Every finding on record at Fountain Springs at Cape May Nursing & Rehab Cente

Based on interview, record review, and other pertinent facility documents, it was determined that the facility failed to ensure that residents received appropriate pain management and that pain medication was administered in accordance with the physician's orders for pain level parameters. This deficient practice was identified for 1 of 5 residents (Resident #2) reviewed for unnecessary medications and was evidenced by the following:On 4/10/2026 at 8:53 AM, the surveyor observed Resident #2 lying on the bed watching television. Resident #2 was pleasant and cooperative and alerted the surveyor that they were hard of hearing. No resident behaviors, or distress were observed.On 4/10/2026 at 9:52 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #2.A review of the admission Record revealed that Resident #2 was admitted with the following but not limited to diagnoses: Chronic pain syndrome, atherosclerotic heart disease, morbid obesity, neuralgia (intense, stabbing, or burning pain caused by damaged , irritated, or compressed nerves) and neuritis (the inflammation of one or more peripheral nerves, often causing pain, tenderness, numbness, tingling, and diminished reflexes or loss of function), cervicalgia (pain in the neck region, ranging from mild discomfort to severe stiffness or muscle spasms, often caused by muscle strain, poor posture, or injury), paranoid schizophrenia, and low back pain.A review of Resident #2's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/14/2026, revealed that the resident had a Brief Interview for Mental Status ( BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Section D of the MDS indicated that the resident had no mood indicators and section E of the MDS revealed that the resident did not have any behaviors during the observation period. According to Section J, the resident had pain that was occasional and was moderate in intensity. Section N indicated that the resident received opioid daily.A review of Resident #2's individual comprehensive care plan (ICCP) included a Focus area, date initiated: 8/3/2022 and revision on: 1/26/2026, [resident name] is at risk for pain r/t (related to) chronic pain. [resident name] is on drugs designed to relieve pain without opioid medication for pain management. Interventions included: Administer analgesics (drugs designed to relieve pain without causing loss of consciousness) as scheduled and as per MD (medical doctor) orders. Assess pain level with appropriate pain assessment scale and document as indicated. Complete pain assessments as per facility policy and ongoing observation and assessment for pain utilizing 0-10 pain scale as indicated.A review of the Order Summary Report (OSR), dated as of 4/14/2026, included the following physician orders (PO):A PO, dated 7/27/2022, for pain scale q (every) shift 0-10 every shift.A PO, dated 9/21/2022, for Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 4 hours as needed for Mild pain 2 tabs = 650 MG Do not give over 4000mg daily.A PO, dated 4/3/2026, for Oxycodone HCL (hydrochloric acid) Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (6-10).A PO, dated 4/14/2026, for Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Severe pain (7-10).On 4/13/2026 at 9:51 AM, the surveyor reviewed Resident #2 for unnecessary medications. The surveyor reviewed the past six months of the consultant pharmacist (CP) medication regimen review (MRR).On 10/27/2025, the CP made the following recommendation:Documented pain level of 0 (zero) does not match PRN (as necessary) oxycodone indication of moderate to severe. Please follow specific order. See 10/1 at 1026, 10/10 at 0402, 10/15 at 0649, and 10/22 at 2330. The surveyor reviewed the Medication Administration Record (MAR) for October 2025 and it was revealed that Resident #2 was provided Oxycodone (HCl) Oral Tablet 5MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (6-10) on 10/1 at 1026 (10:26 AM) for a pain level of 0 (zero), on 10/10 at 0402 (4:02 AM) for a pain level of 0 (zero), on 10/15 at 0649 (6:49 AM) for a pain level of 0 (zero) and on 10/22 at 2330 (11:30 PM) for a pain level of 0 (zero).On 12/31/2025, the CP made the following recommendation: Documented pain level of 0 (zero) and 5 does not match PRN Oxycodone indication of moderate to severe (6-10). Please follow specific order. Review of December 2025 MAR revealed the following: On 12/12/2025 at 1229 (12:29 PM) Resident #2 was administered Oxycodone HCL oral tablet 5MG for a documented pain level of 0. On 12/15/2025 at 0112 (1:12 AM) Resident #2 was administered Oxycodone HCl tablet 5MG for a documented pain level of 5. On 2/25/2026, the CP made the following recommendations: Documented pain level of 0 (zero) and 4 does not match PRN Oxycodone indication of moderate to severe (6-10). Please follow specific order. The surveyor reviewed the February 2026 MAR. The MAR revealed that Resident #2 was administered Oxycodone HCl 5MG for moderate to severe pain (6-10) on 2/5/2026 for a pain level of 0 (zero). On 3/25/2026, the CP made the following recommendation: Documented pain level of 0 does not match PRN Oxycodone indication of moderate to severe (6-10). Please follow specific order. Review of the March 2026 MAR revealed that Resident #2 was administered Oxycodone HCl Oral Tablet 5 MG on 3/16/2026 at 0810 (8:10 AM) for a documented pain level of 0 (zero). Resident #2 was administered Oxycodone HCl Oral Tablet 5 MG on 3/17/2026 at 1016 (10:16 AM) for a documented pain level of 0 (zero). Resident #2 was administered Oxycodone HCl Oral Tablet 5 MG on 3/17/2026 at 2224 (10:24 PM) for a documented pain level of 0 (zero). On 04/14/2026 at 8:28 AM the surveyor asked Resident #2 if he/she experienced pain regularly. Resident #2 stated, I have pain. He/she then told the surveyor I have pain when I sit down. I had five major back surgeries. I get pain in my neck, back and down my leg. The dosage of Oxycodone is too low. On 4/14/2026 at 8:35 AM, the surveyor conducted an interview with the Licensed Practical Nurse (LPN#1) assigned to Resident #2 on that shift. The surveyor asked LPN#1 if Resident #2 dealt with pain. LPN#1 responded, Yes. The way he/she described it, I would say it was chronic. The surveyor then asked if the facility had a pain scale in place. LPN#1 responded we have a pain scale, yes. The pain scale is 1-10. Usually, the Tylenol is for mild to moderate pain (1-5). If they described the pain as 6 or above, then we would use the medication that was prescribed for that pain level. The surveyor then asked LPN#1 if she would prescribe Oxycodone HCl Oral Tablet 5 MG for a resident who reported their pain scale as zero to five (5). LPN #1 stated, if a resident told me their pain level was zero, no, I would not administer Oxycodone. They had no pain. I probably would not administer Oxycodone for a pain level of 1-5, I would administer what was ordered for that pain level by the physician.On 4/14/2026 at 8:45 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM#2) of the wing in which Resident #2 resided. The surveyor asked LPN/UM#2 if the facility utilized a pain scale. LPN/UM #2 responded, Yes. She stated we have a pain scale that we utilized at the facility. The pain scale is 0-10. Mild is 0-3, moderate is 4-6 and severe is 7-10. The surveyor then asked LPN/UM #2 if a resident described a pain level of 0, would you administer Oxycodone HCl Oral Tablet 5 MG. LPN/UM#2 replied, No. She further explained that you want to try first to manage the pain with a lighter drug and see how that worked first. You do not want to jump right to the opioid. The surveyor then asked LPN/UM#2 if the pain scale utilized by the facility indicated administering Oxycodone HCl Oral Table 5 MG for a pain level of 0-5. LPN/UM #2 stated the pain scale that we utilized would not indicate the Oxycodone be administered for a pain level of 0-5. The facility Director of Nursing (DON) has in-serviced us continuously on this matter. She further stated that this has been a problem with Resident #2.On 4/14/2026 at 9:00 AM, the surveyor conducted an interview with the facility Licensed Nursing Home Administrator (LNHA) and the facility DON. The surveyor asked the DON if Resident #2 should have been administered Oxycodone HCl Oral Tablet 5 MG for a pain level that ranged from 0-5. The DON responded that the facility pain scale was mild pain is 0-3, moderate pain is 4-6 and severe pain is 7-10. She then stated that Oxycodone should not have been administered for a pain level of 0-5. A review of the facility provided document titled, Numeric Rating Scale, undated, included the following: One frequently used pain scale is the Numeric Rating Scale (NRS). With the NRS, nurses ask the clients to rate the intensity of their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain the client can imagine. Scores are interpreted as follows: 0 is no pain, 1 to 3 is mild pain, 4 to 6 is moderate pain, and 7 to 10 is severe pain.A review of the untitled/undated facility provided document revealed the following under Pain Management by Level:Mild Pain (0-3): Use non-opioid analgesics like acetaminophen (a medication used to treat pain and fever reduction) or NSAIDS (Non-steroidal anti-inflammatory drugs).Moderate Pain (4-6): Consider weak opioids like codeine or Tramadol, possibly combined with non-opioids.Severe Pain (7-10): Strong opioids like morphine or oxycodone are typical, possibly using a multimodal approach for better relief. The surveyor reviewed the facility provided Pain Management, policy, date reviewed/revised: 5/6/25, which included: The following was observed under Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, goals and preferences. The following was revealed under Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain.NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:On 4/14/2026 at 10:03 AM the surveyor, accompanied by the Director of Dietary (DOD), observed the following in the kitchen:A standup mixer was observed to be bagged and not in use on a metal countertop, The DOD confirmed to the surveyor that the mixer was cleaned and sanitized and was bagged when not in use. The surveyor and DOD removed the plastic bag to observe the mixer. Upon removal of the bag the surveyor observed a yellowish, oily/greasy substance on the upper attachment area. The surveyor used their finger to swipe the area, and a greasy, unidentified substance was observed on the surveyor's finger. In addition, there was unidentified, dried debris on the base arm of the mixer. When interviewed, the DOD agreed that the mixer needed cleaning and immediately cleaned the affected areas in the surveyor's presence.A review of the facility Kitchen Equipment Cleaning Policy, review date: 5/6/25, included: The following was observed under Policy: The facility maintains all kitchen equipment, utensils, and food preparation surfaces in a clean condition to support safe food handling practices. Cleaning of equipment is performed as needed based on use and operational needs. The following were revealed under Policy Explanation and Compliance Guidelines:General requirementsAll kitchen equipment shall be kept clean and free of food debris and residue.Cleaning shall occur at routine intervals and when equipment becomes soiled.Cleaning FrequencyEquipment and utensils used in food preparation shall be cleaned after use. NJAC 8:39-17.2(g)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the resident's environment in a safe, sanitary, and homelike manner by ensuring that damaged flooring was repaired in a timely manner. This deficient practice was identified on 1 of 2 units (West Unit) and 1 of 1 dining rooms and was evidenced by the following: 1.) On 4/13/2026 at 10:42 AM, while conducting an observation in the dining room, the surveyor observed a loose floor tile near the main doors. On 4/13/2026 at 10:48 AM, the surveyor and the Director of Maintenance (DM) returned to the dining room. He confirmed the surveyor's findings. At that time, the surveyor interviewed the DM who stated, it should not be popped up like that. I will address it right away because it is a tripping hazard. He added that normally they checked the floors once per week and they have a maintenance log on each unit for staff to report any issues. He added that most times they just told him verbally if there were any concerns. On 4/13/2026 at 10:54 AM, near the [NAME] -B hall, the surveyor noted uneven flooring secured by black tape. At that time, a family member of an unsampled resident stated, I thought it was decorations, but that looks like break your neck tape to me, as they walked by and looked at the flooring. On 4/13/2026 at 11:23 AM, during a further tour of the facility, located on the [NAME] Unit, near the soiled utility room, the surveyor noted a loose cracked floor tile. On 4/14/2026 at 9:41 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that they were renovating the hallways. He added that he would be conducting an audit and would have them fixed if they were not intact, as someone could trip. On 4/14/2026 at 9:45 AM, the surveyor, accompanied by the LNHA, toured the [NAME] Unit. He pointed to a caution sign that was placed near the uneven flooring after the surveyor's inquiry. He also confirmed the findings of the loose floor tiles. He added that during the renovations, the floor tiles should be maintained in a manner that they did not pose a fall risk to the residents. A review of the facility's Environment of Care: Safety and Maintenance Policy undated policy, included, The facility shall maintain a safe, clean, and functional environment for residents, staff, and visitors.The facility environment shall be kept in a condition that promotes safety, cleanliness, and accessibility. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a.) accurately identify when a medication administered via a patch was applied and removed, b.) ensure an incomplete physician's order was clarified c.) accurately transcribe and implement a diet order in accordance with the Dietician's recommendations. This deficient practice was identified for 1 of 1 resident, (Resident #86) reviewed for Pain and for 1 of 1 resident (Resident #87), reviewed for meal tray accuracy. 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 registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.)On 4/9/2026 at 10:15 AM, the surveyor observed Resident #86 in bed, wearing a sling on their left arm. On 4/9/2026 at 1:14 PM, the surveyor reviewed the medical record for Resident #86. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: pain in left hand, muscle weakness, pain in left shoulder, and a displaced fracture of the left humerus. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/13/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident occasionally experienced moderate pain. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 4/6/2026, that the resident was on a pain management regimen. Interventions included: Administer medications as ordered. Monitor for side effects and effectiveness, and attempt non-pharmacological pain interventions when not contraindicated: massage, repositioning, peaceful environment, aroma therapy, music, etc. A review of the Order Summary Report (OSR), dated as of 4/14/2026, included the following physician orders (PO): A PO, dated 4/6/2026 at 10:21 AM, for Lidoderm external patch 5 %, to be applied to the left shoulder in the evening and to be removed in the morning. A PO, dated 4/6/2026, for Voltaren external gel 1 %, apply to the upper arm, two times per day for pain. The physician's order did not include the location where the Voltaren gel should be applied. A review of the April 2026 MAR revealed that the Lidoderm patch should be applied at 6:00 PM. Check marks and nurse initials were noted for April 6 through April 13, 2026, which indicated that the medication was administered 8 (eight) times. There was no designated time slot for the nurse to sign that the Lidoderm patch was removed. On 4/14/2026 at 10:17 AM, the surveyor made a follow-up visit with Resident #86 who stated that they did not like to consume too many medications. They added that they have never used the Lidoderm patch since they came to the facility. On 4/14/2026 at 10:21 AM, the surveyor interviewed the Registered Nurse (RN) who stated that Resident #86 was on a pain management regimen for their left arm pain. She added that the resident had a Lidoderm patch ordered to be applied in the evening, and she was not sure if they used it because it was applied during the evening hours. She also stated that she has not seen it on Resident #86 and therefore she has not removed it. She further stated that typically, the Medication Administration Record (MAR) would reflect the time that it should be administered and removed, then the nurse would initial accordingly. RN #1 further stated that she would be made aware of the time that the patch needed to be removed by the designated time when the order was noted. On 4/14/2026 at 10:36 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the MAR should reflect the time that the Lidoderm patch should be applied and removed, and the nurse should initial to indicate that it was done. On 4/14/2026 at 10:43 AM, the surveyor interviewed the Director of Nursing (DON) who stated that there should have been a designated time when the PO was entered into the system. She further stated that depending on the PO, it would populate on the MAR or TAR for the nurse to carry out the PO during the med pass. At that time, the DON added that the provider entered the order for the Lidoderm, and she was not sure if they needed education on when something needed to be removed, it also needed to be timed. On 4/14/2026 at 11:03 AM, the surveyor and RN #1 checked the medication cart. There was a package labeled with Resident #86's name on it that contained Lidoderm 5% patch. The plastic package indicated that 14 Lidoderm patches were delivered. There were 11 of 14 Lidoderm patches present, which indicated that only 3 (three) were removed. On 4/14/2026 at 4/15/2026 at 11:38 AM, the surveyor conducted a follow-up interview with the DON who stated that she was still investigating why there were only 3 patches removed from the box, and there were initials on the MAR which indicated that that Lidoderm 5% Patch was administered 8 (eight) times. She further stated that the Voltaren gel order should have been clarified to indicate where it should be applied. 2.) On 4/10/2026 at 11:17 AM, the surveyor observed Resident #87 seated in a wheelchair at the bedside with their meal tray on an overbed table in front of them. The surveyor noted that the resident had a single chicken drumstick on their plate. The resident stated that the Dietician had visited him/her and stated that she would recommend double portions of protein, and a protein supplement, as the resident had a wound that needed protein for wound healing. The resident stated that they had yet to receive double portions of protein. The surveyor reviewed the electronic medical record (EMR) for Resident #87. A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; morbid (severe) obesity due to excess calories, mild protein-calorie nutrition, difficulty in walking, not elsewhere classified, and acute respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues). A review of the comprehensive Minimum Data Set (MDS), (an assessment tool) dated 4/6/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS included that the resident was at risk for Pressure Ulcers/Injuries and was admitted to the facility with 1 (one) unstageable pressure ulcer due to coverage of the wound bed by slough (a layer of dead skin) and/or eschar (dead tissue that forms over a wound). A review of the Individualized Comprehensive Care Plan (ICCP) revealed that the resident had a Focus area initiated on 4/8/2026, with a revision date of 4/15/2026, for Nutritional Status: Resident #87, .I am on a Therapeutic diet and at nutritional & hydration risk related to morbid obesity .receive double protein per RD (Registered Dietician) recommendation. Interventions included: .Registered Dietician to evaluate and make diet/supplement change recommendations as needed (4/8/2026).Provide and serve diet as ordered Therapeutic diet (Double protein) (Revision on 4/15/2026). A review of the Order Summary Report, included the following Physician's Orders (PO): A PO, dated 4/3/2026, for NAS (No added Salt) diet, Regular texture, Thin Consistency. Fruit cup at HS. Juice with meals. Hot tea with meals and 4 (four) oz (ounces) of milk with meal for diet. A PO, dated 4/4/2026, for Give 4 Oz of Pudding with lunch and record the amount consumed. In the afternoon for supplement give 4 oz of pudding po (by mouth) with lunch and record amount consumed. A PO, dated 4/3/2026, for Protein Oral Liquid (Protein) Give 30 ml (milliliters) by mouth in the evening for supplement. Give 30 cc (cubic centimeters) by mouth in the evening for supplement. Give 30 cc po daily and record amount consumed. A review of a Nutritional Risk Evaluation with an Effective date of 3/26/2026 at 9:04 PM, revealed: Albumin (the most abundant protein in human blood plasma, produced by the liver) less than 30 g/L (grams per liter), 3-5 other nutrition-related labs abnormal. Assessment and Plans included: Resident is on a low-fat cholesterol diet. Likes fruit and pudding and juice. We discussed the importance of more protein. PAB (pre-albumin) 18 and alb (albumin) 3.3. Has a wound and is on MVI (multivitamin) with minerals, vit c and vit d. Rec (recommend) double meat and pudding or fruit cup at HS (hours of sleep). Monitor intake, weight and labs. On 4/14/2026 at 11:51 AM, the surveyor observed resident seated in a wheelchair at the bedside. The resident stated that he/she had still not received double portions of protein at meals, but he/she did receive a protein supplement with his/her medications and his family brought in an oral protein drink from home. On 4/14/2026 at 12:04 PM, the surveyor observed the resident's meal tray in the presence of Certified Nursing Assistant (CNA #1) who confirmed that the resident's meal ticket included one 2 (two) Oz (ounce) Baked Herb Chicken drumstick, a small house salad, Italian [NAME] Beans 4 Oz. and did not include double portions of protein as recommended by the RD. On 4/14/2026 at 12:07 PM, the surveyor interviewed Registered Nurse (RN #1) who stated that when the RD made a recommendation an order was placed in the computer for the diet type, and we filled out a diet slip that went to the kitchen. RN #1 stated that the RD would have to tell us about the recommendation in order for the order to be placed into the computer. RN #1 stated that there was an order for the resident to receive pudding, and she had been giving the resident that. At that time, the surveyor returned to the resident's room and confirmed that the resident had received both a container of pudding and fruit juice as described by RN #1, but the resident still had not received double portions of protein as recommended by the RD. On 4/15/2026 at 9:41 AM, the surveyor interviewed the Director of Nursing (DON) who sated that the RD wanted Resident #87 to receive double protein and that the order was clarified and updated in the diet orders after surveyor inquiry. The DON stated that the RD communicated her recommendations to the facility via email and she did receive an email with the RD's recommendations for Resident #87 on 4/3/2026. The DON stated that the Unit Manager (UM) also received it and took off the order, but the double order of protein was missed. The DON stated that she would have expected that the RD's recommendations to have been followed. The DON further stated that there were also orders for oral protein supplements now after surveyor inquiry. On 4/15/2026 at 10:30 AM, the DON provided the surveyor with an email dated 4/3/2026 at 8:00 AM, with a Subject of Diet Recommendations. The diet recommendations that were made by the RD for Resident #87 included: Rec double meats, Provide fruit cup at HS (hours of sleep), Rec juice with meals, Wants hot tea with meals and wants 4 (four) ounce milk with meals (requesting iced tea), Provide pudding with lunch, Rec to liberalize diet D/C (discontinue) low fat low cholesterol diet to be Regular NAS (No added Salt), Rec 30 ml liquid protein 1 (one) time a day. On 4/15/2026 at 10:47 AM, the surveyor interviewed the Registered Dietician (RD) via telephone who confirmed that she worked at the facility one day per week. The RD stated that she completed a Nutritional Risk Assessment for Resident #87 on 3/26/26 and confirmed that she emailed the facility on 4/3/2026 with Diet Recommendations for the resident. The RD stated that she recalled the resident and believed that he/she wanted more foods rather than supplements, so she recommended double portions of protein and pudding. The RD stated that if the resident was at higher risk she would have checked the orders to confirm implementation of her recommendations, but the UM was usually right on it, so she was surprised that the resident did not get double portions because he/she really needed that. A review of the facility's Physician Orders Policy reviewed 5/6/2025, included: It is the policy of the facility to ensure that all physician orders are obtained, documented, communicated, and implemented accurately and in a timely manner to support safe and effective resident care. Physician orders must be complete, legible, and authenticated in accordance with applicable regulatory and professional standards. .All new orders must be reviewed for: Completeness.The nurse must clarify questionable orders with the prescribing practitioner prior to implementation. A review of the facility's Documentation in Medical Record reviewed 5/6/2025 included, Licensed staff . shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. A review of the facility Nutritional Management policy, dated 7/9/2025, included: .Nutritional recommendations may be made by the dietician based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/20/24 at 09:21 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room on a middle shelf a previously opened bag of macaroni pasta was wrapped in plastic wrap. The pasta had no open or use by date. 2. On a middle rack of the spice shelf a stack of four (4) plastic Cambro containers were stacked on top of each other. The surveyor removed the top Cambro container and observed a clear watery substance on the bottom of the container below and a clear watery substance on the interior of the Cambro container that was on the top. In addition, a second stack of two (2) Cambro containers was also observed to be wet with a clear liquid substance, a practice known as wet nesting (the practice of stacking wet dishes, pots, or pans together, which prevents them from drying and can lead to bacteria growth.). On interview the FSD stated that they (Cambro's) should be air dried prior to stacking to prevent wet nesting. The FSD removed the affected Cambro containers to be re- cleaned, sanitized, and air dried. 3. On the pot/pan storage rack next to the steamer on an upper shelf two (2) deep third pans were stacked on top of each other. The surveyor removed the top third pan and observed a clear, wet liquid on the bottom of the third pan below (wet nesting). The FSD removed the two (2) third pans to be re-cleaned, sanitized, and air dried before stacking. 4. During the observation of the walk-in freezer the surveyor observed the temperature log prior to entering the walk-in freezer. The temperature log was observed to be up to date and the temperatures were within acceptable parameters for frozen storage. Upon entering the walk-in freezer, the surveyor, FSD and cook could not find an internal thermometer used to monitor the freezer temperature. The cook stated, We're gonna grab another one. 5. On a middle shelf in the walk-in freezer a previously opened bag of contained frozen soft pretzels. The bag had no dates. In addition, on a middle shelf closest to the door of the walk-in freezer, a previously opened box of bacon was partially covered with plastic wrap. One half of the box of bacon was exposed to the air because the plastic wrap did not fully cover the bacon. The bacon was dry on visual appearance. The cook removed the bacon to the garbage. Adjacent to the bacon, a box wrapped in manufacturers plastic contained Fresh Chorizo (a spiced pork sausage). The plastic on the top of the box was torn leaving the frozen chorizo exposed to the air. The box also had no received date. The cook removed the chorizo to the garbage in the presence of the surveyor. The surveyor reviewed the facility policy titled Date Marking for Food Safety, date implemented: 6/1/2024. The following was revealed under POLICY: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. In addition, the following was revealed under Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. The surveyor reviewed the facility policy titled Cleaning Dishes/Dish Machine, 2021. The following was revealed under Procedure: Staff will follow these procedures for washing dishes: 9. Dishes should be air dried on the dish racks, not dried with towels. 10. Inspect for cleanliness and dryness and put dishes away if clean (be sure hands are clean). Dishes should not be nested unless they are completely dry. NJAC 8:39-17.2(g)

