sorry. She then stated that there was a doctor's order to monitor the access site, but we do that automatically when the resident returns from dialysis to make sure there is no bleeding. We usually check off on the Treatment Administration Record (TAR) that we are monitoring the resident access site. The surveyor reviewed the physician orders and TAR in the presence of LPN #1, and she stated, We should have had an order to monitor Resident # 107's access site. I was not aware she did not have an order to monitor the site. I do not remember signing the TAR that the residents access site was being monitored. LPN #2 also stated that she worked on Friday 9/2/22 and cared for Resident #107. When LPN#2 reviewed the MAR with the surveyor, she stated that she must have made a mistake and did not mean to sign the MAR that she administered the resident's medications when the resident was out to dialysis. The surveyor questioned LPN #2 on how she was able to obtain a blood sugar via accucheck for Resident #107 and administer insulin using the sliding scale when the resident was not present in the facility and LPN #2 could not explain to the surveyor how she documented a blood sugar and gave insulin to the resident when the resident was not in the facility. She stated that it must have been a mistake. On 09/22/22 at 10:43 AM, the surveyor interviewed the Registered Nurse Assistant Director of Nursing Unit Manager for the 3rd floor RN/ADON/UM. The surveyor asked the RN/ADON/UM regarding the facility process for dialysis and she stated the following: Set up transportation, obtain physician orders for dialysis, dialysis center confirmation, contact names, nephrologist, and nurse manager at center. She stated that you would also confirm pick up times and chair times and confirm days. She explained that physician orders were required to monitor the access site for signs and symptoms (S/S) of infection or bleeding. She further added that the nurse was required to sign out a signature in the TAR that the access site was being monitored every shift before and after dialysis. She stated that resident would take a communication sheet to and from dialysis. She explained that the receiving facility fills out a section and the nursing home fills out the assessment section on the communication sheet before and after dialysis. The nurse receiving the resident back to the facility should have documented in the progress note that the resident returned and the condition upon return. It would be important to completely fill out the communication sheet for that the resident returning from dialysis to assure that resident was in stable condition and there were no complications. She stated that medications should not be slotted out to be given at a time that the resident was at dialysis. She further added that it would be important to assure that a resident was receiving all of the medications the MD ordered so that there was not a delay in care or a decline in the resident health. It all has a trickling effect. She confirmed that there were issues regarding Resident #107's medications being slotted at a time that the resident was at dialysis and that the nurses should have notified the MD to get the medication times changed and that the resident did not receive medications when he/she was at dialysis. She also confirmed that the nurses should have completed a Care Plan (CP) at the time dialysis started. She stated that a CP was be important to meet the goals and interventions, and served a communication of care between disciplines. On 09/22/22 at 11:35 AM, the surveyor interviewed the LPN #3 who stated that she was a float nurse and was not assigned to a specific unit. She reviewed the MAR with the surveyor and stated that her signature on the MAR on 9/19/22 reflected that she cared for Resident #107 that day. She stated that she did administer medication to Resident #107 because she documented as such on the MAR. LPN #3 stated that she documented on the MAR that medications were not administered because the resident was out to dialysis. She revealed that she did not give the resident Insulin, Metoprolol Tartrate, Voriconazole, Insulin Lispro, Reglan, and Sevelamer. She admitted that she did not call the MD to inform the doctor that the resident did not receive the insulin or any other medication that she did not administer. The LPN stated that she did not receive any education or competencies on what do when a scheduled medication was to be given when a resident was out to dialysis. The LPN stated that it would have been important to call the MD about the medication times to make sure the resident got his/her medications. She also added that when a resident did not get their medication according to physician's orders that the resident could have health complications. The surveyor reviewed the facility form titled Dialysis Communication Record dated 09/07/22, 09/09/22, 09/12/22 and the facility did not completely fill out the post-dialysis section to include any changes in the resident condition post dialysis, Vital signs, Graft site, pain or nurses' signature that received the resident from the dialysis center. On 09/22/22 