Every finding on record at Lincoln Park Renaissance

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication (med) for 4 of 36 (Res. #14, #173, 205, 166 and 4) residents reviewed for medication regimen. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice is evidenced by the following: 1.On 1/28/26 at 10:50AM, the surveyor conducted an interview of Resident #205. The resident was alert and oriented to self but not to place and time and the resident could not accurately provide a history of his care at the facility. A review of Resident #205's admission Record reflected that the resident was admitted to the facility with Spinal Stenosis lumbar region (narrowing of the spinal canal in the lower back, compressing the nerves), cerebral infarction (stroke) and urinary tract infection. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 1/20/26 reflected the resident had a history of frequent moderate pain in the five days preceding the assessment. The MDS reflected that the resident had a brief interview for mental status (BIMS) score 11 out of 15, which indicated a moderate cognitive impairment. A review of the physician's orders for Resident #205 reflected the resident was ordered medication that included but was not limited to: Oxycodone HCL oral tablet 5 mg. Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4 -10 dated 1/18/26 Lidocaine external patch 5% Apply to left hip and low back topically in the morning for back pain 1/19/26. A review of Plan of Care reflected a focus dated 1/18/2025 of at risk for pain due to advanced age and interventions for that focus that included but were not limited to administer pain medication as ordered. A review of the resident's medication administration record (MAR) reflected the resident was administered the following medications: oxycodone 5mg on 1/19/26 at 3:41 PM for a pain level charted as 0. oxycodone 5mg on 1/20/26 at 3:14 PM for a pain level charted at 0. Both administrations of the medicine were signed for by the LPN. On 2/5/2026 at 11:16 AM, the surveyor interviewed the LPN. The surveyor asked the LPN about pain medication administration, and she verbalized that residents should have pain managed appropriately and that the lowest level of medication or intervention should be implemented to control pain. The LPN confirmed she was knowledgeable of pain scale utilizing 0-10 , and she stated 0 means No pain and 10 is the worst pain they ever had. The surveyor asked the LPN about as needed (PRN) pain medication administration procedures. The LPN stated I ask the residents if they have pain and ask them to give it a number 0-10. If the resident states, they have pain I give them the medicine ordered for that level of pain. The surveyor asked the LPN to review administrations of oxycodone for Resident #205 for 1/19/26 and 1/20/26. The LPN confirmed she signed for the administration of PRN oxycodone 5mg for 1/19/26 at 3:41 PM and that she charted it was for a pain level of 0. The LPN confirmed administration of PRN oxycodone 5mg on1/20/26 at 3:14 PM and that she charted charted it was for pain level of 0. The LPN confirmed the physician's order was Oxycodone HCL oral tablet 5 mg to give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4 -10. The LPN acknowledged that resident should not have received medication if resident reported pain scale of 0 of 10 on the pain scale. The surveyor asked the LPN to review Resident #205's physician order for lidocaine patches, she confirmed the order was for application of lidocaine patch 5% applied to low back and left hip daily in the morning. She confirmed she places 1 patch on the area of skin between the left hip and lower back and indicates left hip as the location of administration. She confirmed order did not include directions for time of removal or total time patch should remain on the resident. The LPN stated, we take them off in the evening when he gets his voltaren gel applied she confirmed we don't chart anywhere that we took it off. On 2/6/26 at 1:43 PM, the surveyor and the team met with the Director of Nursing (DON) and the Administrator and discussed concerns regarding the Oxycodone administration for pain charted as 0 and outside of the administration parameter as well as the lidocaine patch application and lack of removal order. The surveyor reviewed with the DON the concerns with the MAR entries for the lidocaine topical patch administration for January and February. The DON acknowledged that of the 25 days reviewed, nurses had charted 10 days the patch was applied to the left hip, on 14 days the nurses charted the patch was applied to the lower back and on 1 day the nurse charted it was applied to other. The DON confirmed the physician's order was that lidocaine patch should be applied to both the left hip and lower back. On 2/9/26 at 10:35 AM, the surveyor and the team met with the DON and the DON provided the lidocaine patch manufacturer's guidelines that indicated the lidocaine patch could be applied for up to 12 hours and confirmed a removal instruction or removal order for time of removal should have been in place to assure proper use of the product. The DON acknowledged she reviewed the MAR for Resident #205 and confirmed the oxycodone doses on 1/19/26 and 1/20/26 were administered outside of order parameters as documented. 2. On 2/9/26 at 9:26 AM, the surveyor reviewed the electronic medical record of Resident #4. The admission Record (a summary of important information about a resident) revealed Resident #4 had diagnoses that included, but were not limited to, a compression fracture of the spine, a fracture of the humerus (a long bone in the upper arm), and supraventricular tachycardia (a heart rhythm disorder that causes a very fast heartbeat). A comprehensive Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, with an assessment reference date (ARD) of 12/29/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status test. Resident #4 scored 8 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order dated 1/14/26 indicated oxycodone 5 milligram (mg) oral tablet, give 1 tablet by mouth in the morning every 6 hours as needed for pain- moderate 4-7. A physician's order dated 1/14/26 indicated metoprolol succinate extended release 100 mg oral capsule, give 1 capsule by mouth in the morning; Hold for systolic blood pressure (BP) less than 110 or heart rate (HR) less than 60. A review of the February 2026 Medication Administration Record (MAR) revealed the following: For the metoprolol succinate order entry with parameters, there was no documentation of the resident's BP and HR at the time of the medication's administration. For the PRN oxycodone entry, there were three entries with a documented pain level