Based on interviews and review of medical records it was determined that the facility failed to complete and electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of the resident's discharge. This deficient practice was identified for 1 of 1 resident, (Resident # 27) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 05/08/2024 the surveyor reviewed the MDS history in the electronic medical record which revealed: Resident #27 was discharged on 01/08/2024. The surveyor was unable to locate a discharge MDS in Resident #27's electronic medical record. On 05/09/2024, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the discharge MDS on Resident #27 should've been completed within 14 days of discharge date . She also stated, I missed it. On 05/14/2024 the surveyor noted that the discharge MDS was completed on 05/10/2024 and transmitted on 05/13/2024 (completion was due by 1/22/2024 and transmission was due by 02/05/2024). When the surveyor asked for a policy regarding MDS completions, the MDSC stated they did not have a policy for MDS discharge assessments and that they follow the RAI manual. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2023, page 2-17, discharge return-not anticipated must be completed no later than the discharge date + 14 calendar days with the transmission date no later than MDS completion date +14 days. On 05/13/2024, the surveyor interviewed the Director of Nursing who stated that the MDS should have been completed before now. NJAC 8:39-11.2 (e) 3

Based on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to treat a resident's pain to the extent possible in accordance to current professional standards of practice. The deficient practice was identified for 1 of 2 residents (Resident # 38) investigated for Pain. The deficient practice was evidenced by the following: A review of Resident # 38's Significant Change Minimum Data Set (MDS; an assessment tool) dated 05/08/2024 revealed under section J. that he/she received as needed and scheduled medications for pain. A review of Resident # 38's Order Summary Report located in the Electronic Medical Record (EMR) revealed that he/she was receiving oxycodone-acetaminophen (medication used to treat pain) oral tablet 5-325 mg (milligrams) one time a day for pain management prior to care. The order was started on 03/27/2024. Further, the Order Summary revealed an order for Resident # 38 to wear a cervical neck brace at all times. A review of Resident # 38's Diagnoses located in the EMR revealed that he/she was diagnosed with but not limited to Unstable Burst Fraction of First Cervical Vertebra (bone in the cervical spine area crushed in all directions). A review of Resident # 38's Care Plan located in the EMR revealed that Resident # 38 had a focus of chronic pain related to arthritis, neuropathy (Weakness, numbness, and pain from nerve damage) and acute pain related to the cervical fracture. A review of the April, 2024 Medication Administration Audit Report revealed that the oxycodone-acetaminophen oral tablet 5-325mg was scheduled to be given at 9:00 AM. However, the report revealed the following dates an times of the actual administration of the oxycodone-acetaminophen: On 04/06/2024, the medication was administered at 11:03 On 04/09/2024, the medication was administered at 10:26 On 04/12/2024, the medication was administered at 10:21 On 04/13/2024, the medication was administered at 10:55 On 04/14/2024, the medication was administered at 10:37 On 04/21/2024, the medication was administered at 10:46 On 04/28/2024, the medication was administered at 11:02 A review of the facility-provided, undated policy titled, PAIN ASSESSMENT & MANAGEMENT revealed, 11. Medicate the resident as the physician ordered. A review of the facility-provided, undated policy titled, Administering Pain Medications revealed on the second page to, Administer pain medications as ordered. On 05/08/2024 at 12:58 PM during the initial tour of the facility, the surveyor visited Resident # 38 in his/her room. At that time, Resident # 38 stated he/she has neck pain and bilateral leg pain. He/She also had a cervical neck brace on. On 05/10/2024 at 10:43 AM during an interview with the surveyor, Registered Nurse # 1 confirmed that Resident # 38 received oxycodone-acetaminophen 5-325mg and that it was scheduled for 9:00 AM. On 05/13/2024 at 9:41 AM during an interview with the surveyor, Registered Nurse # 2 said We [nurses] have to give them [medications] within the hour. If they are scheduled, they have to be within the hour. On 05/13/2024 at 11:34 AM during an interview with the surveyor, the Director of Nursing confirmed she would consider a medication administered as late an hour after an administration time. Further, the DON stated, If it is a standing order, Yes. If it was given at ten and scheduled for nine, then yes. when the surveyor asked would she considered a nine AM scheduled opioid for pain management given after ten AM or eleven AM, a late medication. § 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to implement, reassess and/or discontinue a physician order for a crash pad (floor mat or crash mat; a piece of thick and soft material that prevents injury from a fall from a height) to the floor by the bed of a resident with a history of falls in accordance with professional standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #35) reviewed for accidents. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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 evidence was as follows: On 8/3/22 at 11:25 AM, during the initial tour, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed a clean room, bed made, call bell was on the resident's bed, and no observed crash pads in the room. The surveyor reviewed the medical record for Resident #35. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility on in July of 2022 with diagnoses that included, displaced intertrochanteric fracture of left femur (fracture outside the hip joint's fibrous capsule), subsequent encounter for closed fracture with routine healing, muscle weakness, repeated falls, and unspecified abnormalities of gait (the way a person walks) and mobility. A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/15/22, reflected the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated severely impaired cognition. The MDS further revealed in Section J. Health Conditions, the resident had a history of falls in the last month prior to admission and had a fall with fracture within two to six months of admission. A review of the Order Summary Report included a physician's order dated 7/9/22 for a crash pad to floor by bed. A review of the Progress Notes included an Alert Note dated 7/9/22 at 10:24 PM, that the resident transferred him/herself to wheelchair independently; was assisted to the bathroom by writer; education given but resident not able to verbalize understanding; call bell placed in reach; new orders for crash pads to be placed bedside to decrease fall risk; will continue checks for duration of shift. A review of the Interdisciplinary Team (IDT) Care Conference Notes dated 7/19/22 did not include an assessment of the crash pad ordered by the physician. A review of the resident's comprehensive care plan did not include a focused area or intervention for a crash pad. A review of Resident #35's [NAME] (a system in which nursing staff was given a brief overview of individual resident care needs) did not include the physician order for the crash pad. On 8/4/22 at 9:55 AM, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed the resident's room was clean, bed made, call bell on the bed, and no crash pads observed in the room. On 8/5/22 at 9:54 AM, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed the resident's room was clean , bed made, call bell on the bed, and no crash pads observed in the room. On 8/5/22 at 10:07 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who confirmed her assignment included Resident #35 and that the resident did not have a crash pad. On 8/8/22 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who confirmed her assignment included Resident #35. The LPN also confirmed the resident was a fall risk and did not have a crash pad. On 8/8/22 at 10:30 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who confirmed Resident #35 was a fall risk. At this time, the surveyor and ADON reviewed the physician's order for a crash pad dated 7/9/22. The surveyor and the ADON then reviewed the comprehensive care. The ADON acknowledged the physician's order for the crash pad as well as the care plan did not include the crash pad. The ADON stated the physician's order was not appropriate for Resident #35 since it was a tripping hazard. The surveyor and the ADON then reviewed the IDT Care Conference Note dated 7/19/22, and the ADON confirmed the note did not include an assessment of the crash pad. On 8/8/22 at 10:54 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who acknowledged that a physician's order should be followed. The LPN/UM further stated that the IDT team decided that the crash pad was a hazard and confirmed there was no documentation to corroborate. The LPN/UM also confirmed the physician's order should have been discontinued and documented upon assessment of the IDT team. On 8/9/22 at 10:26 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), ADON, and survey team stated that the crash pad was a nursing intervention and that the crash pad was not appropriate since Resident #35 was able to ambulate. The DON acknowledged there was an active physician order from 7/9/22 that was discontinued after surveyor inquiry for the crash pad. The DON acknowledged that the nurse on duty failed to communicate to the fall team or IDT team the physician order dated 7/9/22 that was added as a result of a fall risk event. The DON acknowledged physician order's should be carried out or reassessed by the nurses and discontinued if not appropriate because it was a professional standard of practice. A review of the undated facility provided Physician's Orders policy included medications/treatments shall be administered upon the written order of a person duty licensed and authorized to prescribe such medications/treatment in this state .verbal orders must be signed by the prescriber at his or her next visit . NJAC 8:39-27.1