at 12:28 PM, the surveyor interviewed the Director of Nursing (DON) who stated that before a resident was admitted to the facility, information regarding dialysis was obtained prior to admission. The facility received information as to which dialysis center the resident was scheduled to receive dialysis, scheduled times and dates the resident would receive dialysis and who would be transporting the resident to and from dialysis. The DON stated that once the resident was admitted to the unit the nurse would put physicians' orders in the electronic medical record where the resident would receive dialysis, what time the resident would receive dialysis, where the access site was, what type of access site it was and how often the access site would be monitored. She added that the normal practice for scheduling medication would be to schedule the medication time so that it did not interfere with the resident's dialysis schedule. She stated that it would be important for residents to get their medications to maintain their health and well-being. She further added that if a nurse observed that a medication time was scheduled when a resident was at dialysis, then the nurse should call the physician and adjust the medication time. She stated that if the resident was on the medication insulin, then the physician should have been notified right away so that the resident's insulin could have been administered. The DON stated that nurses should not have signed the Medication Administration Record (MAR) that the resident received medications when the resident did not receive them because the resident was not in the facility. If a medication was not given, then the reason would need to be documented in the MAR. The DON further stated that the dialysis communication sheet is a form used to communicate treatments that were rendered at the dialysis center or any recommendation from the nephrologist. She stated that it was important that the receiving nurse in the facility fill out the section of the communication form regarding the condition of the resident's access site, vital signs or if the resident had any pain after the resident returned from dialysis because you would want to document that the resident was stable or an any issues after returning from dialysis. She stated that a CP should have been formulated and developed with interventions and goals as the CP drives the resident care and provided information about how to manage the resident's dialysis. On 09/27/22 at 09:25 AM, the surveyor conducted a telephone interview with the Pharmacy Consultant (PC) for the facility since 2016. She stated that her job responsibilities included resident chart review, unit medication storage inspection, medication pass, in-services, and quarterly meeting (QAPI-Quality Assurance and Performance Improvement). She stated that she performed chart review, reviewed labs, checked timing of the medications, interactions, contraindications, allergies, reviewed admissions, new consults, medication changes and nursing and physician recommendations. The PC stated that if she had any recommendation for the facility that the recommendations were sent via email to the DON and some of the Corporation nurses. She stated that when she reviewed residents' charts that were on dialysis, she would review medications and make sure medications were administered according to the dialysis schedule. She stated that it was important to make sure a resident got their medication correctly so that they were not getting their medication too closely together. She stated that medications should be scheduled for dialysis days and non-dialysis days. She added that the medication schedule should accommodate dialysis because you do not want to administer medications out of the window (timeframe that a medication could be administered), or if medications must be held. The MD needs to be made aware so that the medications could be scheduled correctly. She stated that if a dose of medication was missed because the resident was out to dialysis then the physician needed to be notified to find out what time the medication could be given. She further added that the nurse needed to document and make the physician aware and should not attempted to use their own judgement whether to give medications or not. She stated that when the nurse noticed that the residents' medications were scheduled during the time the resident was out to dialysis, they should have called MD and got the medication times adjusted according to dialysis schedule. The surveyor reviewed the Consultant Pharmacist's Monthly Report dated 09/15/22 which indicated that the PC reviewed Resident #107's medications and there were no recommendations that the Resident's medication times were not scheduled to accommodate dialysis schedule or that medications were not administered to the resident when the resident was out to dialysis. On 09/28/22 at 10:19 AM, the surveyor conducted a telephone interview with the PC who explained to the surveyor that she was not sure why she did not make any recommendations to adjust Resident #107's medication times according to dialysis schedule and would have to review