that was outside the ordered parameters (4-7 pain level) for administering the medication which were as follows: - On 2/2/26 at 7:24 PM, the nurse documented a pain level of 3. -On 2/3/26 at 8:27 PM, the nurse documented a pain level of 2. -On 2/4/26 at 6:51 PM, the nurse documented a pain level of 0. A review of progress notes revealed no documentation of the resident's BP and HR at the time of the metoprolol succinate's administration; and no documentation regarding the PRN oxycodone administration for the three identified entries. A review of the February 2026 Weights and Vitals section of the EMR revealed: There was no documentation to indicate the resident's BP and HR results at the time of the metoprolol succinate's administration. There was no additional documentation for the resident's pain level at the time of the three identified PRN oxycodone administrations. On 2/9/26 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated the nurses checked a resident's BP and HR prior to administering a medication with corresponding parameters and held the medication according to the physician's orders. The LPN/UM explained that the BP and HR results were documented in the supplementary section of the MAR entry at the time of the medication's administration. The LPN/UM added the results could also be documented by the nurses in a progress note in the EMR. The surveyor asked the LPN/UM about PRN pain medications. The LPN/UM stated the expectation was for nurses to follow the indicated pain level when administering pain meds and the resident's reported pain level would be documented in the supplementary section of the MAR entry at the time of the medication's administration. The surveyor with the LPN/UM reviewed the February 2026 MAR entries for metoprolol succinate and PRN oxycodone. The surveyor discussed the above identified concerns for the entries. The LPN/UM stated the BP and HR entries under vitals indicated the nurses checked it. The LPN/UM confirmed the nurses had an hour before and one hour after a routine medication's scheduled time to administer the medication. A review of the BP and HR results in the MAR revealed there was no documentation to indicate the results were taken at the time of the metoprolol succinate's administration. The LPN/UM provided no verbal response regarding the identified PRN entries. The LPN/UM stated she would review to provide any additional information. On 2/9/26 at 2:23 PM, the surveyor informed the LNHA, the DON, and the Regional DON regarding the identified concerns with Resident #4's metoprolol succinate and PRN oxycodone. The DON stated Resident #4's vital signs were documented in the MAR. The surveyor discussed concern that the vital signs entry did not indicate time obtained and there was no documentation of the resident's BP and HR at the time of the metoprolol succinate's administration in the EMR. There was no verbal response regarding the concerns for the PRN oxycodone pain level. There was no additional information provided by the facility. The surveyor reviewed the facility provided policy titled, Pain Management, with a last revised date of 12/22/25 which revealed: . 5. The practitioner is notified of unresolved, new or worsening pain, lack of response to interventions or other concerns requiring medical review. 7. Pain Assessments, interventions, resident response, and relevant communications are documented in the medical record. The surveyor reviewed the facility provided policy titled, Medication Administration, with a last revised date of 1/6/26 which revealed under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation revealed: . 2. Orders are reviewed and clarified as needed prior to administration. 5. Medications are administered as ordered unless clinically contraindicated or refused. 6. Medication administration is documented in the medical record in a timely and accurate manner. 3. On 2/4/26 at 11:51 AM, Resident #173 came to the conference to talk to the team of surveyors. The team of surveyors interviewed Resident #173, who stated that they did not get the clonazepam (medication that helps reduce anxiety) 0.5 mg (milligram) tab. (tablet) medication on 2/1/26 at 9:00 PM and on 2/2/26 at 9:00 AM. The resident said that they asked the nurse to get it from the backup medications. The nurse told the resident that there is no backup medication for clonazepam. Resident #173 stated that they get anxious and cannot sleep if they have not received the clonazepam. The resident decided to call their family and told the daughter that they would miss their medication. The family came to the facility and gave them the clonazepam, and the family gave the resident an extra pill for the next day, as per the resident. Resident #173 added that the nurse was there and verbalized that the family saved the day. The nurse confirmed the bottled medication was prescribed to the resident and the medication inside was confirmed to be the correct medication. On 2/4/26 1:11 PM, the surveyor interviewed the LPN # 2, who is the nurse in charge of the resident on 2/2/26 in the evening and night shift, over the phone. The LPN # 2 stated that they did not have clonazepam that day on 2/2/26 at 9:00 PM for Resident #173. She made the resident aware that clonazepam is not available, and they do not have backup medication. The LPN added that the resident got upset and called the family, and it was around 9:30 pm. The daughter came after 9:30 pm, and she brought the supply of clonazepam from home. The family gave the clonazepam to Resident #173. The LPN did not confirm how many milligrams of clonazepam were given by the daughter. The LPN informed the supervisor, and the supervisor told her to call the doctor since the Nurse Practitioner (NP) was on vacation. On 2/5/26 at 12:23 PM, the surveyor interviewed the NP, who stated that she sent the prescriptions on 1/26/26 because they are not automatically refilled. The script went to the [Name redacted] pharmacy, and on 1/27/26, she faxed the script again to the pharmacy. On 1/29/26, she emailed the script again. The NP stated she does not know what happened after that. On 2/4/26 at 9:39 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #173, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #173 was admitted with diagnoses that included, but were not limited to, general anxiety (excessive feeling of worry, fear and stress) disorder. A review of the annual Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care), dated 1/14/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had intact cognition. A review of the comprehensive Care Plan (CP) report with an initiated date of 1/9/23, with the focus on Resident #173, who uses anti-anxiety medication