Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 21 residents, Resident #69 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: Reference: According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023). This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. Code 99, Not Listed 1. On 6/06/24 at 9:36 AM, the surveyor reviewed the closed medical record for Resident #69 whose discharge MDS was coded for discharge to an acute hospital. The surveyor reviewed the 3/06/24 progress notes which indicated that Resident #69 was discharged home. Review of Resident #69's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to metabolic encephalopathy, acute kidney failure and diabetes mellitus. Review of the A section of the Discharge MDS for Resident #69 revealed that section A2105 Discharge Status documented, 04. Short-Term General Hospital. On 6/06/24 at 11:10 AM, the surveyor interviewed the Clinical Reimbursement Coordinator/MDS Coordinator (MDSC) regarding where Resident #69 was discharged to. The MDSC stated that she believed that Resident #69 went home. The surveyor asked the MDSC about Resident #69's Discharge MDS which was coded for discharge to the hospital. The MDSC stated that she thought it was an error in the coding and that she was going to check the medical record. The MDSC then confirmed that the Discharge MDS was coded incorrectly and that Resident #69 was discharged to home and not to a hospital. On 6/06/24 at 01:43 PM, in the presence of the survey team, the surveyor told the Licensed Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, VP of Special Clinical Projects and the Clinical Reimbursement Coordinator (CRC #2) the concern that Resident #69's Discharge MDS was coded incorrectly. CRC #2 confirmed that Resident #69's Discharge MDS was coded incorrectly and added that the facility modified the MDS. The facility did not provide any additional information. A review of the facility provided policy titled, Comprehensive Assessments with a revised date of March 2022 included the following: Policy Interpretation and Implementation 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. N.J.A.C. 8:39-11.1, 11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent medical records, it was determined that the facility failed to follow physician orders related to the use of continuous oxygen (O2) for 1 of 1 resident, Resident #3. This deficient practice was evidenced by the following: On 6/4/24 at 10:45 AM, the surveyor observed Resident #3, who was laying in bed in their room. Resident #3 was receiving O2 delivered through a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) utilizing a concentrator (an oxygen delivery system) at 3.5 Liters per minute (LPM). Resident #3 stated their O2 should be running at 4 LPM. The surveyor reviewed the resident's medical chart which included a review of a paper as well as computerized medical chart. A review of the admission Record (a summary of important information about the resident) documented the resident was admitted to the facility on [DATE] with diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease, Essential Hypertension, Morbid Obesity, and Obstructive Sleep Apnea. A review of an Annual Minimum Data Set (AMDS, an assessment tool to facilitate care), dated 5/7/24, documented the resident had a Brief Interview for Mental Status (BIMS) and scored a 15 out of 15, indicating that Resident #3 was cognitively intact. The AMDS further revealed Resident #3 is receiving continuous oxygen therapy. A review of the Physician's Orders (PO) and electronic treatment administration record (eTAR) documented a physician's order for, Oxygen at 4 Liters/minute with Humidification VIA: Nasal Cannula (NC) every shift for Acute Respiratory Failure with a start date of 5/20/24. A review of Resident #3's Care Plan (CP) with a revision date of 5/10/24 read, .At risk for respiratory impairment related to Asthma, COPD, morbid obesity, OSA. An intervention for the CP read, Administer oxygen per physician order. On 6/5/24 at 9:42 AM, the surveyor observed Resident #3's O2 concentrator, set at 3 1/2 L/min, second observation of O2 concentrator. On 6/5/24 at 9:45 AM, the surveyor interviewed Licensed Practical Nurse (LPN) caring for Resident #3. The LPN reviewed with the surveyor the PO for the resident's O2 settings. The surveyor informed the LPN of the two observations on 6/4/24 and 6/5/24 in which the resident's O2 setting was at 3 1/2 LPM. The surveyor accompanied the LPN to Resident #3's room to check the O2 settings. The LPN acknowledged the O2 was not set at 4 LPM as ordered by the physician. The LPN could not explain why the resident's O2 setting was at 3 1/2 LPM and adjusted the resident's O2 setting to 4 LPM. On 6/5/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Oxygen Administration, which had a revised date of October 2010. Under the Preparation portion of the policy it read, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the Documentation section of the policy it read, After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record .3. The rate of oxygen flow, route, and rationale. On 6/6/24 at 1:42 PM, the survey team met with the LNHA, Director of Nursing (DON), Assistant Director of Nursing (ADON), [NAME] President of Special Clinical Project (VPSCP), and Clinical Reimbursement coordinator (CRC) The surveyor informed the facility about the concerns of the O2 setting for Resident #3. The DON stated the O2 should be administered according to physicians' orders. There was no further information provided. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to properly store a controlled and noncontrolled medications in a secure manner. This deficient practice was identified for one (1) of 3 units inspected and involved two Residents, Resident #123 and #122. 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: On 6/4/24 at 11:55 AM, the surveyor inspected the medication cart located on Unit 2 of the facility in the presence of the Licensed Practical Nurse (LPN). The surveyor opened the top drawer of the medication cart and noted that there was a medication cup that contained 2 pharmacy wrapped unit dose medications. The surveyor inspected the 2 medications which were found to be Doxycycline 100mg Capsule (an antibiotic) and Oxycodone IR 5 mg tablet (Schedule II Opioid analgesic). The surveyor discussed the storage of the two medications, Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet in the medication cup with the LPN, who stated that he was not made aware by the previous shift that the unit dose Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet were in his cart. The LPN stated that he did not know which resident this belonged to. The LPN explained that if he was aware he would have questioned why they were there because the Oxycodone 5 mg should be stored in the locked narcotic box of the medication cart. On 6/4/24 at 12:00 PM, the Assistant Director of Nursing (ADON) joined the surveyor in investigating the Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet found in a medication cup in the top drawer of the medication cart. The ADON could not identify which resident the medications belonged to and The ADON stated that she was not aware of the medication left in the top drawer. The ADON added that she needed to investigate how and why these medications were left not properly secured in the medication cart, especially a Class II control substance. On 6/4/24 at 12:09 PM, the surveyor and ADON reviewed the medication back up System (Omnicell) printout for history of Doxycycline 100mg Capsule and Oxycodone IR 5 mg tablet activity. The Omnicell printout showed that on 6/1/24 at 16:11 (4:11 PM), 1 capsule of Doxycycline 100mg was removed for the Resident #123 as well as on 6/3/24 at 17:21 (5:21 PM), the printout showed that 2 tablets of Oxycodone IR 5 mg tablets were removed for Resident #122. The physical count for the Class II Controlled Substance Oxycodone IR 5 mg was shown to be correct in the Omnicell. On 6/4/24 at 12:15 PM, the surveyor interviewed the ADON who stated that when a medication is not administered, it needs to be destroyed, relating to the Doxycylcine 100mg and the Oxycodone 5 mg. She added that a control substance (Oxycodone 5 mg) should be stored separated in a double locked area and that the destruction of a control substance should be carried out by two nurses. The surveyor reviewed the medical record for Resident #123. A review of the admission Record for Resident #123 reveals that the resident was admitted with diagnosis that include but are not limited to Fracture of Superior Rim of Left Pubis, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, and Primary Generalized Osteoarthritis. Review of the June 2024 electronic medication administration record (eMAR) documents a physician's order dated 6/1/24 for Doxycycline Hydrate 100 mg to be administered twice daily for skin/soft tissue infection for 10 days. The June eMAR documents the administration of the Doxycycline 100mg twice daily with no missed doses. Review of the admission Record for Resident #122 reveals that the resident was admitted with diagnosis that include but are not limited to Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Type 1 Diabetes Mellitus and Anxiety Disorder. Review of the June 2024 eMAR documents a physician's order dated 5/31/24 for Oxycodone 10 mg every 6 hours as needed for severe pain (8-10) and Oxycodone 5 mg every 6 hours as needed for moderate pain (5-7). Documentation for administration for the Oxycodone 5 mg reveals that it was administered as (1) tablet on 6/3/24 at 17:35 (5:35 PM) even though (2) tablets were removed from the Omnicell at 17:21 (5:21 PM). The Director of Nursing presented an interview with LPN#2 who administered the Oxycodone 5 mg to Resident #122 on 6/3/24. This interview revealed that Resident #123 was going to therapy and requested pain medication. LPN#2 continued