this and get back to the surveyor with the information. On 09/28/22 at 11:42 AM, the surveyor interviewed Registered Nurse (RN) who was employed for the facility since 2019. The RN stated that she worked on 9/5/22 and documented on the MAR that she administered 10 units of insulin to Resident # 107 at 9:00 AM. She stated, I gave the resident the insulin because she came back around 10 am and it was in the scheduled timeframe to give it. She stated that she signed the medication out at 14:01 because she did not have time to sign the medication out at the time that she gave it. She stated that she knows that she is supposed to sign the medication out right after she administered it but did not because she was busy and was always interrupted and does not always get time. The RN also admitted to administering the insulin out of the timeframe on 09/14/22 at 9:00 AM but was not sure why. I am not sure why I did not get the medication times adjusted according to the resident's dialysis days or call the doctor. On 09/29/22 at 10:14 AM, the surveyor interviewed the PC who admitted that she failed to identify that the resident's medication times were not adjusted according to the resident's dialysis time. She stated that the nursing department should have adjusted the times according to the dialysis center and that she should have identified this medication discrepancy during her monthly review on 09/15/22. She stated that she would further review the residents medical record and that the resident did not experience any untoward effects and that the resident recent A1C (blood test shows how well blood sugar levels have been controlled) was 5.1(abnormal was below 5.7). The facility policy titled, Dialysis Policy dated 01/22, indicated that it was the policy of the facility to ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. Upon admission, the nurse will ensure that the following information was located in the resident's medical record: type and location of dialysis access device, must ensure that medications and treatments were timed according to the residents' dialysis schedule, monitor patency of dialysis access, monitor for complications related to renal dialysis, and dialysis communication form will be sent with the resident to dialysis and upon return from dialysis the charge nurse will review and take note of any recommendations. The facility policy titled, Reviewing and Revising Care Plan dated 11/2019, indicated that the purpose of this procedure was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The policy indicated that a person-centered comprehensive care plan will be developed with the facility policy and procedures and will be developed within 7 days after completion of comprehensive assessment, prepared by the interdisciplinary team. The facility policy titled, Medication Administration dated 11/2020, indicated that medications were to be 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 in a manner to prevent contamination or infection. NJAC 8:39 - 27.1 (a,e)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to follow professional standards of nursing practice by not clarifying medication orders in timely manner for 1 of 4 residents (Resident #127) reviewed for tube feeding. This deficient practice was evidenced by the following: On 09/19/22 at 12:18 PM, the surveyor observed Resident #127 in bed with the head of bed elevated. The resident had no facial grimacing and showed no signs or symptoms of distress or discomfort. According to the admission Record, Resident #127 was admitted with diagnoses which included but were not limited to acute respiratory failure, dysphagia (difficulties swallowing), aphasia (loss of ability to understand or express speech) and gastrostomy status (surgical operation for making an opening in the stomach) (peg tube.) Review of Resident #127's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/02/22, indicated the resident had a feeding tube and that the resident received 51% or more of total calories through tube feeding. The MDS further indicated that the average fluid intake was 501 cc (cubic centimeter)/day, or more was received by tube feeding. Review of Resident #127's Care Plan (CP) included a focus, dated 08/29/22, that the resident required tube feedings related to dysphagia NPO (nothing by mouth) status. Review of Resident #127's Speech Therapy (ST) SLP Evaluation and Plan of Treatment, dated 08/30/22, indicated the resident was NPO with all means of nutrition via peg tube and was admitted to this facility NPO. ST recommendations included to continue NPO status and for medications to be administered via the resident's peg tube. Review of Resident 08/27/22-09/30/22 Order Summary Report revealed the following physician orders (order): 1. 08/27/22 order of NPO diet NPO texture. 2. 08/29/22 order for Ascorbic Acid (vitamin C) 250 milligrams (mg), one tablet by mouth daily. 3. 08/29/22 order for Aspirin Chewable 81 mg, one tablet by mouth daily. 4. 09/09/22 order for Florastor Capsule (probiotic) 250 mg, one capsule by mouth two times a day. 5. 08/27/22 order for Metoprolol Tartrate (blood pressure medication) 25 mg, one tablet by mouth every 8 hours. 