Every finding on record at Family of Caring Healthcare at Tenafly, LLC

Based on interviews, record review, and review of pertinent facility documentations on 3/3/26 and 3/10/26, it was determined that the facility failed to completely and accurately document Physician Orders (PO) and medication administration of insulin for Resident #1 in accordance with current professional standards and practices.This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed for documentation as follows: A review of Resident #1's admission Record (AR), an admission record summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to fracture of right femur, muscle weakness, type 2 Diabetes Mellitus (DM) with diabetic chronic kidney disease, heart failure, hypertension, and repeated falls. A review of the resident's Progress Notes (PN) entry dated 07/22/2025 at 4:28 PM signed by the nurse indicated the resident was alert and oriented to person, place, and time (AAOx3) upon initial assessment.A review of the resident's Order Summary Report (OSR), a list of physician's orders, active orders as of 07/23/2025, revealed the resident had orders for the following:-Admelog SoloStar Solution Pen-injector 100 unit/ml (milliliter) (insulin lispro), a phone order, inject as per sliding scale: if 0-70 = 0 call MD/NP; 71-199 = 0; 200-299 = 1; 300-400 = 2; 401-999 call MD/NP for insulin order, subcutaneously before meals for DM eat within 15 minutes of using the medication. Watch for hypoglycemia sx [symptoms] including headache/hunger/sweating - with order date of 07/22/2025 and start date of 07/23/2025.-Humalog Kwikpen Subcutaneous Solution Pen-injector 100 unit/ml (insulin lispro), a prescriber written order, inject as per sliding scale: if 0-149 = 0 units; 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-500 call MD, subcutaneously before meals and at bedtime for DM - with order date 07/23/2025 and start date of 07/23/2025. -Lantus SoloStar Solution Pen-injector 100 unit/ml (Insulin Glargine), a phone order, inject 16 unit subcutaneously at bedtime for DM do not use if it looks cloudy. Watch for hypoglycemia symptoms including headache/hunger/sweating - with order date of 07/22/2025 and start date of 07/22/2025. -Lantus SoloStar Solution Pen-injector 100 unit/ml (Insulin Glargine), a phone order, inject 22 unit subcutaneously at bedtime for DM. Do not use if it looks cloudy. Watch for hypoglycemia symptoms including headache/hunger/sweating - with order date of 07/23/2025 and start date of 07/23/2025.-Lantus SoloStar Solution Pen-injector 100 unit/ml (Insulin Glargine), a prescriber written order, inject 10 unit subcutaneously at bedtime for DM. Do not use if it looks cloudy. Watch for hypoglycemia symptoms including headache/hunger/sweating - with order date of 07/23/2025 and start date of 07/23/2025. There were no further POs for insulin. A review of the resident's Medication Administration Record (MAR) with date range of 7/1/2025-7/31/2025 revealed the following:-Lantus SoloStar Solution Pen-Injector 100 unit/ml (Insulin Glargine) inject 16 unit subcutaneously at bedtime for DM with a Start Date of 9:00 PM and a D/C [discontinue] Date of 07/23/2025 1:52 PM. The Licensed Practical Nurse (LPN) #1 documented code 9 under the Tue 22. The MAR indicated under its Chart Codes (CC), code 9 = Other/See Progress Notes.A review of the resident's PN dated 07/22/2025 at 8:17 PM revealed LPN #1 documented awaiting RX delivery. -Admelog SoloStar Solution Pen-injector 100 unit/ml (Insulin Lispro) inject 4 unit subcutaneously one time only for DM for 1 Day; Start Date of 07/22/2025 9:30 PM and a D/C Date of 07/23/2025 5:05 PM. The MAR revealed the medication entry was initialed by LPN #1 under Tue 22 with a check mark and a time of 2203, indicating the medication was administered and timed at 10:03 PM on July 22.This medication entry was not reflected in the resident's OSR nor documented in the resident's PN. -Admelog Solution 100 unit/ml (Insulin Lispro) inject 7 unit subcutaneously one time only for DM until 07/23/2025 5:59 AM with a Start Date 07/23/2025 0230 [2:30 AM]. The MAR was initialed by Registered Nurse (RN) #1 at 2:47 AM under the Wed 23.This medication entry was not reflected in the resident's OSR.A review of a 07/23/2025 PN at 2:10 AM revealed RN #1 received a PO for 7 units x1 dose but failed to document the type of insulin. -Admelog SoloStar Solution Pen-injector 100 unit/ml (insulin lispro) inject as per sliding scale: if 0-70 = 0 call MD/NP; 71-199 =0; 200-299 =1; 300-400 =2; 401-999 call MD/NP for insulin order, subcutaneously before meals for DM eat within 15 minutes of using the medication. Watch for hypoglycemia sx [symptoms] including headache/hunger/sweating - with a Start Date 07/23/2025 7:30 AM and D/C Date of 09/09/2025 5:46 PM. The MAR revealed under Wed 23, BS (blood sugar) 341 at 11:30 AM, a check mark with LPN #2 initials and the number 2, indicating 2 units of insulin were given. The MAR further revealed under Wed 23 at 4:30 PM LPN #3 documented BS of 400 and code 9, indicating Other/See Progress Notes. A review of a 07/23/2025 PN revealed at 12:37 PM, LPN #2 documented primary nurse and pt's daughter by bedside alerted this nurse that pt's sugar has been running high and over 400mg/dl since last night and during lunch. made MD aware but still awaiting for response. made endocrinologist - Dr [NAME] aware but was told thatdoctor [sic] was away and would come back after 1pm. unable to connect with any MD. extra 2 units of admelog was given for now, with closer monitoring with blood sugar. daughter by bedside and pt agreed to plan. will continue with plan of care.A review of a 07/23/2025 PN revealed at 1:55 PM, LPN #2 documented called back pt's endo Dr [NAME] regarding high blood sugar of 466mg/dl. as per office, Dr. [NAME] came back but currently seeing other patient, office told this writer that this writer needs to wait until Dr [NAME] gets a chance to call me back. this writer made office staff aware that pt's blood sugar has been high and its urgent to connect with Dr [NAME] but office staff continuously said that this writer needs to wait. no time frame given. made MD aware. obtained new order to increase lantus to 22u nightly. gave another 2u for blood sugar coverage. pt denies discomfort. VSS, pt continues to be alert and oriented. clinical team made aware.A review of a 07/23/2025 PN revealed at 4:58 PM, LPN #3 documented, NEW ORDERS; change meds lispro sliding scale 150- 200 2 units, 200-250 4 units, 250 - 300 6 units, 300-350 8 units, and lantus; d/c current lantus and decrease to 10 units.A review of a 07/23/2025 PN revealed at 5:03 PM, LPN #3 documented that orders were received and follow through.A review of a 07/23/2025 PN revealed at 10:20 PM, LPN #3 documented Resident #1 reported uncontrolled blood sugar ranging 400s or higher off and on for the past day. The PN revealed the MD was made aware and ordered 8 units to be given prior to dinner. Insulin given. The PN further revealed Blood sugar read 402 @ 2102 [9:02 PM]. Lantus and 8 units of coverage given .There was no PO on Resident #1's OSR nor order entry on Resident #1's MAR for this medicaiton. On 03/10/26 at 10:34 AM, the surveyor interviewed LPN #1. LPN #1 confirmed she entered code 9 and documented in the 7/22/2025, 8:17 PM PN awaiting pharmacy delivery related to the 16 units of Lantus at bedtime PO. LPN #1 further said she was not able to give the Lantus as we have to wait for the delivery. When asked if she called the doctor, LPN #1 stated she let the RN supervisor know. The RN supervisor called the resident's MD [medical doctor] and the MD ordered a one time dose of the short acting insulin. If a medication is not yet received from pharmacy, the protocol is to document this in the PNs. The MD would be notified and this would also be documented. There was no PN indicating the medication was not received nor the MD was notified. The surveyor was unable to interview LPN #2 or LPN #3.On 03/10/26 at 11:17 AM, the surveyor interviewed the DON regarding LPN #2's documentation on 7/23/2025 at 12:37 PM. The DON stated that LPN #2 was referring to the 11:30 AM sliding scale order of 2 units Admelog that was given for the resident's BS of 341. On 03/10/26 at 11:50 AM, the surveyor interviewed the RN Supervisor.The RN supervisor stated she cannot exactly remember Resident #1's BS on 7/22/2025 or calling the MD. She further stated she was unable to document at the time because there were a lot of orders to carry out and she assumed the nurse would document in the PNs. On 03/10/26 at 12:57 PM, the surveyor interviewed the DON regarding the 7/23/2025,10:20 PM PN and the MAR. DON stated LPN #2 documented the insulin given in the PN as a late entry. The DON affirmed that the documentation did not coincide or reflect timely in the resident's MAR. On 03/10/26 at 1:13 PM, the surveyor interviewed the resident's MD. The MD stated if there was no medication yet the nurses always called me and normally would give the BS result. I do not remember the exact blood sugar result but it was more than 400 plus. I do not remember the nurse's name but they absolutely called me. The insulin order I gave at that time was based on the patient's sliding scale from the medication list from the hospital; the nurses called me when the patient was admitted to the facility. A review of a facility policy titled Charting and Documentation revised on 10/2025 revealed, under Policy Statement, All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Under Policy Interpretation and Implementation revealed 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records.N.J.A.C.8:39-35.2(d)6

REPEAT DEFICIENCY Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more. During the morning medication (med) administration observation on 6/9/25, the surveyor observed 2 nurses administer meds to 5 residents. There were 31 opportunities, and 2 errors were observed which calculated to a med administration error rate of 6.45%. The deficient practice was identified for 2 of 5 residents, (Resident #17 and #50), that were administered meds by 2 of 2 nurses that were observed. The deficient practices were evidenced by the following: 1. On 6/9/25 at 8:10 AM, during the morning med administration pass (med pass), the surveyor observed Licensed Practical Nurse#1 (LPN#1) preparing to administer meds to Resident #50. The resident stated that they would like their protein supplement med when their breakfast tray received, and not at this time. At that time, the surveyor observed LPN#1 prepared and administered the resident's meds that included the following: -two tablets (tabs) of ascorbic acid 500 mg (milligrams) [2 tabs=1000 mg] -one tablet (tab) of apixaban 5 mg -one tab of Vitamin (Vit) D 1000 IU (international unit). LPN#1 did not read the cautionary in the electronic Medication Administration Record (eMAR) for Vit D to take med with food or meals. The resident took the meds to swallow all meds without food or meals, and the surveyor asked LPN#1 to step out of the resident's room to review the orders. LPN#1 took back the meds from the resident and stated to the resident that she would get back. Outside Resident#50's room, the surveyor asked LPN#1 to review the order for Vit D including the cautionary. After reading the order for Vit D, LPN#1 stated that she should not administered the med because the resident did not have breakfast tray (ERROR#1). LPN#1 was unsure if she could give crackers as food or wait for breakfast tray to come. LPN#1 decided to discard all meds in the drug buster (med disposal system quickly turns most non-hazardous meds into a non-toxic slurry that can be safely put in the trash. Drug buster uses activated charcoal to quickly neutralize the active ingredients in pills, liquids, controlled substances and transdermal patches), and informed the surveyor that she would get back to the resident later when breakfast tray arrive, which LPN#1 did after surveyor's inquiry. LPN#1 further explained to the resident that she would return later when breakfast tray was delivered because one med required food or meal. At that time, the surveyor observed crackers, milk, pitcher of water and juice on top of LPN#1's med cart. LPN#1 moved on to the next resident for med pass without signing the eMAR after LPN#1 disposed of the meds. The surveyor reviewed the medical record for Resident #50. A review of the admission Record (AR; an admission summary) revealed diagnoses that included but not limited to unspecified fracture of right lower leg, subsequent encounter for closed fracture with routine healing and age-related osteoporosis without current pathological fracture. A review of the recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/14/25, reflected the resident had a brief interview for mental status (BIMS) score of 13 out of 15, indicating that the resident had an intact cognition. A review of the Order Summary Report (OSR) revealed an active physician's orders (PO) that included but not limited with Vit D tab with a start date of 1/7/25, Vit D 1000 unit, give 1 tab by mouth one time a day for supplement take with food or meals. 2. On 6/9/25 at 9:19 AM, during the morning med pass, the surveyor observed Licensed Practical Nurse#2 (LPN #2) preparing to administer nine meds to Resident #17. The surveyor observed LPN#2 removed the bottle of glycolax from the med cart, poured 17 grams using the cover of the bottle in 5 ounces (oz) of plastic cup, and then stated that usually the resident refuses the med. LPN#2 did not read the cautionary for glycolax, to mix in 4-8 ounces (oz) of juice, tea, coffee, water, or soda, or hold for loose stool. At that time, the surveyor observed LPN#2 prepared and administered the resident's meds that included the following: -one tab of 25 mg metoprolol (blood pressure and heart med) ER (extended release) -one transdermal patch of buprenorphine 10 mcg (microgram) [controlled med] -one tab of 5 mg amlodipine (blood pressure med) -one tab of 5 mg apixaban (blood thinner) -one cap of 30 mg cymbalta delayed release 30 (used to treat depression and anxiety) -one tab of 40 mg furosemide (water pill) -one cap of 30 mg gabapentin (used to treat nerve pain and anticonvulsant) -17 grams of glycolax powder (also known as Miralax, used to treat constipation) to mix with 4-8 ounces juice, tea, coffee, water or soda -15 mls (milliliters)=30 grams of lactulose (used to treat constipation) On that same date and time, the surveyor observed LPN#2 administer eight meds to Resident #17 including the glycolax without mixing it in 4-8 oz of fluids (ERROR#2). The surveyor observed LPN#2 poured approximately half a cup of 5 oz water to glycolax powder without mixing the med and Resident#17 drunk the med. There were white granules of glycolax powder remained in the 5 oz cup. The surveyor observe LPN#2 filled the 5 oz cup with water approximately half a cup, did not mix, and the resident drunk the water with glycolax. There were some white granules of glycolax remained in the cup and the surveyor observed LPN#2 discarded the cup in the garbage upon exiting the resident's room. The surveyor observe Resident#17 refused the lactulose. Outside the room, LPN#2 confirmed he was finished with med pass. The surveyor asked LPN#2 to review the order for glycolax powder and how much fluids should it be mix with, and LPN#2 read the order. The surveyor then asked LPN#2 if he mixed, they glycolax powder and followed the PO, and LPN#2 responded that he did not mix it. LPN#2 confirmed that there were remaining granules in the cup when he disposed of. Afterward, the surveyor observed LPN#2 asked Regional Director of Nursing#1 (RDON#1) to witness the med disposal of refused med lactulose and controlled med buprenorphine transdermal patch (a skin patch is used to treat severe and persistent pain that requires an extended treatment period and when other pain medicines did not work well enough or cannot be tolerated) in the drug buster. The surveyor reviewed the medical record for Resident #17. A review of the AR reflected that the resident was admitted to the facility with diagnosis that included but were not limited to direct infection of left knee in infectious and parasitic diseases classified elsewhere, and difficulty walking, not elsewhere classified. A review of the most recent comprehensive MDS, with an ARD of 4/28/25, had a BIMS score of 15 out of 15, which reflected that the resident's cognitive status was intact. A review of the OSR revealed an active PO that included but not limited with gylcolax powder with a start date of 4/22/25, glycolax powder give 17 grams by mouth one time a day for constipation when administering mix in 4-8 oz of juice, tea, coffee, water, or soda. hold for loose stool. On 6/9/25 at 1:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with med pass for Resident#17 and Resident#50. The DON stated that LPN#1 should had given the Vit D med with snacks, crackers and milk. On 6/11/25 at 9:03 AM, the survey team met with the LNHA and DON. The DON stated that she spoke to the nurses and education was provided to all nurses about meds cautionaries. The DON also stated that nurses were educated that 4 oz of milk was considered food and meds with cautionary to be given with food could use the milk and to follow PO. She further stated that education was provided to all nurses that the Miralax should be dissolved in 4 oz of water, juice or tea. On 6/11/25 at 11:35 AM, Regional DON#2 (RDON#2) in the presence of the DON and survey team stated that they acknowledged the concern with med pass, that LPN#1 should administered Vit D with food. RDON#2 also stated that LPN#1 did not follow the order. A review of the facility's Administering Medications Using Electronic System Policy, with an updated date of 11/2024, that was provided by the DON, revealed, meds shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: 3. Meds must be administered in accordance with doctor's orders, including any required time frame and following med cautionary . On 6/11/25 at 12:30 PM, the survey team met with the LNHA, DON, RDON#1, RDON#2, and Chief Operations Officer for an exit conference, and there was no additional information provided by the LNHA and his team. NJAC 8:39-11.2(b), 29.2(d)

