Complaint # NJ178109 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/21/25 and 4/24/25, it was determined that the facility failed to submit the facility's investigation to the New Jersey Department of Health (NJDOH) in a timely manner for a resident-to-resident incident that occurred. The facility also failed to follow its policy titled Abuse Policy. The deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident # 2 was admitted to the facility in June 2020 with diagnoses which included but were not limited to: Depression, Anxiety, and Bipolar Disorder. According to the quarterly Minimum Data Set (MDS), an assessment tool dated 02/27/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated the resident's cognition was severely impaired. 2. According to the admission Record (AR), Resident # 8 was admitted to the facility in October 2019 with diagnoses which included but were not limited to: Major Depressive Disorder, constipation, and Schizophrenia (a mental health condition that affects the resident's ability to think and behave clearly). According to the quarterly MDS, an assessment tool dated 01/24/25, Resident #8 had a BIMS score of 3 out of 15 which indicated the resident's cognition was severely impaired. According to the Facility Reportable Event (FRE), a NJDOH document used by healthcare facilities to report incidents, with a date of 10/04/2024 and an event date of 9/16/2024 revealed that it was reported to facility administration that Resident #8 had struck Resident #2 on the back while exiting the elevator. Both residents were immediately separated, and body assessments were conducted. On 4/21/25 at 3:41P.M., the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), and the Regional DON. The DON confirmed that the FRE was not sent to the NJDOH until 10/04/24. The DON further stated the FRE was not sent in until October 4th because during this time we were deep in our DPOC (Directed Plan of Correction). On 4/24/25 at 2:13P.M., the surveyor interviewed the LNHA, in the presence of the DON and the Regional DON who stated she submitted the investigation and conclusion for the incident electronically to the DOH and would provide a copy of the email to the surveyor. The facility did not provide the surveyor with documentation that the facility's investigation was submitted electronically to the NJDOH. A review of the facilities undated policy titled Abuse Policy revealed under External Reporting, A follow up investigation will be submitted to the State Agency within five (5) working days. When making a report, the following information should be reported: The facility must include the following investigative components: Have evidence that all alleged violations are thoroughly investigated. NJAC 8.39-9.4

Complaint #: NJ182273 Based on observation, interview, review of the medical records, and pertinent facility documents on 4/21/25 and 4/24/25, it was determined that the facility's nursing staff failed to: a.) sign on the electronic Medication Administration Record (eMAR) that the medications were administered according to the physician's orders, and b.) administer medication according to the physician's order. The facility also failed to follow their policy titled Medication Administration. This deficient practice was identified for 4 of 5 residents (Resident #2, Resident #3, Resident #4, Resident #5) reviewed for medication administration. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/21/25 at 8:56 A.M., the surveyor observed the Licensed Practical Nurse (LPN) during medication administration. While the LPN prepared the medication for Resident #2, the surveyor observed the LPN remove a bingo card from the medication cart. The surveyor reviewed the medication information on the bingo card which revealed Sotalol 80 milligram (MG) and two stickers on it. One sticker stated, partial tab and the other sticker stated 1HT=40 MG. on it. The surveyor turned the bingo card over and observed the packaging seal for each medication slot stated 1/2 of 80 MG. The LPN reviewed the bingo card against the order in the eMAR. The surveyor reviewed the order on the eMAR which stated Sotalol HCL Tab 80 MG. Give 1 tablet orally one time a day for Atrial fibrillation (Afib). The LPN placed the half tab from the bingo card into the medication cup. The LPN went into Resident #7's room and identified the resident. As the LPN was about to administer the medication, the surveyor asked her what was the Sotalol dose that she had placed in the medication cup. The LPN showed the surveyor the same bingo card that contained Sotalol half tabs and stated Both doses match. Bingo card is 80 MG, and it matches order on the computer. On 4/21/25 at 9:03 A.M., the surveyor interviewed the second floor Unit Manager (UM) who confirmed that the dose in the bingo card was Sotalol 40 MG. The UM looked at Resident #2's electronic medical record (EMR) in the presence of the surveyor and stated The order should be 40 MG not 80 MG. The UM further indicated she would call the doctor to verify the Sotalol dose. At 4/21/25 at 9:08 A.M., the UM informed the LPN in the presence of the surveyor that she had received new orders from the nurse practitioner (NP), to administer Sotalol 40 MG by mouth one time a day. The UM entered the order for Sotalol 40 MG in the EMR in the presence of the surveyor and the LPN. The LPN proceeded into Resident #7's room and administered the medication in the cup. After administering the medication to Resident #2, the LPN went into the electronic MAR and signed out the order that stated Sotalol HCL Tab 80 MG. Give 1 tablet orally one time a day for Atrial Fibrillation (Afib). The surveyor asked the LPN why she documented that she administered Sotalol 80 MG when she only gave the resident 40 MG. The LPN stated I signed for 40 MG. How come you had to pick me to watch do meds, there are other people here. I am getting confused now. 1. According to the admission Record (AR), Resident #2 was admitted to the facility in June of 2020 with diagnoses which included but were not limited to Depression, Anxiety, and Bipolar Disorder. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 2/27/25, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #2's order Summary Report (OSR), with active orders as of 4/21/25 included but was not limited to the following Physician's Orders (Pos): Sotalol HCL Tab 80 MG. Give one tablet orally one time a day for Afib. Sotalol HCL AF Oral Tablet. Give 40 mg by mouth one time a day for Afib. Levothyroxine Tab 75 MCG. Give one tablet orally one time a day for Hypothyroidism. A review of Resident #2's April 2025 MAR revealed the LPN's initials for the PO (by mouth) Sotalol HCL Tab 80 MG on 4/21/2025 at 9:00AM. The MAR indicated that for PO (by mouth) Sotalol hydrochloride (HCL) AF Oral Tablet a start date of 4/22/25. The MAR further revealed a blank space for PO (by mouth) Levothyroxine 75 Microgram (MCG) on 4/3/25 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Levothyroxine 75 MCG was administered on 4/3/2025 at 6:00 A.M. On 4/21/2025 at 3:40 P.M., the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the Regional DON. The DON stated The nurse would not give the 80 mgs because one tablet is 40 mgs, and that tablet is half a tab. The DON further indicated You can only order Sotalol under 80 mgs, but it is 40mgs they would receive. The surveyor asked the DON for further clarification. The DON stated, The resident is never getting 80mgs because it only comes from the pharmacy as 40mgs. The surveyor asked the DON what Sotalol dose the resident should have received based on the order in the resident's MAR. The DON replied, Should be getting 40mgs. 2. According to the AR, Resident #3 was admitted to the facility in September 2025 with diagnoses which included but were not limited to Dementia, Bipolar Disorder, and Seizures. According to the admission MDS, an assessment tool dated 3/5/2025, Resident #3 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. A review of Resident #3's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 2/27/2025 for Levothyroxine Sodium Tablet 100 MCG. The PO (by mouth) instructed to administer one tablet by mouth one time a day for low thyroid hormone. A review of Resident #3's April 2025 MAR revealed the 2/27/25 PO for Levothyroxine Sodium Tablet 100 mcg and to administer one tablet by mouth one time a day for low thyroid hormone. The April 2025 MAR did not reveal a signature from the nurse that Levothyroxine Sodium Tablet 100 mcg was administered on 4/3/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Levothyroxine Sodium Tablet 100 mcg was administered on 4/3/2025 at 6:00 A.M. 3. According to the AR, Resident #4 was admitted to the facility in January of 2022 with diagnoses which included but were not limited to Chronic Obstructive Pulmonary Disease, Bipolar Disorder, and Depression. According to the Annual MDS, an assessment tool dated 4/9/2025, Resident #4 had a BIMS score of 8 out of 15, which indicated the resident's cognition was moderately impaired. A review of Resident #4's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 4/28/24 for Omeprazole 20 mg. The PO instructed to administer one capsule orally one time a day for GERD. A review of Resident #4's April 2025 MAR revealed 4/28/24 PO (by mouth) for Omeprazole 20 mg and to administer one capsule orally one time a day for GERD. The April 2025 MAR did not reveal a signature from the nurse that Omeprazole 20 mg was administered on 4/17/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Omeprazole 20 mg was administered on 4/17/2025 at 6:00 A.M. 4. According to the AR, Resident #5 was admitted to the facility in December of 2024 with diagnoses which included but were not limited to Chronic Hepatitis, Hypertension, and Major Depressive Disorder. According to the Quarterly MDS, an assessment tool dated 3/29/25, Resident #5 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #5's OSR, with active orders as of 4/24/25, revealed a PO (by mouth) dated 12/20/24 for Docusate Sodium Capsule 100 mg. The PO (by mouth) instructed to administer 2 capsules by mouth in the morning for constipation. A review of Resident #5's April 2025 MAR revealed 12/20/24 PO (by mouth) for Docusate Sodium Capsule 100 mg and to administer 2 capsules by mouth in the morning for constipation. The April 2025 MAR did not reveal a signature from the nurse that Docusate Sodium Capsule 100 mg 2 capsules was administered on 4/17/2025 at 6:00 A.M. The April 2025 Progress Notes (PNs) did not reveal documentation that Docusate Sodium Capsule 100 mg 2 capsules was administered on 4/17/2025 at 6:00 A.M. On 4/21/2025 at 10:45 A.M., the surveyor interviewed the LPN who stated that once medication had been administered it was signed out on the MAR. The LPN further indicated All meds have to be signed out after you give them. On 4/24/25 at 2:14 P.M., the surveyor interviewed the DON in the presence of the LNHA And Regional DON. The DON stated the expectation was that the nurse signs out the medications on the MAR after administering them. The DON stated this was important to ensure credit is given for administering the medication and ensure it was given as ordered. The DON indicated that if a medication is not signed on the MAR, it would indicate either an omission or refusal. The DON further stated the nurse should indicate a refusal on the MAR, if the resident refused. The DON confirmed blank spaces on MAR for Resident #2, Resident #3, Resident #4 and Resident #5. The DON stated Yes, the nurse should have signed out the MAR after administering meds. A review of the facility's policy titled Medication Administration with a last reviewed date of 09/2024 revealed under Procedure, 11. Verify the pharmacy prescription label on the drug and the manufacturer's identifcation system matches the MAR. 13. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR before administering. 17. Document the following as applicable: Administration of medication on MAR as soon as medications are given. NJAC 8:39-11.2 (b)

NJ Complaint #168809 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to provide a discharged resident with a copy of their medical records within a timely manner of the written request. This deficient practice was identified for 1 of 1 resident reviewed for medical records (Resident #252), and was evidenced by the following: According to the Resident Face Sheet (an admission summary), Resident #252 was admitted to the facility in 2022 with diagnoses kidney failure. The face sheet did not include the resident's discharge date . A review of the electronic Admissions record revealed Resident #252 was discharged from the facility in July of 2022. On 6/19/24 at 12:09 PM, the surveyor interviewed the Medical Records personnel who stated residents and authorized personnel can request medical records. Once the Medical Records personnel received the authorization, she printed out the medical records and had the nurses review to ensure they were complete and accurate. At that time the surveyor provided the Medical Records personnel with a list of residents if she could provide documentation if medical records were requested. On 6/20/24 at 9:12 AM, the Medical Records personnel informed the surveyor that months ago a representative for Resident #252 requested a copy of the resident's medical records. The Medical Records personnel stated she had made copies and provided them to the previous Administrator, and she was unsure if he sent them to the representative for Resident #252. At that time, the surveyor requested a copy of the medical records request and any documentation the medical records were released. A review of the documentation provided by the facility's Licensed Nursing Home Administrator (LNHA) revealed that on 10/27/23, a representative for Resident #252 made a request to receive a copy of the resident's medical records. On 6/25/24 at 10:33 AM, the surveyor interviewed the LNHA who stated the facility had a form that was to be completed and medical records were released. The LNHA stated a resident, family member, or representative as long as they were authorized could receive access to medical records with a small fee up to $20. The medical records were printed out as soon as possible after the request was made. The LNHA stated at the time of Resident #252's stay at the facility, the facility utilized paper medical records, and the facility was trying to locate the records. On 6/25/24 at 1:22 PM, the LNHA informed the surveyor that there was no evidence that the representative for Resident #252 received the records. A review of the facility provided Medical Record Policy dated last revised 5/1/24, did not include the process for obtaining medical records. NJAC 8:39-35.2(h)

Complaint NJ #162168 Based on interviews, review of the closed medical records, and pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 35 sampled residents (Resident #247), and was evidenced by the following: A review of the closed medical record for Resident #247 revealed the resident was admitted to the facility in 2019 and discharged from the facility in 2023. A review of the Minimum Data Set (MDS), an assessment tool dated 2/3/23, indicated that the resident had unclear speech and usually understood with diagnoses which included hypertension, depression, bipolar, and schizophrenia. A review of the Progress Notes included a Nurses Note (NN) dated 11/13/22, that the resident was noted sitting on the floor in their bathroom with no injuries. Vital signs were obtained, and the resident attempted to stand up from their wheelchair without assistance, and slipped on their feces that they spread around their bathroom. The nurse noted that they left a message for the physician, but they were unable to call a responsible party because there was no phone number available. On 6/19/24 at 1:25 PM, the surveyor requested from the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) a change of condition policy. On 6/20/24 at 9:54 AM, the surveyor interviewed the DON who stated family was notified anytime there was a change in condition. The surveyor asked the DON why there was no phone number for Resident #247's representative, and the DON stated the resident had a responsible party who was very involved in their care, and the Social Worker (SW) would be able to contact them. The facility's SW worked at the only one week, and the surveyor asked the DON to provide any documentation they were informed of the change in condition on 11/13/22. On 6/20/24 at 12:57 PM, the survey team met with the LNHA and DON, and requested any additional information on Resident #247's change of condition notification. The DON stated that the resident had a responsible party who was very involved, and needed to check the Progress Notes. The surveyor requested a change of condition policy. On 6/26/24 at 10:36 AM, the Assistant Director of Nursing (ADON) in the presence of the LNHA, DON, and survey team stated that she usually spoke to Resident #247's responsible party member via the telephone that she stored in a separate book, and the ADON always made sure the responsible party was aware of any changes. The ADON confirmed the phone number should have been located in the resident's medical record, and that Resident #247's responsible party should have been made aware of the resident's change of condition. No policy was received. NJAC 8:39-13.1(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #159783 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to to maintain the residents' environment, equipment, and living areas in a safe, sanitary, and homelike manner that included clean linens and privacy curtains. This deficient practice was identified for 2 of 2 nursing units observed for the facility environment task. This deficient practice was evidenced by the following: 1. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked what the resident census in the facility was, and the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) stated 94 residents. On 6/17/24 at 10:42 AM, during initial tour of the Second Floor nursing unit, the surveyor observed that the clean linen cart located near Resident room [ROOM NUMBER] did not contain any towels. On 6/19/24 at 11:16 AM, the surveyor toured the Second Floor nursing unit and observed no clean towels in the clean linen cart located by Resident room [ROOM NUMBER], and one clean towel in the clean linen cart by Resident room [ROOM NUMBER]. On 6/20/24 at 10:48 AM, the surveyor toured the Second Floor nursing unit and did not observe any clean towel in the clean linen cart by Resident room [ROOM NUMBER]. On 6/24/24 at 1:39 PM, the surveyor interviewed the Director of Housekeeping (DH) who stated that linens and towels were routinely processed throughout the day. The DH indicted that there was no storage area where clean towels were kept and ready for the residents. The surveyor completed an inspection of the laundry room, where it was observed that only six towels were clean. At that time, Housekeeper #1 (HK #1) entered the laundry room and stated that they were responsible for checking the clean linen carts every two hours. When asked the times in which laundry was brought to the floors, HK #1 explained that it was brought up at 7:30 AM before morning care, 1:30 PM, and about 2:30 to 3:00 PM before end of shift. When asked how many towels were brought to the floor, HK #1 reported twenty towels and twenty washcloths. The surveyor questioned if there were any issues with the stock of towels, at which time HK #1 admitted that the facility can run low because the agency nurses threw away a lot of the towels and washcloths. On 6/25/24 at 11:49 AM, the surveyor interviewed the [NAME] President of Environmental Services (VPE) who acknowledged that the DH approached them and identified that the number of towels has gone down. The VPE further confirmed that towels were a problem and that the facility had placed an order for additional towels. On 6/26/2024 at 10:35 AM, the LNHA, in the presence of the Regional Nurse, Assistant Director of Nursing (ADON), and DON, confirmed that there was not enough towels in the facility for the residents and that morning they stopped at a sister facility to pick up more towels. 2. On 6/17/24 at 10:47 AM, during initial tour of the facility, the surveyor observed Resident room [ROOM NUMBER] which was occupied by four residents in beds A, B, C, and D. Bed C had a privacy curtain pulled around the bed and was observed to be soiled with a reddish/brown substance along the bottom of the curtain. On 6/20/24 at 12:55 PM, in the presence of the survey team and the LNHA, the DON, when presented with a photograph of the observed soiled privacy curtain, stated that privacy curtains were to be cleaned monthly or more frequently if needed and that it should not look like that. Review of the facility's Cleaning and disinfecting wheelchairs, gerichairs, bedside commode, and privacy curtain policy dated last reviewed March 2024, included ensure that privacy curtains are kept clean and in good repair by: Conduct daily review of all privacy curtains to identify if any. Soiling is noted. Remove and replace monthly/as need for cleaning service . A review of the facility's Resident Rights policy, created February 2024, included .The resident has a right to a safe, clean, comfortable and Homelike Environment, including but not limited to receiving treatment and supports for daily living safely . A review of the facility's undated Quality of Life- Homelike Environment policy included .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. NJAC 8:39-31.4(a)

NJ Complaint #166562 Based on interview and review of pertinent facility documents, it was determined that the facility failed to a.) initiate an investigation at the time of an injury of unknown origin was discovered on 8/13/23; and b.) complete a thorough investigation of how a resident on one-to-one (1:1) monitoring by staff had an unwitnessed fall. The deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #254), and was evidenced by the following: A review of the facility's One-to-One Observation policy and procedure dated revised January 2024, included the aim of one-to-one nursing is to provide continuous observation for an individual patient for a period of time during acute physical or mental illness .Primary Physician/Nurse Practitioner shall be notified about the change in patient's condition and order will be obtained for continuous 1:1 observation until further evaluation. Resident/patient's care plan will be initiated and/or updated with resident centered interventions . On 6/17/24 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of investigations for reportable events to the New Jersey Department of Health (NJDOH) or any investigations that included injury of unknown origin or allegation of abuse and neglect for July and August 2023. The surveyor reviewed an investigation for the closed medical record for Resident #254. A review of the Incident Report dated 8/14/23 at 8:30 AM, revealed that the Assistant Director of Nursing (ADON) was called to Resident #254's room to assess the resident who had blue discoloration on both ears, a three centimeter by three centimeter (3 cm x 3 cm) abrasion to right knee; discoloration on right side of face and mid arm. When staff attempted to turn the resident over, they screamed in pain; the physician was made aware and a new order was put into place to send to the emergency room for evaluation. The report indicated no witnesses with additional comments or steps taken to prevent recurrence included resident will be continuously monitored every shift on 1:1. A review of the statement dated 8/14/23 by the Registered Nurse (RN) included they were called to the resident's room and they observed the resident in bed with black and blue marks on right side of face. The resident was confused and unable to say what happened; upon further assessment noted multiple black and blue discoloration on both ears and right side of face. Resident complained of pain when attempted to turn side to side and Supervisor was notified. A review of the Emergency Department Discharge Note dated 8/14/23, included the resident had an acute fracture to the transverse process of the lumbar 3 (L3) and lumbar 4 (L4) on left side (lower spine fracture) with no significant abnormalities. A review of the individual comprehensive care plan (ICCP) included in the investigation, had a focus area dated effective 11/16/22, for behavior related to cognitive impairments; desire to manipulate; chronic mental illness; decline in medical condition; and mood state. Goal included to feel safe in my environment; resident to continue on 1:1 all shifts. A further review included a focus area dated effective 11/16/22, for falls due to medication use with an intervention that included to remain on 1:1 every shift. A review of an additional Incident Report included in the investigation packet dated 8/14/23 at 7:00 PM, prepared by the ADON included that they saw the resident on the ground floor, and the ADON asked the resident about their bruise, and the resident stated they fell. The resident did not know when they fell. A review of the Progress Notes included a Nursing Note (NN) dated 8/13/23 at 3:06 PM, that on arrival it was noted by the incoming 1:1 staff that the resident had an abrasion on their knee, because the resident was a poor historian, it was unknown how the abrasion got there. Resident alert and oriented to person, denied pain and on assessment no additional injuries noted except abrasion to right knee with no bleeding or discharge noted. This note indicated that the resident's abrasion was discovered on 8/13/23, and not on 8/14/23, as reported on the Incident Report dated 8/14/23 at 8:30 AM. On 6/19/24 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON) stated that Resident #254 was on a 1:1 monitoring and should have been monitored at all times so there should not have been an unwitnessed fall. The DON stated that usually the Certified Nursing Aide (CNA) was with the resident, and CNA #1 was looked at. The DON confirmed there were video cameras in the hallways, but could not speak to if the cameras were checked. At that time, the surveyor requested the resident's 1:1 monitoring logs for 8/13/23 and 8/14/23. On 6/19/24 at 12:00 PM, the surveyor interviewed the ADON who stated she could not recall if the resident's incident occurred on Sunday (8/13/23) or Monday (8/14/23), but when they were in the building on 8/14/23, they were asked to assess the resident. The surveyor continued to review the closed medical record for Resident #254. A review of the Resident Face Sheet (admission summary) reflected the resident was admitted to the facility with diagnoses which included schizoeffective disorder, bipolar, and slipping, tripping, and stumbling without fall due to stepping from one level to another. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 5/16/23, reflected the resident usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time and sometimes understands by responds adequately to simple, direct communication only. The MDS further reflected the resident transferred between surfaces including to or from bed, chair, wheelchair, standing position with one person physical assist and used a wheelchair. On 6/20/24 at 8:59 AM, the surveyor re-interviewed the ADON who stated she thought Resident #254 was placed on a 1:1 monitoring in April of 2023 because they were combative and a fall risk. The ADON stated they were still looking for the resident's 1:1 monitoring log from August 2023, but stated CNA #1 was their aide that day. The ADON stated CNA #1 no longer worked at the facility, and the surveyor requested their phone number. On 6/20/24 at 10:12 AM, the surveyor asked the DON what the facility's process for investigating was, and the DON stated staff was interviewed and statements were obtained, resident was spoke to, and any additional witnesses. The facility investigated skin tears, injuries of unknown origin, fractures of unknown origin, complaints, verbal, physical, and sexual abuse. The DON stated they gathered statements from staff for 72 hours prior to incident of unknown origin, and the investigation was started immediately. After statements were gathered and the resident was assessed, the statements were reviewed to determined what occurred; if abuse was substantiated; and what interventions could be put into place to prevent the situation from occurring again. On 6/20/24 at 11:30 AM, the surveyor requested from the ADON again for CNA #1's phone number. On 6/20/24 at 12:17 PM, the surveyor observed CNA #2 and CNA #3 outside of two resident rooms. Both aides confirmed the residents in the rooms were on 1:1 monitoring; and they both confirmed that someone stayed with the resident at all times, and every hour another aide would come to switch with them. They both confirmed the resident was never left alone. On 6/20/24 at 1:24 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON, and the surveyor informed them that they were still waiting for the resident's 1:1 monitoring sheets from August 2023. The surveyor also requested additional information regarding why the Progress Notes documented the resident's had a skin abrasion on their right knee on 8/13/24, but it was not investigated until 8/14/24. The surveyor also asked for additional information on how a resident who was on 1:1 monitoring had an unwitnessed fall that resulted in two bruised ears and a fractured back. At that time, the LNHA acknowledged that the investigation should include how the resident on a 1:1 had an unwitnessed fall. On 6/26/24 at 9:45 AM, the surveyor reviewed the 1:1 monitoring logs for Resident #254 for 8/13/23 and 8/14/23. The log indicated that CNA #1 was monitoring the resident on 8/13/23 from 7:00 AM through 11:00 PM; CNA #4 and #5 monitored from 8/13/23 at 11:00 PM until 8/14/23 at 7:00 AM; and CNA #6 monitored the resident on 8/14/23 from 7:00 AM until 11 PM. A review of CNA #6's statement from 8/14/23, indicated that at around 8:00 AM on that day, they entered the resident's room to do morning care, and the resident was in bed laying on their back, and the aide noticed black and blue marks on both ears and they called the nurse. CNA #6's statement that they saw the resident at 8:00 AM for care contradicted the 1:1 assignment that indicated CNA #6 was with the resident from 7:00 AM until 11:00 PM on 8/14/23. A review of the 8/13/23 11:00 PM to 7:00 AM Certified Nursing Assistant Assignment Schedule reflected that CNA #4 and #5 both had resident assignments that night as well as an assignment of 1:1 with Resident #254. A review of CNA #4's statement dated 8/13/23, indicated that they took care of the resident on 8/13/23 during the 11:00 PM to 7:00 AM shift, and they did not observe any bruising and the resident did not complain of pain. There was no statement from CNA #5 who according to the 1:1 monitoring log took care of Resident #254 that night as well. On 6/26/24 at 10:36 AM, the survey team met with the LNHA, DON, and ADON to discuss their concerns. The LNHA stated an investigation should have included an assessment of the resident, interviews of possible witnesses and resident, psychology if needed, psychosocial if needed with a social worker, summary, conclusion and interventions put in place so will not happen again, and ICCP was updated. The ADON confirmed CNA #1, #4, and #6 no longer worked at the facility, and CNA #5 worked the overnight shift and was currently not in the building but there should have been a statement. The ADON continued that the incident either occurred on 8/13/23 or 8/14/23, but no one was certain, but she assessed the resident's on 8/14/23. The ADON acknowledged the CNA discovered the abrasion on 8/13/23, and the investigation should have been started then. The ADON stated the resident's was unable to ambulate, but attempted to get out of bed or wheelchair. The ADON stated the resident was confused and unable to make their needs known, and the facility determined it was a fall because the resident later stated they fell. At that time, the DON acknowledged it should have been looked at how a resident on 1:1 had an unwitnessed fall since staff should be with the resident at all times. The DON stated it also should have been looked out where and when the resident fell. A review of the facility's undated Abuse Policy included each resident will be free from abuse.residents will be protected from abuse, neglect, and harm while they are residing at the facility .it is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated .the investigation is the process used to try to determine what happened . NJAC 8:39-4.1(a)5

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an individualized comprehensive care plan (ICCP) consistent with the resident's history of sex offenses. This deficient practice was identified for 1 of 35 residents reviewed for care planning (Resident #73), and was evidenced by the following: On 6/19/24 at 10:01 AM, the surveyor observed Resident #73 in their room. On 6/20/24 at 11:23 AM, the surveyor interviewed the Registered Nurse (RN) who stated an ICCP was a picture of the resident and explained what needed to be done or expected for the resident. The RN confirmed that a resident's behavior or ongoing behavior patterns should be identified on the ICCP. On 6/25/24 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #73's needs, and the DON identified Resident #73 as a registered sex offender. The surveyor reviewed the medical record for Resident #73. A review of the Order Summary Report revealed that Resident #73 was admitted to the facility with diagnosis that included, but not limited to diabetes mellitus, mood disorder, and hypertension (high blood pressure). The ICCP did not include a focus area identifying the resident's history as being a sex offender. On 6/25/24 at 1:30 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Nurse, Assistant Director of Nursing (ADON), and survey team acknowledged that Resident #73's ICCP should have identified them as a registered sex offender. A review of the facility's undated Care Plan policy included that all residents admitted to the facility will have adequate person centered care plans that provide for all their needs in a timely manner .Procedure [ .] 2. They will include initial goals, [physician's orders] orders, medications, treatments, dietary orders, therapy orders, social services, and PASARR recommendations .11. Care plans will be updated timely and necessary revisions will be made . NJAC 8:39-31.2(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individualized comprehensive care plan (ICCP) in a timely manner for a resident whose orthotic was discontinued. This deficient practice was identified for 1 of 35 residents reviewed for comprehensive care plans (Resident #60), and was evidenced by the following: On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. The resident was not observed wearing any orthotics to lower extremities. The surveyor reviewed the medical record for Resident #60. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/16/24, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. A review of the ICCP included a focus area dated 7/13/22, for activities of daily living (ADL) Functional/Rehabilitation Potential. Interventions included to apply left ankle foot orthotic (AFO), a brace, when out of bed. Further review of the ICCP identified the following note with a creation date of 10/19/23: Resident use left AFO in the morning and must remove prior going to bed at night. A review of the Order Summary Report reflected an active order, dated 6/4/24, for left AFO to prevent food drop every day shift and left AFO to prevent foot drop every evening shift. On 6/25/024 at 9:43 AM, the surveyor and Director of Nursing (DON) passed Resident #60 in the hallway. The surveyor inquired if Resident #60 was currently wearing a left AFO. The DON denied and Resident #60 stated that they had not had it in while. On 6/25/24 at 10:22 AM, the surveyor interviewed the Director of Rehabilitation (DOR) regarding Resident #60's AFO physician order, who stated that the AFO was discharged on 9/25/23 at 4:51 PM. The DOR provided the following order: Physical Therapy Other Left AFO splint discharge order: resident was refusing to use left AFO because [they] feel uncomfortable while using it; and splint was adjusted by orthotist, but refused to use it On 6/26/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Regional Nurse and Assistant Director of Nursing (ADON), DON, and survey team acknowledged that the order was discontinued but was still identified on the ICCP. A review of the facility's undated Care Plan policy included all residents admitted to the facility will have adequate person centered care plans that provide for all their needs in a timely manner .Procedure [ .] 2. They will include initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social services, and PASARR recommendations .11. Care plans will be updated timely and necessary revisions will be made . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/19/24 at 10:01 AM, the surveyor observed Resident #73 in their room with their fingernails as long and dirty. When asked if their nails have been cleaned or cut by the facility, Resident #73 denied and voiced that they do not like them long and would like them cut. On 6/20/24 at 9:25 AM, the surveyor observed Resident #73 the facility's lobby biting on their long and dirty fingernails. The surveyor reviewed the medical record for Resident #73. A review of the Order Summary Report revealed that Resident #73 was admitted to the facility with diagnosis that included, but not limited to diabetes mellitus, mood disorder, and hypertension (high blood pressure). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/3/24, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. Section GG (Functional Abilities and Goals) of the MDS identified the resident as requiring Substantial/Maximal Assistance with Personal Hygiene. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 10/11/23, for activities of daily living (ADL) Functional/Rehabilitation (Rehab) Potential with interventions that included to have all my needs met. On 6/19/24 at 10:20 AM, the surveyor interviewed CNA #2 and #3 who both confirmed that they were responsible for nail care, which included cleaning and filing the nail to a reasonable length. On 6/20/24 at 11:23 AM, the surveyor interviewed the Registered Nurse who stated that the CNAs were responsible for assisting in residents' ADLs which included nail care. When asked how resident nails are supposed to appear, the RN responded, clean and short with underneath also clean. The RN further explained that skin checks were completed by the CNA daily and weekly by the nurse during bathing, in which nails were checked for length and appearance. On 6/26/24 at 10:35 AM, the LNHA, in the presence of the DON, Regional Nurse, ADON, and survey team acknowledged that it was the expectation of the facility that nail care was completed on the residents. 2. On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. The surveyor observed Resident #60's nails were long and dirty. When asked if their nails have been cleaned or cut by the facility, Resident #60 denied and stated they would their nails cut. The surveyor reviewed the medical record for Resident #60. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. A review of the ICCP included a focus area dated 7/13/22, for ADL Functional/Rehab Potential with interventions that included personal hygiene expected with limited assistance of one person physical assist. On 6/19/24 at 10:20 AM, the surveyor interviewed CNA #2 and #3 who both confirmed that they were responsible for nail care, which included cleaning and filing the nail to a reasonable length. On 6/20/24 at 11:23 AM, the surveyor interviewed the RN who stated that the CNAs were responsible for assisting in residents' ADLs which included nail care. When asked how residents' nails were supposed to appear, the RN responded, clean and short with underneath also being clean. The RN further explained that skin checks were completed by the CNA daily and weekly by the nurse during bathing, in which nails were checked for length and appearance. At that time, Resident #60 approached the nursing station, and the surveyor questioned the length and appearance of the resident's fingernails. Both the RN and UM/LPN #1 confirmed that they were long, dirty, and unacceptable. On 6/25/24 at 9:43 AM, the surveyor and DON passed Resident #60 in the hallway. At that time, the DON confirmed that their fingernails were long and dirty, and stated that nail care was an everyday thing and it should have been addressed by the CNAs. The surveyor informed the DON that Resident #60's fingernails were previously addressed with the RN and UM/LPN #1 on 6/20/24, and the DON confirmed that the nail care should have been completed at that time. On 6/26/24 at 10:35 AM, the LNHA, in the presence of the DON, ADON, Regional Nurse, and survey team acknowledged that it was the expectation of the facility that nail care was completed on the residents. A review of the facility's Resident Care- Grooming policy dated last reviewed January 2023, included .6. Trim the nails using the nail clipper and file to round the tips of the nails. 7. Clean around and under the nails using a moistened cotton swab. Essential Points: the nursing staff will provide observation and care of nails for all residents on bath day as needed . A review of the facility's undated Certified Nurse Aide Position document included .5. Bathes the resident in bed, tub or shower, combs hair, cleans and cut fingernails and gives shampoos .22. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right . A review of the facility's undated Licensed Practical Nurse Position document included .9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal regulations. 10. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and right . A review of the facility's undated Registered Nurse Position document included .2. 9. Supervises and coordinates nursing personnel in providing direct resident care in adherence with state and federal regulations. A review of the facility's undated Unit Manager/Director Nurse Position document included .4. Assesses the work performance of nursing personnel as it relates to their job description, unit standards of care and goals of the individual 6. Encourages nursing staff to perform their jobs to the fullest of their potential . NJAC 8:39-27.2 (g) Complaint #: NJ 159451 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) incontinence care was provided for 2 out of 7 residents observed during incontinence rounds (Resident #32 and Resident #147) and b.) nail care was provided during activities of daily living (ADLs) for residents 2 of 4 residents reviewed for ADLs (Resident #60 and Resident #73). This deficient practice was evidenced by the following: Refer F725 1. According to the admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). The comprehensive Minimum Data Set (MDS), an assessment tool dated 4/10/24, reflected that Resident #147 had moderate cognitive deficits and was dependent on staff for hygiene. Resident #147's individualized comprehensive care plan (ICCP) reflected that the resident required total dependence and one-person physical assistance with personal hygiene. According to the AR, Resident #32 was admitted to the facility with the diagnoses which included but not limited to cerebral infarction (stroke). The comprehensive MDS dated [DATE], reflected that Resident #32 had severe cognitive deficits and was dependent on staff for hygiene. Resident #32's ICCP reflected that the staff provided the resident incontinent care every two to four hours, and that the resident required total dependence and one-person physical assistance with personal hygiene. On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Unit Manager/Licensed Practical Nurse (UM/LPN #1) and observed the following: The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 asked the resident if she could check their incontinent brief and the resident gave UM/LPN #1 permission. The surveyor observed that the resident's incontinent brief was dry and the chuck (protective bed pad) that was directly under the resident was dry, however the fitted sheet located under the chuck had a large brown/yellow stain that smelled like urine and contained some dry brown stains which UM/LPN #1 identified as bowel movement (bm). UM/LPN #1 was interviewed at this time and stated that the Certified Nursing Assistant (CNA) that was assigned to care for Resident #32 should have changed the resident's sheet when performing incontinence care and should not have left a urine-soaked sheet on the resident's bed. UM/LPN #1 stated that the agency CNA that cared for the resident on the 11:00 PM to 7:00 AM shift must have left the dirty sheet on the resident's bed, because the CNA (CNA #1) that came in this morning just got to the unit and had not made rounds yet. UM/LPN #1 stated that incontinence rounds should be done by the CNA every two hours. The surveyor observed the resident's skin during the tour and the resident's skin was free of skin breakdown. On 6/18/24 at 8:45 AM, the surveyor conducted an incontinence tour on the First Floor nursing unit with a Licensed Practical Nurse (LPN #1) and observed the following: At 9:00 AM, the surveyor accompanied LPN #1 entered Resident #32's room observed the resident lying in bed and the resident was non-verbal. The resident's brief was observed to be very wet with urine and the sheets were observed with a large urine stain that had a strong smell of urine. LPN #1 was interviewed at the time and confirmed that the stain the surveyor observed on the resident's sheet was urine, and that the resident's incontinence brief and the entire bed linen should have been changed. The resident's skin was observed, and the resident's skin was intact and free of breakdown. On 6/18/24 at 9:10 AM, the surveyor interviewed UM/LPN #2 for the First Floor nursing unit who stated that the CNA (CNA #2) who was assigned to care for Resident #32 should have made rounds that morning when she had arrived to the unit and checked the residents to see if any residents were incontinent and needed to be changed right away. UM/LPN #2 could not speak to why Resident #32 was wet including the resident's bed linens. She stated that it was import to ensure that residents were clean and dry to protect their skin and to keep the residents comfortable. On 6/18/24 at 9:20 AM, the surveyor interviewed CNA #2 who stated that she made rounds that morning and performed an incontinence check for Resident #32. CNA #2 stated that she conducted rounds on Resident #32 in the dark, and did not see the large urine stain on the resident's bed sheets or notice the resident's brief was soaked with urine. CNA #2 stated that the resident's brief and bed linen should have been changed and that it must have been an oversight. On 6/19/24 at 9:08 AM, the surveyor interviewed CNA #1 who stated that all incontinent residents should be checked every two hours, and every hour if they urinated more frequently because the resident was on diuretics. CNA #1 stated that it was important to assure that residents' incontinent briefs were changed timely, so that they did not develop breakdown of skin. CNA #2 stated that bed linen should also be changed when the resident wets the bed because leaving urine-soaked bed linen on the bed could also cause odor and skin breakdown, and it was not appropriate to put clean bed linen over wet bed linen. CNA #1 stated that when she arrived on the unit, she made rounds with the CNAs from the previous shift so that she could ensure that all the residents were safe, clean, and dry. CNA #1 stated that breakfast was served at 8:00 AM, so residents should be clean and dry before they start their meals. On 6/20/24 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that incontinent rounds should be done when staff arrived to the unit to ensure that any priority residents should be taken care of. The DON stated that during shift rounds, the staffs responsibility was to identify soiled residents, change them, and ensure bed linen was changed when soiled; even if a drop of urine got onto the linen, then the linen should be changed. The DON stated that clean linen should not be put on top of dirty linen. The DON stated that all residents should be checked on every two hours to ensure that residents were provided incontinence care timely because residents left soiled were at risk for skin breakdown. On 6/26/24 at 10:36 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team acknowledged it was unacceptable to put chuck on a wet and soiled fitted bed sheet. The DON acknowledged it was not appropriate to make care rounds in the dark. A review of the facility's Bowel and Bladder Incontinence Care policy dated May 2023, included controlling common infections for incontinent residents was part of the overall infection control program .the facility was committed to providing a safe a healthy environment for residents and to minimize or prevent the spread of infections .