that the nursing supervisor went to the Omnicell and removed 2 tablets of Oxycodone 5 mg (logged into the Omnicell) but that Resident #122 only requested 1 tablet of Oxycodone 5 mg. LPN#2 stated that she forgot to destroy the extra Oxycodone 5 mg that was not administered. On 6/6/24 at 1:30 PM, the surveyor telephoned the Provider Pharmacy and spoke to a Pharmacy Technician who revealed that #30 tablets of Oxycodone IR 5 mg and #30 tablets of Oxycodone IR 10 mg were delivered to the facility for Resident #123 on 6/4/24 at 3:50 PM. The Pharmacy Technician explained that a Class II control substance does not automatically get transmitted, the pharmacy needs a physician's written and signed order. The Pharmacy Technician continued by stating that this is the reason that the facility has a back up medication unit, Omnicell so that there is no delay in treatment if medication is needed prior to the pharmacy delivery. The Pharmacy Technician stated that the order was received from the facility on 6/4/24 at 7:00 AM. The Pharmacy Technician stated that the Doxycycline 100mg was ordered and delivered on 6/1/24. Review of the Controlled Substances policy section Storing Controlled Substances, 1. Controlled substances are separately locked in permanently affixed compartments,. Documented under Dispensing and Reconciling Controlled Substances, 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. And 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. On 6/6/24 at 1:51 PM, the surveyor met with facility staff Clinical Reimbursement Coordinator, ADON, Director of Nursing, and [NAME] President of Special Clinical Projects who did not provide any further information. NJAC 8:39-11.2(b), 29.2 (a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was identified that the facility's housekeeper failed to practice appropriate hand hygiene in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19 and other infections. The deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a clean towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. On 12/16/22 at 12:22 PM, the surveyor observed a housekeeping staff member wearing disposable gloves in the COVID 19 unit emptying the used room gown bin (contaminated bin) from room [ROOM NUMBER] into a covered rolling container. The housekeeper proceeded to room [ROOM NUMBER], wearing the same dirty gloves and touching the doorknob to open the door. The surveyor further observed that same housekeeper empty the used gown bin (contaminated bin) from room [ROOM NUMBER] again, into the covered rolling container. The surveyor observed another facility staff member from the same COVID 19 unit instruct the housekeeper to stop emptying the dirty gown bins into the covered rolling container because the lunch trays were being served to the residents. The surveyor observed that the housekeeper removed his dirty gloves and continued holding onto and pushing the covered rolling container used to collect the dirty gowns from the unit. The housekeeper pushed the covered rolling cart containing the contaminated collected gowns with his bare hands while exiting the COVID 19 unit. The housekeeper was then observed discarding the used dirty gloves prior to exiting the COVID 19 unit and entering the laundry room, without sanitizing with Alcohol based hand rub gel (ABHR) or washing his hands. The surveyor interviewed the housekeeper who acknowledged that he did not apply ABHR gel nor washed his hands after removing his dirty gloves. The housekeeper acknowledged that he should have sanitized or washed his hands after leaving room [ROOM NUMBER] and prior to entering room [ROOM NUMBER]. The housekeeper added that he should have also washed his hands after removing his gloves and leaving the COVID 19 Unit. A review of the facility's policy titled Laundry and Linen under General Guidelines Standard Precautions explains, 2.) Wash hands after handling soiled linen and before handling clean linen. 3.) Consider all soiled linen to be potentially infectious and handle with standard precautions. On 12/16/22 at 1:30 PM, the surveyor discussed the above concern with the facility's Licensed Nursing Home Administrator, the Director of Nursing and Infection Preventionist who did not provide any further information. NJAC 8:39-19.4(a)(1) (2) (n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to 1.) appropriately put on personal protective equipment (PPE) while in the rooms of residents on transmission-based precautions (TBP). This was observed for1 of 1 housekeepers on the unit, and 2.) failed to appropriately handle potentially contaminated items coming from TBP rooms for 2 of 2 Certified Nursing Assistants (CNA) observed and evidenced by the following: 1. On 8/4/22 at 10:45 AM, the surveyor observed a sign on the door to resident room [ROOM NUMBER]-46 which indicated that the residents were on Isolation Droplet/ Contact Precautions and that PPE including a gown, N-95 respirator, eye protection, and