3. A review of Resident#21's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow that progresses slowly, usually affecting older adults), cytomegaloviral disease (common viral infection that can cause a wide range of symptoms, from mild, flu-like illness to serious health problems in certain individuals), and hypertension (high blood pressure). A review of Resident#21's hybrid MR did not reveal a Universal Transfer Form (UTF, communication form when a resident is transferred from facility to facility) for the 8/6/24 transfer to the hospital. A review of Resident#21's PN included a PN dated 5/9/25 19:24, for a Infectious Disease Consult which included information regarding another resident at another facility. On 6/9/25 at 11:43 AM, Surveyor#4 (S#4) interviewed the Licensed Practical Nurse#2 (LPN#2) regarding the UTF. LPN#2 stated that when a resident was transferred a UTF was filled out and sent with the resident. LPN#2 stated that a copy of the UTF was placed in the front of the paper chart and that if the resident was admitted then the paperwork would be given to the medical record department. He added that it would be scanned into the electronic medical record and a hard copy would be stored. On 6/9/25 at 12:20 PM, the MR Staff brought multiple envelopes of Resident#21's medical records. S#4 reviewed the papers in the multiple envelopes and there was not a UTF dated 8/6/24. On 6/9/25 at 12:39 PM, S#4 asked the DON and Regional DON#1 (RDON#1) to review the envelopes. The DON and RDON#1 confirmed that the envelopes did not contain the requested UTF. The DON called the MR Staff and asked if there was any additional records. On 6/9/25 at 12:42 PM, RDON#1 stated that she was emailing someone that had access to the hospital records to get a copy of the requested UTF. S#4 asked RDON#1 if the UTF should have been accessible. RDON#1 stated that it should be accessible and that the nurse probably forgot to make a copy of the UTF. On 6/9/25 at 12:58 PM, the MR Staff gave S#4 additional envelope of Resident#21's medical records which included information for the 8/6/24 hospitalization and the UTF of the transfer from the hospital back to the facility. The UTF for the transfer from the facility to the hospital was not included in the envelope. On 6/9/25 at 1:02 PM, in the presence of the survey team and LNHA, the DON confirmed that the requested UTF was not in the envelope. On 6/10/25 at 9:59 AM, in the presence of RDON#1, S#4 interviewed the DON regarding the process for the UTF. The DON stated that the nurse would make a copy of the UTF and put it in in medical record or scan it into the miscellaneous section of the electronic MR. She then added that it should be in both. On 6/10/25 at 10:06 AM, RDON#1 stated that the UTF was found in one of the medical records folders. She added that it should have been scanned into the electronic record or available in the medical record. On 6/10/25 at 10:40 AM, S#4 notified that DON and RDON#1 that there was a PN dated 5/9/25 in Resident #21's electronic MR that was for a different resident at a different facility. RDON#1 after viewing the note in the electronic MR, stated that the PN should not be there. On 06/10/25 at 12:50 PM, S#4 notified the LNHA and DON the concern that Resident#21's PN was not accurate and that the UTF was not easily accessible. On 6/11/25 at 11:03 AM, in the presence of the DON, the LNHA stated that he did not have any response to the concerns. The LNHA did not provide any additional information. A review of the facility's Physician Progress Notes Policy, with a reviewed date of 10/2024, included the following: Policy Statement Physician PN must be maintained for each resident. Policy Interpretation and Implementation 1. Physician PN are maintained for each resident residing in the facility. 2. Physician PN reflect the resident's progress and response to his or her care plan, meds, etc. 3. The resident's attending physician must write, sign and date the physician PN upon each visit. 4. Inquiries concerning physician PN should be referred to the attending physician, medical director or director of nursing services. A review of the facility's Medical Records Policy, with a reviewed date of 11/2024, included the following: Medical records shall be retained by the facility in accordance with current applicable laws . The policy did not include any information regarding accuracy or accessibility. A review of the facility provided policy titled Transfer and Discharge (Including AMA (against medical advice), with a reviewed date of 10/2024, included the following: 7. Emergency Transfers/Discharges . f. The original copies of the transfer form .accompany the resident. Copies are retained in the medical record. N.J.A.C. 8:39-35.2 Based on observation, interview, and record review, it was determined that the facility failed to maintain accurate, complete, and readily accessible medical records. This deficient practice was identified for 3 of 17 residents reviewed (Resident#16, #21, and #38). 1. On 6/4/25 at 10:24 AM, Surveyor #1 (S#1) observed Resident#16 sitting in a chair in their room. The resident was alert, verbally responsive in Spanish, and stated they lost their [resident's representative (RR)]. A hospice staff in the room stated the RR was alive and visited frequently. On 6/10/25 at 9:57 AM, Surveyor #2 (S#2) reviewed the electronic medical record (EMR) of Resident#16. A review of the admission Record (AR; a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to; dementia, heart failure, and osteoarthritis. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 4/6/25, had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated the resident had moderate cognitive impairment. A review of the physician's order (PO) dated 4/13/24, indicated, quetiapine fumurate (Seroquel) 25 milligram (mg) tablet (tab), give 1 tab by mouth in the morning for psychosis. The medication (med) was scheduled to be administered at 9:00 AM. A review of PO dated 4/13/24, indicated, quetiapine fumurate 25 mg tab, give 1 tab mouth in the evening for auditory and visual hallucinations. The med was scheduled to be administered at 6:00 PM. A review of the PO dated 4/13/24, indicated, seroquel 25 mg tab, give 0.5 tab (12.5 mg) by mouth at bedtime (HS) for psychosis. The med was scheduled to be administered at 9:00 PM. A review of the Psychiatric Advance Practice Nurse (PAPN) note dated 4/21/25, documented that the psychotropic med being monitored for the resident was donepezil 10 mg tab for dementia and quetiapine fumarate 25 mg tab qd [every day] and 12.5 mg HS. The note did not account for the resident receiving quetiapine fumarate 25 mg tab in the evening. On 6/10/25 at 1:14 PM, S#2 notified the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the concern for the PAPN differing from the psychotropic med the resident was ordered to receive. The surveyor requested to speak with the psychiatric consultant. The LNHA stated the PAPN was not at the facility currently and provided the PAPN's phone number. The surveyor also requested a copy of the psychiatry consultant notes. On 6/10/25 at 1:19 PM, S#2 placed a call to the PAPN, there was no answer, and a message could not be left as the voicemail was full. S#2 notified the LNHA and the DON, who stated they would reach out to the consultant for a call back to the surveyor. On 6/10/25 at 1:46 PM, S#2 interviewed the PAPN over the phone. The PAPN stated that when she consulted with residents at the facility, the PAPN would assess the resident, speak with staff, speak with family, and review the resident's medications (meds). The PAPN stated that she made recommendations, did not enter med orders, and that the nursing staff would have to follow up with the primary physician about recommendations for approval. At that same time, S#2 notified the PAPN about the discrepancy between the PO of Resident#16's Seroquel meds and the documented med regimen in her consultant notes. While on the phone, the PAPN reviewed the documentation in Resident#16's EMR. The PAPN stated she could not speak to exactly why there was a discrepancy between her notes and the resident's active orders for Seroquel. The PAPN stated that it was either a typo in her notes or the primary physician added an order. S#2 asked the PAPN if a primary physician did add a med different from psychiatry meds recommendation would it be documented in her consultant note. The PAPN replied yes that she would indicate that the physician added a med to the resident's psychotropic regimen. The PAPN stated that the active PO would reflect the resident's current med regimen and believed it was most likely a typo in her notes. On 6/11/25 at 10:05 AM, S#2 further reviewed the PAPN notes which revealed the following: A PAPN note dated 9/16/24, documented recommendations for Seroquel 12.5 mg at HS to be started for the resident and for the rest of the resident's med to be continued, which included Seroquel 25 mg tab in the morning and Seroquel 12.5 mg at HS. The following PAPN notes dated 9/30/24, 12/9/24, 2/10/25, and 3/10/25, did not include that the resident's med regimen included the dose of Seroquel 25 mg tab in the evening. The meds listed were Seroquel 25 mg in the morning and Seroquel 12.5 mg at HS. A review of monthly psychotropic monitoring documentation by nursing staff revealed the resident's documented psychotropic med regimen did not reflect the resident's actual med regimen as follows: On 9/17/24, the nurse documented the meds ordered for Resident#16 as Seroquel 12.5 mg at HS and Seroquel 25 mg in the am (morning). On 10/17/24, the nurse documented the meds ordered for Resident#16 as Seroquel 12.5 mg in am and Seroquel 25 mg in the evening. On 11/17/24, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in am and Seroquel 25 mg in the evening. On 12/17/24, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in the am and Seroquel 25 mg in the evening. On 2/22/25, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in the am and Seroquel 25 mg in the evening. On 3/22/25, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in the am and Seroquel 25 mg in the evening. On 4/22/25, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in the am and Seroquel 25 mg in the evening. On 5/22/25, the nurse documented the meds ordered for Resident#16 as documented Seroquel 12.5 mg in the am and Seroquel 25 mg in the evening. On 6/11/25 at 10:58 AM, the LNHA and DON met with the survey team. The DON stated they were still in the process of following up on the concern for Resident#16. S#2 notified the DON and the LNHA regarding the inaccuracy of the monthly psychotropic monitoring forms with the resident's med orders, as it did not reflect the resident's psychotropic med regimen at the time of the assessment. On 6/11/25 at 11:25 AM, the DON and the LNHA met with the survey team. The DON stated the resident's medical record including orders were reviewed and she spoke with PAPN. The DON acknowledged the documentation in the notes were inaccurate and the resident was receiving the correct med as ordered. There was no additional information provided by the facility's management. 2. Surveyor#3 (S#3) reviewed Resident#38's hybrid (paper and electronic) medical record (MR). A review of AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, essential hypertension (high blood pressure), major depressive disorder (a disorder of persistent feeling of sadness and loss of interest). A review of Resident#38's Significant Change MDS, with an ARD of 5/2/25, had a BIMS score of 12 out of 15, which indicated the resident had moderate cognitive impairment. Section N revealed that there was no indication that the resident was taking an antipsychotic med. A review of Resident#38's Comprehensive Care Plan (CCP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, did not reveal any documentation that the resident was taking an antipsychotic med. A review of Resident#38's Order Summary Report (OSR), a listing of the resident's current meds and treatments, did not reveal any antipsychotic med orders. A review of the resident's Order Audit Report (OAR), a document that shows the history of a med order, for olanzapine (an antipsychotic med), revealed that an order for olanzapine 5 mg tab, give ½ tab every 12 hours as needed (PRN) for agitation was discontinued (d/c) 4/1/25. S#3 also reviewed the resident's electronic medication administration record (eMAR), for April 2025. The eMAR also reflected that the order for olanzapine was d/c on 4/1/25. A review of the resident's Progress Notes (PN) revealed 14 PN authored by a nurse practitioner (NP) that reflected the dates 4/4/25, 4/7/25, 4/14/25, 4/17/25, 4/21/25, 4/24/25, 4/28/25, 5/1/25, 5/5/25, 5/12/25, 5/15/25, 5/22/25, 5/28/25, and 6/2/25, that also reflected the resident taking olanzapine 2.5 mg every 12 hours PRN and that the PN was discussed with the resident and the nursing staff. A review of the paper MR of Resident#38, revealed a handwritten PN titled Medical Admit H&P (History & Physical) dated 3/4/25, and signed by the attending physician. The PN did not reflect any mention of olanzapine. On 6/5/25 at 11:20 AM, S#3 interviewed the Licensed Practical Nurse#1 (LPN#1) on duty on the unit where Resident#38 resides. S#3 asked LPN#1 when did the NP visit and usually see Resident#38. LPN#1 stated that the NP usually comes on Wednesdays. S#3 asked if the NP discussed the resident's care, and LPN#1 stated that the NP asked if there were any concerns with the residents. On 6/10/25 at 12:39 PM, the survey team met with the LNHA and DON to discuss concerns with Resident#38's medical PN. On 6/11/25 at 10:58 AM, the survey team met with the LNHA and DON, and the DON stated that she would have to contact the NP for clarification of the medical record. The LNHA did not provide any further pertinent information. A review of the facility's Physician Services Policy, revised date of 10/2024, reflected under Line 6, the attending physician shall also be responsible for initial and ongoing medical evaluation as follows: b) The physician PN shall be maintained in accordance with acceptable professional standards and practices as necessitated .

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 17 residents, Resident #21, reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 6/5/25 at 10:07 AM, the surveyor observed Resident#21 seated on their bed. Resident#21 stated that they had wounds (PUs) that had gotten smaller and had a wound vac (vacuum-assisted closure (VAC) therapy device used to help wounds heal by creating negative pressure around the wound area that promotes healing by removing excess fluid and debris, reducing infection, and encouraging the growth of new tissue) for months that was removed about two weeks ago. A review of Resident#21's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow that progresses slowly, usually affecting older adults), cytomegaloviral disease (common viral infection that can cause a wide range of symptoms, from mild, flu-like illness to serious health problems in certain individuals), and hypertension (high blood pressure). A review of Resident#21's most recent quarterly MDS, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident#21 was cognitively intact. Further review indicated that Resident#21 had one or more unhealed PU. A review of Resident#21's Discharge Return Anticipated MDS (DRAMDS) indicated that the resident had 1 Unstageable and 2 Stage 2 PUs that were not present on admission (facility acquired). On 6/5/25 at 11:05 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a timeline of Resident#21's PUs and any incident/investigation since admission. A review of the facility provided PU timeline indicated that Resident#21 did not have any facility acquired PU's (PUs that were not present on admission or readmission). The LNHA did not provide any incident/investigation for any new skin impairments or PU. On 6/9/25 at 10:47 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the Resident#21's PUs. The LPN stated that he did not believe that any of the resident's PUs were facility acquired and that the resident came to the facility with the PUs. On 6/9/25 at 11:18 AM, the surveyor interviewed the MDS Coordinator (MDSC) regarding Resident#21's DRAMDS. The MDSC stated that she coded the DRAMDS according to what the Wound Consultant wrote on their notes. She added the resident had two blisters from the tape. On 6/9/25 at 11:56 AM, the surveyor interviewed Regional Director of Nursing #1 (RDON#1) in the presence of the DON regarding Resident#21's PU timeline that was provided by the facility that indicated the PUs were not facility acquired. RDON#1 stated that she interviewed the staff and that the resident did not have any facility acquired wounds. She added that the hospital records did not indicate any other PUs then the PUs that was present on the initial admission. On 6/10/25 at 10:14 AM, RDON#1 stated that she spoke with the Wound Care Consultant regarding his report of a blister and that he could not remember but that it may have been the beginning of an abscess. She added that the UTF only had the 1 PU listed on it that was a PU that the resident had when admitted to the facility. RDON#1 stated that the MDS must have been coded incorrectly. On 6/10/25 at 12:50 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that the Resident#21's DRAMDS was coded incorrectly. On 6/11/25 at 11:03 AM, in the presence of the DON, the LNHA stated that there was no response to the concern. The facility did not have a policy regarding MDS. N.J.A.C. 8:39-11.2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow the recommendations of the Wound Care Consultant Physician (WCCP) for 1 of 2 residents reviewed for PU (Pressure Ulcer), (Resident#21). This deficient practice was evidenced by: On 6/5/25 at 10:07 AM, the surveyor observed Resident#21 seated on their bed. Resident#21 stated that they had wounds (PUs) that had gotten smaller and had a wound vac (vacuum-assisted closure (VAC) therapy device used to help wounds heal by creating negative pressure around the wound area that promotes healing by removing excess fluid and debris, reducing infection, and encouraging the growth of new tissue) for months that was removed about two weeks ago. A review of Resident#21's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to, chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow that progresses slowly, usually affecting older adults), cytomegaloviral disease (common viral infection that can cause a wide range of symptoms, from mild, flu-like illness to serious health problems in certain individuals) and hypertension (high blood pressure). A review of Resident#21's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident#21 was cognitively intact. Further review indicated that Resident#21 had one or more unhealed PU. A review of Resident#21's WCCP's 5/14/25, wound treatment recommendations included the following: Wound #38 Right, Superior Buttock Wound Dressing: Apply: - Xeroform. Dry Dressing Mon (Monday)-Wed (Wednesday)-Friday. Monitor for changes. A review of Resident#21's WCCP's 5/21/25, wound treatment recommendations included the following: Wound #27 Sacral Wound Dressing D/C (discontinue) Treatment - Wound Vac Cleanse with Saline. - Adaptic. Collagen Sheet. Dry Dressing Daily. Wound #31 Right, Inferior Buttock Wound Dressing D/C Treatment - Wound Vac. Collagen Sheet. Cleanse with Saline. - Adaptic. Dry Dressing Daily. A review of Resident#21's WCCP's 5/28/25, wound treatment recommendations included the following: Wound #27 Sacral Wound Dressing D/C Treatment - Wound Vac Cleanse with Saline. - Xeroform. Adaptic. Collagen Sheet. Dry Dressing Daily. Wound #31 Right, Inferior Buttock Wound Dressing D/C Treatment - Wound Vac. Collagen Sheet. Cleanse with Saline. - Xeroform. Adaptic. Dry Dressing Daily. A review of Resident#21's May and June 2025 electronic Treatment Administration Record (eTAR) included the following orders: Right inferior buttocks-cleanse with NS (normal saline), pat dry. Apply Collagen sheet then cover with DDSG (dry dressing) every day shift with a start date of 5/22/25. Sacral- cleanse with NS, pat dry. Apply Collagen sheet then cover with DDSG every day shift with a start date of 5/22/25. The WCCP's wound treatment recommendations for the 5/21/25 and 5/28/25 visit for the right inferior buttock and sacral PUs were not followed. Further review of the May 2025 eTAR did not include any order for the right superior buttock. The WCCP's wound treatment recommendation for the 5/14/25 visit for the right superior buttock was not followed. On 6/9/25 at 10:47 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the WCCP's recommended orders for PU treatment. The LPN stated that the WCCP tells the nurse or Unit Manager (UM) and would write a hand written order and that the regular physician would be notified. On 6/10/25 at 9:59 AM, in the presence of Regional Director of Nursing #1 (RDON#1), the surveyor interviewed the Director of Nursing (DON) regarding the process of WCCP's treatment recommendations. The DON stated the WCCP visited every Wed and would give them the measurements of the PU(s) and the recommendation for the treatment. She added then the resident's physician was called for the approval of the treatment and then write the order in the electronic medical record and transcribe it to the Treatment Administration Record (TAR). The surveyor asked what was done if the physician did not agree with the WCCP's treatment recommendation. The DON stated that if the physician did not agree with the WCCP's recommendation there would be documentation in the resident's Progress Notes (PN). On 6/10/25 at 10:17 AM, the surveyor asked the DON and RDON#1 what the reason was that the WCCP's recommendations that were in the WCCP's Visit Reports for 5/14/25, 5/21/25 and 5/28/25 were not followed. RDON#1 stated that she did not know why the orders were not carried out. She added that the UM usually made rounds with the WCCP and the WCCP should tell the UM the order and then sent the paper later. The DON added that the WCCP gave them a handwritten recommendation. On 6/10/25 at 10:21 AM, in the presence of the DON and RDON#1, the UM of the South Unit (UMSU) stated that the WCCCP had a medical scribe that had their own spreadsheet that they wrote on during the WCCP visit. She added that they would give her a copy of the spreadsheet and that she would work on it at the end of the day. The UMSU stated that the WCCP did not communicate the recommendations to her verbally but that they wrote them. The UMSU stated that she did not review the final visit report that was emailed to the facility and uploaded to the electronic medical record. The surveyor asked who would review the final WCCP visit report. The UMSU stated that the DON or MDS Coordinator would check it. The UMSU stated that she carried out the orders that were handwritten on the spreadsheet that was given to her on the day of the visit and that she did not review the final visit report. The UMSU showed the surveyor a copy of the spreadsheet which had typewritten information for the PU treatment and also handwritten information. The top of the spreadsheet had a date range of 5/14/25 to 5/20/25, and did not indicate when the actual visit was or when the handwritten orders were written. The spreadsheet was not uploaded into the resident's electronic medical record. The UMSU showed the surveyor an additional dated (which was difficult to determine the range) spreadsheet that was typewritten and handwritten and had xeroform circled by pen that was in the typewritten order of cleanse with saline, xeroform, adaptic, dry dressing daily .DC treatment wound vac. Collagen sheet. A review of Resident#21's PNs did not indicate any documentation that the WCCP's recommendations should not have been followed. On 6/10/25 at 12:50 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that the WCCP's wound treatment recommendations were not followed for Resident#21. On 6/11/25 at 11:03 AM, in the presence of the DON, the LNHA stated that there was no response to the concern. A review of the facility's Wound Care and Pressure Ulcer Risk Assessment Policy, with a reviewed date of 10/2024, did not contain any information regarding WCCP recommendations. A review of the facility's Measuring Wound and Treatment Protocol, dated 1/22, included under the section of Declining Pressure Ulcer or Pressure Ulcer that is not showing improvement in the past two weeks: 2. Notify Physician, Resident/Resident Representative, Interdisciplinary team a. Request Wound Service Consult as needed (i.e., Consulting Wound Physician, NP (Nurse Practitioner)). 3. Obtain new treatment order 4. If the physician chooses NOT to change the pressure ulcer treatment, document the conversation with the physician in the Progress Notes. The LNHA did not provide any additional information. N.J.A.C. 8:39-27.1 (a)(e)