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for pressure reducing devices and b.) implement the individualized comprehensive care plan (ICCP) intervention to use a pressure reducing device on a resident's bed. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcer/injury(Resident #9), and was evidenced by the following: On 6/17/24 at 10:54 AM, during initial tour of the facility, the surveyor observed Resident #9 lying in bed. The resident was on a regular mattress which was placed atop a deflated low air loss mattress/pressure reducing mattress, which was connected to an air pump that was not plugged into the power outlet or turned on. On 6/19/24 at 11:01 AM, the surveyor observed Resident #9's bed which contained a regular mattress covered with bed linens placed on top of a a deflated low air loss mattress. The resident was not present at the time of observation. On 6/19/24 at 11:05 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated, Resident #9 was being followed by wound care consultations (consults) for a pressure ulcer, which was now resolved. The UM/LPN reviewed the resident's ICCP with the surveyor, and identified that the resident was care planned for being at risk for skin breakdown, having been treated for a pressure ulcer with interventions that included to use a pressure reducing device when in bed. The UM/LPN further stated that the resident did not have physician's order for pressure reducing devices. At that time, the surveyor and the UM/LPN went to the resident's room to observe the mattress setup. The UM/LPN confirmed that there was a regular mattress on top of deflated air loss/pressure reducing mattress. The UM/LPN acknowledged there was no pressure reducing device in bed for the resident; that the air mattress underneath the regular mattress was used incorrectly. The surveyor reviewed the medical record for Resident #9. A review of the admission Record face sheet (an admission summary) indicated the resident was admitted to the facility with diagnosis which included rash and other nonspecific skin eruption and erythematous condition (skin redness can have causes that are not due to underlying disease. Examples include too much pressure on the area, blushing, or exercise). A review of the current Physician Order Summary Report did not include a physician's order for use of pressure reducing devices. A review of the ICCP included a focus for risk for skin breakdown with interventions which included the use of pressure reducing device for bed and chair. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/9/24, indicated under section M: Skin Conditions that the resident had one stage two pressure ulcer (partial thickness loss of dermis skin layer presenting as a shallow open ulcer with a red or pink wound bed) with treatments including pressure reducing device for chair and for bed. On 6/20/24 at 10:34 AM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) confirmed that Resident #9 had history of pressure ulcers and that the resident should be on a pressure reducing air mattress set to the resident's weight. The DON was presented with a photograph of how the resident's bed was arranged with a regular mattress atop a deflated air mattress, to which the DON stated that was unacceptable and that she had never seen that done this way, we don't use it this way. She further stated we should not have a regular mattress on top, it defeats the purpose [of the air mattress]. On 6/26/24 at 10:46 AM, the surveyor, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), and Assistant Director of Nursing (ADON), asked the DON if Resident #9 had an order for use of a pressure reducing device on the bed, to which the LNHA shook her head No and the DON stated, there should have been one. Review of the facility's Wound Prevention and Treatment policy dated reviewed March 2024, included Pressure Ulcer Prevention .Provide a pressure reduction surface for bed and/ or wheelchair per the facility's Support Surface Selection Algorithm. (Refer to Algorithm of this Wound Prevention and Management Protocol) .Stage II Treatment .Notify physician and obtain orders for the most appropriate treatment protocol . NJAC 8:39-27.1(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to monitor an enteral tube feeding administration pump to ensure the total volume administered was in accordance with physician's orders. This deficient practice was identified for 1 of 1 residents reviewed for tube feeding (Resident #32), and was evidenced by the following: On 6/17/24 at 10:54 AM, the surveyor observed Resident #32 lying in bed awake with a tube feeding pump (TF; a tube feeding surgically inserted into the stomach) was located on a pole near their bed. There was no nutritional formula being administered at this time. When asked by the surveyor if they received tube feedings daily, Resident #32 shook their head indicating yes. On 6/19/24 at 10:35 AM, the surveyor observed Resident #32 lying in bed awake with the TF pump administering Jevity 1.5 (nutritional formula) at a rate of 70 milliliters (mL) an hour with a total volume infused thus far of 464 mL. The Jevity 1.5 bottle was labeled as hung on 6/18/24 at 7:30 PM. On 6/19/24 at 12:30 PM, the surveyor observed Resident #32 lying in bed with the TF pump administering Jevity 1.5 at a rate of 70 mL an hour with a total volume infused thus far of 600 mL. The surveyor reviewed the medical record for Resident #32. According to the admission Record face sheet (admission summary), the resident was admitted to facility with diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), dysphagia (difficulty swallowing), aphasia (affects how you communicate), and vitamin deficiency (do not have enough vitamins in the body). According to the most recent Minimum Data Set (MDS), an assessment tool dated 3/22/24, revealed Resident #32 did not have a Brief Interview for Mental Status (BIMS) score due to the resident was rarely or never being understood with short term and long-term memory problems with moderately impaired cognition. A review of the MDS Section K. Swallowing/Nutritional Status, revealed that Resident #32 had a feeding tube (TF) while a resident, and received more than 51% of their total calories through the tube feeding. A review of the individualized comprehensive care plan (ICCP) dated effective 7/13/22 to present, included that the resident required a TF for nutritional support related to need for nothing by mouth (NPO) status with dysphagia. Interventions included to monitor labs as ordered; tolerate tube feeding; maintain fairly stable weight without significant change; provide Jevity 1.5 as ordered; and monitor weight monthly. A review of the June 2024 Physician Order Sheet (POS) included a physician's order (PO) dated 6/10/24, to administer Jevity 1.5 via pump at the rate of 70 mL an hour; start at 4:00 PM (4 PM) until completion of total volume to equal 1260 mL. A review of the corresponding June 2024 electronic Medication Administration Record (eMAR) indicated the following: The TF order for Jevity 1.5 was signed by the nurse indicating it was administered at 4 PM on 6/18/24. A review of the corresponding June 2024 Administration History Report indicated that on 6/18/24, the enteral tube feeding Jevity 1.5 was hung at 4:50 PM. During an interview with the surveyor on 6/19/24 at 12:15 PM, the Unit Manager/Licensed Practical Nurse (UM/LPN) was asked how the facility monitored the amount of formula infused by the TF pump. The UM/LPN responded, if the resident's tube feeding order was for a total volume amount of 1270 mL, then the pump was set to administer the total volume of 1270 mL, and the pump stopped when the total volume was infused. The UM/LPN also stated that the nurse signed on the eMAR when they started the tube feeding, but the nurses did not document the total volume infused at the end of each shift. On 6/19/24 at 12:30 PM, the UM/LPN accompanied the surveyor to Resident #32's room, and they observed the resident in bed with the TF running at a rate of 70 mL per hour with a total volume of 600 mL infused. The UM/LPN stated that Resident #32's TF was usually completed around 10:00 AM, and that possibly the nurse who changed the Jevity 1.5 bottle, cleared the total volume infused on the pump which the UM/LPN confirmed they should not do. The surveyor asked can you determine the total amount of the Jevity 1.5 that the resident received since the feeding was started on 6/18/24 at 4 PM, and the UM/LPN responded, they could not say for certain if the total volume was cleared. The UM/LPN also acknowledged that the TF would continue to administer the formula until it reached a total volume of 1270 mL which would take approximately nine hours to reach that volume, and it would overlap the resident's next feeding that started at 4 PM. The UM/LPN also acknowledged it was possible that the resident could have received more than 1270 mL, since the feeding usually ended at 10:00 AM, and overfeeding could have led to the resident vomiting. At that time, the UM/LPN instructed a nearby nurse to stop the feeding. On 6/20/24 at 12:30 PM, the surveyor interviewed the Director of Nursing (DON) who stated that a resident's TF was hung according to the physician's orders; that the TF should be administered at the time ordered, and continue to infuse until the resident received the total volume. When asked how do the facility monitored the total volume administered each shift, the DON responded, the total volume the resident received was displayed on the pump. The DON also stated the nurse documented on the eMAR when the TF was started, but the nurses did not document the total volume administered each shift. The surveyor then asked, how do you know if Resident #32 received the ordered amount of Jevity 1.5 6/19/24, if at 12:30 PM, the TF pump indicated 600 mL as the total volume. The DON stated that she could not confirm if the resident received the ordered amount, and the nurse should have documented in the Progress Notes if they held the feeding and why, and it should have been communicated to the next shift. On 6/26/24 at 10:35 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and survey team stated that through interviews with staff, they were assuming the tube feeding was hung late, and the nurse should be have been checking and making rounds on the units. The DON acknowledged the facility needed to be more diligent in tracking when the tube feeding was hung and how much was infused each shift, and the nurse should have documented if the TF was hung late or the feeding was held for a length of time. When asked if the facility conducted an investigation, the DON stated that she verbally spoke to staff but did not document anything. The DON also acknowledged there was no documentation that the physician was made aware. The DON could not speak to why the nurse signed the TF was started on 4/18/24 at 4:50 PM, but acknowledged it was not appropriate to start the next TF directly after the previous TF ended. A review of the facility's Enteral Feeding policy dated revised 5/1/11, included Procedure: [ .] 16. Document administration of feeding on Medication Administration Record (MAR) including: Date, Formula, Rate and Continuous bolus. 17. Document total intake separated into formula and water flush on MAR or Intake & Output Record if applicable. 18. Document the following, including, but not limited to: Tube placement verification, Time tube feeding initiated, Resident/patient tolerance, and Amount of gastric residual, as applicable . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. According to the admission Record, Resident #80 was admitted to facility with diagnoses including but not limited to: Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood) and Schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly.) According to the most recent Minimum Data Set (MDS), an assessment tool dated 04/25/24, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating cognitively intact cognition. Section I of the MDS revealed Resident #80 had an active diagnosis of Bipolar Disorder. According to section N of the MDS Resident #80 receives antipsychotic medications on a routine basis. During the initial tour of the 2nd floor on 06/17/24 at 10:52 AM, the surveyor observed resident #80 lying in bed awake and alert. Resident #80 was receiving humidified oxygen at 3 liters per minute (lpm) via nasal cannula. The surveyor did not observe the resident displaying any behaviors at this time. The surveyor reviewed the residents Physician Order Summary sheet (POSS) which reflected that Resident #80 was on the following psychoactive medications: 1.) The POSS reflected an order dated 04/11/2024, for Divalproex sodium (used to treat the manic phase of bipolar disorder (manic-depressive illness) 125MG CAPS-HD, give 3 capsules orally two times a day related to Bipolar Disorder. 2.) The POSS reflected an order dated 05/07/2024, for Lurasidone (class of antipsychotic used to treat schizophrenia and bipolar depression) TAB 40 MG, administer 3 tablets orally at bedtime for psychotic disorder related to other psychotic disorder not due to a substance or known physiological condition. The surveyor reviewed the resident's MAR and TAR and there was no episodic documentation on Resident #80's targeted behaviors. On 06/20/24 at 09:42 AM, in the presence of the survey team the Director of Nursing (DON) stated that resident's behaviors are documented in the progress notes. The DON stated that targeted behaviors would have to be reviewed in the progress notes and how many times a resident experienced a targeted behavior. She stated that there should be a monthly psychotropic summary sheet (PSS) and indicated that it would be documented in the progress notes. The DON stated that as the behaviors were occurring then the behavior should be documented in the progress notes. She added that side effects from medications should also be documented in the progress notes. On 06/20/24 at 11:24 AM, the DON could not provide the surveyor with PSS or documentation that the psychotropic drugs summaries were being documented monthly. On 06/24/2024 at 11:39 AM, the facility could not provide any additional information. The facility policy titled, Medication Use dated 09/2017 indicated that behavior monitoring for all residents on antipsychotic, antianxiety, antidepressant hypnotic medications will be incorporated with the MAR monthly. The nurse must monitor their subsequent effects on the resident every shift. Specific behaviors to be monitored will be identified for residents on antianxiety and antipsychotic medications. The policy also indicated that monthly psychotropic summaries would be completed monthly describing resident progress or deterioration, including summary of psychotropic medications being used and their subsequent effects to the resident/patient. The summary would include psychiatrist/psychologist visits and any plan for reduction and/or continuation of the medications. 2. A review of the admission Record face sheet (an admission summary) reflected that Resident #61 was admitted to the facility with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) affecting right dominant side, Type 1 diabetes mellitus with diabetic chronic kidney disease, and persistent mood disorder. The surveyor reviewed the resident's Physician Order Summary sheet (POS) which reflected that Resident #61 was on the following psychoactive medications: A PO dated 6/10/24, for buspirone (a medication primarily used to treat anxiety disorders) 10 MG; give 1 tablet by mouth two times a day for anxiety. A PO dated 6/11/24, for quetiapine 150 MG (a medication used to treat certain mental/mood disorders); give 1 tablet by mouth at bedtime for schizophrenia (a mental disorder characterized by significant alterations in perception, mood, thoughts, and behaviors). A PO dated 6/11/24, for trazodone (antidepressant that belongs to a group of drugs called serotonin receptor antagonists and reuptake inhibitors ([NAME]) used to treat major depressive disorder) 50 MG; give 1/2 tablet by mouth at bedtime for depression. A PO dated 6/11/24, for trazodone 50 MG; give 1 tablet by mouth at bedtime for depression. Give with Trazodone 50mg to equal 75mg. The CP report dated 5/27/24, indicated that the resident was on psychotropic medications and recommended to please monitor and document target behaviors (number of episodes that occurred) and side effects daily when the resident is on psychotropic medications. Please complete monthly psychotropic reviews. There were none seen. The surveyor did not find that the recommendation was followed in the resident's electronic medical record. The surveyor reviewed the resident's MAR and TAR and there was no episodic documentation on Resident #61s targeted behaviors. On 6/20/24 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated behaviors were documented in the Progress Notes. The DON stated that targeted behaviors were reviewed in the Progress Notes and how many times a resident experienced a targeted behavior. The DON stated that there should be a monthly Psychotropic Summary Sheet (PSS) and indicated that it would be documented in the Progress Notes. The DON stated that as the behaviors were occurring, then the behavior were documented in the Progress Notes. The DON added that side effects from medications should also be documented in the Progress Notes. On 6/20/24 at 11:24 AM, the DON could not provide the surveyor with PSS or documentation that the psychotropic drugs summaries were being documented monthly. No additional information was provided. 3. A review of the admission Record face sheet reflected that Resident #60 was admitted to the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. The surveyor reviewed the resident's POS which reflected that Resident #60 was on the following psychoactive medications: A PO dated 4/14/24, for buspirone 15 MG; give 1 tablet three times a day for depression related to major depressive disorder, single episode, mild. A PO dated 5/5/24, for divalproex sodium 125 MG; give 3 capsule orally one time a day for bipolar disorder related to bipolar disorder, current episode hypomanic. A PO dated 5/24/24, divalproex sodium 250 MG; give 1 tablet orally at bedtime for bipolar disorder related to bipolar disorder. A PO dated 5/25/24, divalproex sodium 500 MG; give 1 tablet orally at bedtime for bipolar disorder give with 250 MG for total dose of 750 MG. A PO dated 6/23/24, for trazodone 100 MG; give 1 tablet orally at bedtime related to insomnia. The surveyor reviewed the resident's MAR and TAR and there was no episodic documentation on Resident #60s targeted behaviors. The CP report dated 5/27/24, indicated that the resident was on psychotropic medications and recommended to please monitor and document target behaviors (number of episodes that occurred) and side effects daily when the resident is on psychotropic medications. Please complete monthly psychotropic reviews. There were none seen. The surveyor did not find that the recommendation was followed in the resident's electronic medical record. On 6/20/24 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated behaviors were documented in the Progress Notes. The DON stated that targeted behaviors were reviewed in the Progress Notes and how many times a resident experienced a targeted behavior. The DON stated that there should be a monthly Psychotropic Summary Sheet (PSS) and indicated that it would be documented in the Progress Notes. The DON stated that as the behaviors were occurring, then the behavior were documented in the Progress Notes. The DON added that side effects from medications should also be documented in the Progress Notes. On 6/20/24 at 11:24 AM, the DON could not provide the surveyor with PSS or documentation that the psychotropic drugs summaries were being documented monthly. No additional information was provided. Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medications. This deficient practice was identified for 4 of 5 residents reviewed for unneccessray medications (Resident #34, #60, #61, and #80), and was evidenced by the following: 1. According to the admission Record (AR), Resident #34 was admitted to the facility with the diagnoses which included unspecified dementia with behavior disturbance and bipolar disorder (a type of mental illness). The quarterly Minimum Data Set (MDS), an assessment tool dated 3/30/24, reflected that the resident had severe cognitive deficits and had behaviors directed toward others. The MDS also reflected that the resident was dependent for activities of daily living (ADLs) and was on psychoactive medications. On 6/17/24 at 10:06 AM, the surveyor observed Resident #34 in bed sleeping. The surveyor also observed a Certified Nursing Assistant (CNA #1) sitting in a chair next to the resident's door. CNA #1 stated that the resident had behaviors such as touching others and required one to one (1:1) supervision. On 6/18/24 at 9:59 AM, the surveyor observed Resident #34 in the room lying in bed. The surveyor did not observe the resident displaying any behaviors at this time. The resident was unable to be interviewed due to cognitive impairments, and the surveyor observed that the resident was being monitored 1:1 by a staff member in front of the resident's door. The surveyor reviewed the residents Physician Order Summary sheet (POS) which reflected that Resident #34 was on the following psychoactive medications: A physician's order (PO) dated 6/11/24, for sertraline (class of antidepressants called selective serotonin reuptake inhibitors (SSRIs)) 25 milligram (MG) tablet; administer 1 tablet orally one time a day related to the diagnoses of depression. A PO dated 6/11/24, for divalproex sodium (used to treat the manic phase of bipolar disorder (manic-depressive illness)) 500 MG tablet; give 1 tablet orally at bedtime related to depression. A PO dated 6/11/24, for divalproex sodium 250 MG tablet; give 1 tablet orally two times a day related to depression. A PO dated 6/11/24, clonazepam (antianxiety) 0.5 MG tablet; give 0.25 mg orally three times a day related to anxiety disorder. On 6/18/24 at 10:26 AM, the surveyor interviewed CNA #2 who stated that she worked for the agency. CNA #2 stated that Resident #34 was 1:1 supervision around the clock because the resident was at risk for falling. The CNA stated that the resident became combative at times with the staff and when she received report from the facility staff this morning, they told her that if the resident became too difficult to handle, to come get help from additional staff members. On 6/18/24 at 10:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #34 was on 1:1 supervision for behaviors such as picking up objects and eating them. The LPN stated that the facility provided the resident with crossword puzzles to occupy their time as a distraction. She stated that she had not noticed on the new electronic medical record (EMR) that behavior monitoring was being documented for Resident #34. The LPN stated that behaviors were documented on the Progress Notes, however there were no episodic behaviors documented on the resident's Medication Administration Record (MAR) or Treatment Administration Record (TAR). The surveyor reviewed the resident's MAR and TAR and there was no episodic documentation on Resident #34s targeted behaviors. On 6/18/24 at 10:35 AM, he surveyor interviewed the Unit Manager/LPN (UM/LPN) for the First Floor nursing unit who stated that Resident #34 was on 1:1 supervision for behaviors such as touching and grabbing other residents and eats things that were not on the resident's diet. The UM/LPN stated that behaviors were charted by exception in the Progress Notes, and that there was no episodic documentation of behavior monitoring in the MAR or TAR. She also stated that she did not know if a monthly psychotropic summary was completed for Resident #34. The Consultant Pharmacist (CP) report dated 5/27/24, indicated that the resident was on psychotropic medications and recommended, to please monitor and document target behaviors (number of episodes that occurred) and side effects daily when the resident was on psychotropic medications. Please complete monthly psychotropic reviews (none found in the EMR). The surveyor did not find that the recommendation was followed in the resident's electronic medical record. On 6/20/24 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) who stated behaviors were documented in the Progress Notes. The DON stated that targeted behaviors were reviewed in the Progress Notes and how many times a resident experienced a targeted behavior. The DON stated that there should be a monthly Psychotropic Summary Sheet (PSS) and indicated that it would be documented in the Progress Notes. The DON stated that as the behaviors were occurring, then the behavior were documented in the Progress Notes. The DON added that side effects from medications should also be documented in the Progress Notes. On 6/20/24 at 11:24 AM, the DON could not provide the surveyor with PSS or documentation that the psychotropic drugs summaries were being documented monthly. No additional information was provided.

Based on observation and interview, it was determined that the facility failed to a.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; and b.) maintain storage and preparation areas in a sanitary manner. This deficient practice was evidenced by the following: On 6/19/24 at 9:15 AM, the surveyor conducted a kitchen tour with the Regional District Operations (RDO) and observed the following: 1. In the walk-in freezer, the vinyl strip curtains located in the entrance to the freezer, there were only two curtain strips. These curtains protect the inside of the freezer from outside dust particles as well as keep the cold air from escaping the freezer when the door was opened. There was also ice accumulation around the door frame. The RDO acknowledged the freezer needed vinyl curtains and there should not be ice around the door frame. The RDO stated the vinyl curtains maintained the freezer temperature and the ice was a result of the temperature changing in the freezer. 2. At 9:30 AM, the Food Service Director (FSD) joined the tour, and they observed several large multi-colored cutting boards on the storage rack that were pitted and discolored. The FSD acknowledged the cutting boards needed to be changed. 3. Around the preparation sink on the metal work surface, a pinkish colored liquid. The [NAME] stated he discarded the juice from the bag of chicken he was preparing in the sink, and the juice must have gotten on the surface. The FSD and [NAME] both acknowledged the chicken juice needed to be cleaned up and sanitized immediately. On 6/26/24 at 10:34 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team acknowledged these findings. A review of the facility's Cutting Board Care and Use Policy dated revised October 2023, included once cutting boards develop hard to clean grooves or are excessively worn, they will be replaced. A review of the facility's Maintaining and Cleaning Equipment policy dated revised March 2024, included the Director of Dining Services or designee will ensure all equipment is maintained, kept clean, and in sanitary condition before and after each use . NJAC 8:39-17.2(g)

Complaint NJ #163249; 168809 Based on observation, interview, review of the medical record, and other pertinent facility documents, it was determined that the facility failed to maintain an accurate, complete, and easily accessible medical record. This deficient practice was identified for 3 of 35 residents' medical records reviewed (Resident #97, #248, and #252), and was evidenced by the following: 1. On 6/17/24 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the investigation for the reportable event to the New Jersey Department of Health (NJDOH) for Resident #248 reported on 4/3/23. On 6/18/24, the surveyor was provided with a copy of the form submitted to the NJDOH, but was not provided with the investigation. The surveyor requested a copy of the investigation. A review of the investigation reported to the NJDOH included an Investigation Summary dated 4/3/23, that Resident #248 on 4/3/23 at approximately 1:00 PM was observed by the nurse to be lethargic sitting in their wheelchair. The nurse immediately performed a sternal rub (rubbing the knuckles on the breastbone) and the resident immediately responded physically and verbally. The report did not include any statements or assessments. On 6/19/24 at 1:25 PM, the surveyor asked for a third time to provide the investigation for the incident that occurred with Resident #248. On 6/20/24 at 10:12 AM, the surveyor interviewed the Director of Nursing (DON) regarding the investigation process who stated interviews were obtained from staff, residents, and any witnesses; the resident was assessed; and then based on the information gathered, the facility determined what happened and put interventions in place to prevent the incident from reoccurring. On 6/20/24 at 1:16 PM, the surveyor requested for the fourth time the investigation for the facility reported event. The DON stated regarding the investigation, accident/incident reports, and/or witness statements, We have them but can't find it. On 6/25/24 at 1:28 PM, the surveyor interviewed the LNHA who confirmed medical records should be easily accessible, complete, and accurate. The LNHA confirmed all medical records that the survey team had requested should be easily accessible, accurate, and maintained. On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and survey team stated the facility was unable to locate the investigation for Resident #248. The LNHA confirmed the investigation should have included an assessment of the resident; interview of possible witnesses and resident; psychological evaluation if needed; psychosocial if needed with a social worker; summary, conclusion, and interventions put in place so incident would not occur again which was updated in the care plan. 2. According to the Resident Face Sheet (an admission summary) Resident #252 was admitted to the facility in 2022 with diagnoses kidney failure. The face sheet did not include the resident's discharge date . A review of the electronic Admissions Record revealed Resident #252 was discharged from the facility in July of 2022. On 6/19/24 at 12:09 PM, the surveyor interviewed the Medical Records personnel who stated after a resident was discharged from the facility, the facility maintained the medical records for ten years. On 6/25/24 at 10:33 AM, the surveyor requested for the LNHA a copy of Resident #252's discharge summary. The LNHA stated that at the time of the resident's stay in the facility, the facility utilized paper medical charts and needed to locate the record from medical records. On 6/25/24 at 1:28 PM, the surveyor requested again from the LNHA a copy of Resident #252's discharge summary. At that time, the LNHA confirmed medical records should be easily accessible, complete, and accurate. The LNHA confirmed all medical records that the survey team had requested should be easily accessible, accurate, and maintained. On 6/26/24 at 10:14 AM, the LNHA informed the surveyor that there was no discharge summary for the resident. The LNHA stated that staff informed her that one was completed, but the facility was unable to locate it. The surveyor asked why and where the resident was discharged to, and the LNHA was unable to speak to it stating the facility did not have electronic medical records at the time. On 6/26/24 10:35 AM, the ADON in the presence of the LNHA, DON, and survey team stated Resident #252 was transferred to another facility, and the discharge summary should have been completed, but cannot be located. 3. On 6/20/24 at 9:23 AM, the surveyor reviewed the closed medical record for Resident #97. A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included malignant neoplasm of unspecified site of left and right [male/female] breast (breast cancer); malignant pleural effusion (a condition that occurs when cancer cells cause abnormal amount of fluid to build up between lung and chest cavity); chest pain; and heart failure. A review of the June 2023 Medication Administration Record (MAR) revealed a physician's order (PO) dated 6/21/23, for tramadol 50 milligram (mg) tablet; give one tablet three times a day for pain scheduled at 9:00 AM; 1:00 PM; and 5:00 PM. A review of the corresponding administration times revealed the following: On 6/22/24 at 9:00 AM, an indication for not administered see last section A review of the corresponding last section indicated on 6/22/23 at 9:00 AM, tramadol not administered and comment not applicable [n/a]. A review of the corresponding Progress Notes (PN) included a Nursing Note (NN) dated 6/21/23 at 7:53 PM, that the resident was received from the hospital at 4:30 PM, denies pain at this time. The next NN was dated 6/21/23 at 2:42 PM, that included the resident continued on tramadol and was observed in no distress. The note did not include why the resident did not receive their tramadol on 6/22/23 at 9:00 AM. A review of the July 2023 MAR revealed a PO dated 7/7/23, for tramadol 50 mg tablet; give one tablet by mouth every six hours for pain scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. A review of the corresponding administration times revealed the following: On 7/21/23 at 12:00 AM, 6:00 AM, and 12:00 PM, tramadol was not administered and to comment (see last section). On 7/27/23 at 6:00 AM, tramadol was not administered. A review of the corresponding last section indicated on 7/21/23 at 12:00 AM and 6:00 AM, awaiting medication from pharmacy, and at 12:00 PM, the resident was not in the facility. There was no documentation for the 7/27/23 at 6:00 AM dose. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated the facility had a backup narcotic medication supply, but review of the inventory revealed tramadol was not included. At this time, the surveyor requested the resident's tramadol declining inventory sheets for June and July 2023. On 6/20/24 at 1:24 PM, the surveyor informed the DON and LNHA about the missing doses of tramadol, and requested the resident's June and July 2023 tramadol declining inventory sheets. On 6/25/24 at 1:22 PM, the surveyor in the presence of the LNHA, DON, and survey team requested for the third time a copy of the resident's June and July 2023 tramadol declining inventory sheet. On 6/26/24 at 8:45 AM, the surveyor received the resident's Individual Patient Controlled Substance Administration Record for Tramadol dated first dose administered 7/5/23 at 9:00 AM, and the last dose administered 7/20/23 at 12:00 PM. There were no additional declining inventory sheets. On 6/26/24 at 10:35 AM, DON in the presence of the LNHA, ADON, and survey team stated they were unable to locate any additional declining inventory sheets for tramadol. A review of the facility provided Medical Record Policy dated last revised 5/1/24, included Purpose: To ensure that each resident's medical record is maintained in accordance with accepted professional standards and practices . NJAC 8:39-35.2(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to implement their policy to a.) ensure all eligible residents were educated on the benefits and potential side effects of the pneumococcal immunization and b.) document in the medical record the residents' education and refusal of the pneumococcal immunization. The deficient practice was identified for 2 of 8 residents reviewed for immunizations (Resident #76 and Resident #87), and was evidenced by the following: 1. According to the admission Record, Resident #87 was admitted to the facility with diagnoses including but not limited to diabetes mellitus (a disease of inadequate control of blood levels of glucose), hypertension (high blood pressure), heart failure (heart muscle does not pump blood as well as it should), and stroke (damage to the brain from interruption of its blood supply). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 3/18/24, reflected the resident had a brief interview for mental status score of 15 of out of 15, indicating a fully intact cognition. A review of Section O0300 indicated Resident #87's pneumococcal vaccine (immunization) was not up to date; that the resident was offered and declined. A review of Resident #87's Immunization Record revealed no pneumococcal vaccine was administered, but the resident was administered influenza vaccine on 3/11/24. A review of Resident #87's Progress Notes did not include documentation that the resident was educated, offered, and declined the vaccination. On 6/20/24, the surveyor requested the Pneumococcal Immunization Informed Consent declination form from the Director of Nursing (DON). On 6/24/24, a review of a Pneumococcal Immunization Informed Consent, revealed that Resident #87 was offered the pneumonia vaccine on 6/18/24 and declined. There was no documentation that the resident was offered or that the resident was offered the pneumococcal vaccine prior to survey. On 6/24/24 at 10:02 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated upon admission, the nurse reviewed the resident's vaccination status. The ADON stated if there was no documented immunizations received, the nurse offered the immunization and had the resident signed the consent form or declined the immunization on the same form. The ADON stated the resident was offered the pneumococcal vaccine on 6/18/24, but declined. The ADON confirmed the facility did not have the resident's declination form from admission. On 6/26/24 at 10:35 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), ADON, and survey team stated, the resident was offered on admissions, but the facility could not provide documentation. 2. According to the admission Record, Resident #76 was admitted to the facility with diagnoses included hypertension (high blood pressure), stroke (damage to the brain from interruption of its blood supply), and end stage renal disease (kidneys can no longer function on their own). A review of the most recent MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of Section O0300 indicated Resident #76's pneumococcal vaccine was not up to date; that the resident was offered and declined. A review of Resident #76's Immunization Record, revealed no pneumococcal vaccine administered, but the resident was administered influenza vaccine on 9/22/23. A review of Resident #76's Progress Notes did not include documentation that the resident was educated, offered, and declined the pneumococcal vaccine. On 6/20/24, the surveyor requested the Pneumococcal Immunization Informed Consent declination form from the DON. On 6/24/24, a review of a Pneumococcal Immunization Informed Consent, revealed that Resident #76 was offered the pneumonia vaccine on 6/23/24, and declined. There was no documentation that the resident was educated or that the resident was offered the pneumococcal vaccine prior to surveyor inquiry. On 6/24/24 at 10:02 AM, the surveyor interviewed the ADON who stated upon admission, the nurse reviewed the resident's vaccination status. The ADON stated if there was no documented immunizations received, the nurse offered the immunization and had the resident signed the consent form or declined the immunization on the same form. The ADON stated the resident was offered the pneumococcal vaccine on 6/23/24, but declined. The ADON confirmed the facility did not have the resident's declination form from admission. On 6/26/24 at 10:35 AM, the DON in the presence of the LNHA, ADON, and survey team stated, the resident was offered on admissions, but the facility could not provide documentation. A review of the facility's undated Pneumococcal Vaccine policy included all residents will be offered pneumococcal vaccines to aide in preventing pneumonia/pneumococcal infections. Prior to admissions residents will be assessed for eligibility to receive pneumococcal series, and when indicated, will be offered the vaccine series within thirty days of admission .before receiving the pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccines[ .]provisions of such education shall be documented in the resident's medical record .residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination . NJAC 8:39-19.4(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #159451; 159539; 159783; 162168 Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain resident environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 2 of 2 nursing units (First and Second Floor) and was evidenced by the following: On 6/19/24 at 9:09 AM, the surveyor observed in the hallway by Resident room [ROOM NUMBER] a wheelchair with brown matter that resembled fecal matter, smeared across the seat cushion and down the leg of the wheelchair onto the wheels. On 6/20/24 at 10:52 AM, the surveyor observed on the Second Floor nursing unit a strong urine odor while approaching Resident room [ROOM NUMBER]. The surveyor entered the room to discover the floor by Bed B was wet and sticky. In addition, puddles of wetness was observed on the bed. On 6/20/24 at 11:41 AM, the surveyor requested that Registered Nurse (RN #1) walk with them to Resident room [ROOM NUMBER]. While approaching the room, RN #1 acknowledged the strong urine odor, and confirmed that they were aware of the room's condition. On 6/20/24 at 11:55 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN #1) confirmed the strong smell of urine and acknowledged that Resident room [ROOM NUMBER] should not be in that condition. On 6/25/24 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON) who acknowledged that Resident room [ROOM NUMBER] should have been cleaned in a timely fashion; that residents should receive quality of care and living environments. On 6/26/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Assistant Director of Nursing (ADON), and survey team acknowledged that the wheelchair and resident room, which resulted in the urine smell in the hallway, were not acceptable. A review of the facility's undated Quality of Life- Homelike Environment policy included .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order .e. Pleasant, neutral scents . A review of the facility's Cleaning and Disinfecting Wheelchairs, [Reclining Chairs, Bedside Commode, & Privacy Curtains policy dated last reviewed March 2024, included . 1. Ensure that wheelchairs and [reclining chairs] are kept clean and in good repair [ .] 4. Designate an area for cleaning wheelchairs, [reclining chairs], and bedside commode. If necessary, use a power spray and clean heavily soiled wheelchairs outside . NJAC 8:39-4.1 (a), 11

Based on interview and review of pertinent facility documents, it was determined that the facility failed to issue the required Advance Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) forms prior to discharge from Medicare Part A services. This deficient practice was identified for for 3 of 3 residents reviewed for beneficiary notifications (Resident #28, #55, and #82), and was evidenced by the following: On 6/25/24 at 9:18 AM, the surveyor reviewed three residents (#28, #55, #82) who were discharged from their Medicare Part A stay with benefit days remaining within the past six months and should have received Beneficiary Notices. Resident #28 had a last documented covered day of Medicare Part A service coverage date of 4/12/24, from a facility-initiated discharge when benefit days were not exhausted. The facility did not have the resident or resident representative sign the required NOMNC form to notify them of the termination of insurance. The ABN form was also unsigned and dated 6/12/24 (two months after discharge), and only included rehabilitation (rehab) services with no documented estimated costs. The ABN form contained no other services Medicare would not cover with the estimated costs. Resident #55 had a last documented covered day of Medicare Part A service coverage date of 6/13/24, from a facility-initiated discharge when benefit days were not exhausted. The facility provided the NOMNC form for the resident to sign on 4/12/24 with a notation that the date was incorrect; it was signed on 6/21/24, which was eight days after the last covered day. The ABN form was also signed and dated 4/12/24 (two months prior to discharge), and only included rehab services with no documented estimated costs. The ABN form contained no other services Medicare would not cover with the estimated costs. Resident #82 had a last documented covered day of Medicare Part A service date of 5/31/24, with the resident discontinued from services due to non-participation. The facility provided the NOMNC form for the resident to sign on 5/29/24; which the facility noted the resident refused to sign and responsible party notified but no signature. The ABN form was unsigned and dated 5/29/24, and only included rehab services with no documented estimated costs. The ABN form contained no other services Medicare would not cover with the estimated costs. On 6/25/24 at 10:01 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the ABN and NOMNC forms were provided to residents who received Medicare Part A services that benefit time still remained, but the services were discontinued. The NOMNC was provided forty-eight hours prior to discharge from rehab that informed the resident their right to appeal the discharge. The ABN form was also provided then, and listed what Medicare services would not be covered and the cost of those services. At that time the surveyor reviewed the residents' ABN and NOMNC forms, and the LNHA confirmed they were not completed appropriately. The LNHA stated the facility had no Social Worker (SW) since October of 2023 until about a week ago who worked ten hours a week, and usually the SW had the resident complete the forms. The LNHA continued the Rehab Department provided at that time the NOMNC forms, and she did not believe the ABN forms were being completed with no SW. A review of the facility's Advance Beneficiary Notices (ABN) and Notice of Medicare Non-Coverage (NOMNC) Guidelines dated last revised 1/1/24, included the facility shall obtain in a timely manner and retain all Advance Beneficiary Notices (ABN) and Notice of Medicare Non-Coverage as required by [Centers for Medicaid Medicare Services] guidelines. The [Minimum Data Set] Coordinator is responsible for monitoring and ensuring the ABN's are completed on each resident in a timely manner .ABN is issued when you expect Medicare to deny payment for an item or service because it is not reasonable and necessary under Medicare Program standards .The ABN allows the beneficiary to make an informed decision about whether to get services and accept financial responsibility for those services if Medicare does not pay .Medicare considers issuance of ABN and/or NOMNC effective when the notice is [ .] provided far enough in advance of potentially non-covered items or services to allow sufficient time for the beneficiary to consider available options (at least two days) .The beneficiary or the beneficiary's representative must sign and retain the ABN and send a copy of the signed ABN to you for retention in the beneficiary's record. Keep a copy of the unsigned ABN on file while awaiting receipt of the signed ABN. If the beneficiary fails to return a signed copy, document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the ABN. NJAC 8:39-5.4 (b)(c)

Based on interview, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete criminal background checks on employees prior to employment; b.) to complete reference checks on employees before their start date; and c.) to complete license checks on employees prior to their start date. The deficient practice was identified for 2 of 10 employees reviewed for new hires (Employee #9 and Employee #10), and was evidenced by the following: A review of facility's undated Abuse Policy included in the section titled Screening Components that it is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check .Employee Screening and Training a. Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as appropriate board registrations and certifications regarding the prospective employee's background .d. Criminal background check will be conducted on all prospective employees as provided by the facility's policy in criminal background check . On 6/20/24 at 12:47 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) ten employee files hired since last standard survey who were currently employed or terminated from the facility. The files include both their personnel and medical. A review of employee personnel files revealed the following: For Employee #9, a registered nurse with a start date of 2/2/23, there was no evidence of a reference check prior to the start of employment. For Employee #10, an administrator with a start date of 1/30/23, there was no evidence of a license check, reference check, or criminal background check prior to the start of employment. On 6/25/24 at 12:57 PM, the surveyor interviewed the Human Resources Director (HRD) about the facility's screening process for new hires, and the HRD stated the facility completed criminal background checks prior to their first day of employment to ensure no one had a criminal history to put our residents at risk for harm. The HRD stated the facility also completed reference and license checks prior to the first day of employment. On 6/26/24 at 10:35 AM, the LNHA in the presence of the Director of Nursing (DON), Assistant Director of Nursing (ADON), and survey team acknowledged the missing pre-employment checks. The LNHA who confirmed every employee should have a criminal background and reference check prior to employment. NJAC 8:39-4.1(a)(5); 9.3(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 6/17/24 at 10:52 AM, the surveyor observed Resident #80 lying in bed receiving humidified oxygen at 3 liters per minute (lpm) via nasal cannula (tubing that delivers oxygen through the nose). The surveyor reviewed the medical record for Resident ##80. A review of the admission Record face sheet reflected the resident was admitted to facility with diagnoses which included chronic obstructive pulmonary disease (COPD; refers to a group of diseases that cause airflow blockage and breathing-related problems), morbid obesity (having too much body fat, which increases the risk of health problems) and anemia (low levels of healthy red blood cells to carry oxygen throughout your body). A review of the most recent MDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15; indicating a fully intact cognition. A review of Section I, included the resident had an active diagnoses for COPD, and Section O, did not include that the resident received oxygen therapy while a resident. A review of the Physician Orders with active orders as of 6/12/24, included a physician order to administer oxygen at 3 lpm via nasal cannula as needed for shortness of breath if oxygen saturation was below 92. On 6/20/24 at 12:16 PM, the surveyor interviewed the MDS Coordinator via the phone who acknowledged that Section O of the MDS for Resident # 80 was inaccurate and should have been coded for intermittent oxygen. The MDS Coordinator added that the facility had changed computer systems and that there were inaccuracies in the transfer. On 6/20/24 at 9:30 AM, the survey team met with the LNHA and DON who both acknowledged that the MDS for Resident #80 was inaccurate. A review of facility provided policy Completion of MDS reviewed 04-2023 indicated that: The RN MDS Coordinator is responsible for ensuring the completion of the MDS. This policy also indicated that Section O is to be completed by Nursing/Therapy Dept. A review of facility's Resident Assessment Instrument (RAI) Process policy dated reviewed April 2023, included the Clinical Reimbursement Manager will oversee that the Interdisciplinary Team will complete an assessment of each resident as part of the Resident Assessment Instrument (RAI) process to assure data accuracy for the State-specific version of the Minimum Data Set (MDS) within the required timeframes according to applicable laws and regulations . NJAC 8:39-11.2(e)1; 27.1(a) 4. The surveyor reviewed the closed medical record for Resident #96. A review of the admission Record face sheet indicated that the resident was admitted to the facility with diagnosis that included but not limited to a tracheostomy (a surgically created opening in the neck to allow breathing). A review the comprehensive MDS dated [DATE], indicated in Section O, question F1 Invasive Mechanical Ventilator (a machine that supports or replaces a person's breathing) was coded as in use while a resident. A review of the medical record included no indication that Resident #96 was on a ventilator. On 6/19/24 at 11:35 AM, the surveyor interviewed the MDS Coordinator who confirmed that Resident #96 was not on a ventilator while in the facility and that the assessment was not coded correctly. On 6/20/24 at 9:30 AM, the survey team met with the LNHA and DON who both acknowledged that the MDS for Resident #96 was inaccurate. The RAI manual, version 1.18.11, October 2023, Page O-5 provided the following guidance for coding this question Code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. 2. On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. Resident #60 stated that they were waiting to go outside to smoke (cigarettes). On 6/19/24 at 10:27 AM, the surveyor observed Resident #60 outside smoking cigarettes. On 6/20/2024 at 9:22 AM, the surveyor observed Resident #60 outside smoking cigarettes. The surveyor reviewed the medical record for Resident #60. A review of the admission Record face sheet (an admission summary) reflected that Resident #60 was admitted to the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. Section J of the most recent comprehensive MDS assessment failed to identify Resident #60 as a current tobacco user. On 6/20/24 at 12:11 PM, the survey team interviewed the MDS Coordinator via telephone, who identified that the MDS department was haphazard when they arrived and has been attempting to clean it up since arriving in April. The MDS Coordinator acknowledged that they were aware of Resident #60's smoking habit, and confirmed that the MDS was coded incorrectly. On 6/25/24 at 1:30 PM, the DON, in the presence of the LNHA, Regional Nurse and Assistant Director of Nursing (ADON), and and survey team acknowledged that Resident #60's MDS was coded incorrectly. 3. On 6/19/24 at 10:01 AM, the surveyor observed Resident #73 in their room. Resident #73 explained that they had issues with bladder incontinence and urinated on the floor because I can't hold it. The surveyor reviewed the medical record for Resident #73: A review of the Order Summary Report revealed that Resident #73 was admitted to the facility with diagnosis that included, but not limited to diabetes mellitus, mood disorder, and hypertension (high blood pressure). A review of the most recent quarterly MDS dated [DATE], reflected the resident had a BIMS score of 12 out of 15, which indicated a moderately impaired cognition. In addition, Section H (Bowel and Bladder) of the MDS identified Resident #73 as continent of bladder. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 10/11/23, for activities of daily living (ADL) Functional/Rehabilitation Potential. Interventions included: I will have all my needs met. In addition, another focus area, dated 10/25/22, for Elimination for incontinence as evidenced by: frequent incontinence of bladder. On 6/19/24 at 10:20 AM, the surveyor interviewed Certified Nursing Assistant (CNA #1 and #2), who both confirmed that Resident #73 unable to hold their urine, and was being changed almost daily due to the incontinence. On 6/20/24 at 11:23 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #1) who identified Resident #73 as incontinent. On 6/20/24 at 7:50 AM, the surveyor interviewed the MDS Coordinator who acknowledged that they are aware of Resident #73 and confirmed that the MDS should not be coded as continent of bladder. The RAI manual, version 1.18.11, October 2023, Page H-8 provided the following guidance for coding this question, Review the medical record for bladder or incontinence records or flow sheets, nursing assessments and progress notes, physician history, and physical examination. 2. Interview the resident if they are capable of reliably reporting their continence. Speak with family members or significant others if the resident is not able to report on continence. 3. Ask direct care staff who routinely work with the resident on all shifts about incontinence episodes. Based on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to evaluate resident's care needs. This deficient practice was identified for 5 of 35 residents reviewed for accuracy of assessments (Resident #29, #60, #73, #80, and #96), and was previously cited during the facility's last standard survey on 10/20/22. The evidence was as follows: Refer F865 1. On 6/17/24 at 10:57 AM, the surveyor observed Resident #29 sitting on their bed. The surveyor attempted to interview the resident, but the resident was unable to verbally be understood. The surveyor reviewed the medical record for Resident #29. A review of the admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to schizophrenia, A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 5/11/24, reflected a brief interview for mental status (BIMS) score of 5 out of 15, indicating that the resident had a severely impaired cognition. In addition, in Section A: Identification Information indicated that the resident was not considered by the state level II Preadmission Screening and Resident Review (PASARR II) process to have serious mental illness and/or intellectual disability or a related condition. A review of a level I PASARR dated 3/12/2020, that was in the paper medical record, indicated that the resident had a positive screen for mental illness and that a PASARR II was recommended. In addition, a review of a level II PASARR dated 3/12/2020, that was in the paper medical record, indicated that it was completed. On 6/20/24 at 12:54 PM, the surveyor interviewed the MDS Coordinator via the phone who stated that he had started as the MDS Coordinator in March of 2024, acknowledged that Section A of the MDS for Resident # 29 was inaccurate and he had to complete a modification to correct the 5/11/24 MDS. The MDS Coordinator added that the facility had changed computer systems and that there were inaccuracies in the transfer. On 6/20/24 at 9:30 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who both acknowledged that the MDS for Resident #29 was inaccurate. On 6/20/24 at 12:55 PM, the survey team met with the LNHA and DON, and the DON stated that the previous MDS Coordinator resigned approximately six months ago, and the current MDS Coordinator started in March 2024, and had been working to upload from the previous computer system and paper versions to the current computer system.