gloves should be worn while in the room. At the same time the surveyor observed the housekeeper inside room [ROOM NUMBER]-46 mopping the floor. The surveyor observed that the housekeeper wore a gown, N-95 respirator, and eye protection but did not have gloves on and mopped with bare hands. On 8/4/22 at 10:46 AM, the surveyor interviewed the Housekeeper. The surveyor asked what type of unit this was. The housekeeper stated that it was a COVID-19 unit. The surveyor asked if he was in a COVID-19 room. The housekeeper stated, this is a COVID room. The surveyor asked what kind of PPE he needed to wear in a COVID-19 room. The housekeeper stated that he wore goggles, a face mask, and a gown. The surveyor asked if the housekeeper needed to wear gloves while in the room. The housekeeper gestured to the housekeeping cart outside of the room which held his cleaning supplies and stated that he had gloves but that he took the gloves off after he changed the mop head. The surveyor asked if the Housekeeper should have put new gloves on after changing his gloves. The housekeeper did not respond. On 8/4/22 at 10:56 AM, the surveyor observed that the housekeeper's cart was still outside of room [ROOM NUMBER]-46 and that two plastic meal trays were positioned on top of the cart. The surveyor observed that each meal tray had several items on it including utensils, plates, and cups. At this time the surveyor observed CNA #1 and CNA #2 each pick up one of the meal trays. The surveyor followed CNA #1 and CNA #2 as they walked through three doors and several hallways carrying the meal trays. CNA #1 and CNA #2 brought the meal trays to the kitchen and left the trays on a metal tray truck which held several meal trays. On 8/4/22 at 10:58 AM, the surveyor interviewed CNA #1 and CNA #2. The surveyor asked why they were carrying meal trays from a COVID-19 room to the kitchen. CNA #1 stated that kitchen staff took the tray truck before the residents in room [ROOM NUMBER]-46 were finished eating. The surveyor asked if this was normally the way that they would bring meal trays that were in a COVID-19 room back to the kitchen. CNA #1 stated that normally they would go on the tray truck but that it was not on the nursing unit. The surveyor asked if it was alright to transport meal trays from COVID-19 rooms to the kitchen in this way. CNA #1 stated that the housekeeper used wipes on the trays and sanitized them and that the trays were clean. The surveyor stated that there were several items on the tray and how were they sure all items were sanitized. CNA #1 restated that the trays were clean. On 8/4/22 at 11:30 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM). The surveyor described her observation, that CNA #1 and CNA #2 carried meal trays from a COVID-19 room into the kitchen. The LPN/UM stated that this was not an acceptable way to transport meal trays that were in a COVID-19 room. The surveyor asked what the proper way to transport the meal trays from the COVID-19 room was. The LPN/UM stated that the meal trays should be in the closed meal tray truck. On 8/4/22 at 11:57 AM, the surveyor interviewed the Regional Environmental Services Director (RESD). The surveyor described how she observed the housekeeper in a COVID-19 room mopping without gloves. The RESD stated that the housekeeper should have been wearing gloves in the COVID-19 room. The surveyor also stated that the housekeeper had meal trays from a COVID-19 room on top of his housekeeping cart. The RESD stated that the housekeeper should not take meal trays out of resident rooms and should not have touched the meal trays. On 8/4/22 at 12:02 PM, the surveyor interviewed the housekeeper. The surveyor asked if the housekeeper took the trays out of room [ROOM NUMBER]-46 and put them on the housekeeping cart. The housekeeper acknowledged that he did. The surveyor asked if he sanitized the meal trays when he took them out of the COVID-19 room. The housekeeping aide stated, how would I clean the tray, there's food on it?. The surveyor reviewed the facility's policy titled, Coronavirus Disease (COVID-19)- Identification and Management of Ill Residents with a revised date of 8/22 indicated that residents who test positive for COVID-19 are cared for by staff using a NIOSH approved N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and a gown. The surveyor reviewed the facility's policy titled, Coronavirus Disease (COVID-19)- Cleaning and Disinfecting reviewed 12/21, indicated to clean and disinfect areas, material and equipment that have likely been contaminated by a person with COVID-19 in the last 24 hours using a disinfectant found on the EPA's List N (disinfectants effective against COVID-19). 