Based on observation, interview, and record review, it was determined that the facility failed to clarify physician's orders to ensure appropriate care and services for a resident receiving an enteral tube feedings. This deficient practice was identified for 1 of 2 residents (Residents#56), reviewed for enteral tube feeding. This deficient practice was evidenced by the following: On 6/4/25 at 11:08 AM, the surveyor observed Resident#56 lying in bed with the head of bed elevated, eyes open, non-verbal and responsive with gestures. The resident was receiving an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) which was running at 40 milliliters/hour (ml/hr) on the feeding pump. On 6/9/25 at 10:20 AM, the surveyor reviewed the electronic medical record (EMR) of Resident#56. A review of the admission Record (an admission summary) reflected the resident had diagnoses that included but were not limited to; cerebral infarction (stroke), encephalopathy (any disorder or disease of the brain), and dysphagia (difficulty swallowing). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 5/3/25, had a Brief Interview Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. In Section K (Swallowing/Nutritional Status), Resident#56 was coded as receiving nutrition through a feeding tube while a resident. A review of the physician's order (PO) revealed: -a PO dated 5/9/25, indicated, to administer Nutren 2.0 per percutaneous endoscopic gastrostomy (PEG) tube via pump; Rate: 40 ml/hr for 24 hours/day to provide 1000 ml with water flushed of 200 ml every 4 hours; total volume: 840 ml/24 hours; total calorie: 2000 calories/24 hours. -a PO dated 4/29/25, indicated, to record the reading on the enteral feeding pump at the end of each shift every shift. A review of the May and June 2025 electronic Medication Administration Record (eMAR) revealed: -The Nutren enteral feeding order was scheduled every day (7:00 AM-3:00 PM) shift, evening (3:00 PM-11:00 PM) shift, and night (11:00 PM-7:00 AM) shift. -The entry to record the reading of the enteral feeding pump at the end of each shift revealed the entries varied and did not total the amount of 840 ml, which was the total volume to be infused to the resident as per the PO. A review of Resident#56's weight history did not present any significant weight changes in the last month. A review of the Registered Dietician (RD) note dated 5/12/25, revealed, the resident's feeding rate was increased to 45 ml/hr on 5/8/25, which Resident#56 did not tolerate due to stomach discomfort and vomiting. The feeding rate was decreased back to 40 ml/hr with a total volume of 840 ml/24 hours to be infused, which the resident had been tolerating well. On 6/9/25 at 11:06 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) about enteral feeding orders and the documentation of a resident's enteral feeding intake. The LPN stated the PO for the enteral feeding to be administered to the resident would be reviewed. The feeding rate, type of feeding, the total volume, and the duration would be included in the enteral feeding order for a resident. The LPN further explained at the end of the shift the feeding machine was checked for the total volume the resident received during the shift and it would be documented in the resident's eMAR. The surveyor reviewed with the LPN the enteral feeding order for Resident#56. The LPN read the order, stated, the resident's feeding rate was 40 ml/hr, and the total volume to be infused to resident was 840 ml/24 hour. The surveyor asked about the entry to record the reading on enteral feeding pump at the end of each shift, if the daily total for all three shifts would be equal the total volume of feeding infused to the resident. The LPN was unsure, and was unable to identify an issue with the enteral feeding order. On 6/9/25 at 11:19 AM, the surveyor interviewed the RD about enteral feeding orders and management. The RD stated she made enteral feeding recommendations which were entered under orders in the EMR for physician approval. The RD added that she informed the nurses, and they would call the physician to obtain approval of RD recommendations. The RD stated when assessing residents, she verbally confirmed with staff if the resident was having any issues with their enteral feeding, and she did not review the total volume infused documented by the nurses. On that same date and time, the surveyor asked the RD about Resident#56's current enteral feeding orders. The RD stated the resident's current orders started on 5/9/25, for Nutren enteral feeding at 40 ml/hr for a total of 840 ml. The RD explained the feeding should be for 21 hours in a day or until complete. The RD confirmed the order would be expected to include the total volume/total calorie, and the duration of the enteral feeding administration. At that same time, the surveyor reviewed with the RD the current enteral feeding order in the EMR for Resident#56. The RD confirmed the order should have been clarified and that it was not correct. The RD stated someone may have revised the original recommendation order and made an entry error. The surveyor asked the RD about the entry to record the reading on enteral feeding pump at the end of each shift, if the daily total for all three shifts would be equal the total volume of feeding infused to the resident. The RD replied that she could not speak to that as it was a task for nursing. The RD stated she would review the concern with the Director of Nursing (DON) and have the resident's order clarified. On 6/9/25 at 11:24 AM, the surveyor interviewed the DON who started at the facility three weeks ago. The surveyor reviewed with the DON the enteral feeding order for Resident#56. The DON acknowledged the order needed to be clarified. The surveyor asked the DON about the entry to record the reading on the pump at the end of every shift, if the daily total for all three shifts would equal the total volume to be infused to the resident. The DON was unsure and would follow up to provide further information. On 6/9/25 at 1:01 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the DON of the above concerns with Resident#56's enteral feeding order. There was no verbal response at this time by the LNHA and DON. On 6/10/25 at 12:38 PM, the LNHA and the DON met with the survey team. The DON stated the enteral feeding order was clarified by the RD. There was no additional information provided by the facility's management. A review of the facility's Administering Medications through an Enteral Tube Policy, with a revised date of November 2024, the policy did not address the protocol for documentation of an enteral tube feeding order or total volume. There were no additional policies related to enteral feedings or feeding tubes provided by the facility. A review of the facility's Administering Medications Using Electronic System [EMR] Policy, with a revised date of November 2024, under Policy Statement revealed, Medications shall be administered in a safe and timely manner, and as prescribed . Under Policy Interpretation and Implementation revealed: . 4. If a dosage is believed to be inappropriate or excessive for a resident .the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns . 6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication . NJAC 8:39-25.2(c)2; 27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the necessary respiratory care and services of residents by following the physician order for one 1 of 2 residents, (Resident #47), reviewed for respiratory care, in accordance with professional standards of practice and facility policy. 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 6/4/25 at 10:16 AM, Surveyor#1 (S#1) observed Resident#47 in bed wearing their own clothes, alert and able to answer surveyor's inquiry. The resident was observed on continuous oxygen (O2) via nasal cannula (n/c; the device has two prongs and sits below the nose) connected to the concentrator (is a medical device that gives extra O2). A review of the admission Record (an admission summary) or face sheet revealed diagnoses which included but not limited to; chronic obstructive pulmonary diseases with (acute) exacerbation (COPD; is an ongoing lung condition caused by damage to the lungs), pulmonary fibrosis (serious lung disease characterized by the thickening and scarring of lung tissue, which makes it increasingly difficult to breathe unspecified, and anemia (is a problem of not having enough healthy red blood cells or hemoglobin to carry O2 to the body's tissues) unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 5/30/25, revealed in Section C Cognitive Patterns, had a brief interview for mental status (BIMS) score of 10 out of 15, which reflected that the resident's cognition was moderately impaired. A review of the personalized care plan (CP) revealed a focus that resident had O2 therapy related to COPD that was initiated on 3/13/24. The CP interventions included but not limited to, give medications (meds) as ordered by physician, monitor/document side effects and effectiveness that was initiated on 3/14/24. A review of the Order Summary Report revealed the following active Physician's Order (PO): -order date 1/23/25, O2 via n/c or mask continuous at 2 LPM (liter per minute) every shift for O2 supplementation, administer O2 via n/c, monitor pulse ox (oximeter) every shift. Notify MD (medical doctor) if pulse ox less than or equal to 90%. The above PO for O2 was transcribed to May 2025 and June 2025 electronic Medication Administration Record (eMAR) and was plotted for Day (7:00 AM-3:00 PM) shift, Evening (3:00 PM-11:00 PM) shift, and Night (11:00 PM-7:00 AM) shift, and was signed by nurses as administered. Further review of the May and June 2025 eMAR revealed that there was no documented evidence that the pulse ox was monitored every shift according to the PO. A review of the medical records revealed, there was no documented evidence that pulse ox was monitored every shift and there was no documented evidence as to why the order was not followed. On 6/9/25 at 1:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and Surveyor#2 (S#2) notified them of the above concerns with Resident #47's O2 order was not followed. On 6/11/25 at 8:35 AM, S#2 interviewed the Licensed Practical Nurse (LPN), who informed S#2 that if the order was to monitor the pulse ox (or O2 saturation), it should be followed and document it in eMAR or at times in progress notes (PN). The LPN stated that the only place to document pulse ox was in those areas, eMAR and PN. She confirmed that the resident was on continuous O2 order. S#2 notified the LPN of the above findings and concerns that pulse ox was not monitored according to the PO, and the LPN had no response. On 6/11/25 at 9:03 AM, the survey team met with the LNHA and DON, and the DON stated that she did an in service with nurses that the order for O2 should be followed including monitoring of pulse ox or O2 saturation. A review of the facility's Physician Medication Orders Policy, with a revised/reviewed date of 10/2024, that was provided by the LNHA, revealed, meds shall be administered only upon the written order of a person duly licensed and authorized to prescribe such meds .Policy Interpretation and Implementation .3. Verbal orders for drugs and treatments shall be received only by Licensed nurses .and certified respiratory therapists when the orders relate specifically to respiratory care . On 6/11/25 at 12:30 PM, the survey team met with the LNHA, DON, Regional DON#1 (RDON#1), RDON#2, and Chief Operations Officer for an exit conference, and there was no additional information provided by the LNHA and his team. NJAC 8:39-25.2(3); 27.1(a)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to ensure; a.) specimen refrigerator was free from frost and temperature was routinely monitored, b.) eyewash station area was clean and routinely monitored, c.) proper maintenance of biohazard disposal system, and d.) resident's environment and equipment were clean and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was identified in 2 of 2 soiled utility rooms and 1 of 2 residents (Resident#47) reviewed for tube feeding. This deficient practice was evidenced by the following: According to the CDC Guidelines for Environmental Infection Control in Health-Care Facilities dated 6/6/2003, Recommendations --- Regulated Medical Wastes I. Categories of Regulated Medical Waste Designate the following as major categories of medical waste that require special handling and disposal precautions: 1) microbiology laboratory wastes [e.g., cultures and stocks of microorganisms]; 2) bulk blood, blood products, blood, and bloody body fluid specimens; 3) pathology and anatomy waste; and 4) sharps [e.g., needles and scalpels . II. Disposal Plan for Regulated Medical Wastes Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of regulated medical wastes .Designate a person or persons as responsible for establishing, monitoring, reviewing, and administering the plan. III. Handling, Transporting, and Storing Regulated Medical Wastes .Manage the handling and disposal of regulated medical wastes generated in isolation areas by using the same methods used for regulated medical wastes from other patient-care areas . Store regulated medical wastes awaiting treatment in a properly ventilated area inaccessible to vertebrate pests; use waste containers that prevent development of noxious odors . According to the CDC, I. Regulated Medical Waste, dated 1/8/24, 3. Management of Regulated Medical Waste in Health-Care Facilities. Transporting and storing regulated medical wastes within the health-care facility prior to terminal treatment is often necessary. Both federal and state regulations address the safe transport and storage of on- and off-site regulated medical wastes .Health-care facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations. On 6/4/25 at 10:46 AM, Surveyor#1 (S#1) with the Staffing Coordinator (SC) went inside the North unit soiled utility room with a posted sign outside the door for biohazard (a biological hazard, or biohazard, is a biological substance that poses a threat (or is a hazard) to the health of living organisms, primarily humans) in red sign. Both S#1 and the SC observed bins of soiled linens inside a bag and there was a small refrigerator (ref)with a paper outside for Refrigerator Temperature (temp) Check for month of June 2025, for Unit North for specimen fridge, and there was a hand signed temp of 38F (Fahrenheit) on date 1, and signature. The paper for dates 2, 3, and 4 were blank. The instruction in the paper was to check every night on 11-7 (11:00 PM-7:00 AM) shift, range should be 36F-46F. The temp at that time was 40F. On that same date and time, both S#1 and the SC observed the specimen fridge with accumulation of frost and there was one specimen inside a bag with paper, the SC unable to state at that time when the specimen was collected but mentioned that was probably today, and waiting for pick up. On 6/4/25 at 10:55 AM, the Director of Maintenance (DoM) informed S#1 that it was the responsibility of nurses to log specimen temp of the ref in the soiled utility room. On 6/4/25 at 11:00 AM, S#1 and Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1) went inside the South unit soiled utility room, and both observed the vent on the ceiling blowing air and there was an accumulation of grayish substance, LPN/UM#1 stated that should have been cleaned and will notify housekeeping. Both S#1 and LPN/UM#1 observed the biohazard container (big red bin with cover), and she stated that was for the biohazard and she acknowledged the accumulation of dust and unknown dark brownish/blackish substances around the red container. On 6/9/25 at 1:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), S#1 notified them of the above findings and concerns from the soiled utility rooms in the North and South units. On 6/11/25 at 8:40 AM, S#1 asked the DON to accompany S#1 inside the South unit soiled utility room. Both S#1 and the DON observed the eye wash station with accumulation of grayish substances, the sink with whitish substances, the red covered bin for biohazard with accumulation of dust and unknown dried brownish/blackish substances that was noted on 6/4/25. S#1 asked the DON why the eyewash log was not signed for dates 4/24/25, 5/6/25, 5/13/25, 5/20/25, 5/27/25, 6/2/25, and 6/9/25, and the DON responded that she had to ask the Housekeeping Director (HD). On 6/11/25 at 8:45 AM, S#1 interviewed the HD, who informed S#1 that she was a contracted employee of the facility. The HD stated that she was responsible for weekly rounds for eyewash to ensure the eyewash stations was clean and functioning. She further stated that the eyewash station should always be clean. S#1 notified the HD of the above findings and concerns with South unit soiled utility room that the eyewash log was not filled out, and the HD responded that she probably forgot to sign. At that same time, S#1 notified the HD of the concern with cleanliness. Both S#1 and HD went to the South unit to check the soiled utility room. Inside the South unit utility room, the HD stated that the whitish substances around the sink area where the eyewash station was located was calcium build up (also known as limescale, is a result of water that contains dissolved calcium salts flowing through pipes and out faucets and showerheads. Water with high levels of these calcium salts and other minerals is referred to as hard water.) and should have been cleaned. 2. On 6/4/25 at 10:19 AM, Surveyor#2 (S#2) in the presence of the LPN observed Resident#47 on continuous tube feeding (TF) via a pump at the rate of 40 ml/hr (milliliters/hour), with 900 ml remaining. S#2 observed the TF pole had a spill of whitish substance on the foot of the pole. On 6/11/25 at 8:30 AM, S#1 with LPN/UM#2 entered Resident#47's room and both observed the whitish brownish dried substances in the resident's right wheelchair (w/c) and the TF machine cord that was attached to an outlet, while a TF formula Nutren 2.0 was infusing at 40 ml/hr. LPN/UM#2 confirmed it was from the TF milk dripped and should have been cleaned. LPN/UM#2 also stated that she would call and notify the HD. On 6/11/25 at 8:35 AM, S#1 notified the LPN of the above findings and concerns with TF, and the LPN stated that it happened at times depending on who was the nurse, that the TF dripped, and the nurse should have cleaned it immediately. The LPN confirmed that the resident was on TF. On 6/11/25 at 9:03 AM, the survey team met with the LNHA and DON. The LNHA stated that the staff cleaned the soiled utility room after surveyor's inquiry. The LNHA further stated that some of the markings on the biohazard covered bin was unable to get off and the facility was on the process of ordering new bins. The LNHA confirmed that the bins should not be like that. At that same time, S#1 notified the LNHA and the DON of the concerns regarding the South unit soiled utility room eyewash station area with accumulation of dust and the eyewash station, the form was not filled out accordingly, from 4/24/25 to 6/9/25. S#1 also notified the concerns with Resident #47's TF dried whitish/brownish substances in the TF machine cord and the resident's w/c which LPN/UM#2 confirmed that was from the TF milk and should have been cleaned. A review of the facility's Specimen Refrigerators Policy, with a reviewed date of 10/2024, that was provided by the LNHA, revealed, the facility will ensure safe specimen ref maintenance, temp, and sanitation. Policy Interpretation and Implementation: 2. Monthly tracking sheets will include the temp, the signature and this will be done daily . 8. Specimen refrigerators will be kept clean with sanitizing solution, free of debris and good condition will maintain records of daily temp log. A review of the facility's Medical Waste-Segregating and Separating Policy, with last reviewed date of 10/2024, that was provided by the LNHA, revealed, medical waste generated by the facility will be segregated from general waste in accordance with current federal and state guidelines . On 6/11/25 at 12:30 PM, the survey team met with the LNHA, DON, Regional DON#1 (RDON#1), RDON#2, Chief Operations Officer for an exit conference. There was no further information provided by the LNHA. NJAC 8:39-19.4(a)(2)(l)