2. On 6/17/24 at 10:27 AM, the surveyor observed Resident #60 in their room watching television. Resident #60 was observed without any orthotic to lower extremities, specifically a left ankle foot orthosis [brace] (AFO). The surveyor reviewed the medical record for Resident #60. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included, but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/16/24, reflected a brief interview for mental status (BIMS) score of 12 out of 15, which indicated a moderately impaired cognition. A review of the Order Summary Report reflected an active order, dated 6/4/24, for left AFO to prevent food drop every day shift and left AFO to prevent foot drop every evening shift. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 7/13/22, for activities of daily living (ADL) Functional/Rehabilitation Potential with interventions that included to apply left AFO when out of bed. Further review of the ICCP identified the following note with a creation date of 10/19/23: Resident use left AFO in the morning and must remove prior going to bed at night. On 6/20/24 at 11:55 AM, the surveyor observed Resident #60 without a left AFO applied. On 6/25/24 at 9:43 AM, the surveyor and Director of Nursing (DON) passed Resident #60 in the hallway. The surveyor inquired if Resident #60 was currently wearing a left AFO, and the DON denied. Resident #60 stated that they had not had it in while. The surveyor and the DON reviewed the electronic medical record for Resident #60, which revealed an active order to apply left AFO to prevent foot drop everyday shift, and apply left AFO to prevent foot drop every evening shift. The surveyor and DON identified that the Treatment Administration Order also that displayed the nurses initials identifying that the AFO has been applied today and within the past survey dates (6/17/24 to present). The DON confirmed that nurses should not be signing off on the order if it was not applied. On 6/25/24 at 11:06 AM, the surveyor interviewed the Director of Rehabilitation (DOR) who reported that the AFO was discontinued on 9/25/23 at 4:51 PM. The DOR provided a copy of the order that identified the order as signed off by the physician on 10/30/23 at 1:22 PM. On 6/26/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Regional Nurse, Assistant Director of Nursing (ADON), and survey team confirmed that Resident #60's AFO should have been discontinued in the system and that the nurses were identifying the AFO was applied when it was not. The facility could not provide any policy regarding discontinuation of physician's orders and/or accuracy of completing the treatment administration orders. NJAC 8:39-11.2(b); 27.1(a) Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) administer multiple medications on multiple dates and times on a timely basis in November of 2022, and b.) ensure a discontinued physician's order was removed from active orders in accordance with professional standards of practices. This deficient practice was identified for 4 of 4 residents reviewed for medication administration times (Resident #32, #43, #60, and #250) and 1 of 24 residents reviewed for professional standards of practice (Resident #60). 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. The deficient practice was evidenced by the following: 1. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that the facility relied heavily on Agency staffing. At that time, the surveyor requested the Nurse Staffing Report to be completed for the weeks of 11/6/22 to 11/19/22. On 6/18/24 at 11:56 AM, the LNHA informed the surveyor that the facility did not have the staffing records for 2022; that they were trying to get the information from the payroll company. The surveyor asked the LNHA if the facility needed to maintain staffing records, and the LNHA confirmed the facility should have the records. On 6/25/24 at 10:13 AM, the surveyor reviewed the Nurse Staffing Report sheets completed by the facility for 11/6/22 through 11/19/22 which revealed the facility had zero to four nurses scheduled daily in a twenty-four hour period. At that time, the LNHA stated that the facility could not locate the November 2022 staffing sheets, and they used payroll documents to complete the staffing report. The LNHA stated the facility relied heavily on Agency staff who were not included in those reports. On 6/25/24 at 10:17 AM, the surveyor interviewed the Staffing Coordinator in the presence of the LNHA who stated she was not here at the time, and could not locate the staffing sheets for that time. The Staffing Coordinator stated she could reach out to the Agencies to determine the staff provided. On 6/25/24 at 10:21 AM, the surveyor interviewed the DON in the presence of the LNHA and Staffing Coordinator who acknowledged the staffing sheets needed to be maintained and kept as a reference at all times. The DON stated the unit managers kept records of the assignment sheets, but the sheets cannot be located. The DON acknowledged her role was to oversee the nursing department, and confirmed the staffing levels were not acceptable. On 6/25/24 at 10:21 AM, the surveyor requested the Medication Administration Record with the times medication was administered for five sampled residents (Resident #32, #43, #60, #250, and #252) for the time period of 11/6/22 through 11/19/22. On 6/25/24 at 12:30 PM, the LNHA provided the surveyor with Administration Documentation Audit Detail Report (ADADR) for the weeks of 11/1/22 to 11/13/22 for Resident #32, #60, and #250. The LNHA stated Resident #252 was discharged from the facility in July of 2022, and Resident #43 was out of the facility at the time, so she provided the week of 11/25/24. On 6/25/24 at 1:30 PM, the surveyor interviewed the DON who stated medication should be administered as ordered; the right person, medication, dose, route, and time. The DON continued medication was to be administered at the time prescribed or one hour before or after the medication was timed for. The surveyor reviewed the ADADR reports provided which revealed the following: For the weeks of 11/1/22 through 11/13/22: For Resident #32, their medications were administered out of the time parameters: for the 8:00 AM dose on 11/2/22, 11/3/22, 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/10/22, 11/11/22, 11/12/22, and 11/13/22; for the 9:00 AM doses on 11/4/22, 11/5/22, 11/11/22, and 11/12/22; for the 12:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/10/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, and 11/11/22; for the 6:00 PM dose on 11/2/22; and the 10 PM dose on 11/11/22. It was documented the resident's tube feeding (nutrition administered through a surgical tube into the stomach) scheduled at 4:00 PM, was administered late on 11/3/22, 11/7/22, 11/8/22, 11/9/22, 11/11/22, and 11/12/22. It was also documented on 11/4/22, that their 8:00 AM medications were administered at 2:04 PM; and their 11/11/22 8:00 AM and 9:00 AM medications were administered at 1:26 PM. For Resident #60, their medications were administered out of the time parameters: for the 8:00 AM doses on 11/1/22; 11/2/22; 11/3/22; 11/4/22; 11/5/22; 11/6/22; 11/7/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for the 9:00 AM doses on 11/1/22, 11/4/22, 11/5/22, and 11/12/22 for the 1:00 PM doses on 11/1/22, 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/8/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/11/22, and 11/12/22; and the 9:00 PM doses on 11/2/22, 11/11/22, 11/12/22, and 11/13/22. It was documented that they received their 11/4/22 9:00 AM medications at 2:18 PM. For Resident #250, their medications were administered out of the time parameters: for the 8:00 AM dose on 11/11/22; for the 9:00 AM doses on 11/3/22, 11/8/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for the 1:00 PM doses on 11/9/22, 11/10/22, and 11/13/22; and the 5:00 PM doses on 11/3/22, 11/4/22, 11/5/22, and 11/8/22. It was documented the resident's 9:00 AM doses on 11/3/22 were administered at 1:52 PM, and their 5:00 PM doses on 11/5/22 were administered at 10:26 PM. For the week of 11/25/22 through 11/30/22, Resident #43's medications were administered out of the time parameters: for the 9:00 AM dose on 11/29/22; the 5:00 PM dose on 11/27/22; and the 6:00 PM dose on 11/27/22. It was documented the 9:00 AM medications were administered at 12:06 PM on 11/29/22. On 6/26/24 at 10:34 AM, the LNHA acknowledged these concerns. A review of the facility's Medication Administration Policy dated effective 12/23/23, included medications are administered in a timely fashion as specified by policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a Justice Involved Resident (JIR) was provided since admission activities of their choice designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This deficient practice was identified for 1 of 1 JIR (Resident #1) reviewed. The findings were as follows: Reference: The Centers for Medicare and Medicaid Services (CMS) updated Guideline to Surveyors on Federal Requirements for Providing services to Justice Involved individuals, revised 12/23/2016 S & C 16-21-ALL documented Skilled Nursing Facilities must permit residents to have autonomy and choice to the maximum extent practicable regarding how they wish to live their everyday lives and receive care with the same rights as nursing home residents. A review of the facility's Resident Rights dated revised 1/3/24, included 10. all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .Resident Rights: 1. the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .5. the resident has the right to be treated with respect and dignity including: the right to be free from physical or chemical restraints imposed for the purpose of discipline or convenience [ .] the right to retain and use personal possessions [ .] the right to receive services in the facility with reasonable accommodation of resident needs and preferences [ .]the right to share a room with a roommate of his/her choice [ .] 6. Self-determination: the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice including but not limited to; [ .] choose activities, schedules [ .] consistent with their interests; the right to make choices about aspects of his or her life that are significant to the resident; interact with members of the community; receive visitors of their choosing at the time of their choosing .participate in other activities including social, religious, and community activities .8. Privacy and confidentiality: the resident has the right to personal privacy and confidentiality of their personal and medical records .9. Safe environment: the resident has the right to a safe, clean, comfortable and homelike environment . A review of the facility's Activities policy dated reviewed 5/1/24, included the facility's activity programs are designed to meet the needs of each resident and are available on a daily basis .the facility's activity programs are designed to encourage participation and are individualized to meet each resident's needs . On 8/29/24 at 9:45 AM, the surveyor observed a personal protective equipment (PPE) bin outside of Resident #1's room. At that time, the surveyor interviewed the Licensed Practical Nurse Supervisor (LPN Supervisor #1), who stated Resident #1 had a stage 4 pressure wound (full-thickness skin loss extends through the fascia with considerable tissue loss) to their right buttock, and when staff provided care, they needed to don (wear) additional PPE. The surveyor asked if staff had to wear PPE when the resident was out of the room, and LPN Supervisor #1 stated that Resident #1 was a Justice Involved Resident (JIR) who remained in their room unless to go to the rehabilitation (rehab) gym. LPN Supervisor #1 continued that the resident did not participate in activities; ate all their meals in their room on disposable ware; wore an orange jumpsuit in therapy; visitors needed to be scheduled through the CF by appointment; and the resident always remained in the room alone with two armed Correctional Officers (COs). On 8/29/24 at 9:55 AM, the surveyor observed Resident #1 lying in bed with two-armed COs (CO #1 and CO #2) who were on their cell phones stationed at the resident's door (CO #1) and the resident's window (CO #2). At that time, the surveyor interviewed the resident, who stated they had been at the facility for over a year now, and they were receiving rehab and wound care at the facility. Resident #1 stated that they wanted to return to the Correctional Facility (CF); they were lonely and depressed at the facility because they remained in their room twenty-four hours a day, seven days a week with two COs and a television. The resident stated they ate in their room on disposable ware and there were no activities. Resident #1 stated that they were prohibited visitors unless the CF approved the visits, and the CF was not responding to their visitors for appointments. Resident #1 stated they were waiting for grievance paperwork from the CF to complain about it, which they had not received, and the CF's Social Worker (SW) was supposed to come to the facility weekly so they could have their weekly phone call. Resident #1 stated the CF's SW maybe came to the facility twice a month, so they missed their allowed phone calls, and the resident wanted to call their attorney to request to be transferred back to the CF. Resident #1 stated they had no privacy, anytime they received care the COs were in the room, and if they had visitors or made a call, the COs were present. Resident #1 stated that when they went to rehab, they wore an orange jumpsuit which embarrassed them because it let everyone know they were a JIR. The surveyor asked if the resident had to wear any cuffs (wrist or ankle) in the room or in rehab, and the resident stated, no, they could not walk. The surveyor asked if the resident saw the facility's SW, and the resident stated, no, but they thought they were supposed to. At the time of the interview, the surveyor asked CO #1 if everything the resident reported was accurate, and the CO confirmed yes, the resident was incarcerated. On 8/29/24 at 10:41 AM, the surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; paraplegia (leg paralysis); chronic pain; depressive disorder; anxiety disorder; insomnia; and stage 4 pressure ulcer of right buttock. A review of the Progress Notes included a Nursing Note dated 4/27/23 at 7:37 AM, which included the resident was admitted to the facility on [DATE] at 6:55 PM, accompanied by two COs. The resident was admitted with a right ischial (lower buttock) pressure sore; was receiving intravenous (IV) antibiotics; and had a wound vacuum (negative pressure wound therapy treatment that uses suction to assist in wound healing). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected the resident had a brief interview for mental status score of 15 out of 15, which indicated a fully intact cognition. A review of the individual comprehensive care plan (ICCP) included the following focus areas: A focus area dated 7/3/24, that the resident was not permitted access to telephones, not landlines or cell phones. In the rare circumstances when phone use was permitted, the CF, not the staff take care of it. The resident was not permitted to go out on pass or out of the facility unless escorted by COs and authorized by the CF. The intervention was that the resident would be closely monitored by the CF. A focus area dated 7/3/24, inmate dining: there was to be no food or drinks other than water pitcher (when clinically approved) to be stored at bedside. The intervention included was the resident would maintain stable weight and be free from dehydration. The ICCP did not include a focus area for activities. On 8/29/24 at 11:24 AM, the surveyor interviewed the facility's SW, who stated she had just started at the facility last week and had not gotten to speak to all the residents yet. The surveyor asked if the SW spoke with Resident #1, and she stated no, but the resident was on her list. On 8/29/24 at 11:55 AM, the surveyor interviewed the Director of Activities (DA) who stated activities were conducted in groups on both nursing units, and staff did one-to-one (1:1) activities as needed. The DA stated that 1:1 activities included providing puzzles and crossword puzzles. The surveyor asked if she provided 1:1 activities for Resident #1, and the DA stated that activity staff did not see them that often. The DA continued that there were two COs in there and staff were not really supposed to be in there; that she could not provide any activities, crossword puzzles, or games. The DA stated the resident requested a pack of playing cards about a month ago, and the facility was not allowed to provide, that the CF's SW had to provide. On 8/29/24 at 12:30 PM, the surveyor observed Resident #1 sitting in a wheelchair being transported down the hallway in wrist and ankle cuffs in an orange jumpsuit with three-armed COs. The surveyor asked Resident #1 where they were going, and the resident stated to see the wound doctor, that they did not want to see the doctor here. The resident reported their appointment was at the hospital, and that their wound was improving. The surveyor asked the resident if they ever received the playing card they requested, and the resident confirmed no. On 8/29/24 at 12:56 PM, the surveyor interviewed the LNHA in the presence of the DON, who stated that she had started at the facility on 4/11/24, and the previous owners of the facility had a contract with the CF since 2022. The LNHA stated that the JIRs were only at the facility for medical services, and when their medical treatment was completed, the JIRs returned to the CF. The LNHA continued that Resident #1 stayed in their room with the two COs and went to rehab accompanied by them. The LNHA stated that everything was controlled by the CF; that the facility could not provide playing cards; phone usage; visitors. The LNHA stated the CF's SW came to the facility she thought once a month for the resident to make a phone call, but she did not believe there was a set schedule. At that time, the DON stated that the resident informed the facility that the CF had to approve all visits, and the resident could not have a visitor unless the CF approved it. The DON stated there were no private visits, that there were always COs; the resident could not be without them. The DON stated it was the CF's policies; the resident could have no other clothes except their orange jumpsuit that identified them as a JIR as a safety precaution. The DON stated only the resident and the COs could be in the elevator during transportation, and the resident saw an outside wound doctor that the appointments were scheduled by the CF. The DON stated that Resident #1 received the same level of care as all the other residents in the facility, they just did not have the freedoms. The DON stated that the facility was in control of the resident's nursing care, and everything else was controlled by the CF. The surveyor requested a copy of the resident's activity assessments. On 8/29/24 at 3:05 PM, the DON informed the survey team that she had spoken to the CF to have the CF inform the facility who was permitted to visit the resident and when. No additional information was provided. NJAC 8:39-7.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ Complaint #166769 Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who received daily pain management a.) received their pain medications as order and b.) ensure the resident's pain was being assessed and monitored every shift. This deficient practice was identified for 1 of 1 residents reviewed for pain management (Resident #97), and was evidenced by the following: On 6/20/24 at 9:23 AM, the surveyor reviewed the closed medical record for Resident #97. A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included malignant neoplasm of unspecified site of left and right [male/female] breast (breast cancer); malignant pleural effusion (a condition that occurs when cancer cells cause abnormal amount of fluid to build up between lung and chest cavity); chest pain; and heart failure. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/14/23 for pain with a goal to be free from pain, and interventions which included assess for signs and symptoms of pain; establish baseline pain through pain assessment. An additional focus are dated 1/7/23, for breast cancer as evidenced by visible lumps/tumors; pain and weight loss with an invasive carcinoma (cancerous tumor) grade two to the right breast and stage 4 that metastasized (spread from one part of the body to another) to the left proximal humerous (upper arm bone); right middle lobe (lung); lytic lesions (bone damage appearing as holes) to bilateral ilia and lumbar vertebrea (upper hip and lower spine) with no interventions exist for this focus. A review of the June 2023 Medication Administration Record (MAR) revealed a physician's order (PO) dated 6/21/23, for tramadol 50 milligram (mg) tablet; give one tablet three times a day for pain scheduled at 9:00 AM; 1:00 PM; and 5:00 PM. A review of the corresponding administration times revealed the following: On 6/22/24 at 9:00 AM, an indication for not administered see last section A review of the corresponding last section indicated on 6/22/23 at 9:00 AM, tramadol not administered and comment not applicable [n/a]. A review of the corresponding Progress Notes (PN) included a Nursing Note (NN) dated 6/21/23 at 7:53 PM, that the resident was received from the hospital at 4:30 PM, denies pain at this time. The next NN was dated 6/21/23 at 2:42 PM, that included the resident continued on tramadol and was observed in no distress. The note did not include why the resident did not receive their tramadol on 6/22/23 at 9:00 AM. A further review on the June 2023 MAR, revealed a PO dated 6/21/23, for pain assessment every shift; use pain scale 0-10. A review of the corresponding pain assessment for 6/22/23 during the 7:00 AM to 3:00 PM shift; reflected the resident was in no pain. A review of the July 2023 MAR revealed a PO dated 7/7/23, for tramadol 50 mg tablet; give one tablet by mouth every six hours for pain scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. A review of the corresponding administration times revealed the following: On 7/21/23 at 12:00 AM, 6:00 AM, and 12:00 PM, tramadol was not administered and to comment (see last section). On 7/27/23 at 6:00 AM, tramadol was not administered. A review of the corresponding last section indicated on 7/21/23 at 12:00 AM and 6:00 AM, awaiting medication from pharmacy, and at 12:00 PM, the resident was not in the facility. There was no documentation for the 7/27/23 at 6:00 AM dose. A further review of the July 2023 MAR included no PO for pain scale every shift as previously documented in June 2023. A review of the Progress Notes for 7/21/23, included a NN at 1:34 PM, that call was placed to the Pharmacy to be made aware of the need for tramadol, and the Pharmacy stated they were awaiting a prescription. The nurse documented they called the Nurse Practitioner (NP) who stated a prescription was sent over the night before, and nurse called Pharmacy to relay information who denied having prescription. The nurse documented they made NP aware. An additional note dated 7/21/23 at 1:37 PM, that resident was out of the facility at 9:05 AM to go to oncology (cancer doctor) with no distress observed. There was no documentation on 7/21/23, that either the physician or NP was made aware the resident did not receive their tramadol for three scheduled administrations or any alternative. There was no documentation of the resident's pain for the missed 12:00 AM and 6:00 AM doses. A further review of the Progress Notes did not include any documentation as to why the resident did not receive the tramadol on 7/27/23 at 6:00 AM. A review of the comprehensive Minimum Data Set (MDS) dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of a 14 out of 15, which indicated a fully intact cognition. A further review revealed the resident received routine pain medication. On 6/20/24 at 9:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated pain was monitored for all residents on the MAR using a pain scale every shift. The DON stated if the resident did not receive their scheduled pain medication, the nurse documented why it was not received. The DON stated the facility had a backup narcotic medication supply, but review of the inventory revealed tramadol was not included. At this time, the surveyor requested the resident's tramadol declining inventory sheets for June and July 2023. On 6/20/24 at 1:24 PM, the surveyor informed the DON and Licensed Nursing Home Administrator (LNHA) about the missing doses of tramadol. The surveyor requested any additional information for what was done for those shifts; pain scale; and the resident's June and July 2023 tramadol declining inventory sheets. On 6/25/24 at 1:22 PM, the surveyor in the presence of the LNHA, DON, and survey team requested for the third time a copy of the resident's June and July 2023 tramadol declining inventory sheet. On 6/26/24 at 8:45 AM, the surveyor received the resident's Individual Patient Controlled Substance Administration Record for Tramadol dated first dose administered 7/5/23 at 9:00 AM, and the last dose administered 7/20/23 at 12:00 PM. There were no additional declining inventory sheets. On 6/26/24 at 10:35 AM, DON in the presence of the LNHA, Assistant Director of Nursing (ADON), and survey team stated they were unable to locate any additional declining inventory sheets for tramadol. The DON was unable to provide any additional information regarding the missing doses, but confirmed medication should be administered as ordered. The DON acknowledged the facility should have assessed the resident's pain every shift, and if medication was unavailable, the physician was immediately notified and asked if another medication should be given instead. The DON confirmed the resident was on pain medications and it was important to monitor their pain to ensure the medication prescribed was effective. At that time, the ADON confirmed the resident had cancer at the time the pain medication was not received. A review of the facility's Pain Management policy dated reviewed February 2024, included the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences .reassess patients with pain regularly based on facility's established intervals. If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that the facility relied heavily on Agency staffing. At that time, the surveyor requested the Nurse Staffing Report to be completed for the weeks of 11/6/22 to 11/19/22. On 6/18/24 at 11:56 AM, the LNHA informed the surveyor that the facility did not have the staffing records for 2022; that they were trying to get the information from the payroll company. The surveyor asked the LNHA if the facility needed to maintain staffing records, and the LNHA confirmed the facility should have the records. On 6/25/24 at 10:13 AM, the surveyor reviewed the Nurse Staffing Report sheets completed by the facility for 11/6/22 through 11/19/22 which revealed the following: On 11/6/22, there was a census of 91 residents with a total of four nurses throughout the twenty-four hour period. On 11/7/22, there was a census of 91 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the overnight. On 11/8/22, there was a census of 91 residents with a total of four nurses throughout the twenty-four hour period. On 11/9/22, there was a census of 93 residents with a total of three nurses throughout the twenty-four hour period with no nurses on the overnight. On 11/10/22, there was a census of 93 residents with a total of four residents throughout the twenty-four hour period. On 11/11/22, there was a census of 92 residents with a total of four nurses throughout the twenty-four hour period. On 11/12/22, there was a census of 93 residents with a total of three nurses throughout the twenty-four hour period. On 11/13/22, there was a census of 93 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the evening shift. On 11/14/22, there was a census of 94 residents with a total of two nurses throughout the twenty-four hour period with no nurses on the overnight shift. On 11/15/22, there was a census of 95 residents with a total of three nurses throughout the twenty-four hour period. On 11/16/22, there was a census of 95 residents with a total of three nurses throughout the twenty-four hour period with no nurses on the evening shift. On 11/17/22, there was a census of 93 residents with a total of two nurse throughout the twenty-four hour period with no nurse on the evening shift. On 11/18/22, there was a census of 94 residents with a total of one nurse throughout the twenty-four hour period with no nurses on the day or evening shifts. On 11/19/22, there was a census of 93 residents with a total of one nurse throughout the twenty-four hour period with no nurse on the day or evening shifts. At that time, the LNHA stated that the facility could not locate the November 2022 staffing sheets, and they used payroll documents to complete the staffing report. The LNHA stated the facility relied heavily on Agency staff who were not included in those reports. On 6/25/24 at 10:17 AM, the surveyor interviewed the Staffing Coordinator in the presence of the LNHA who stated she was not here at the time, and could not locate the staffing sheets for that time. The Staffing Coordinator stated she could reach out to the Agencies to determine the staff provided. On 6/25/24 at 10:21 AM, the surveyor interviewed the DON in the presence of the LNHA and Staffing Coordinator who acknowledged the staffing sheets needed to be maintained and kept as a reference at all times. The DON stated the unit managers kept records of the assignment sheets, but the sheets cannot be located. The DON acknowledged her role was to oversee the nursing department, and confirmed the staffing levels were not acceptable. At that time, the surveyor requested the Medication Administration Record with the times medication was administered for five sampled residents (Resident #32, #43, #60, #250, and #252) for the time period of 11/6/22 through 11/19/22. On 6/25/24 at 12:30 PM, the LNHA provided the surveyor with Administration Documentation Audit Detail Report (ADADR) for the weeks of 11/1/22 to 11/13/22 for Resident #32, #43, and #250. The LNHA stated Resident #252 was discharged from the facility in July of 2022, and Resident #43 was out of the facility at the time so she provided the week of 11/25/24. On 6/25/24 at 1:30 PM, the surveyor interviewed the DON who stated medication should be administered as ordered; the right person, medication, dose, route, and time. The DON continued medication was to be administered at the time prescribed or one hour before or after the medication was timed for. The surveyor reviewed the ADADR reports provided which revealed the following: For the weeks of 11/1/22 through 11/13/22: For Resident #32, their medications were administered out of the time parameters: for the 8:00 AM dose on 11/2/22, 11/3/22, 11/4/22, 11/5/22, 11/6/22, 11/7/22, 11/10/22, 11/11/22, 11/12/22, and 11/13/22; for the 9:00 AM doses on 11/4/22, 11/5/22, 11/11/22, and 11/12/22; for the 12:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/8/22, 11/10/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, and 11/11/22; for the 6:00 PM dose on 11/2/22; and the 10 PM dose on 11/11/22. It was documented the residents tube feeding (nutrition administered through a surgical tube into the stomach) scheduled at 4:00 PM, was administered late on 11/3/22, 11/7/22, 11/8/22, 11/9/22, 11/11/22, and 11/12/22. It was also documented on 11/4/22, that their 8:00 AM medications were administered at 2:04 PM; and their 11/11/22 8:00 AM and 9:00 AM medications were administered at 1:26 PM. For Resident #60, their medications were administered out of the time parameters: for the 8:00 AM doses on 11/1/22; 11/2/22; 11/3/22; 11/4/22; 11/5/22; 11/6/22; 11/7/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for the 9:00 AM doses on 11/1/22, 11/4/22, 11/5/22, and 11/12/22 for the 1:00 PM doses on 11/1/22, 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/8/22, and 11/11/22; for the 5:00 PM doses on 11/2/22, 11/3/22, 11/4/22, 11/7/22, 11/11/22, and 11/12/22; and the 9:00 PM doses on 11/2/22, 11/11/22, 11/12/22, and 11/13/22. It was documented that they received their 11/4/22 9:00 AM medications at 2:18 PM. For Resident #250, their medications were administered out of the time parameters: for the 8:00 AM dose on 11/11/22; for the 9:00 AM doses on 11/3/22, 11/8/22, 11/9/22, 11/11/22, 11/12/22, and 11/13/22; for the 1:00 PM doses on 11/9/22, 11/10/22, and 11/13/22; and the 5:00 PM doses on 11/3/22, 11/4/22, 11/5/22, and 11/8/22. It was documented the resident's 9:00 AM doses on 11/3/22 were administered at 1:52 PM, and their 5:00 PM doses on 11/5/22 were administered at 10:26 PM. For the week of 11/25/22 through 11/30/22, Resident #43's medications were administered out of the time parameters: for the 9:00 AM dose on 11/29/22; the 5:00 PM dose on 11/27/22; and the 6:00 PM dose on 11/27/22. It was documented the 9:00 AM medications were administered at 12:06 PM on 11/29/22. On 6/26/24 at 10:30 AM, the LNHA provided additional staffing for the weeks of 11/6/22 through 11/19/22, which revealed on 11/6/22, there were three nurses for the day shift and one for the overnight; on 11/7/22, there were two nurses for the day and overnight shifts and three for the evening; on 11/8/22 there were three nurses for the evening and two nurses for the overnight shifts; on 11/9/22 four nurses for the day shift, two for the evening and one for the overnight shifts; on 11/10/22 there was four for the day, three for the evening, and two for the overnight shift; for 11/11/22 there was four for the day, three for the evening, and one for the overnight shift; on 11/12/22 there were two nurses for the day four for the evening, and two for the overnight; for 11/13/22 there was three for the day, two for the evening, and one for the overnight; for 11/14/22 there was two for the evening and one for the overnight; for 11/15/22 and 11/16/22 there was two for the evening and overnight; 11/17/22 there were three for the evening and two for the overnight; for 11/18/22 there were three for the evening and one for the overnight; and for 11/19/22 there were two for the evening and one for the overnight. On 6/26/24 at 10:34 AM, the LNHA acknowledged these concerns. A review of the facility's Bowel and Bladder Incontinence Care policy dated May 2023, included that controlling common infections for incontinent residents was part of the overall infection control program .the facility was committed to providing a safe a healthy environment for residents and to minimize or prevent the spread of infections . A review of the facility's Nursing and Sufficient Staff policy dated last reviewed July 2023, included it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .the facility will supply sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans . NJAC 8:39-25.2 (a); 27.1(a) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide sufficient nursing staff to ensure residents were provided with care to achieve their highest practical wellbeing by failing to ensure a.) incontinence care was provided for 2 out of 7 residents observed during incontinence rounds (Resident #32 and Resident #147) and b.) medications were administered according to physician's orders for 4 of 4 residents reviewed for medication administration timing (Resident #32, #43, #60, and #250). This deficient practice was evidenced by the following: Refer F658 and F677 1. According to the admission Record (AR), Resident #147 was admitted to the facility with the diagnoses which included but not limited to chronic respiratory failure and tracheostomy (hole in the windpipe to facilitate breathing). The most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/10/24, reflected that Resident #147 had moderate cognitive deficits and was dependent on staff for hygiene. Resident #147's individualized comprehensive care plan (ICCP) reflected that the resident required total dependence and one-person physical assistance with personal hygiene. According to the AR, Resident #32 was admitted to the facility with the diagnoses which included but not limited to cerebral infarction (stroke). The most recent comprehensive MDS dated [DATE], reflected that Resident #32 had severe cognitive deficits and was dependent on staff for hygiene. Resident #32's ICCP reflected that the staff provided incontinent care every two to four hours and that the resident required total dependence and one-person physical assistance with personal hygiene. On 6/18/24 at 8:02 AM, the surveyor conducted an incontinence tour on the Second Floor nursing unit accompanied by the Unit Manager/Licensed Practical Nurse (Um/LPN #1) and observed the following: The surveyor and UM/LPN #1 entered Resident #147's room who was observed lying in bed. UM/LPN #1 asked the resident if she could check their incontinent brief and the resident gave UM/LPN #1 permission. The surveyor observed that the resident's incontinent brief was dry and the chuck (protective bed pad) that was directly under the resident was dry, however the fitted sheet located under the chuck had a large brown/yellow stain that smelled like urine and contained some dry brown stains which UM/LPN #1 identified as bowel movement (bm). UM/LPN #1 was interviewed at that time, and stated that the Certified Nursing Aide (CNA) that was assigned to care for Resident #32 should have changed the resident's sheet when performing incontinence care and should not have left a urine-soaked sheet on the resident's bed. UM/LPN #1 stated that the Agency CNA that cared for the resident on 11:00 PM to 7:00 AM shift must have left the dirty sheet on the resident's bed because the CNA (CNA #1) that came in that morning just got to the unit and had not made rounds yet. UM/LPN #1 stated that incontinence rounds were completed by the CNA every two hours. The surveyor observed the resident's skin during the tour and the resident's skin was free of skin breakdown. A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 47, there were five assigned CNAs. CNA #1 had thirteen assigned residents to care for. On 6/18/24 at 8:45 AM, the surveyor conducted an incontinence tour on the First Floor nursing unit with a Licensed Practical Nurse (LPN) and observed the following: On 6/18/24 at 9:00 AM, the surveyor accompanied the LPN into Resident #32's room observed the resident lying in bed and was non-verbal. The resident's incontinence brief was observed to be very wet with urine and the sheets were observed with a large urine stain that had a strong smell of urine. The LPN was interviewed at the time and confirmed that the stain the surveyor observed on the resident's sheet was urine and that the resident's incontinence brief should have been changed and the entire bed linen should have been changed. The resident's skin was observed, and the resident's skin was intact and free of breakdown. On 6/18/24 at 9:10 AM, the surveyor interviewed UM/LPN #2 for the First Floor nursing unit who stated that CNA #2 who was assigned to care for Resident #32 should have made rounds that morning when she had arrived at the unit and checked the residents to see if any residents were incontinent and needed to be changed right away. UM/LPN #2 could not speak to why Resident #32 was wet including the resident's bed linens. UM/LPN #2 stated it was import to assure that the residents were clean and dry to protect the resident's skin and to keep residents comfortable. A review of the CNA Assignment sheet for 6/18/24, revealed that for the resident census of 50, there were five assigned CNAs. CNA #2 had eleven assigned residents to care for. On 6/18/24 at 9:20 AM, the surveyor interviewed the CNA #2 who stated that she made rounds that morning and performed an incontinence check for Resident #32. CNA #2 stated that she did not see the large urine stain on the resident's bed sheets and did not notice that the resident's incontinence brief was soaked with urine because she did not turn the light on in the resident's room. CNA #2 stated that the resident's incontinence brief and bed linen should have been changed and that it must have been an oversight. On 6/19/24 at 9:08 AM, the surveyor interviewed CNA #1 who stated that all incontinent residents should be checked every two hours, and if a resident urinated more frequently because the resident was on diuretics, that they should be checked every hour. CNA #1 stated that it was important to assure that residents' incontinent briefs were changed timely so that they did not develop breakdown of skin, as well as bed linen should be changed when the resident wets the bed. CNA #1 explained that leaving urine-soaked bed linen on the bed could also cause odor and skin breakdown, and it would not be appropriate to put clean bed linen over wet bed linen. CNA #1 stated that when she arrived on the unit, she made rounds with the CNAs from the previous shift so that she could ensure that all the residents were safe, clean, and dry. CNA #1 stated that breakfast was served at 8:00 AM, so residents should have been clean and dry before they started their meals. On 6/20/24 at 9:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that incontinence rounds should be done when staff arrived at the unit to ensure that any priority residents should be taken care of. The DON stated that during shift rounds, the staffs responsibility was to identify soiled residents and to ensure that the residents were changed and bed linen were changed when soiled, emphasizing that even if a drop of urine got onto the linen, then the linen should be changed. The DON stated that clean linen should not be put on top of dirty linen, and all residents should be checked on every two hours. The DON explained that it was important to assure that residents were provided incontinence care timely and that residents left soiled were at risk for skin breakdown. On 6/25/24 at 10:13 AM, the surveyor interviewed the Staffing Coordinator in the presence of the Licensed Nursing Home Administrator (LNHA), who stated she scheduled nursing staff in accordance with State regulation which required one CNA to every eight residents for the morning shift; one CNA for every ten residents for the evening shift; and one CNA to every fourteen residents for the overnight shift. The Staffing Coordinator stated it was very hard to find staff; that the facility did not always meet the required ratios. On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and survey team acknowledged it was unacceptable to put chuck on a wet and soiled fitted bed sheet. The DON acknowledged it was not appropriate to make care rounds in the dark.