2. On 8/5/22 at 11:00 AM, the surveyor observed a housekeeper don (put on) PPE appropriately, outside the room of a resident who was on contact and droplet precautions due to a Covid-19 infection (red room) as evidenced by a red sign posted on the door that read: Isolation Droplet/Contact Precautions. When the housekeeper came out of the room the surveyor asked the housekeeper how he doffed (removed) PPE and what order he cleaned the resident rooms. He described appropriately how he doffed PPE but when describing the order in which he cleaned the rooms he said he cleaned the red rooms first. On 8/5/22 at 11:20 AM the surveyor observed the housekeeper in the hallway outside of the shower room next to the Covid-19 positive room he had just cleaned. He said he already cleaned the red room and the shower room next to it. He said he cleaned the red rooms first and then the yellow rooms (residents who were on contact and droplet precautions due to exposure to Covid-19, or new admissions), and then the green rooms (residents who had no known exposure to Covid-19). The surveyor asked the Infection Preventionist (IP) what order the housekeeper should have cleaned the resident rooms, the IP said green rooms first, then yellow rooms, then red rooms last, using a well to ill flow in accordance with guidance from Centers for Disease Control and Prevention. The surveyor confirmed with the IP that the rooms in question were rooms of residents who were on isolation due to a confirmed positive test result for Covid-19 infection. She further confirmed that there were two rooms that were coded as red for having residents in them who had Covid-19, and she pointed out those rooms. On 8/5/22 at 11:25 AM the surveyor asked the RESD what order the housekeeper should have been cleaning the rooms with respect to different cohorts, red, yellow, and green. He said the housekeepers should clean the green rooms first, then the yellow rooms, then the red rooms last. The surveyor joined the RESD when he went to speak with the housekeeper. When the surveyor and RESD approached the housekeeper he was donning PPE outside of a red room. The RESD explained to him what order to clean the rooms. The housekeeper did confirm that he had finished cleaning a red room and was going to clean the second red room then he would clean the yellow and the green rooms. The RESD said he was going to get an interpreter and explain to the housekeeper in his own language. As the surveyor and the ESRD were walking away the housekeeper, who was wearing full PPE (N95 mask, goggles, gown, gloves), started to enter the red room. The ESRD stopped the housekeeper from entering the red room and said to wait there and he would be right back. The housekeeper waited outside the red room. The ESRD came back within a few minutes and asked the housekeeper to go with him for training with an interpreter and they left the unit. On 8/5/22 at 1:20 PM, the surveyors discussed the above concerns to the Administrator and Director of Nursing. No additional information was provided. The surveyor reviewed the policy and procedure titled General Cohort Guidelines. The guidelines described the different cohorts as follows: Red (Confirmed Covid Positive), Yellow (Potentially Incubating, not up to date with vaccinations and exposed or newly admitted ), [NAME] (Naive, negative, recovered, vaccinated, asymptomatic, no known exposure, admits/readmits post quarantine, Covid recovered/released from transmission based precautions). 08/17/22 10:26 AM, the surveyor asked the DON for the policy and procedure the housekeeper or nursing would follow to address the well to ill flow when entering rooms for care or cleaning. She said they didn't have a policy but that was their practice. NJAC 8:39-19.4 (a)

Based on observation, interviews, and record review, it was determined that the facility failed to identify and address weight loss in a timely manner for 1 of 7 residents reviewed for nutrition (Resident #21). This deficient practice was evidenced by the following: According to the admission Record, Resident #21 was admitted to the facility with diagnoses that included, but were not limited to, carcinoma of the endometrium (cancer of the pelvic organ); iron deficiency anemia (iron poor blood); Type 2 Diabetes Mellitus (high blood sugar); hypertension (elevated blood pressure), and Stage 4 pressure ulcer of the sacrum. Review of the Annual Minimum Data Set (MDS), an assessment tool dated 12/03/19, reflected the resident had a Brief Interview for Mental Status (BIMS) of 14, which indicated that the resident's cognition was intact. The Annual MDS also reflected Resident #21 was on a therapeutic diet with a weight of 283 pounds (lb). On 02/25/20 at 10:17 AM, the surveyor observed Resident #21 sitting up in bed with a breakfast tray in front of him/her. At that time, Resident #21 stated he/she had one egg and one muffin for breakfast. Resident #21 stated he/she had diabetes and was making an effort to eat healthier by eating less but was not actually on a diet to lose weight, but would welcome the weight-loss. The resident stated he/she would eat more carbohydrates in the morning and protein in the afternoon. Review of the Order Summary Report, printed