Based on interview, record review and review of other facility documentation and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS) assessments, a resident assessment tool used to facilitate the management of care, in a timely manner for 46 of 49 residents reviewed for system selected MDS over 120 days for late submissions., (Residents #49, #24, #29, #55, #32, #33, #48, #13, #8, #51, #11, #22, #27, #3, #50, #72, #18, #19, #9, #54, #57, #64, #70, #58, #37, #36, #45, #337, #187, 336, #21, #5, #4, #20, #69, #34, #16, #28, #66, #15, #25, #30, #17, #38, #42, #67). This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly Assessment was considered timely if 1) The Assessment Reference Date (ARD) of the Quarterly MDS (QMDS) was within 92 days after the ARD of the previous MDS and 2) the completion date was no later than 14 days after the ARD. 1. Resident #49's Quarterly MDS (QMDS) ARD was 10/10/24, the Quarterly Assessment (QA) had not been completed as of 11/25/24 and was 32 days overdue. 2. Resident #24's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 3. Resident #29's QMDS ARD was 09/26/24, the QA had not been completed as of 11/25/24 and was 46 days overdue. 4. Resident #55's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 5. Resident #32's QMDS ARD was 09/11/24, the QA had not been completed as of 11/25/24 and was 61 days overdue. 6. Resident #33's QMDS ARD was 10/10//24, the QA had not been completed as of 11/25/24 and was 32 days overdue. 7. Resident #48's QMDS ARD was 10/02/24, the QA had not been completed as of 11/25/24 and was 40 days overdue. 8. Resident #13's QMDS ARD was 09/11/24, the QA had not been completed as of 11/25/24 and was 61 days overdue. 9. Resident #8's QMDS ARD was 10/10/24, the QA had not been completed as of 11/25/24 and was 32 days overdue. 10.Resident #51's QMDS ARD was 09/12/24, the QA had not been completed as of 11/25/24 and was 60 days overdue. 11.Resident #11's QMDS ARD was 09/18/24, the QA had not been completed as of 11/25/24 and was 54 days overdue. 12.Resident #22's QMDS ARD was 09/12/24, the QA had not been completed as of 11/25/24 and was 60 days overdue. 13.Resident #27's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 14.Resident #3's QMDS ARD was 10/10/24, the QA had not been completed as of 11/25/24 and was 32 days overdue. 15.Resident #50's QMDS ARD was 09/19/24, the QA had not been completed as of 11/25/24 and was 53 days overdue. 16.Resident #72's QMDS ARD was 09/03/24, the QA had not been completed as of 11/25/24 and was 69 days overdue 17.Resident #18's QMDS ARD was 09/17/24, the QA had not been completed as of 11/25/24 and was 55 days overdue. 18.Resident #19's QMDS ARD was 09/11/24, the QA had not been completed as of 11/25/24 and was 61 days overdue. 19.Resident #9's QMDS ARD was 10/02/24, the QA had not been completed as of 11/25/24 and was 40 days overdue. 20.Resident #54's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 21.Resident #57's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 22.Resident #64's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 23.Resident #70's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue 24.Resident #58's QMDS ARD was 09/26/24, the QA had not been completed as of 11/25/24 and was 46 days overdue. 25.Resident #37's QMDS ARD was 09/5/24, the QA had not been completed as of 11/25/24 and was 67 days overdue. 26.Resident #36's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 27.Resident #45's QMDS ARD was 09/19/24, the QA had not been completed as of 11/25/24 and was 53 days overdue. 28.Resident #337's QMDS ARD was 08/16/24, the QA had not been completed as of 11/25/24 and was 87 days overdue. 29.Resident #187's QMDS ARD was 07/25/24, the QA had not been completed as of 11/25/24 and was 109 days overdue. 30.Resident #336's QMDS ARD was 07/17/24, the QA had not been completed as of 11/25/24 and was 117 days overdue. 31.Resident #21's QMDS ARD was 09/19/24, the QA had not been completed as of 11/25/24 and was 53 days overdue. 32.Resident #5's QMDS ARD was 09/12/24, the QA had not been completed as of 11/25/24 and was 60 days overdue. 33.Resident #4's QMDS ARD was 09/04/24, the QA had not been completed as of 11/25/24 and was 68 days overdue. 34.Resident #20's QMDS ARD was 09/18/24, the QA had not been completed as of 11/25/24 and was 54 days overdue. 35.Resident #69's QMDS ARD was 09/21/24, the QA had not been completed as of 11/25/24 and was 51 days overdue. 36.Resident #34's QMDS ARD was 08/29/24, the QA had not been completed as of 11/25/24 and was 74 days overdue. 37.Resident #16's QMDS ARD was 10/3/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 38.Resident #28's QMDS ARD was 09/26/24, the QA had not been completed as of 11/25/24 and was 46 days overdue. 39.Resident #66's QMDS ARD was 09/07/24, the QA had not been completed as of 11/25/24 and was 65 days overdue. 40.Resident #15's QMDS ARD was 09/05/24, the QA had not been completed as of 11/25/24 and was 67 days overdue. 41.Resident #25's QMDS ARD was 08/01/24, the QA had not been completed as of 11/25/24 and was 102 days overdue. 42.Resident #30's QMDS ARD was 09/12/24, the QA had not been completed as of 11/25/24 and was 60 days overdue. 43.Resident #17's QMDS ARD was 10/03/24, the QA had not been completed as of 11/25/24 and was 39 days overdue. 44.Resident #38's QMDS ARD was 09/11/24, the QA had not been completed as of 11/25/24 and was 61 days overdue. 45.Resident #42's QMDS ARD was 09/05/24, the QA had not been completed as of 11/25/24 and was 67 days overdue. 46.Resident #67's QMDS ARD was 09/03/24, the QA had not been completed as of 11/25/24 and was 66 days overdue. On 11/25/24 at 11:00 AM, the survey team interviewed the MDS Coordinator (MDSC). The MDSC stated that she had worked as the MDSC in the facility for 3 years. The MDSC stated that she was doing the MDS in 2 buildings at this time. The MDSC said she knew things were behind and she had to help the other building. The MDSC acknowledged that MDS were behind. A review of the facility policy entitled MDS 3.0 Completion with an implemented date of 10/15/24 under Types of OBRA Assessments: 2.e. Quarterly Assessment - completed using an ARD no > (greater than) 92 days from the most recent prior quarterly or comprehensive assessment (counting ARD to ARD).

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to develop and implement a comprehensive person-centered care plan specifically for a resident who required a Foley Catheter and a Peripherally Inserted Central Catheter (PICC) used to deliver the antibiotic. This deficient practice was identified for 1 of 26 sampled residents, (Resident #1) and was evidenced by the following: On 11/20/2024 at 10:43 AM, during the initial tour, Resident #1 was observed as having a left upper arm Peripherally Inserted Central Catheter (PICC), (used for administration of an Intravenous Medication or fluids). Resident #1 was also noted to have a Foley Catheter ( a thin, flexible tube that drains urine from the bladder into a collection bag outside the body), hanging to the left side of the bed in a privacy bag. A review of the Electronic Medial Record for Resident #1 revealed the following: A review of Resident #1's Admission Record revealed that he/she had diagnoses that included but not limited to, infected sacral wound with wound botulism and possible osteomyelitis, complicated Urinary Tract Infection, Dementia. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 10/31/2024, under Section H: Indwelling Catheter, under Section N: Medications: High-Risk Drug Classes: Use and Indication: indicated that Resident #1 is taking an Antibiotic; Under Section O: Special Treatments, Procedures, and Programs: IV Access-Central. A review of the Physician Orders on 11/21/2024 at 09:29 AM, revealed the following: -Maintain Enhanced Barrier Precautions related to Foley/wound/PICC line. -Foley Catheter Care every shift and as needed. -Foley Catheter indwelling 15 French. -Change Foley Catheter collection bag as needed. -Double Lumen PICC to Right Upper Arm (RUA). -PICC line, monitor site every shift for signs and symptoms of infection every shift. -PICC line flush every shift with 10 millimeters (ml) to maintain line every shift. -PICC line measure 32 centimeters on admission. -PICC line flush with 10 ml Normal Saline, before & after INTERMITTENT medication one time a day for Bacteremia/Fungemia. -PICC line change transparent dressing Weekly & as needed every day shift every Thursday AND as needed. A review of Resident #1's Care Plan dated 10/3/2024, did not include focus areas that addressed that the resident had a PICC line and a Foley Catheter. During an interview with the surveyor on 11/25/2024 at 01:55 PM, the Director of Nursing when asked what the expectations for a comprehensive person-centered Care Plan to include, agreed that a PICC line and Foley Catheter should be included in the residents Care Plan. A review of a facility policy on titled, Comprehensive Care Plans, implemented date of 01/10/2024, objectives include, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. NJAC 8:39-11.2(f)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care, (Resident # 7) and was evidenced by the following: During the initial tour on 11/20/2024 at 10:20 AM, Resident #7 was observed sitting in the dayroom with a high back wheelchair. The surveyor observed the oxygen tubing draped on top of the concentrator uncovered and exposed. The concentrator was turned off. Resident #7 also had an e cylinder (portable oxygen tank) secured on the back of the wheelchair with oxygen tubing draped over the strap used to secure the cylinder to the wheelchair. Resident #7 said he/she was waiting for his/her ride to the Dr. as he/she had lung cancer and was going for a follow-up. Resident #7 was not currently using oxygen. On 11/20/2024 at 11:04 AM, Resident #7 was observed on the unit self-propelling his/her wheelchair with no oxygen in use. On 11/21/2024 at 09:14 AM, a review of the EMR revealed the following: According to the Admission Record Resident #7 was admitted with diagnoses including but not limited to: Heart Failure, Chronic Obstructive Pulmonary Disease. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 10/29/2024, Resident #7 has a Brief Interview for Mental Status score of 12/15 indicating Resident #7 had intact cognition. Section J indicated Resident #7 had shortness of breath when lying flat and with exertion. Section O revealed Resident #7 used oxygen upon admission and while a resident. A review of the Order summary Report with active orders as of 11/25/2024, showed a physician order for oxygen at 2 liters via n/c (nasal cannula) continuous, every shift. A review of Resident #7's care plan revealed a focus area with date initiated of 10/25/2024, [resident name] has a potential at risk for altered respiratory status. CHF (congestive heart failure), dysphagia, hx (history) of pulmonary tuberculosis, chronic airway obstruction, and hx of smoking. Under the Goal section the resident will display optimal breathing pattern daily through review date. Interventions included but were not limited to: oxygen administered as per MD (physician) order. There was no documentation to indicate the resident refused oxygen. During an interview with the surveyor on 11/25/2024 at 09:56 AM, the Registered Nurse/Unit Manager RN/UM #1 was asked what the facility policy regarding oxygen use is. RN/UM #1 responded I would have to check with DON (Director of Nursing) about the policy to confirm what the policy is. The surveyor questioned what the procedure was for storage of respiratory equipment. RN/UM #1 said we put it (oxygen tubing) in a bag, label tubing and change tubing and bags every week and as needed. When asked what the expectation is for wearing oxygen if there is a physician order for continuous use RN/UM #1 responded, It should always be on if ordered continuously. If the resident refuses to wear oxygen, we document it in EMR and notify NP (Nurse Practitioner) and family and we put that on the care plan. During an interview with the surveyor on 11/25/2024 at 01:56 PM, when asked what the facility policy regarding oxygen use the DON replied, We get a physician order and put it in the EMR. We also put on the care plan and with changes we update the care plan. We change tubing weekly and as needed and verify oxygen settings. The surveyor then asked the DON what the facility policy was regarding the storage of respiratory equipment when not in use. The DON said if package (tubing) is sealed, we keep it in the package. Once opened the tubing is dated and labeled. Then we would continue to make sure to change on the weekly schedule and oxygen tubing stored in the bag when not in use. When questioned what the expectation was if the order for oxygen was continuous the DON said, If the resident is alert and oriented and will remove the oxygen, we care plan it. The DON further stated we (nursing) provide education. The DON then confirmed to the surveyor that if it's not on (oxygen) the care plan as refusing, the oxygen should have been on. On 11/26/2024 at 09:30 AM, the DON brought in an employee statement from the nurse who had this resident on 11/20/2024. The nurse confirmed with the DON that the resident's oxygen tubing was not covered, and the oxygen was not on. The surveyor reviewed the evidence of the tubing positions with the DON who confirmed Resident #7 could not have physically placed the oxygen tubing where it was observed by the surveyor as it was on the concentrator of the e cylinder. On 11/25/2024 at 11:49 AM, a review a facility policy titled Oxygen Administration with date implemented of 10/10/24 revealed under the Policy section: Oxygen is administered to residents who need it, consistent with professional standards of practice, the person-centered care plans, and the resident's goals and preferences. The following was revealed under Policy Explanation and Compliance Guidelines section 5. Other infection control measures include: e. Keep delivery devices covered in plastic bag when not in use. NJAC 8:39-27.1(a)

Based on interview, observation, and record review it was determined the facility failed to develop a person-centered comprehensive care plan to address the residents medical, physical, mental, and psychosocial needs. This practice was identified in 1 of 23 residents reviewed for care plans (Resident #27) and was evidenced by the following: On 04/17/2023 at 11:38 AM, during the initial tour of the facility, the surveyor observed Resident #27 sitting in the hallway on a rolling seat walker crouched over. The resident told the surveyor he/she has a lot of pain all the time. The resident did not say the location of the pain. Review of the Admission Record revealed Resident #27 was admitted to the facility 10/2018. Medical diagnoses included, but not limited to asthma (inflammed airways making it difficult to breathe), depressive disorder, hypertension (high blood pressure), and Hepatitis C (chronic virus of the liver). Review of the Comprehensive Minimum Data Set (MDS), an annual assessment tool dated 02/08/2023, indicated the resident had a Brief Interview of Mental Status of 13, meaning the resident was cognitively intact. Section G of the MDS, functional status showed the resident was a set up for help for hygiene, eating, and ambulation. On 04/18/2023 at 10:15 AM, the surveyor observed Resident #27 sitting in the hallway on a rolling seat walker. The resident's head was to the left side, eyes closed but arousable. The resident told the surveyor he/she had just received pain medication at 8-8:15. While the resident was talking with the surveyor, the resident would close eyes and lay head down. Surveyor asked if medication always made resident feel that way and the resident said, yes, but it helps my pain. On 04/18/2023 at 10:34 AM, the surveyor reviewed the physician orders which showed the resident was receiving the following for pain: Percocet Tablet (opiod pain medication) 5-325 Milligrams, one tablet by mouth every 12 hours as needed for moderate to severe pain (pain on numeric scale from four to 10). On 04/18/2023 at 10:39 AM, the surveyor reviewed the resident's current and active care plan. The care plan included a psychotropic medication focus but the surveyor could not locate pain as part of the resident's care plan. On 04/18/2023 at 10:42 AM, the surveyor reviewed Medication Administration Record (MAR) in the Electronic Medical Record (EMR), which showed that the residents pain was assessed every shift and ranged from zero pain to nine, which is severe pain on the numeric pain scale. At the same time, the surveyor reviewed the Annual Comprehensive Minimum Data Set (MDS), an assessment tool dated 02/08/2023. Review of section J, health conditions, indicated the resident was receiving as needed (PRN) pain medication and at the time of the assessment, the resident's pain was described by the resident as mild. On 04/18/2023 at 10:48 AM, the surveyor reviewed the MAR which showed that the resident's pain was assessed on 04/18/2023 at 8:29 AM and the resident was given Percocet for severe pain. The pain was reassessed after the