related to anxiety. A review of the Order Summary Report (OSR) with the start date of 2/28/25, clonazepam 0.5 mg by mouth every 12 hours for anxiety. A review of the February electronic Medical Administration Record (eMAR) revealed that there is no documentation of the clonazepam 0.5 mg on 2/2/26 at 9:00 PM. A review of the Medication Admin Audit Report with a schedule date of 1/31/26 to 2/2/26 revealed that on 2/1/26 at the scheduled time of 9:00 PM, the clonazepam 0.5 mg was documented on 2/5/26 at 10:10 AM after the surveyor's inquiry. A review of the Packing Slip form dated 2/2/26, with an unknown time received by the nurse for Resident #173, revealed that the clonazepam 0.5 mg had 14 tablets and was received by the facility. A review of the Individual Patient's Controlled Drug Record (IPCDR) with a received date on 2/2/26 and amount received was 14 tablets for Resident #173 revealed that the clonazepam tab 0.5 mg was administered with a handwritten note on 2/2/26 at 9:00 PM and initialed by the letter AH. A review of the IPCDR for Resident #166 for clonazepam tab 0.5 mg revealed that the clonazepam 0.5 mg tab was given on 2/1/26 at 9:00 AM, and was administered with a handwritten note on 2/1/26, no time provided, and initialed by the letter AH and co-initialed by the letter JP. On 2/5/26 at 1:47 PM, the surveyor interviewed the Director of Nursing, who stated that the clonazepam 0.5 mg tabs for Resident #173 were received on 2/2/26 and could not confirm the exact time they were delivered. On 2/6/26, O2 at 10:08 AM, the team of surveyors met with the Regional Nurse, LNHA, and the Director of Nursing (DON). The DON stated the clonazepam 0.5 mg tab for Resident #173 was given on the following: 2/1/26 at 9:00 AM, was borrowed from Resident #166, which was discontinued. 2/1/26 at 9:00 PM, the dose came from the family. 2/2/26 at 9:00 AM, the dose was provided by the family again. The medication was in a prescription bottle with the resident's name on it from home. 2/2/26 at 9:00 PM, the dose was signed on the declining inventory, but the eMAR was not signed by accident, and it was signed on 2/5/26. On the same day at 10:15 AM, the surveyor interviewed the DON regarding narcotics borrowing and whether it was allowed in the facility. The DON stated, I don't know. On 2/9/26 1:18 PM, the surveyor interviewed the DON, who stated that they do not have any policy for borrowing narcotics from one resident to another. 4. On 1/28/226 at 9:55 AM, the surveyor observed Resident #14 in bed asleep. On 2/9/26 at 1:29 PM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #14, which revealed the following: A review of the AR reflected that Resident #14 was admitted with diagnoses that included, but were not limited to, chronic pain syndrome. A review of the recent quarterly MDS (Q/MDS) dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 15 out of 15, which indicated that the resident had intact cognition. A review of the comprehensive Care Plan (CP) report with an initiated date of 12/23/19, with the focus on Resident #14, who uses comfort related to non-healing right hip surgical wound, right foot abrasion, impaired mobility, and diabetic neuropathy. A review of the OSR with an order date of 11/17/25, Dilaudid 2 mg by mouth every 4 hours as needed for severe pain, and acetaminophen 325 mg 2 tabs by mouth every 6 hours as needed for pain with an order date of 3/3/23. No indication of pain level scale for both medications. A review of the January 2026 eMAR revealed that the nurse's documentation of acetaminophen 325 mg 2 tabs by mouth every 6 hours as needed was given on 1/28/26 at 3:09 PM for a pain level of 7 (seven). Furthermore, the Dilaudid 2 mg for the pain level is the following: On 1/15/26 - 0 (zero) pain given and signed at 9:47 AM On 1/24/26 - 0 pain given and signed at 9:35 AM On 1/24/26 - 0 pain given and signed at 11:30 PM On 2/9/26 at 1:40 PM, the surveyor interviewed Asst. DON/Unit Manager, who stated that they do have a scale for pain medications. The scale could vary for each resident. When the nurses were giving pain meds, the system automatically asked about the pain level. If the resident cannot verbalize their pain, there is a sequence of questions/assessments for pain. NJAC 8:39-11.2 (b); 29.2(d)

REPEAT DEFICIENCY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide ordered respiratory care consistent with professional standards of practice. This deficient practice was identified for 3 of 4 residents (Residents #13, #102, and #103) reviewed for respiratory care, and was evidenced by the following: 1.On 1/28/26 at 10:20 AM, the surveyor interviewed Resident #102. The resident was lying in bed and the surveyor observed a nasal canula connected to a wall oxygen outlet, which was was in use. The surveyor examined the wall oxygen meter and observed it was set at 0.5 liters/minute of flow. The humidification bottle attached to the wall meter had no date indicating start of use. The resident stated he was not short of breath and demonstrated no signs or symptoms of distress or difficulty breathing. A review of the resident's admission record reflected he was admitted to the facility on [DATE] with diagnoses including but not limited: pneumonia and acute respiratory failure. A review of Resident #102's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/14/26 indicated a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which reflected that the resident's cognition was severely impaired. A review of the resident's physician's orders reflected an order dated 1/9/26 for the resident to receive oxygen via nasal canula at 3 liters per minute continuously as well as an order dated 1/9/26 to date the oxygen humidifier bottle if in use per protocol. On 01/29/2026 at 11:49 AM, the surveyor observed Resident #102 in his room seated in a wheelchair. The resident's nasal canula was in place and connected to the wall oxygen outlet and the flow rate read zero which indicated the oxygen was not turned on. The humidification bottle connected to the wall outlet was not dated. The resident did not exhibit signs of distress or shortness of breath. The resident denied shortness of breath or difficulty breathing. The surveyor requested Registered Nurse (RN) for the unit to enter the resident's room. The RN confirmed resident was ordered for 3 liter/minute of continuous oxygen via nasal canula. The RN confirmed that the resident's Nasal canula was in place and the tubing was connected to the wall outlet, but the valve was not turned on and no oxygen was flowing. The RN turned on the oxygen and set the flow to 3 liters/minute. The RN acknowledged that the resident should always be connected to oxygen at a flow rate of 3 liters/minute. The