on 02/25/20, revealed an order dated 11/10/19, for house carbohydrate consistency/consistent carbohydrate diet (HCC/CCHO) with regular texture and regular, thin liquid consistency, for diabetes. Review of the Clinical Physician Orders revealed an order, dated 11/15/18, for weekly weight-documented, one time a day every Monday with a discontinue date of 02/21/20. Review of the Weight Summary sheet, revealed the following recorded weights for Resident #21: On 12/02/19, the weight was 284.6 lb; On 01/13/20, the weight was 263.8 lb; On 02/17/20, the weight was 240.7 lb. The Weight Summary sheet did not reflect any re-weights noted after the 01/13/20 weight loss of 20.8 lb = 7% and did not reflect any re-weights noted after the 02/17/20 weight loss of 23.1 lb = 9%. Review of the Progress Notes (PNs), from 01/13/20 through 02/03/20, revealed that the facility did not address the 7% weight loss. Review of the PNs, dated from 01/13/20 to 02/24/20, revealed that there was no documentation that the physician or nurse practitioner was made aware of the 20.8 lb weight loss between 12/02/19 and 01/13/20 or the 23.1 lb weight loss between 01/13/20 and 02/17/20. The PNs did not reveal Registered Dietitian (RD) documentation that addressed the weight changes within 72 hours. Additionally, the PNs did not reveal an assessment, analysis and conclusion by the multidisciplinary team regarding the weight changes for Resident #21. Review of Resident #21's Care Plan (CP), date initiated 12/16/19, revealed a focus of nutritional status as evidenced by actual/potential weight loss/gain related to therapeutic diet, and chronic wounds. The CP goals included to tolerate diet and textures/consistency, consume appropriate amounts of food and fluids, and maintain nutritional status. The CP interventions included, but were not limited to, notify physician and responsible party of significant weight changes. During an interview with the surveyor on 02/21/20 at 9:50 AM, the RD stated all resident notes were in the electronic medical record. The RD stated the Certified Nursing Assistants (CNA) would obtain the weights as ordered and that she would review weekly weights on Tuesday and monthly weights every month. The RD stated the nurses and CNAs should re-weigh a resident if there was a 3-5 lb change or if the weight was outside the ordered parameter. During an interview with the surveyor on 02/21/20 at 12:34 PM, the Registered Nurse Unit Manager (RN/UM) stated she would be responsible to review resident weights also and, if there was a discrepancy, she would either observe or re-weigh the resident herself. The RN/UM stated the CNAs could see the previous weights and should report any discrepancy to the nurse. The RN/UM stated that she would expect a change of 4-5 lb to be re-weighed and reported. In the presence of the surveyor, the RN/UM accessed the electronic medical record and acknowledged there had been no re-weights for Resident #21 in January or February. During an interview with the surveyor on 02/24/20 at 10:16 AM, CNA #1 stated the CNAs would get a list of the residents that needed to be weighed. The CNAs would enter the weight into the computer and were able to see the previous weight. CNA #1 stated if the resident's weight was 3-4 lb different, they would verbally communicate to the nurse and the nursing supervisor, and re-weigh the resident. During an interview with the surveyor on 02/24/20 at 10:53 AM, RN #1 stated the process was for the CNA to obtain the weight and tell the nurses verbally if there was a big change. RN #1 stated the nurses entered the weights on the Medication or Treatment Administration Record (MAR) in accordance with the physician's orders. RN #1 add that if the nurses see a weight change, they should report it to the physician. During an interview with the surveyor on 02/24/20 at 11:12 AM, the Director of Nursing (DON), stated the CNAs would get a weight list and weigh the resident. If the resident's weighed was under a 100 lb and the weight was up or down by 2 lb or if the resident was over 100 pounds and the weight was up or down 5 lb, the staff would re-weigh the resident and notify the physician. The resident would be re-weighed by the CNA and nurse to see if it was accurate. The DON stated the re-weights would be listed in the electronic medical record weight summary. During an interview with one of the surveyors on 02/25/20 at 10:14 AM, CNA #2 stated CNAs would take a residents weight, compare it to the last one and, if the weights did not match, the CNA should re-weigh the resident and inform the nurses. CNA #2 stated it was important to re-weigh, especially if the resident had a weight loss so they can tell the nurse and the nurse could call the physician. During an interview with one of the surveyors on 02/25/20 at 10:25 AM, RN #2 stated the CNAs would get a list in their computer tasks of which residents needed to be weighed. RN #2 stated it would be the nurses responsibility to