6. 08/29/22 order for Multiple Vitamins-Minerals, one tablet by mouth daily. Review of Resident #127's August 2022 and September 2022 Medication Administration Record (MAR) indicated that the resident received the following medications by mouth on the following days: 1. Ascorbic Acid 250mg was administered by mouth on 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/13/22, 09/14/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22 and 09/19/22. 2. Aspirin Chewable 81 mg was administered by mouth on 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/13/22, 09/14/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22 and 09/19/22. 3. Florastor Capsule 250 mg was administered by mouth on 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/13/22, 09/14/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22 and 09/19/22. 4. Metoprolol Tartrate 25 mg was administered by mouth on 08/27/22, 08/28/22, 08/29/22, 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/13/22, 09/14/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22 and 09/19/22. 5. Multiple Vitamins-Minerals tablet was administered by mouth on 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22, 09/08/22, 09/09/22, 09/10/22, 09/11/22, 09/12/22, 09/13/22, 09/14/22, 09/15/22, 09/16/22, 09/17/22, 09/18/22 and 09/19/22. During an interview with the surveyor on 09/29/22 at 10:35 AM, the Licensed Practical Nurse (LPN) #2 stated that a check on the MAR indicated the medication was administered. LPN #2 added that she would hold the medication and call the physician to clarify the resident's NPO status if she was not sure of what route to administer the medication. During an interview with the surveyor on 09/29/22 at 10:51 AM, LPN #1 stated that a check on the MAR indicated the medication was administered. LPN #1 further stated that she checked for the right resident, right medication, and right route when administering medications to residents. LPN #1 added she would hold the medication and call the physician to clarify the resident's NPO status if she was not sure of what route to administer the medication. During an interview with the surveyor on 09/29/22 at 10:59 AM, the Registered Nurse/Charge Nurse (RNCN) stated the check on the MAR indicated the medication was administered. The RNCN further stated that nurses were to clarify medication orders with the physician if unsure of the resident's NPO status. During an interview with the surveyor on 09/29/22 at 12:19 PM, the Director of Nursing (DON) stated the check on the MAR indicated the medication was administered and that nurses were to clarify medication orders with the physician if unsure of the resident's NPO status. Review of Resident #127's Progress Notes from 08/26/22 to 09/19/22 reveal no documentation that nursing clarified the resident's by mouth medication orders with the physician. Review of the facility's Medication Administration policy, revised on 11/2020, indicated to compare medication source with MAR to verify resident name, medication name, form, dose, route and time. NJAC 8:39-11.2(b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 09/16/22 at 10:00 AM, the surveyor, in the presence of the Food Service Director (FSD) and Ambassador of Dietary Services (ADS), observed the following during the kitchen tour: 1. A food service worker (FSW) was observed walking in the kitchen with a blue baseball cap with hair sticking out the back. When interviewed, the FSD stated the FSW's hair should be covered. 2. A stack of uncovered coffee filters was stored directly on the shelf and a second stack of uncovered coffee filters was stored in a bin containing coffee packets. When interviewed, the FSD stated the stacks of coffee filters should be stored in plastic. 3. A stack of uncovered plastic lids was stored directly on the shelf and a second stack of uncovered plastic lids was stored directly on the shelf behind the coffee machine. When interviewed, the FSD stated the stacks of plastic lids should be stored in plastic. 4. In the second snack refrigerator, 10 undated pieces of cakes wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the cakes should have been dated. 5. In the second snack refrigerator, a box containing 26 undated vanilla health shakes was stored on a shelf. When interviewed, the FSD stated the health shakes should be dated with a pull date and that staff forgot to label them. 6. The mixer was covered with plastic. When interviewed, the FSD stated the mixer was clean and sanitized. Upon inspection, the mixer was noted covered with debris. When interviewed, The ADS stated a clean and sanitized mixer should not have debris on it. 7. The left-side oven had a box containing clear film, three rolls of black trash bags, and package of roasted peanuts stored inside. The right-side oven had an aluminum bin containing scoops, a package of Styrofoam plates, three aluminum bins with plastic forks and napkins, an open and undated bag of potato chips, an aluminum bin with coffee packages and an open package of disposable plates stored inside. When interviewed, the ADS stated the left and right stoves were not being used and pointed to the