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to offer the resident an influenza (flu) vaccine. This deficient practice was identified for 1 of 5 residents (Residents#16) reviewed for immunizations. This deficient practice was evidenced by the following: On 6/5/25 at 11:06 AM, the surveyor interviewed Licensed Practical Nurse#1 (LPN#1) who was covering as unit manager for the unit about immunizations. LPN #1 stated the Infection Preventionist (IP) was responsible for the vaccination process for residents. LPN #1 could not provide details on the vaccination process. The surveyor asked LPN #1 about where documentation for vaccinations administered could be found. LPN #1 replied he was not sure and could follow up with the IP to ask. On 6/5/25 at 11:18 AM, the surveyor interviewed the IP, who confirmed she was responsible for overseeing vaccinations and ensuring immunization history of residents. The IP stated the facility would call a resident's representative (RR) and/or check the state online database for a resident's immunization status. The IP explained the facility sent via email notification of vaccination availability, which included links to fact sheets and vaccination education. The surveyor asked about the documentation of immunizations and consent for vaccination administration. The IP stated the information could be found in the immunization section of the electronic medical record (EMR) and it could be documented in a nurse's progress note (PN). On 6/9/25 at 12:39 PM, the surveyor reviewed the EMR of Resident#16. A review of the admission Record (admission summary) documented that the resident had diagnoses that included but were not limited to; dementia, heart failure, and osteoarthritis. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 4/6/25, had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated the resident had moderate cognitive impairment. Under Section O of the MDS assessment documented the flu vaccine was offered and declined. A review of immunizations listed in the EMR revealed for the flu vaccine, the last documented entry was dated 11/3/19, and indicated refused. Additional review of the immunization list revealed no additional documentation of the resident's flu vaccination status for the 2024 to 2025 flu season. A review of the paper chart revealed there was no documentation to indicate Resident#16 was offered or declined the flu vaccine. On 6/9/25 at 1:01 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) additional information of the flu vaccination consent or declination for Resident#16. On 6/10/25 at 8:55 AM, the IP provided the surveyor documentation of the email notifications of vaccinations available which was sent to the RR in 2024 and 2025. The documentation included an undated flyer listing available vaccines which had an attached page indicating that consent or declination could also be mailed to the facility. The IP stated that the information was sent, and the RR declined. The surveyor asked the IP how consent or declination was verified. The IP replied, the RR would call or return a email would inform the facility of interest for the resident to be vaccinated. The surveyor asked the IP if vaccination consent would be documented in the resident's medical record. The IP stated it was mostly verbal consent that was obtained and there were times it would be documented in a nurse PN. The surveyor asked the IP how it was known if a RR who received an email received the information and reviewed the documentation. The IP stated there was email delivery confirmation and showed email delivery confirmation in the provided documentation. On 6/10/25 at 10:40 AM, the surveyor reviewed nurse PN for Resident#16 which revealed the following: A nurse PN dated 10/2/2024, written by an LPN/Unit Manager (LPN/UM), which documented the LPN/UM spoke with the RR, discussed flu vaccination, and the RR requested Resident#16 receive the flu vaccine. There were no additional PN regarding flu vaccine declination or that the resident had received the vaccine for the 2024-2025 flu season. A review of the physician's order revealed there were no orders for the flu vaccine to be administered. On 6/10/25 at 11:00 AM, the IP provided the surveyor documentation and explains it indicated when the RR opened and reviewed the emails sent regarding vaccination. The dates in the provided documentation were in 2025. The surveyor notified the IP about the nurse PN dated 10/2/24, which indicated the RR desired for Resident#16 to receive a flu vaccine. IP stated she would review to follow up. On 6/10/25 at 11:18 AM, the surveyor interviewed the LPN/UM who had written the PN. The LPN/UM stated the IP oversaw and did most of the vaccination and immunization processes. The LPN/UM stated once consent was received from a resident or RR, an order to administer the vaccine would be obtained from the physician. The LPN/UM stated that it was the IP or the previous DON, who usually handled the process after consent was obtained for vaccination. The current DON started at the facility three weeks ago after the previous DON had left. The LPN/UM stated consent was obtained verbally or paper form; a PN would be written; and in the immunization section of the EMR it would be documented whether a resident had received a vaccination or declined. At that time, the surveyor asked the LPN/UM about the PN written on 10/2/24. The LPN/UM could not recall details from the time the PN. The LPN/UM explained the process was to tell the IP or DON that a resident wanted a vaccine, and they would follow up. The LPN/UM could not recall exactly who she informed. The LPN/UM stated it was done verbally and there was no documentation for when staff informed the IP or DON. The surveyor asked if there were consent forms for vaccination. The LPN/UM stated there used to be a form used and now mostly consents were done verbally now. Furthermore, the LPN/UM stated the resident may have refused after the note was written. The surveyor asked the LPN/UM if a resident or RR decided not be vaccinated after giving consent would it be expected for staff to document in the EMR. The LPN/UM replied yes, it should be documented. On 6/10/25 at 12:49 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the DON of the concern regarding Resident#16 not being provided the flu vaccine for the 2024-2025 season after the RR requested for the resident to receive the vaccine. On 6/11/25 at 11:25 AM, the DON and LNHA met with the survey team. There was no additional response provided by facility management. A review of the facility's Influenza Vaccine Policy, with a last reviewed date of October 2024, under procedures, revealed: . 1) Yearly determination between October 1st to March 31st should be made on all residents concerning the offering of Influenza vaccine . 5) Documentation at the time of vaccine administration must be recorded on the Medication Administration Record, Resident's Immunization Record, and/or PN . 6) Documentation of refusal or allergy must be recorded on the resident's medical record . N.J.A.C. 8:39-19.4 (h)

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training for 1 of 5 CNA education reviewed (CNA #1). This deficient practice was evidenced by the following: On 6/9/25 at 9:22 AM, the surveyor reviewed the provided in-service education for five randomly selected CNAs for the 2024 to 2025 year, which revealed the following: CNA #1 with a date of hire on 3/21/21, had documentation of in-service training from 2023. There was no in-service training from date of hire anniversary dates for 2024 to 2025. On 6/9/25 at 10:42 AM, the surveyor requested from the Director of Nursing (DON) the annual 12-hour in-service education training for CNA #1. On 6/9/25 at 11:25 AM, the Licensed Nursing Home Administrator (LNHA) provided documentation which indicated CNA #1 completed 12-hour education at another health care facility. On 6/9/25 at 11:45 AM, the surveyor interviewed the LNHA who stated the previous DON was responsible for staff and CNA education. The LNHA stated he could answer questions regarding the CNA education provided. The LNHA explained the CNA also worked at the other healthcare facility and was able to get the education information from the other healthcare facility. The surveyor asked if the other facility was part of their facility's company. The LNHA replied it was not, but they had a close relationship with the other facility. The LNHA stated CNA #1 was currently out on medical leave starting approximately 1-2 weeks ago, they had been trying to get her complete her annual 12 hours of training and she was not able to finish. The surveyor asked if it would be expected for the previous DON to ensure that the CNA had completed their mandatory education. The LNHA acknowledged it was part of the DON's responsibility to ensure CNAs completed at least 12 hours of their mandatory annual education training. The surveyor asked if CNA #1 completed any education training between March 2024 and March 2025 at the facility. The LNHA stated he believed she completed a few hours and would check. The surveyor requested from the LNHA the policy for staff and CNA education. On 6/9/25 at 12:23 PM, the LNHA provided the surveyor documentation of CNA #1's training hours from 3/21/24 to 6/5/2025. A review of the provided document revealed CNA #1 completed 6 courses on 4/1/25, for a total of 5.75 hours. On 6/9/25 at 1:01 PM, the surveyor informed the LNHA and the DON, of the concern for CNA #1 not completing their 12-hour annual in-service education. On 6/10/25 at 12:38 PM, the LNHA and the DON met with the survey team. The LNHA stated the documentation of education for CNA #1 was what had been already provided to surveyor and the CNA's certification remained in good standing. There was no additional information provided by facility management. The surveyor reviewed the facility provided policy titled, Staff Education dated September 2024. The policy revealed: . 2. The facility will ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, an identified through resident assessment, and described plan of care . 6. Staff will demonstrate competency with the following training requirements including: preventing and reporting abuse neglect, and exploitation, dementia management, and infection control . 7. Nurse aides will demonstrate competency with activities and components that are required to be part of an approved nurse aide training . 11. The amounts and types of training will also be based on the facility assessment . N.J.A.C. 8:39-43.17(b)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physician's order for appropriately assessing resident's pain and b.) ensure appropriate indication of as needed (PRN) pain medications, according to facility's policy and standards of clinical practice. This deficient practice was identified for 1 of 5 residents, Resident#17, observed during medication administration pass. 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 6/9/25 at 9:19 AM, the surveyor observed Licensed Practical Nurse#1 (LPN#1) asked Resident#17 during medication (med) administration pass (med pass) if they had pain, and the resident responded that they had pain in their left leg. The resident also asked for pain med. LPN#1 informed the resident that the resident had an order for gabapentin for neuropathic pain (is a type of pain caused by damage or dysfunction in the nervous system, often resulting in chronic and debilitating symptoms) for their leg and LPN#1 had prepared for resident to take. LPN#1 also stated to the resident that he would get back in 30 minutes to re-assess the resident if they still have pain, after the resident take the prepared meds. The resident stated to LPN#1 to ensure that he would get back in 30 minutes to get the PRN pain med. The resident then took the medications (meds) whole with water that LPN#1 had prepared which included gabapentin 30 mg (milligrams) one capsule (cap). At that same time, the surveyor did not observe LPN#1 asked the resident what kind and level of pain when the resident complained of left leg pain. LPN#1 did not complete the assessment for pain (a pain assessment is a systematic process used to evaluate and quantify an individual's experience of pain, which is essential for effective pain management and treatment). LPN#1 did not review the resident's records for any PRN order for pain nor the indication of gabapentin. LPN#1 did not offer any PRN pain meds. On 6/9/25 at 9:49 AM, the surveyor interviewed LPN#1 in the presence of Regional Director of Nursing#1 (RDON#1) in the South Nursing station regarding Resident#17's pain assessment. LPN#1 informed the surveyor that the resident was cognitively intact. The surveyor asked LPN#1 if he asked the resident what pain level when the resident complained of left leg pain. LPN#1 responded that he did not ask for pain level according to numeric level, but he did assess the resident for pain according to Wong-Baker Faces Pain Rating Scale (with use facial expressions), that even though the resident had complained pain to left leg, no grimace was noted. LPN#1 stated that he administered the gabapentin which was for neuropathic pain. The surveyor asked LPN#1 what the order for pain assessment was, and LPN#1 reviewed the electronic Medication Administration Record (eMAR). LPN#1 stated that the order was to assess the resident for pain using the numeric level and not the Wong-Baker Faces Pain Rating Scale. The surveyor asked LPN#1 if he should follow the physician order (PO) for numeric pain level assessment and if he completed the appropriate pain assessment, and LPN#1 did not respond. On that same date and time, the surveyor asked LPN#1 if there was a PO for PRN pain med, and LPN#1 responded that there was an order for PRN Oxycodone (an opioid analgesic used to treat moderate to severe pain), and that the resident had history of overuse of controlled pain meds. LPN#1 also stated that at times, the resident was found to be groggy during therapy (physical/occupational therapy) due to Oxycodone use. The surveyor then asked if there was other PO for PRN pain med other than Oxycodone, and LPN#1 responded yes, and it was Tylenol. The surveyor asked LPN#1, if there were PO for PRN pain meds, why the PRN pain meds were not offered, and LPN#1 did not respond. The surveyor reviewed the medical records of Resident#17, and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to, direct infection of left knee in infectious and parasitic diseases classified elsewhere, and difficulty walking, not elsewhere classified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 4/28/25, Section C Cognitive Patterns revealed a brief interview for mental status score (BIMS) of 15 out of 15 reflected that the resident's cognitive status was intact. A review of the personalized care plan, with focus on resident's acute/chronic pain and potential for pain that was initiated on 4/21/25, and revised on 5/1/25, with an intervention that included but not limited to anticipate resident's needs for pain relief and respond immediately to any complaint of pain. A review of the Progress Notes (PN) dated 6/10/25, that was electronically signed by Licensed Practical Nurse#2 (LPN#2), revealed, Resident#17's recent left knee X-ray was emailed to Ortho (orthopedic) Doctor today . A review of the most recent X-ray results, dated 6/3/25, revealed, left knee X-ray impressions: 1. Total knee replacement with intact femoral and tibial components in anatomic alignment .In comparison with prior examination, previously noted intramedullary fusion rod (is surgery to repair a broken bone and keep it stable) from the femur (thigh bone) to tibia (shin bone) has been replaced with left knee joint prosthesis . 4. Mild osteopenia. A review of the resident's Order Summary Report (OSR, a listing of the resident's active meds and other orders) revealed the following active orders: -a Physician's Order (PO), revision date 4/21/25, Pain level every shift for monitoring pain, pain rating range: 0=no pain, 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain. -a PO, revision date 4/30/25, gabapentin cap 300 mg, give 1 cap by mouth three times a day for pain. -a PO, revision date 5/20/25, Oxycodone HCL (hydrocholoride) 10 mg tab, give 1 tablet (tab) by mouth every 4 hours (hrs) PRN for pain. -a PO, revision date 6/7/25, acetaminophen 325 mg, give 2 tablets (tabs) by mouth every 6 hrs PRN for mild pain (2 tabs=650 mg). Do not exceed 3000 mg/24 hrs from all sources. A review of the above PO revealed that the gabapentin order indication was for pain and not neuropathic pain. The PN reflected that the resident was being seen by Ortho Doctor for their left leg and X-ray results total knee replacement and mild osteopenia. On 6/9/25 at 1:03 PM, the survey team met with the Licensed Nursing Home Administration (LNHA) and Director of Nursing (DON). The surveyor notified of the above concerns with Resident #17's indications of pain meds and appropriate pain assessment. The DON stated that the PRN Oxycodone should have been sequenced to indicate when to use and usually if the Tylenol (as known as acetaminophen) was ordered for PRN mild pain, the Oxycodone indication should be for moderate to severe pain. On 6/11/25 at 9:03 AM, the survey team met with the LNHA and DON. The DON stated that education was provided to the nurse regarding the proper sequencing of PRN Oxycodone, and the order was updated to indicate for moderate to severe pain. The DON further stated that the nurse should have followed the PO to assess the resident according to numeric pain level and offered the PRN pain meds as ordered. The DON confirmed that the LPN went back to reassess the resident for pain after surveyor's inquiry. A review of the facility's Administering Medications Using Electronic System Policy, with an updated date of 11/2024, that was provided by the DON, revealed, meds shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: 3. Meds must be administered in accordance with doctor's orders, including any required time frame and following med cautionary . A review of the facility's Pain Assessment and Management Policy, with revised date of October 2024, that was provided by the DON, revealed, the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . General guidelines: 3. Pain management is multidisciplinary care process that includes the following: a. assessing the potential for pain; b. effectively recognizing the presence of pain; c. identifying the characteristics of pain . Equipment and supplies . 1. Pain assessment tool, as indicated per facility protocol .Assessing Pain . 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level .Implementing pain management strategies . 6. Implement the med regimen as ordered, carefully documenting the results of the interventions .Document the resident's reported level of pain with adequate detail as necessary and in accordance with pain management program . On 6/11/25 at 12:30 PM, the survey team met with the LNHA, DON, RDON#1, Regional DON#2, Chief Operations Officer (COO) for an exit conference. The LNHA did not provide additional information. NJAC 8:39-11.2(b)