medication, and it was documented as being effective. The surveyor could not determine where the resident had pain. On 04/19/2023 at 11:23 AM, the surveyor interviewed West Unit Licensed Practical Nurse #1 (LPN#1) regarding the resident's pain. LPN#1 said, Normally, the resident always complained of generalized pain everywhere and received Percocet (narcotic pain medication). On 04/25/2023 at 10:50 AM, the surveyor interviewed a West Unit LPN#2 regarding a resident with pain. The surveyor asked if pain would appear on a care plan for a resident receiving pain medication and LPN#2 responded, Yes it would. On 04/25/2023 at 10:58 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) of the West Unit regarding Resident #27 and pain. The UM/LPN told the surveyor that all residents with pain are care planned for pain. The UM/LPN proceeded to go into the care plan for Resident #27 in the EMR and was unable to find it. The UM/LPN told the surveyor, Looks like there isn't one, I will update it. On 04/27/2023 at 10:41 AM, the Director of Nursing (DON) provided the surveyor with an in-service attendance sign in sheet for care plan education dated 04/25/2023. The DON told the surveyor, I just want to show you we take these things serious, and we act on them right away. On 04/28/2023 at 08:51 AM, the surveyor reviewed the policy titled, Comprehensive Care Plans, a policy dated 12/6/2022. The policy indicated that the facility was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. On 04/28/23 at 10:15 AM, the surveyor reviewed the care plan titled, Pain Mangement and Intervention, an undated policy. Under the section Practice Guidelines, number IV, it indicated that initial documentation of resident pain will occur on the interim care plan if present at admission. Under section V. (c) it said to use evaluation data and revise care plan. NJAC 8:39-11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services according to standards of practice by a.) ensuring a residents oxygen tubing was stored in a manner to prevent the spread of infection b.) follow physicians orders by assessing a residents oxygen saturation every shift and documenting the results and c.) failing to document administration of oxygen. This deficient practice was identified for 3 of 3 residents reviewed for respiratory care (Residents #28, #42, and #74) and was evidenced by the following: a. On 04/17/23 at 12:04 PM, during the initial tour of the facility Resident #74 was sitting in a wheelchair on the side of the bed having lunch. There was a portable oxygen tank with nasal cannula (device worn in the nares to deliver supplemental oxygen) tubing connected to the tank and wrapped around the left handle on the back of the wheelchair. The resident was not wearing the oxygen. The tubing did not have a date and was not in a plastic bag. The surveyor also observed an oxygen concentrator in the room. The surveyor asked the resident how often he/she wore oxygen and the resident said, I'm supposed to wear it all the time, but they didn't hook it up yet. Review of Resident #74 Admission Record indicated that the resident was admitted to the facility 03/2023. Medical diagnoses included, but not limited to hip pain, dependence on supplemental oxygen, depression, and diabetes (high blood sugar). Review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 04/03/23 revealed Resident #74 had a Brief Interview of Mental Status of 15, meaning the resident was cognitively intact. Under section O, special procedures/treatments indicated the resident wore supplemental oxygen. On 04/18/23 at 10:30 AM, the surveyor observed Resident #74 in the room in a wheelchair. The resident's wheelchair had a portable oxygen tank on the chair with an nasal cannula oxygen tubing attached to the tank. The oxygen was not being worn by the resident and the tubing was wrapped around the arm of the wheelchair. The tubing was not in a bag, and no dates could be located on the oxygen tubing. On 04/18/23 at 01:27 PM, the surveyor reviewed the Physician Orders which showed the following oxygen order: Oxygen at 2Liters per minute via nasal cannula every shift and another order for Oxygen tubing to be changed weekly. On 04/19/23 at 10:17 AM, the surveyor observed the resident sitting on the side of the bed. The resident was wearing nasal cannula oxygen which was connected to an oxygen concentrator (a device that takes air from the room and filters out nitrogen to provide higher levels of oxygen). The surveyor also observed the resident's wheelchair in the room with a portable oxygen tank with a nasal cannula connected. The nasal cannula tubing was wrapped around the arm of the wheelchair. The tubing was not in a bag and the tubing was not dated. The surveyor asked the resident if he/she wore the tubing on the arm of the wheelchair also. As the resident pointed to the tubing wrapped around the arm, the resident said, oh yea, when I get up and go to therapy, I will put that one on. The surveyor asked if it was the same tubing from the day prior and the resident said yes. On 04/19/23 at 01:49 PM, the surveyor observed the resident in the therapy room sitting in a wheelchair. The resident was wearing oxygen via nasal cannula hooked to a portable tank on the wheelchair. On 04/20/23 at 09:42 AM, the surveyor observed the resident in the room in a wheelchair. The wheelchair had a portable oxygen tank attached but there was no tubing attached to the oxygen tank. On 04/20/23 at 10:15 AM, the surveyor interviewed LPN #1 regarding oxygen tubing storage. The LPN#1 told the surveyor that oxygen not being used should be stored in a bag. On 04/27/23 at 10:41 AM, the Director of Nursing (DON) provided the surveyor with an in-service attendance by staff dated 4/26/23, titled, oxygen tubing in bags education. The DON told the surveyor, I just want to show you we take these things serious, and we act on it right away. On 04/28/23 at 11:30 AM, the surveyor reviewed the policy titled, Oxygen Administration, a policy dated 1/5/23. Under the section policy explanation and compliance guidelines, number five (e) was to keep delivery devices covered in plastic bag when not in use. b. On 04/17/23 at11:30 AM, during the initial tour of the facility the surveyor observed Resident #42 sitting on the side of the bed. The resident was wearing oxygen via nasal cannula and was requesting a respiratory treatment. Review of the Admission Record indicated Resident #42 was admitted to the facility on ,d+[DATE]. Medical diagnoses included, but not limited to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), heart failure and depression. Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/31/23 revealed Resident #42 had a Brief Interview of Mental Status of 14, meaning the resident was cognitively intact. On 04/19/23 at 10:29, the surveyor observed Resident #42 in the room sitting in a wheelchair. The resident was not wearing oxygen at the time of the observation. Resident #42 told the surveyor he/she wore it when it was needed, but not all the time. On 04/19/23 10:31 AM, the surveyor reviewed the Physician Orders which showed an order for oxygen two to three liters per minute via nasal cannula. On 04/19/23 at 10:34 AM, the surveyor reviewed the physician orders which revealed an order for pulse oximetry (noninvasive method to monitor a person's blood oxygen level) every shift and notify the doctor if below 90 percent. It was an active order with a start date of 7/25/22. Further review of the pulse oximetry results in the vital signs section of the EMR showed that on 12/4/22 the resident had a pulse oximetry of 88 percent. On 04/19/23 at 10:35 AM, the surveyor reviewed the progress notes and could not locate a note indicating the physician was notified for a pulse oximetry below 90 percent as ordered. Review of the Medication Administration Record (MAR) indicated the resident oxygen levels were being check daily, not every shift as physician ordered. On 04/19/23 at 10:38 AM, review of the care plan included a focus for respiratory status: potential risk for altered respiratory status, initiated on 08/08/22 and revised on 01/25/23. On 04/14/23 another care plan focus of pneumonia was initiated with a revision on 4/18/23 which included an intervention of oxygen as ordered by the physician. On 04/19/23 at 10:42 AM, the surveyor reviewed the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 1/23/23. Under section O, special procedures/treatments were marked yes for oxygen. On 04/24/23 at 11:10, the surveyor interviewed the unit Licensed Practical Nurse #2 (LPN#2) caring for resident #42 regarding oxygen saturations for the resident. LPN#2 told the surveyor that she would check the resident's oxygen saturations throughout the day and after the resident smoked. The surveyor asked where they would be documented and LPN#2 told the surveyor, On my roster and then I would put it in PCC (meaning the electronic medical record system). The surveyor asked LPN#2 at what numbers would a physician need to be notified and LPN#2 said, I would notify the doctor if the oxygen saturation was in the 80's, but usually when it is below 92 percent. On 04/27/23 at 10:41 AM, the Director of Nursing (DON) provided the surveyor with an in-service attendance sign in sheet dated 4/24/23 showing education was provided to nursing staff for documenting oxygen saturation per physician orders. The don told surveyor, I just want to show you we take these things serious, and we act on it right away. On 04/28/23 at 1:13 PM, the surveyor reviewed the policy titled, Oxygen Administration a policy dated 1/5/23. Under the section Policy Explanation and Compliance Guideline, number 12 stated that staff shall notify the physician of any changes in the resident condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. NJAC 8:39-27.1 (a) 38680 c. On 4/17/23 11:33 AM, the surveyor observed Resident #28 in his/her wheelchair. He/She stated that she uses oxygen. On 4/18/23 at 12:56 PM the surveyor observed Resident #28 utilizing Oxygen at 2 liters per minute via nasal cannula (a small tube placed near nose). Subsequent observations were made on 4/19/23 at 10:56 AM, 4/20/23 at 12:33 PM, 4/24/23 at 1:26 PM, 4/25/23 at 11:54 AM of Resident # 28 utilizing Oxygen. A review of the Admission Record showed that Resident #28 was admitted to the facility with medical diagnosis that included but were not limited to chronic respiratory failure (a lung condition). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/1/23 reflected that Resident #28 was cognitively intact. It also reflected that Resident # 28 utilized Oxygen. A review of Resident # 28's Physician's Orders reflected an order dated 3/22/23 for O2@2L via nasal cannula for SPO2 below 93% as needed for SOB. A review of Resident #28's April 2023 Treatment Administration Record (TAR) reflected the order for the as needed Oxygen. There were no signatures for the use of the Oxygen. During an interview on 4/26/23 at 11:02 AM, the Licensed Practical Nurse stated Resident # 28 utilizes Oxygen as needed. She stated she is not signing it out on the TAR, but she should be. During an interview on 4/26/23 at 12:26 PM the Director of Nursing stated if the Oxygen is being delivered it should be signed out. The surveyor reviewed the facility's undated Medication Administration Policy. The policy included to sign administration record after administered. NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to properly store medications and maintain clean and sanitary medication storage areas. This deficient practice was observed in 2 of 2 observed medication carts on 2 of 2 nursing units and was evidenced by the following: On 04/20/23 at 12:29 PM, the surveyor in the presence of Licensed Practical Nurse (LPN #1) observed the East wing nursing unit's B medication cart which contained a total of 78 loose medication pills of various colors and sizes in the bottom of the drawers. LPN #1 collected these pills as they were discovered and were counted. At this time, LPN #1 informed the surveyor that medication carts were cleaned weekly and that the nurses assigned to each cart should be checking when starting each shift for cart cleanliness and ensured medication pills were not loose in the drawers. LPN #1 further stated that there should not be loose pills in the cart as they could possibly fall out and be picked up and consumed by residents. She also stated the possible reason for so many loose pills could have been due to the overcrowding of medication cards (bingo cards) in the drawers causing pills to be popped out as nurses reach into the drawers. At this time LPN #1 disposed of the found loose medication pills using the medication drug buster bottle in the medication storage room. On 04/24/23 at 10:06 AM, the surveyor in the presence of the Licensed Practical Nurse/Unit Manager LPN/UM observed the East wing nursing unit's B medication cart which contained one loose medication pill in the bottom of a drawer. LPN/UM collected this pill as it was discovered and disposed of it in the medication room drug buster bottle. On 04/24/23 at 12:19 PM, the surveyor interviewed the Director of Nursing (DON) who stated there was no official routine cleaning schedule for the medication carts and since the surveyor's observations the facility implemented a new cleaning schedule. The DON further stated that all nurses should be responsible for ensuring carts are clean and have no loose medications. She continued to inform the surveyor that the pharmacy consultant is supposed to also be checking the medication storage areas and carts for this as well as part of her inspections. The DON explained a possible reason for loose medications in the cart drawers would be from over crowding of the medication cards which then causes pills to be popped out as the cards are handled by nursing staff. A review of the facility's Storage of Medications policy with an implemented date 6/1/22, included that it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the section labeled Policy Explanation and Compliance Guidelines under General Guidelines includes a. all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . b. Only authorized personnel will have access to the keys to locked compartments . c. during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. N.J.A.C. 8:39-29.4