5. On 6/18/24 at 11:45 AM, the surveyor, in the presence of RN #1, reviewed the First Floor nursing unit high side medication cart's narcotic logs. The following was observed: The June 2024 shift-to-shift Narcotic Count Sheet, RN #1 pre-signed for the 6/18 3 PM outgoing nurse. The Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #51's pregabalin 150 MG capsules (a controlled medication used to treat nerve and muscle pain) was missing Nurse Administering signatures for 6/14/24 9 AM and 9 PM doses. At that time, the surveyor interviewed RN #1, who confirmed she had pre-signed the outgoing nurse portion of the shift-to-shift stating I shouldn't have pre-signed informing the surveyor that this sheet was to be signed by the incoming and outgoing nurses together at shift change after a complete count of narcotics had been performed together. RN #1 further stated that there should be no missing signatures or documentation on the individual patient-controlled substance logs. On 6/18/24 at 12:25 PM, the surveyor, in the presence of the LPN, reviewed the Second Floor nursing unit high side medication cart's narcotic logs. The following was observed: Resident #9's tramadol HCl 50 MG tablet (controlled pain medication) declining inventory log was missing the administration time documentation for 5/30/24. At that time, the LPN stated that declining inventory logs should not have any missing documentation for doses that have been dispensed. On 6/18/24 at 12:53 PM, the surveyor interviewed UM/LPN #2 who stated there should be no missing documentation on narcotic declining inventory logs. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the inventory count of the controlled drugs in the medication carts were completed before each shift and there were three shifts; 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. The DON explained that the inventory count was completed when the incoming nurse comes in for their shift and the outgoing nurse was leaving their shift and the Narcotic Count Sheet should be signed when the inventory completed. In addition, if there are any discrepancies then that should be reported to a supervisor immediately. The DON added that the individual resident controlled drug sheets were to be signed when the controlled drug was removed from inventory so that there were no discrepancies. Review of the facility's undated Schedule II Controlled Substance Medication included .a declining inventory sheet will be provided with each dispensed prescription for controlled dangerous medications .when CDS medication is administered, in addition to proper procedure for charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining, and his/her initials. An inventory count of all CDs medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form . NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(k), 29.7(c) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring a.) the accurate documentation of medication administration during the 6/18/24 medication administration observation for ten residents by 1 of 2 nurses; b.) accurate documentation of the administration of a medication (Depakote) according to physician's orders from 6/11/24 until surveyor inquiry; c.) accurate inventory documentation of a controlled medication (methadone) administered on 6/17/24; d.) maintain accurate documentation for signing the controlled drug shift-to-shift inventory counts of the controlled medications on the morning shift of 6/18/24 by 1 of 2 nurses observed during the medication administration observation and an additional six shifts in June for one 1 of 2 medication carts inspected; and e.) accountability of the narcotic shift count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications identified on 2 of 2 medication carts 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 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. The deficient practices were evidenced by the following: 1. On 6/18/24 at 7:57 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN #1) entering electronic signatures for the medications that she had administered to Resident #89 in the electronic Medication Administration Record (eMAR). On 6/18/24 at 8:13 AM, RN #1 stated I had to borrow a password, explaining that she was using the login password for the Unit Manager/Licensed Practical Nurse (UM/LPN #1) because she was an agency nurse, and she had a problem with her login. On 6/18/24 at 8:21 AM, the surveyor observed RN #1 entering electronic signatures for the 8:00 AM (8 AM) and 9:00 AM (9 AM) medications for four sampled residents, (Resident #32, #61, #79, and #84), and six unsampled residents, (unsampled Resident #1, #2, #3, #4, #5, #6). RN #1 stated that she had already administered the morning medications to those residents and needed to sign the eMAR. RN #1 explained that she administered morning medications to the residents earlier because they were a priority since the residents were either diabetic, on dialysis or had a feeding tube (surgical tube inserted into the stomach), and she had not had a chance to sign the eMAR. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 administer and electronically sign for medications that were administered to Resident #51. A review of the eMARs for Resident #89, #51, #32, #61, #79, #84 and the six unsampled residents revealed that the initials for the 8 AM and 9 AM medications on 6/18/24 had the electronic signature initials for UM/LPN #1. On 6/18/24 at 11:27 AM, the surveyor interviewed UM/LPN #1 at the nurse's station, who stated that she had given RN #1 her login because there was a problem this morning. In addition, UM/LPN #1 stated that medications should be signed for immediately after administering them to the resident. At that time, the Assistant Director of Nursing (ADON) was at the nurse's station and confirmed UM/LPN #1 should not have given RN #1 her login password. The ADON stated that when the computer system changed on 6/11/24, the staff were trained on how to use the system, but that agency nurses were already familiar with the system. On 6/18/24 at 12:12 PM, the surveyor interviewed the Human Resources/Staff Coordinator (HR/SC) who stated that she was responsible for providing the login passwords for the agency nurses. The HR/SC also stated that each nurse had their own login password, and that she had tested RN #1's login password at 7:45 AM that morning, but that RN #1 had entered the password wrong three times and was locked out. On 6/19/24 at 8:30 AM, the surveyor interviewed the Director of Nursing (DON) who stated that every nurse had their own login password and were not to use another nurse's login. The DON added that UM/LPN #1 should not have given her login password to RN #1 because the login corresponded to the nurse's signature. The DON explained that the administrative staff which included the UM had the capability to unlock the RN's login or provide a new one. The DON also stated that the computer system was changed on 6/11/24, but that nursing procedures were still to be followed. The DON explained that the eMAR was to be signed immediately after the medication was administered. On 6/19/24 at 3:50 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she had started as the CP in March of 2024, and she had not done any medication passes on nurses or inservices for medication administration yet. On 6/20/24 at 1:21 PM, the survey team met with the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that there were no medication administration observations performed with RN #1, and the facility had not done any inservices on medication administration recently. A review of the facility's Medication Administration Policy dated 12/23/2, included that after medication administration document necessary medication administration/treatment information (e.g. (for example), when medications are administered, medication injection site, refused medications, and reason, prn (as needed) medications, etc.) on appropriate forms . 2. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed RN #2 preparing eight medications for Resident #5 which included a 125 milligram (MG) tablet of divalproex sodium delayed release (Depakote) (a medication used for mood stabilization). On 6/18/24 at 9:08 AM, the surveyor observed RN #2 administer seven medications to Resident #5 which included the Depakote 125 MG tablet. Upon returning to the medication cart, the surveyor observed RN #2 electronically sign the eMAR for Resident #5 for all the highlighted medications that were due for 9 AM. The surveyor reviewed the medical record for Resident #5. A review of the admission Record face sheet (admission summary) revealed diagnoses that included bipolar disorder (a mental health disorder) and generalized anxiety disorder. A review of the Order Summary Report revealed a physician's order (PO) with a start date of 6/6/24, for Depakote 125 MG tablet, give 1 tablet orally two times a day for bipolar disorder. Give with 500 MG for a total dose of 625 MG. Further review of the Order Summary Report revealed PO with an active date of 4/29/24, and a start date of 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG. A review of the June eMAR revealed the above PO for Depakote 125 MG. In addition, the eMAR revealed a PO dated 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG. The eMAR reflected all June dates with an X until 6/30/24. There was no documentation that Depakote 500 MG was administered from 6/11/24 until surveyor inquiry. On 6/18/24 at 12:23 PM, the surveyor interviewed UM/LPN #2 regarding the dose of Depakote that was to be administered at 9:00 AM (9 AM) to Resident #5. UM/LPN #2 checked the electronic records for Resident #5 and stated that the facility had changed electronic charting systems recently and was checking both systems. UM/LPN #2 then verified that the dose of Depakote that Resident #5 was to receive at 9 AM was a total of 625 MG. UM/LPN #2 explained that there was a PO for Depakote 125 MG and Depakote 500 MG to be administered together for a total dose of 625 MG. UM/LPN #2 then reviewed the current eMAR and stated that the Depakote 500 MG order was entered incorrectly because the PO had a start date of 6/30/24, and should have been started on 6/11/24, with the Depakote 125 MG PO. UM/LPN #2 added that the Depakote 125 MG PO had instructions regarding the total dose, but that when the electronic system started on 6/11/24, the Depakote 500 MG dose would not be highlighted for administration at 9 AM until 6/30/24. UM/LPN #2 was unable to speak to how the PO was entered incorrectly. A review of the previous computer system Physician's Orders revealed a PO dated 9/13/22, for Depakote 125 MG tablet, delayed release; give 1 tablet (125 MG) by oral route 2 times per day. Take with 500 MG for a total of 625 MG. In addition, a PO dated 9/13/22, for Depakote 500 MG tablet; give 1 tablet (125 MG) by oral route 2 times per day. Take with 500 MG for a total of 625 MG. A review of the previous computer system eMAR reflected the administration of Depakote 125 MG and Depakote 500 MG together at 9 AM for a total dose of 625 MG. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the facility had changed computer systems on 6/11/24, and that all PO were transferred to the new computer system. On 6/20/24 at 10:45 AM, the survey team met with the DON who acknowledged that there was an error in the dosage of Depakote for Resident #5 that occurred on 6/18/24. The DON added that she was continuing to investigate how the entry error occurred. The DON added that she was reviewing with each nurse that administered medications regarding the Depakote PO for the total dose of 625 MG. A review of the facility's Medication Administration policy dated effective 12/23/23, included prior to medication administration Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER .Verify that the MAR reflects the most recent medication order . 3. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 preparing to administer medications to Resident #51 which included 50 milliliters (ML) of methadone (a controlled medication used for opioid addiction) liquid with a concentration of 10 milligrams/10 ml. RN #1 stated that the methadone was obtained by the nursing supervisors from the methadone clinic on a weekly basis. RN #1 explained that the methadone was a controlled drug and had an inventory sheet (Methadone Chain of Custody Record) that was provided by the methadone clinic and had to be signed by the nurse and the resident for the appropriate date and all empty bottles were returned back to the clinic. At that time, the surveyor, with RN #1 reviewed the resident's Methadone Chain of Custody Record and the methadone bottles. RN #1 stated that there were seven bottles in a bag for Resident #51. RN #1 added that four were empty and three contained 50 ML of methadone. RN #1 stated that she was removing one bottle and signing the record for 6/18/24. The Methadone Chain of Custody Record revealed that on 6/17/24, there was no signature by a nurse for the removal of the methadone. At that time, RN #1 stated that she thought the Assistant Director of Nursing (ADON) was supposed to sign the form on 6/17/24. Resident #51 stated that they thought they had taken their methadone on 6/17/24, and had not remembered signing. A review of the eMAR for Resident #51 for Methadone administration on 6/17/24, revealed the electronic signature of the ADON. On 6/18/24 at 9:18 AM, the surveyor interviewed the ADON who stated that she was the nurse on the medication cart on 6/17/24. The ADON was unsure about administering methadone to Resident #51. The surveyor with the ADON, reviewed the Methadone Chain of Custody Record for Resident #51. The ADON then stated that she had not realized she was supposed to sign the record and should have signed the record for the removal of the methadone. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the resident's individual controlled drug sheet was to be signed when the controlled drug was removed from inventory so that there were no discrepancies. In addition, if there were any discrepancies then a supervisor was to be notified and the discrepancy was to be corrected immediately. A review of the facility's undated Schedule II Controlled Substance Medication policy included .When a CDS (controlled substance medication) is administered, in addition to following procedures for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials . 4. On 6/18/24 at 8:45 AM, the surveyor observed RN #1 preparing to administer medications to Resident #51 which included 50 ML of methadone liquid with a concentration of 10 milligrams/10 ML. RN #1 stated that the methadone was obtained by the nursing supervisors from the methadone clinic on a weekly basis. RN #1 explained that the methadone was a controlled drug and had an inventory sheet (Methadone Chain of Custody Record) that was provided by the methadone clinic and had to be signed by the nurse and the resident for the appropriate date and all empty bottles were returned back to the clinic. At that time, the surveyor, with RN #1, reviewed the resident's Methadone Chain of Custody Record and the Methadone bottles. The RN #1 stated that there were seven bottles in a bag for Resident #51. The RN #1 added that four were empty and three contained 50 ML of methadone. RN #1 stated that she was removing one bottle and signing the record for 6/18/24. The Methadone Chain of Custody Record revealed that on 6/17/24, there was no signature by a nurse for the removal of the methadone. At that time, RN #1 stated that she thought the Assistant Director of Nursing (ADON) was supposed to sign the form on 6/17/24. Resident #51 stated that they thought they had taken their methadone on 6/17/24, and had not remembered signing. At that time, the surveyor with RN #1 reviewed the Narcotic Count Sheet (a monthly sheet for daily nurses' signatures to verify the inventory count of the controlled drugs at the change of shift) that corresponded to the First Floor nursing unit high side medication cart, which revealed that the sheet was not signed for 6/18/24 for the Nurse In. RN #1 stated that she had done an inventory count at the beginning of her shift with the outgoing nurse, but had forgotten to sign the Narcotic Count Sheet and proceeded to sign the sheet in front of the surveyor. RN #1 then stated that she had not told the ADON or any other supervisor about the missing signature for the methadone inventory because there was no discrepancy. Further review of the Narcotic Shift Count revealed that the following nurse signatures were missing: -6/4/24 11 PM Nurse Out -6/7/24 11 PM Nurse Out -6/10/24 11 PM Nurse In -6/11/24 7 AM Nurse Out -6/14/24 11 PM Nurse In -6/15/24 7 AM Nurse Out On 6/18/24 at 9:18 AM, the surveyor interviewed the ADON who stated that she was unaware of any discrepancies regarding the Narcotic Count shift to shift sheets. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the inventory count of the controlled drugs in the medication carts were completed before each shift and there were three shifts; 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. The DON explained that the inventory count was completed when the incoming nurse came in for their shift and the outgoing nurse was leaving their shift. The DON further explained that the Narcotic Count Sheet should be signed when the inventory was completed. The DON stated that the Narcotic Count Sheets should be thoroughly completed meaning there were no blanks. In addition, the DON stated that if there were any discrepancies, then that should be reported to a supervisor immediately. The DON explained that this system prevented any discrepancies from occurring with the controlled drug inventories. A review of the current facility's undated Schedule II Controlled Substance Medication policy included .when dispensing controlled substances An inventory count of all CDS (controlled drug substance) medications stored on each nursing unit shall be performed at each change of each shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 6/18/24, the surveyor observed two (2) nurses administer medications to three (3) residents. There were 29 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 10.3%. The deficient practices were identified for 2 of 3 residents, (Resident #51 and #5), that were administered medications by 2 of 2 nurses that were observed. The facility was previously cited for this during their last standard survey. The deficient practices were evidenced by the following: 1. On 6/18/24 at 8:28 AM, during the morning medication administration pass, the surveyor, observed the Registered Nurse (RN #1) preparing nine (9) medications for Resident #51 which included a 200 milligram (MG) tablet of lamotrigine (Lamictal). RN #1 stated that the medication card of Lamictal 200 MG tablets for Resident #51 was empty, and that she did not have any to administer to Resident #51 for the 9 AM dose. RN #1 stated that she would have to call the provider pharmacy and tell the Unit Manager/Licensed Practical Nurse (UM/LPN #1). RN #1 stated that she was an agency nurse and had not worked at the facility for months and could not speak to why the medication was not available in the cart. At that time, Resident #51 stated that they were not upset that the Lamictal was not available because they received their other medications. The surveyor reviewed the medical record for Resident #51. A review of the admission Record face sheet (an admission summary) revealed diagnoses that included bipolar disorder (a mental health disorder), anxiety disorder and psychoactive substance abuse. A review of a comprehensive Minimum Data Set (MDS), an assessment tool dated 4/29/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report revealed a physician's order (PO) with a start date of 6/6/24, for Lamictal 200 MG; administer 1 tablet orally two times a day for bipolar disorder. A review of the backup inventory list that was stored in the facility was provided by the Director of Nursing (DON). The list reflected that Lamictal 25 MG tablets were in supply with eight tablets On Hand. On 6/18/24 at 11:27 AM, the surveyor interviewed UM/LPN #1 who stated that she was unaware that Resident #51 had a medication that was not available. On 6/18/24 at 11:41 AM, the surveyor interviewed RN #1 who stated that she had not yet told UM/LPN #1 the resident's Lamictal was not available. Resident #51 had not received the Lamictal as ordered by the physician. (ERROR #1) On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who acknowledged that the facility's Medication Administration policy had not included a procedure for medications that were not available. The DON stated that when a medication was not available during medication administration, then a supervisor should be contacted. The DON further explained that the in house backup supply would then be checked, and the provider pharmacy called because the medication should be available within one hour. The DON added if the medication was not able to be available within one hour, then the physician must be called for follow up orders and documented in the Nursing Progress Notes. The DON stated that the medication administration computer system was recently changed but that nurses should still follow nursing procedures. A review of the Nursing Progress Notes for 6/18/24 and 6/19/24, did not include Progress Notes regarding the Lamictal not being administered. On 6/19/24 at 2:57 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that she had started as the CP in March of 2024. The CP added that she had not done any med passes on nurses or inservices for medication administration yet. On 6/20/24 at 1:21 PM, the survey team met with the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that there were no medication administration observations performed with RN #1, and the facility had not done any inservices on medication administration recently. 2. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed RN #2 preparing eight (8) medications for Resident #5 which included three (3) tablets of risperidone (Risperdal) 0.25 MG for a total of 0.75 MG. RN #2 stated that she did not have the Risperdal 0.25 MG tablets in the medication cart to administer to Resident # 5 that was due at 9 AM. On 6/18/24 at 9:17 AM, the surveyor interviewed RN #2 who stated that according to the computer the Risperdal was on order. RN #2 explained that the ordering system can be done electronically with the provider pharmacy. RN #2 stated that she was an agency nurse and had not worked at the facility for months, so she could not speak to when the Risperdal would be available. RN #2 stated that she would have to check the backup supply to see if Risperdal was available or call the provider pharmacy to see when the Risperdal would be delivered. The RN also stated that she would have to tell UM/LPN #2 and might have to call the physician if the Risperdal was not available to be administered for the 9 AM dose to obtain follow up orders. The surveyor reviewed the medical record for Resident #5. A review of the admission Record face sheet revealed the resident had diagnoses that included bipolar disorder (a mental health disorder) and generalized anxiety disorder. A review of the Order Summary Report revealed a PO with a start date of 6/7/24, for Risperdal oral tablet 0.25 MG; give 3 tablets by mouth in the morning for bipolar disorder; 3 tabs = 0.75 MG. On 6/18/24 at 11:08 AM, the surveyor interviewed RN #2 who stated that she had not yet checked the backup supply or called the provider pharmacy. On 6/18/24 at 12:23 PM, the surveyor interviewed UM/LPN #2 who stated that she was unaware of a medication not being available for Resident #5. On 6/18/24 at 12:34 PM, the surveyor interviewed RN #2 who stated that she had not yet checked the backup supply, told the UM or called the physician. Resident #5 had not received the Risperdal as ordered by the physician. (ERROR #2) A review of the backup inventory list that was stored in the facility was provided by the DON indicated that Risperdal tablets was not on the list. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who acknowledged that the Medication Administration policy had not included a procedure for medications that were not available. The DON stated that when a medication was not available during medication administration, then a supervisor should be contacted. The DON further explained that the backup supply would then be checked, and the provider pharmacy called because the medication should be available within one hour. The DON added if the medication was not able to be available within one hour, then the physician must be called for follow up orders and documented in the Nursing Progress Notes. The DON stated that the medication administration computer system was recently changed but that nurses should still follow nursing procedures. A review of the Nursing Progress Notes for 6/18/24 and 6/19/24, included no Progress Notes regarding the Risperdal not being administered. On 6/19/24 at 2:57 PM, the surveyor interviewed the CP via the telephone who stated that she had started as the CP in March of 2024. The CP added that she had not done any med passes on nurses or inservices for medication administration yet. On 6/20/24 at 1:21 PM, the survey team met with the DON and the LNHA. The DON stated that there were no medication administration observations performed with RN #2 and the facility had not done any inservices on medication administration recently. 3. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed RN #2 preparing eight (8) medications for Resident #5 which included a 125 MG tablet of divalproex sodium delayed release (Depakote) (a medication used for mood stabilization). On 6/18/24 at 9:08 AM, the surveyor observed RN #2 administer seven (7) medications to Resident #5 which included the Depakote 125 MG tablet. (As noted above the Risperdal was not administered.) Upon returning to the medication cart, the surveyor observed the RN #2 electronically sign the Medication Administration Record (MAR) for Resident #5 for all the highlighted medications that were due for 9 AM. The surveyor reviewed the medical record for Resident #5. A review of the admission Record revealed diagnoses that included bipolar disorder (a mental health disorder) and generalized anxiety disorder. A review of the Order Summary Report revealed a PO with a start date of 6/6/24, for Depakote 125 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 500 MG for a total dose of 625 MG. Further review of the Order Summary Report revealed PO with an active date of 4/29/24, and a start date of 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG. A review of the June 2024 MAR revealed the above PO for Depakote 125 MG. In addition, the MAR revealed a PO dated 6/30/24, for Depakote 500 MG tablet; give 1 tablet orally two times a day for bipolar disorder. Give with 125 MG for a total dose of 625 MG. The MAR reflected all June dates with an X until 6/30/24. On 6/18/24 at 12:23 PM, the surveyor interviewed UM/LPN #2 regarding the dose of Depakote that was to be administered at 9 AM to Resident #5. UM/LPN #2 checked the electronic records for Resident #5 and stated that the facility had changed electronic charting systems recently and was checking both systems. UM/LPN #2 then verified that the dose of Depakote that Resident #5 was to receive at 9 AM was a total of 625 MG. UM/LPN #2 explained that there was a PO for Depakote 125 MG and Depakote 500 MG to be administered together for a total dose of 625 MG. UM/LPN #2 then reviewed the current MAR and stated that the Depakote 500 MG order was entered incorrectly because the PO had a start date of 6/30/24, and should have been started on 6/11/24, with the Depakote 125 MG PO. UM/LPN #2 added that the Depakote 125 MG PO had instructions regarding the total dose but that when the electronic system started on 6/11/24, the Depakote 500 MG dose would not be highlighted for administration at 9 AM until 6/30/24. UM/LPN #2 was unable to speak to how the PO was entered incorrectly. (ERROR #3) A review of the previous computer system Physician's Orders revealed a PO dated 9/13/22, for Depakote 125 MG tablet, delayed release; give 1 tablet (125 MG) by oral route 2 times per day. Take with 500 MG for a total of 625 MG. In addition, a PO dated 9/13/22, for Depakote 500 MG tablet; give 1 tablet (125 MG) by oral route 2 times per day. Take with 500 MG for a total of 625 MG. A review of the previous computer system MAR reflected the administration of Depakote 125 MG and Depakote 500 MG together at 9 AM for a total dose of 625 MG. On 6/19/24 at 8:30 AM, the surveyor interviewed the DON who stated that the facility had changed computer systems on 6/11/24, and that all PO were transferred to the new computer system. On 6/20/24 at 10:45 AM, the survey team met with the DON who acknowledged that there was an error in the dosage of Depakote for Resident #5 that occurred on 6/18/24. The DON added that she was continuing to investigate how the entry error occurred. The DON also stated that there were no medication administration observations performed on RN #2 and there were no recent medication administration inservices completed. A review of the facility's Medication Administration policy dated 12/23/23, included .Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER .Verify that the MAR reflects the most recent medication order .Medications are administered in a timely fashion as specified by policy . NJAC 8:39-11.2(b), 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly store medications, b.) maintain clean and sanitary medication storage areas, and c.) properly label opened multidose medications. This was observed in 2 of 2 observed medication carts on 2 of 2 nursing units and was previously cited during the facility's last standard survey on [DATE]. The evidence was as follows: Refer F865 On [DATE] at 10:44 AM, during initial tour of the facility, the surveyor observed in Resident room [ROOM NUMBER], which was occupied by four residents, a box of sodium chloride (NaCl) inhalation solution individual vials (medication used to treat lung disease) stored unsecured and in the open, on top of a table next to the room door. On [DATE] at 11:45 AM, the surveyor, in the presence of the Registered Nurse (RN), reviewed the First Floor nursing unit's high side nursing medication cart, and observed the following: 32 unidentifiable loose pills of various colors, shapes, and sizes. Two opened foil packages of ipratropium bromide 0.5 milligrams (MG) and albuterol sulfate 3 MG inhalation solution individual vials (a medication used to treat lung disease), one dated with an opened date of [DATE] and the second with opened date [DATE]. The foil packages included printed manufacture instructions that indicated a one-week expiration once opened. At that time, the RN confirmed that the two foil packages of inhalation solution should have been discarded and there should have been no loose pills in the medication cart. On [DATE] at 12:25 PM, the surveyor, in the presence of the Licensed Practical Nurse (LPN), reviewed the Second Floor nursing unit's high side medication cart, and observed ten unidentifiable loose pills of various colors, shapes, and sizes. At that time, the LPN confirmed that there should not be any loose pills in the medication cart. On [DATE] at 10:05 AM, the surveyor, in the presence of the survey team and the Licensed Nursing Home Administrator, interviewed the Director of Nursing (DON) who stated that there should not be any medications stored in a resident's room, and that the medication observed in Resident room [ROOM NUMBER] should not be there. The DON further confirmed that there should be no loose pills in the medication carts, and that medication identified as expired should not have been in the cart and should have been discarded. Review of the facility's Medication Storage/Labeling policy with initiated date of February 2019 included .medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . N.J.A.C. 8:39-29.4

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 5 of 7 residents during the Resident Council meeting (Resident #23, #55, #61, #74, and #79), and was evidenced by the following: On 6/19/24 at 9:15 AM, the surveyor in the presence of the District Operations (Regional Food Service Director; Regional FSD) observed labeled snacks in the reach-in refrigerator in the kitchen. The Regional FSD stated that the facility supplied approximately seventy-five snacks in total for three snack times a day for residents. The Regional FSD continued that not all residents received snacks; some had physician ordered snacks that were sent up at a certain time and labeled, and then the facility provided a few additional sandwiches if a resident wanted. The Regional FSD confirmed there was not enough snacks for every resident, and not every resident received a hour of sleep (HS) snack. On 6/19/24 at 10:03 AM, the surveyor conducted a Resident Council meeting which included seven residents (Resident #3, #13, #23, #55, #61, #74, and #79). Five of the seven residents stated that they did not receive HS snacks. They stated that you must be on the list to receive HS snacks. A review of the facility mealtimes provided by the facility on entrance, indicated that breakfast was served at 7:30 AM and dinner was served at 4:30 PM; which was fifteen hours in between dinner and breakfast. On 6/20/24 at 9:17 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN #1) who stated that the HS snacks arrived at the nursing unit before 7:00 PM, and some were labeled for particular residents and there were also extra. UM/LPN #1 stated that the certified nursing aides (CNAs) handed out the snacks, and there were never any snacks left at the end of the night. On 6/20/24 at 9:22 AM, the surveyor interviewed the LPN who stated that HS snacks were distributed by the CNAs and nurses, and there were no signature sheets to sign that a resident received a snack. On 6/20/24 at 9:29 AM, the surveyor interviewed the Dietary Aide who stated that there was a list with names and snacks that were sent to the nursing units. On 6/20/24 at 9:34 AM, the surveyor interviewed UM/LPN #2 who stated that snacks were not signed for, and there were never any leftover snacks. On 6/20/24 at 10:06 AM, the surveyor interviewed the Director of Nursing (DON) who stated that snacks were served at 10:00 AM, 2:00 PM, and evening. There were specific snacks for some residents and then extra snacks also. The DON stated that whoever wanted a snack, it was provided. She further stated that she was not going to say the staff go door to door, but they offered snacks to the residents. On 6/20/24 at 11:01 AM, the surveyor interviewed the FSD who confirmed there was approximately seventy-five snacks made throughout the day. The FSD continued that some snacks were labeled with residents' names who had a physician's ordered snack, but there were not enough snacks for everyone to have at night. The FSD stated the kitchen provided sandwiches, cookies, crackers, juice, and milk as snacks. The FSD provided the surveyor with a list of residents who received snacks throughout the day. A review of the list provided by the FSD revealed that Resident #3 and Resident #13 had a physician's ordered snack. On 6/20/24 at 1:24 PM, the surveyor in the presence of the Licensed Nursing Home Administrator (LNHA), DON, and survey team informed the facility of the identified concern, and asked what was considered a nourishing snack. The DON stated the facility provided peanut butter and jelly sandwiches or applesauce, but the LNHA could not speak to it. On 6/25/24 at 11:40 AM, the surveyor interviewed the Registered Dietitian (RD) who stated residents received HS snacks upon request or by physician order. The RD stated there was no formal policy regarding snacks, but not everyone received one, and he was unsure about the regulation regarding the time in between dinner and breakfast. When asked what a nourishing snack was considered, the RD stated eight ounces of milk, whole sandwich, or pudding. A review of facility provided Snack Program Policy dated revised October 2022, included .All residents are offered snacks upon admissions and continuously throughout their stay .HS (Hour of Sleep):1. Dietary Service employees prepare, label, and date snacks including the use by date, according to the menu and in sufficient quantity to serve all residents; 2. Dietary Service delivers snacks to nursing units/stations at specified times; 3. Nursing or designated staff offers snack to each resident;4. Snacks are passed within 15 minutes of delivery to the unit or are properly stored at the nursing station and offered at a later time . NJAC 8:39-17.2 (f)(1)(i-ii)

Based on observation, interview, review of pertinent facility documents, it was determined that the facility failed to: a) change respiratory equipment tubing in a manner to prevent the spread of infection for 1 of 1 resident reviewed for respiratory care (Resident #80); b.) ensure that infection control standards were followed during medication pass for 1 of 2 nurses observed during medication administration; and c.) ensure staff maintained appropriate nail length to prevent the spread of infection for 1 of 2 unit managers. This deficient practice was identified on 2 of 2 nursing units, and was evidenced by the following: 1. During the initial tour of the Second Floor nursing unit on 6/17/24 at 10:52 AM, the surveyor observed Resident #80 lying in bed. Resident #80 was receiving humidified oxygen at 3 liters per minute (lpm) via nasal cannula (tubing that delivered oxygen through the nose). The surveyor observed the nasal cannula tubing with a piece of clear tape attached to the tubing dated 6/5/24. The surveyor reviewed the medical record for Resident #80. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to facility with diagnoses which included chronic obstructive pulmonary disease (COPD) (refers to a group of diseases that cause airflow blockage and breathing-related problems), morbid obesity (having too much body fat, which increases the risk of health problems), and anemia (low levels of healthy red blood cells to carry oxygen throughout your body). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 4/25/24, revealed the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the June 2024 Treatment Administration Record (TAR) included a physician's order (PO) dated 6/12/24, to change oxygen cannula/tubing once weekly on Wednesday during the night shift and as needed. On 6/19/24 at 10:18 AM, the surveyor observed Resident #80 lying in bed awake and alert. Resident #80 was receiving humidified oxygen at 3 lpm via nasal cannula. The surveyor observed the nasal cannula tubing with a piece of clear tape attached to the tubing dated 6/5/24. Resident #80 said that they change my oxygen tubing when I ask the nurse, and the last time it was done was about two weeks ago. On 6/20/24 at 11:48 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) regarding how often oxygen tubing was changed, and LPN #1 responded it was changed weekly by the overnight nurse. LPN #1 confirmed the resident should not be using nasal tubing that was more than seven days old. On 6/20/24 at 12:20 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed oxygen tubing was changed weekly on the 11:00 PM to 7:00 AM shift by the nurse. The DON stated the nurse dated when they changed the tubing. The DON acknowledged nasal tubing should not be used past seven days because it was an infection control issue. The facility had no Infection Preventionist. A review of the facility's Cleaning Respiratory Equipment policy dated revised May 2022, included Procedure: 1. Supplies: Replace masks and/or cannula used by an individual resident within seven (7) days and as needed (PRN) when obviously contaminated . 3. On 6/17/24 at 9:56 AM, the surveyor observed the Unit Manager/Licensed Practical Nurse (UM/LPN) at a medication cart. The UM/LPN stated she was administering medication to residents. The surveyor observed her nails to be manicured and long in length. On 6/25/24 at 11:30 AM, the surveyor observed The UM/LPN at the nurse's station with long manicured acrylic nails that were over an inch in length and curled. The surveyor commented to the UM/LPN that their nails were long, and the UM/LPN hid their nails and replied not to look at them. The surveyor asked the UM/LPN if they provided resident care, and the UM/LPN replied no. On 6/25/24 at 1:30 PM, the surveyor interviewed the DON and LNHA, and the DON stated if there was a staffing issue, the unit manager should assist with resident care. The DON acknowledged administering residents' medications was considered resident care. When asked if they were aware of the UM/LPN's nail length, both the LNHA and DON acknowledged that the UM/LPN's nail length was not appropriate. The DON stated they were too long which could result in bacterial growth underneath as well as resident care issues. The facility had no Infection Preventionist. A review of the facility provided Dress Code which required an employee signature and date, included the length of nails should be reasonable so as not to interfere with resident care or time clock . NJAC 8:39-19.4(a)(k) 2. On 6/18/24 at 8:59 AM, during the morning medication administration pass, the surveyor, observed the Registered Nurse (RN) preparing eight (8) medications for Resident #5 which included Cosopt (an eye drop medication used for glaucoma) eye drops. The RN stated that she did not have any tissues on the medication cart to use when administering the Cosopt eye drops. The surveyor observed the RN, with gloved hands, go into the resident's bathroom and removed toilet paper from the roll that was hanging in the bathroom. The RN then folded the toilet paper into a small wad, and used the toilet paper to dab the right eye after administering one drop of the Cosopt and then turned the toilet paper wad over and used the other side to dab the left eye after administering one drop of Cosopt into the left eye. On 6/18/24 at 9:13 AM, the surveyor interviewed the RN who stated that she felt the toilet tissue was clean. The RN also stated that she was an agency nurse, and this was not her usual medication cart and that it was difficult to know what was stocked in the cart. On 6/19/24 at 1:13 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON confirmed that toilet paper from the bathroom should not have been used while administering eye drops, it was not sanitary. The DON stated that there were boxes of tissues provided for the medication carts. The facility had no Infection Preventionist. A review of the facility's Medication Administration policy dated 12/23/23, included .Prior to preparing and administering medications, follow the facility's infection control policies (for example, handwashing) .

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to hire a designated Infection Preventionist (IP) who worked at least part-time and had completed specialized training in infection control and prevention. The deficient practice was identified and evidenced by the following: Refer F880; F881; and F883 During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who the facility's Infection Preventionist (IP) was, and the DON stated the facility's previous IP left about two or three months ago and the position was vacant. The DON stated herself, the Assistant Director of Nursing (ADON), and the two unit managers reviewed immunizations, antibiotic stewardship, and infection control issues. At that time the surveyor requested a copy of the infection control certifications as well as the date the IP stopped working. On 6/18/24 at 11:42 AM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked. On 6/19/24 at 12:55 PM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked. On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the Assistant Director of Nursing (ADON) who also was not certified. The DON stated only the Unit Manager/Licensed Practical Nurse (UM/LPN) had an infection control certification. The DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-serviced staff on infection control. On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. The ADON stated she had just completed May's antibiotic stewardship review yesterday. On 6/25/24 at 10:58 AM, the surveyor re-interviewed the ADON who confirmed she had no infection control certification, and she was responsible for providing staff with infection control training. On 6/25/24 at 1:30 PM, the surveyor informed the LNHA and DON of the concern with infection control. The LNHA stated the previous IP's last day of work was 5/3/24. No additional information was provided. A review of the facility's undated Infection Prevention and Control Program policy included the infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description . NJAC 8:39-19.1(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/19/24 at 1:27 PM, the surveyor requested from the LNHA and DON the CP's recommendations for Resident #80 from March 2024 until present. According to the admission Record, Resident #80 was admitted to facility with diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood) and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly.) According to the most recent MDS dated [DATE], Resident #80 had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review of the MDS revealed the resident had an active diagnosis of bipolar disorder, and received antipsychotic medications on a routine basis. On 6/20/24 at 9:00 AM, the DON provided the surveyor with Resident #80's CP's recommendation reports for March 2024 and April 2024. The CP recommendation dated 3/31/24, indicated that the medication pantoprazole 20 milligrams (MG) two tablets equal 40 MG daily has been administered since 1/18/24 for heartburn. It was recommended, if the resident was asymptomatic, to consider tapering to the pantoprazole to 20 MG daily, then discontinue the medication. This recommendation was not completed or acted upon by the facility until 6/19/24. The CP recommendation dated 3/31/24, indicated that the medication Combivent inhaler should include a frequency. This recommendation was not completed or acted upon by the facility until 6/19/24. The CP recommendation dated 3/31/24, indicated that the medication acetaminophen 325 MG (Tylenol) two tablets order indicated to administer as needed for complain of pain or elevated temperature. The acetaminophen order should be indicated for either pain or elevated temperature according to the CP. This recommendation was not completed or acted upon by the facility until 6/15/24 and 6/19/24. The CP recommendation dated 3/31/24, indicated that the medication Xarelto 10 MG needed a correct diagnosis for use; long term use of anticoagulants was not a diagnosis. The surveyor reviewed the Physician Order Summary sheet, and the recommendation was not acted upon by the facility. The Xarelto 10 MG continued to have long term (current) use of anticoagulants as a diagnosis. The CP recommendation dated 3/31/24, indicated that the medication gabapentin 400 MG needed a clarified diagnosis from pain to neurological pain. This recommendation was not completed or acted upon by the facility until 6/19/24. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers. The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry. On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve. 3. On 6/19/24 at 1:27 PM, the surveyor requested from the LNHA and DON the CP's recommendations for Resident #60 from March 2024 until present. A review of the admission Record face sheet (an admission summary) reflected that Resident #60 was admitted to the facility with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (stroke) affecting left dominant side, candidiasis (fungal infection) of skin and nail, and bipolar disorder. On 6/20/24 at 9:00 AM, the DON provided the surveyor with Resident #60's CP recommendation reports for March 2024 and May 2024. The CP recommendation dated 3/31/24, indicated that there were two pain assessment orders; please discontinue the order from 9/25/23 that was an needed (prn). This request was acknowledged with a handwritten done, but the facility could not provide documentation that it was completed in timely fashion. The CP recommendation dated 5/28/24, requested to do an order correction to allow for the results of temperature for acetaminophen prn for fever to be documented on the [medication administration record (MAR)]. This request was acknowledged with a handwritten done, but upon review of the physician's orders, the surveyor observed that the temperature could not be documented in the MAR. On the same recommendation, the CP requested that an order correction to allow for results of pain level for acetaminophen prn for pain to be documented on the MAR. These requests were acknowledged with a handwritten done, but the facility could not provide documentation that it was completed in timely fashion. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers. The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry. On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve. 4. On 6/19/24 at 1:27 PM, the surveyor requested from the LNHA and DON the CP's recommendations for Resident #61 from March 2024 until present. A review of the admission Record face sheet (an admission summary) reflected that Resident #61 was admitted to the facility with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one entire side of the body) affecting right dominant side, Type 1 diabetes mellitus with diabetic chronic kidney disease, and persistent mood disorder. On 6/20/24 at 9:00 AM, the DON provided the surveyor with Resident #61's CP recommendation reports for May 2024. The CP recommendation dated 5/27/24, requested to clarify Keppra (a seizure medication) by mouth every 12 hours and give at 9 AM and 9 PM. This request was acknowledged with a handwritten done, but upon review of the MAR (prior to surveyor inquiry) the order was not clarified until 6/20/24, when the administration times were adjusted per CP recommendation. The CP recommendation dated 5/27/24, requested to clarify the diagnosis for acetaminophen prn for pain not fever. This request was acknowledged with a handwritten done, but upon review of the MAR (prior to surveyor inquiry) it was not updated and continued to have the fever diagnosis. The CP recommendation dated 5/27/24, requested to do an order correction that allowed for blood sugar to be documented on the MAR. This request was acknowledged with a handwritten done, but upon review of the MAR (prior to surveyor inquiry) there was no space identified to allow documentation of the resident's blood sugar level. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers. The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry. On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve. NJAC 8:39-29.3 (b) Based on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 4 of 5 residents reviewed for medication management (Resident #34, Resident #80, Resident #60, and Resident #61) and was previously cited during the facility's last standard survey on 10/20/22. The evidence was as follows: Refer F865 1. On 6/19/24 at 1:27 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the CP's recommendations for Resident #34 from March 2024 until present. According to the admission Record (AR), Resident #34 was admitted to the facility with the diagnoses which included but was not limited to unspecified dementia with behavior disturbance and bipolar disorder (a type of mental illness). The quarterly Minimum Data Set (MDS), an assessment tool dated 3/30/24, reflected that the resident had severe cognitive deficits and had behaviors directed toward others. The MDS also reflected that the resident was dependent for activities of daily living (ADLs). On 6/20/24 at 9:00 AM, the DON provided the surveyor with Resident #34's CP recommendation reports for March 2024, April 2024, and May 2024. The CP recommendation dated 3/31/24, indicated that the medication Colace (stool softener) liquid should be diluted in 4 ounces of juice before administering. This recommendation was not completed or acted upon by the facility until 6/19/24. The CP recommendation dated 5/27/24, indicated the use of aspirin (ASA) 81 mg needed a diagnosis for use. The surveyor reviewed the Physician Order Summary sheet, and the recommendation was not acted upon by the facility. The ASA 81 mg continued not to have a diagnosis for the use. On 6/20/24 at 9:36 AM, the surveyor interviewed the DON who stated that the CP reports were sent to the facility through email by the CP, and the CP's recommendations were to be completed by the unit managers. The DON stated that an appropriate time for the CP's recommendations to be completed was within seven days of receiving. The DON could not explain why the recommendations provided from the CP from March 2024, April 2024 and May 2024 were not completed until 6/19/24 after surveyor inquiry. On 6/20/24 at 10:16 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN #1) for the First Floor nursing unit who stated that the CP report recommendations were usually completed by the unit manager, but could be assigned to the nurse on the unit or divided amongst the nursing staff to complete. UM/LPN #1 stated that an appropriate time to complete the CP's recommendation report was within one week. She continued to add that the unit managers usually received an email of the recommendations, but since switching over to the new electronic medical records (EMR), which was switched on 6/11/24, the DON received the recommendations. UM/LPN #1 revealed that the CP recommendations from March 2024, April 2024 and May 2024 were not given to the unit managers to complete until yesterday (6/19/24). On 6/20/24 at 12:24 PM, the surveyor interviewed the facility's CP who stated that she had been at the facility since March 2024, and it was important that the facility acted upon the pharmacy recommendations as soon as possible (ASAP) so that if there was a medication safety concern, it could be taking care of immediately. The CP stated that the facility needed more education because the new pharmacy consultant company was new to the facility and the staff was on a learning curve.