surveyor requested the RN examined the humification bottle and the RN confirmed the humidification bottle in use for this resident was not labeled with a start date. The RN immediately changed the humification bottle with a new one, dated at the time of application and acknowledged that humidification bottles should always be labeled with the date they were started. On 2/4/26 at 1:45 PM, the surveyor and the team met with Director of Nursing (DON) and Administrator and presented the concern over oxygen not set properly for Resident #107. The DON acknowledged that oxygen administration ordered by provider should always be set and delivered at the prescribed route and rate of flow. The DON acknowledged that humidification bottles should be labeled with the start date by the nurse putting the bottle in use. A review of the facility's Oxygen Therapy policy, with a revised date of April 2025, included the following procedures: Adjust liter flow per MD order. Observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. 2. On 1/28/26 at 11:35 AM, the surveyor observed Resident #103 sitting in a wheelchair at their bedside. The resident was alert and verbally responsive. The surveyor observed respiratory equipment at the bedside which included a Continuous Positive Airway Pressure (CPAP) machine (a treatment for obstructive sleep apnea and other respiratory issues that uses a machine to deliver steady, pressurized air through a mask to keep airways open during sleep and improve breathing). Resident #103 stated the CPAP machine was their own from home and they used it at night. On 1/29/26 at 8:58 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #103. The Face Sheet (a summary of important resident information) revealed Resident #103 had diagnoses that included but were not limited to, Chronic Obstructive Pulmonary Disease (COPD; a progressive, long-term lung disease that makes it hard to breathe due to damaged, inflamed, and narrowed airways), and obstructive sleep apnea. A Comprehensive Minimum Data Set assessment, a tool used to facilitate management of care, dated 12/17/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #103 scored 11 out of 15, which indicated the resident had moderate cognitive impairment. A review of the physician's orders for Resident #103 revealed there was no order for the CPAP machine. A review of the resident's care plan revealed no documentation regarding the use of a CPAP machine. A respiratory note dated 1/19/26 indicated the resident used a CPAP machine at bedtime. A nurse progress note dated 1/24/26 at 12:28 AM indicated the resident was using the CPAP machine and was in no respiratory distress. On 1/29/26 at 11:43 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated there should be physician's orders for CPAP machines. The surveyor informed the LPN/UM of the concern Resident #103 had a CPAP machine at their bedside that was being used and there was no physician order. The LPN/UM reviewed with the surveyor Resident #103's physician's orders and confirmed there was no physician order for the CPAP machine. The LPN/UM stated she would review to provide any additional information. On 1/29/2026 at 1:14 PM, the LPN/UM informed the surveyor the physician was called, an order was received for the CPAP machine, and the resident would be referred to a pulmonologist (a medical doctor specialized in respiratory care and treatment). The LPN/UM could not speak to why there was no physician's order for the resident's CPAP machine. On 2/4/26 at 1:30 PM, Surveyor #2 informed the Administrator and the DON of the concern there was no physician's order for Resident #103's CPAP machine. On 2/5/26 at 10:34 AM, the LNHA, the DON, the regional DON and the IP met with the survey team. The DON acknowledged after surveyor inquiry a physician's order was entered for Resident #103's CPAP machine. There was no additional information provided by the facility. A review of the facility provided policy titled CPAP. revealed under Procedure: . Verify the physician's order for BIPAP/CPAP. Apply the settings per physician's order. NJAC 8:39-27.1(a) 3. On 1/28/26 at 9:47 AM, the surveyor observed Resident #13 awake, lying on the bed, with a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 (oxygen) flows) on both nostrils attached to a portable oxygen tank (a device that supplies O2). The surveyor observed that the portable O2 tank was empty. The surveyor got the attention of the Licensed Practical Nurse (LPN), who checked that the tank was empty, then replaced it with a new full portable O2 tank. On 2/4/26 at 1:21 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #13, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #13 was admitted with diagnoses that included but were not limited to osteomyelitis of the vertebra (an infection in a bone), sacral, and sacrococcygeal (part of the body located in the lower back and the tail bone). A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 1/13/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severely impaired cognition. Further review of the Q/MDS revealed in Section J – Health Conditions revealed that Resident #13 had a shortness of breath. A review of the Order Summary Report (OSR) with the start date of 1/26/26, oxygen at 2 lpm (liters per minute) via nasal cannula continuously every shift for SOB (shortness of breath). A review of the January 2026 Treatment Administration Record (TAR) revealed that the nurses recorded oxygen use every shift. On 2/5/26 at 9:15 AM, the surveyor interviewed the Registered Nurse, who stated that when she starts her shift, she will check the oxygen, make sure the tank is full, labeled, and that there is a humidifier. On 2/5/26 at 9:27 AM, the surveyor interviewed the LPN/Unit Manager, who stated that the resident's oxygen should be checked by the nurses who are in charge of the resident, and that the oxygen was labeled in the correct flow. If it's a portable tank, it should be full. On 2/5/26 at 10:34 AM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing (DON), Infection Preventionist, and the Regional Nurse. The DON stated that the portable O2 tank was immediately bought for the nurses' attention, and the resident's O2 saturation is normal during those times. On 2/5/26 at 11:15 AM, the surveyor reviewed the facility's policy titled Oxygen Therapy, revised on 4/19/25, but it does not talk about the portable oxygen tank procedures. NJ 8:39-25.2(c)3,6