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. On 04/17/2023 at 9:28 AM, upon arrival of the surveyors to the facility, the surveyor observed a facility entrance sign displayed on the street that had a name of Fountain Springs at Cape May that did not correspond with the CMS licensed, approved name and provider registered name Oceana Rehabilitation and Nursing Center. As the surveyor entered the facility, there was a displayed sign with the same name Fountain Springs at Cape May which was not the CMS licensed, approved and provider registered name, Oceana Rehabilitation and Nursing Center. The facility name displayed on the outside of the facility and in the lobby, Fountain Springs at Cape May did not correspond with the CMS (Center for Medicaid and Medicare Services) licensed and approved name of Oceana Rehabilitation and Nursing Center. On 04/17/2023 at 10:50 AM, the State Surveyor met with the Assistant Licensed Nursing Home Administrator (ALNHA) and the Director of Nursing (DON) for the Entrance Conference. During entrance conference, the facility management confirmed that the facility's name was changed about a year ago in 2022. That same day, at 11:16 AM, the surveyor reviewed various documents and facility policies that were provided by the ALNHA that presented with Fountain Springs at Cape May demonstrated on the letterhead as the title. The documents provided showed the facility's name that was being used was not in accordance to the facility's licensed name and prior to CMS approved name/change of ownership approval. On 04/18/2023 at 09:53 AM, the state surveyor met with the ALNHA to clarify the facility's name. At this time, the surveyor discussed the facility's license displayed on the wall in the reception area which reflected the CMS approved name of the facility, Oceana Rehabilitation and Nursing Center, which was different than the name displayed on all of the signs and documents presented by the ALNHA and the DON with Fountain Springs at Cape May. During the meeting with the State Surveyor, the ALNHA provided a letter the facility received from the State of New Jersey Department of Health (NJDOH), dated 10/27/2022. The letter referenced an application for transfer of ownership application received by the NJDOH on 06/16/2022 that has been approved to proceed. The letter establishes, approving your request to proceed with the transfer of ownership interests of Oceana Rehabilitation and nursing Center. The letter continues to present, The referenced application submitted is for the transfer of ownership of Oceana Rehabilitation and nursing Center from the previous owner to the current owner. In addition, the letter establishes, Simultaneously with the transfer of ownership, the Facility will be renamed Fountain Springs at Cape May. On page 2 of the NJDOH letter, Although the new owner was authorized to operate the facility following the transaction, the Department will not issue the license under the new ownership until the items listed below are received and reviewed by staff from the Department. The letter continues to list a number of items that need to be submitted for the NJDOH to issue a new license for the new owners allowing them to change the name of the facility. On 04/18/23 at 11:35 AM, the State Surveyor interviewed the ALNHA who explained that the facility was in the transition process of converting Oceana Rehabilitation and Nursing Center to Fountain Springs at Cape May and could not confirm that the items listed on page 2, to complete the name change, was sent to the NJDOH nor could the ALNHA provide a copy of the final license. The ALNHA could not provide any additional information to further explain this and stated the LNHA would know more but was out of the country and unavailable. On 04/27/2023 at 11:45 AM, the State Surveyor met with the facility's ALNHA and DON to discuss the deficient practice of utilizing the facility's name change to Fountain Springs at Cape May without NJDOH Licensure approval. No further information or documentation was provided to the survey team to refute these findings. NJAC 8:39-5.1 (a)

Based on interview and record review, it was determined that the facility failed to complete an annual Minimum Data Set Assessment (MDS), an assessment tool, as required for 5 of 5 residents (Resident #1, #6, #9, #11, and #21) system selected for MDS over 120 days and was evidenced by the following: On 2/11/22 at 10:00 AM, the surveyor interviewed the MDS Coordinator who stated that she was unable to provide the survey team with a matrix (provider tool utilized to identify all the residents in the facility and their pertinent care categories) since she had only been at the facility for three weeks and not all the residents were in the system. On 2/14/22 at 9:44 AM, the surveyor re-interviewed the MDS Coordinator who stated that she completed the MDS for all the residents upon admission, quarterly, annually, and if there was a significant change of two or more activities of daily living or significant weight loss or wounds. The MDS Coordinator stated that each assessment had an assessment reference date (ARD) which the facility completed a seven day look back period from that date. The facility had fourteen days to complete the assessment from the ARD and then they had an additional seven days after to submit the assessment. The MDS Coordinator stated that when she started this job, MDS was a mess and there were a lot of late and not completed MDS assessments and she was trying to put everything in order. The MDS Coordinator stated that billing for the MDS was still not completed for December of 2021, and she was unsure when the previous MDS Coordinator resigned. At this time, the surveyor provided the MDS Coordinator with a list of twenty-two system selected residents with their MDS record that was over 120 days and asked her to provide the survey team with the date the last MDS was submitted and the next MDS that was due. On 2/14/22 at 9:57 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that the MDS Coordinator was new to the facility and the Licensed Practical Nurse (LPN) East Side medication cart nurse was completing MDS assessments in the interim. The DON stated that she had only been at the facility for three months and since she started, the facility had been behind on MDS assessments. The DON stated that she was unsure how long the facility did not have a MDS Coordinator. On 2/14/22 at 10:30 AM, the surveyor interviewed the LPN who confirmed that she was the previous MDS Coordinator but resigned from that position in March of 2021. The LPN stated that the facility had several other MDS Coordinators since, but they had all resigned. The LPN thought the last MDS Coordinator resigned in September of 2021. The LPN stated that in the interim, she was helping complete MDS assessments if she had time, but she did not have a set schedule for when she completed resident assessment that were due, she would just complete an assessment if she had time to. On 2/16/22 at 10:10 AM, the MDS Coordinator provided the surveyor with the requested system selected MDS information. The MDS Coordinator confirmed that all the selected residents were overdue for their next MDS assessment, and the facility had identified that MDS assessment completion was an issue. A review of the twenty-two system selected MDS assessments over 120 days not completed, five residents did not have a completed annual MDS as follows: 1. Resident #1 last completed MDS was a quarterly dated 8/22/21. The next ARD was 11/20/21, that was not completed. 2. Resident #9's last completed MDS was a quarterly dated 9/17/21. The next ARD was 12/17/21, that was not completed. 3. Resident #11's last completed MDS was a quarterly dated 9/17/21. The next ARD was 12/17/21, that was not completed. 4. Resident #6's last completed MDS was a quarterly dated 9/27/21. The next ARD was 12/26/21, that was not completed. 5. Resident #21's last completed MDS was a quarterly dated 10/6/21. The next ARD was 1/4/22, that was not completed. On 2/17/22 at 3:20 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and survey team, stated that the facility was transitioning ownership and acknowledged that the facility was behind on MDS assessments. NJAC 8:39-11.1

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set Assessment (MDS), an assessment tool, as required for 17 of 17 residents (Resident #2, #3, #4, #5, #7, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, and #23) system selected for MDS over 120 days and was evidenced by the following: On 2/11/22 at 10:00 AM, the surveyor interviewed the MDS Coordinator who stated that she was unable to provide the survey team with a matrix (provider tool utilized to identify all the residents in the facility and their pertinent care categories) since she had only been at the facility for three weeks and not all the residents were in the system. On 2/14/22 at 9:44 AM, the surveyor re-interviewed the MDS Coordinator who stated that she completed the MDS for all the residents upon admission, quarterly, annually, and if there was a significant change of two or more activities of daily living or significant weight loss or wounds. The MDS Coordinator stated that each assessment had an assessment reference date (ARD) which the facility completed a seven day look back period from that date. The facility had fourteen days to complete the assessment from the ARD and then they had an additional seven days after to submit the assessment. The MDS Coordinator stated that when she started this job, MDS was a mess and there were a lot of late and not completed MDS assessments and she was trying to put everything in order. The MDS Coordinator stated that billing for the MDS was still not completed for December of 2021, and she was unsure when the previous MDS Coordinator resigned. At this time, the surveyor provided the MDS Coordinator with a list of twenty-two system selected residents with their MDS record that was over 120 days and asked her to provide the survey team with the date the last MDS was submitted and the next MDS that was due. On 2/14/22 at 9:57 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that the MDS Coordinator was new to the facility and the Licensed Practical Nurse (LPN) East Side medication cart nurse was completing MDS assessments in the interim. The DON stated that she had only been at the facility for three months and since she started, the facility had been behind on MDS assessments. The DON stated that she was unsure how long the facility did not have a MDS Coordinator. On 2/14/22 at 10:30 AM, the surveyor interviewed the LPN who confirmed that she was the previous MDS Coordinator but resigned from that position in March of 2021. The LPN stated that the facility had several other MDS Coordinators since, but they had all resigned. The LPN thought the last MDS Coordinator resigned in September of 2021. The LPN stated that in the interim, she was helping complete MDS assessments if she had time, but she did not have a set schedule for when she completed resident assessment that were due, she would just complete an assessment if she had time to. On 2/16/22 at 10:10 AM, the MDS Coordinator provided the surveyor with the requested system selected MDS information. The MDS Coordinator confirmed that all the selected residents were overdue for their next MDS assessment, and the facility had identified that MDS assessment completion was an issue. A review of the twenty-two system selected MDS assessments over 120 days not completed, seventeen residents did not have a completed quarterly MDS as follows: 1. Resident #13's last completed MDS was a quarterly dated 9/16/21. The next ARD was 12/17/21, that was not completed. 2. Resident #10's last completed MDS was a quarterly dated 9/17/21. The next ARD was 12/18/21, that was not completed. 3. Resident #18's last completed MDS was a quarterly dated 9/18/21. The next ARD was 12/19/21, that was not completed. 4. Resident #19's last completed MDS was an annual dated 9/18/21. The next ARD was 12/19/21, that was not completed. 5. Resident #2's last completed MDS was a quarterly dated 9/24/21. The next ARD was 12/25/21, that was not completed. 6. Resident #3's last completed MDS was a quarterly dated 9/25/21. The next ARD was 12/26/21, that was not completed. 7. Resident #4's last completed MDS was a quarterly dated 9/26/21. The next ARD was 12/27/21, that was not completed. 8. Resident #5's last completed MDS was a quarterly dated 9/28/21. The next ARD was 12/29/21, that was not completed. 9. Resident #7's last completed MDS was an annual dated 9/29/21. The next ARD was 12/30/21, that was not completed. 10. Resident #20's last completed MDS was an admitted d 9/29/21. The next ARD was 12/30/21, that was not completed. 11. Resident #12's last completed MDS was a quarterly dated 10/3/21. The next ARD was 1/3/22, that was not completed. 12. Resident #14's last completed MDS was a quarterly dated 10/4/21. The next ARD was 1/4/22, that was not completed. 13. Resident #15's last completed MDS was a quarterly dated 10/6/21. The next ARD was 1/6/22, that was not completed. 14. Resident #16's last completed MDS was a quarterly dated 10/6/21. The next ARD was 1/6/22, that was not completed. 15. Resident #22's last completed MDS was an annual dated 10/7/21. The next ARD was 1/7/22, that was not completed. 16. Resident #17's last completed MDS was a quarterly dated 10/7/21. The next ARD was 1/7/22, that was not completed. 17. Resident #23's last completed MDS was a quarterly dated 10/10/21. The next ARD was 1/10/22, that was not completed. On 2/17/22 at 3:20 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and survey team, stated that the facility was transitioning ownership and acknowledged that the facility was behind on MDS assessments. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every thirty days. This deficient practice was identified for 19 of 20 long-term care residents (Resident #1, #3, #10, #13, #22, #31, #32, #39, #50, #52, #56, #69, #79, #83, #85, #88, #129, #145, and #146) sampled and evidenced by the following: On 2/16/22 at 10:30 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that the physician came in monthly to see the residents. LPN #1 could not speak to which residents the physician saw when he was in the building. On 12/16/22 at 12:13 PM, the surveyor interviewed LPN #2 who stated that the facility had two physicians who physically came into the building to see the residents. LPN #2 stated that the physicians did not use nurse practitioners, so it was the physician seeing the residents. LPN #2 stated that the physicians saw the residents once a month and in between if needed. LPN #2 stated that all the residents should be seen by the physician at least once a month. On 2/16/22 at 12:30 PM, the surveyor interviewed LPN #3 who stated that the physicians came in monthly to the facility and should see every resident monthly. On 2/16/22 at 1:14 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility had two physicians (Physician #1/Medical Director and Physician #2). The DON stated that Physician #1/Medical Director was in the facility frequently and Physician #2 usually came late on Sunday nights to look at the residents' charts. The DON stated that she could not speak to how often Physician #2 was in the building because he came to the facility late at night when she was not there. The DON stated that both physicians documented on the chart in the Physician's Progress Notes and all the notes should be on the residents' charts. At this time the surveyor requested copies of the twenty long-term care sampled residents' physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/17/22 at 9:25 AM, the DON provided the surveyor with the requested physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor conducted observations, interviews, and reviewed the medical records including the Physician's Progress Notes provided by the DON for Residents #1, #3, #10, #13, #22, #31, #32, #39, #50, #52, #69, #79, #83, #85, #88, #129, #145, and #146 as follows: 1. On 2/11/22 at 10:31 AM, the surveyor observed Resident #56 lying in bed asleep. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in January of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review on the most recent annual Minimum Data Set (MDS), an assessment tool dated 11/22/21, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the resident's medical record reflected no Physician's Progress Notes. On 2/17/22 at 9:25 AM, the surveyor interviewed the resident who stated that he/she had not seen the physician in over a year and that they would like to see the physician. 