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary to protect the health, safety, and welfare of all residents prior to admission of registered sex offenders and residents admitted from the correctional facility. This deficient practice was previously identified and cited during the facility's last standard survey on 10/20/22, and was evidenced by the following: Refer F865 During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the facility's assessment. During initial tour on 6/17/24 at 10:29 AM, the surveyor observed Resident #26 observed in bed asleep. The surveyor observed that both the resident and their unsampled roommate were both incarcerated with four Corrections Officers (CO) present in the room. On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail. A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the Quality Assurance and Performance Improvement (QAPI) committee on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population. On 6/26/24 at 10:36 AM, the LNHA in the presence of the DON, Assistant Director of Nursing (ADON), and survey team acknowledged the registered sex offenders and inmates were not included in the facility assessment. During an interview regarding the facility's QAPI program on 6/26/24 at 11:52 AM, the LNHA acknowledged the facility was previously cited for this during the facility's last annual survey. On 6/26/24 at 12:00 PM, the LNHA informed the survey team that the facility did not have a main contract with the prison, but the facility had individual contracts for the two residents who were inmates currently residing at the facility. NJAC 8:39-5.1(a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure that a.) their Quality Assurance and Performance Improvement (QAPI) Program was being implemented to ensure sustainability with previously cited deficiencies and b.) sources of quantitative data was being analyzed to identify quality deficiencies and evaluate program effectiveness. The facility was cited during last standard survey on 10/20/22, and was evidenced by the following: Refer F641, F756, F761, F838, and F881 During entrance conference on 6/17/24 at 10:00 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) a copy of the facility's QAPI program plan and the last three quarterly sign-in sheets. On 6/18/24 at 11:52 AM, the surveyor requested from the LNHA a copy of the facility's QAPI program plan and last three quarterly sign-in sheets. On 6/19/24 at 9:00 AM, the surveyor received a copy of the last three quarterly sign-in sheets for the facility's QAPI program, but no policy was provided. On 6/20/24 at 12:57 PM, the survey team met with the LNHA and DON to discuss their concerns which included accuracy of the Minimum Data Set (MDS) assessments; medication storage; acting on Consultant Pharmacy (CP) reports; and antibiotic stewardship program. On 6/24/24 at 1:03 PM, the surveyor asked the LNHA and Maintenance Director if the facility had any special populations, and the LNHA confirmed the facility had registered sex offenders and inmates from the [Local] County Jail. A review of the facility provided Facility Staffing & Resource Assessment Completion Based indicated persons completing assessment included the LNHA, DON, and Medical Director updated 9/17/23 and reviewed with the QAPI committee on 4/30/24, did not include registered sex offenders or incarcerated residents as part of the facility's population. On 6/25/24 at 1:22 PM, the survey team met with the LNHA, DON, and Regional Nurse to discuss additional concerns which included the facility's assessment did not include registered sex offenders or inmates in their special population. A review of the Centers for Medicare & Medicaid Services (CMS) 2567 statement of deficiencies from the facility's last standard survey included the facility was cited for the following concerns: MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment to include registered sex offenders and inmates, and the facility's QAPI program. On 6/26/24 at 11:52 AM, the survey team met with the LNHA, DON, and Assistant Director of Nursing (ADON) to discuss the facility's QAPI program which all three staff members were part of. When asked where the facility obtained their concerns for their QAPI program, the LNHA stated the facility utilized the CMS 2567 statement of deficiencies from previous surveys. The survey team informed the facility that there were repeated concerns from the last standard survey which included MDS assessments, medication storage, acting on CP reports, antibiotic stewardship program, facility assessment, and QAPI, and asked what the facility implemented to ensure sustainability. The LNHA acknowledged that even though she started at the facility in April 2024, she was present for the April quarterly QAPI meeting as well as reviewed and signed the facility assessment and reviewed the CMS 2567 from last standard survey. At that time the DON stated she was aware of the facility's previous deficiencies and that facility educated staff and completed reports. No additional information was provided. A review of the facility provided Administrator job descriptions included the Administrator is responsible for planning and is accountable for all activities and departments at [name redacted] subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of care is constantly provided to the residents . A review of the facility provided Senior Director of Nursing Services job descriptions included in addition to the standard responsibilities of Director of Nursing, Senior Director of Nursing is responsible for providing leadership, training and expert guidance. Individuals selected for this position and must be knowledgeable in all aspects of long term care nursing and have demonstrated ability in managing a nursing department .Performs Related Duties: 1. in the absence of the Administrator and/or licensed Assistant Administrator, the DON is responsible carrying out the administrative duties of the nursing facility . NJAC 8:39-33.1(a)(e); 33.2 (a)(b)(c)(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) implement a facility-wide system to monitor antibiotic use specifically according to the facility's antibiotic stewardship program and b.) monitor antibiotic use and conduct surveillance from January 2024 through June 2024. This deficient practice was cited during the facility's last standard survey on 10/20/22, and was evidenced by the following: Refer F865 According to the U.S. CDC Core Elements of Antibiotic Stewardship for Nursing Home, page last reviewed June 11, 2020, included, Tracking and Reporting Antibiotic Use and Outcomes Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Process measures: Tracking how and why antibiotics are prescribed Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. A review of the facility's Antibiotic Stewardship policy dated reviewed January 2022, included the [Infection Preventionist (IP)] or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics .All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: resident name and medical record number; unit and room number; date and symptoms appeared; name of antibiotic; start date of antibiotic; pathogen identified; site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. During entrance conference on 6/17/24 at 10:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who the facility's Infection Preventionist (IP) was, and the DON stated the facility's previous IP left about two or three months ago and the position was vacant. The DON stated herself, the Assistant Director of Nursing (ADON), and the two unit managers reviewed immunizations, antibiotic stewardship, and infection control issues. At that time the surveyor requested a copy of the infection control certifications as well as the date the IP stopped working. On 6/18/24 at 11:42 AM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked. On 6/19/24 at 12:55 PM, the surveyor requested from the LNHA a copy of the infection control certifications and the last date the IP worked as well as the antibiotic stewardship tracking and surveillance. On 6/19/24 at 1:36 PM, the surveyor interviewed the DON who stated she did not have a certification in infection control; but she reviewed infection control with the ADON who also was not certified. The DON stated only the Unit Manager/Licensed Practical Nurse (UM/LPN) had an infection control certification. The DON stated the unit managers provided the antibiotic stewardship information to the ADON who reviewed, summarized, and completed the monthly report, and the ADON in-services staff on infection control. On 6/20/24 at 12:36 PM, the ADON provided the surveyor with a copy of the facility's Monthly Antibiotic Summary since January 2024. A review of the summary revealed the following: In January 2024, four residents received antibiotics, and three residents had a blank for the diagnostic section (X-ray and laboratory). In February 2024, six residents received antibiotics, and all six had a blank for the diagnostic section. Resident #40 had no documented symptoms. In March 2024, six residents received antibiotics, and all six had a blank for the diagnostic section. Resident #44 and Resident #98 both were not indicated if they met the criteria for an antibiotic. For April 2024, four residents received antibiotics with no residents having documented symptoms; two had diagnostic test documented; none had the origin documented; and no one had documented if the criteria was met. For May 2024, eleven residents received antibiotics with only two residents had documented symptoms; no one had diagnostic tests documented; none had the origin documented; and no one had documented if the criteria was met. For June 2024, eight residents received antibiotics with Resident #197 with no documented symptoms; and no one had documented diagnostic testing, origin, or criteria met. On 6/20/24 at 12:36 PM, the surveyor interviewed the ADON who stated the facility had no IP since April of 2024, everyone was pitching in with infection control. When asked why the summaries were not completed, the ADON stated she had just completed May's antibiotic stewardship review yesterday. On 6/20/24 at 12:57 PM, the surveyor informed the LNHA and DON about the missing documentation for the antibiotic stewardship. The DON stated there was a log on the medication cart with the antibiotic that was being tracked. No additional information was provided. NJAC 8:39-19.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and review of other facility documentation, it was determined that the facility failed to accurately document and clarify a resident's life-sustaining treatment preferences on physician's orders for one (1) of two (2) residents (Resident #47) reviewed for advanced directives. This deficient practice was evidenced by the following: According to Resident #47's Resident Face Sheet the resident was admitted to the facility with the diagnoses that included but were not limited to; depression, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and convulsions. The annual Minimum Data Set (MDS), an assessment tool for managing the resident's care dated [DATE], indicated that the resident had a good long-term memory, poor short-term memory and reflected that the resident required extensive to total care with all aspect of activities of daily living. The surveyor reviewed Resident #47's paper medical records as well and the electronic health record (EHR) which revealed the following conflicting information: The New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form signed by the physician on [DATE], reflected that Resident #47 was to have full treatment and use of all appropriate medical and surgical interventions as indicated to support life and if no pulse or is not breathing and that Cardiopulmonary Resuscitations (CPR) should be attempted. There was also a form undated and titled, Do Not Resuscitate located in the resident's medical records. This form indicated that Resident #47 was to have no resuscitative attempts in an event of cardiac and/or respiratory arrest should occur. The Physician Orders (PO) dated [DATE], reflected a PO that the resident's advanced directive indicated: Do not hospitalize (DNH) and full CPR. On [DATE] at 12:58 PM, the surveyor interviewed the acting Registered Nurse Unit Manager (RN/AUM) who confirmed that there were two PO put into the computer and one order indicated that the resident was to be a full code and another physician's order indicated do not hospitalize (DNH). She stated that the nurse that put the PO in the EHR on [DATE], for DNH and full CPR did not know how to put the orders in. She stated that this was a dilemma, but that if need be, they would perform CPR and send the resident to the hospital. On [DATE] at 01:48 PM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been employed in the facility for three (3) years and that if a resident coded (a slang term for cardiac or respiratory arrest) and the physician orders were contradictory such as full code verses DNH, the responsible party (RP) would have to be called to clarify whether the code status was a full code or if it was a DNH. She stated that when a resident returned from the hospital that the nurses would check for a new directive and the physician would need to clarify the code status for the resident. The DON stated that she was unsure of where the confusion happened and indicated that it happened when the resident returned from the hospital. The DON added that the resident was a full code, but when he/she returned from the hospital there was a do not resuscitate (DNR). The DON further added that if the resident was unable to decide then the family would needed to be contacted for clarification. On [DATE] at 09:15 AM, the surveyor attempted to telephone interview the resident's RP unable to reach and a phone message was left. On [DATE] at 09:40 AM, the surveyor interviewed the DON who stated that the resident's code status was clarified with the doctor and that the resident's code status was changed to full code. The DON further stated that she informed the RN/AUM of the need to closely review and accurately transcribe the resident's code status information in the residents' medical records. On [DATE] at 12:32 AM, the surveyor interviewed the RN/AUM who stated that two (2) code statuses for a full code and DNR were put in the physician orders wrong during the admission process. The facility policy titled, Advanced Directives and dated [DATE] indicated: - The residents wishes will be communicated to the staff by way of the care Plan and to the resident physician. Request made for MD order. -A Medical alert symbol will be placed in the electronic medical record for appropriate advanced directive as indicated. NJAC 8:39-4.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care. This deficient practice was identified for one (1) of one (1) resident (Resident #266) reviewed, and was evidenced by the following: According to the Resident Assessment Instrument (RAI) Manual Version 3.0 Chapter 2 Assessment for the RAI pages 2-23 of CMS (Center for Medicare/Medicaid Services) guidelines, updated October 2019 included, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. On 10/06/22 at 10:50 AM, during the initial tour of the facility the surveyor interviewed Agency Licensed Practical Nurse (ALPN #1) who stated Resident #266 was the only resident on hospice at the facility. On 10/06/22 at 11:06 AM, during the initial tour, the surveyor observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. A review of the Resident Face Sheet (an admission summary) included that the resident was admitted to the facility in July of 2022, with diagnoses which included: hypertension (high blood pressure), chronic respiratory failure with hypoxia (low blood oxygen levels), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). On 10/11/22 at 09:21 AM, the surveyor interviewed the Social Worker who stated Resident #266 was the only resident at the facility on hospice. A review of the physician's order (PO) dated 08/05/22 reflected an order for a hospice evaluation. The PO further reflected on 08/09/22 an order to discontinue skilled occupational therapy (OT) services because the resident was on hospice. On 10/12/22 at 09:17 AM, the Registered Nurse/Acting Unit manager stated the Resident #266 was recently placed on hospice. On 10/13/22 at 01:08 PM, Regional Nurse #2 confirmed Resident #266 was placed on hospice in August of 2022. A review of the MDS's that were completed in the resident's electronic medical record (EMR) did not reflect that a significant change in status (SCSA) MDS was completed. On 10/17/22 at 09:55AM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #266 was placed on hospice over a month ago. The DON stated that if a resident had a decline and was placed on hospice that would have triggered for a SCSA MDS to be completed and that it would be started immediately. The DON acknowledged that the resident's SCSA should have been completed within 14 days of the significant change. On 10/17/22 at 10:06 AM, the Regional Minimum Data Set Coordinator (MDS/RMC) in the presence of the survey team stated that she had been an MDS coordinator for 12 years. The MDS/RMC stated that she supervised nine (9) other sister facilities MDS departments for this company. She stated that the facility had per diems (as needed) Registered Nurses Minimum Data Set coordinators (RN/MDS) nurses that performed the MDS assessment for the residents in the facility. She stated that there has not been a full time MDS coordinator in the facility since August 2022 and that the RN/MDS per diem nurses come into the facility to assess the resident, interview the residents, review the medical record, and clarify and confirm what was in the medical record was accurate. She stated that the MDS clinical assessment opened in the EMR for completion seven (7) days prior to the Assessment Reference Date (ARD, the date that signifies the end of the look back period). She stated once the specific MDS opens, all disciplines can enter the MDS to complete their section. She stated that the quarterly, annuals and significant changes MDS were due to be completed 14 days from the ARD. She confirmed that there were multiple MDS that were not completed or were late in the facility. She stated that the quarterly, annual, and significant change assessment and quarterly assessment were required to be submitted 14 days from the completion date. She stated that it was a challenge to try and find a full time MDS coordinator and that the facility corporate office was aware that the assessments were overdue. She said that they were trying their best to have the MDS assessments done timely. She stated that it would be important to assure timely completion and timely transmission of assessments because the MDS was a that tool to identify problems and assure that care plans were completed accurately and provide the proper services to the residents. On 10/18/22 at 12:31 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team acknowledged the MDS assessments should have been completed within the 14-day timeframe. He further stated it was important to complete the MDS because it ensured that staff was aware of the resident's needs. The facility policy titled. Minimum Data Set with a revised date of 09/28/22 indicated that the RN MDS coordinator schedules the residents' assessments and care plan meetings in accordance with Center for Medicare and Medicaid Services (CMS) regulations and guidelines and resident's needs. The facility job description titled; Director of Clinical Reimbursement (MDS Coordinator) indicated that the MDS Coordinators duties included: -Ensuring that all assessments are completed and transmitted in a timely manner and to report problem areas to the Administrator. NJAC 8:39-11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one (1) of one (1) resident (Resident #266) reviewed for hospice and for one (1) of one (1) resident reviewed for restraints (Resident #63). This deficient practice was evidenced by the following: On 10/06/22 at 10:50 AM, during the initial tour of the facility the surveyor interviewed Agency Licensed Practical Nurse (ALPN #1) who stated Resident #266 was the only resident on hospice at the facility. On 10/06/22 at 11:06 AM, during the initial tour, the surveyor observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. A review of the Resident Face Sheet (an admission summary) included that the resident was admitted to the facility in July of 2022, with diagnoses which included: hypertension (high blood pressure), chronic respiratory failure with hypoxia (low blood oxygen levels), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). A review of the physician's order (PO) dated 08/05/22, reflected an order for a hospice evaluation. The PO further reflected on 08/09/22, an order to discontinue skilled occupational therapy (OT) services because the resident was on hospice. A review of the admission MDS, dated [DATE], revealed under Section O: Special Treatment, Procedures, Programs that the resident was hospice care while not a resident and while a resident. A further review of the MDS revealed it was completed and signed on 10/16/2022. On 10/19/22 at 11:59 AM, the surveyor interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) who stated that the admission MDS for Resident #266 was due on 07/16/22 and completed and signed on 10/16/22. She further stated that the admission MDS was coded for hospice but could not confirm if the resident was admitted on hospice. On 10/19/22 at 12:31 PM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #266 was not admitted to the facility under hospice care. The DON stated the resident was placed on hospice 08/05/22. The DON acknowledged the admission MDS was not accurately coded. On 10/19/22 at 12:33 PM, the MDS/RMC stated that the MDS assessments were a systemic issue and acknowledged that the MDS for Resident #266 was coded inaccurately. 2. On 10/06/22 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #63 lying in bed asleep with full metal side rails in place on both sides of the resident's bed. On 10/07/22 at 09:48 AM, the surveyor observed Resident #63 lying in bed asleep. The right side of the resident's bed was positioned up tightly up against the wall. The left full side rail was pulled up and a full-sized bumper pad covered the entire length of the side rail. On 10/12/22 at 11:08 AM, the surveyor interviewed Certified Nursing Assistant (CNA #2) who confirmed that Resident #63's hands were contracted bilaterally and the resident was unable to assist to with bed mobility for transfers. CNA #2 stated that the resident had bilateral side rails and was required to have a bumper pad on the left side because the resident tended to slide off of the end of the bed. CNA #2 stated that the resident was transferred from the first floor with bilateral full side rails in place. CNA #2 stated that the right full side rail did not need to be maintained in the upward position as the bed was also pushed firmly up against the wall on the right side. On 10/12/22 at 11:14 AM, the Registered Nurse/Acting Unit Manager (RN/AUM) entered the room to assist CNA #2 to pull Resident #63 up in bed. The RN/AUM stated that the resident was unable to assist with bed mobility. She stated that the full side rails were in place for seizure precautions. The RN/AUM stated that the use of full bilateral side rails was not considered a restraint. The RN/AUM stated that the Director of Maintenance was going to remove the bilateral full side rails and change them to half rails instead so that it were not considered a restraint. She stated that she would pull the bed out away from the wall because it was not supposed to be like that because that was a restraint. She stated that a physician's order, care plan entry and a side rail assessment were required for full side rail placement. The RU/AUM reviewed the resident's care plan in the electronic health record (EHR) and confirmed that an entry was placed for full side rail use on 10/07/22. The RN/AUM stated that if the full side rails were utilized for bed mobility then a Care Plan should have done prior. The RN/AUM further stated that because the full side rails were implemented for seizure precautions a care plan was not initiated. The RN/AUM stated that she did not know why a side rail assessment or family consent was not obtained prior to implementation. A review of the Resident Face Sheet revealed that Resident #63 was admitted to the facility in July of 2021 with diagnoses which included but were not limited to: Anoxic (without oxygen) brain damage, muscle spasm, and seizures. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 07/14/22, revealed that Resident #63 was readmitted to the facility from an acute care hospital in May of 2022 with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident was severely cognitively impaired. The assessment identified that the resident required total dependence of one person for bed mobility, and total assistance of two persons for transfers. Further review of the MDS revealed that the resident had functional limitation in range of motion of both the upper and lower extremities. Review of section P of the MDS titled Restraints and Alarms, revealed that the resident had bed rails that were used daily. According to the MDS, a physical restraint was defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones' body. A review of Resident #63's quarterly MDS dated [DATE] that was due for submission on 10/06/22, and was instead submitted 13 days later on 10/19/22, revealed under Section P, Restraints and Alarms, that the assessment was coded to reflect that the resident had not used bed rails. On 10/19/22 at 12:17 PM, the surveyor interviewed the Regional MDS coordinator (RMC) who stated that when the MDS Coordinator completed Resident #63' MDS, there was a seven day look back period that was reviewed for restraint usage that corresponded to Section P, Restraints and Alarms. The RMC stated that the MDS Coordinator was on-site and should have reviewed the resident's Care Plan, Treatment Assessment Record (TAR) and physically assessed the resident prior to completion. The RMC stated that since the facility recently transitioned from paper to electronic health record charting both records should have been reviewed prior to assessment completion. The RMC stated that she did not know this resident well, but if she observed that the resident had bilateral side rails on his/her bed and the bed was pushed up against the wall, then she would have spoken to the team directly for clarification. The RMC stated that a restraint restricted someone from movement and according to section G of the MDS, the resident was totally dependent for care and had restricted movement. The RMC stated that the facility had not had a full-time MDS Coordinator since April 2022 and there were a few MDS Coordinators that helped out now. The facility policy titled. Minimum Data Set with a revised date of 09/28/22, indicated that the RN MDS coordinator schedules the residents' assessments and care plan meetings in accordance with Center for Medicare and Medicaid Services (CMS) regulations and guidelines and resident's needs. The facility job description titled; Director of Clinical Reimbursement (MDS Coordinator) indicated that the MDS Coordinators duties included: -Ensuring that all assessments are completed and transmitted in a timely manner and to report problem areas to the Administrator. NJAC 8:39-11.2

Based on observations, interview, and review of pertinent facility documentation, it was determined that the facility failed to update and revise the resident Care Plan (CP) to include goals and interventions for one (1) of one (1) resident (Resident #266) reviewed for hospice care. This deficient practice was evidenced by the following: On 10/06/22 at 10:50 AM, during the initial tour of the facility the surveyor interviewed Agency Licensed Practical Nurse (ALPN #1) who stated Resident #266 was the only resident on hospice at the facility. On 10/06/22 at 11:06 AM, during the initial tour, the surveyor observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. A review of the Resident Face Sheet (an admission summary) included that the resident was admitted to the facility in July of 2022, with diagnoses which included: hypertension (high blood pressure), chronic respiratory failure with hypoxia (low blood oxygen levels), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). A review of the physician's order (PO) dated 08/05/22, reflected an order for a hospice evaluation. The PO further reflected on 08/09/22, an order to discontinue skilled occupational therapy (OT) services because the resident was on hospice. A review of the electronic individualized comprehensive CP for October of 2022 reflected that there was no documentation of the current condition and needs related to hospice care for Resident #266. On 10/17/22 at 09:55AM, the surveyor interviewed the Director of Nursing (DON) who stated Resident #266 was placed on hospice over a month ago. The DON stated that the CPs reflected special services that assisted the staff in providing the appropriate care for the resident. She further stated in the electronic medical record (EMR) that it would appear on the CP as hospice care. On 10/18/22 at 10:01 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated she completed most of the CPs for the second floor. She further stated that other nurses had started to help with the CPs, since they transitioned to the EMR. The RN/AUM stated it was important to create and update the CP because it was a tool to communicate the resident's plan of care to staff. The RN/AUM stated that Resident #266 was on hospice and there should be a CP. She further stated that the DON had taught her how to complete the CPs and with the DON's oversight they reviewed them every three (3) months for any revision. The RN/AUM concluded the EMR was a new system and that the previous CPs were on paper and she would provide it to the surveyor. On 10/19/22 at 10:57 AM, the RN/AUM provided the paper CP that was dated 07/02/22. A review of the CP reflected a hospice CP dated 08/05/22. A further review of the CP reflected there was no documented signature on the CP for the 08/05/22 revision. On 10/19/22 at 01:34 PM, the DON in the presence of the LNHA, the Regional Licensed Nursing Home Administrator (Regional LNHA) and the survey team acknowledged that the paper CP for Resident #266 should have been signed and dated on the day it was reviewed and revised. On 10/20/17 at 11:38 AM, the Regional LNHA provided the electronic CP for Resident #266. A review of the provided electronic CP from the scheduled 10/01/22 to 10/18/22 with corrections reflected under Focus Nutrition - Additional Detail: Resident on hospice service's overall goal is comfort. A further review reflected the Nutrition focus was effective on 07/14/22, with no revision date but was noted entered on 10/17/22. The electronic CP revealed that there was no specified documentations of goals or interventions related to hospice care. A review of the undated facility's Hospice Program policy reflected, 4. When a resident participates in a hospice program, a coordinated plan between the facilities, hospice agency/family will be developed The care plan shall be revised and updated as necessary to reflect the resident current status. A review of the facility's Care Planning policy last review dated 05/26/22, reflected to provide an individualized comprehensive care plan (CCP) for each resident based on assessments done at the time of admission, quarterly, annually, and when there is a change in condition .A new care plan will be initiated for significant change .If the current care plan reflects the actual need of the resident the CCP will be revised to reflect the aspect of the resident's condition that triggered the significant change . Registered Nurse Responsibility 4. Makes an entry into the outcome column of the care plan to indicate that the care plan has been reviewed and is appropriate for the current status of the resident .9. Formulates care plans for specific discipline on admissions, quarterly, significant change, return from the hospital and as needed with change in condition. NJAC 8:39:11.2 (1)(2); 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to follow professional standards of practice by ensuring a.) that staff did not utilize personal equipment, a personal blood pressure (BP) monitor for resident care and b.) that staff obtained vital signs prior to administering a medication and hold a medication used to treat hypotension (low BP) in accordance with the physician's order (PO). This deficient practice was identified for one (1) of two (2) Licensed Practical Nurses (LPN) observed during medication administration. 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 casefinding, 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 casefinding; 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. The deficient practice was evidenced by the following: a.) On 10/13/22 at 08:22 AM, the surveyor began the medication administration on the first floor. On 10/13/22 at 08:28 AM, the surveyor observed LPN #1 obtain a BP result of 102/64 for Resident #268. On 10/13/22 at 08:31 AM, the surveyor observed LPN #1 return to her medication cart and then cleaned the BP monitoring machine with a disinfectant wipe. LPN #1 then placed it inside of a bag that had her name handwritten on the outside of the bag. On 10/13/22 at 08:46 AM, the surveyor interviewed LPN #1 who stated that she used her personal BP monitoring machine because the one for the unit was currently broken. She further stated it was reported but until the facility provide one, she would utilize her personal BP monitoring machine. On 10/13/22 at 11:54 AM, the surveyor interviewed Agency Licensed Practical Nurse (ALPN #2) on the second floor who stated the facility provided a BP monitoring machine which worked. He further stated there was no need to bring in his own BP machine. On 10/13/22 at 12:01 PM, the surveyor interviewed LPN #2 on the first floor who stated that she utilized the facility's BP machine which was provided because the standing tower vital signs machine was broken. LPN #2 also showed the surveyor a second BP machine she used for the residents on Transmission Based Precautions (TBP). She stated the standing tower BP machine had been broken for a few days but that the supervisors were aware. LPN #2 stated she never had to bring a personal BP machine to the facility because they provided one. She further stated the facility did not allow staff to bring in a personal BP machine. On 10/13/22 at 12:07 PM, the surveyor conducted a follow up interview with LPN #1 who stated she was unsure if she was allowed to bring in her personal BP machine. LPN #1 stated she brought in her personal BP machine because her residents needed their BP taken and the facility's machine was broken. She further stated that the facility should have provided a BP machine since the one for the first floor was broken. LPN #1 concluded she was unsure if other nurses brought in their own personal medical equipment, but she concluded she does. On 10/14/22 at 11:48 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated that the facility provided the medical equipment to the staff and that staff was not allowed to bring in their own. She stated staff should not use their personal BP machines because of infection control. She further stated there was a risk for cross contamination and that staff needed to follow the facility's policy and protocol. The RN/AUM stated she was unsure if the policy addressed staff utilizing personal medical equipment. On 10/14/22 at 02:09 PM, Regional Nurse #2 provided the facility's policy regarding obtaining vital signs. Regional #2 stated she was unable to find a policy that specifically addressed staff utilizing personal medical equipment. On 10/17/22 at 11:30 AM, the Director of Nursing (DON) stated the facility provided staff with medical equipment. She stated it was not recommended for staff to bring in their personal medical equipment because, we don't know if the equipment is accurate and working properly. The DON stated that staff were informed not to bring in their own medical equipment and emphasized that staff should not have utilized their own personal medical equipment to obtain vital signs. A review of the facility's policy, Vital Signs, date reviewed 03/01/22, does not reflect staff utilizing their personal medical equipment. b.) On 10/13/22 at 08:27 AM, the surveyor observed LPN #1 administer two (2) BP medications, Metoprolol (used to treat high BP) 25 milligrams (mg) one (1) tablet (tab) and Lisinopril (used to treat high BP) 5 mg one (1) tab to Resident #268. LPN #1 then went back into the electronic Medication Administration Record (EMAR) to sign that the medications were administered to Resident #268. LPN #1 then grabbed her personal BP machine which was located on top of the medication cart to obtain Resident #268's vital signs (VS) which included the BP. On 10/13/22 at 08:28 AM, the surveyor observed LPN #1 obtain a BP result of 102/64. On 10/13/22 at 08:31 AM, the surveyor asked LPN #1 if it was the first time she checked the resident's BP today (10/13/22). LPN #1 confirmed that was the first time that she checked the resident's BP today. LPN #1 then proceed to document the resident's VS in the EMAR. On 10/13/22 at 09:05 AM, the surveyor and LPN #1 reviewed the EMAR for Resident #268. LPN #1 stated that according to the physician's order (PO) on the EMAR, the BP medications Metoprolol and Lisinopril had physician ordered parameters which included to hold the BP medication for a systolic BP (SBP: the top number, is the amount of force put on the arteries as the heart beats) less than 110. At that time, the surveyor interviewed LPN #1 who stated the BP should be checked prior to administering the medication. She stated she thought she checked the resident's BP prior to administering the medications but could not recall. LPN #1 then confirmed the resident's SBP was 102. The surveyor continued to interview LPN #1 regarding the process for administering blood pressure medications. LPN #1 stated she should have held the BP medications because of the ordered parameters indicated that the medication should be held for SBP less than 110. She stated if the SBP was less than 110, she should have rechecked the resident's BP and if the SBP was greater than 110 and it was within the appropriate timeframe of one hour before or one hour after of the scheduled dose that she would administer the medication. LPN #1 further stated she would also inform the primary care physician (PCP). On 10/13/22 at 11:51 AM, LPN #1 stated after her interview with the surveyor, she immediately rechecked the resident's BP and the result was 132/76. She further stated that she monitored the resident for any adverse reactions and that the resident stated he/she was okay. On 10/14/22 at 11:47 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated staff should never give medications prior to checking the BP. She further stated they checked the BP prior to administering medication because the medication could have parameters and the medication may have needed to be held. On 10/17/22 at 11:28 AM, the Director of Nursing (DON) stated the process for administering BP medications was to first review the PO to check if there were parameters. The DON stated staff should always follow the PO as it could be detrimental to the resident if staff were not administering the medication according to the PO. She further stated administering BP medication prior to checking the BP and administering the BP medication without regards to the hold parameters was not the proper practice and not safe. The DON explained because it put the resident at risk for hypotension (low BP) if the BP was already low. A review of the in-service 'Medication Administration with regards to meds [medications] hold parameter dated 12/01/21 provided by the DON revealed, Review of medications with hold parameters and separation requirements of meds. A further review reflected LPN #1 was not in attendance as she was not employed as a nurse at that time. A review of the Medication Pass Observation for LPN #1 conducted by the Licensed Practical Nurse/Infection Preventionist (LPN/IP) on 09/14/22, reflected LPN #1 obtained VS per policy before medications were administered. A review of the facility's policy titled, Medication Administration and Documentation Policies, Procedures and information dated effective 7/1/22, reflected .7. Monitors vital signs when appropriate prior to medication administration A review of the facility's policy titled, Blood Pressure Medication Administration dated and reviewed 04/15/22, reflected .contact the physician/NP [nurse practitioner] when resident's blood pressure is outside the parameters set by the doctor of [or] if it is below a standard reading. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 10/13/22 and 10/14/22, the surveyor observed two (2) nurses administer medication to six (6) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.14%. This deficient practice was identified for one (1) of six (6) residents, (Resident #268), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced by the following: On 10/13/22 at 08:22 AM, the surveyor conducted the medication administration task and observed the Licensed Practical Nurse (LPN #1) reviewing the electronic medication administration record (EMAR) for Resident #268. At that time, the surveyor observed Resident #268 self-propelling in the wheelchair towards LPN#1 and the medication cart located in the hallway. LPN #1 proceeded to remove the following medications from the medication cart and placed them into a medication cup: Metoprolol (used to treat high blood pressure (BP)) 25 milligrams (mg) one (1) tablet (tab), Lisinopril (used to treat high BP) 5 mg one (1) tab, Eliquis (a blood thinner) 2.5 mg one (1) tab, Lasix (reduces extra fluid in the body) 20 mg one (1) tab and Genvoya (treatment for HIV - human immunodeficiency virus) 150mg/20mg/10mg one (1) tablet. On 10/13/22 at 08:27 AM, LPN #1 administered all five (5) medications to the resident whole with water. LPN #1 then went back into the EMAR to sign that all five (5) medications were administered to Resident #268. LPN #1 then grabbed the blood pressure (BP) machine which was located on her medication cart to obtain Resident #268 vital signs (VS) which included the BP. On 10/13/22 at 08:28 AM, the surveyor observed LPN #1 obtain a BP result of 102/64. On 10/13/22 at 08:31 AM, the surveyor asked LPN #1 if that was the first time she checked the resident's BP today (10/13/22) and the LPN stated that it was the first time she checked the resident's BP today. LPN #1 then proceed to document the resident's VS in the EMAR. On 10/13/22 at 09:05 AM, the surveyor and LPN #1 reviewed the EMAR for Resident #268. LPN #1 stated that according to the physician's order (PO) on the Medication Adminitration Record (MAR), the BP medications Metoprolol and Lisinopril had parameters which included instructions to hold the BP medication for a systolic BP (SBP: the top number, is the amount of force put on the arteries as the heart beats) less than 110. At that time, the surveyor interviewed LPN #1 who stated the BP should have been checked prior to administering the medication. She stated that she thought she checked the resident's BP prior to administering the medications but could not recall. LPN #1 then confirmed that the resident's SBP was 102. The surveyor continued to interview LPN #1 regarding the process for administering blood pressure medications. LPN #1 stated she should have held the BP medications because of the BP parameters. She stated if the SBP was less than 110, she should have rechecked the resident's BP and if the SBP was greater than 110 and it was within the appropriate timeframe of one hour before or one hour after of the scheduled dose she would administer the medication. LPN #1 further stated she would also inform the primary care physician (PCP). On 10/13/22 at 11:51 AM, LPN #1 stated after her interview with the surveyor, she immediately rechecked the resident's BP and the result was 132/76. She further stated that she monitored the resident for any adverse reactions and that the resident stated he/she was okay. On 10/13/22 at 12:05 PM, the surveyor interviewed Resident #268 who stated he/she was feeling good and that they get their BP checked twice a day. On 10/14/22 at 11:47 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated staff should never give medications prior to checking the BP. She further stated they checked the BP prior to administering medication because the medication could have parameters and the medication may needed to be held. On 10/17/22 at 11:28 AM, the Director of Nursing (DON) stated the process for administering BP medications was to first review the PO to check if there were parameters. The DON stated staff should always follow the PO as it could be detrimental to the resident if staff was not administering the medication according to the PO. She further stated administering BP medication prior to checking the BP and administering the BP medication without regards to the hold parameters was not the proper practice and not safe. The DON explained because it put the resident at risk for hypotension (low BP) if the BP was already low. A review of the in-service Medication Administration with regards to meds [medications] hold parameter dated 12/01/21 provided by the DON revealed, Review of medications with hold parameters and separation requirements of meds. A further review reflected LPN #1 was not in attendance as she was not employed as a nurse at that time. A review of the in-service dated 06/30/22 reflected safety regarding medication administration (making sure resident swallowed meds whole, not leaving medication at bedside, on top of med cart, at nursing station or anywhere else) provided by the DON reflected that LPN #1 was in attendance. A review of the Medication Pass Observation for LPN #1 conducted by the License Practical Nurse/Infection Preventionist (LPN/IP) on 09/14/22, reflected LPN #1 obtained VS per policy before medications were administered. A review of the facility's policy Medication Administration and Documentation Policies, Procedures and information dated effective 07/01/22, reflected .7. Monitors vital signs when appropriate prior to medication administration A review of the facility's policy Blood Pressure Medication Administration dated reviewed 04/15/22, reflected .contact the physician/NP [nurse practitioner] when resident's blood pressure is outside the parameters set by the doctor of [or] if it is below a standard reading. NJAC 8:39 - 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documents, it was determined that the facility failed to ensure medications were appropriately dated when opened and implement a comprehensive policy to address dating medication after opening. This was observed for one (1) of two (2) medication carts reviewed during the medication storage and labeling task. This deficient practice was evidenced by the following: On [DATE] from 09:11 AM to 09:25 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN#1), observed the following within the first-floor on medication cart one (1): -One (1) opened and undated box of insulin Humalog 100 unit/milliliter (ml) was located inside a plastic bag for unsampled Resident #1. LPN #1 confirmed that the insulin was opened and that it did not have an opened date written on the plastic bag, the box, or the bottle. At that time, LPN #1 acknowledged the insulin should have been dated once the medication was opened and that the resident was just readmitted to the facility. LPN #1 stated the insulin was good for 28 days and that the insulin was delivered on [DATE]. She further stated the insulin was within the 28 days timeframe and that it could still be used. LPN #1 then pulled out a black marker from her pocket and dated the plastic bag with a date of [DATE] and placed the insulin back inside of the medication cart. -Two (2) opened and undated bottles of Risperidone (used to treat certain mental/mood disorders) oral solution 1 milligram (mg)/ml for Resident #1 and unsampled Resident #2. LPN #1 acknowledged the two (2) bottles of Risperidone were opened and undated and that the medications should have been dated once they were opened. LPN #1 stated Resident #1's medication was delivered on [DATE] and unsampled Resident #2's medication was delivered on [DATE]. She further stated when she opened a medication she dated them, but it seems like other nurses don't do that. - One (1) opened and undated Incruse Ellipta Aerosol Inhalation Powder 62.5 micrograms (mcg) (used to treat asthma or Chronic Obstructive Pulmonary Disease-COPD) for Resident #37. LPN #1 confirmed the inhaler was opened and undated. -One (1) opened and undated Atrovent Inhaler 17 mcg (used to treat asthma or Chronic Obstructive Pulmonary Disease-COPD) for unsampled Resident #3. LPN #1 confirmed the inhaler was opened and undated. - One (1) opened and undated True Plus Glucose tablets (tabs) (used to treat low blood sugar levels) 16 grams (gm) equals four (4) tabs for Resident #46. LPN #1 confirmed the medication was opened and undated. LPN #1 checked for an expiration on the bottle, but she stated she was unsure and couldn't find it. The surveyor and LPN #1 observed a date of [DATE] on the bottle but LPN #1 was unable to confirm what that date meant. On [DATE] at 12:27 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when a medication such as insulin or an inhaler was opened, the nurse should immediately write the date it was opened on the medication. She further stated that if a medication was opened and undated then the medication should have been discarded immediately because you don't know when it was opened. The DON stated she could not remember off the top of her head the expiration date for insulin and inhalers once they were opened. However, she stated she believed they had an expiration date of 30 days after the medication was opened. On [DATE] at 11:35 AM, the Regional Licensed Nursing Home Administrator (Regional LNHA) stated in the presence of the DON, Licensed Nursing Home Administrator (LNHA), Regional Nurse #1, and survey team that the glucose tablets did not have to be dated. The Regional LNHA further stated she spoke with the manufacturing company who confirmed that the glucose tablets had no expiration date. A review of the Injectable Diabetes Medication - Expiration Dates After Opening provided by Regional Nurse #2 reflected, Humalog's expiration date after opening was 28 days. A review of the Expiration Dates of Opened Inhalation Devices/Packaging provided by Regional Nurse #2 reflected, Incruse Ellipta's expiration date after opening was 42 days and to date all devices with first use. A review of the email correspondence provided by the Regional LNHA reflected, As a stable compound, glucose has no expiration . A review of the facility's policy Medication Storage, last review date [DATE] revealed, To make sure all medications and medical supplies are checked before using meds [medication] or supplies on a patient .1. Checks medication storage at least monthly to ensure all meds and supplies are checked for labels, expiration date and to ensure the labels are legible . 3 the nurse administering the meds or performing IV [intravenous - administered into a vein] activities is responsible for checking all meds and supplies at the time of use to ensure no expired meds or supplies are used on any patient. A further review of the facility's policy Medication Storage revealed there was no comprehensive implementation related to dating medications after opening. The facility was unable to provide additional information that addressed the process for dating medications after opening until [DATE]. On [DATE] at 01:26 PM, Regional Nurse #1 provided Storage of injectable Medication's policy dated last reviewed [DATE], which reflected all bottles of injectables will be inspected for manufacturer's expiration date prior to use and will be initialed and dated when opened. NJAC 8:39-29.4(a)(g)

Based on interview and record review, it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) attended the quarterly Quality Assurance (QA) meetings. This was identified for one (1) of two (2) QA meetings reviewed. This deficient practice was evidenced by the following: On 10/12/22 at 12:30 PM, the LNHA provided a list of the QA committee which revealed that the Medical Director (MD), the LNHA, the Director of Nursing (DON), and the Director of Social Worker (DSW) attendance was mandatory at the quarterly meetings. On 10/14/22 at 09:45 AM, the LNHA provided the surveyor with only one (1) quarterly QA meeting sign-in sheet for 08/29/22 which reflected the following: -The DON, the Licensed Practical Nurse/Infection Preventionist (LPN/IP), the DSW, the Registered Dietitian (RD), the Director of Activities (DA), the Licensed Practical Nurse/Unit Manager (LPN/UM), the Registered Nurse/Acting Unit Manager (RN/AUM), and the Admissions Coordinator (AC) were in attendance. It further reflected that the LNHA and the MD did not sign the attendance sheet. On 10/17/22 at 08:43 AM, the surveyor inquired additional information regarding the Quality Assurance Performance Improvement (QAPI) quarterly meeting. On 10/17/22 at 10:01 AM, the DON in the presence of the survey team stated that the QAPI committee met quarterly with all the department heads which included the mandatory attendees: the MD, the LNHA, the DON, and the DSW. On 10/17/22 at 11:08 AM, the LNHA in the presence of the DON and the survey team stated that the QAPI committee met quarterly. The LNHA acknowledged he was not in attendance at the August QAPI meeting. He stated the reason he was not in attendance was because he had just started as the new LNHA for the facility on 06/28/22. He then stated he was on vacation during the scheduled QAPI meeting in August and did not feel that the committee should have rescheduled the meeting because of his scheduling conflict. The LNHA stated it was mandatory for the MD and the DON to be in attendance, but he did not think it was mandatory for the LNHA. The surveyor presented the LNHA with the QA committee list he provided on 10/12/22, which supported that the LNHA was a mandatory attendee. The LNHA was unable to speak on the mandatory attendance any further but concluded that in his absence that the DON was his designee for the QAPI meetings. On 10/17/22 at 11:12 AM, the surveyor inquired about the MD attending the August QAPI meeting. The DON stated she was unsure and could not remember if the MD was in attendance for the August QAPI meeting. On 10/17/22 at 12:55 PM, Regional Nurse #2 provided the surveyor with the sign-in sheet for a second QA meeting held 04/13/2022, which reflected the following: -The previous LNHA, the DON, the MD, the LPN/UM, the LPN/IP, the DSW, the Director of Maintenance (DOM), the RN/AUM, the DA, and Director of Housekeeping (DH) were in attendance. At that time, Regional Nurse #2 stated the facility was unable to provide the survey team with additional quarterly QAPI meetings. On 10/18/22 at 01:52 PM, the surveyor interviewed the MD on the telephone who stated he was involved in the quarterly QAPI meetings and attended the meeting in August. He further stated that he may have forgotten to sign the attendance sheet at the meeting. On 10/20/22 at 11:37 AM, the Regional Licensed Nursing Home Administrator (Regional LNHA) in the presence of the LNHA, the DON, Regional Nurse #1 and the survey team stated that the MD did attend the meeting. The Regional LNHA further stated the MD attested that he failed to sign the attendance sheet in August. The Regional LNHA confirmed that the facility was unable to provide additional information regarding the quarterly QAPI meetings. There were no further meeting attendance or agenda records provided. A review of the facility's Quality Assurance Performance Improvement policy date reviewed 5/15/22, indicated 2. The QA Steering Committee will consist of the Administrator [LNHA], Director of Nursing, Medical Director, and Department Heads. A further review of the policy did not specify the mandatory attendees for the quarterly QAPI meetings. NJAC: 8:39-33.1(b)

Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program including ongoing monitoring and use of a nationally recognized surveillance criteria prior to consulting the prescriber. This deficient practice was identified for One (1) of one (1) resident reviewed for antibiotic stewardship, (Resident #11) and was evidenced by the following: On 10/11/22 at 11:34 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that she had worked in the role since May of 2022 and did not have previous IP experience. On 10/14/22 at 11:21 AM, the surveyor interviewed the LPN/IP who stated that she utilized a Monthly Antibiotic Summary form that she placed on the front of the Medication Administration Record (MAR) for the nurses to complete when they initiated an antibiotic. The LPN/IP stated that the nurse phoned the physician and reported resident signs and symptoms of possible infection and if an antibiotic was ordered the nurse would e-mail, text or call the LPN/IP to advise that an antibiotic was ordered for further evaluation. The LPN/IP stated that the Regional Nurse (RN) recently reviewed the aforementioned process utilized by the LPN/IP and informed her of a new computer program that she had not yet begun to utilize which tracked antibiotic usage over a three month time span. The LPN/IP stated that she also just learned about the McGeer Criteria for Infection Surveillance Checklist form (surveillance checklist used for retrospectively counting true infections) a week prior to survey, when the RN informed the LPN/IP that she was required to utilize the form in order to assess for appropriateness for antibiotic treatment prior to antibiotic initiation. The LPN/IP stated that she had not utilized the McGeer Form previously, but it was now included within the computer software utilized by the facility. The LPN/IP stated that she intended to do an in-service to educate the nursing staff regarding the McGeer Criteria so that nursing can complete the form at the time an antibiotic was ordered. The LPN/IP further stated that at this time Resident #11 was the only resident who was ordered an antibiotic. The LPN/IP stated that the resident was ordered Levaquin to treat an upper respiratory infection which was diagnosed with a chest x-ray. The LPN/IP stated that on 10/03/22, the RN began training me on how to do antibiotic stewardship and I was provided with access to the computer software and the required McGeer Form at that time. The LPN/IP stated that she was still learning and was informed by the RN that she needed to expand on the process that she currently utilized to track antibiotic usage at the facility because the process entailed more than what I was doing. On 10/17/22 at 12:51 PM, the LPN/IP provided the surveyor with a copy of the Monthly Antibiotic Summary which was reviewed and revealed that Resident #11 was ordered Levofloxacin (Levaquin) 500 mg orally (frequency and duration not specified) on 10/01/22. The form did not list the end date for Levofloxacin, resident's signs and symptoms, x-ray result, origin of illness, or whether or not the resident met the criteria for antibiotic stewardship which were required elements of the form. A review of Resident #11's Resident Face Sheet revealed that the resident was readmitted to the facility in August of 2022 with diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease (condition involving constriction of the airways and difficulty breathing), and acute respiratory infection. A review of Resident #11's Progress notes revealed that on 10/01/22 at 1:40 PM, Nursing documented that the resident was examined by the Medical Doctor (MD) on clinical rounds and a new order was transcribed for an Acute Upper Respiratory Infection for the resident to begin Levaquin 500 mg daily for 10 days, chest x-ray revealed a diagnoses of Pneumonia. A review of Resident #11's Medication Administration Record (MAR) revealed that the resident received Levaquin 500 mg orally once daily from 10/02/22 through 10/11/22. On 10/18/22 at 1:52 PM, the surveyor phoned the Medical Director (MD) in the presence of the survey team. The MD stated that he provided education to the facility staff related to antibiotic stewardship during the Quality Assurance (QA) Meeting in August 2022. The MD stated that he informed the staff that nursing should have a process in place when they phoned the physician to initiate an antibiotic as we were fighting to avoid providing the wrong information. The MD stated that nursing was required to provide the resident's vital signs, presentation, appropriateness for treatment such as diagnostic testing prior to antibiotic usage. The MD stated that the nursing department had a tool that they showed him at the QA meeting and he was okay with it, though he did not recall the name of the tool. On 10/19/22 at 11:19 AM, the surveyor interviewed the LPN/IP who stated that the MD informed her that she was required to utilize a spreadsheet as she was reportedly, Just writing stuff down on notes in a notebook. The LPN/IP further stated that that was when she started typing up the antibiotic monitoring. The LPN/IP was unable to furnish the surveyor with the notebook for review when requested. The LPN/IP further stated that on 10/03/22, the RN came to the facility and assessed the process that she had in place for antibiotic stewardship as they had told me prior that I was required to use the McGeer Criteria, but I was not using it. The LPN/IP stated that the RN then showed me how to use the McGeer Criteria in the computer and I am going to begin using it going forward this month to get comfortable with the process. The LPN/IP stated that the RN intended to assist her with the transition to organize the antibiotic stewardship program. On 10/20/22 11:22 AM the Regional Licensed Nursing Home Administrator (RLNHA) who stated that education was conducted with the LPN/IP last night, in the past, and this past Monday on 10/17/22 regarding full Antibiotic Stewardship implementation. The RLNHA stated that as of Monday, the staff nurses were in-serviced and were expected to utilize the McGeer Criteria for all antibiotic orders and the Director of Nursing (DON) stated that the McGeer SBAR (Situation, Background, Assessment, Recommendation) should have already be in use as of 10/17/22. The RLNHA stated that she had documentation of the in-services which were left on her desk. When requested by the surveyor prior to exit, the facility failed to provide the surveyor with documented evidence that the nursing staff was in-serviced as previously described by the RLNHA. Review of the facility policy titled, Antibiotic Stewardship, reviewed 01/2022, revealed the following: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Review of the facility policy titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, reviewed 01/2022, revealed the following: Policy Statement: Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: 1. The organism is not susceptible to antibiotic chosen; 2. The organism is susceptible to narrower spectrum antibiotic 3. Therapy was ordered for prolonged surgical prophylaxis; or 4. Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number; b. Unit and room number; c. Date symptoms appeared; d. Name of antibiotic (see approved surveillance list); e. Start date of antibiotic; f. Pathogen identified (see approved surveillance list); g. Site of infection; h. Date of culture; i. Stop date; j. Total days of therapy; k. Outcome; and i. Adverse events. NJAC 8:39-19.4(a)(d)

Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to ensure that mitigation measures were followed to prevent the potential spread of COVID-19, a contagious respiratory infection. This deficient practice was identified for two (2) of three (3) unvaccinated staff, and was evidenced by the following: On 10/06/22 at 09:07 AM, the survey team was greeted by the Licensed Nursing Home Administrator (LNHA) who stated that there were three COVID-19 positive residents at the facility. He clarified that two of the residents were positive upon admission and one resident tested positive at the facility. He stated that staff were expected to wear a surgical mask throughout the facility and were required to wear full Personal Protective Equipment (PPE, protective clothing or equipment worn to minimize exposure to hazards that cause injuries or illness) which included an N-95 mask (filters at least 95% of airborne particles), surgical mask, eye protection, gown and gloves when they entered the area designated for COVID-19 positive residents and Persons Under Investigation (PUI, persons who were under observation for signs and symptoms of COVID-19). On 10/11/22 at 11:34 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that she was new to the role as of May 2022. The LPN/IP stated that Human Resources (HR) determined staff vaccination status prior to hire and informed her of their status. The LPN/IP presented the surveyor with the completed COVID-19 Staff Vaccination Status for Providers form which indicated that there were two staff members who were not vaccinated that were granted an exemption. On 10/18/22 at 11:26 AM, the surveyor interviewed the LPN/IP and requested to view the vaccination status of the contracted staff. At 2:25 PM, in a later interview with the LPN/IP, she provided the surveyor with the requested vaccination status of contracted staff. At that time, the newly hired Food Service Director (FSD) who wore only a surgical mask and eye glasses, presented to the lobby of the facility and informed the surveyor that she was not vaccinated against COVID-19 and was granted an exemption. The FSD showed the surveyor documented evidence of exemption on her cell phone. On 10/19/22 at 10:34 AM, the surveyor interviewed the FSD who wore only a surgical mask and eye glasses. The FSD stated that she began working at the facility a week ago. She stated that she was required to wear a surgical mask unless she were to go upstairs to the nursing units, then she was required to wear an N-95 mask. She further stated that she was required to be tested twice weekly for COVID-19 due to her vaccination status. On 10/19/22 at 10:42 AM, the surveyor interviewed the Human Resources Staffing Coordinator (HRSC) who confirmed that the mask that she wore was a surgical mask. The HRSC stated that she was hired six months ago. The HRSC stated that due to her vaccination status she was required to wear a surgical mask unless she went up to the first floor, then she was required to wear an N-95 mask due to positive COVID-19 cases on the unit. The HRSC stated that she was tested twice weekly for COVID-19 and once weekly if there were no cases of COVID-19 in the building. The HRSC stated that due to her vaccination status she was told to practice social distancing, perform hand hygiene and was told that N-95 mask use was optional. The HRSC confirmed that she was not fit tested for N-95 mask usage. The survey team who was present at that time, confirmed that the HRSC wore a surgical mask each day of the survey when she dropped off the daily staffing sheets to the team. On 10/20/22 at 8:35 AM, the HRSC entered the conference room and wore only a surgical mask when she dropped off the daily staffing sheet. The HRSC stated that she spoke to the LPN/IP yesterday and was informed of the need to perform hand hygiene and wear an N-95 mask when there were positive COVID-19 cases on the first floor. The HRSC further stated that was the only guidance that she received regarding N-95 mask usage. On 10/19/22 at 11:20 AM, the surveyor interviewed the LPN/IP who stated that staff who were not vaccinated and were granted an exemption were informed that they were required to wear a surgical mask and that an N-95 mask was only required if someone tested positive on the first floor. The LPN/IP stated that staff were fit tested for N-95 use with the exception of the FSD as she was newly hired. The LPN/IP stated that she received guidance regarding PPE usage of unvaccinated staff from a former nurse colleague who precepted her and no longer worked at the facility. The facility was unable to provide the surveyor with a contingency plan or policy related to required PPE usage for unvaccinated staff to prevent the spread of COVID-19. On 10/20/22 at 11:22 AM, the RLNHA stated that Fit testing was required for N-95 usage and that an attestation was signed by all exempted employees of the need to wear an N-95 mask at all times within the facility. At that time, the RLNHA provided the surveyor with an undated attestation form that was signed by the HRSC which indicated that she was required to wear an N-95 mask at all times, in addition to weekly COVID-19 testing. The RLNHA also provided the surveyor with an attestation form that was signed by the FSD that was dated 10/20/22, which indicated that the FSD was educated to wear an N-95 at all times at work and was fit tested for appropriateness to wear an N-95 mask on 10/19/22. NJAC 8:39-5.1(a), 19.4

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents were free from physical restraints which included the use of full side rails to both sides of a cognitively impaired, dependent resident's bed. This deficient practice was identified for one (1) of one (1) resident reviewed for Restraints, (Resident #63) and was evidenced by the following: On 10/06/22 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #63 lying in bed asleep with full metal side rails in place on both sides of the resident's bed. On 10/07/22 at 9:48 AM, the surveyor observed Resident #63 lying in bed asleep. The right side of the resident's bed was positioned tightly up against the wall. The left full side rail was pulled up and a full-sized bumper pad covered the entire length of the side rail. On 10/07/22 at 10:48 AM, the surveyor reviewed Resident #63's paper chart which failed to contain documented evidence of a physician's order for bilateral full side rails, a consent for side rails, or a bed safety assessment to assess for the possibility of entrapment with full bilateral side rail application. On 10/07/22 at 11:55 AM, the surveyor also reviewed the Electronic Health Record (EHR) which also failed to contain the aforementioned documentation to validate that Resident #63 was properly assessed for bilateral full side rail use prior to implementation. A review of the Resident Face Sheet revealed that Resident #63 was admitted to the facility in July of 2021 with diagnoses which included but were not limited to: Anoxic (without oxygen) brain damage, muscle spasm, and seizures. A review of the quarterly Minimum Data Set (MDS), an assessment to manage care dated 07/14/22, revealed that Resident #63 was readmitted to the facility from an acute care hospital in May of 2022 with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident was severly cognitively impaired. The assessment identified that the resident required total dependence of one person for bed mobility, and total assistance of two persons for transfers. Further review of the MDS revealed that the resident had functional limitation in range of motion of both the upper and lower extremities. Review of section P of the MDS titled Restraints and Alarms, revealed that the resident had bed rails that were used daily. On 10/12/22 at 11:08 AM, the surveyor interviewed Certified Nursing Assistant #2 who confirmed that Resident #63's hands were contracted bilaterally and the resident was unable to assist with bed mobility for transfers. CNA #2 stated that the resident had bilateral side rails and was required to have a bumper pad on the left side because the resident tended to slide off of the end of the bed. CNA #2 stated that the resident was transferred from the first floor with bilateral full side rails in place. CNA #2 stated that the right full side rail did not need to be maintained in the upward position as the bed was also pushed firmly up against the wall on the right side. At 11:14 AM, the Registered Nurse/Acting Unit Manager (RN/AUM) entered the room to assist CNA #2 to pull Resident #63 up in bed. RN/AUM stated that the resident was unable to assist with bed mobility. The RN/AUM stated that the full side rails were in place for seizure precautions. The RN/AUM stated that the use of full bilateral side rails was not considered a restraint. The RN/AUM stated that the Director of Maintenance was going to remove the bilateral full side rails and change them to half rails instead so that it were not considered a restraint. The RN/AUM stated that she would pull the bed out away from the wall because it was not supposed to be like that because that was a restraint. The RN/AUM stated that a physician's order, care plan entry and a side rail assessment were required for full side rail placement. The RU/AUM reviewed the resident's care plan and confirmed that an entry was placed for full side rail use on 10/07/22. The RN/AUM stated that if the full side rails were utilized for bed mobility then a Care Plan should have done prior. The RN/AUM further stated that because full side rails were implemented for seizure precautions, a care plan was not initiated. The RN/AUM stated that she did not know why a side rail assessment or family consent were not obtained prior to implementation. On 10/13/22 at 10:51 AM, the surveyor interviewed the Director of Nursing (DON) regarding the policy for bilateral full side rails. The DON stated that Resident #63 had full side rails due to seizure activity and the family insisted on full side rails with padding. The DON explained that the resident had jerking movements and full side rails were required for safety reasons. The DON stated that there should have been a physician's order for the full side rails and a side rail assessment should have been done. The DON stated that the bed should not have been placed against the wall because that was an added restraint. The DON stated that, The resident's full side rails were removed and were replaced with quarter railings with padding in order to decrease the restraint situation. On 10/18/22 at 9:01 AM, the surveyor observed Resident #63 lying in bed with b/l quarter rails on the bed with padding and fall mats were positioned on both sides of the resident's bed. On 10/18/22 at 12:15 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that Resident #63 should have had an order for full side rails. The LNHA stated that a side rail assessment was required to determine if they were needed and definitely to look at the risk of entrapment. The DON who was present stated that the previous Rehabilitation Company insisted on full side rails and there was a trial on the use of a bumper, for jerking movements, not full seizure activity. On 10/20/22 at 11:22 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator (RLNHA) who stated that Resident #63's family wanted full rails and a meeting was suggested after a therapy screening. The RLNHA stated that a full side rail assessment should have been done, as a restraint was indicated at that time. The RLNHA stated that she ran a restraint free facility and an order should have been obtained from the physician. The RLNHA stated that the facility was looking at family involvement so that everyone was involved in the determination. Review of Resident #63's Interdisciplinary Care Plan which contained both typed and hand written entries was provided by the Registered Nurse/Acting Unit Manager (RN/AUM) on 10/19/22 at 9:58 AM, revealed an entry dated 1/7/22, which revealed an entry for At risk for seizure as evidenced by: history of seizure activity at risk for falls. Interventions included monitor resident for seizure activity, padded side rails for safety and to prevent falls and injury. Resident to be monitored for safety every shift. On 10/19/22 at 12:30 PM, the Director of Nursing (DON) provided the surveyor with the resident's Care Plan Activity Report (CPAR) which contained an entry that was effective 08/09/22 but failed to contain a review date, indicated the Focus was for Side rails, Etiology: I have requested side rails to get in and out of bed; I have requested side rails to assist in turning and positioning myself in bed. As evidenced by: b/l full side rails. The Goals related to the entry effective on 10/07/22 included the following: I will maintain as much independence in bed mobility as possible through the use of side rails, I will maintain feeling of self esteem through active participation in transfers and bed mobility through the use of side rails, My ability to safely participate in ADLs (Activity of Daily Living) in bed mobility and transfers will be enhanced through use of side rails. Interventions included: Effective 10/07/22, We will explain risks and benefits of using side rails as enabler for bed mobility and getting in and out of bed to you and or family/designated representative so the safety of these side rails can be determined for me. We will ensure that you are able to safety demonstrate the use of side rails to participate in transfers and bed mobility. Complete a 24 hour bed mobility assessment to monitor behaviors and positions while in bed. We will ensure that you are able to demonstrate proper use of side rails to assist self in positioning. Through assistance of therapy will ensure that you can raise and lower side rail independently. Review of Resident #63's Occupational Therapy Progress Report dated 09/22/22, revealed that the resident exhibited total dependence without attempts to initiate grasp/hold of items and on 10/05/22. The resident progressed to maximum assistance for this task. Review of an Occupational Therapy OT Evaluation and Plan of Treatment for Certification period 09/22/22-10/21/22 revealed the following Clinical Impression: Resident will benefit from skilled OT for right hand/wrist contracture, wheelchair positioning, resident has a preexisting anti-thrust cushion, bilateral full bed rails, and bed rail pads as per family request. On 10/06/22 at 1:28 PM, the Occupational Therapist (OT) documented changes in Assessment which included: Left Upper Extremity (LUE) strength value changed from 3 out of 5 to 2 out of 5. On 10/13/22 at 11:18 AM, the OT Modified her Assessment to include the following changes: Clinical Impressions: Current Value changed from Resident will benefit from skilled OT for right hand/right wrist contracture and wheelchair positioning to Resident will benefit from skilled OT for right hand/wrist contracture and wheelchair positioning, resident has a preexisting anti-thrust cushion, bilateral full bed rails, and bed rail pads as per family request. Review ofthe facility policy titled, Side Rails (Reviewed 04/18/22) revealed the following: Policy: It is the policy of the Rehabilitation Center to use side rails only to promote independence and well-being and not to restrict freedom of movement. Purpose: To assure safety and optimum bed mobility side rails may be utilized for some residents. We recognize that even if a side rail increases a resident's bed mobility it could have the effect of restraining him/her. .If a resident can either exit bed freely around the rail or lower the rail independently it is not considered a restraint. Side rails recommended for facilitating bed mobility are not considered restraints if the resident is cognitively and physically able to exit bed on each side independently where side rails are present. If the side rails, despite facilitation of bed mobility, impede resident from exiting the bed they will be considered a restraint and procedure for restraint use must be followed. M. D. order will be obtained for all side rail use. NJAC 8:39-4.1(a) 6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10/06/22 at 11:06 AM, during the initial tour, surveyor #3 observed Resident #266 lying in bed. Resident #266 was non-verbal but acknowledged the surveyor by nodding his/her head. The surveyor reviewed the medical record for Resident #266. A review of the Resident Face Sheet (an admission summary) included that the resident was admitted to the facility in July of 2022, with diagnoses which included: hypertension (high blood pressure), chronic respiratory failure with hypoxia (low blood oxygen levels), severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). A review of the Comprehesive admission MDS, dated [DATE], it was completed on 10/16/2022, 92 days later. On 10/19/22 at 11:42 AM, the surveyor interviewed the MDS/RMC who stated that the admission MDS for Resident #266 was due on 07/16/22 and acknowledged it was not completed until 10/16/22. The MDS/RMC stated, it was late, and it should have been done. The surveyor reviewed the Resident Assessment Instrument (RAI) 3.0 manual (updated October 2019), Chapter 5: Submission and Correction of MDS Assessments, which indicated that the Annual MDS assessment has a completion date No Later Than the ARD +14 calendar days. The facility policy titled. Minimum Data Set with a revised date of 09/28/22, indicated that the RN MDS coordinator schedules the residents' assessments and care plan meetings in accordance with Center for Medicare and Medicaid Services (CMS) regulations and guidelines and resident's needs. The facility job description titled; Director of Clinical Reimbursement (MDS Coordinator) indicated that the MDS Coordinators duties included: -Ensuring that all assessments are completed and transmitted in a timely manner and to report problem areas to the Administrator. NJAC 8:39 - 11.2 b.) 1.) Resident #22's ARD was 09/03/2022, the Comprehensive MDS assessment was not completed until 10/17/22, 44 days later. 2.) Resident #217's ARD was 08/05/22, the Comprehensive MDS assessment was not completed until 10/19/22, 75 days later. b.) Resident #216's ARD was 09/19/22, the Comprehensive MDS was not completed until 10/18/22, 29 days later. On 10/14/22 at 12:14 PM, surveyor #2 interviewed the MDS/RMC who stated that admission and annual MDS's should have been done within 14 days. The MDS/RMC stated that it was important to complete MDS's accurately and in a timely manner because they were assessment tools that guided the care plan and were used to identify any problems that could cause potential harm. On 10/18/22 at 12:36 PM, the DON and the LNHA were made aware of the late MDS's. The LNHA stated the MDS's should have been done within 14 days so the rest of the team could have been exposed to the information on the MDS. Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to a.) complete the Comprehensive Minimum Data Set (an assessment tool that accurately reflected the resident's status) in a timely manner for six (6) of 27 residents (Residents #9, #10, #11, #23, #30, and #33) reviewed for system selected MDS over 120 days for late submissions to CMS (Center for Medicare/Medicaid Services) and b.) complete the Comprehensive MDS in a timely manner for four (4) of 19 residents (Resident #22, #216, #217 and #266) reviewed. This deficient practice was identified by the following: a.) On 10/14/22 at 10:36 AM, surveyor #1 interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. The surveyor provided the MDS/RMC with a list of resident MDS assessments that were late or not submitted and the MDS/RMC stated that she would email the surveyor information regarding the late assessments and why the assessments were not completed or transmitted timely. She stated she would investigate the issue. On 10/17/22 at 10:06 AM, the surveyor interviewed the MDS/RMC who stated that she had been an MDS coordinator for 12 years. The MDS/RMC stated that she supervised nine (9) other sister facilities MDS departments for this company. She stated that the facility had per diems (as needed) Registered Nurses Minimum Data Set coordinators (RN/MDS) nurses that performed the MDS assessment for the residents in the facility. She stated that there has not been a full time MDS coordinator in the facility since August 2022 and that the RN/MDS per diem nurses come into the facility to assess the resident, interview the residents, review the medical record, and clarify and confirm that what was in the medical record was accurate. She stated that the MDS clinical assessment opened in the EMR for completion seven (7) days prior to the Assessment Reference Date (ARD, the date that signifies the end of the look back period). She stated that once the specific MDS opens, all disciplines can enter the MDS to complete their section. She stated that the quarterly, annuals and significant changes MDS were due to be completed 14 days from the ARD. She confirmed that there were multiple MDS that were not completed or were late in the facility. She stated that the quarterly, annual, and significant change assessment were required to be submitted 14 days from the completion date. She stated that it was a challenge to try and find a full time MDS coordinator and that the facility corporate office was aware that the assessments were overdue. She said that they were trying their best to have the MDS assessments done timely. She confirmed that there multiple comprehensive and quarterly assessments that were late but that they were doing their best to try and complete them. She stated that it would be important to assure timely completion and timely transmission of assessments because the MDS was a tool that was used for identification of problems, care plan accuracy, and to ensure proper services were provided to the residents. 1.) Resident #9's ARD was 08/27/2022, the comprehensive assessment was not completed until 10/17/22, 51 days later, and was submitted on 10/17/2022. 2.) Resident #10's ARD was 08/12/2022, the comprehensive assessment was not completed until 10/18/2022, 67 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 3.) Resident #11's ARD was 08/11/2022, the comprehensive assessment was not completed until 10/16/2022, 66 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 4.) Resident #23's ARD was 09/03/2022, the comprehensive assessment was not completed until 10/17/2022, 44 days later, and submitted on 10/17/2022. 5.) Resident #30's ARD was 07/15/2022, the comprehensive assessment was not completed until 10/17/2022, 94 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 6.) Resident #33's ARD was 07/19/2022, the comprehensive assessment was not completed until 10/16/2022, 89 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. On 10/17/22 at 10:19 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the most recent MDS coordinator resigned August 26th and has not been replaced. She stated that the facility had per diem RN/MDS coordinators who were completing MDSs. She stated the RN/MDS coordinators were doing their best to assure timely completion and transmission of the MDS. She confirmed that there was an issue concerning the timeliness of MDS completion and submission. She stated that she had a conversation with the Licensed Nursing Home Administrator (LNHA) and facility cooperate office regarding the late assessments and that part time RN/MDS coordinators were working on the late assessment to get them completed. She stated that late MDS assessments were being discussed weeks after the last RN/MDS coordinator left. She stated, We did not discuss specific late MDS, just the whole picture of what was happening with the MDS process, and I was told we had individuals were working both remotely and on site to get assessment completed. On 10/17/22 at 11:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding his knowledge of late completion and transmission of the MDS assessments. The LNHA stated that he was not aware of that MDSs were late and was not informed by clinical staff that the MDSs were not completed or transmitted timely. He stated that he was not told that the MDS's were a major outstanding issue in the facility. He stated that the only issue that was a concern regarding MDS, was them being uploaded to the new electronic medical record (EMR). The LNHA stated that the MDS/RMC should have notified him that there were MDS were not completed timely or transmitted timely.

Based on interview and record review, it was determined that the facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASARR) to include all psychiatric diagnoses to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of five (5) residents (Resident #35) reviewed for level II PASARR and was evidenced by the following: According to the Resident Face Sheet, Resident #35 was admitted to the facility with the diagnoses that included but were not limited to: Schizophrenia, generalized anxiety disorder, and bipolar disorder. The quarterly Minimum Data Set (MDS) and assessment tool to manage the residents care, indicated that Resident #35 had both a short term and long-term memory problem, was inattentive and had disorganized thinking. The MDS also reflected that the resident required extensive assistance with all aspect of activities of daily living and indicated that the resident had the diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. On 10/07/22 at 09:42 AM, the surveyor observed the resident lying in bed awake, was dozing at intervals and responded to the surveyor with one-word answers, yes or no. On 10/07/22 at 09:42 AM, the surveyor interviewed the acting Registered Nurse/Acting Unit Manager (RN/AUM) who stated that the resident had behaviors which included screaming, cursing, and pulling their hair out. The RN/AUM indicated that the resident had not required any psychiatric hospital admissions and was followed by the facility psychiatrist. The surveyor reviewed the PASARR level one (1) Screen dated 09/01/22, which reflected the following question: Does the individual have diagnoses or evidence of major mental illness to the following disorders: schizophrenia, schizoaffective, mood (bipolar and major depressive type), paranoid, delusional, panic, or other severe anxiety disorder; somatoform or paranoid disorder, personality disorder; atypical psychosis or other psychiatric disorder not otherwise specified) or another mental disorder that may lead to chronic disability? According to the question asked, the facility Social Worker documented on the form that the resident did not have any psychiatric diagnoses. On 10/11/22 at 12:09 PM, the surveyor interviewed the Director of Social Services (DOSS) who stated that a Medicaid worker came to the facility and requested a PASARR Level one (1) for Resident #35. The DOSS stated that she completed a new one on 09/01/22. The DOSS stated that while the resident was still schizophrenic, their behaviors had improved and was not documented on the PASARR level one (1) that she completed on the resident's behalf. On 10/14/22 at 10:47 PM, the DOSS confirmed that she completed the level one (1) PASARR dated 09/01/22 and did not include the resident's psychiatric diagnoses of schizophrenia or bipolar disorder. The DOSS stated, I screwed up. The DOSS admitted that she did not include the psychiatric diagnoses and therefore Resident #35 was not properly assessed for referral to the appropriate state agencies such as Office of Community Choice Options (OCCO), Division of Developmental Disabilities (DDD) and/or Division of Mental Health and Addiction Service (DMHAS) for a level two (2) PASARR. On 10/20/22 at 11:22 AM, The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the resident should have been referred to OCCO for level two PASARR screening due to psychiatric diagnoses. According to the facility policy titled, Pre-admission Screen and Resident Review (PASRR) dated 07/03/22, indicated that all residents must have a PASRR Screen prior to admission to the facility and thereafter when there is a significant change that has bearing on the resident's specialized service needs. The screen assesses residents for mental illness (MI), dementia and mental retardation. The screen is to determine if the person's ability to be cared for in a setting other, than Residential Health Care Facility (RHCF). The second purpose of the screen is to assess persons being recommended for RHCF placement for possible mental illness, mental retardation, developmental disability. The policy also indicated that in the event the completed PASRR screen reflects a need for further review please refer to appropriate agency and follow referral procedure. A resident who was previously identified as having a serious mental illness and or mental retardation/developmental disability and now is identified as having a significant change in physical or mental condition a new screen and level two (2) evaluation must be completed within 14 calendar days and a certified screener will complete the screen as necessary and an RN will complete a PASAR level one (1). NJAC 8:39-27.1(a)

Based on observation, interview and review of other pertinent facility documents, it was determined that the facility failed to provide a hand splint for a resident with decreased range of motion related to a right hand contracture (shortening and hardening of muscles and tendons that often leads to deformity and rigidity of joints) in accordance with therapy recommendations and physician's orders. This deficient practice was identified for one (1) of two (2) residents reviewed for limited range of motion, (resident #63) and was evidenced by the following: On 10/06/22 at 11:06 AM, during the initial tour of the facility the surveyor observed Resident #63 lying in bed asleep. The resident's right wrist was contracted (an abnormal, often permanent shortening, as of muscle or scar tissue, that results in distortion or deformity, especially of a joint of the body) and the resident did not wear any type of support device to hold his/her hand upright. On 10/07/22 at 9:46 AM, Resident #63 was observed lying in bed asleep. The surveyor observed a hand splint that was hung on a hook on the outside of the resident's closet door and was not utilized by the resident at that time. On 10/11/22 at 9:57 AM, the surveyor observed Resident #63 lying in bed asleep. The resident did not have a right hand splint on and the splint was not observed within the resident's immediate surroundings. Review of the Resident Face Sheet revealed that Resident #63 was admitted to the facility in July of 2021 with diagnoses which included but were not limited to: Anoxic (without oxygen) brain damage, muscle spasm, and seizures. Review of the quarterly Minimum Data Set (MDS), an assessment to manage care dated 07/14/22, revealed that Resident #63 was readmitted to the facility from an acute care hospital in May of 2022 with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident was severly cognitively impaired. The assessment identified that the resident required total dependence of one person for bed mobility, and total assistance of two persons for transfers. Further review of the MDS revealed that the resident had functional limitation in range of motion of both the upper and lower extremities. Review of section O of the MDS revealed that the resident had not received any range of motion or splint/brace application during the seven day look back record review period. Review of the Physician's Orders revealed a written order dated 09/23/22 which indicated, Per PT (Physical Therapy)/OT please place order for right hand resting hand splint. Pt s/p (status post) fall and it is needed for support. On 10/12/22 at 11:08 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #2 who stated that she was not assigned to the resident today, but had given report to the agency CNA who was assigned to the resident but who was not available for interview. CNA #2 stated that the resident's hands were contracted and the resident was unable to assist with bed mobility when the resident was placed on the mechanical lift for transfers out of bed. She stated that the resident did not have any splints to her knowledge. The resident's room mate who was present at that time, stated that the resident wore a gray thing on his/her hand when the staff assisted the resident to get out of bed into the chair. The room-mate further stated that the splint was kept in the top drawer of Resident #63's bureau. CNA #2 opened the drawer and thanked the room mate. She stated, Here it is in the top drawer. On 10/12/22 at 11:14 AM, the Registered Nurse/Acting Unit Manager (RN/AUM) came into Resident #63's room to assist CNA #2 to pull the resident up in the bed. When interviewed, she stated that the staff placed the splint on the resident when they got the resident out of bed. She further stated that she was unsure how the splint was ordered. The RN/AUM then proceeded to review the order in the presence of the surveyor and stated that the palm guard should be worn by the resident at all times unless the resident received AM care. She stated that the order should have been on the Treatment Administration Record (TAR) to document resident usage. She further stated that she would put it on the resident now. On 10/13/22 at 10:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #63 was expected to wear his/her splint as ordered. The DON stated that the resident could have worsened contractures if the splint was not maintained as ordered. The DON stated that the splints should have been monitored every shift for usage. The DON further stated that the nurse on the unit was responsible to ensure that the splints or supportive devices that were ordered were in use. On 10/13/22 at 12:59 PM, the surveyor interviewed the Occupational Therapist (OT) who stated that she had to tell the agency aides to put Resident #63's splints on. The OT stated that when she observed the resident without the splint on in-services were provided to the staff. The OT provided the surveyor with an In-Service form dated 10/4/22 which specified that the resident required a splint at all times except with AM/PM care and also required range of motion exercises to the left elbow. The OT did not provide any additional in-services to substantiate that she observed Resident #63 without the splint on more than one occasion as previously described. On 10/14/22 at 10:13 AM, the surveyor observed Resident #63 lying in bed without a splint on his/her right hand as required. On 10/18/22 at 12:10 PM, the Licensed Nursing Home Administrator (LHNA) stated that OT was responsible to obtain physician orders for splint usage and educate the nursing staff on use. He further stated that it was then up to to nursing to ensure that it was being properly used. The LHNA further stated that that the DON would then be responsible at that point. The DON who was present, stated that nursing should have been aware that Resident #63 required a hand splint and ensured that it was utililized. The DON stated that OT should have sent an e-mail to to the DON and Assistant Director of Nursing to inform them that the nursing staff was non-compliant. The DON further stated that the order must be on the TAR in order to document usage. On 10/19/22 at 8:48 AM, the surveyor interviewed the RN/AUM who stated that Resident #63's splint order was noted on 09/23/22. The RN/AUM stated that she found out on 10/18/22 that the way the OT placed the order in the electronic health record, it was not visible to the nursing staff on the TAR for signage. The RN/AUM acknowledged that the resident was on therapy services prior to 09/23/22 and the splint should have been utilized prior to the new order being written on 09/23/22. The RN/AUM confirmed that the order was improperly transcribed by the nurse who reviewed the order. On 10/19/22 at 10:54 AM, the surveyor interviewed the OT who stated that Resident #63 was issued a splint in January 2022 when the company took over from the previous therapy provider. The OT stated that she did not note any loss or decline in the resident's right hand as a result of the resident not wearing the splint as directed by therapy. Review of the Care Plan Activity Report (CPAR) provided on 10/19/22 from the Electronic Health Record (EHR), revealed an entry dated 10/04/22, which indicated that the focus of the entry was for ADL (activities of daily living) Functional/Rehab Potential and etiology of transfers was mechanical lift for transfer to wheelchair. Further review of the CPAR illustrated that the goal of the entry was: I will have all my needs anticipated and my ADLS will be provided to me, wear resting hand splint on right hand at all times except AM/PM care as tolerated. On 10/19/22 at 9:58 AM, the RN/AUM provided the surveyor with a hand written Interdisciplinary Care Plan (ICP) which contained an entry dated 09/30/22, which indicated that Resident #63 would continue to wear his/her right hand resting splint at all times except for AM and PM care as tolerated. Staff educated on splint application. The evaluation included that the resident's contractures on the right hand would not worsen in the next 90 days. On 10/19/22 at 12:30 PM, the DON provided the surveyor with a Physician's Order Sheet from the EHR which contained the following orders: On 10/18/22 an order was placed by the RN/AUM for Splint/Brace every day at 11:00 PM-7:00 AM, 3:00 PM-11:00 PM, and 7:00 AM-3:00 PM. A second entry and interim order was entered on 10/04/22 at 6:12 PM by OT for: Resident to wear right hand resting hand splint, at all times except AM and PM care, as tolerated. Lastly, a third interim order was placed by the RN/AUM on 10/18/22 at 6:38 PM for the following Treatment: Apply splint to right hand daily. Only to be removed fro AM and PM Care . On 10/19/22 at 12:30 PM, the DON provided the surveyor with the TAR which revealed an entry dated 10/18/22 at 6:36 PM, was placed for nursing to document that Resident #63 received the following treatment: Apply splint to right hand daily. Only to be removed for AM and PM Care. Start Date: 10/18/22 at 6:36 PM. The entry was only signed out for the 3:00 P-11:00 P and 11:00 P-7:00 A shifts on 10/18/22. Review of an Occupational Discharge Summary (ODS) dated 03/02/22, indicated that Resident #63 received rehabilitation services from 01/29/22-02/24/22. Summary since last progress report section of the ODS revealed that Caregivers were educated on splinting management in order to reduce contractures and protect skin integrity for safe functional task participation. Discharge recommendations included: Functional maintenance program recommended in order to reduce contractures, protect skin integrity, and promote joint mobility for increased task participation. The facility failed to provide the surveyor with any documented evidence that the splint was utilized as directed by therapy services prior to October 18, 2022. Review of the facility policy titled, Splints and Devices Policy) (Reviewed 08/17/22) revealed the following: Policy: All .Splints/orthoses/prostheses that are issued by the Rehabilitation Dept. will be issued after the therapist assesses the resident and recommends the appropriate device. Procedure: 1. The issuing therapist will recommend a wearing schedule for the device 2. Orders will be obtained from the MD/NP for the wearing schedule. 3. The issuing therapist will document in the EMR-an interdisciplinary note detailing the recommended resident's wearing schedule of the device 5. The Nursing department will take responsibility for daily applications/removal of device and Nurse Manager will be responsible to ensure that the information is entered in the CNA Accountability record . NJAC 8:39-27.2(m)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) identify and monitor the dialysis access site, b.) consistently maintain ongoing complete communication notes between the facility and the dialysis center and, c.) follow physician ordered fluid restriction, and d.) update the care plan to include the dialysis access site and fluid restriction for one (1) of one (1) resident (Resident #116) reviewed for dialysis and was evidenced by the following: On 10/06/22 at 10:27 AM during tour, Resident # 116 was observed in bed. The resident stated that he/she goes to dialysis and his/her access site was in the chest area. The resident could not explain to surveyor what days he/she went to dialysis, what time he/she went or what the name of the dialysis center was. The resident was not a good historian and could not be interviewed regarding a detailed history. The surveyor did not observe any liquids or cups at the resident's bedside. The resident Face Sheet (FS) indicated that Resident # 116 was admitted to the facility with the diagnoses that included but was not limited to diabetes mellitus (DM) and end stage renal failure (ESRD) (a condition where the kidney reaches advanced state of loss of function). The admission Minimum Data Set (MDS) and assessment tool dated 08/21/22, indicated that Resident # 116 required extensive assistance with activities of daily living. The MDS also reflected that the resident had severe cognitive impairment, exhibited no behaviors, and received hemodialysis (filtration of the blood by artificial equipment). On 10/07/22 09:10 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that she was employed for the facility for 22 years. She stated that Resident # 116 was cognitively impaired, however could express basic needs such as hunger, thirst, pain or if needed toileting. She stated that the resident was continent (they are able to control their bladder and/or their bowel of their own ) of bladder and bowel and required of one (1) staff member for total care with all aspects of activities of daily living (ADLs). She stated that the resident could feed himself/herself after setting up of food tray. She stated that the resident was on renal diet but not on a fluid restriction and explained to the surveyor that she was never told by the nurses that the resident was on fluid restriction. She then added that the resident went to the dialysis center on Monday, Wednesday, and Friday at 10:30 AM and returned around 2:30 PM. She stated that the resident had a dialysis catheter on the left side of the chest where he/she received dialysis. On 10/07.22 at 09:15 AM, the surveyor reviewed the Medication Administration Record (MAR) and Treatment Administration Record (TAR) and there was no documentation that the resident was on a fluid restriction or that the nurses were following the physician orders for a fluid restriction. On 10/07/22 09:35 AM, the surveyor interviewed the License Practical Nurse (LPN #1) who provided care for Resident # 116 today (10/07/22). LPN #1 stated that she had been employed at the facility for 23 years however has only been an LPN in the facility for one year and six (6) months. She stated that Resident # 116 went to dialysis three ( 3) times a week on Monday, Wednesday, and Friday and that the resident was transported to dialysis at 10:30 AM and the chair time at the dialysis center was at 11:30 AM. She stated that the resident was given a communication form to take to the dialysis center. She explained that the form was utilized for communication between the dialysis center and the facility. She stated that she would complete the pre-dialysis section of the form which included, vital signs, what the resident ate, if the resident was compliant with medications and if the dialysis access site was intact. She stated that the dialysis center filled out their section on the form and when the resident returned to the facility, the nurse would fill out the post-dialysis section area of the communication form. She confirmed that it was important to complete the form in its entirety because it was a communication tool used between the facility and dialysis center regarding residents status. LPN #1 reviewed Resident #116's dialysis communication forms with the surveyor, and she confirmed that the form was not always completed by the facility nurse post-dialysis. The LPN stated that she monitored the resident's dialysis access site on her shift but could not speak to what the other nurses monitor on their shifts. She added that the only place that there was documentation regarding the dialysis access site was on the dialysis communication form. She stated that there should be a physician's order of what type of access site the resident what was required for monitoring such as patency, bleeding or signs and symptoms of infection. LPN #1 also stated that the resident was not on a fluid restriction. LPN #1 reviewed the physician orders and the MAR and TAR with the surveyor and confirmed that there was not an order to monitor the dialysis access site and confirmed that there was not an order on the MAR for the resident to be on a fluid restriction. She stated that the nurses should be signing out in the MAR that they were adhering to the resident's fluid restriction that was ordered by the physician. The Physician Order Sheet (POS) dated 09/30/22 at 03:10 PM, reflected a physician's order for Resident #116 to go to the dialysis center on Monday, Wednesday, and Friday at 7:00 AM to 3:00 PM. Pick up was at 10:30 AM and chair time for dialysis was at 11:30 AM. The POS dated 09/30/22 at 03:10 PM, reflected a physician's order for the resident to be on a fluid restriction 1500 ml/24 total volume as follows: Dietary: 780 mls (Milliliters) (24-hour total volume) Nursing: 720 mls (24-hour total volume) -On the 7:00 AM-3:00 PM shift the resident was ordered to only have 360 mls during the shift. -On the 3:00 PM-11:00 PM shift the resident was ordered to have 240 mls during the shift. -On the 11:00 PM-7:00 AM shift the resident was ordered to have 120 mls during the shift. During review of the POS the surveyor could not find physician orders in medical record regarding Resident # 116's location of dialysis access site or dialysis site monitoring. On 10/07/22 at 10:00 AM, the surveyor interviewed Licensed Practical Nurse Unit Manger (LPN/UM) for the 1st floor who explained the dialysis process to the surveyor. She stated that dialysis should be set up for the resident prior to admission to the facility as well as transportation. She stated that the dialysis access site should be identified and monitored every shift for functioning, bleeding and signs and symptoms of infection. She confirmed that dialysis access site monitoring should be documented on the TAR and signed out by the nurses that it was completed. She then explained to the surveyor that if a resident was on a fluid restriction there would be an order on the POS explaining the breakdown of amounts provided for each shift between nursing and dietary and that would be documented on the MAR. She stated that it would be important to make sure that the fluid restriction was adhered to because you would want to make sure the resident did not develop a fluid overload (a medical condition in which when your body starts to retain more water than it needs). She explained that the dialysis communication form was a form utilized to communicate between the facility and dialysis center. She stated that all sections of the dialysis communication sheet was to be completed to assure the resident was getting the proper dialysis care and to facilitate care for the resident. The LPN/UM confirmed that the nurses were not completing the post-dialysis section of the dialysis communication form and that it should be completed after the resident returned from dialysis to assure that the resident was stable. On 10/07/22 10:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been employed in the facility since 2019. The DON stated that the facility process for residents receiving hemodialysis would include the following: 1.) Prior to admission to the facility arrangements would be made for time and days the resident would receive dialysis, facility that the resident would receive dialysis, transportation to dialysis and obtain a schedule for dialysis. 2.) A physician's order was required for the resident to receive dialysis. 3.) Dialysis communication book and communication forms were required to be completed and that there were three sections to be completed: pre-dialysis section, a section that the facility completed and then a post dialysis that the facility completed. She stated that the importance of the communication form was so that the resident received quality of care and necessary services and that the resident needed and that the resident remained stable going to the center and returning from the dialysis center. 4.) Access site: the nurse was to assess the site every shift and immediately following dialysis. Dialysis access site identification and monitoring requires a physician's order, and the nurses were required to document that they performed the monitoring on the Treatment Administration record. 5.) Diet should be ordered, and any fluid restriction should be ordered by the physician and followed be the dietary department and the nursing department to assure that the resident received the proper amounts of fluids. The nurses should be signing out the TAR that they followed the resident's fluid restriction. The DON confirmed that the nurses were not following the physician ordered fluid restrictions because there was no documentation that they were doing it. On 10/07/22 at 10:51 AM, the surveyor interviewed the Regional Food Service Director Manager (RFSD) who was covering for the facility's Food Service Director (FSD) who was not in the facility at this time. She stated that when the nurse obtained a dietary order, the order was put into the electronic medical record (EMR) which linked to meal tracker and produced a resident's food ticket. She stated that the FSD was notified by meal tracker and that the food ticket was printed and put on the tray line. She stated that the dietary staff then scan the ticket and the meal was prepared. She stated that fluid restrictions orders were written on the meal ticket. On 10/07/22 at 10:55 AM, the surveyor interviewed the DON who reviewed Resident # 116's physician orders and dialysis communication sheets with the surveyor and confirmed that the post dialysis section of the dialysis communication form was not being completed and that there were not physician orders to indicate where the resident's dialysis access site location was or that the access site was being monitored. The DON stated that the communication sheets were the communication tool used for communication between the dialysis center and the facility and that all sections were to be completed pre-dialysis, at the dialysis center and post dialysis. She stated the nurse were responsible to assure completion of these sheets. The surveyor showed the incomplete communication sheets to the DON, and she confirmed that the dialysis communication sheets were not consistently filled out correctly and added that there were many dialysis communication sheets missing from the resident's dialysis communication book. The DON then added the dialysis access site should be monitored every shift for patency (state of being open or unobstructed), signs and symptoms of infection and bleeding. She stated that it was important to assure that the dialysis access site was being monitored. The surveyor questioned the DON regarding the physician's order that indicated that Resident #116 was on a fluid restriction and why the LPN and CNA caring for the resident did not know that the resident was on a fluid restriction. She stated that the nurse should have known that the resident was on a fluid restriction because she was responsible to review the residents medical record and should know what care was to be provided to the resident. She stated that the fluid restriction should have been written on the MAR and that the nurses should be signing the MAR which would have indicated that they were following the resident's fluid restriction. On 10/07/22 at 11:41, the Food Service Director (FSD) provided the surveyor with Resident #116's meal ticket that indicated that dietary was providing the correct fluid restriction of 780 ml and according to the Resident Profile Detail (RPD) the fluid restriction for dietary of 780 ml was ordered on 09/30/22 and documented on the RPD on 09/30/22. The FSD was interviewed at this time and stated that the Dietician ordered the recommended fluid restrictions and inserted the information onto the meal ticket. The FSD stated that she was not sure what the process was for the nursing part of the fluid restriction order. On 10/07/22 12:16 PM, the surveyor interviewed the LPN/UM for 1st floor who stated that the Care Plan (CP) that was being utilized was in the EMR and that they were not using paper written care plans. She stated that Resident #116 confirmed that Resident #16 should have had a care plan initiated for fluid restriction and dialysis access site monitoring, however, could not locate that information on the resident's CP. On 10/11/22 at 01:16 PM, the surveyor interviewed the facility Registered Dietician (RD) who stated that she worked part time which was approximately two (2) days in the facility. She stated that she recommended a fluid restriction for Resident #116 and added it into the meal tracker program and EMR. She stated that any recommendations she had for residents were filled out on a recommendation form or she sent an email to the nurses and the DON so that the recommendations would be put in the EMR as an order. She added that if she was in the facility, she would completed a recommendation form and she was working off-site she would have emailed the facility with her recommendations. She stated that the nurses were responsible to put the recommendation in the EMR so that the physician order would populate onto the MAR or the TAR. The RD stated that the only way she would know if a recommendation was not followed was when she reviewed the resident again which was usually quarterly and monthly for residents with wounds, tube feedings, weight loss and dialysis residents. The RD explained that she recommended a fluid restriction for Resident # 116 because the resident was on dialysis and does not want the resident to have retention, edema, or fluid overload. She stated that if the nurses did not follow the fluid restriction recommendations it could cause the resident to experience edema or fluid overload which is detrimental to the resident. The dietician reviewed the residents medical record and stated that Resident #116 did not experience any untoward effects from nursing not adhering to recommended fluid restrictions from 09/30/22-10/7/22 and that the resident was stable at 193.6 pounds pre-dialysis. On 10/18/22 at 12:08 PM, the surveyor interviewed the DON who stated that the communication forms that were provided to the surveyor were the only communication forms that facility had and that they did not have a dialysis contract with any dialysis facility. The Licensed Nursing Home Administrator also confirmed that he could not find any contract with a dialysis center. The facility policy titled, Hemodialysis and dated 04/06/22, indicated that it was the policy of the facility to assess and develop a care plan to meet the special clinical and emotional needs f resident receiving dialysis. Responsibilities include the following: -Provide a notebook to be used as a communication book between the dialysis center and the center. -If shunt or fistula is mature, assesses bruit and thrill every shift and document the same on the treatment record. -Upon return from dialysis reviews the communication book for any orders, concerns etc. From the dialysis center. -Upon return for dialysis, monitor access site for signs and symptoms of bleeding or infection. -Notified Medical Doctor (MD) or Nurse Practitioner (NP) all items requiring review and obtains orders as appropriate. - Notes and carries out orders as appropriate and notified all disciplines as needed. -Maintains effective communication between the dialysis center and the facility. The facility policy titled, Fluid Restrictions dated 11/07/22 indicated that it was the facility policy to maintain fluid restrictions as per Medical Doctor (MD) or Nurse Practitioner (NP) order and an accordance with the recommendations from nephrology or dialysis. The procedure is as follows: -The Dietician communicates with nursing and dietary and inform both departments of their respective daily allotted fluid amounts. -Educate nursing staff on fluid restrictions and the total amounts allotted for each medication pass. -Utilizing the fluid restriction order set, and place the order for fluids to be given, including fluid breakdown. -Nursing to review fluids consumed during medication pass. -Document fluid restrictions and updates the CP. NJAC 8:39-27.1(a)