signage posted that indicated the Not in Use. The ADS added that it was not normal practice to store items inside either oven. 8. On the spice rack, an open and undated package of creamy rice wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the package should have been labeled with an open date. 9. On the spice rack, an open and undated package of brown sugar wrapped in plastic was stored on a shelf. When interviewed, the FSD stated the package should have been labeled with an open date. 10. In the walk-in refrigerator, a box containing two undated vanilla health shakes was stored on a shelf. When interviewed, the ADS stated the health shakes should be labeled with a pull date and use by date. 11. In the walk-in refrigerator, an aluminum bin containing speared pickles had a use by date of 09/10/22. When interviewed, the FSD stated it should not have been in the walk-in refrigerator. 12. In the walk-in freezer, a personal can of soda was stored on a shelf. When interviewed, the FSD stated the can of soda was for an employee and that it should not be stored in the walk-in freezer. 13. In the walk-in freezer, an open and undated package of breaded eggplant wrapped with plastic was stored on a shelf. When interviewed, the ADS stated the package was supposed to be labeled with a date. On 09/28/22 at 11:33 AM, the surveyor inspected the nourishment stations on the units and observed the following: 14. In the second-floor nourishment station, an open and undated package of rolls were stored in a cabinet. 15. In the second-floor nourishment station, two stacks of clear plastic tray lids were stored on a counter. The stacks of clear plastic tray lids were visible were not dry and wet nesting. 16. In the third-floor nourishment station refrigerator, two undated muffins wrapped in plastic were stored on a shelf. During an interview with the surveyor on 09/28/22, the ADS stated the clear plastic tray lids were not supposed to be stored in that manner and that they should have been fully dried. Review of the facility's Ware Washing HCSG policy 025 policy, dated May 2014, indicated that the FSD would ensure that all dishware is air dried and properly stored. Review of the facility's Staff Attire HCSG Policy 024 policy, revised on 02/05/18, revealed that all staff members will have hair confined in a hair net. Review of the facility's Equipment HCSG policy 030 policy, dated May 2014, indicated that the FSD would ensure that all equipment is routinely cleaned. Review of the facility's Food Storage: Cold HCSG Policy 022 policy, dated May 2014, indicated that the FSD would ensure that all food items are stored properly in covered containers, labeled, and dated. NJAC 8:38-17.2 (g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) utilize an infection assessment tool for 4 of 4 residents (Resident #124, #127, #487, and #488) prescribed antibiotic medications in the facility, and b.) monitor and review actual antibiotic use according to the facility's Antibiotic Stewardship Program. This deficient practice was evidenced by the following: Review of the Antibiotic Stewardship Meeting Minutes, dated 07/26/22, provided by the Infection Preventionist (IP), revealed a section titled Discussion with the following listed below it: Antibiotic Stewardship Program Goals, Antibiotic Use Reports, Antibiotic Resistance Reports, Newly Diagnosed Infection Report, C Difficile Report (Outcome Measure Review), and Antibiotic Prescription Review. However, the only documents attached to the meeting minutes were Infection Control Logs of the residents who were on antibiotics during the month of July 2022. There were no reviews or reports related to antibiotic use attached to the meeting minutes. Review of the Antibiotic Stewardship Meeting Minutes, dated 08/26/22, provided by the Infection Preventionist (IP), revealed a section titled Discussion with the following listed below it: Antibiotic Stewardship Program Goals, Antibiotic Use Reports, Antibiotic Resistance Reports, Newly Diagnosed Infection Report, C Difficile Report (Outcome Measure Review), and Antibiotic Prescription Review. However, the only documents attached to the meeting minutes were Infection Control Logs of the residents who were on antibiotics during the month of August and September 2022. There were no reviews or reports related to antibiotic use attached to the meeting minutes. Further review of the logs attached to the Antibiotic Stewardship Meeting Minutes included the following information related to residents who were prescribed antibiotics while at the facility: -Resident #124 was admitted on [DATE] and was started on antibiotics on 09/12/22 for a Urinary Tract Infection (UTI). -Resident #127 was admitted on [DATE] and was started on antibiotics on 09/11/22 for a UTI. -Resident #487 was admitted on [DATE] and was started on antibiotics on 09/07/22 for Right Infiltrate (substance in the lung). -Resident #488 was admitted on [DATE] and was started on antibiotics on 08/12/22 for a UTI. During an interview with the surveyor on 09/27/22 at 11:40 AM, the IP stated she was unsure what infection assessment tool the facility used to assess residents for