2. On 2/11/22 at 10:32 AM, the surveyor observed Resident #50 in their room. The surveyor interviewed the resident who stated that he/she had not seen the physician in a while. A review of the Face Sheet reflected that the resident was admitted to the facility in November of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent annual MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes reflected that for the year of 2021, the physician only saw the resident on 11/21/21. A further review reflected that the resident was seen in 2022 on 2/6/22. The resident was not seen in January of 2022. 3. On 2/11/22 at 10:37 AM, the surveyor observed Resident #1 sitting in their room. A review of the Face Sheet reflected that the resident was admitted to the facility in November of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 13 out 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes reflected that the resident was only seen by the physician from April 2021 until present on 5/15/21. The physician had not seen the resident in 2022. On 2/17/22 at 12:40 PM, the surveyor interviewed the resident who stated that the physician came to the facility monthly, and he/she saw the physician last two weeks ago. The resident continued that he/she did not always see the physician monthly though because he had a lot of patients to see when he comes in. 4. On 2/11/22 at 10:55 AM, the surveyor observed Resident #88 sitting in their wheelchair in activities. A review of the Face Sheet reflected that the resident was admitted to the facility in August of 2012 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Progress Notes reflected no physician's progress notes for the year of 2021 to present. The last physician's progress note was dated 5/22/2020. 5. On 2/11/22 at 10:21 AM, the surveyor observed Resident #85 sitting in their wheelchair. A review of the Face Sheet reflected that the resident was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Progress Notes reflected that the resident was only seen by the physician on 3/10/21. There was no further documentation for 2021 or 2022. 6. On 2/11/22 at 11:22 AM, the surveyor observed Resident #52 in bed asleep. A review of the Face Sheet reflected a re-admission to the facility in January of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, which indicated an intact cognition. A review of the Physician's Progress Notes reflected the resident was seen from April 2021 until present on 8/6/21, 11/6/21, and 2/8/22. There was no documentation that in 2021, the resident was seen by the physician in April, May, June, July, September, October, or December. On 2/17/22 at 10:39 AM, the surveyor interviewed the resident who stated that he/she could not recall the last time that they had seen their physician. The resident stated that he/she did not see the physician routinely. 7. On 2/11/22 at 11:28 AM, the surveyor observed Resident #146 sitting in their wheelchair in their room. A review of the Face Sheet reflected that the resident was admitted to the facility in November of 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent annual MDS dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes reflected that since April 2021, the resident saw the physician on 8/13/21, 11/10/21, and 2/8/22. There was no documentation that the resident was seen in 2021 by the physician in April, May, June, July, September, October, November, and December. There was no documentation that the resident was seen in January of 2022. On 2/17/22 at 10:31 AM, the surveyor interviewed the resident who stated that he/she did not see the physician routinely. 8. On 2/11/22 at 11:20 AM, the surveyor observed Resident #145 sitting in their wheelchair in the hallway. A review of the Face Sheet reflected that the resident was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes from April 2021 until present, reflected that the resident was seen by the physician monthly until 7/9/21. There was no documentation that the resident was seen from August of 2021 until present. On 2/16/22 at 10:18 AM, the surveyor interviewed the resident who stated that he/she did not see the physician often; if there is nothing wrong with me, do not see the doctor. The resident stated that he/she did not see the physician routinely, but they could ask to see the physician. 9. On 2/11/22 at 10:50 AM, the surveyor observed Resident #3 sitting in their wheelchair in their room. A review of the Face Sheet reflected that the resident was admitted to the facility in July of 2011 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Progress Notes reflected that from April 2021 to present, the resident saw the physician on 8/13/21, 11/6/21, and 2/8/22. There was no documentation that the resident saw the physician in 2021 in April, May, June, July, September, October, and December. There was no documentation that the resident saw the physician in January of 2022. 10. On 2/11/22 at 10:26 AM, the surveyor observed Resident #13 outside smoking a cigarette. A review of the Face Sheet reflected that the resident was admitted to the facility in March of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 9 out of 15, which indicated moderately impaired cognition. A review of the Physician's Progress Notes reflected the following dates the resident was seen: 6/8/21, 7/30/21, 11/5/21, 12/3/21 and 2/6/22. The resident was not seen in 2021 for the months of April, May, August, September, and October. On 2/14/22 at 10:30 AM, the surveyor interviewed the resident who stated that he/she had seen the physician recently due to loss of voice and a cough. 11. On 2/11/22 at 11:26 AM, the surveyor observed Resident #22 lying in bed. The resident was unable to be interviewed. A review of resident's Face Sheet reflected that the resident was readmitted to the facility in June of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed MDS dated [DATE], reflected that the resident had a severely impaired cognition. A review of the resident's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The last documented physician visit was 2/26/21. 12. On 2/11/22 at 10:41 AM, the surveyor observed Resident #29 in bed asleep. A review of the resident's Face Sheet reflected that the resident was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed annual MDS dated [DATE], reflected that the resident had a BIMS score of a 13 out of 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes reflected that the resident was seen not seen by the physician from April 2021 until present day. The last documented physician visit was 3/9/21. On 2/17/22 at 10:04 AM, the surveyor observed the resident awake in bed. The surveyor interviewed the resident who stated that he/she saw Physician #1/Medical Director every couple of months. 13. On 2/11/22 at 12:09 PM, the surveyor observed Resident #31 sitting in the dining room waiting for lunch. A review of the Face Sheet reflected that the resident was readmitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected that the resident had short and long-term memory problems with moderately impaired cognition. A review of the Physician's Progress Notes reflected that the last time the resident was seen by the physician was 6/30/21. 14. On 2/11/22 at 11:57 AM, the surveyor observed Resident #32 sitting in their wheelchair. A review of the Face Sheet reflected that the resident was admitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes reflected that the last time the resident saw the physician was on 6/30/21. On 2/17/22 at 10:01 AM, the surveyor interviewed the resident who stated that he/she last saw the doctor two weeks ago. 15. On 2/11/22 at 11:44 AM, the surveyor observed Resident #69 lying in bed. The resident stated that he/she just returned from their [CONDITION(S)] treatment; they go to [CONDITION(S)] on Mondays, Wednesdays, and Fridays. A review of the Face Sheet reflected that the resident was admitted to the facility in February of 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 11 out of 15, which indicated a moderately impaired cognition. A review of the resident's Physician's Progress Notes reflected that the physician had not seen the resident from April 2021 until present. The last documented physician visit was 2/18/21. 16. On 2/11/22 at 11:35 AM, the surveyor observed Resident #10 sitting in their room. A review of the Face Sheet reflected that the resident was admitted to the facility in March of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed MDS dated [DATE], reflected a BIMS score of 15 out of 15, which reflected an intact cognition. A review of the Physician's Progress Notes from April 2021 until present reflected that the resident was seen in May, June, July, and August only. The was no documentation that the resident was seen by the physician in 2021 in April, September, October, November, and December. There was no documentation that the resident was seen by the physician in 2022. On 2/17/22 at 11:46 AM, the surveyor interviewed the resident who stated that he/she saw Physician #1/Medical Director. The resident stated that they did not see the physician often. The resident stated that last week Physician #1/Medical Director saw his/her roommate, so when the physician was walking out the room, he stopped by to say hi. The resident stated they tried to ask him about my teeth and my hip but he just walked out and didn't answer. 17. On 2/11/22 at 11:57 AM, the surveyor observed Resident #39 in their room. The resident stated that they were informed that their physician was coming to visit them tomorrow. A review of the Face Sheet reflected that the resident was admitted to the facility in October of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent admission MDS dated [DATE], reflected that the resident had a BIMS score of 11 out of 15, which indicated a moderately impaired cognition. A review of the Physician's Progress Notes from admission until present, reflected that the resident was seen by the physician on 10/13/21 and 11/6/21. There was no documentation that the resident was seen by the physician in December of 2021 or January of 2022. 18. On 2/11/22 at 11:46 AM, the surveyor observed Resident #79 lying in bed. A review of the Face Sheet reflected that the resident was admitted to the facility in February of 2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician's Progress Notes reflected that from April 2021 until present, the resident was seen by the physician on 8/6/21 and 11/4/21. There was no documentation that the resident was seen by the physician in 2021 in April, May, June, July, September, October, and December. There was no documentation that the resident was seen by the physician in 2022. 19. On 2/11/22 at 10:30 AM, the surveyor observed Resident #83 lying in bed. A review of the Face Sheet reflected that the resident was admitted to the facility in January of 2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent annual MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the Physician's Progress Notes from April 2021 until present reflected that the resident was seen by the physician on 8/13/21, 11/6/21, 11/10/21, and 2/8/22. There was no documentation that the resident was seen by the physician in 2021 in April, May, June, July, September, October, and December. There was no documentation that the resident was seen by the physician in January of 2022. On 2/17/22 at 11:42 AM, the surveyor interviewed the resident who stated that last time he/she saw Physician #2 was before Thanksgiving in 2021. The resident stated that Physician #2 was their primary physician, and he did not see them monthly. The resident stated that he/she saw Physician #2 monthly walking the hallways, but he/she did not visit them monthly. On 2/18/22 at 10:37 AM, the surveyor attempted to interview Physician #1/Medical Director on the telephone. A Receptionist answered the telephone who stated that Physician #1/Medical Director was on a medical leave and Physician #2 was covering his patients. The Receptionist stated that she would leave a message for one of the physicians to call back. On 2/18/22 at 11:21 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team, stated that physicians were supposed to see every resident monthly. At this time, the LNHA acknowledged that there was no documentation that the above residents were seen monthly. On 2/18/22 at 12:23 PM, the surveyor interviewed Physician #1/Medical Director via telephone who stated that he was in the facility twice a week and saw most residents monthly. Physician #1/Medical Director stated that he made rounds with the nurses and talked to the residents to see if they had any concerns. Physician #1/Medical Director stated that he documented all his notes in the Physician's Progress Notes and was behind on progress notes. A review of the facility's Physician Services policy dated 12/2014, included hat physician visits will be conducted as required by state and federal guidelines, or based on resident's individual needs. NJAC 8:39-23.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to implement interventions in accordance with residents' individualized person-centered care plans for a.) a resident with chronic pain on pain management and b.) two residents who used tobacco products. This deficient practice was identified for 3 of 22 residents (Resident #3, #145, and #146) reviewed for implementation of care planning and was evidenced by the following: 1. On 2/11/22 at 11:50 AM, the surveyor observed Resident #3 sitting in his/her room. The resident stated that he/she had back pain and received pain medication. The resident appeared to be in no distress. On 2/16/22 at 11:43 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert, oriented, and able to make their needs known. The CNA stated that the resident liked to stay in their room by themselves. On 2/16/22 at 11:58 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN #1) who stated that the resident was able to express their needs and was very particular. LPN #1 stated that the resident had pain and received a standing order for [MEDICATION(S)]. The surveyor reviewed the medical record for Resident #3. A review of the Face Sheet (an admission summary) indicated that the resident was admitted to the facility in July of 2011 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly Minimum Data Set (MDS), an assessment tool dated 9/25/21, reflected that the resident had a brief interview for mental status (BIMS) score that was unable to be completed. The resident had no long or short-term memory problems with independent cognitive skills for daily decision making. A review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's individualized person-centered Care Plan (CP) initiated 12/30/2020, included a problem area of at risk for alteration in comfort with regards to chronic pain secondary to foot drop and bilateral hand contractures. Interventions included to: pain assessment upon admission and as needed; assess for signs and symptoms of pain every shift verbal and nonverbal; and medicate for pain as needed. A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Interdisciplinary Progress Notes did not include any Nurse's Notes documented for the month of February 2022. On 2/17/22 at 10:34 AM, the surveyor observed the resident sitting in his/her room and appeared to be in no distress. The resident stated that he/she received [MEDICATION(S)] daily for foot pain. On 2/17/22 at 12:25 PM, the surveyor interviewed the resident's medication nurse for the day, LPN #2 who stated that the nurses monitored for pain verbally and nonverbally by looking for facial grimacing or moaning when administering medications. LPN #2 stated that if the resident was on a pain medication, then a pain scale would be on that resident's MAR. LPN #2 stated that Resident #3 did not complain of pain to her, and she did not document the resident's pain level. On 2/18/22 at 11:17 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident was on pain medications for muscular skeleton pain. The DON stated that nurses should be assessing pain every shift and documenting on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time, the DON acknowledged that the nurses were not documenting the resident's pain level every shift. A review of the facility's undated Pain Management Policy included that all residents will be assessed for pain by the nursing staff upon admission and on an ongoing basis . Initial documentation of resident's pain will occur on the interim care plan if the pain is present upon admission . (b) Nurses are responsible for implementation and coordination of the plan for managements of pain, using clinical and administrative resources to ensure progress towards achieving relief or control of pain . Evaluation by nurses of resident's responses to interventions for pain control. (a) evaluate responses. (b) document responses on MDS, in the Interdisciplinary and Functional Care Plans and in the Nurses' Notes. (c) use evaluation data to revise care plan . 