Based on record review, and review of other pertinent facility documentation, it was determined that the facility to respond to comments and recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications, (Resident #57) and was evidenced by the following: On 10/07/22 at 11:30 AM, the surveyor reviewed the Electronic Health Record (EHR) of Resident #57 which failed to contain specific CP recommendations. The surveyor requested to view the CP reviews and recommendations that were provided to the facility. The surveyor received and reviewed Resident #57's CP Summary Report which revealed that the CP made a recommendation directed to Nursing on 01/25/22, 02/09/22, 03/15/22, and 04/25/22 to separate Calcium from Iron by two hours as Antacids (calcium etc.) should not be given at the same time as Iron or it will reduce the absorption. When replotting, please make sure Calcium is plotted at meal times. Further review of the Summary Report revealed that on 05/12/22, the CP made the following recommendation directed to Administration: Recommendation repeated for the 6th time please address: Nursing: Separate Calcium from Iron by 2 hours. Antacids (calcium etc.) should not be given at the same time as Iron as Iron is as they will reduce absorption. When replotting, please make sure Calcium is plotted at meal times. The same recommendation was made to Nursing again on 06/02/22 and 09/20/22. A review of Resident #57's Resident Face Sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: anemia (deficiency of red blood cells or hemoglobin in blood resulting in pallor (pale) and weariness), deficiency of vitamins, arteriosclerotic heart disease (build up of fat, cholesterol and substances on the artery walls), and schizoaffective disorder (mental health disorder). On 10/12/22 at 11:31 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated that the CP notified the Director of Nursing (DON) of any CP recommendations and then nursing was informed . The RN/AUM was unable to provide the surveyor with documented evidence that she reviewed the monthly CP recommendations that were made on behalf of Resident #57 or that the resident's physician was informed of the recommendations. The RN/AUM stated that she had a book where she maintained resident records of the CP recommendations and related interventions and someone from Corporate threw the book away when the new computer system was recently implemented. The RN/AUM further stated that she changed the time for Calcium administration to 12 Noon. The surveyor reviewed Resident #57's Medication Administration Record (MAR) in the presence of the RN/AUM which revealed that the Calcium was ordered at 5:00 PM and the Iron was ordered at 11 AM. The RN/AUM stated at one point she changed the calcium administration time to noon and when the computer system was implemented the administration times were changed. The RN/AUM stated that she did not know why the CP made six separate recommendations to change the aforementioned medications times because, when the DON informed her of CP recommendations, she got it done. On 10/13/22 at 11:26 AM, the surveyor interviewed the DON who stated that the CP completed resident medications assessments, wrote recommendations, then sent the recommendations to the DON, Licensed Nursing Home Administrator (LNHA), the first floor Unit Manager, and the Regional LNHA. The DON stated that the RN/AUM did not have e-mail access, so the copies of the CP recommendations were brought to the unit and the DON reviewed the recommendations with the Unit Managers and the physician was notified. The DON stated that in the morning meeting there was an opportunity to discuss the CP recommendations as a team. The DON stated that once reviewed, the physician was notified of required changes. The DON stated that the CP recommendations were initialed once reviewed and the information was sent to the primary physician. The DON stated that as of 09/16/22, the facility implemented a new computer system. The DON further stated that she did not recall that the CP had made six or seven requests to change Resident #57's medication administration times related to both Calcium and Iron administration. On 10/14/22 at 8:49 AM, the surveyor conducted a phone interview with the CP via Speakerphone in the presence of the survey team. The CP stated that when he made a recommendation and repeated it, he then sent the recommendations to the LNHA, DON and Medical Director. The CP stated that in September of 2022 the failure to change Resident #57's medications times may have been related to the implementation of the new computer system. He further stated that in previous months the failure to change the medication times may have been due to noncompliance. The CP stated that he addressed the failure to change the medication administration times on 06/06/22, it was at that point the facility addressed the repeated requests. The CP stated that he documented that nursing was notified because it was a repeated recommendation. On 10/18/22 at 12:21 PM, the surveyor interviewed the LNHA who stated that the facility required that audits be done once the CP brought repeat recommendations to his attention. The DON who was present at that time, stated that she did not conduct an audit. The LNHA stated that an audit was necessary to do due to change in personnel. The LNHA stated that he also followed up on the CP recommendations so there should have been two different audits or weigh-ins. The LNHA stated that the RN/AUM's records should not have been destroyed by Corporate as they could be needed. The DON stated that record destruction should not have occurred with the implementation of the new computer system. The DON further stated that the Medical Director (MD) was also copied on the CP recommendations and had not questioned any of the recommendations recently. On 10/18/22 at 1:52 PM, the surveyor phoned the MD in the presence of the survey team. The MD stated that he had served in the role since 2018. The MD stated that he did not receive CP recommendations for this facility. The MD stated that the CP recommendation to separate the administration of both calcium and iron was of minor significance as it could make a precipitation of the calcium and became more thick when mixed with iron and definitely posed an issue with absorption because there was competition in the absorption. A review of the facility policy titled, Pharmacy Consultant Services (Reviewed 04/05/22) revealed the following: Purpose: To ensure that all medications and pharmacy services are in compliance with NJ Department of Health Guidelines and provide direction to physicians, NP and nurses when irregularities are noted. Pharmacy Consultant Duties: .If irregularities are noted, communicates suggestion for physician to assist to the DON and cc. to DON and the Medical Director including a coversheet indicating who has irregularities noted to ensure all information has been received. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what if any action will be taken to address it. If there is no change to the medication, the attending physician should document his or her rationale in the resident's medical record. .Nurse Managers review consultant recommendation and contacts MD/NP to address as soon as possible . NJAC 8:39-29.3(a)1,(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 10/06/22 from 09:49 AM until 10:47 AM, the surveyor toured the kitchen in the presence of the Certified Dietary Manager (CDM) and observed the following: 1. In the walk-in freezer, there were five sealed ten pound frozen logs of ground beef with manufacturer marked best before or freeze by [DATE] with no received or use by date. There were two sealed ten pound frozen tan and white packages of meat, that the CDM identified as pork loins, with no label and no received or use by dates. There was one tied large clear plastic bag that contained frozen tan meat, that the CDM identified as chicken drumsticks, with no label and no received or use by dates. There were three holes in the bag of chicken drumsticks with the meat visible and exposed to air. During an interview with the surveyor at that time, the CDM acknowledged that there were no received or use by stickers on the meats, and that there were no labels on the pork loins nor on the chicken drumsticks. She stated that it was important to label and date all food products when they were delivered to know when they were received and to tell how long they had been in storage. The CDM acknowledged the holes in the bag of chicken drumsticks and stated they should not have been packaged that way and that it was important to package food correctly so that bacteria was kept out, freezer burn was prevented, and the product was kept intact. The CDM removed the bag of chicken drumsticks and instructed the cook to throw them in the garbage. 2. On the top inside rim of the door to the full ice machine there was brown debris observed. The CDM acknowledged the debris and stated it should not have been there and that the ice machine was cleaned weekly and as needed and that every month it was emptied and sanitized. 3. On the bottom shelf of a two-tiered metal table in the prep area was a white rag with a brown spot lying in a red bucket that contained clear liquid and a white rag lying in a green bucket that contained clear liquid. The CDM stated the red bucket was sanitizer and the green bucket was soap and that the liquids were used to clean and sanitize the prep area before use, as needed, and when finished. The CDM used test strips to check the liquid in the red sanitizer bucket which read 50 parts per million (ppm). The CDM stated the ppm should be over 200 ppm and that the liquid would be changed and the bucket was removed. 4. On the drying rack were 2 stacked six-inch hotel pans with clear liquid observed between pans. The CDM acknowledged the wetness and stated they should not have been stacked and should have been dry to prevent bacterial growth. 5. On the inside doors of the left upper convection oven there was a brown greasy residue. On the inside doors of the left lower convection oven there was a brown greasy residue. The CDM acknowledged the residue and stated, there is a lot of carbon on them and that it should not have been there. The CDM further stated it was important to keep the ovens clean to decrease the chance of contamination. 6. On the bottom shelf of a two-tiered metal table in the cook prep area was a white rag lying in a red bucket that contained cloudy liquid. The CDM identified it as sanitizer and used [NAME] test strips to check the liquid in the red sanitizer bucket which had no reading. The CDM stated that it should have read 200 ppm and that it was important to clean and sanitize after using the station to prevent bacterial growth. The CDM instructed the cook to replace the bucket. 7. In the can section of the dry storage area there was one ten pound six ounce can of pineapple tidbits with a large dent. The CDM acknowledged the dent and stated it should not have been stored there and removed the can to the dented can section. The CDM stated it was important to not serve from dented cans because a resident could have gotten sick or gotten botulism. The surveyor reviewed the facility's policy, Dating and Labeling Policy, revised 4/2019, which revealed Policy: Kitchen will assure food safety by maintaining proper dates and labels to all ready to eat food products. Procedure: 2. Label products in storage with date the package was opened or expiration date with no more than 48 hours after opening, whichever is appropriate .4. Use the Pinnacle address label dating and labeling system to date all items. 6. Foods marked with manufactures (sic) use by date maybe used and stored until expiration date. The surveyor reviewed the facility's policy, Receivable and Storage Policy, revised 6/3/2013, which revealed Procedure: 11. Ensure that all foods are securely covered, dated, and labeled. The surveyor reviewed the facility's policy, Sanitizing Food Surfaces, revised 10/6/22, which revealed Policy: To ensure food safety, all food related surfaces will be cleaned and sanitized. Procedure: 3. Test sanitizer using a test strip to ensure proper concentration. Repeat every 2 hours. Follow instructions on test tube. 4. Repeat step 1 every shift or if solution becomes visibly dirty. The surveyor reviewed the facility's undated policy, Ice Machine Sanitation Policy, which revealed Procedure: 7. Spray inside of bin and lid with sanitizing solution. 8. Wipe bin and lid with clean disposable kitchen wipe. The surveyor reviewed the facility's undated policy, Kitchen Equipment General Cleaning Policy, which revealed Policy: the Director of Dining Services or designee will ensure that all equipment is maintained, kept clean, and in a sanitary condition before and after each use. Procedure: 1. Conventional/Convection Ovens, a. Clean after each use, inside and out, using soap and water. b. For heavy carbon build up, use easy-off (oven grill cleaner) or blend rite (degreaser) .5. Convection Oven- a. Clean after each use, both inside and out, using soap and water. b. For heavy cleaning, as needed, use the self clean feature (using the chemical specified in its instructions). The surveyor reviewed the facility document marked kitchen cleaning list that was dated 10/2-10/8. The document revealed Position: am cook, Clean and maintain daily: .inside and outside of ovens .10/2-10/6 initials were noted that task was completed. Position: pm cook, Clean and maintain daily: .inside and outside of ovens .10/2-10/5 initials were noted that task was completed. The surveyor reviewed the facility's policy, Dented Can Policy, revised 6/3/2013, which revealed Policy: .will identify cans with dents .Procedure: 2.cans have been placed on the appropriate shelf labeled Dented Cans. The surveyor reviewed the facility's policy, Wet Nesting Policy, revised 4/2019, which revealed Policy: .cooking ware, and equipment they must be air dried completely before being placed into storage for use. Procedure: Place items on drying rack and allow them to air dry. Do not stack. The surveyor reviewed the facility's undated policy, Pot Washing Policy, which revealed Procedure: 10. Air dry all clean and sanitized pots and wares (place in angle at least 20*-30*). Do not wipe dry. Do not stack. NJAC 8:39 17.2(g)

Based on interview and review of facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary to protect the health, safety, and welfare of all residents prior to the admission of registered sex offenders and residents admitted from the correctional facility. On 10/06/22 from 10:07 AM to 10:43 AM, the surveyor conducted the entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and Regional Nurse #1 and requested a copy of the Facility Assessment. On 10/13/22 at 01:03 PM, after multiple requests the LNHA provided the Facility Assessment to the surveyor. At that time, the surveyor reviewed the Facility Assessment which revealed in the Person (names/titles) involved in completing assessment section the LNHA had crossed out the previous LNHA and wrote in blue ink his name and initials. In the Date(s) of assessment or update section it was dated 03/08/21 and the LNHA wrote in blue ink the date 06/30/22 and his initials in blue ink. In the Date(s) assessment reviewed with QAA [Quality Assessment and Assurance]/QAPI [Quality Assurance and Performance Improvement] committee the LNHA had crossed out 1st [first] Quarter and wrote 3 [third] Quarter in blue ink. A further review of the Facility Assessment revealed that it did not address the identified required services and procedures necessary to protect the health, safety, and welfare of all residents prior to the admission of registered sex offenders and residents admitted from the correctional facility. On 10/18/22 at 11:44 AM, the LNHA in the presence of the Director of Nursing (DON) and the survey team stated that the facility had admitted registered sex offenders and from the correctional facility for years. He further stated that 31.7 percent of the facility's population were from correctional facilities or sex offenders. The LNHA acknowledged it was not addressed in the Facility Assessment. He stated it should have been a part of the Facility Assessment because we are identifying the needs to care for the particular population. The LNHA stated the Facility Assessment should have been updated but emphasized that this has been happening for years in this facility. The LNHA stated the facility had no contract with the correctional facilities and that the corporate company sold us a bill of goods. He further stated, we were supposed to have contracts with the prison; however, we do not have them and corporate said we had them. On 10/18/22 at 11:59 AM, the surveyor continued to interview the LNHA in the presence of the DON and survey team. The LNHA stated he had 30 years of experience as an LNHA, but he had just started 06/28/22 at this facility. The LNHA stated he had reviewed the Facility Assessment in July and he was confident that the Facility Assessment did not address the residents that were sex offenders and from the correctional facilities. The LNHA acknowledged he should have reviewed the Facility Assessment and ensured it was addressed. A review of the Administrator's Job Description reflected, The primary purpose of your position is to direct the day to the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. NJAC 8:39-5.1(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that their Quality Assurance and Performance Improvement (QAPI) Program was being implemented, and sources of quantitative data was being analyzed to identify quality deficiencies and evaluate program effectiveness. This deficient practice was identified during the standard survey, and was evidenced by the following: On 10/14/22 at 09:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with only one (1) quarterly Quality Assurance (QA) meeting from 08/29/22, which reflected the following: -QAPI Meeting Minutes: The COVID-19 (a contagious respiratory infection) outbreak in the month of August. It further reflected they discussed infection control precautions related to COVID-19. The QAPI Meeting Minutes for August did not reveal other topics were discussed. On 10/17/22 at 08:43 AM, the surveyor inquired additional information regarding the Quality Assurance Performance Improvement (QAPI) quarterly meetings. On 10/17/22 at 10:01 AM, the Director of Nursing (DON) in the presence of the survey team stated that the QAPI committee met quarterly with all the department heads. The DON stated that at the QA meetings they discussed antibiotic stewardship and immunizations. She further stated that the Medical Director (MD) had provided education on COVID-19 and vaccinations. The DON stated that the department heads discussed issues related to their departments but was unable to elaborate on the topics that were discussed. The surveyor inquired about other topics that may have been discussed such as falls. The DON then stated they discussed falls, and issues related to activities but was still unable to elaborate. On 10/17/22 at 10:19 AM, the surveyor interviewed the DON in the presence of the survey team regarding the facility's completion and submission of the Minimum Data Set (MDS) which was identified as a concern during the standard survey. The DON confirmed that there was an issue concerning the timeliness of the MDS completion and submission and that she had a conversation with the LNHA and facility cooperate office regarding the late assessments. She further stated that the late assessments were being discussed but that they did not discuss specific late MDS, just the whole picture of what was happening with the MDS process. The DON emphasized I was told we had individuals were working both remotely and on site to get assessments completed. The DON acknowledged the MDS was an identified concern and that it should have been brought to the QAPI committee. On 10/17/22 at 11:08 AM, the LNHA in the presence of the DON and the survey team stated that the QAPI committee met quarterly. The LNHA stated he was not in attendance at the August QAPI meeting and had started as LNHA for the facility on 06/28/22. The LNHA indicated that at previous QA meetings they discussed the transition to the new electronic medical record which started in July of 2022 and went live on 09/16/2022. On 10/17/22 at 12:55 PM, Regional Nurse #2 provided the surveyor with a second QA meeting held 04/13/2022, which reflected the following topics were discussed: -Review of COVID vaccination/Immunization statistics -QAPI on Activities of Daily Living (ADLs), Medication Administration Record (MAR), Treatment Administration Record (TAR) documentation missing signatures. -Successful Prevention of resident infections -Review of resident council meetings -Audit on COVID-19 vaccinations of residents completed by the DON on 04/01/22. -Audit on COVID-19 vaccinations on staff completed by the DON on 04/01/22. -Education for both residents and employees who refused vaccination. At that same time, Regional Nurse #2 stated the facility was unable to provide the survey team with additional quarterly QAPI meetings. On 10/18/22 at 12:04 PM, the DON in the presence of the LNHA and survey team stated they only had the QAPI meetings for April and August of 2022. The DON confirmed there was no QAPI for January and that she was unable to provide additional information for QAPI. On 10/18/22 at 01:52 PM, the surveyor interviewed the MD on the telephone who stated he was involved and attended the quarterly QAPI meetings. The MD stated he had conducted educations with the staff related to infections, falls and COVID. He further stated in April they discussed infection control and COVID and that in August he did the presentation for the antibiotic stewardship to ensure that the facility was following the appropriate criteria. The MD concluded additional QA topics included hospital transfers, readmissions, dietary concerns, physical therapy, and the pharmacy consultant's statistics. On 10/18/22 at 02:02 PM, the surveyor continued to interview the MD who stated the QAPI committee generally met every three (3) months unless something occurred. He stated he remembered the last two QAPI meetings but could not confirm if there was a meeting in January of 2022. The MD explained since it was a change in ownership in January it probably delayed the QAPI meeting. He concluded the meeting could have been towards the end of January but again he could not confirm. On 10/19/22 at 09:41 AM, the DON informed the surveyor she had a QAPI book that showed their root cause analysis and would provide it. On 10/20/22 at 11:37 AM, the Regional Licensed Nursing Home Administrator (Regional LNHA) in the presence of the LNHA, the DON, Regional Nurse #1 and the survey team confirmed that the facility was unable to provide additional information regarding the quarterly QAPI meetings. There were no sources of quantitative data provided that showed the facility had analyzed and identified quality deficiencies and evaluate program effectiveness. A review of the facility's Quality Assurance Performance Improvement policy date reviewed 5/15/22, reflected To study, plan analyze, validate specific areas of improvement for positive resident care outcomes .Guiding Principles: 3.We will use QAPI to make decisions to guide our day to day operations. 4. We will set goals for performance and measure progress towards those goals 7. We will use root cause analysis to identify specific areas to target and systems that need revision Feedback, Data Systems and Monitoring: 4. The facility will utilize multiple data sources to monitor performance including Quality Measures. State and National Benchmarks as well as tracking and investigating and adverse events affecting residents Procedure: Person Responsible QAPI committee members duties: 8. Complete audit tools as indicated to track progress. 9. Analyzes the data. 10. Determines interventions needed to improve the situation. NJAC 8:39-33.1(a)(c)(e); 33.2(a)(b)(c)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c.) On 10/14/22 at 8:37 AM, the surveyor observed an Agency Licensed Practical Nurse (ALPN #2) reviewing medications in the Electronic Medication Administration Record (EMAR) for Resident #4. ALPN #2 stated prior to administering medications he had to check Resident #4's blood pressure (BP). ALPN #2 then went down the hallway and returned with a standing tower blood pressure machine. On 10/14/22 at 08:39 AM, ALPN #2 and the surveyor entered the room of Resident #4. ALPN #2 informed the resident that he was there to check the BP prior to administering the medication. ALPN #2 then donned (put on) gloves without performing hand hygiene. On 10/14/22 at 08:42 AM, ALPN #2 obtained the BP results of 125/76 and removed his gloves. He then proceeded out of the room and immediately applied alcohol-based hand rub (ABHR) at the medication cart. On 10/14/22 at 08:46 AM, ALPN #2 gathered all the medications for Resident #4 from the medication cart and entered back into the resident's room and administered the medications. He then returned to the medication cart and applied ABHR. On 10/14/22 at 08:52 AM, ALPN #2 stated he needed to waste the BP medication Norvasc (used to treat high BP) 5 milligrams (mg) and proceeded to the medication storage room and obtained a medication disposable bottle to be placed in the medication cart. ALPN #2 returned to his medication cart and informed the surveyor he forgot to administer the resident's Breo Ellipta inhaler (used to treat asthma). On 10/14/22 at 08:56 AM, ALPN #2 entered the room of Resident #4 without performing hand hygiene, donned a pair of gloves, and administered the inhaler to the resident. He removed his gloves and immediately applied alcohol-based hand rub (ABHR) at the medication cart. On 10/14/22 at 08:57 AM, ALPN #2 donned a new pair of gloves and opened the medication disposable bottle and disposed of the Norvasc 5 mg inside of the bottle. He then removed his gloves and applied ABHR. On 10/14/22 at 09:03 AM, the surveyor observed ALPN #2 prepare five (5) medications which included Enoxaparin (used to treat or prevent a blood clot) 40 mg/0.4 ml injection for Resident #5. The ALPN #2 placed the oral (by mouth) medications inside a medication cup. He then placed the Enoxaparin injection inside his pocket. On 10/14/22 at 09:12 AM, the surveyor observed ALPN #2 administered the oral medications to Resident #5. At that time, ALPN #2 took the Enoxaparin out of his pocket and without performing hand hygiene donned a pair of gloves. ALPN #2 then cleaned the resident's abdomen with an alcohol pad and administered the Enoxaparin. ALPN #2 placed the syringe into the sharp's container, removed his gloves and applied ABHR. On 10/14/22 at 09:17 AM, ALPN #2 went down the hallway again and obtained the BP machine. ALPN #2 then entered Resident #5's room to obtain the vital signs. ALPN #2 donned a new pair of gloves without performing hand hygiene. At that time, ALPN #2 obtained the BP results, removed his gloves, and applied ABHR. On 10/14/22 at 09:21 AM, the surveyor interviewed ALPN #2 who stated hand hygiene should be performed before donning gloves and after removing them. He further stated since he was agency, he had been to so many facilities and was not sure if he had an in-service at this facility. When the surveyor asked if he used the appropriate hand hygiene technique before and after glove useage ALPN #2 concluded hopefully I did but was not sure because he was nervous since the surveyor watched him during medication pass. On 10/14/22 at 12:17 PM, in the presence of the survey team the Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated she in-serviced all staff including agency regarding hand hygiene. The LPN/IP stated staff should have used hand hygiene before donning gloves and after they removed the gloves. She further stated that staff should perform appropriate hand hygiene because they constantly touched surfaces and interacted with residents during care and medication administration. The LPN/IP concluded the importance of appropriate hand hygiene was to prevent the spread of infections. On 10/17/22 at 11:39 AM, the Director of Nursing (DON) acknowledged ALPN #2 should have applied ABHR before he donned his gloves and after he removed them. She further stated that ALPN #2 should have performed hand washing both before and after he administered the injection. The DON stated that it was important to appropriately perform hand hygiene to ensure their hands were properly sanitized before and after contact with residents. The DON concluded improper hand hygiene increased the risk for infection. A review of the in-service Handwashing on 10/3/22, that was provided by the LPN/IP, reflected that ALPN #2 was in attendance and revealed handwashing is to be performed for at least 20 seconds .or after 3 [three] uses of hand sanitizer. It further reflected Hand washing during Medication Administration: Soap and water must be used [for] the following circumstances: 3. After any direct physical contact with any resident . A review of the facility's policy, Handwashing/Hand Hygiene, revised date 08/06/2020, provided by the Regional Nurse #2, reflected 6. Use an alcohol-based hand rub .;or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations.: b. Before and after contact with residents; c. Before and after preparing or handling medications; d. Before performing any non-surgical invasive procedures; f. Before and after donning/doffing; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; 9. Single-use disposable gloves should be used: a. Before aseptic procedures. A review of the facility's policy, Infection Control: Wound Management, last reviewed 06/12/22, that was provided by the DON, revealed the following: Policy: It is the policy of this center to ensure that all appropriate personnel receive training and competency validation on wound management. Purpose: To comply with the Department of Health guidelines promote healing of wounds and prevent nosocomial infections related to wounds. 6. The Licensed Nurse: Gathers all supplies needed .9. Clean wound supplies are handled in a way to prevent cross contamination .10. Follow MD/NP for specific treatment, frequency and dressing covers. 11. Multi-dose creams and ointments should be dedicated to one resident whenever possible (maintain in plastic bag with resident's name) .and should not enter the resident treatment area. For example, a small allocation of medication can be dispensed into a clean container for single resident use. NJAC 8:39-27.1(a); NJAC 8:39:19.4 (a)(n) Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner for one (1) of one (1) nurse observed providing a wound care treatment to one (1) of one (1) resident (Resident #57); b.) maintain and store Personal Protective Equipment (PPE) and non-sterile resident care equipment in a safe and sanitary manner; and, c.) follow appropriate hand hygiene practices for one (1) of two (2) nurses who administered medications to two (2) of six (6) residents (Resident #4, and #5) during the medication pass. This deficient practice was evidenced by the following: 1. On 10/06/22 at 11:26 AM, the surveyor observed Resident #57 who was seated in a wheelchair in the dining room prior to meal service. The resident was pleasant when interviewed and voiced no concerns. On 10/07/22 at 9:40 AM, the surveyor observed Resident #57 lying in bed awake on a low air loss mattress (a mattress designed to prevent and aid in treatment of pressure wounds). The resident stated that he/she received wound treatments to their bottom daily. Review of the Resident Face Sheet revealed that Resident #57 was admitted to the facility with diagnoses which included but were not limited to: Schizoaffective disorder (a mental health condition), chronic multifocal osteomyelitis (inflammation of the bone usually due to infection), pain, unspecified, anemia (deficiency of red blood cells or hemoglobin in the blood), and artherosclerotic heart disease (disease of the arteries characterized by the deposition of plaques of fatty materials on the inner walls). Review of Resident #57's quarterly Minimum Data Set (MDS), an assessment tool dated 07/08/22, revealed that the Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated that the resident was moderately cognitively impaired. Further review of the MDS revealed that the resident required extensive assistance of one person for bed mobility and required extensive assistance of two (2) persons for transfers. The MDS indicated that the resident had diagnoses which included complete traumatic amputation between the left hip and knee and complete traumatic amputation of the right lower leg. Review of Section M of the MDS revealed that the the resident had one (1) facility acquired stage four pressure ulcer (deep wound reaching the muscles, ligaments, or bones). Review of a Report of Consultation dated 07/27/22, revealed that the Wound Care Consultant documented that Resident #57 had a left posterior thigh wound that measured 1.5 x 1 x 0.5 (unit of measurement not specified) and a right posterior thigh wound that measured 0.5 x 1 x 0.2 (unit of measurement not specified) with a diagnosis of: b/l (bilateral) Stage III (full thickness skin loss involving damage or necrosis of subcutaneous tissue that extended down to, but not through the underlying fascia) ischeal (buttock) ulcers. Recommendations: .Continue Santyl/dressing b/l ischeal ulcer q-day (daily). On 10/12/22 at 11:49 AM, the surveyor interviewed the Registered Nurse/Acting Unit Manager (RN/AUM) who stated that she was about to do Resident #57's wound treatment and agreed to permit the surveyor to observe. The RN/AUM stated that the resident was a b/l amputee and had a chronic wound. The RN/AUM then proceeded to go into the medication room where she accessed the treatment cart and obtained supplies to be used during the treatment. At 12:01 PM, the RN/AUM washed her hands for 34 seconds and donned (put on) a pair of gloves after. At 12:03 PM, the RN/AUM picked up a bottle of hand sanitizer and poured some onto Resident #57's over bed table and immediately wiped it off with a bath towel afterward. She stated that the hand sanitizer contained alcohol and was used to clean the table. The RN/AUM then placed the bath towel used to clean the table in a trash bag when finished. At 12:04 PM, the RN/AUM placed a chux pad (thin, disposable absorbent pad) on the resident's overbed table before she arranged the wound care supplies on the table. The RN/AUM then removed a previously opened tube of Santyl (removes dead tissue from wounds) from her uniform pocket which was in the same pocket as the keys to the medication room. She then dispensed Santyl into a plastic medication cup before she laid the tube of Santyl on the resident's night stand. At 12:06 PM, the RN/AUM used her gloved hands as she searched through Resident #57's top drawer of the night stand for wound treatment supplies. The RN/AUM then stated that she forgot to get cotton tipped applicator sticks from the treatment cart in order to apply the Santyl to the resident's wound bed. The RN/AUM then reached into her uniform pocket with her gloved hand and pulled out a cell phone and proceeded to attempt to call a staff member to request cotton tipped applicators. At 12:13 PM, the RN/AUM again used her gloved hands and attempted to call another staff member for assistance. The RN/AUM stated that she did not want to leave the site in order to obtain the cotton tipped applicators. At 12:17 PM, the RN/AUM doffed (removed) her gloves, used hand sanitizer and donned gloves. At 12:23 PM, the RN/AUM stated that the Certified Nursing Assistant (CNA) had previously removed Resident #57's dressing prior to the observation as the resident was soiled. The RN/AUM then stated that she intended to use saline to cleanse the wounds that were present on the resident's right and left buttocks prior to Santyl application. At 12:26 PM, the RN/AUM stated that the tube of Santyl fell off of the top of Resident #57's night stand and into the resident's drawer. The RN/AUM stated that she would return the tube of Santyl to the treatment cart after the wound treatment. At 12:28 PM, the RN/AUM doffed her gloves, failed to first perform hand hygiene after, and used her cell phone in an attempt to call a staff member for assistance. At 12:30 PM, the RN/AUM stated that wound treatment competencies were last done at the facility by a wound consultant prior to the pandemic but had not been done since. At 12:41 PM, the RN/AUM used hand sanitizer to perform hand hygiene and donned gloves. A staff member responded at that time with the cotton tipped applicators. The RN/AUM used her gloved right hand and retrieved the cotton tipped applicators directly at the tips from the package. At 12:43 PM, the RN/AUM pulled back Resident #57's sheets and applied saline to a 4 x 4 dressing that she used to cleanse the resident's wound. At 12:44 PM, the RN/AUM used a cotton tipped applicator stick and applied Santyl to the wound bed. She then folded a 4 x 4 dressing, and lined the inside of the border dressing with the folded 4 x 4 and placed the dressing over the wound on the right posterior thigh. At 12:45 PM, the RN/AUM doffed her gloves, and used hand sanitizer. At 12:46 PM, the RN/AUM donned new gloves, applied saline to a 4 x 4 dressing and cleansed the left posterior thigh wound. She then proceeded to use another 4 x 4 dressing to blot the wound dry. At 12:47 PM, the RN/AUM used a cotton tipped applicator stick to apply Santyl to Resident #57's left thigh wound. She then folded a 4 x 4 dressing and placed it beneath a border gauze dressing and applied it to the wound. At 12:49 PM, the RN/AUM doffed her gloves and washed her hands. She dried her hands on a paper towel and did not discard the paper towel in the trash can bedside the sink as she stated that the lid on the trash can was not utilized to discard the paper towel as it was a swing top lid and she did not want to recontaminate her hands. The RN/AUM then proceeded to carry the soiled paper towel out of the bathroom and discarded it in the trash can beside Resident #57's bed. At 12:56 PM, the RN/AUM gathered Resident #57's wound treatment supplies and disposed of them in the soiled utility room. When the RN/AUM and surveyor returned to the resident's room, the resident had already been served lunch and had began to eat on top of the over bed table which had not been cleaned post-wound treatment. At 12:58 PM, the RN/AUM obtained a canister of disinfectant bleach wipes and used them to clean the outside of a stainless steel container that the RN/AUM stated was used to store 4 x 4 dressings. At 1:01 PM, the RN/AUM removed a set of keys from her pocket and unlocked the door to the medication room. The RN/AUM stated that Resident #57's tube of Santyl was in her pocket and she then proceeded to remove the Santyl from her pocket and returned the tube to an unsecured area of the top drawer of the treatment cart before she left the medication room. At 1:03 PM, the RN/AUM attempted to sign out the treatment but was unable to do so. She stated that she intended to write a note to document that the treatment was administered instead. When interviewed at that time, the RN/AUM stated that she should have checked the order for the wound treatment prior to administration. She also stated that, She used hand sanitizer to clean Resident #57's over bed table because it was closest item to her at that time and since it contained alcohol, it was Okay. The RN/AUM stated that she should have used disinfectant wipes to clean the over bed table after the wound treatment because it was an infection control issue. The RN/AUM stated that it was also an infection control risk when she used her gloved hands and touched the tube of Santyl, the keys to the medication room and her cell phone. The RN/AUM stated that she should have cleaned the tube of Santyl before she returned it to the treatment cart. At 1:17 PM, in a later interview with the RN/AUM, she stated that she should have doffed her gloves and washed her hands after she cleansed Resident #57's wounds with saline and patted the wounds dry prior to Santyl and dressing application. The RN/AUM stated that she did not know what the facility wound treatment policy specified and added that she would have to review it. The RN/AUM stated that she was not going to lie, but her usual practice was to doff her gloves and perform hand hygiene after she cleansed the wound immediately prior to Santyl application. On 10/13/22 at 11:03 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the RN/AUM should have cleaned the table prior to performing Resident #57's wound treatment with disinfectant wipes and allowed the table to dry for three minutes in accordance with the manufacturers instructions for disinfection. The DON stated that the RN/AUM was required to cleanse the resident's wound by swiping once and discarding the 4 x 4 dressing after, doffing her gloves and washing her hands after. The DON stated that the purpose was to maintain an aseptic technique to prevent contamination before treatment application. She stated that the next step was to pat the wound dry and apply the dressing. The DON stated that application of hand sanitizer to clean the table was not usual practice and a bath towel should not have been used to to clean a dirty surface as the towels were to be used for resident care. The DON stated that that the RN/AUM should have allowed the surface of the table to dry before she applied a chux on top of it to prevent contamination. The DON stated that the RN/AUM should not have placed the tube of Santyl into her pocket with her cell phone and retrieved it with her gloved hands as the tube was considered contaminated. She further stated that if the resident's over bed table was not cleaned prior to meal service it could have potentially resulted in contamination. On 10/14/22 at 12:33 PM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that Resident #57's over bed table should have been cleaned with disinfectant wipes as it was not acceptable to use hand sanitizer to clean the table to ensure that all germs were killed, because hand sanitizer did not kill everything. The LPN/IP stated that she would not have placed the tube of Santyl on Resident #57's night stand. The LPN/IP stated that it was not appropriate to touch wound treatment supplies with gloved hands and then touch your cell phone as whatever was in the room was now transferred onto the phone. The LPN/IP stated that the RN/AUM should have doffed her gloves and washed her hands and donned new gloves prior to the treatment after the wound was cleansed with saline because the gloves were considered dirty and there was a big risk of contamination. She further stated that if the RN/AUM removed the tube of Santyl from her pocket and placed it back into the treatment cart there was a risk of infection. 2. On 10/14/22 at 11:21 AM, the surveyor interviewed the LPN/IP who stated that the facility stored their 60 day emergency back up supply of Personal Protective Equipment (PPE, clothing and equipment worn to provide protection against hazardous substances or environments) outside in trailers. On 10/18/22 at 2:35 PM, the Licensed Nursing Home Administrator (LNHA) agreed to show the surveyors the emergency back up supply of PPE. The LNHA led the surveyors through the laundry area and called for the Director of Maintenance (DOM) to unlock the door to access the PPE storage area which was kept outside of the facility. The DOM and a member of Housekeeping responded and led the surveyors outdoors to a locked fence that led to a covered area beneath the building. The surveyors observed multiple boxes of PPE, and resident care supplies such as adult briefs, egg crate foam (used to cover and cushion a mattress surface), and respiratory tubing which were stacked on pallets that were placed directly on the ground. The boxes were not covered and were stacked to a level that was just below the ceiling of the area that was adjacent to the refuge storage and the covered parking area under the building. The PPE that was observed was verified by the LNHA which he stated consisted of KN-95 masks (face mask that blocks 95% of particles), gowns, and gloves. There was a soiled take-out food container, a loose surgical mask and a box of plastic disposable gowns that laid directly on the ground in direct contact with the pallets that held the PPE. The PPE storage area was in the same area that contained discarded medical equipment and furniture that was stacked high in the densely packed, crowded area. Some of the equipment observed was covered by tarps. A portion of the ceiling that was closest to the outside perimeter of the storage area had collapsed and hung in place and both furniture and equipment were positioned directly below the hole in the ceiling. When interviewed at that time, the LNHA stated,Technically, we are outside under the building. He stated that the PPE was kept outdoors because the building was [AGE] years old and did not have enough storage. He stated that the supplies were maintained on skids and were technically off of the ground. The LNHA stated that there was no other place to store the PPE and various medical equipment. The LNHA opened a box of KN-95 masks and stated, See, they are sealed in plastic and the integrity is preserved. The LNHA further stated that there were fences around the area so critters could not get in. On 10/20/22 at 9:22 AM, the surveyor interviewed the LPN/IP in the presence of the survey team, who stated that she knew that the PPE was stored outside in the cages since she began working at the facility in March of 2022. The LPN/IP stated that she did not go into the area where the PPE was stored due to a fear of bugs. The LPN/IP stated that though the area was locked, squirrels, raccoons or anything could get in there. The LPN/IP further stated that if there were heavy rain or snow it could compromise the integrity of the PPE and supplies. She further stated that the PPE was moved out of the cages and into the building yesterday (10/19/22). On 10/20/22 at 12:03 PM, the surveyor interviewed the MD who stated that he worked at the facility for 15 years. He stated that while he did not have an inventory sheet to validate the quantity of PPE and the duration that the PPE was kept outdoors, he was certain that the PPE was moved to the outdoor area in 2022 under previous administration. Both the MD and the Housekeeper led the surveyor to the Barber Shop where the PPE had been moved to. The Housekeeper stated that the boxes that were stacked high on pallets that were previously kept outdoors contained: gloves, gowns, respirator masks, COVID-19 rapid test kits, and hand sanitizer. The surveyor requested the MD to open one of the boxes whose cardboard exterior appeared weathered and the texture of the box was not smooth in appearance. When the MD opened the box it contained individually wrapped, disposable isolation gowns. The MD stated that he would open the boxes and examine the contents for mold and mildew prior to the PPE being released to the nursing units.

b.) 1.) Resident #45's ARD was 09/24/22, the quarterly MDS assessment was not completed until 10/18/22, 24 days later. On 10/14/22 at 12:14 PM, Surveyor #2 interviewed the MDS/RMC who stated that Resident #45's last quarterly MDS was completed on 6/24/22 and that the next quarterly MDS was due on 9/24/22, it was not completed, and that it should have been done by 10/8/22. The MDS/RMC stated that it was important to complete MDS's accurately and in a timely manner because they were assessment tools that guided the care plan and were used to identify any problems that could cause potential harm. On 10/18/22 at 12:36 PM, in the presence of the Director of Nursing (DON), the surveyor interviewed the LNHA who acknowledged Resident #45's last quarterly MDS that was due on 09/24/22 was not completed. The LNHA stated the MDS should have been done within 14 days so the rest of the team could have been exposed to the information on the MDS. 2.) Resident #57's ARD was 07/08/22, the quarterly MDS assessment was not completed until 09/14/22, 68 days later. 3.) Resident #63's ARD was 09/22/22, the quarterly MDS assessment was not completed until 10/19/22, 27 days later. According to the CMS RAI Version 3.0 Manual Chapter 2 Assessment for the RAI pages 2-16: Quarterly (Non-Comprehensive) must be completed 14 calendar days after the ARD and submitted 14 calendar days after the assessment is completed. The facility policy titled. Minimum Data Set with a revised date of 09/28/22 indicated that the RN MDS coordinator schedules the residents' assessments and care plan meetings in accordance with Center for Medicare and Medicaid Services (CMS) regulations and guidelines and resident's needs. The facility job description titled; Director of Clinical Reimbursement (MDS Coordinator) indicated that the MDS Coordinators duties included: -Ensuring that all assessments are completed and transmitted in a timely manner and to report problem areas to the Administrator. NJAC 8:39 - 11.2 Based on interview and record review, it was determined that the facility failed to a.) complete and submit to Centers for Medicare and Medicaid Services (CMS) a Quarterly Minimum Data Set (MDS), a resident assessment tool used to facilitate the management of care, in a timely manner for 16 of 27 residents (Resident #1, #3, #4, #5, #6, #7, #8, #14, #16, #17, #21, #27, #31, #35, #36, and #37) reviewed for system selected MDS over 120 days for late submissions b.) complete a Quarterly MDS in a timely manner for three (3) of 19 residents reviewed (Resident #45, #57, and #63). This deficient practice was evidenced by: a.) On 10/14/22 at 10:36 AM, surveyor #1 interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. The surveyor provided the RMC with a list of resident MDS assessments that were late or not submitted and the MDS/RMC stated that she would email the surveyor information regarding the late assessments and why the assessments were not completed or transmitted timely. She stated she would investigate the issue. On 10/17/22 at 10:06 AM, the surveyor interviewed the MDS/RMC who stated that she had been an MDS coordinator for 12 years. The MDS/RMC stated that she supervised nine (9) other sister facilities MDS departments for this company. She stated that the facility had per diems (as needed) Registered Nurses Minimum Data Set coordinators (RN/MDS) nurses that performed the MDS assessment for the residents in the facility. She stated that there has not been a full time MDS coordinator in the facility since August 2022 and that the RN/MDS per diem nurses come into the facility to assess the resident, interview the residents, review the medical record, and clarify and confirm what was in the medical record was accurate. She stated that the MDS clinical assessment opened in the EMR for completion seven (7) days prior to the Assessment Reference Date (ARD, the date that signifies the end of the look back period). She stated once the specific MDS opens, all disciplines can enter the MDS to complete their section. She stated that the quarterly, annuals and significant changes MDS were due to be completed 14 days from the ARD. She confirmed that there were multiple MDS that were not completed or were late in the facility. She stated that the quarterly, annual, and significant change assessments were required to be submitted 14 days from the completion date. She stated that it was a challenge to try and find a full time MDS coordinator and that the facility corporate office was aware that the assessments were overdue. She said that they were trying their best to have the MDS assessments done timely. She confirmed that there were multiple comprehensive and quarterly assessments that were late but that they were doing their best to try and complete them. She stated that it would be important to assure timely completion and timely transmission of assessments because the MDS was a tool that was used for identification of problems, care plan accuracy, and to ensure proper services were provided to the residents. 1.) Resident #1's ARD was 08/05/22, the quarterly assessment (QA) was not completed until 10/17/22, 73 days later, and was submitted 10/17/22. 2.) Resident #3's ARD was 08/10/22, the QA was not completed until 10/17/22, 68 days later, and was submitted 10/17/22. 3.) Resident #4's ARD was 08/10/22, the QA was not completed until 10/16/22, 67 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 4.) Resident #5's ARD was 08/10/22, the QA was not completed until 10/17/22, 68 days later, and was submitted 10/17/22. 5.) Resident #6's ARD was 08/17/22, the QA was not completed until 10/17/22, 61 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 6.) Resident #7's ARD was 08/17/22, the QA was not completed until 10/16/22, 60 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 7.) Resident #8's ARD was 08/27/22, the QA was not completed until 10/17/22, 51 days later, and was submitted 10/17/22. 8.) Resident #14's ARD was 08/11/22, the QA was not completed until 10/16/22, 66 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 9.) Resident #16's ARD was 08/18/22, the QA was not completed until 10/16/22, 59 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 10.) Resident #17's ARD was 08/18/22, the QA was not completed until 10/17/22, 60 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 11.) Resident #21's ARD was 08/15/22, the QA was not completed until 10/16/22, 62 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 12.) Resident #27's ARD was 09/15/22, the QA was not completed until 10/17/22, 32 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 13.) Resident #31's ARD was 04/17/22, the QA was not completed until 07/22/22, 96 days later, and was submitted 07/22/22. 14.) Resident #35's ARD was 09/03/22, the QA was not completed until 10/11/22, 38 days later, and was not submitted yet. 15.) Resident #36's ARD was 09/03/22, the QA was not completed until 10/18/22, 45 days later, and was not submitted yet. 16.) Resident #37's ARD was 09/03/22, the QA was not completed until 10/17/22, 44 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, did not indicate that this assessment was submitted. On 10/17/22 at 10:19 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the most recent MDS coordinator resigned August 26th, 2022 and has not been replaced. She stated that the facility had per diem RN/MDS coordinators who were completing MDS's. She stated the RN/MDS coordinators were doing their best to assure timely completion and transmission of the MDS. She confirmed that there was an issue concerning the timeliness of MDS completion and submission. She stated that she had a conversation with the Licensed Nursing Home Administrator (LNHA) and facility corporate office regarding the late assessments and that part time RN/MDS coordinators were working on the late assessment to get them completed. She stated that late MDS assessments were being discussed weeks after the last RN/MDS coordinator left. She stated, We did not discuss specific late MDS, just the whole picture of what was happening with the MDS process, and I was told we had individuals who were working both remotely and on site to get assessments completed. On 10/17/22 at 11:10 AM, the surveyor interviewed the LNHA regarding his knowledge of late completion and transmission of the MDS assessments. The LNHA stated that he was not aware that the MDS's were late and was not informed by clinical staff that the MDS's were not completed or transmitted timely. He stated that he was not told that the MDS's were a major outstanding issue in the facility. He stated that the only issue that was a concern regarding MDS, was them being uploaded to the new electronic medical record (EMR). The LNHA stated that the MDS/RMC should have notified him that there were MDS's that were not completed timely or transmitted timely.