Based on observation, interview and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 2 of 17 residents reviewed, Resident#3 and Resident#37, and as 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. 1. Surveyor#1 (S#1) reviewed the electronic medical record (EMR) for Resident #3. A review of the resident's admission Record (AR; an admission summary) reflected that the resident was re-admitted to the facility with diagnoses which included but not limited to, hypertension (high blood pressure) and chronic kidney disease (a condition where the kidneys do not function fully). A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/8/25, had a Brief Interview Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. A review of the resident's Comprehensive Care Plan (CCP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, dated 3/8/25, revealed, under the nutrition focus area, interventions section, an entry reflecting, provide and serve diet as ordered -CCD (carbohydrate controlled diet) 1500 cc (cubic centimeters) fluid restriction/24 hrs (hours). A review of the resident's Dietician progress notes (DPN) revealed a note dated 1/21/25, reflected, the resident receiving a 1500 cc fluid restriction. A DPN dated 5/25/25, reflected, that the diet was changed upon readmission and that they were no longer on a fluid restricted diet by resident request. On 6/5/25 at 12:07 PM, Surveyor#2 (S#2) interviewed the Registered Dietician (RD), and S#2 asked the RD who completes the resident's nutrition section of the CCP. The RD stated that they review and complete the nutrition care plans. S#2 asked the RD if they signed off on Resident#3's nutrition section of the CCP. The RD verbally confirmed that they had signed off on Resident#3's current CCP on 6/5/25, indicating that they had reviewed the CCP, and considered it to be accurate. S#2 asked the RD what Resident#3's current diet was and if they were on any fluid restrictions. The RD stated that the diet was CCD, and that the fluid restriction was discontinued (d/c) as per the resident's request prior to the most recent hospital admission. S#2, in the presence of the RD reviewed the signed off CCP which reflected a 1500 ml (milliliters) fluid restriction under the interventions section. The RD stated that they must have missed the fluid restriction and that it should have been removed prior to the CCP being signed off as complete and accurate. 2. S#1 reviewed the EMR for Resident#37. A review of the resident's AR reflected that the resident was re-admitted to the facility with diagnoses which included but not limited to, osteoarthritis (a degenerative joint condition) and venous insufficiency (a condition where blood has difficulty returning to the heart). A review of the QMDS, with an ARD of 3/13/25, had a BIMS score of 10 out of 15, which indicated the resident had moderate cognitive impairment. A review of Section J revealed that the resident had not received any pain medications (meds) in the previous five days and had not reported any pain in the previous five days. A review of the resident's CCP, dated 3/21/25, revealed, under focus, that the resident has chronic pain, revised date of 3/25/24, under interventions, administer analgesia oxycodone HCL (hydrocholoride) as per orders, revised date of 7/21/22. A review of the resident's Order Summary Report (OSR), a listing of the resident's current meds and treatments, did not reveal any current orders for oxycodone (a narcotic pain medication (med)). A review of the resident's Order Audit Report (OAR), a listing of the status of a med order, for oxycodone, revealed that the oxycodone order was d/c 9/7/23. On 6/5/25 at 1:05 PM, S#1 interviewed the Director of Nursing (DON), and S#1 surveyor asked the DON what the process was for initiating and revising a resident's CCP. The DON stated that the care team will meet to initiate the CCP based on the resident's needs, assessments and MDS and will revise as needed based on a resident's change in condition or outcomes. S#1 asked the DON if a d/c med should be included in the CCP, and the DON stated, no, it should be removed with a revision. S#1 asked if a change in diet or fluid intake should also be included in a CCP revision, and the DON stated, yes, that should be also. On 6/10/25 at 12:39 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON, and S#1 discussed the concerns with Resident#3 and Resident#37's CCP. On 6/11/25 at 10:58 AM, the survey team met with the LNHA and DON, and the DON stated that the CCP for both residents have been revised and updated. A review of the facility's Care Plans- Comprehensive Policy, dated revised 10/2024, reflected under Line 2. The CCP is based on a thorough assessment that includes, but is not limited to, the MDS. Line 6.developing interventions targeted and meaningful . Line 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Line 9.c. When the resident has been readmitted to the facility from a hospital stay. The LNHA did not provide any further pertinent information. NJAC 8:39-11.1

Based on interview and record review, it was determined that the facility failed to ensure that the residents Attending Physician visited and documented monthly visits alternately visited every other month when the Nurse Practitioner (NP) visited on the subsequent month for 2 of 17 residents reviewed (Resident #21 and #33). This deficient practice was evidenced by the following: 1. On 6/5/25 at 12:09 PM, the surveyor reviewed Resident#21's hybrid (paper and electronic) medical record which revealed that the resident's attending physician's last documented visit was dated 8/1/24, in the electronic medical record, and there was one visit which was dated 3/4/25, listed as an H&P (history and physical) in the paper medical record. The remaining documented visits in the resident's electronic medical record were done by the NP since 8/1/24. A review of Resident#21's admission Record face sheet (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow that progresses slowly, usually affecting older adults), cytomegaloviral disease (common viral infection that can cause a wide range of symptoms, from mild, flu-like illness to serious health problems in certain individuals), and hypertension (high blood pressure). On 6/10/25 at 9:59 AM, in the presence of Regional Director of Nursing #1 (RDON#1), the surveyor interviewed the Director of Nursing (DON) regarding physician visits. The DON stated that the physician and NP should alternate visits. On 6/10/25 at 10:31 AM, the surveyor interviewed the Unit Manager of the South Unit (UMSU) regarding physician visits. The UMSU stated that the NP visited regularly. The UMSU stated that the attending physician visited on Tuesdays and mostly visited the new admission residents. On 6/10/25 at 11:20 AM, the DON confirmed that the only physician note in Resident#21's paper chart was an H&P that was dated 3/4/25. On 6/10/25 at 12:50 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident#21's physician did not have the required documented visits that alternated with the NP. 2. On 6/10/25 at 11:46 AM, the surveyor reviewed Resident#33's hybrid medical record which revealed that the resident's attending physician only documented one visit, the admit note, dated 1/7/25, in the resident's paper chart. All of the remaining documented visits were done by the NP. A review of Resident#33's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; malignant neoplasm of endometrium (endometrial cancer, which is a type of cancer that develops in the lining of the uterus (the endometrium), hypertension (high blood pressure), and hyperlipidemia (condition where there are excessive levels of lipids (fats) in the blood, including cholesterol and triglycerides). On 6/10/25 at 1:12 PM, the DON confirmed that the only attending physician note in Resident#33's paper chart was an admission note dated 1/7/25. On 6/10/25 at 1:15 PM, the surveyor notified the LNHA and DON the concern that Resident#33's attending physician did not have the required documented visits that alternated with the NP. On 6/11/25 at 11:03 AM, in the presence of the DON, the LNHA stated that he did not have any response to the concerns regarding physician visits for Residents#21 and #33. A review of the facility provided policy titled Physician Services with a revised date of 10/2024, included the following: 9. After the initial 30-day visit, all visits must then occur at 30-day intervals up until 90 days after admission date. After the first 90 days, visit must be conducted at least every 60 days thereafter. Additional visits after the initial visit can be conducted the physician, physician's assistant or Nurse Practitioner. S483.30(c)(1) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A review of the facility's Physician Progress Notes Policy, with a reviewed date of 10/2024, included the following: Policy Statement Physician progress notes must be maintained for each resident. Policy Interpretation and Implementation 1. Physician progress notes are maintained for each resident residing in the facility. 2. Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc. 3. The resident's attending physician must write, sign and date the physician progress notes upon each visit. 4. Inquiries concerning physician progress notes should be referred to the attending physician, medical director or director of nursing services. The LNHA did not provide any additional information. N.J.A.C. 8:39-23.2(d)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) acquire, accurately administer and document a medication (Polysaccharide Iron complex) from 10/7/23 until surveyor inquiry on 11/16/23 for one (1) of five (5) residents, (Resident #50), observed during the medication administration observation, b.) administer medications in a timely manner to five (5) residents, (2 sampled residents :Resident #23 and #53 and 3 unsampled Residents #1, #2 and #3) by one (1) of two (2) nurses observed administering morning medications on 11/16/23 and c.) accurately document the administration of an as needed (PRN) medication (Tylenol) for one (1) of nine (9) residents, (Resident #44), reviewed for medication management. 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: REFER TO F759 1. On 11/16/23 at 9:37 AM, during the morning medication administration pass, the surveyor, in the presence of another surveyor, observed the Licensed Practical Nurse (LPN) preparing seven (7) medications which included one 150 milligram (MG) capsule of Polysaccharide Iron Complex (an iron supplement) for Resident #50. The LPN stated that he was unable to find the Polysaccharide Iron Complex capsule in the medication cart and would have to check with the Charge Nurse/LPN (CN/LPN) or call the physician. On 11/16/23 at 9:55 AM, the surveyors observed the CN/LPN join the LPN at the medication cart and assisted the LPN in searching the medication cart for the Polysaccharide Iron Complex capsules. The CN/LPN stated that she was unable to find the Polysaccharide Iron Complex capsules and would have to check why it was not available. On 11/16/23 at 10:08 AM, the LPN had completed administering the morning medications to Resident #50 which included six (6) of the seven (7) medications that had an administration time of 9 AM. The surveyors had not observed the LPN administer the Polysaccharide Iron Complex according to the PO. The LPN signed the electronic medication administration record (EMAR) indicating the number five (5) which corresponded with Hold/see Progress Notes for the administration of the Polysaccharide Iron Complex. The surveyor reviewed the medical record for Resident #50. A review of the resident's Admission Record (AR) revealed diagnoses which included fracture of right femur, anemia and deficiency of other specified B group vitamins. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 10/13/2023, reflected the resident had a brief interview for mental status (BIMS) score of 11 out of 15, indicating that the resident had a moderately impaired cognition. In addition, the MDS revealed in section A1110 for Language that the resident spoke another language and required an interpreter. A review of the Order Summary Report revealed a physician's order (PO) dated 10/7/23 for Polysaccharide Iron Complex capsule 150 MG, Give 1 capsule by mouth one time a day for supplement. A review of the nursing Progress Notes (PN) dated 11/16/23 at 10:58 AM completed by the CN/LPN indicated that MD called made aware of AM medication being administered late. On 11/16/23 at 1:30 PM, the surveyor interviewed the LPN who stated that he was an agency nurse and that this was his first day at the facility. The LPN stated that he was given an orientation handout that morning but was unsure who had given it to him. The LPN added that the CN/LPN was working on locating the Polysaccharide Iron Complex capsules and had called the physician. On 11/16/23 at 1:38 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the CP was in the facility this morning and gave out Med Pass information to the nurses. On 11/16/23 at 1:44 PM, the surveyor interviewed the CP who stated that she had given an in-service information handout on Medication Pass that morning to the nurses who were doing the medication pass because there were agency nurses. A review of the Medication Pass in-service information handout provided by the CP reflected that under Miscellaneous Situations: Missing Medications: If a medication is not found on the med cart, notify another nurse to first check the backup supply. If not available from back up, notify the physician for further orders, such as stat delivery from pharmacy and a one-time order to administer later in the day. Follow up with the surveyor to let them know how the problem was resolved. On 11/16/23 at 1:16 PM, the surveyor interviewed the CN/LPN who stated that she was the not the usual Unit Manager (UM) and was acting as the CN for that day. The CN/LPN stated that the Polysaccharide Iron Complex was technically an over the counter (OTC) medication and was a house stock medication to be provided by the facility. The CN/LPN added that she could not find the Polysaccharide Iron Complex capsules and thought they were on order, so she had called the provider pharmacy and requested 20 capsules to be delivered. The CN/LPN explained that the facility could order any OTC but that the order could take a couple days to come in so during the interim they requested a small amount of the OTC medication be delivered from the provider pharmacy so that it would be available to the resident. At that time, the surveyor, with the CN/LPN, reviewed a Fax Log dated 11/16/23 and timed for 10:29 AM that she had completed so that the facility would receive the Polysaccharide Iron Complex in the next delivery from the provider pharmacy. The CN/LPN also stated that the 3 PM to 11 PM shift would administer the medication because she had also called the physician and obtained a PO to administer the medication late. The CN/LPN could not speak to why the medication was not available for the 9 AM medication pass. At that time, the CN/LPN reviewed the electronic PO for the Polysaccharide Iron Complex and stated that the start date for the PO was 10/7/23. The CN/LPN also reviewed an electronic Progress Note (EPN) which indicated that the pharmacy was contacted with regard to delivering the Polysaccharide Iron Complex but could not speak to whether the medication was delivered. On 11/16/23 at 1:48 PM, the surveyor interviewed the Director of Nursing (DON) who stated that she was aware that the Polysaccharide Iron Complex capsules were not available during the medication pass and had called the provider pharmacy. The DON added that the provider pharmacy had never delivered any Polysaccharide Iron Complex capsules for Resident #50 because it was an OTC medication. The DON then explained that she had checked with their supplier and the Polysaccharide Iron Complex was out of stock. The DON then stated that she would have to investigate what the nurses were administering since the EMAR indicated that the medication was administered and why there was no follow up when the medication was not administered and documented as awaiting delivery or called pharmacy. A review of the October EMAR for Resident #50 revealed that the Polysaccharide Iron Complex had a start date of 10/7/23 and on 10/13, 10/16 and 10/31 the medication was not administered and had a chart code of the number nine (9) entered for the 9 AM administration which indicated Other/See Progress Notes. In addition, on 10/21/23 there was a chart code of the number five (5) which indicated Hold/see Progress Notes. Further review of the EMAR revealed that the medication was administered on 10/7, 10/8, 10/9, 10/10, 10/11, 10/12, 10/14, 10/15, 10/17/10/18, 10/19, 10/20, 10/22, 10/23, 10/24, 1025, 10/26, 10/27, 10/28, 10/29, and 10/30. A review of the corresponding EPN regarding the PO for Polysaccharide Iron Complex 150 MG revealed the following: 10/13/23 at 10:23 Pharmacy to deliver 10/21/23 at 08:25 on order 10/31/23 at 10:06 AM meds not available A review of the November EMAR for Resident #50 revealed that Polysaccharide Iron Complex was not administered at 9 AM on 11/1, 11/2, 11/3,11/6, 11/8, 11/9 and 11/10 and had a chart code of the number nine (9) which indicated Other/See Progress Notes. Further review of the EMAR revealed that the medication was administered on 11/4, 11/5, 11/7, 11/11, 11/12, 11/13, 11/14 and 11/15. A review of the corresponding EPN regarding the PO for Polysaccharide Iron Complex 150 MG revealed the following: 11/1/23 at 9:37 Pending delivery from pharmacy; MD notified regarding missing dose. 11/2/23 at 11:15 on order 11/3/23 at 10:27 On order. MD notified of missed dose. No new orders at this time. 11/6/23 at 10:32 Med on order. Pending pharm delivery. 11/8/23 at 10:37 waiting for pharmacy There was no corresponding EPN found for 11/10/23. 11/10/23 at 9:00 Pending med delivery On 11/17/23 at 9:31 AM, the surveyor, in the presence of the survey team, interviewed the Unit Clerk (UC) who stated that he was responsible for the Central Supply of the facility which required keeping stock and ordering of the OTC medications that the facility provided. The UC explained that there was a list of the usual OTC medications that he ordered but the list could be added to. The UC further explained that if an OTC medication that was not on the list had to be ordered that sometimes it would take a couple days to receive and that the nurses were aware of that. The UC was unaware of the need to order Polysaccharide Iron Complex capsules. A review of the House Stock Medications list provided by the DON reflected that Polysaccharide Iron Complex 150 MG capsules were not on the list. On 11/17/23 at 10:40 AM, the surveyor interviewed the CN/LPN who stated that the Polysaccharide Iron Complex 150 MG capsules had been delivered on 11/16/23 and was able to show the surveyor the capsules in the medication cart. The CN/LPN added that one (1) capsule was missing from the delivery of 20 capsules because it had been administered that morning for the 9 AM dose. The CN/LPN also added that it was her mistake that the medication was not administered in the evening on 11/16/23 because she had not entered the PO to administer the medication as a one-time PO correctly in the electronic system. The CN/LPN stated that she had verbally told the 3 PM to 11 PM shift but had not electronically entered the PO correctly to prompt the medication nurse to administer the medication on 11/16/23. The CN/LPN acknowledged that the PO for Polysaccharide Iron Complex 150 MG was to be administered on 11/16/23 and that the resident had not received any doses on 11/16/23. The CN/LPN stated that the UM was currently not working and could not speak to the administration of the medication when it was not available. On 11/20/23 at 9:39 AM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that the facility policy does not speak to the process when a medication is not available. The DON added that the nurses should know that if a medication was not available that they have to find out why and let the physician know to get a PO to discontinue the medication or change to another medication. The DON stated that she was still investigating what the nurses had administered and why there was no follow up. The DON acknowledged that the Polysaccharide Iron Complex capsules were not available from 10/7/23 until 11/16/23 when the provider pharmacy delivered the medication. On 11/20/23 at 1:23 PM, the survey team met with the facility administrative team. The DON provided the surveyor with an Investigational Summary regarding the Polysaccharide Iron Complex. The DON stated that some of the nurses who signed as administering the Polysaccharide Iron Complex were agency nurses and was not able to contact every nurse. The DON added that the nurses that she had contacted had stated that they had administered the iron supplement but were unable to remember what iron medication or exact name they administered. The DON added that the nurses should have followed up when the medication was not available on 10/7/23. 