look at the weights when they are logged into the computer and that the nurses were able to see the last two or three weights. RN #2 stated a weight change of 2 lb in a day or maybe 5 lb would indicate the staff needed to re-weigh the resident to ensure it was accurate and that the re-weigh should be done within the day because if there was a problem, the staff could catch it. RN #2 stated weight loss would be reported to the nursing supervisor and RD. During an interview with one of the surveyors on 02/25/20 at 10:26 AM, RN #3 stated if there was a discrepancy in weights, the staff would obtain a re-weight and if it was a true discrepancy, the nurses would report it to the nursing supervisor and RD. During an interview with the surveyors on 02/25/20 at 12:13 PM, the RD stated Resident #21 should have had a re-weight and that she had requested a re-weight but it was never done. The RD stated if she had a hard time getting the staff to re-weigh a resident, that she would have gone to the DON but there was no record of this communication. The RD acknowledged there had been no re-weight for Resident #21 in the medical record and documentation that a re-weight was discussed with staff. During an interview with the surveyor on 02/26/20 at 10:51 AM, Resident #21 stated he/she always tried to eat healthy but had been in the hospital a few times, which could have resulted in a weight loss, but was unaware of how much weight he/she had lost. Resident #21 stated none of the staff, including the physician and the RD had ever discussed any weight loss plans but that the RD discussed it with him/her on 02/25/20. During an interview with the surveyor on 02/26/20 at 10:55 AM, RN #2 stated Resident #21's normal intake for breakfast was one or two eggs, a bagel or sometimes cereal, coffee or tea. For lunch, the resident ate chicken and one or two bites of dessert. RN #2 stated the resident had been trying to eat more protein in the evening and was cutting down on carbohydrates. RN #2 stated she had a discussion in passing with the resident regarding healthy eating. RN #2 stated there was no formal discussion or weight loss plan documented in the resident's medical record and that she should have documented the conversation. Review of the facility's Weighing and Measuring the Resident policy and procedure, dated 08/16, revealed to note and record the weight and report significant weight loss/weight gain to the nurse supervisor: 1 month=5%; 3 months=7.5%, and 6 month=10%. Review of facility's Weight Assessment and Intervention Policy, dated 01/20, revealed weights would be recorded in each resident's medical record; a change of 5 lb or more in a resident weighing more than 100 lb or 2 lb in a resident weighing less than 100 lb, will be retaken for validation. If weight was verified, nursing would notify the Dietitian. The Dietitian will respond within 72 hours. Assessment information shall be analyzed by the multidisciplinary team and conclusion shall be made regarding the resident's target weight range; calorie, protein and nutrient needs, the relationship between current medical condition or clinical situation and recent fluctuations in weight and whether and to what extent weight stabilization or improvement can be anticipated. Review of the the provided Monthly Weight Meetings, dated 01/06/20, 01/14/20, 01/22/20, 01/29/20, 02/05/20, and 02/12/20, revealed Resident #21 had not been included or listed in the meeting notes and the attached Monthly Weight Report, dated from March 2019 to February 2020, did not have Resident #21 listed on the report at all. Review of the facility's Change in a Resident's Condition or Status policy, dated 05/17, revealed the facility shall promptly notify the resident, Physician and representative of changes in the medical/mental condition. The nurse will notify the resident's Physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition. The nurse will record in the resident's medical record, information relative to changes in the resident's medical/mental condition or status. If significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition would be conducted. Review of the Dietitian Job Description, dated revised 01/19, revealed the dietitian was responsible for the nutritional oversight of all residents, which included review of weekly weights, as applicable, and completion of reassessments and care plan revisions on all residents that display a significant weight change. A review of monthly weights and completion of reassessments and care plan revisions on all residents that display a significant weight change of greater than or equal to 5% in one month. During an interview with the survey team on 02/26/20 at 11:50 AM, the Administrator stated the facility did not have the signed RD job description there so they could not provide it, but that the Job Description-Dietitian that was provided to the surveyors was the same one signed by the RD. NJAC 8:39-17.1(c); 27.2(a)