Based on observation, interview, and record review, it was determined that the facility failed to electronically submit the Minimum Data Set (MDS), a resident assessment tool, within 14 days after completion as required. This deficient practice was identified for 22 of 27 residents (Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #14, #16, #17, #21, #23, #27, #30, #31, #33, #35, #36, and #37) reviewed for MDS record over 120 days . This was evidenced by the following: On 10/14/22 at 10:36 AM, the surveyor interviewed the Regional Minimum Data Set Coordinator (MDS/RMC) regarding late, non-completed MDS assessments. The surveyor provided the MDS/RMC with a list of resident MDS assessments that were late or not submitted and the MDS/RMC stated that she would email the surveyor information regarding the late assessments and why the assessments were not completed or transmitted timely. She stated she would investigate the issue. On 10/17/22 at 10:06 AM, the surveyor interviewed the MDS/RMC who stated that she had been an MDS coordinator for 12 years. The MDS/RMC stated that she supervised nine (9) other sister facility's MDS departments for this company. She stated that the facility had per diems (as needed) Registered Nurses Minimum Data Set Coordinators (RN/MDS) nurses that performed the MDS assessment for the residents in the facility. She stated that there had not been a full time MDS coordinator in the facility since August 2022 and that the RN/MDS per diem nurses came into the facility to assess the resident, interview the residents, review the medical record, and clarify and confirm that what was in the medical record was accurate. She stated that the MDS clinical assessment opened in the EMR for completion seven (7) days prior to the Assessment Reference Date (ARD, the date that signifies the end of the look back period). She stated once the specific MDS opens, all disciplines can enter the MDS to complete their section. She stated that the quarterly, annuals and significant changes MDS's were due to be completed 14 days from the ARD. She confirmed that there were multiple MDS's that were not completed or were late in the facility. She stated that the quarterly, annual, and significant change assessment were required to be submitted 14 days from the completion date. She stated that it was a challenge to try and find a full time MDS coordinator and that the facility corporate office was aware that the assessments were overdue. She said that they were trying their best to have the MDS assessments done timely. She confirmed that there were multiple comprehensive and quarterly assessments that were late but that they were doing their best to try and complete them. She stated that it would be important to assure timely completion and timely transmission of assessments because the MDS was a tool that was used for identification of problems, care plan accuracy, and to ensure proper services were provided to the residents. 1.) Resident #1's ARD was 08/05/22, the assessment was not completed until 10/17/22, 73 days later, and was submitted 10/17/22. 2.) Resident #3's ARD was 08/10/22, the assessment was not completed until 10/17/22, 68 days later, and was submitted 10/17/22. 3.) Resident #4's ARD was 08/10/22, the assessment was not completed until 10/16/22, 67 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 4.) Resident #5's ARD was 08/10/22, the assessment was not completed until 10/17/22, 68 days later, and was submitted 10/17/22. 5.) Resident #6's ARD was 08/17/22, the assessment was not completed until 10/17/22, 61 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 6.) Resident #7's ARD was 08/17/22, the assessment was not completed until 10/16/22, 60 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 7.) Resident #8's ARD was 08/27/22, the assessment was not completed until 10/17/22, 51 days later, and was submitted 10/17/22. 8.) Resident #9's ARD was 08/27/2022, the assessment was not completed until 10/17/22, 51 days later, and was submitted on 10/17/2022. 9.) Resident #10's ARD was 08/12/2022, the assessment was not completed until 10/18/2022, 67 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 10.) Resident #11's ARD was 08/11/2022, the assessment was not completed until 10/16/2022, 66 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 11.) Resident #14's ARD was 08/11/22, the assessment was not completed until 10/16/22, 66 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 12.) Resident #16's ARD was 08/18/22, the assessment was not completed until 10/16/22, 59 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 13.) Resident #17's ARD was 08/18/22, the assessment was not completed until 10/17/22, 60 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 14.) Resident #21's ARD was 08/15/22, the assessment was not completed until 10/16/22, 62 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 15.) Resident #23's ARD was 09/03/2022, the assessment was not completed until 10/17/2022, 44 days later, and submitted on 10/17/2022. 16.) Resident #27's ARD was 09/15/22, the assessment was not completed until 10/17/22, 32 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 17.) Resident #30's ARD was 07/15/2022, the assessment was not completed until 10/17/2022, 94 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 18.) Resident #31's ARD was 04/17/22, the assessment was not completed until 07/22/22, 96 days later, and was submitted 07/22/22. 19.) Resident #33's ARD was 07/19/2022, the assessment was not completed until 10/16/2022, 89 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. 20.) Resident #35's ARD was 09/03/22, the assessment was not completed until 10/11/22, 38 days later, and was not submitted yet. 21.) Resident #36's ARD was 09/03/22, the assessment was not completed until 10/18/22, 45 days later, and was not submitted yet. 22.) Resident #37's ARD was 09/03/22, the assessment was not completed until 10/17/22, 44 days later. The facility provided the surveyor with a CMS submission report MDS 3.0 final Validation report dated 10/17/22, which did not indicate that this assessment was submitted. On 10/17/22 at 10:19 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the most recent MDS coordinator resigned August 26th and has not been replaced. She stated that the facility had per diem RN/MDS coordinators who were completing MDS's. She stated the RN/MDS coordinators were doing their best to assure timely completion and transmission of the MDS. She confirmed that there was an issue concerning the timeliness of MDS completion and submissions. She stated that she had a conversation with the Licensed Nursing Home Administrator (LNHA) and facility corporate office regarding the late assessments and that part time RN/MDS coordinators were working on the late assessment to get them completed. She stated that late MDS assessments were being discussed weeks after the last RN/MDS coordinator left. She stated, We did not discuss specific late MDS, just the whole picture of what was happening with the MDS process, and I was told we had individuals who were working both remotely and on site to get assessments completed. On 10/17/22 at 11:10 AM, the surveyor interviewed the LNHA regarding his knowledge of late completion and transmission of the MDS assessments. The LNHA stated that he was not aware of that MDSs were late and was not informed by clinical staff that the MDSs were not completed or transmitted timely. He stated that he was not told that the MDS's were a major outstanding issue in the facility. He stated that the only issue that was a concern regarding MDS, was them being uploaded to the new electronic medical record (EMR). The LNHA stated that the MDS/RMC should have notified him that there were MDS were not completed timely or transmitted timely. According to the CMS RAI Version 3.0 Manual Chapter two (2) Assessment for the RAI pages 2-16: Quarterly (Non-Comprehensive) must be completed 14 calendar days after the ARD and submitted 14 calendar days after the assessment is completed. Annual (Comprehensive) assessment must be completed 14 calendar days after the ARD and submitted 14 calendar days after the assessment is completed. The facility policy titled. Minimum Data Set with a revised date of 09/28/22, indicated that the RN MDS coordinator schedules the residents' assessments and care plan meetings in accordance with Center for Medicare and Medicaid Services (CMS) regulations and guidelines and resident's needs. The facility job description titled; Director of Clinical Reimbursement (MDS Coordinator) indicated that the MDS Coordinators duties included: -Ensuring that all assessments are completed and transmitted in a timely manner and to report problem areas to the Administrator. NJAC8:39-11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to a) properly transcribe and document a physician order and; b) obtain a physician order for transmission-based precautions (infection prevention and control practices for individuals known or suspected to be infected with infectious agents) in accordance with professional standards of clinical practice and facility policy. This deficient practice was identified for 2 of 3 Residents (Resident #273 and #275) reviewed for infections and 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 (RN) 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 (LPN) 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 10/14/20 beginning at 11:32 AM, the surveyor toured the second floor Long Term Care Unit (LTC) and observed two residents on transmission-based precautions and a 14-day quarantine. 1. On 10/14/20 at 12:13 PM, the surveyor observed Resident #273's door was open. There was no sign on the door informing staff of infection control precautions and there was no personal protective equipment (PPE - equipment worn to protect the body from injury or infection) outside the room. On 10/16/20 at 11:13 AM, the surveyor reviewed the medical record for Resident #273 which revealed a physician order for Transmission Based precaution x 14 days. The physician order was acknowledged, signed, and dated by the physician on 10/3/20. On 10/19/20 at 9:40 AM, a review of October 2020 Treatment Administration Record (TAR) revealed a physician order for Transmission Based Precaution x 14 days, FYI, and dated 10/3/20. The surveyor interviewed Resident #273 on 10/19/20 at 9:23 AM. The resident stated that during admission to the facility they were on isolation and could not leave the room unless it was to smoke outside. Resident #273 was wearing a surgical face mask. On 10/20/20 at 12:43 PM, the surveyor interviewed LPN #1 at the nurse's desk. She stated that PPE was worn in the rooms of residents who were on 14-day quarantine and consisted of an N95 mask, goggles, gloves, gown, and face shield. The surveyor showed LPN #1 the medical chart and she confirmed Resident #273 had a physician order that read: Transmission Based Precaution x 14 days. 2. On 10/16/20 at 9:30 AM, the surveyor observed Resident #275's door was closed. Outside the door was a red sign that read: Stop isolation room precaution, please use proper PPE prior to entering isolation room. Also located outside the door was a black container with three drawers that contained PPE. Located on top of the container was a white sign that read: Stop please speak with nursing before entering. On 10/19/20 at 10:58 AM, the surveyor reviewed the medical record for Resident #275 which did not reveal a physician order for Transmission-Based Precautions x 14 days. The physician orders, that were hand- written, was acknowledged, signed, and dated on 10/6/20 On 10/20/20 at 12:37 PM, the surveyor interviewed LPN #1 who stated that the PPE worn in the rooms of a resident that was quarantined for 14 days was gloves, N95 mask, gown, face shield, goggles, and hair net. All PPE was discarded in the room before leaving and placed in the red biohazard bag. Staff were to wash their hands after removal of PPE. In the presence of the surveyor, LPN #1 confirmed that Resident #275's medical order did not reveal a physician order for transmission-based precaution and stated, It should be written. On 10/21/20 at 10:03 AM, the Administrator, Director of Nursing (DON), Regional Minimum Data Set (MDS) Coordinator, Regional Director/IP, and LPN #2 were interviewed in the survey team's presence. The DON stated that for Resident #273 and Resident #275, there was no physician order for TBP, therefore one had to be created. The Regional Director/IP stated that the nurses were not aware that they had to obtain an order for TBP x 14 days on all newly admitted residents. The Regional Director/IP added that when obtaining a physician order, the order should be written as a telephone order and not written on the POS. The DON viewed the POS and confirmed that the order should have been written as a telephone order. At 12:44 PM, the DON, Regional Minimum Data Set (MDS) Coordinator, and Regional Director/IP returned to the conference room to be interviewed in the survey team's presence. The surveyor showed the facility provided copies of the POS that read: Transmission Based Precaution x 14 days and written above the order was a date of 10/20/20. The DON stated that the date was written on the POS to indicate that Resident #273 and Resident #275 did not have an order for TBP since their admission and that the nursing staff was made aware that an order was needed for TBP and they thought that a correction had to be made. The DON confirmed that an order must be obtained for residents on isolation precaution, and was unsure who wrote the date of 10/20/20 on the POS. The surveyor showed the facility provided copy of the POS for Resident #273 that was copied on 10/19/20 and reflected a physician order which indicated Transmission Based Precaution x 14 days and was without a date. The DON responded that she did not realize that the resident already had an order; and that the order already existed and that it should have been left as is without a date. The DON continued to mention that when a resident was admitted to the facility that the orders were handwritten on the POS, afterwards any further order should be written as a telephone order and not on the POS. The DON confirmed that the physician had already approved the orders that were handwritten on 10/3/20. The DON, Regional (MDS) Coordinator, and Regional Director/IP confirmed that the POS was altered. On the same day at 2:13 PM, the DON, Administrator, Regional MDS Coordinator, Regional Director/IP, and LPN #2 were interviewed in the survey team's presence. The Regional Director/IP clarified the facility policy titled, Monthly Recaps, indicated new physician orders. The Regional Director stated that the night shift nurse will transcribe new orders onto the medication administration record (MAR), TAR and telephone order sheet. The DON stated the only exception was for new admissions; new orders were written on the telephone order sheet. The Regional Director/IP indicated that the facility policy should reflect the DON's statement. Review of a facility policy titled, Telephone Orders, dated 1/16/2020, Section #2 read: The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Review of a facility policy titled, Physician Services, dated 2/25/2020, Section #4 read: Physician orders and progress notes shall be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy. N.J.A.C. 8:39-11.2(b)

4. On 10/14/20 at beginning at 11:32 AM, the surveyor toured the second floor Long Term Care Unit (LTC) and observed two residents on TBP. On 10/14/20 at 12:13 PM, the surveyor observed Resident #273's door open. There was no sign on the door informing staff of infection control precautions and no PPE outside the room. This resident had tested negative for the COVID virus in the hospital prior to admission. At 12:25 PM, the surveyor observed LPN #1 enter Resident #273's room wearing only a black cloth mask. LPN #1 then exited the resident's room and proceeded to enter and exit two additional resident's rooms. The surveyor interviewed LPN #1 at 12:25 PM on 10/14/20. LPN #1 was wearing a black cloth mask with a retail store's name printed on one side of the mask. LPN #1 stated that Resident #273 had been admitted to the facility for two weeks and was placed in a private room. LPN #1 identified the resident as person under investigation (PUI) and was on a 14-day quarantine for the observation of COVID. LPN #1 mentioned that PPE worn to enter the room was an N95 mask or surgical mask. LPN #1 added that when providing care to the resident, a gown and gloves were to be worn. LPN #1 stated that staff did not like to wear the surgical mask and preferred to wear a cloth mask. During the interview with the LPN #1, the surveyor observed the QA staff member enter Resident #273's room wearing only an N95 mask. The QA staff member walked out of the resident's room wearing the same N95 mask and proceeded to walk down the hallway. On 10/15/20 at 9:40 AM, the surveyor observed that Resident #273's door was slightly opened and there was no sign outside the door concerning infection control. There was a black container with three drawers that contained PPE located outside the residents room. On 10/16/20 at 12:00 PM, the surveyor observed Resident #273 leaving the room in a wheelchair, wearing a surgical mask. Resident #273 propelled themselves in the hallway past LPN #1. LPN #1 did not redirect the resident back to the room and the Resident entered the elevator. At 12:04 PM, the surveyor observed Resident #273 outside in the smoking area. The Resident was sitting in a wheelchair, a surgical mask rested on their chin, and was smoking a cigarette. There was a second resident in the smoking area with Resident #273 that was more than 15 feet away. At 12:20 PM, the surveyor observed Resident #273 wearing a surgical mask, return to their room and close the door. On 10/19/20 at 9:23 AM, the surveyor interviewed Resident #273. The resident was wearing a surgical mask. The Resident stated that during their admission they were on isolation and could not leave their room unless it was to smoke outside. The Resident mentioned that the facility scheduled designated times that they could go out to smoke cigarettes alone in the smoking area, a mask had to be worn when out of the room, and that the facility did not inform them that they could not go out to smoke. On 10/20/20 at 12:20 PM, the surveyor interviewed CNA #2 who was wearing a multicolor black cloth mask with filter located inside the mask, black cloth head covering, and goggles. CNA #2 removed the cloth mask to show the surveyor. CNA #2 stated that all newly admitted residents were isolated for infection control precautions. CNA #2 stated that the precaution was to protect the resident and staff and that upon entering the isolation room, the PPE to be worn was a head covering, gown, gloves, foot coverings, and goggles. When leaving the resident's room, staff were to remove the PPE and discard it in the trash receptacle. CNA #2 continued to mention that there were disposable head coverings in the PPE cart, such as hair nets, and that she would place one over her black head covering. CNA #2 wears her personal goggles that are cleaned with disinfectant wipes and then placed in a plastic bag. CNA #2 also stated that if she was to go into the resident's room, that an N95 mask was supposed to be worn, however she could only wear a cloth mask due to a medical condition. CNA #2 was not observed rendering care to the resident. At 12:43 PM, the surveyor interviewed LPN #1 at the nurse's desk. She stated that PPE was worn in the rooms of residents who were on a 14-day quarantine and consisted of an N95 mask, goggles, gloves, gown, and face shield. She recalled the date, 10/16/20, when the resident left the room to go out to smoke and stated that the resident had scheduled times to go outside to smoke cigarettes. The surveyor showed LPN #1 the medical chart which she confirmed that Resident #273 had a physician order for Transmission Based Precaution for 14 days. When asked if the resident should be out of his/her room, LPN #1 had no response. 5. On 10/14/20 at 12:14 PM, the surveyor observed Resident #275's door was closed. There was no sign on the door identifying infection control procedures. Located outside the room was a white container with three drawers that contained PPE. On 10/16/20 at 9:30 AM, the surveyor observed the resident's door was closed. Outside the door was a red sign that read: Stop isolation room precaution, please use proper PPE prior to entering isolation room. Also located outside the door was a black container with three drawers that contained PPE. Located on top of the container was a white sign that read: Stop please speak with nursing before entering. At 12:24 PM, the surveyor observed CNA #2 enter the resident's room wearing a face shield, a white multi-colored cloth mask, a plastic gown, and gloves. The surveyor interviewed CNA #2 at 1:11 PM on 10/16/20. CNA #2 was wearing the same white multi-colored cloth mask. She mentioned that the cloth face mask has a filter and was worn because she was allergic to the N95 mask. CNA #2 also mentioned that the PPE to be worn in the isolation room was a head covering, face shield, cloth mask, gowns, gloves, and foot coverings. CNA #2 added that the cart outside the resident's room contained PPE. CNA #2 stated that she wears a different cloth mask and brings her own face shield to work daily. On 10/19/20 at 9:07 AM, the surveyor observed LPN #1 in front of the medication cart outside of the Resident #275's room. She was wearing a blue plastic isolation gown, two hairnets, goggles,and a cloth mask under the N95 mask. LPN #1 entered the resident's room to administer medications. On 10/20/20 at 12:37 PM, the surveyor interviewed LPN #1 who stated that the PPE worn by staff were gloves, N95 mask, gown, face shield, goggles,and hair net and that all PPE was to be discarded in the red biohazard bag in the room before leaving. Staff were to wash their hands after removal of PPE. In the presence of the surveyor, LPN #1 confirmed that Resident #275's Physician Orders did not reveal a physician order for transmission-based precaution and stated, It should be written. At 2:00 PM, the LNHA, DON, Regional Minimum Data Set (MDS) Coordinator, Regional Director/IP, and LPN #2 were interviewed in the survey team's presence. The DON stated that upon entering isolation rooms, staff were to wear the N95 mask and when walking in an area outside of isolation rooms staff should wear surgical masks. The Regional MDS Coordinator and Regional Director/IP confirmed the DON's statement. The Regional MDS Coordinator mentioned that the facility smoking policy indicated that residents on 14-day quarantine can smoke in a separate area to address social distancing. On 10/21/20 at 10:03 AM, the Administrator, DON, Regional MDS Coordinator, Regional Director/IP, and LPN #2 were interviewed in the survey team's presence. Regional Director stated that cloth mask with and without filters can not be worn by staff and stated that, Cloth mask is not PPE in the facility. The Regional Director/IP continued to state that N95 mask's were worn in isolation rooms. The Administrator, DON, and LPN #2 confirmed the Regional Director/IP's statement. 6. On 10/14/20 at 11:43 AM, the surveyor arrived on the first floor and interviewed the LPN #3 who stated that Resident #223 was in a private room, and isolated for 14 days after coming back from the hospital. This resident had tested negative for the COVID virus when in the hospital. When asked what PPE was needed to speak with the resident, LPN #3 stated to make sure you have a surgical mask on, that's it. You should make sure your hands are clean and be socially distant. She further stated that Resident #223 was COVID negative, as far as she knew. When asked what additional precautions must be taken regarding Resident #223, she stated we make sure the resident stays in the room for 14 days. The surveyor questioned LPN #3 on what to wear into a quarantine room and LPN #3 stated you don't need a gown or gloves or N95 mask. If a CNA was giving care, they would wear a gown, a surgical mask and gloves. If a nurse was giving meds, they should wear gloves and a surgical mask, not gown, if a nurse was doing a treatment, they would wear, a gown, gloves and a surgical mask, no eye protection was needed. At 11:57 AM, the surveyor observed Resident #223's closed door, there was no sign on the door warning the resident was on isolation precautions. Located in the hallway outside the room was a plastic bin with drawers that contained PPE, gowns, gloves, and surgical masks. Directly beside the PPE bin was a black plastic bin with a foot pedal and red bag that was empty. On 10/14/20 at 12:48 PM, the surveyor observed the Director of Social Services (DSS) enter Resident #223's room wearing only a cloth mask to speak to the resident. The DSS exited the room and continued down the hallway, the surveyor was unable to see where the DSS went next. At 12:51 PM, the surveyor observed the facility MDS coordinator enter Resident #223's room to remove the resident's lunch tray wearing only a surgical mask. The MDS Coordinator immediately came back out of the room, went to the PPE tower, donned gloves and went back into the room to remove the residents lunch tray. The MDS Coordinator retrieved the lunch tray, placed it on the food cart, then disposed of the gloves in the black bin located in the hallway outside the Resident #223's room. He then sanitized his hands using alcohol-based hand rub, the MDS Coordinator did not don a gown, eye protection or an N95 mask. On the same day at 4:36 PM, the surveyor reviewed Resident #223's medical records which revealed that the resident transferred to the facility in October of 2020 for rehabilitation after a hospitalization for a hip fracture. Included in the hospital records was a COVID negative laboratory result dated 10/7/20. At 4:37 PM, the surveyor interviewed the facility DON who stated Resident #223 was not COVID tested upon admission to the facility and that the resident had been admitted to the facility the day before (10/13/20), and added that as the facility starts to do whole house testing the resident would be included. The residents who are currently here have had two negative COVID tests in a row and we have stopped the routine testing of residents. The most recent testing of residents in the facility was 9/24/20 and all the residents tested were negative. On 10/15/20 at 9:39 AM, the surveyor observed the Regional MDS Coordinator on the ground floor wearing a cloth mask and walking toward the front desk. At 9:41 AM, the surveyor observed LPN #4 seated at the nurse's station on the first floor, wearing a cloth mask that kept slipping to expose her nose. At 9:47 AM, the surveyor observed Resident #223 self-propelling in a wheelchair backward out of their room, the surveyor again did not observe an isolation precaution sign on the door. The resident had a surgical mask on and was attempting to back down the hallway to get on to the service elevator. The resident stopped in the hallway to speak to CNA #3 and was not redirected back to his/her room. When CNA #3 stepped away from the resident, the resident remained in the hallway and their mask had fallen and was exposing their nose and mouth. At 9:55 AM, the surveyor observed CNA #4 encounter Resident #223 in hallway. CNA #4 also did not redirect the resident back to their room. At 9:57 AM, Resident #223 proceeded further down the hallway and attempted to get onto the service elevator. As the resident was attempting to enter the service elevator the surveyor observed the Regional Director/IP attempt to redirect the resident not back to their room, but to the public elevator instead. When the surveyor asked if the resident should be going in the elevator the Regional Director/IP responded not that elevator because that elevator was for food delivery. At 10:00 AM, the LPN #4 assigned to the high side of the unit on the first floor intervened and told Resident #223 that they needed to stay in their room. At that same time LPN #4, came around the nurse's station to redirect Resident #223 and wheeled them back to their room. LPN #4 was observed trying to explain to the resident they needed to stay in their room, because they had just been in the hospital and were on quarantine precautions. At 10:02 AM, the DON stated the resident should be in their room, and was surprised that Resident #223 was out of their room. The DON stated she had just spoken with LPN #4 and the Regional Director/IP on how they must convince Resident #223 to stay in his/her room. The DON further stated that she had held a meeting with the floor staff the day before and again that morning about Resident #223. At 10:08 AM, the surveyor observed Resident #223 return to their room. The resident did not have contact with any other residents. The resident closed the door behind them. At 10:09 AM the surveyor interviewed CNA #4 who stated the plastic bin outside of Resident #223's room had PPE because the resident was on quarantine. The resident had to be in the room for 10-14 days to see if they were infected or not. She stated if she saw the resident in the hallway, she should redirect the resident to their room. CNA #4 knew that Resident #223 was on quarantine because they just came from the hospital and that none of her supervisors had informed her. CNA #4 further stated information regarding residents was discussed at change of shift, but there had been no discussion about Resident #223 that morning. CNA #4 confirmed that she should have redirected the resident back to their room. At 10:18 AM, the surveyor observed the DSS enter Resident #223's room, wearing only a cloth mask. The DSS stated to the surveyor that she was aware the resident was on isolation, but understood she only needed to wear PPE if she was doing direct patient care. She also stated that she had not been educated about proper use of PPE and that if she was just speaking with the resident, she didn't have to wear PPE because she was not touching the resident. The DSS further stated she had her mask on and she indicated the cloth mask on her face. The surveyor clarified that she was referring to the cloth mask and the DSS stated, Yes, and that she did not have an additional mask under her cloth mask. Immediately after speaking with the surveyor, the DSS was observed going into another resident's room without washing her hands or using alcohol-based hand rub. On 10/16/20 at 10:49 AM, the surveyor observed the DSS wearing a cloth mask at the first-floor nurses' station, she looked around and headed back to stairwell/elevator area. At 11:00 AM, the DSS was again observed wearing a cloth mask enter the nurses' station and then exit the floor using the stairs On 10/20/20 at 9:13 AM, the surveyor observed a housekeeper on the first-floor hallway wearing a cloth face mask that was hanging below her nose. The housekeeper confirmed she was wearing only a cloth mask. When asked if she had been in-serviced on the proper use of PPE the housekeeper stated she had a discussion that morning with the DON. The housekeeper stated she always wore a cloth mask and that she had worn a surgical mask in the beginning, but her skin broke out so now she wore a cloth mask instead. She further stated that if she was going into Resident #223's room, a contaminated room, she would swap out her cloth mask for a surgical mask. She further stated that the DON did not specify she should not wear a cloth mask. 7. On 10/15/2020 at 1:17 PM and again at 1:58 PM, the surveyor observed LPN #3 sitting at the desk at the first floor nurses station wearing a blue [brand name logo] cloth mask with a surgical mask underneath. 8. On 10/16/2020 at 10:04 AM, the surveyor observed the Food Service Director wearing a black sequenced cloth mask. On 10/19/20 at 11:30 AM, the surveyor reviewed the facility's Policy and Procedure titled, Isolation-Categories of Transmission Based Precautions. Under Policy Interpretation and Implementation it read: Transmission Based Precautions will be used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection and Under Droplet Precautions there was no specific information that would direct staff to the type of Personal Protective Equipment they would wear when entering the room of a resident on Droplet Precautions. A review of an undated Policy and Procedure titled, Infection Control Guidelines for Mandatory Health Alerts, under Procedure: Guidelines for Providing Care number 3 read: In most situations, the preferred method of hand hygiene is with soap and water. If hands are not visibly soiled, use and alcohol-based hand rub sanitizer, a. Before providing care to a resident diagnoses or suspected to have Covid-19 virus, the employees that provide care or services in the room must wear the appropriate PPE required. this includes gown, mask, gloves, shoe booties and eye protection; and, b. Position a trash can near the exit inside resident room to make it easy to discard PPE, The surveyor then reviewed an undated facility Policy and Procedure titled, Isolation - Initiating Transmission-Based Precautions which read under Policy Interpretation and Implementation: 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor shall notify the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions, and; 4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinue them, which should occur after pertinent criteria for discontinuation are met, and; 5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or Designee) shall: a. Ensure that all protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room; and; d. Place necessary equipment and supplies in the room that will be needed during the period of Transmission-Based Precautions . The surveyor then reviewed an undated Policy and Procedure titled, Isolation - Notices of Transmission-Based Precautions, which read under Policy Interpretation and Implementation: When Transmission-Based Precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. A sign will be used to alert staff of the implementation of Transmission-Based Precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy. The surveyor also reviewed an undated facility policy titled, Quarantine, which read under the Policy Statement that, The facility will protect the health and well being of our residents and staff during infectious outbreaks. Quarantine is generally enacted by governmental authorities, and under Policy Interpretation and Implementation it read: 1. Should quarantine be declared, the Administrator, with the input of the Medical Director and Director of Nursing Services, will work with governmental authorities to implement quarantine practices appropriate for the specific threat and as directed by authorities, 2. The requirements of the quarantine directive will determine who may enter or leave the facility; and, 3. A quarantine directive will initiate the facility's Emergency Management System. N.J.A.C. 8:39 - 19.4(a) Based on observation, interview, record review and review of other facility documents, it was determined that the facility failed to a) follow proper infection control practices and utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection; b) re-used medical equipment without a facility policy and procedure and; c) provide ongoing education for the staff regarding Covid-19. This deficient practice was identified for 6 staff members on 2 of 2 nursing units and 3 of 20 Residents observed (Resident #223, #273 and #275) for infection control. This deficient practice was evidenced by the following: 1. On 10/14/2020 at 1:23 PM, the surveyor observed the Second Floor Unit Manager (UM) at the nurses station on the unit wearing a cloth mask with a flag motif. The UM stated that residents that were new admissions or re-admissions to the facility were to be quarantined for 14 days, from the day of admission, because the facility did not know what the resident had been exposed to. The UM added that staff were made aware of the quarantined residents during the shift report and that a bin with personal protective equipment (PPE) was placed outside the resident's room. The UM also stated that signs had been posted during the outbreak, but that now the staff were told about which residents were quarantined. She added that the staff should wear full PPE upon entering a quarantined residents room, which included an N95 mask, gown, gloves and goggles. She added that hand hygiene should take place in the resident room after the PPE was removed and discarded in the garbage can inside the resident room. The UM stated that the staff were able to wear the cloth face coverings or surgical masks, because the facility did not have any confirmed cases of COVID-19 currently. On 10/15/2020 at 11:40 AM, the surveyor interviewed Resident #275's assigned Licensed Practical Nurse (LPN #1) who stated that, [The resident] is a new admission from the hospital in [October of 2020] and [the resident] is on droplet precautions. The surveyor asked what kind of precautions should be taken when going into the room? LPN #1 stated, You need to wear a gown, gloves, mask, head cover, face shield. LPN #1 showed the surveyor those items outside of the room readily accessible in a bin for the staff to use. This resident tested negative for the COVID virus in the hospital prior to admission. At 11:56 AM, the surveyor observed a Certified Nursing Assistant (CNA #1) enter the room of Resident #275. Resident #275 was on Transmission Based Precautions (TBP: Infection-control precautions in health care). CNA #1 donned a head cover over her hair, and a gown. CNA #1 did not put on gloves or a face shield. CNA #1 left the door ajar, and the surveyor observed her hand the resident two hand wipes from a packet of wipes she had in her hands. While in the doorway, prior to exiting the room, CNA #1 removed the head cover and gown and placed them in a receptacle with a red bag inside of the doorway. The surveyor said to CNA #1, I noticed you didn't wear gloves or a face shield when you entered the room. Would you normally? CNA #1 stated, Yes, I just forgot. I gave the resident wipes to clean [their] hands before lunch. CNA #1 then continued on to other resident rooms, handing out wipes for the resident's to clean their hands with no hand hygiene observed between residents. On 10/16/20 at 10:30 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) if he ever went into isolation rooms. He stated, If I absolutely have to. When asked what PPE he would wear, he stated the following, Mask, N95, shoe covers, hair cover, gown, gloves, face shield. The LNHA confirmed that the new admissions were placed on TBP for 14 days. At 1:00 PM, the LNHA, as well as the Director of Nursing (DON), confirmed that any residents who are newly admitted or re-admitted were quarantined for 14 days, kept on TBP's, and that all PPE was to be worn with those residents. On 10/19/20 at 11:00 AM, the surveyor interviewed the Regional Director/Infection Preventionist (IP) and asked what was expected when a CNA went into an isolation room, such as for new admissions who were quarantined for 14 days, to provide hand wipes for a resident before lunch, should the CNA wear gloves? The IP stated, Not just gloves, she needs to do the whole thing, gown, gloves, face masking. 2. On 10/16/20 at 11:35 AM, the surveyor asked the LNHA who was the staff member responsible for stocking the isolation carts with PPE. The LNHA identified a staff person with the title Q.A., which he said stood for Quality Assurance. The surveyor asked the QA where the PPE was stored. The QA showed the surveyor a room on the ground floor which had multiple cartons of PPE and an exterior area with multiple piles of cartons of PPE behind a locked gate. The QA also showed the surveyor where they stored PPE in the treatment rooms on the 1st and 2nd floors. The QA then showed the surveyor the isolation carts outside of the two rooms for residents on the 2nd floor who were on Transmission Based Precautions. Inside of the first isolation cart there was no face shield or goggles. The QA stated that he would put a pair of goggles in the cart. The surveyor looked in the second isolation cart and there was one pair of goggles in that isolation cart. The QA explained that he put one pair of goggles in the cart every day and all of the staff would use that same pair of goggles. There was an LPN standing near the QA who corrected the QA and said, We don't all share the same goggles. I have my own that I bring in. The LPN showed the surveyor a pair of goggles in a slider zip plastic bag that she stored in a drawer of the medication cart. The LPN stated that she washed the goggles with soap and water or used an alcohol wipe after using them in an isolation room. The surveyor then spoke with three CNA's who were handing out lunch trays at the time. One CNA explained that she brought her goggles in from home, she carried them in a slider zip plastic bag and cleaned them after use with a wipe from the nurse's medication cart. The second CNA was wearing goggles and said she wears them all day and that she never went into isolation rooms because she had a medical condition. The third CNA stated that she used goggles from the isolation cart when she needed them and she threw them away after every use. On 10/16/20 at 12:35 PM, the surveyor asked the DON for the facility's policy and procedure for the re-use of medical equipment such as goggles. The DON stated, No PPE leaves the room. Everything should be discarded before the staff exit the room. They should be discarded in the special garbage bin with the red bag. We have no policy and procedure for repurposing or re-use of medical equipment. On 10/19/20 at 11:00 AM, the surveyor asked the IP about the concern of the staff re-using goggles. The IP stated, I look at it this way. It's not goggles, it's face shields we use. We have thousands of them. When we actually had Covid at times we would re-use PPE and use it for the day. There is no reason to be re-using. It's not like we don't have enough, We have plenty. As far as people bringing in their own, they shouldn't be re-using them, so we are going to have to educate the staff. 3. On 10/19/20 at 11:00 AM, the surveyor spoke with the IP and asked about ongoing education for the staff regarding Covid 19. The IP stated, I asked the DON when was the last time they did any training on Covid and she said it was some time in May and she will provide the sign-in sheets with the content. The IP explained that she had been the IP at the facility for two weeks. The surveyor asked the IP if she thought the facility should be providing ongoing education to the staff regarding Covid. The IP stated, Yes, every two weeks. In my other facility, we do it every payroll day. The IP provided the training history with content and sign in sheets as follows: On 3/9/20 there was an in-service (educational class) with the topic, Coronavirus (Covid-19). The education provided was identified as; What is the coronavirus?, identification, criteria guiding evaluation, signs and symptoms, transmission, hand washing/hand sanitizing, environmental cleaning disinfection recommendations, donning/doffing personal protective equipment, coughing etiquette, What you need to know about the coronavirus, Covid-19 update # 2, Letter to residents, families, and staff. Sign in sheets for the above topics were dated 3/10/20 and 3/18/20. There were eighteen staff who signed that they attended. On 3/27/20 there was an in-service with the topic, Germs. The summary was listed as, (handout) Clean hands/hand sanitizer, protect yourself and your patients. There were nine staff who signed that they attended. On 3/27/20 there was an in-service with the topic, PPE. The summary was listed as, (handout and demonstration) How to put on PPE, How to safely remove PPE. There were ten staff who signed that they attended. On 4/2/20 there was an in-service with the topic, Infection Control. The summary was listed as, Transmission method, contact, droplet, airborne, vectors, use universal precautions, handwashing, gowns, gloves. Protect yourself and patient. There were 11 of the 73 staff who work at the facility who signed that they attended. On 6/30/20 there was an in-service with the topic, Infection Control. The summary was listed as, Procedure demonstrated to employees re: Donning and doffing, Infection control policy and procedure reviewed with employees. There were 17 staff of the 73 staff who work at the facility signed that they attended. On 9/11/20 there was an in-service with the topic, Covid 19. The summary was listed as, See attached. Attached was a sheet that read: Attention All Staff: It is mandatory per the state that every member of staff watched these video on COVID: Prevention of COVID, Clean Hands, and Using PPE correctly. On the bottom of the form were the directions to: Please sign the attached that you received this information for education. The second attached document was a form titled, Hand Washing/Hand Sanitizing Policy, which included a line for the signature of the employee and the date. There were 63 staff of 73 staff who work at the facility who signed the attached Covid In-Service sign in sheets. On 10/16/20 at 10:00 AM, the surveyor reviewed the facilities, Outbreak Plan. The Purpose read: To create a constant state of readiness; prepare for challenges through the development of an adequate Outbreak Plan (the Plan) that can be integrated with external agencies; and to educate and respond effectively. The Plan will address prevention, mitigation, response and recovery from an outbreak; to lesson the impact should an outbreak occur. Under Education and Training it read, Facilities will provide Staff education regarding the Outbreak as follows: 1. General topics for staff education will include: Prevention and control of the infectious disease which includes practicing social distancing and performing frequent hand hygiene. Implications of the disease. Identify signs and symptoms of infectious disease that can result in an outbreak. Infection con[TRUNCATED]