2. On 11/16/23 at 9:26 AM, during the morning medication observation, the surveyor in the presence of another surveyor, observed the LPN preparing to administer medications to an unsampled Resident #1. The LPN attempted to obtain a blood pressure result for and was unable to get the BP machine to function. The LPN stated that he was going to skip to another resident. On 11/16/23 between 9:37 AM and 10:08 AM, during the morning medication administration observation, the surveyor in the presence of another surveyor, observed the LPN prepare and administer medications to Resident #50. On 11/16/23 at 10:12 AM, after the LPN completed the administration documentation for Resident #50, the surveyors interviewed the LPN regarding the names highlighted in red on the EMAR. The LPN stated that he just had to administer medications to the unsampled Resident #1 and was then complete with his morning medication pass. The LPN added that he would have to call the physician for the unsampled Resident #1 because the medications were going to be administered late and that was the reason why the name was highlighted in red. The LPN explained that the medications were due at 9 AM and he had one (1) hour before 9 AM and one (1) hour after 9 AM to administer the medications to be on time. The surveyors, with the LPN, again reviewed the EMAR which revealed five (5) resident names that were highlighted in a red color which included the unsampled Resident #1. The LPN stated that he thought the four (4) other residents that were highlighted in red just had monitoring information that he was able to document during his shift. The surveyors, with the LPN, then reviewed each of the five (5) residents that were highlighted in red (Residents #23, #53, and unsampled Residents #1, #2 and #3), and revealed that each resident had morning medications that were due for 9 AM that had not been administered yet. The LPN stated that the physician would have to be contacted for all the residents that had late medications. On 11/16/23 at 1:22 PM, the surveyors interviewed the CN/LPN who stated that she had called the physicians regarding the medications being administered late and there was no issue. The CN/LPN stated that this was the LPN's first day and knew that should not be an excuse, but she handled as much as she could. The CN/LPN stated that nothing unusual occurred this morning to make the medications late. On 11/16/23 at 1:30 PM, the surveyors interviewed the LPN who stated that he was an agency nurse, and this was his first day at the facility. The LPN also stated that he was late getting to the facility this morning since it was the first time coming to the facility and then had to get a login password for the electronic system and do a walk around which he explained meant that the CN/LPN showed him where things were available in the facility and which residents he was responsible for. In addition, the LPN stated that he thought he received an orientation information packet when he came to the floor but was unable to speak to who had given him the handout. The LPN stated that his shift started at 7 AM but knew he arrived after 7 AM but could not speak to what time he actually started his morning medication pass. On 11/16/23 at 1:48 PM, the surveyor interviewed the DON who stated that the usual process for a new agency nurse was an onboarding orientation which meant that they were given a packet that had to be completed before starting work. The DON thought the LPN had received an orientation packet. At that time the DON made a phone call and then stated that the LPN had not received or completed an orientation packet. The DON further explained that the LPN had received an in-service handout on Med Pass from the Consultant Pharmacist. The DON provided the surveyor with the facility Agency Employee & Temporary Staff Orientation Packet. On 11/20/23 at 11:15 AM, the surveyor interviewed the DON who stated that the orientation packet had not contained any information regarding the medication pass and that she would have to have the packet updated. The surveyor reviewed the EMAR for the five (5) residents that were highlighted in red, (Residents #23, #53, and unsampled Residents #1, #2 and #3), which revealed the following medications that were due at 9 AM on 11/16/23: -Resident #23 had a total of seven (7) medications timed for 9 AM which included: Centrum (a vitamin), Jardiance (a medication to lower blood sugar), Folibic (a combination of vitamins), Folic acid (a supplement), Toprol XL (a medication used to lower blood pressure), Spironolactone (a medication used to decrease fluid retention), and Vasotec (a medication used to lower the blood pressure). -Resident #53 had a total of ten (10) medications timed for 9 AM which included: Amiodarone (a medication used to prevent an arrythmia), Lipitor (a medication used to lower cholesterol), B complex ( a vitamin), Protonix (a medication used to lower the acid in the stomach), Eliquis (an anticoagulant), Mucinex Extended Release (ER)(a medication used for cough), Midodrine (a medication used to increase the blood pressure), Tessalon [NAME] (a medication used to relieve persistent cough), Albuterol Nebulizer and Ipratropium nebulizer (medications used to help open the lungs). -Unsampled Resident #1 had a total of 14 medications timed for 9 AM which included: Norvasc, Aspirin Enteric Coated, Bacid (a probiotic), Lovenox injection (a medication used to prevent DVT), Hydrochlorothiazide ( a medication used to prevent fluid retention), Elipta Inhaler (an inhaler to treat Chronic Obstructive Pulmonary Disease (COPD)), Losartan (a medication used to treat high blood pressure), Oxybutynin Extended Release for overactive bladder), Prednisone (a steroid used to decrease inflammation for COPD), Advair Inhaler, Colace (a stool softener), Mucinex ER, Labetalol (a medication used to treat high blood pressure) and Nystatin suspension (a medication used for oral fungus infection). -Unsampled Resident #2 had a total of seven (7) medications timed for 9 AM which included: Allopurinol (a medication used to lower uric acid levels) Norvasc, Multivitamin, Protonix, Wellbutrin extended release (XL) (an antidepressant), Ativan (an antianxiety) and Effexor (an antidepressant). -Unsampled Resident #3 had a total of four (4) medications timed for 9 AM which included: Lipitor, Prednisone, Vitamin D3, DuoNeb nebulizer (a combination medication used to treat COPD). On 11/21/23 at 12:59 PM, the surveyor interviewed the DON who stated that the managers on the floor should be checking the electronic dashboard to make sure medications were not administered out of the time compliance. The DON acknowledged that the medications were to be administered one hour before the time of administration or one hour after the administration time in order to be in compliance. The DON added that if a nurse was going to be late or there was an issue administering medications on time then the Unit Manager should step in and help out. The DON added that the CN/LPN was covering for the usual Unit Manager. On 11/22/23 at 9:20 AM, the surveyor interviewed the DON who stated that she had done an investigation regarding the medications being administered late. The DON stated that the physicians were notified and that there were no negative outcomes. The DON acknowledged that the LPN was aware that he had residents with overdue medications and were not administered in a timely manner and that the Unit Manger should have taken over if the LPN was starting late for medication administration or going to be late administering medications. A review of the Medication Pass in-service handout provided by the CP reflected General Rule: For medications scheduled at the times designated by facility policy (i.e., BIS at 9am and 5 pm), they must be administered up to one hour before and one hour after the scheduled time. A facility policy dated as revised 6/3/2323 for Administering Medications Using Electronic System (name redacted) reflected that Medications shall be administered in a safe and timely manner, and as prescribed. In addition, Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 49078 3. On 11/14/23 at 11:51 AM, the surveyor interviewed Resident #44. Resident reported pain in knee at times due to arthritis. Surveyor asked if she reported this to the staff or her doctor. The resident stated that her doctor was aware, and the staff gave the resident pain medication when it was needed. The surveyor reviewed the medical record for Resident #44. On 11/20/23 at 09:58 AM, the surveyor reviewed the paper chart for physician's progress notes. A diagnosis of osteoarthritis (OA) was noted. The Physician's progress note dated 6/27/23 revealed that the resident's main complaint is knee pain and the resident had obesity with severe arthritis. On 11/21/23 at 12:12 PM, the surveyor reviewed the resident's electronic medical record, nurses/progress notes and electronic medication administration record (eMAR) for use of pain relief medications. There were two nurse progress notes that stated acetaminophen (Tylenol) was administered for pain as needed on 10/30/23 and 10/31/23. Upon reviewing the October eMAR for this resident, there was no electronic documentation for acetaminophen which was administration on 10/30/23 and 10/31/23. On 11/21/23 at 12:27 PM, the surveyor discussed the concern with the Director of Nursing (DON). The DON stated that she would look into this concern. On 11/21/23 at 1:00 PM, the DON provided a statement from medication nurse, that the nurse gave the acetaminophen but forgot to sign the administration of the medication in the October eMAR. NJAC 8:39-11.2(b), 29.2 (a)(d)

Based on observation, interview, and record review it was determined that the facility failed to provide indwelling urinary catheter care in a manner to prevent the spread of infection to a resident with a history of urinary tract infection (UTI). The deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for indwelling urinary catheter care and was evidenced by the following. On 11/14/23 at 10:37 AM, the surveyor observed Resident #7 awake in bed. The resident's large (overnight) urinary drainage bag was observed placed in a black privacy bag hanging on the bed frame. The surveyor inspected the resident's bathroom on 11/14/23 at 10:37 AM and again on 11/15/23 at 9:38 AM and observed a small (daytime) urinary drainage bag with uncapped tubing open to air stored in a plastic bag which hung from a handrail next to the toilet. On 11/15/23 at 9:38 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) assigned to Resident #7. The CNA confirmed the urinary drainage bag was uncapped and open to air. She stated the tubing should be capped. She further stated I don't know anything about it when asked whose drainage bag it was. On 11/15/23 at 9:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) in charge of the unit. The LPN confirmed the presence of an uncapped small urinary drainage bag in the resident's bathroom. She stated of the four residents sharing the bathroom, only one resident, Resident #7, had an indwelling urinary catheter. She stated she would educate the CNA as to why the tubing needed to be capped. A review of the electronic medical record revealed the following information. The resident was admitted to the facility with the diagnoses of retention of urine and UTI. The November 2023 Treatment Administration Record included a 10/25/23 physician's order for the use of an indwelling urinary catheter. The 10/31/23 Admission Minimum Data Set (MDS), an assessment tool used to guide the care of the resident, included in Section H that the resident used an indwelling urinary catheter and in Section I that the resident had a current UTI. On 11/17/23 at 1:15 PM, the surveyor discussed the concern of the uncapped indwelling urinary drainage bag with Director of Nursing (DON), the Licensed Nursing Home Administrator, and the Day to Day Manager. The DON provided the surveyor with the facility's policy for Urinary Catheter Care, revised October 2010. General Guideline #1 included the directive to maintain a closed drainage system. NJAC 8:39-19.4(a)5

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 11/16/23, the surveyors observed two (2) nurses administer medications to five (5) residents. There were 28 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.1%. This deficient practice was identified for one (1) of five (5) residents, (Resident #50), that were administered medications by one (1) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. On 11/16/23 at 9:37 AM, during the morning medication administration pass, the surveyor, in the presence of another surveyor, observed the Licensed Practical Nurse (LPN) preparing seven (7) medications which included one red colored tablet of One Daily (a multivitamin) (MVI) for Resident #50. The LPN stated that the MVI tablet was house stock meaning that the MVI was an over the counter (OTC) medication that was provided by the facility. On 11/16/23 at 9:52 AM, the surveyors observed the LPN attempting to administer six (6) of the seven (7) medications which included the red colored MVI tablet. Resident #50 was on the telephone speaking in another language and the LPN was unable to administer the medications. The LPN placed the medication cup containing the (6) medications on the resident's overbed table. At that time, the Charge Nurse/LPN (CN/LPN) joined the LPN in the resident's room and spoke to the resident and then spoke on the resident's phone. While the CN/LPN was speaking on the phone, the surveyor asked the LPN to review the medications that were in the medication cup that were ready to be administered to the resident. On 11/16/23 at 9:55 AM, the surveyors, with the LPN, reviewed the electronic medication administration record (EMAR) which revealed a physician's order (PO) dated 10/7/23 for One Daily/Minerals (Multiple Vitamins with Minerals) Give 1 tablet by mouth one time a day for Supplement. The surveyors with the LPN reviewed the house stock bottle in the medication cart that the LPN had removed the red colored MVI tablet from. The surveyors observed the LPN remove the red colored tablet of MVI from the resident's medication cup. The LPN stated that the red colored MVI tablet had not contained minerals. The LPN then stated that usually from his experience there was another house stock bottle that contained MVI with minerals but was unable to find one in his medication cart. The LPN stated that he would have to check with the CN/LPN. (ERROR #1) At that time, the surveyors observed the CN/LPN join the LPN at the medication cart and assisted the LPN in searching the medication cart for a house stock bottle containing MVI with minerals. The CN/LPN stated that the facility had a house stock of MVI with minerals and it was an orange or peach colored tablet. The CN/LPN verified that the red colored MVI tablet was not the MVI with minerals. The CN/LPN stated that she would obtain the house stock bottle of MVI with minerals. On 11/16/23 at 10:08 AM, the surveyors observed the CN/LPN give the LPN a house stock bottle of MVI with minerals that contained peach-colored tablets. The surveyor reviewed the medical record for Resident #50. A review of the resident's Admission Record (AR) revealed diagnoses which included fracture of right femur, anemia and deficiency of other specified B group vitamins. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 10/13/2023, reflected the resident had a brief interview for mental status (BIMS) score of 11 out of 15, indicating that the resident had a moderately impaired cognition. In addition, the MDS revealed in section A1110 for Language that the resident spoke another language and required an interpreter. A review of the Order Summary Report revealed a physician's order (PO) dated 10/7/23 for One Daily/Minerals (Multiple Vitamins with Minerals) Give 1 tablet by mouth one time a day for Supplement. On 11/16/23 at 1:30 PM, the surveyor interviewed the LPN who stated that he was an agency nurse and that this was his first day at the facility. The LPN stated that he was given an orientation handout that morning but was unsure who had given it to him. On 11/16/23 at 1:38 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Consultant Pharmacist (CP) was in the facility that morning and gave out Med Pass information to the nurses. On 11/16/23 at 1:44 PM, the surveyor interviewed the CP who stated that she had given an in-service information handout on Medication Pass that morning to the nurses who were doing the medication pass because there were agency nurses. A review of the Medication Pass in-service information handout provided by the CP reflected that The rights of med pass included Right Drug: Compare the pharmacy label/package to the MAR-the medication and strength must match exactly what is ordered. Example: multivitamin with minerals is NOT equivalent to a regular multivitamin or a multivitamin with iron. In addition, OTC (stock meds) are a common cause of medication errors due to the multiple different types and strengths. A review of the House Stock Medications list provided by the DON reflected that the facility provided Multivitamin with Minerals tablets. A review of the facility policy dated as revised 6/3/23 for Administering Medications Using Electronic System (name redacted) provided by the DON reflected that Medications must be administered in accordance with doctor's orders, including any required time frame and following medication cautionary. In addition, The individual administering medications must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. REFER TO F755 2. On 11/16/23 at 9:37 AM, during the morning medication administration pass, the surveyor, in the presence of another surveyor, observed the LPN preparing seven (7) medications which included one 150 milligram (MG) capsule of Polysaccharide Iron Complex (an iron supplement) for Resident #50. The LPN stated that he was unable to find the Polysaccharide Iron capsule in the medication cart and would have to check with the CN/LPN or call the physician. On 11/16/23 at 9:55 AM, the surveyors observed the CN/LPN join the LPN at the medication cart and assisted the LPN in searching the medication cart for the Polysaccharide Iron Complex capsules. The CN/LPN stated that she was unable to find the Polysaccharide Iron Complex capsules and would have to check why it was not available. On 11/16/23 at 10:08 AM, the LPN had completed administering the morning medications to Resident #50 which included six (6) of the seven (7) medications that had an administration time of 9 AM. The surveyors had not observed the LPN administer the Polysaccharide Iron Complex according to the PO. The LPN signed the EMAR indicating the number five (5) which corresponded with Hold/see Progress Notes for the administration of the Polysaccharide Iron Complex. The surveyor reviewed the medical record for Resident #50. A review of the resident's Admission Record (AR) revealed diagnoses which included fracture of right femur, anemia and deficiency of other specified B group vitamins. A review of the admission MDS, an assessment tool used to facilitate the management of care, with an assessment reference date of 10/13/2023, reflected the resident had a BIMS score of 11 out of 15, indicating that the resident had a moderately impaired cognition. In addition, the MDS revealed in section A1110 for Language that the resident spoke another language and required an interpreter. A review of the Order Summary Report revealed a PO dated 10/7/23 for Polysaccharide Iron Complex capsule 150 MG, Give 1 capsule by mouth one time a day for supplement. A review of the nursing Progress Notes dated 11/16/23 at 10:58 AM completed by the CN/LPN indicated that MD called made aware of AM medication being administered late. On 11/16/23 at 1:30 PM, the surveyor interviewed the LPN who stated that he was an agency nurse and that this was his first day at the facility. The LPN stated that he was given an orientation handout that morning but was unsure who had given it to him. The LPN added that the CN/LPN was working on locating the Polysaccharide Iron Complex capsules and had called the physician. On 11/16/23 at 1:38 AM, the surveyor interviewed the DON who stated that the CP was in the facility that morning and gave out Med Pass information to the nurses. On 11/16/23 at 1:44 PM, the surveyor interviewed the CP who stated that she had given an in-service information handout on Medication Pass that morning to the nurses who were doing the medication pass because there were agency nurses. A review of the Medication Pass in-service information handout provided by the CP reflected that under Miscellaneous Situations: Missing Medications: If a medication is not found on the med cart, notify another nurse to first check the back up supply. If not available from back up, notify the physician for further orders, such as stat delivery from pharmacy and a one-time order to administer later in the day. Follow up with the surveyor to let them know how the problem was resolved. On 11/16/23 at 1:16 PM, the surveyor interviewed the CN/LPN who stated that she was the not the usual Unit Manager and was acting as the CN for that day. The CN/LPN stated that the Polysaccharide Iron Complex was technically an OTC medication and was a house stock medication to be provided by the facility. The CN/LPN added that she could not find the Polysaccharide Iron Complex capsules and thought they were on order, so she had called the provider pharmacy and requested 20 capsules to be delivered. The CN/LPN explained that the facility could order any OTC but that the order could take a couple days to come in so during the interim the nurses would request a small amount of the OTC medication be