2. On 2/11/22 at 11:25 AM, the surveyor observed outside Resident #146's door on the floor next to a small trash receptacle two broken cigarettes with loose nicotine. On 2/11/22 at 11:28 AM, the surveyor interviewed LPN #2 who stated that residents were not allowed to hold onto their own cigarettes and lighters, that the Smoke Monitor held onto them. LPN #2 stated that residents were able to smoke throughout the day in a designated smoking area outside. The surveyor showed LPN #2 the broken cigarettes and loose nicotine on the floor. LPN #2 identified Resident #146 as a smoker. At this time, LPN #2 interviewed Resident #146 regarding the broken cigarettes and loose nicotine outside their door. Resident #146 stated that the cigarettes were broken from his/her pocket and that he/she swept it from his/her room into the hallway. The resident stated that he/she does not smoke in the building. On 2/16/22 at 11:04 AM, the surveyor observed that the resident was not in their room. The resident's roommate stated that they were outside smoking. On 2/16/22 at 11:36 AM, the surveyor observed the resident with their coat on in the hallway returning to their room. The resident stated that he/she was outside and that they smoked earlier today. The resident stated that he/she had no more cigarettes and needed to purchase more. The surveyor reviewed the medical record for Resident #146. A review of the Face Sheet reflected that the resident was admitted to the facility in November of 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's individualized person-centered CP initiated 10/28/2020, for a problem area at risk for injury/complications with regards to use of tobacco. Interventions included to: will continue to follow the facility smoking policy and only smoke in the designated area of the facility; staff will continue to monitor and assess for safety; and complete smoking assessment at least quarterly and thereafter. There was no smoking assessment located in the resident's chart. On 2/17/22 at 11:52 AM, the surveyor interviewed the Social Worker (SW) who stated that she was new to the facility and was in charge of smoking assessments. The SW stated that since she had been at the facility, she started identifying smokers and updating their smoking assessments. She stated that some residents had smoking assessments, and some did not. The SW stated that Resident #146 was not her list as a smoker, and she did not have a smoking assessment completed for that resident. On 2/17/22 at 12:05 PM, the surveyor interviewed the Smoke Monitor who stated that their job was to ensure that the residents smoked safely. The Smoke Monitor stated that he held onto the residents' cigarettes and lighters. The Smoke Monitor stated that Resident #146 was a smoker and that he/she currently had no cigarettes. The Smoke Monitor stated that the resident smoked safely; did not burn themselves or others; did not try to light their own cigarettes; and did not try to carry their cigarettes or lighters. On 2/17/22 at 12:57 PM, the SW informed the surveyor that she did not find any completed smoking assessment for the resident. On 2/18/22 at 11:21 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON and survey team, stated that the facility was transitioning ownership and acknowledged that not all residents had smoking assessments. 3. On 2/14/22 at 12:40 PM, the surveyor observed Resident #145 sitting in their wheelchair in their room. The resident stated that he/she usually ate their breakfast after they went outside at 9:00 AM for their morning cigarette. At this time, the surveyor observed no cigarettes or lighters on the resident. On 2/16/22 at 11:39 AM, the surveyor interviewed the resident's CNA who stated that the resident liked to smoke cigarettes all day and drink tea. On 2/16/22 at 11:50 AM, the surveyor interviewed LPN #1 who stated that the resident went outside to smoke cigarettes daily. The LPN stated that she was new to the facility and was unsure if the residents were allowed to hold onto their cigarettes and lighter, but she had not observed Resident #145 to have cigarettes or a lighter on them. LPN #1 stated that there was a Smoke Monitor outside with the residents. On 2/16/22 at 12:13 PM, the surveyor interviewed LPN #2 who stated that the resident was very pleasant and went outside to smoke cigarettes. The surveyor reviewed the medical record for Resident #145. A review of the Face Sheet reflected that the resident was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated fully intact cognition. A review of the resident's individualized person-centered CP initiated 12/30/2020 included a problem area for at risk for injury/complications regards to use of tobacco with a history of being observed in the lobby of the building smoking cigarettes. Interventions included to: will continue to follow facility smoking policy and only smoke in the designated area of the facility; staff will continue to monitor and assess for safety; and complete smoking assessment at least quarterly and thereafter. A review of the Resident Smoking Assessment reflected for Include in Nursing Care Plan & Interdisciplinary resident Care Plan was dated second quarter assessment 3/19/2021 and was not completed or signed. The document was also blank for the third and fourth quarter. On 2/17/22 at 11:52 AM, the surveyor interviewed the SW who stated that she was new to the facility and was in charge of smoking assessments. The SW stated that since she had been at the facility, she started identifying smokers and updating their smoking assessments. She stated that some residents had smoking assessments, and some did not. The SW stated that Resident #145 was not her list as a smoker, and she did not have a smoking assessment completed for that resident. On 2/17/22 at 12:05 PM, the surveyor interviewed the Smoke Monitor who stated that their job was to ensure that the residents smoked safely. The Smoke Monitor stated that he held onto the residents' cigarettes and lighters. The Smoke Monitor stated that Resident #145 was a smoker who smoked safely; did not burn themselves or others; did not try to light their own cigarettes; and did not try to carry their cigarettes or lighters. On 2/17/22 at 12:56 PM, the SW informed the surveyor that Resident #145 has not had a completed smoking assessment since 2019. On 2/18/22 at 11:21 AM, the LNHA in the presence of the DON and survey team, acknowledged that all residents did not have completed smoking assessments. A review of the facility's Care Planning-Resident Participation dated copyright 2021, included that the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a) accurately assess a resident for smoking and b) implement the facility's smoking policy and procedure for a resident who smoked cigarettes. This deficient practice was identified for 1 of 3 residents (Resident #56) reviewed for smoking and the evidence was as follows: On 2/11/22 at 10:31 AM, the surveyor observed Resident #56 resting in their room with a cigarette lighter on the nightstand by their bed. The resident stated that they were not really supposed to keep their own cigarettes or lighters and confirmed they were a smoker. On 2/11/22 at 10:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that residents who smoked were assessed quarterly for smoking, and the residents were not supposed to hold on to their own cigarettes or lighters. LPN #1 stated that all cigarettes and lighters were locked-up and kept by the facility, and residents were provided smoking material by the Smoke Monitor at the time they were smoking. On 2/11/22 at 11:00 AM, the surveyor interviewed the Director of Activities (DA) who confirmed that all smoking paraphernalia were locked in a box and kept by the facility. On 2/11/22 at 11:17 AM, LPN #1 approached the surveyor and informed them that after speaking with the facility Smoking Monitor, she was informed that no residents were supposed to have a lighter; that all lighters are locked up. The surveyor reviewed the medical record for Resident #56. A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in April of 2015 with diagnosis which included altered mental status/possibly [CONDITION(S)] related dementia. A review of the most recent annual Minimum Data Set (MDS), an assessment tool dated 11/22/2021, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review reflected the resident was a current tobacco user. A review of the resident's individualized resident-centered Care Plan initiated on 11/24/2020, included a problem area for tobacco use. Interventions included to: complete a smoking assessment at least quarterly and thereafter; a copy of the facility smoking policy to be provided to the resident upon admission and as the policy is revised; and the resident will continue to follow the facility smoking policy. A review of the facility Resident Smoking Assessment reflected quarterly assessments completed on 11/26/19 and 2/21/20, and a Safe Smoking assessment dated [DATE]. There was no documentation that the resident was assessed for smoking quarterly in 2021 or a smoking contract with the resident. On 2/16/22 at 8:57 AM, the surveyor observed Resident #56 walking out from their room to the smoking courtyard and removed a pack of cigarettes and a lighter from their jacket pocket. The resident lit the cigarette and proceeded to smoke. On 2/16/22 at 9:09 AM, the surveyor interviewed the Temporary Nursing Aide (TNA) who stated that he was currently acting as a smoke monitor for the Smoke Monitor who was currently out of the facility with a resident. The TNA stated that no residents were allowed to carry their own cigarettes or lighters. When asked if Resident #56 was able to carry their own smoking paraphernalia, the TNA responded, No, I do not know how [he/she] got them, they were all supposed to be locked up in the box. On 2/16/22 at 9:21 AM, the surveyor interviewed the Social Worker (SW) who confirmed that residents were not supposed to carry their own cigarettes or lighters. The SW stated that there were many smoking assessments that were not completed. On 2/16/22 at 10:00 AM, the SW and the Director of Nursing (DON) confirmed the facility did not have an initial admission smoking agreement for Resident #56. They were also unable to provide any quarterly smoking assessments for 2021. On 2/16/22 at 10:46 AM, the surveyor observed the resident in their room watching television. The resident confirmed that he/she had been an active smoker since they were 16 or [AGE] years old with no attempts to quit smoking. On 2/17/22 at 2:31 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Assistant Administrator, and the survey team, confirmed that no residents should be holding onto their own lighters or cigarettes in the building. A review of the facility's undated Smoking Policy included procedures: 1. Upon admission, an assessment will be completed . 3. A smoking monitor has been designated by the facility to handle all tobacco products and smoking apparatus and paraphernalia . All residents shall be encouraged to have products lit by the smoking monitor or designated staff members. NJAC 8:39- 33.1(d)

Based on observations, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain an indwelling urinary catheter bag off the floor to prevent the spread of infection and b.) ensure catheter care was performed and documented every shift in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/11/22 at 11:22 AM, the surveyor observed Resident #52 lying in bed asleep. The surveyor observed an indwelling urinary catheter bag secured to the bed frame in a dignity bag. On 2/16/22 at 11:47 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated that the resident was paralyzed from the waist down and had an indwelling urinary catheter. The CNA stated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA stated that she reported the amount of urine output to the nurse. On 2/16/22 at 11:55 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that the resident was recently readmitted from the hospital for COVID-19. LPN #1 stated that the CNA emptied the resident's urinary catheter bag, but she was unsure if the CNA recorded the urine output amount because it was not documented on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 2/16/22 at 12:22 PM, the surveyor interviewed LPN #2 who stated that the nurses performed catheter care for the resident and the CNA emptied the urinary catheter bag. LPN #2 stated that the CNA did not record urine output. The LPN stated that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the medical record for Resident #52. A review of the Face Sheet (an admission summary) reflected that the resident was last admitted to the facility in January of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/2/21, reflected that the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. It further included that the resident had an indwelling catheter. A review of the resident's individualized person-centered Care Plan (CP) included a problem area initiated on 11/8/2020 for reoccurring catheter associated UTIs secondary to catheter placement. Interventions included to: monitor, document, notify medical doctor of signs and symptoms of complication; assess for urine characteristics (volume, color, clarity, odor) and document; keep drainage bag off the floor and cover for dignity; and change bag per facility protocol. A review of the telephone physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the January 2022 TAR from 1/1/22 until transfer to the hospital revealed the following: A PO dated 11/30/21 for change urinary bag weekly reflected a blank for the change on 1/1/22. A PO dated 11/30/21 for urinary catheter care every shift, reflected blanks for: the 11:00 PM to 7:00 AM shifts on 1/1/22, 1/2/22, 1/3/22, and 1/4/22; the 7:00 AM to 3:00 PM shift on 1/3/22; and the 3:00 PM to 11:00 PM shift on 1/3/22 and 1/4/22. A review of the January 2022 TAR from 1/24/22 until 1/31/22 revealed the following: A PO dated 1/24/22 for urinary catheter care every shift, reflected blanks for the following: For the 11:00 PM to 7:00 AM shift on 1/25/22, 