antibiotic treatment. At that time, the surveyor requested the infection assessment tools that were used prior to prescribing antibiotics for Resident #124, #127, #487, and #488. At 1:17 PM, the IP stated she was unable to provide any completed infection assessment tools and stated, it fell through the cracks, and acknowledged that the assessments were not completed for Resident #124, #127, #487, and #488. The IP then provided a blank copy of the Loeb's Minimum Criteria for Starting Antibiotic Therapy in LTC (Long Term Care) and stated that it was the form that should have been completed for those residents. During a follow-up interview with the surveyor on 09/28/22 at 11:35 AM, the IP stated her responsibilities related to the Antibiotic Stewardship Program included reviewing antibiotic logs, educating nurses on antibiotics, collecting antibiotic logs from the pharmacy, and ensuring antibiotic orders are written correctly. She then explained that if a resident is suspected of having an infection, the nurse should contact the Infectious Disease (ID) physician, contact the resident's physician, contact the resident's family, and transcribe any antibiotic orders given. When asked if the nurse should complete an infection assessment tool, the IP stated the nurse should complete the Loeb's Minimum Criteria form and document it in the resident's progress notes. The IP further stated that if the resident did not meet the criteria, the resident should not be put on an antibiotic. During the same interview, the IP stated that antibiotic usage was tracked using the Infection Control Logs and the facility's pharmacy also sends a log of antibiotics used in the facility. The IP further stated that the Infection Control Logs, which tracked how many residents were on antibiotics and the type of infection being treated, were reviewed monthly at the Antibiotic Stewardship Program meetings. The IP also stated that the purpose of the Antibiotic Stewardship Program was to prevent residents from being prescribed antibiotics if they don't need it because it could make the resident worse with the side effects from the medication. When asked for the facility's annual report on antibiotic usage, the IP stated she would not have that because she has only worked at the facility for two months. During an interview with the surveyor on 09/28/22 at 12:02 PM, the Director of Nursing (DON) explained that when a resident is suspected of having an infection, the nurse should assess the resident, call the physician, and consult the ID physician. When asked if the nurse should complete an infection assessment tool, the DON stated the nurse should complete the Loeb's Minimum Criteria to prevent the unnecessary use of antibiotics. During the same interview, the DON stated that the IP was responsible for reviewing antibiotic use monthly. The DON also stated that antibiotic use was discussed monthly during the Antibiotic Stewardship Program meetings and quarterly during the QAPI (Quality Assurance and Performance Improvement) meetings. The DON further stated that the facility's annual report on antibiotic usage included all the antibiotics used in the year and that the ID physician was consulted to determine interventions to prevent repeated infections. The DON then stated that the Antibiotic Stewardship Program was important to prevent further infections and treat infections appropriately. On 09/28/22 at 1:19 PM, the IP sent the surveyor an email with the subject line of Annual ABT [antibiotic] & Physician Data Report. The email contained two attachments - Antibiotics Dispensed 01-01-2021 - 12-31-2021 and Antibiotics Dispensed 01-01-2022 - 09-28-2022. Both attachments contained a log of residents who were prescribed antibiotics, their room location, their physician, the antibiotic prescribed, the timeframe for the antibiotic, and the instructions for the antibiotic. The attachments did not contain feedback on antibiotic use in the facility. On 09/29/22 at 11:10 AM, the surveyor again requested any reviews and/or reports related to the antibiotic usage since the facility had only provided antibiotic tracking logs to the surveyor. During an interview with the surveyor on 09/29/22 at 11:20 AM, the Medical Director (MD) stated the purpose of the Antibiotic Stewardship Program was to reduce the use of unnecessary antibiotic treatments. He further stated that he does not attend the monthly Antibiotic Stewardship Program meetings but attends the quarterly QAPI meetings to discuss the usage of antibiotics. When asked, the MD was unsure what infection assessment tool was used by the facility and could not recall ever receiving an annual antibiotic use data report from the facility. During a follow-up interview with the surveyor on 09/30/22 at 9:35 AM, the DON stated that since the IP started working at the facility two months ago, she had not completed any antibiotic reviews or reports. The DON then provided a Performance Improvement Plan (PIP) titled UTI's, dated 04/30/21, that assessed the number of UTIs in the facility for March 2021 only. The PIP did not include all antibiotics prescribed in the facility or a timeframe longer than one