delivered from the provider pharmacy so that it would be available to the resident. At that time, the surveyor with the CN/LPN reviewed a Fax log dated for 11/16/23 and timed for 10:29 AM that she had completed so that the facility would receive the Polysaccharide Iron Complex in the next delivery from the provider pharmacy. The CN/LPN also stated that the 3 PM to 11 PM shift would administer the medication because she had called the physician and obtained a PO to administer the medication when it arrived. The CN/LPN could not speak to why the medication was not available for the 9 AM medication pass. On 11/17/23 at 9:31 AM, the surveyor, in the presence of the survey team, interviewed the Unit Clerk (UC) who stated that he was responsible for the Central Supply of the facility which required keeping the stock and ordering of the OTC medications that the facility provided. The UC explained that there was a list of the usual OTC medications that he ordered but the list could be added to. The UC further explained that if an OTC medication that was not on the list had to be ordered and that would take a couple days to receive, and the nurses were aware of that. The UC was unaware of the need to order Polysaccharide Iron Complex capsules. A review of the House Stock Medications list provided by the DON reflected that Polysaccharide Iron Complex 150 MG capsules were not on the list. On 11/17/23 at 10:40 AM, the surveyor interviewed the CN/LPN who stated that the Polysaccharide Iron Complex 150 MG capsules had been delivered on 11/16/23 and was able to show the surveyor the capsules in the medication cart. The CN/LPN added that one (1) capsule was missing from the delivery of 20 capsules because it had been administered that morning for the 9 AM dose. The CN/LPN also added that it was her mistake that the medication was not administered in the evening on 11/16/23 because she had not entered the PO to administer the medication as a one-time PO correctly in the electronic system. The CN/LPN stated that she had verbally told the 3 PM to 11 PM shift but had not electronically entered the PO correctly to prompt the medication nurse to administer the medication on 11/16/23. The CN/LPN acknowledged that the PO for Polysaccharide Iron Complex 150 MG was to administer on 11/16/23 at a later time and that the resident had not received the 9 AM dose or any dose on 11/16/23. The PO for the Polysaccharide Iron Complex, although received on 11/16/23, was omitted. (ERROR #2) A review of the Progress Notes (PN) for dated 11/16/23 at 10:58 AM by the CN/LPN indicated MD called-made aware of AM medication being administered late. In addition, a PN dated 11/16/23 at 11:34 AM by the LPN indicated MD aware time to be changes. And a PN on 11/17/23 at 7:58 AM by the CN/LPN indicated Dr. (name redacted) contacted, updated, medication received. To start Polysaccharide Iron Complex Capsule 150 MG this am. A review of the November EMAR reflected that there was no administration of the Polysaccharide Iron Complex capsules on 11/16/23. Further review revealed that on 11/17/23 at 9 AM the Polysaccharide Iron Complex was administered. On 11/20/23 at 9:39 AM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that the facility policy does not speak to the process when a medication is not available. The DON added that the nurses should know that if a medication was not available that they have to find out why and let the physician know to get a PO to discontinue the medication or change to another medication. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in two (2) of four (4) medication carts inspected on 2 of 2 units. This deficient practice was evidenced by the following: On [DATE] at 11:46 AM, the surveyor inspected South Cart 1 in the presence of the Unit Manager (UM) and observed one (1) vial Ultra Track test strips (testing strips used to check blood glucose levels with a blood glucose monitor) with no date documented on the vial when opened. The surveyor also observed one (1) box of Ipratropium/Albuterol (DuoNeb) nebulizer solution (an inhalant liquid used with a mechanical nebulizer to treat asthma), which contained one (1) open foil packet with two (2) vials. There was no date when opened observed on the foil packet or box. On [DATE] at 11:55 AM, the surveyor interviewed the UM who stated that he could not find any dates when opened on the Ultra Track vial or the Ipratropium/Albuterol package. The surveyor with the UM reviewed the test strip manufacturer label and packaging which indicated discard remaining test strips 90 days after first opening date. The surveyor with the UM reviewed the manufacturer label for the Ipratropium/Albuterol nebulizer solution which indicated once opened they should be used within one (1) week of opening. The UM acknowledged that he was unsure of when the test strips or the DuoNeb were opened. The UM stated he would talk to the staff about dating medications when opened. On [DATE] at 12:42 PM, the surveyor inspected North Cart 1 in the presence of the Licensed Practical Nurse (LPN) and observed one (1) box of Budesonide nebulizer solution (a steroid inhalant liquid used with a mechanical nebulizer to treat asthma) containing one (1) foil packet that was opened and contained three (3) vials that had no date when opened on the foil package or on the box. At that time, the surveyor interviewed the LPN who stated there should be a date on the foil package when it is opened but did not see one on this package. The surveyor with the LPN reviewed the manufacturer label for the budesonide nebulizer solution which reflected once the foil pouch was opened, use ampules within 2 weeks. On [DATE] at 10:57 AM, the surveyor interviewed Consultant Pharmacist (CP) by telephone. The CP stated she is the regular consultant and conducts unit inspections on a regular basis. The CP stated that she checks medication carts, for expired items and for items to be properly labeled. The CP also stated that any irregularities were documented and immediately reported to the staff and then put into a written report to the facility. The CP added that the staff will usually correct any issue right away. On [DATE] at 11:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she spoke to the staff regarding dating when medications were opened, and the staff said they were unaware. The DON added that the staff should have known because they were dating medications when opened prior. On [DATE] at 12:32 PM, the surveyor interviewed the DON who stated that the CP had previously provided a handout to the nurses regarding Medications with shortened expiration dates. A review of the handout Medications with shortened expiration dates provided by the DON reflected under miscellaneous Test Strips Expires: 90 days after opening (or per manufacturer), under Nebulizer Inhalation Solutions DuoNeb (ipratropium bromide & albuterol) Date foil package or vial: Discard 7 or 14 days once removed from foil pouch, refer to manufacturer packaging, Pulmicort respules (budesonide) Date foil package or vial: Discard 14 days after opening foil package. NJAC 8:,d+[DATE].4(d)(g)

Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer a resident the pneumonia (PNA) vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident # 5 and # 16), reviewed for vaccination status and was evidenced by the following: CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: (last reviewed 9/21/23). 1. The surveyor reviewed Resident #16's medical record, who was over the age of [AGE] years old. A review of the resident's immunization history in the resident's electronic medical record revealed that there was no evidence that the resident had been offered or administered the PNA vaccination. 48781 2. The surveyor reviewed Resident #5's medical record, who was over the age of [AGE] years old. A review of the resident's immunization history in the resident's electronic medical record revealed that there was no evidence that the resident had been offered or administered the PNA vaccination. On 11/17/23 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN), who stated, I don't know why Pneumonia Vaccine was not documented that it was offered on admission. On 11/17/23 at 11:43 AM, the surveyor interviewed the LPN # 1, who stated that this is her first time to work on the North Wing, and another LPN # 2 stated she has been working here for a year. LPN # 2 stated, The protocol on admission is we ask residents for vaccine information. We make sure to offer all vaccines and ask the doctor for orders if resident wants to receive them. On 11/20/23 at 9:40 AM, the surveyor interviewed the Regional Registered Nurse (RRN), who confirmed that the documentation for PNA vaccine being offered on admission was not documented in the progress notes. She stated, The company did away with the consent form but staff should document on the progress notes. On 11/20/23 at 11:12 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the residents should have been offered all vaccines, including PNA and it should be documented in the resident's record. On 11/20/23 at 1:25 PM, the surveyor discussed with the RRN, interim Director Of Nursing, Administrator and Regional Administrator regarding the above concerns and no further information was provided. The surveyor reviewed the facility policy and procedure adapted from the Center for Disease Control (CDC) dated January 27, 2022. The facility policy stated, All newly admitted , readmitted and current residents are to be offered a pneumococcal vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. NJAC 8:39-19.4 (i)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to: a) implement and account for the necessary transmission based precautions to prevent the spread of infection during an identified upper respiratory infection outbreak, b.) ensure adequate and convenient placement of personal protective equipment supplies and receptacles for the disposal of used materials, c.) conduct a timely and accurate tracking of facility-acquired infections, and d.) report the upper respiratory outbreak in a timely manner to the local county department of health. This deficient practice was identified for 9 of 10 residents reviewed for infections (Resident #23, #24, #25, #37, #48, #49, #53, and #160), and was evidenced by the following: On 9/26/19 at 9:43 AM, the first day of the survey, the Licensed Nursing Home Administrator (LNHA) informed the survey team that the facility currently had an upper respiratory infection outbreak that had been reported to the local county department of health on 9/18/19. The LNHA added that the last recorded new onset of infection had been 9/23/19 and that the surveyors should wear personal protective equipment (PPE) including a mask when in resident rooms. The LNHA stated that the nurses on the units could further answer to what PPE specifics were required for each resident on the unit. He stated that the Director of Nursing (DON) was the designated Infection Preventionist at the time, but that they were working on getting two other staff members involved in that role. On 9/26/19 at 9:50 AM, the surveyor observed stop signs outside of the following rooms with no garbage cans or laundry bins within proximity of the entrance/exit of each rooms: room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. On 9/26/19 at 9:56 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN) who stated that there were stop signs outside of the some of the resident rooms. These signs indicated that one or more of the residents in that room had symptoms of an upper respiratory infection and the staff had to take special transmission-based precautions before entering the room. The RN/CN stated the precautions were droplet precautions (infection can be spread through contact with secretions). The surveyor asked the RN/CN what droplet precautions included. The RN/CN stated that the droplet precautions depended on the type of care the staff were going to give to the designated resident. The RN/CN stated that if the CNA was going to perform physical care for the resident, the CNA would be required to apply a gown, gloves, and mask. The surveyor asked the RN/CN what type of special precaution the surveyor should take before entering the resident's room. The RN/CN stated that a mask was the only PPE required prior to entering the resident's room. The RN/CN further stated that all the residents that were showing signs and symptoms of having a respiratory infection such as coughing were required to stay in their rooms. The RN/CN further told the surveyor that the symptoms of the respiratory outbreak on the North Unit had started a few weeks ago and Resident #24 was currently symptomatic with a cough. The surveyor team observed the following: 1. On 9/26/19 at 10:46 AM, the surveyor was standing outside of the private room of Resident #24. The surveyor heard the resident produce a moist, productive cough. The surveyor observed a stop sign outside of the resident's door which indicated to stop and please check in at the nurse's station before entering. The surveyor did not observe any personal protective equipment (PPE) outside of the resident's room. The surveyor walked approximately twenty feet down the hallway to a plastic bin which contained the PPE materials of gowns, gloves, and a mask. This bin was the closest bin in proximity to the resident's room for obtaining PPE before entering the resident's room. There was no trash can and/or laundry bin near the exit doorway of the room. The surveyor applied the PPE and entered the resident's room. Resident #24 was observed lying in bed. The resident stated that he/she had a cough for a long time now. The surveyor entered the resident's bathroom and observed an open-top small sized trash can with a clear plastic liner. The can was empty of trash. The surveyor further observed a green trash can in the back of the resident's room which did not contain a plastic liner. The surveyor removed the PPE and discarded it in the trash can in the bathroom and performed hand hygiene. The PPE filled the trash can. As the surveyor was exiting the room, a Certified Nursing Aide (CNA) entered the resident's room and walked over to the resident's bed. The CNA was not wearing a gown, gloves, and/or a surgical protective mask upon entering the resident's room to provide care. On 9/26/19 at 11:53 AM, the surveyor observed a Physical Therapist (PT) walking Resident #24 down the hallway using an assistive device. The PT was not wearing any PPE and the resident was not wearing a mask. The Restorative Certified Nursing Aide (R/CNA) was walking behind the resident with a wheelchair. The R/CNA was wearing gloves only. On 9/26/19 at 12:01 PM, the surveyor observed the R/CNA exit Resident #24's room, take off a pair of gloves and throw them in a trash can that was newly placed by the resident's bedroom door. The surveyor then observed the R/CNA walk over to a multi-use rolling walker that the resident had just used and touch the rolling walker with her hands without performing hand hygiene. There was no cleaning/disinfecting of the walker after it's use by Resident #24. On 9/26/19 at 12:02 PM, the surveyor interviewed the R/CNA of Resident #24 who stated that the stop sign outside of the resident's door indicated that the resident had an infection and the staff was required to wear a mask and gloves inside of the resident's room. The R/CNA further stated that when exiting the resident's room, the staff was supposed to perform hand hygiene using soap and water or an alcohol-based hand gel. On 9/26/19 at 12:32 PM, the surveyor interviewed the CNA who was observed entering the room of Resident #24 without wearing PPE. The CNA stated that staff were required to apply a gown, gloves, and a mask before entering a resident's room who had a signs and symptoms of a respiratory infection in order to prevent the spread of infection. She did not speak to why she wasn't wearing the PPE during the surveyor's observation. 2. On 9/26/19 at 11:01 AM, the surveyor observed a CNA apply a mask outside of the private room of Resident #53. The CNA was not wearing gloves or a gown before entering the resident's room to assist the resident with handling items in the bathroom. The surveyor observed the resident in the bathroom brushing his/her teeth. The resident exited the bathroom with the CNA behind her and the surveyor observed the resident produce a moist cough into a terry cloth towel. The surveyor observed the CNA apply one glove to their right hand only and the left hand was holding a clear plastic bag. The CNA took the used towel with the gloved hand and disposed of it into the trash bag. Upon exiting the resident's room the surveyor observed that the CNA had not performed hand hygiene and then proceeded to walk to the storage room on the unit to place the towel into a large laundry receptacle. Without washing her hands she opened the door to the storage room and obtained a new box of gloves. The CNA then performed hand hygiene. There was no trash can for used/soiled PPE and/or laundry disposal in the vicinity of the resident's entry/exit of the room. On 9/26/19 at 11:02 AM, the surveyor interviewed the CNA who was assisting Resident #53 in the bathroom who stated that staff just had to wear a mask when caring for a resident who had a respiratory infection. The CNA further stated that if the surveyor had any further questions to ask a nurse. 3. On 9/26/19 at 12:11 PM, the surveyor observed a stop sign outside of the shared room of Resident #23 which indicated to stop and please check in at the nurse's station before entering. The surveyor further observed a PPE bin in the hallway outside of the resident's bedroom. The surveyor observed a CNA apply a mask in the hallway outside of the resident's room and then a pair of gloves inside of the resident's room. The CNA then applied a plastic bracelet to the wrist of Resident #23 who was seated in their wheel chair. On 9/26/19 at 12:14 PM, the surveyor interviewed the CNA who applied the bracelet to Resident #23's wrist. The CNA stated that the stop signs were outside of the doors because the staff had to stop and ask the nurse what type of precaution were required for that resident. The CNA further stated that before entering Resident #23's room she had to apply a mask and gloves. The CNA stated that a gown was only indicated if the resident was coughing a lot because that meant the resident was on droplet precautions. On 9/26/19 at 12:20 PM, the surveyor observed a CNA making the bed of Resident #23. The CNA was not wearing a gown, gloves, and/or a mask. The surveyor observed another staff member standing in the resident's room wearing gloves and a mask. The staff member was not wearing a gown. On 9/26/19 at 12:32 PM, the surveyor interviewed the CNA who was observed making Resident #23's bed without wearing PPE. The CNA stated that the stop signs outside of the resident's room indicated that the resident had an infection and the staff had to apply a gown, gloves, and a mask before going into the room to prevent the spread of infection. The surveyor asked the CNA which resident in the room had an infection. The CNA stated that she didn't know. The CNA further stated that she should have asked the nurse what resident was sick before entering the resident's room. The CNA admitted that she wasn't wearing PPE when in the resident's room and stated, Oh, you seen that. 4. On 9/26/19 at 11:11 AM, the surveyor observed a stop sign outside of the Resident #160's door. This sign directed anyone entering the room to stop and please check in at the nurse's station before entering. The surveyor further observed that there was no bin containing PPE outside or in close proximity to the resident's room. The surveyor observed the resident lying in bed produce several moist, productive coughs. The surveyor observed the Licensed Practical Nurse (LPN) from the south unit and the CNA both wearing masks inside the resident's room and assisting the resident up in bed. The LPN and CNA were not wearing a gown and gloves. The surveyor interviewed a visitor with Resident #160 who was not wearing PPE while in the room with the resident. The visitor indicated that the LPN and CNA had just changed the resident's mattress to an air mattress. The visitor further indicated that he/she was not aware of the need for PPE while visiting the resident. On 9/26/19 at 11:15 AM, the surveyor interviewed the LPN who was assisting Resident #160 in bed. The LPN stated that the stop sign did not mean anything and stated that no additional care or precautions were required for the resident. On 9/26/19 at 11:17 AM, the surveyor observed Resident #160 lying in bed wearing oxygen at two liters per minute via nasal cannula. The surveyor overheard the resident emit another productive cough. The surveyor reviewed the medical record for Resident #160. A review of the resident's Admission Record (an admission summary) reflected that the resident was admitted to the facility on [DATE] and re-admitted on [DATE] and had [DIAGNOSES REDACTED]. A review of the (MONTH) 2019 Physician order [REDACTED]. There was no evidence in the order sheet for an order for [REDACTED].