1/26/22, 1/27/22, 1/28/22, 1/29/22, 1/30/22, 1/31/22. For the 7:00 AM to 3:00 PM shift on 1/25/22, 1/26/22, 1/27/22, 1/28/22, 1/29/22, 1/30/22, and 1/31/22. For the 3:00 PM to 11:00 PM shift on 1/25/22, 1/26/22, 1/27/22, 1/28/22, 1/29/22, 1/30/22, and 1/31/22. A PO dated 1/24/22 to change urinary bag weekly, reflected no urinary bag changes were done. On 2/17/22 at 10:03 AM, the surveyor observed the resident sitting in their wheelchair with their catheter bag lying directly on the floor underneath their wheelchair. The CNA was with the resident and stated that she had just transferred the resident from bed into their wheelchair and emptied their urinary bag. The CNA stated that she was going to put the urinary bag into the dignity bag and attach it to the back of the resident's wheelchair. The CNA picked up the resident's urinary bag to show the surveyor the clear yellow urine, and then placed the urinary bag directly back on the floor. Then the CNA retrieved the dignity bag and placed the urinary bag in the dignity bag and attached it to the back of the resident's wheelchair. On 2/17/22 at 10:07 AM, the surveyor interviewed the CNA who stated that the resident does not use a leg urinary bag, only the large urinary bag that she placed in the dignity bag. The CNA stated that when the resident was in bed, she attached the dignity bag to the bed frame, but when the resident was in his/her wheelchair, she attached the bag to the back of the chair. The CNA stated that the tubing was too short for her to be able to reach from the front of the wheelchair to the back, that she placed the urinary bag on the floor while she went to the back of the wheelchair. When asked, the CNA confirmed that the urinary should not be on the floor because it was an infection control issue, so she needed to inform the nurse that the bag needed to be changed. On 2/17/22 at 10:39 AM, the surveyor interviewed the resident who confirmed that his/her urinary bag was just changed, and he/she had no recent UTIs. On 2/17/22 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated that catheter care should be completed every shift and documented as completed on the TAR. The DON stated that the urinary bag should be kept off the floor for infection control and placed in a dignity bag for privacy. The DON stated that if the urinary bag was on the floor, then the nurse changed the bag and not the CNA because it was a sterile process. On 2/18/22 at 11:02 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team confirmed that the CNA should not have placed the resident's urinary bag on the floor. The DON acknowledged the blanks in the January TAR and stated that catheter care was being done, but not documented. The DON also stated that she spoke to the night nurse, who stated that she changed the resident's urinary bag in January but did not document it. The DON acknowledged that not documenting was equivalent to not being done. A review of the facility's Catheter Care policy dated copyright 2021, included catheter care will be performed every shift and as needed by nursing personnel . The policy does not include that urinary catheter bags should be maintained off the floor. NJAC 8:39- 19.4 (a)5; 27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow the physician's order for the administration of oxygen. This deficient practice was identified for 1 of 2 residents (Resident #10) reviewed for respiratory care and was evidenced by the following: On 2/11/22 at 11:35 AM, the surveyor observed Resident #10 in bed with oxygen being administered at 3 liters per minute (lpm) via a nasal cannula (NC; a tube with prongs that sit in the nostrils) that was attached to an oxygen concentrator. On 2/14/22 at 9:57 AM, the surveyor observed the resident in their bed with oxygen being administered at 3 lpm via NC. The resident appeared to be in no distress. On 2/15/22 at 9:24 AM, the surveyor observed the resident in bed with oxygen being administered at 3 lpm via NC. The resident appeared to be in no distress. The surveyor reviewed the medical record for Resident #10. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility in March of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the last completed Minimum Data Set (MDS), an assessment tool dated 9/17/21, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review in Section O. Treatment and Procedures, indicated that the resident received oxygen treatments in the facility. A review of the February 2022 Treatment Administration Record (TAR) reflected a physician's order (PO) dated 3/13/19 for oxygen to be administered at 2 lpm via NC continuously every shift. An additional PO dated 3/13/19 to check pulse oximeter ( pulse ox; a machine placed on the finger to check a person's oxygen saturation in the body) every shift. The corresponding administration record reflected that the 7:00 AM to 3:00 PM shifts on 2/13/22, 2/14/22, 2/15/22, and 2/16/22 were blank for both. The TAR also reflected that the 3:00 PM to 11:00 PM shifts on 2/14/22 and 2/15/22 were blank for both. A review of the undated individualized person-centered Care Plan included a problem area for at risk for respiratory distress related to hypoxic respiratory failure, [CONDITION(S)] and required oxygen. Interventions included to: administer oxygen at 2 lpm via NC continuously; assess lung sounds; monitor for increased shortness of breath, wheezing, monitor my oxygen toleration. On 2/17/22 at 9:49 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident received oxygen at 2 lpm via NC continuously. The LPN stated that the oxygen setting was checked by the nurse every shift and signed on the TAR that it was checked. The LPN accompanied the surveyor into Resident #10's room. The LPN confirmed that the oxygen was not set to 3 lpm and not the ordered 2 lpm. The LPN stated that she had administered the resident medications earlier, but she did not check the oxygen setting at that time. At this time, the surveyor requested the LPN check the resident's oxygen saturation (level of oxygen saturation in the resident's body checked with a pulse oximeter). The LPN checked the resident's oxygen saturation level which was at 97%, an acceptable range. On 2/17/22 at 2:38 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team regarding the concern with the oxygen not being administered in accordance with the resident's PO. The DON stated that the nurses were expected to follow the PO and check the oxygen setting and the resident's oxygen saturation each shift and document this in either the Nurse's Notes or on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor then reviewed the February TAR for the resident with the administration team. The DON acknowledged the omissions on the record and stated that the nurse should have recorded the resident's oxygen saturation and also signed/initialed the TAR on the corresponding dates to indicate the oxygen settings and oxygen saturation had been completed. A review of the facility's policy and procedure titled Oxygen Administration and dated issued 4/5/22, included that .oxygen will be administered as per MD order to aid in breathing . Note: Residents using oxygen will be checked at the beginning of each shift to make sure that the dial is at the correct setting, and that the equipment(s) is in proper working order NJAC 8:39-27.1 (a)

Based on observations, interview, and review of facility documentation it was determined that the facility failed to a.) follow the physician's order to document the monitoring of the [CONDITION(S)] access site every shift and b.) follow the facility's policy by assessing and documenting care upon return on resident's [CONDITION(S)] days. This deficient practice was identified for 1 of 1 resident (Resident #69) reviewed for [CONDITION(S)] and was evidenced by the following: On 2/14/22 at 9:54 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that Resident #69 was currently out of the facility to [CONDITION(S)]. The surveyor reviewed the medical record for Resident #69. A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in February of 2017 and then readmitted in January 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/11/21, reflected that the resident had a brief interview for mental status (BIMS) score of 11 out of 15, indicating a moderately impaired cognition. A review of Section O, Special Treatment and Procedures, reflected that the resident received hemodialysis services (a process of purifying the blood due to impaired kidney function). A review of the individualized Care Plan initiated 3/15/21, included to assess the right chest wall permacath (a piece of plastic tubing placed in the chest/neck for hemodialysis) every shift and before/after each [CONDITION(S)] session - check for warmth, redness, and bleeding at the site. A review of the physician's orders (PO) which reflected the following: 1. A PO dated 9/30/21, to monitor permacath to the right chest wall for [CONDITION(S)] (swelling), bleeding, infection. 2. A PO dated 9/30/21, for [CONDITION(S)] every Monday, Wednesday, and Friday. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Nurse's Notes and Interdisciplinary Progress notes from December 2021 to February 14, 2022, reflected the documentation of monitoring of the permacath every shift and vital signs and assessment upon returning from [CONDITION(S)] was not consistent. On 2/15/22 at 9:36 AM, the surveyor observed Resident #69 lying in bed. The resident asked the surveyor what do you want? and briefly spoke with the surveyor. Resident #69 stated he/she was tired because he/she had [CONDITION(S)] yesterday. On 2/15/22 at 9:43 AM, the surveyor interviewed LPN #2 who stated that Resident #69 was picked up between 4:30 AM and 5:00 AM for [CONDITION(S)] on Monday, Wednesday, and Friday. She further stated the resident had a right chest wall permacath which they monitored. LPN #2 stated the resident had a failed left arm fistula (a surgically created [CONDITION(S)] access site where the vein is connected to the artery). She further stated the resident was scheduled for a revision of the left arm fistula in March of 2022. At the time, the LPN #2 showed the surveyor the [CONDITION(S)] Communication Record (DCR - a form used to communicate the resident's status on [CONDITION(S)] treatment days between the facility and the [CONDITION(S)] center) binder. LPN #2 explained the staff nurse filled out the top portion and the [CONDITION(S)] facility filled out the bottom portion. She concluded if the [CONDITION(S)] facility needed to provide additional information it would be in an envelope upon the resident's return. A review of the DCR which contained four (4) separate sections to be filled out: the top section - Facility communication to [CONDITION(S)] center, the second section - Facility to complete prior to [CONDITION(S)], the third section - [CONDITION(S)] center to complete for facility, and the fourth section - Facility to complete upon return from [CONDITION(S)]. The DCR forms from 12/17/21 to 2/14/22 reflected the fourth section - Facility to complete upon return from [CONDITION(S)] was not completed. On 2/15/22 at 12:13 PM, LPN #2 stated they did not have to complete the bottom portion because they do an assessment upon return. She stated that they documented the assessments in the Nurse's Notes every time Resident #69 came back from [CONDITION(S)]. LPN #2 stated they conducted a head-to-toe assessment and monitored for any signs of distress, swelling, check the permacath and do vital signs. The surveyor and LPN #2 reviewed the DCR binder together. LPN #2 stated she honestly never paid attention to the bottom portion. LPN #2 acknowledged all sections of the DCR should be completed before and after [CONDITION(S)]. On 2/16/22 at 10:45 AM, the surveyor interviewed LPN #1 who stated that she took care of Resident #69 on 2/14/22 and explained the process for [CONDITION(S)] residents which included taking vital signs before and after [CONDITION(S)] and checking the DCR for new orders. LPN #1 stated that she completed the DCR prior to sending the resident to [CONDITION(S)] but was not sure if the form had to be filled out upon return. The surveyor and LPN #1 reviewed the DCR binder together. LPN #1 acknowledged the bottom portion was not filled out and that she should have filled it out. LPN #2 further stated she did take the resident's vital signs but did not remember if she put them in the Nurse's Notes. She concluded the assessment should have been in the Nurse's Notes and filled out on the DCR and that they always did assessments on all their residents returning to the facility. On 2/16/22 at 11:11 AM, the Director of Nursing (DON) explained to the surveyor the process for [CONDITION(S)] residents which included, the nurses would conduct vital signs and an assessment before [CONDITION(S)] which was documented on the DCR, the [CONDITION(S)] facility filled out their portion, and then upon return the nurse conducted vital signs and an assessment which should be documented on the bottom portion of the DCR. The surveyor reviewed with the DON the bottom portion of the DCR from the above dates that were not completed. The DON acknowledged the bottom portion should have been completed upon the resident's return from [CONDITION(S)]. On 2/16/22 at 12:48 PM, the surveyor observed the resident lying in bed resting with his/her eyes closed after returning from [CONDITION(S)]. On 2/16/22 at 12:53 PM, the DON provided a copy of the TAR for February 2022 which reflected an undated for your information (FYI) no blood pressure (BP)/ labs to left arm which was left blank. The surveyor interviewed the DON regarding the undated FYI, no BP/labs on the left arm and that it was not being signed off. The DON stated Resident #69 had a non-functional left arm fistula and the resident was scheduled for a revision on 3/1/22. The DON concluded the FYI note written on the TAR did not have a PO date and it was just an FYI. On 2/16/22 at 1:07 PM, the surveyor interviewed LPN #3 who stated that the resident had left arm restrictions. She stated honestly, I just learned today that the resident had arm precautions. The LPN #3 stated Resident #69 does not let her use that arm because he/she referred to it as the bad arm. On 2/16/22 at 1:09 PM, Resident #69 stated they only used his/her right arm because the left arm was bad and that he/she had one of those things in his/her arm for [CONDITION(S)] but it was old. On 2/18/22 at 11:04 AM, the DON in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Assistant LNHA stated that Resident #69's left arm fistula was not working because it did not have a bruit and thrill (turbulent blood flow that can be heard (bruit) by placing a stethoscope over the area and felt (thrill) by placing fingers over the access site). The DON stated the permacath monitoring was originally ordered 9/30/21 but then reordered on 2/17/22 with the left arm no blood pressures or needlesticks. The DON acknowledged the facility did not receive an order from the physician or update the care plan until after the surveyor inquired. A review of the facility's Care Planning Special Needs - [CONDITION(S)] policy dated 10/31/21 included .3. Interventions will include, but not limited to: .a. Documentation and monitoring of complications, .c. assessing, observing, and documenting care of access sites, as applicable .f. vital signs .5. If no written report is received upon return from [CONDITION(S)], nursing staff will call the [CONDITION(S)] provider to receive a report. NJAC 8:39-27.1(a)