Based on interview and record review, it was determined that the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the appropriate timeframe and in accordance with federal guidelines for 2 of 35 residents (Residents #19, and #103), reviewed for resident assessments. This deficient practice was evidenced by the following:Reference: Centers For Medicare and Medicaid Services (CMS), RAI manual, Version 3.0, last revised in October 2025 indicated in Chapter 2, pages 2-8: .admission refers to the date a person enters the facility and is admitted as a resident.this date is considered the 1st day of admission .Under Chapter 2, Section 2.6-Required OBRA [Omnibus Budget Reconciliation Act] Assessments for the MDS revealed: .MDS Completion Date (Item Z0500B) No Later Than. 14th calendar day of the resident's admission (admission date + 13 calendar days) .Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. The IDT may choose to start and complete the admission comprehensive assessment at any time prior to the end of day 14 .On 1/29/26 at 12:34 PM, the surveyor reviewed the MDS assessments of the following residents which revealed: 1. A review of Resident #19's admission (comprehensive) MDS assessment with an Assessment Reference Date (ARD) of 1/17/26 revealed that the MDS was dated and signed complete on 1/30/26. The resident's admission entry was 1/11/26. The MDS assessment was completed more than 14 days after the admission date.2. A review of Resident #103's admission MDS assessment with an ARD of 12/17/25 revealed that the MDS was dated and signed complete on 12/26/25. The resident's admission entry was 12/11/25. The MDS assessment was completed more than 14 days after the admission date. On 1/29/26 at 1:03 PM, the surveyor interviewed the Registered Nurse MDS coordinator (RN/MDSC) who stated an admission (comprehensive) MDS assessment should be completed within 14 days of a resident's admission entry. The surveyor informed the RN/MDSC about concern for the late completion of Residents #19's and #103's MDS assessments.On 1/29/26 at 1:29 PM, the RN/MDSC acknowledged the identified MDS assessments were completed late. The RN/MDSC stated the facility followed the RAI manual guidelines for MDS assessments. On 2/5/26 at 1:33 PM, Surveyor #2 informed the Licensed Nursing Home Administrator, the Director of Nursing (DON), and the Regional DON regarding the concern of late MDS assessment completion for Residents #19 and #103. There was no additional information provided by the facility.NJAC 8:39-11.1, 11.2(e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 32 residents (Resident #3) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: The surveyor observed Resident #3 on 1/28/26 at 10:02 AM in bed with eyes closed. The resident's call device was clipped to the sheet behind the head of the bed. The device cord hung down behind the bed out of the reach of the resident. The surveyor observed the resident on 2/4/26 at 9 AM in bed with eyes closed. The call device was in the same position as the previous observation, hanging down behind the head of the bed. The surveyor observed the wound treatment nurse perform a treatment to Resident #3 on 2/4/26 beginning at 11:38 AM. The call device was observed on the floor under the resident's bed throughout the 40 minute treatment observation. At the conclusion of the treatment, the nurse picked up the call device from the floor and placed it on the resident's chest area. The surveyor interviewed the nurse on 2/4/26 at 12:25 PM. He stated call bells should always be accessible to the resident. A review of the resident's 11/19/25 significant change in status Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment (brief interview for mental status score of 8). The MDS also indicated the resident had no upper body limitations and was at risk for falls. The surveyor discussed the concern with Administrator and the Director of Nursing on 2/4/26 at 1:15 PM. They confirmed the call device should be in reach of the resident at all times. The facility Call Bell policy and procedure, revised 9/15/25, indicated the call bell will be placed within the resident's reach. NJAC 8:39-31.8 (c)9

Based on observation, interview, and record review it was determined that the facility failed to provide services in a manner to prevent or limit the spread of infection during a wound treatment observation. The deficient practice was observed for 1 resident (Resident #3) of 3 reviewed for pressure ulcers and other skin conditions and was evidenced by the following: The surveyor observed Resident #3 in bed with eyes closed on 1/28/26 at 10:02 AM and on 2/4/26 at 11:38 AM. A review of the resident's medical record revealed the following information. The 11/19/25 significant change in status Minimum Data Set (MDS) assessment tool indicated the resident had moderate cognitive impairment (brief interview for mental status score of 8). The MDS also indicated the resident had one pressure ulcer. The resident had a 1/22/26 physician's order for a sacral pressure ulcer as follows. Apply Santyl External Ointment 250 units/gram to sacrum topically every day shift for wound after cleansing with normal saline, pack with calcium alginate, and cover with dry dressing. The surveyor reviewed the facility Handwashing Technique Competency Validation, undated, which indicated after applying soap to hands, employees should lather all surfaces of hands, wrists, and fingers producing friction for at least 20 seconds, then rinse hands under running water. A review of the facility Hand Washing/Hand Hygiene Policy and Procedure, revised 4/2012, indicated employees must wash their hands for at least 20 seconds using soap and water. The surveyor observed the Licensed Practical Nurse (LPN) perform the full thickness sacral pressure ulcer treatment on 2/4/26 beginning at 11:38 AM. During the course of the 40 minute treatment, the following breaks in infection control technique were observed. The LPN washed their hands 8 times during the treatment pass. Of the 8 handwashing observations the LPN lathered outside of running water before rinsing for 15 seconds on 2 occasions, once for 13 seconds, once for 11 seconds, twice for 10 seconds, once for 7 seconds, and once placed hands under running water immediately after applying soap. Additionally, during the treatment pass, the LPN removed a pen from their uniform pocket, dated a bottle of normal saline and dated the cover dressing. The LPN then placed the pen onto the clean drape on the over bed table where the clean treatment supplies were gathered. After the treatment was completed, the drape and used supplies were bundled and discarded, however the used pen, scissors, and open bottle of normal saline were placed directly on the resident's over bed table. The pen, scissors, and normal saline bottle were then placed on the top of the treatment cart. The unsanitized pen was returned to the LPN's uniform pocket, the unsanitized bottle of normal saline was returned to