>A review of the resident's ICP which had been revised on 7/15/19 did not reflect that the resident had an URI, was on droplet precautions or care interventions related to the resident having an URI. 5. On 9/26/19 at 11:32 AM, the surveyor observed outside room [ROOM NUMBER] a stop sign which indicated to stop and please check in at the nurse's station before entering. The surveyor observed the south unit LPN enter room [ROOM NUMBER] wearing a mask and gloves, hand the call bell to the resident and exit the room. The surveyor did not observe the LPN perform hand hygiene when she exited room [ROOM NUMBER]. The LPN then walked down an adjacent hallway and was handed a temporal thermometer from another nurse. The surveyor observed the LPN walk over to the treatment cart and apply a gown, gloves and mask. The LPN then entered room [ROOM NUMBER] to take the temperature of the resident in the room. The LPN did not clean the multi-use temporal thermometer before and/or after taking the temperature of the resident in room [ROOM NUMBER]. The LPN then placed the thermometer on the resident's bedside table. 6. On 9/26/19 at 11:53 AM, the surveyor interviewed a CNA who worked on the south unit at the facility. The CNA stated that about two days ago on a Tuesday, the residents on south wing started to get sick and were coughing so they had to separate the residents. The CNA further stated that they would separate the residents who had symptoms of the upper respiratory infection and bring them in the TV room and the other residents without symptoms were designated to stay in the activity room. The CNA stated that the stop signs outside of the resident's room indicated that the staff were required to apply a gown, gloves, and a mask prior to entering the resident rooms because the residents were sick. On 9/26/19 at 11:57 AM, the surveyor interviewed the LPN on the north unit who stated that the respiratory outbreak started last week on a Tuesday or Wednesday. The LPN further stated that that the stop signs outside of the resident's room were a precautionary measure, meaning that staff had to apply a mask before entering the resident's rooms so the infection doesn't spread. The LPN stated that if staff were going into the resident's room to provide direct patient care then they would have to put on a gown, glove and a surgical mask. On 9/26/19 at 12:23 PM, the surveyor conducted a follow up interview with the RN/CN who stated that the facility's respiratory outbreak started last Tuesday or Wednesday. The RN/CN stated that the resident's that were identified as being symptomatic were encouraged to stay in their rooms. The RN/CN further stated that the confused residents who presented with signs and symptoms of a respiratory infection and were also considered fall risks were not left in their rooms alone. These residents were cohorted (grouped) together in the activity room. 7. On 9/26/19 at 10:23 AM, the South Unit Licensed Practical Nurse (LPN) informed the surveyor that over the weekend, the facility had an outbreak of upper respiratory infections among the residents. The facility had two separate activity rooms; one designated for sick residents and one designated for non-sick residents. The LPN stated that just to communicate with a resident, the surveyor would just need to wear a mask and gloves, but that the surveyor should keep a clear distance, and if getting close to the resident a gown was necessary. The surveyor observed the following: a.) room [ROOM NUMBER] had a a stop sign outside the door which directed those entering the room to see the nurse prior to entering. There was no personal protective equipment (PPE) located outside the door or within close proximity. b.) At 10:28 AM, the South Unit LPN stated that Resident #37 had an upper respiratory infection and a mask and gloves were required to enter the room, and a gown to go near the resident. The resident had pushed the call bell and was requesting hot water and tea. The LPN donned only a mask and gloves to bring in the tea. The LPN came out of the room, removed the mask and gloves in the hallway disposing of them in the medication cart trash container. The surveyor observed that the LPN did not perform hand hygiene. The LPN then rummaged through the medications in the drawer of the medication cart. The LPN then closed the cart and donned a mask and gloves and returned to Resident #37's room to bring him/her a cup with a spoon. The LPN then exited the room, removed the mask and gloves in the hallway and disposed of them in the treatment cart trash container. The surveyor observed that the LPN did not perform hand hygiene. The LPN then proceeded to room [ROOM NUMBER] that had no stop sign or PPE outside the door to speak with Resident #48. c.) At 10:35 AM, the Activity Aide was observed inside the activity room designated as the infected activity room. The Activity Aide wore a mask and gloves only. The surveyor observed the Activity Aide remove her gloves in the activity room and don new gloves. There was no hand hygiene in-between removing the old gloves and donning new gloves. d.) At 10:38 AM, the South Unit LPN wheeled Resident #21 out of the infected activity room into the resident's room. The resident was not wearing a mask. There was no observed stop sign to see the nurse or PPE located outside of the resident's door. At 10:42 AM, the LPN was observed on the telephone requesting a stop sign. The LPN instructed the R/CNA to stand outside the doorway and allow no one to go into the room until she got back. The R/CNA was observed inside the room with Resident #21 wearing gloves only. The LPN came back and instructed the R/CNA to get out of the room, since the resident was coughing too much. The LPN placed a stop sign outside the door. e.) At 10:51 AM, the surveyor observed a stop sign and PPE outside of Resident #49's room. The door to the room was closed. The surveyor knocked, slowly opened the door, and observed the CNA standing over Resident #49. The CNA stated she had just finished the resident's care and needed to get the hoyer lift to transfer the resident out of bed into the wheelchair. The CNA was observed wearing only gloves and no mask or gown. The CNA removed her gloves in the room and grabbed the garbage bags with her bare-hands and brought the garbage bags down the hall to the soiled utility room. The CNA did not perform hand hygiene after disposing of the bags. f.) At 11:07 AM, the surveyor observed stop signs located outside room [ROOM NUMBER] and room [ROOM NUMBER]. There was no PPE located outside the doors. 8. On 9/30/19 at 9:33 AM, the Activity Aide informed the surveyor that when inside the infected activity room, you need to wear a gown, gloves, and mask. When you are leaving the room, all PPE was to be disposed of in the trash located next to the door inside the room, and hand hygiene would be performed. The Activity Aide stated that she should have been wearing a gown along with the gloves and mask during activities, but she was not on 9/26/19. On 9/30/19 at 11:23 AM, the RN/CN informed the surveyor that Resident #48 did not have an upper respiratory infection. The resident's roommate had symptoms of an upper respiratory infection so the facility was monitoring Resident #48. On 10/2/19 at 10:03 AM, the surveyor observed a used/disposed of gown and mask in Treatment Cart South II. The LPN stated that PPE should not be discarded on the treatment cart, but inside the room prior to exit. On 10/2/19 at 2:25 PM, the DON informed the survey team that she keeps in-servicing staff based on the local health department's recommendation to wear a gown, mask, and gloves every time they go into an infected room. A review of the line listing (a tracking list of residents consisting of infection data) updated on 10/1/19 reflected a total of 33 residents that exhibited respiratory symptoms. The line listing reflected that a total of 17 residents exhibited symptoms with an initial onset date of 9/5/19. The line listing reflected: One resident infected on the south unit on 9/5/19. One resident infected on the south unit on 9/13/19. Two residents infected on the south unit on 9/15/19. Five residents infected on the south unit on 9/16/19 Eight residents infected on the south unit on 9/17/19. Four residents infected on the south unit on 9/18/19. Five residents infected on the north unit on 9/19/19. One resident infected on the south unit on 9/19/19 One resident infected on the north unit on 9/20/19. One resident infected on the north unit on 9/23/19. One resident infected on the south unit on 9/23/19. One resident infected on the north unit on 9/28/19. One resident infected on the south unit on 9/30/19. The line listing did not reflect a date of onset for one of the residents. 9. A review of the line listing dated 10/1/19 reflected that Resident #24's onset date of the respiratory illness started on 9/19/19. A review of the line listing reflected that the resident presented with a cough, sore throat, and myalgia (muscle pain). The surveyor reviewed the medical records for Resident #24. A review of the (MONTH) 2019 Physician order [REDACTED]. A further review of the (MONTH) 2019 POS reflected a Physicians Order (PO) dated 9/19/19 for a chest x-ray to rule out an Upper Respiratory Infection (URI), but there was no evidence of a physician order [REDACTED]. A review of the resident's Individualized Care Plan (ICP) revised on 7/11/19 did not reflect that the resident had an URI, was on droplet precautions or care interventions related to the resident having an URI. 10. A review the line listing dated 10/1/19 reflected that Resident #53's onset date of the respiratory illness started on 9/18/18. A further review of the line listing reflected that the resident presented with a cough and an elevated white blood cell count (a blood test indicative of an infection). The line listing reflected the resident was discharged home on[DATE]. The surveyor reviewed the medical records for Resident #53. A review of the resident's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's (MONTH) 2019 Physician order [REDACTED]. This order sheet also contained additional physician orders [REDACTED]. A PO dated 9/20/19 for [MEDICATION NAME]/[MEDICATION NAME] give 5 ml every six hours as needed for cough. A PO dated 9/21/19 for [MEDICATION NAME] 600 mg ER tab by mouth every 12 hours for seven days for cough. A PO dated 9/23/19 for [MEDICATION NAME] 200 mg by mouth every eight hours for five days. There was no evidence of a physician's orders [REDACTED]. A review of the resident's ICP dated 9/23/19 did not reflect that the resident had an URI, was on droplet precautions or care interventions related to the resident having an URI. 11. A review of the line listing dated 10/1/19 did not reflect that Resident #23 had an infection or that the roommate of Resident #23 had an infection. This did not correspond with the the stop sign to stop and see nurse before entering the room (indicative of the necessity to perform transmission-based precautions) and PPE outside of the residents' room. The surveyor reviewed the medical records for Resident #23. A review of the resident's Admission Record reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A complete review of the resident's medical record did not reflect documented evidence that the resident had a respiratory illness or symptoms of a respiratory illness. 12. A review of the line listing dated 10/1/19 reflected that Resident #160's onset of respiratory illness was 9/16/19. The line listing further reflected that the resident had a cough and was discharged to the hospital on [DATE] and re-admitted on [DATE]. On 9/26/19 at 12:49 PM, the surveyor interviewed the LNHA who stated that the infection was challenging to track. The LNHA further stated he was the person responsible for completing the line listing because it was all on his computer, and he was in the process of Trying to get it solid. As much as possible. He stated that he started to track the infections on 9/18/19. On 9/26/19 at 2:11 PM, the survey team interviewed the LNHA and the Director of Nursing (DON). The LNHA stated that the outbreak was first identified on 9/18/19 and he was unsure of what constituted an outbreak, so he stated he contacted the local health department. The DON stated that according to the local health department an outbreak was more than one individual showing the same signs and symptoms of an infection. The DON further stated that on 9/18/19 there was a cluster of individuals on the south unit that had a fever and/or a cough. The DON stated that the local health department recommended that garbage cans be placed by the exits in the resident's rooms so the staff could easily dispose of the PPE before exiting. The LNHA acknowledged there were no easily accessible trash cans at the exit of each room, but stated the possibly staff had moved them. The surveyor asked the DON and LNHA about the accuracy of the line listing versus what was observed on the units, and the LNHA stated that he believed it was accurate but that he would have to look at it again. He indicated that every resident room that had a sign on the door should be on the line listing and vice versa. The LNHA stated that all residents were considered exposed to the the infection, so they were closely watching all residents for signs of infection. The survey team asked the DON what her role in infection control was as it related to the respiratory outbreak at the facility. The DON stated that her role was to perform an assessment of the residents who were symptomatic of an infection because that would be carried over into the surveillance aspect. The survey team asked the DON if the staff had been educated on infection control and droplet precautions related to the recent respiratory outbreak. The DON stated that the staff were in-serviced on how to appropriately apply PPE and what PPE equipment to wear. The DON stated that the staff were in-serviced that if the resident was showing signs and symptoms of an active infection the staff would be required to gown, glove, and mask prior to entering the resident's room. The DON further stated that for residents that were asymptomatic of an infection the staff were in-serviced to apply a mask and gloves when caring for the residents. The DON stated that staff were in-serviced on hand hygiene which required them to wash their hands with warm soap and water for 20 seconds and then use a paper towel when turning off the faucet. The DON did not explain when it was appropriate for hand hygiene to be performed. The LNHA stated that staff were required to wash hands when they were visible soiled. The DON provided the surveyors in-service sign in sheets. The DON was unable to provide documented evidence that all the facility staff had been in-serviced on infection control during the outbreak. She acknowledged that she did not have documented evidence that the staff observed providing care on 9/26/19 had attended the in-services On 10/3/19 at approximately 11:30 AM, the LNHA and DON were unable to provide documented evidence of infection tracking from 8/9/19 until 9/18/19 when the LNHA stated they started tracking the respiratory outbreak. The DON acknowledged that there was no consistent tracking of infections after 8/9/19 due to a shifting of new positions. The LNHA acknowledged that had there been live tracking of infections at the time of the outbreak it would have been identified sooner. The LNHA acknowledged that the outbreak should have been reported to the local county department of health on 9/15/19. The DON acknowledged that the residents with the symptoms of a respiratory infection did not have a physician's orders [REDACTED]. She acknowledged all the resident's on the line listing should have had that, and that they had just started implementing that on all the resident's last night. She stated that when the resident's were added to the active line listing that their physician order's and care plans should have been immediately updated by the assigned nurse. She could not speak to why it had not been done until surveyor inquiry. A review of the facility's Infection Control Program Policy and Procedure revised 9/2019 reflected, The Infection Preventionist Nurse (IPN) in collaboration with the facility interdisciplinary team members will monitor, investigate, control and prevent infections in the facility through audits and surveillance reflecting current Center for Disease Control (CDC) guidelines. The facility's Isolation Precaution Policy and Procedure dated revised 9/2019 reflected, Droplet Precautions- masks are required if coming within (3) feet of the resident. Gloves are required if resident or items in residents rooms are to be touched. Gowns are to be worn if rendering personal care. A review of the facility's Handwashing/Hand Hygiene Policy and Procedure dated 12/2017 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. The Handwashing/Hand Hygiene Policy and Procedure further reflected, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b) Before and after direct contact with residents; i) After contact with a resident's intact skin k) After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident m) After removing gloves n) Before and after entering isolation precaution setting. 8. Hand hygiene is the final step after removing and dispensing of personal protective equipment. A review of the facility's Standard Precaution Policy and Procedure 9/2019 reflected, Resident-Care Equipment 2. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed. NJAC 8:39-19.4

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an incident in which a resident fell from an ambulance and required emergency care. The deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #20) and was evidenced by the following: On 9/26/19 at 11:04 AM, the surveyor observed Resident #20 in a wheelchair with his/her eyes closed. The surveyor was unable to interview the resident. On 9/26/19 at 9:56 AM, the surveyor interviewed the Charge Nurse/Registered Nurse (RN) who stated that Resident #20 had a fall with a major injury which occurred around March/April due to a mishap with the ambulance transporter. The surveyor reviewed the medical record for Resident #20. A review of the admission record revealed an original admission date of [DATE] and readmission date of [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/29/19 reflected the resident had a brief interview for mental status (BIMS) score of 6 out of 15, indicating that the resident had moderately impaired cognition. On 10/1/19 at 10:51 AM, the surveyor reviewed an incident/accident report and investigative summary dated 3/29/19 for Resident #20 provided by the Director of Nursing (DON). The reports revealed that the transporter from an ambulance service provider forgot that the ramp was still down and the resident fell out of the truck. The resident had to be sent to the hospital immediately by 911 emergency services. The investigation did not include documented evidence that the NJDOH had been notified of the incident. On 10/1/19 12:02 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated that the Licensed Nursing Home Administrator (LNHA) had additional information regarding the investigation of the incident and could not speak to whether the incident had been reported to the NJDOH. The DON added that at the time of the incident she was the Assistant Director of Nursing and the DON who had completed the summary was no longer employed at the facility. On 10/2/19 at 11:13 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA acknowledged that the transporter for the ambulance service provider had accidentally caused the resident to fall from the ambulance, and that the resident had to be sent to the hospital immediately by emergency services. The LNHA stated that he did not report the incident to the NJDOH because he didn't think incidents that were determined to be purely an accident were necessary to be reported. On 10/3/19 at 11:34 AM, the survey team met with the LNHA, DON and Regional Nurse Consultant. The LNHA acknowledged that he reviewed the incident again and agreed that the incident should have been reported. The LNHA added that he had reported the incident to the NJDOH on 10/2/19 after surveyor inquiry. A review of the facility policy for Resident Abuse/Neglect dated (MONTH) (YEAR) reflected that the Administrator or a designee would lead the investigation of an allegation of abuse/neglect. In addition, the NJDOH and the Office of the Ombudsman would be notified immediately meaning as soon as possible but not to exceed 2 hours of an alleged violation. NJAC 8:39-9.4 (e)(3)(i)