month. When asked if there was an annual report on antibiotic usage since the April 2021 PIP, the DON stated there was not because the facility did not have an IP at the time the report was due. The facility was unable to provide any reports or reviews related to the antibiotic usage in the facility over the last year. Review of the facility's Antibiotic Stewardship Program policy, revised 09/2020, included, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy also included, Nursing staff assess residents who are suspected to have an infection and complete an SBAR [Situation Background Assessment Recommendation] form prior to notifying the physician, and, The Loeb Minimum Criteria are used to determine whether to treat an infection with antibiotics. Further review of the policy included a section about monitoring antibiotic use which included, At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. The policy also included, At least annually, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, resident and family council, and the QAA Committee, and, At least annually, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report (i.e 'antibiotic report card'). NJAC 8:39-19.4(d)

Based on facility staff interviews and review of other facility documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control and was qualified by certification and experience for 1 of 1 staff member reviewed in accordance with the facility job description, Center for Medicare and Medicaid Services (CMS) and New Jersey State guidelines. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2; or b. A Physician who has completed an infectious disease fellowship; or c. A healthcare professional licensed and in good standing by the State of New Jersey, with five (5) or more years of Infection Control experience. iv. Facilities with 100 or more beds or on-site hemodialysis services must: 1. Hire a full-time employee in the infection prevention role, with no other responsibilities and must attest to the hiring no later than August 10, 2021. On 09/22/22 at 11:17 AM, the surveyor interviewed the IP who stated that she had been a nurse for twenty years, recently obtained a Bachelor's Degree in Public Health in May of 2022, and began working at the facility in the role of IP on 07/11/22. The IP stated that she did not possess an infection control certification nor had she completed an infection control course. The IP stated that the Director of Nursing (DON) supported her in the role of IP, although she was unsure if the DON possessed any sort of Infection Control Certification. The IP further stated that she previously worked as an emergency room nurse and her job duties included IP training related to COVID-19 testing and vaccination of staff. The surveyor requested to view the IP's Job Description, resume, and supporting documentation. The surveyor reviewed the IP's Resume which indicated that the IP worked as an emergency room Nurse from January 2022 through June 2022, and failed to demonstrate that the IP received infection prevention training as the IP previously indicated or that she had five years of experience as an IP. On 09/22/22 at 11:48 AM, the surveyor interviewed the Administrator and asked if he assisted the IP with her job duties. The Administrator stated that he did not have a clinical background and his role in infection control was limited to reporting the numbers. He further stated that the DON did not possess any type of infection prevention experience or certification. On 09/27/22 at 10:00 AM, the surveyor interviewed the DON who stated that the Administrator and the Regional Staff were involved in assisting the IP. The DON stated that she was unsure if they held any sort of infection control certification. The DON further stated that she may have completed the Center for Disease Control Training Course (CDC TRAIN), but would have to confirm successful completion of the course with a former employer. The DON was unable to provide documented evidence that she or the Regional Staff completed an infection control training course. On 09/27/22 at 11:54 AM, the surveyor interviewed the Human Resources Liaison (HRL) via speaker phone (with permission) in the presence of the survey team. The HRL stated that she covered in the position for the former HRL who resigned on 09/19/22. The HRL stated that to the best of her knowledge, when the facility hired they looked for experience. The HRL stated that she was removed from clinical, was not involved in the hiring of IP staff, and was not aware of the requirements that were set forth. Review of the facility provided job description revealed the following: Position Summary: The essential functions of the job for an Infection Preventionist are to develop, implement, and maintain a facility-wide infection prevention and control program. Required Qualifications included: A professionally-trained nurse that has earned a certificate/diploma or degree in nursing; .Education, training, experience, or certification in infection control and prevention. Completed specialized training in infection prevention and control through accredited continuing education. NJAC 8:39-20.2