the inside of the treatment cart. The scissors were sanitized and returned to the treatment cart. The LPN returned to the resident's bedside. They did not sanitize the resident's over bed table where lunch was to be served to the resident. Additionally, the LPN observed that the resident's call device was on the floor. The LPN picked the device up off the floor and placed it on the resident's chest without sanitizing it. The surveyor interviewed the LPN. They stated hands should be lathered outside of running water for at least 20 seconds. The surveyor discussed the breaks in infection control techniques with the Administrator and the Director of Nursing on 2/4/26 at 1:15 PM. NJAC 8:39-19.4(a)1; 19.4(m); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified in 1 (one) of 3 residents (Resident #18) who were reviewed for urinary catheter use. This deficient practice was evidenced by the following: On 1/28/26 at 9:50 AM, the surveyor observed Resident #18 in bed, asleep. It was observed that the resident's indwelling catheter, draining yellowish urine, was lying on the floor outside the privacy bag. The surveyor observed that there was a family member of the roommate inside the room. On the same day at 10:00 AM, the surveyor observed that the Licensed Practical Nurse (LPN) went inside the resident's room to give the resident's medication. The LPN left after he gave the medications to the resident. On the same day at 10:05 AM, the surveyor went back to Resident #18's room to observe the indwelling catheter. The surveyor observed the indwelling catheter bag with yellowish urine draining outside of the privacy bag, still lying on the floor. On 2/4/26 at 10:02 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #18, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #18 was admitted with diagnoses that included but were not limited to obstructive and reflux uropathy (the flow of urine is blocked in the bladder, causing the urine to flow backward), unspecified. A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care), which was dated 12/13/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated that the residents had severe impairment of cognition. Further review of Q/MDS revealed in Section H - Bladder and Bowel that Resident #18 has an indwelling catheter. A review of the Order Summary Report (OSR) revealed an active order for indwelling catheter care every shift as of 10/3/25. A review of the comprehensive Care Plan (CP) report initiated on 11/6/25 focused on the resident's indwelling catheter due to the diagnosis of obstructive uropathy. On 2/5/26 at 9:16 AM, the surveyor interviewed the Registered Nurse, who stated that the indwelling catheter should not be touching the floor and it should be inside the privacy bag. On 2/5/26 at 9:27 AM, the surveyor interviewed the LPN/Unit Manager, who stated that the indwelling catheter should be checked by the nurse in charge of the resident. The catheter is not on the floor; there should be a privacy bag for dignity reasons because there is a family member visiting the roommate. On 2/6/26 at 10:08 AM, the team of surveyors met with the Regional Nurse, Licensed Nursing Home Administrator, and the Director of Nursing, but did not provide further information. The facility policy title Indwelling Urinary Catheter and Suprapubic Catheter Care has the revised date of 4/19/25 under Procedure: 14. Keep the bag covered for privacy and dignity. NJAC 8:39-33.2(c)5

Based on observation, interviews, and record review, it was determined that the facility failed to ensure the resident's designated smoking area was free from accident hazards, specifically by failing to clear snow and ice from the smoking area after the snow, to prevent slips and falls for 1 (one) of 2 residents (Resident #15), who were reviewed for smoking. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, seated in a motorized wheelchair, who stated that they would go down to smoke to the 1st floor of the facility at the back patio. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. The surveyor observed that the RN gave the vaping (handheld electronic device) device to Resident #15. On 1/29/26 at 9:03 AM, the surveyor went with Resident #15 to the first floor, to the back patio, to observe the resident vaping. The surveyor observed the No Smoking sign right in front of the automatic door. The surveyor observed there were cigarette butts right in front of the doorway in the no-smoking designated area. On 1/29/26 at 9:05 AM, the surveyor interviewed Resident #15, who stated that they made the administration aware that it is not safe to go there in the smoking designated area, which is why they stayed near the doorway. Resident #15 revealed that they cannot bring their motorized wheelchair to maneuver to the smoking area since there is a layer of snow and ice that makes it slippery. On 1/29/26 at 9:10 AM, the surveyor, together with the team coordinator (TC), came to the area and observed that the smoking designated area is full of snow and ice around the walkway, on top of the table, and on two benches. It was also observed that the fire extinguisher behind the bench was covered with snow. On 1/29/26 at 9:20 AM, the Licensed Nursing Home Administrator (LNHA) went to the designated smoking area together with the TC. The LNHA stated that the ice in the surrounding site is dangerous and is a big issue, but did not provide further information. On 2/4/26 at 9:39 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #15, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #15 was admitted with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe). A review of the annual Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care), dated 9/19/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. A review of the comprehensive Care Plan (CP) report with an initiated date of 11/6/25, with the focus on Resident #15, who is a smoker. On 1/29/26 at 1:43 PM, the surveyor met with the LNHA and the Director of Nursing, but did not provide further information. The surveyor reviewed the facility titled Smoking Safety, revised on 1/4/26, which revealed under Policy interpretation and implementation 2. Smoking and /or vaping is permitted only in the designated resident smoking area, and no smoking is permitted in any other area of the facility under any circumstances, including residents' rooms. NJAC 8:39-33.1(d)

