**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to complete a death Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 system selected for residents with MDS record over 120 days reviewed (Resident #22), and was evidenced by the following: On 4/2/25 at 9:45 AM, the surveyor reviewed the system selected MDS record over 120 days which revealed Resident #22 was overdue for a MDS assessment. A review of Resident #22's medical record (MR) revealed that the resident had a death in the facility on 1/17/25. A review of the resident's MDS assessments revealed the last MDS completed was a quarterly assessment dated [DATE]. The was no assessment for the resident's death. On 4/3/25 at 12:08 PM, the surveyor interviewed the MDS Coordinator, who confirmed Resident #22 had a death in the facility on 1/17/25, and there was no completed MDS assessment for the death. The MDS Coordinator stated the facility had seven days after the resident's death to complete the assessment and an additional fourteen days to transmit it. The MDS Coordinator stated that the resident's assessment was missed. On 4/3/25 at 12:28 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who confirmed that Resident #22's MDS should have been completed and then transmitted within 14 days. The LNHA could not speak to why the MDS was missed. On 4/7/25 at 10:27 AM, the Director of Nursing (DON), in the presence of the survey team, acknowledged that the completion and transmission of the death in facility MDS for Resident #22 was missed in error. A review of the facility's MDS Assessments policy dated revised January 2025, did not include MDS timing. A review of the facility's MDS Comprehensive policy dated revised 4/3/25, did not include MDS timing. NJAC 8:39 - 11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The surveyor reviewed the medical records of Resident #24. Review of the AR reflected that the resident was admitted to the facility with diagnoses which included but was not limited to dementia, heart failure, and pneumonia. Review of the NJUTF, dated 01/01/23, indicated the resident was transferred to the hospital. Review of Resident #24's Progress Notes revealed a 01/01/23 Nursing Notes that indicated the physician requested for the resident to be transferred to the hospital. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of the facility's HTR indicated that Resident #24 was discharged on 01/01/23 and revealed under the Date of Letter Send to POA [power of attorney] section that the representative was notified by phone. Review of Resident #24's medical record did not include a notification letter to the Office of the State Long-Term Care Ombudsman of the transfer to the hospital. On 02/09/23 at 12:32, the surveyors interviewed the Administrator who confirmed that the facility did not inform the Office of the State Long-Term Care Ombudsman or the RP in writing regarding Resident #17 and Resident #24's unplanned discharges to the hospital. The Administrator explained that the process for notifying the Ombudsman and RP regarding the written notice for discharge was not yet explained to the new Social Worker, (SW) so the SW did not know that it was her responsibility to complete the notifications in writing of discharge to the Ombudsman and RP. NJAC 8:39-5.3; 5.4 Based on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to notify the resident and/or the resident's representative in writing of the reason for transfer or discharge to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents reviewed for hospitalization, Residents #17 and Resident #24. This deficient practice was evidenced by the following: According to the admission Record (AR) Resident #17 was admitted to the facility with the diagnoses which included but was not limited to hypertension, depression, and age-related physical disability. The surveyor reviewed the unplanned discharge Minimum Data Set (MDS-an assessment that facilitates a resident care) dated 11/08/2022, which indicated that the resident was discharged to the hospital. The surveyor reviewed the New Jersey Universal Transfer form (NJUTF) dated 11/08/2022, which indicated that Resident #17 was discharged to the hospital for a right leg wound. The surveyor also reviewed the physician's order dated 11/08/2022, that the resident was to be sent to the hospital's emergency room for evaluation of a right leg wound. The facilities Hospitalization Tracking Record (HTR) indicated that Resident #17 was discharged to the hospital on [DATE] and returned on 11/13/2022. The HTR also indicated that the residents responsible party (RP) was notified by phone and not letter. The surveyor could not find any documentation in the resident's medical record that the RP or Office of the State Long-Term Care Ombudsman was notified about the resident's transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The surveyor reviewed the medical records of Resident #24. Review of the AR reflected that the resident was admitted to the facility with diagnoses which included but not limited to dementia, heart failure, and pneumonia. Review of the NJUTF dated 01/01/23, indicated the resident was transferred to the hospital. Review of Resident #24's Progress Notes revealed a 01/01/23 Nursing Notes that indicated the physician requested for the resident to be transferred to the hospital. Review of the MDS dated [DATE], indicated the resident had a discharge assessment with return anticipated. Review of Resident #24's medical record did not include a notification letter to the residents and/or their representatives with the facility's notice of bed-hold policy. On 02/09/23 at 12:32, the surveyors interviewed the Administrator who confirmed that the facility did not inform the RP in writing regarding the facility's notice of bed-hold policy. The Administrator explained that the process for notifying the RP regarding the bed hold policy in writing was not yet explained to the new Social Worker (SW) so the SW did not know that it was her responsibility to complete the notifications of bed hold to the RP. NJAC 8:39-5.3 Based on interview and review of the medical record and other facility documentation, it was determined that the facility failed to provide a bed-hold and return policy to a resident representative. This deficient practice was identified for Resident #17 and #24, 2 of 2 residents reviewed for transfer and was evidenced by the following: 1.) According to the admission Record (AR) Resident #17 was admitted to the facility with diagnoses which included but were not limited to hypertension, depression, and age-related physical disability. The surveyor reviewed the unplanned discharge Minimum Data Set (MDS-an assessment that facilitates a resident care) dated 11/08/2022, which indicated that the resident was discharged to the hospital with return to the facility anticipated. The surveyor reviewed the New Jersey Universal Transfer form (NJUTF) dated 11/08/2022, which indicated that Resident #17 was discharged to the hospital for a right leg wound. Review of Resident #17's medical record did not include a notification letter to the residents and/or their representatives with the facility's notice of bed-hold policy.