Based on observation, interview, record review, and review of facility polices, it was determined that the facility failed to document the non-compliance of the resident's fluid restriction. This deficient practice was identified for 1 (one) of 1 resident (Resident #11) reviewed for dialysis.The deficient practices were evidenced by the following: On 2/5/26 at 9:07 AM, the surveyor observed that the resident was not in the room. The staff stated that Resident #11 was on dialysis. The surveyor observed that the residents had 8 unopened cups of cranberry juice and 4 empty cups, for a total of 12 cups, on top of the overbed table. There are also 5 unopened bottles of bottled water (500 ml (milliliter) each) on top of the windowsill, 2 half-empty bottles of bottled water, and one 120 ml full bottle of water on top of the bedside table. On 2/5/26 at 11:51 AM, the surveyor reviewed the hybrid (paper and electronic) medical record for Resident #11, which revealed the following: A review of the Resident #11's admission Record (AR, an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to end-stage renal disease (ESRD, the kidney cannot function adequately) and dependence on dialysis (treatment that helps the kidney function). A review of the annual Minimum Data Set (A/MDS) (an assessment tool used to facilitate the management of care) of 11/21/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the A/MDS under section O shows that Resident #11 was receiving dialysis. A review of the Order Summary Report (OSR) with the start date of 11/10/25, fluid restriction 1000 ml/day, Nursing (7-3 Nursing 120 ml, 3-11 Nursing 120 ml, 11-7 Nursing 40 ml) = 280 ml. Dietary (Breakfast 240 ml, Lunch 240 ml, Dinner 240 ml) excludes liquid supplements, meds, and sauces/gravy every shift. A review of the January 2026 electronic Medication Administration Record (eMAR) shows that from January 1 to 31, the total amount of fluids is more than 280 ml, as documented by Nursing. A review of the comprehensive Care Plan (CP) report with an initiated date of 11/18/24, under focus that Resident #11 requires 1000 ml of fluid restriction daily related to ESRD. Interventions included, but were not limited to, monitoring for compliance with fluid restriction daily. Ensure to document all episodes of non-compliance. A review of the nursing progress notes revealed that there is no documentation that reflects that the resident is getting more than 1000 ml daily, and there is no compliance with fluid restrictions. On 2/5/26 at 9:17 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the resident likes to drink juices, milk, and coffee. The family brings food to the residents. The RN added that the resident is getting 300 ml of water during her shift and will document it to the eMAR, but did not state that she was documenting the non-compliance in the medical record. On 2/5/26 at 10:00 AM, the surveyor interviewed the Registered Dietitian (RD), who stated that if there is a fluid restriction, each department, like Nursing, will get a certain amount of fluids. The dietary department has an allotted number of fluids. The coffee, milk, tea, juices, and soup are counted for fluid restrictions. The RD added that she knew the residents, and in her CP, she stated that the nurses should document if the resident is non-compliant with fluid restriction. On 2/6/26 at 10:08 AM, the team met with the Licensed Nursing Home Administrator, Regional Nurse, and the Director of Nursing (DON). The DON stated that Resident #11 wants the fluids on the bedside. The DON added that, with the fluid restrictions of 1000 ml in January, there was an incorrect documentation error in place for those shifts. The DON did not provide further information on why the non-compliance was not documented in the electronic medical records. A review of the facility's policy titled Fluid Restriction, revised on 12/30/25 under Policy Interpretation and Implementation, 11. Licensed staff should document in the electronic medical record as appropriate fluids taken from medication administration, meal consumption, and any additional fluid intake as observed or reported. NJAC 8:39-19.4 (a) (1)

REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 of 36 residents (Resident #15), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 1/29/26 at 8:57 AM, the surveyor observed Resident #15, who is seated in a motorized wheelchair, and stated that they would go down to smoke. The surveyor interviewed the Registered Nurse (RN), who stated that the resident is alert and oriented x3, and they can go by themselves to the smoking area. On 2/4/26 at 9:39 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #15, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #15 was admitted with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe). A review of the annual Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care), dated 9/19/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the A/MDS in Section J - Current Tobacco Use 0. No. A review of the Smoking/Vaping (handheld electronic device) Contract form dated 6/18/25 revealed that Resident #15 signed the form regarding the facility's smoking policy. A review of the Smoking Safety Screen assessment dated [DATE] revealed that the resident is a smoker. A review of the comprehensive Care Plan (CP) report with an initiated date of 11/6/25, with the focus on Resident #15, who is a smoker. On 2/5/26 at 10:42 AM, the surveyor interviewed the MDS/Licensed Practical Nurse (MDS/LPN), who stated that she is aware that Resident #15 is smoking either vape or tobacco, and she added that she must have missed coding the smoking status in the MDS assessment. On 2/5/25 at 1:33 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing, and Regional Nurse regarding the concern above, but did not provide further information. NJAC 8:39-33.2 (d)

REPEAT DEFICIENCY Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 2 of 36 residents (Resident #13 and #18) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 1/29/26 at 10:03 AM, the surveyor provided the MDS Coordinator/Registered Nurse (MDSC/RN) with the list of 2 residents who had completed an MDS assessment for Residents #13 and #18. The surveyor also requested a copy of the resident's final validation report (generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On the same date at 1:03 PM, the surveyor interviewed the MDSC/RN, who provided the surveyor with the final validation of the late MDS submission. The MDSC/RN stated that it was submitted late because they needed to check if the assessment was completed by another department, which is also busy. If the other department is late for the assessment, the submission will be late too. The MDSC/RN stated that the MDS should be completed within 14 days and submitted at least 21 days. The MDS assessments that were not submitted within fourteen days after the assessment reference date (ARD, the last day of the observation period) are as follows: 1. Resident #13 admission MDS (A/MDS) assessment had an ARD of 10/19/25. It was signed as completed but not transmitted until 11/3/25. 2. Resident #18 A/MDS assessment had an ARD of 9/12/25. It was signed as completed on 10/9/25 and not transmitted until 10/13/25. On 2/5/25 at 1:33 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing, and Regional Nurse regarding the concern above, but did not provide further information. NJAC 8:39-11.1

Based on observation, interview, record review, and review of other facility's documentation, it was determined that the facility failed to ensure a.) the Professional Standards of Practice to assess a resident's pain at least each shift for significant changes in levels of chronic pain, b.) a physician order for administration with parameters was followed (Resident #131) and c.) a narcotic medication for pain was administered when documented as administered (Resident #367). The deficient practice was identified for one (1) of one (1), Resident #14, reviewed for pain management, one (1) of (4) four residents administered by one (1) of four (4) nurses observed during the medication administration, and for one (1) of (5) medication carts observed during the medication storage and labeling inspection. 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 regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1.) On 10/01/24 at 11:20 AM, the surveyor observed Resident#14 lying in bed, alert, awake and oriented able to make needs known. The resident did not appear to be in distress. The resident complained of chronic aching pain on the right hip upon movement. On 10/03/24 at 10:00 AM, the surveyor reviewed the following records: Review of Admission Records revealed the following Diagnosis which include but not limited to Encounter for Palliative Care, Alcoholic Cirrhosis of Liver, Chronic Pain Syndrome and Pain , unspecified. Review of Quarterly Pain Interview Assessment record dated 8/29/2024 revealed severe frequent pain. A review of Pain Level Summary revealed that there were only pain assessments done on the following month of August: 8/26/2024, month of May: 5/23/2024, and month of February: 2/26/2024. Review of Care plan for chronic pan, initiated on 12/23/19, and revised on 11/23/2020, revealed that Resident # 14 had chronic pain related to non-healing right hip surgical wound, impaired mobility and diabetic neuropathy. Review of Medication Order for Resident # 14 revealed the following pain management regimen which included but was not limited to Acetaminophen (a non-steroidal anti-inflammatory drug used for pain management) Tablet 325 milligram (mg) give 2 tablets by mouth every 6 hours as needed for pain. Celebrex (a non-steroidal anti-inflammatory drug used for pain management) Oral Capsule 100 mg give 1 capsule by mouth in the morning for chronic pain. Gabapentin (a medication used for nerve pain) Oral Tablet 600 mg, give 1 tablet by mouth three times a day for neuropathy and chronic pain. Morphine Sulfate ER (a non-synthetic narcotic medication used for pain; Extended Release) Oral Tablet 30 mg, give 1 tablet by mouth three times a day for chronic pain. On 10/02/24 at 10:30 AM, the surveyor interviewed the Unit Manager (UM) Licensed Practical Nurse (LPN) working full time in the facility about pain management for Resident #14. She described the Resident # 14 is on palliative care due to poor prognosis. She further explained that the floor nurses were the ones doing pain assessment and were responsible for monitoring the effectiveness of the pain regimen. When the surveyor requested documentation related to pain, the UM/LPN showed the surveyor a list of pain levels which were not consistent and did not show pain assessments done every shift. On 10/7/24 at 11:05 AM, the surveyor discussed the concern with the Director of Nursing (DON), who acknowledged that the pain assessments were not done every shift. The surveyor reviewed the Pain Assessment and Management Protocol policy, revised on 6/24/2024, which revealed to assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. 45449 2.) On 10/3/24 at 8:23 AM, the surveyor observed the Registered Nurse (RN) prepare medications for Resident #131 that included a physician order for Losartan 25 milligram (mg) tablet, one (1) tablet by mouth in the morning for hypertension. Hold for systolic blood pressure (SBP) less than 110. On 10/3/24 at 8:36 AM, the surveyor observed the Certified Nursing Assistant (CNA) and the RN use an alcohol-based hand rub (ABHR), then put on their personal protective equipment prior to entering the resident's room. The RN informed, the surveyor that they will adjust the resident to a seated position prior to the administration of the medications. The surveyor observed the RN enter the resident's room with the resident's medication in a medication cup. The resident was adjusted to a seated position, the RN was about to administer the medications, and the surveyor requested to speak with the RN outside the room. At 8:37 AM, during an interview with the surveyor, the RN stated she took Resident #131's blood pressure reading at 8:00 AM and confirmed she did not take the SBP prior to entering the resident's room for medication administration. At that time, the RN stated that the parameters should have been taken immediately prior to the medication administration of the high blood pressure medicaiton, Losartan. 3.) On 10/4/24 at 11:04 AM, the surveyor and RN #2 began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box) located in 2A. RN #2 stated her cart was called 2A split. At that time, in the presence of RN #2, the surveyor observed Resident #367's bingo card (blister packet which contains the medication) with a pharmacy label for Methadone 5 mg (narcotic medication; a controlled-dangerous substance medications, that due to their high potential for abuse, are tracked with a degree of detail and attention). The bingo card contained two (2) tablets. At that time, in the presence of RN#2 the surveyor compared the bingo cared against Resident #367's Individual Patient's Controlled Drug Record (IPCDR; declining inventory sheet used to track removal of a controlled drug from inventory) for Methadone 5 mg. The IPCDR log reflected a documented quantity of one (1). At that time, during an interview with the surveyor, RN #2 stated that she did not administer the medication but had signed the IPCDR. The surveyor and the RN reviewed Resident #367's electronic Medication Administration Record (eMAR) which revealed the RN's initials attesting the resident had consumed the medication. On 10/4/24 at 11:15 AM, the surveyor and the RN entered Resident #367's room. The resident informed, the surveyor that she had pain every day and stated that she took her methadone that morning and was feeling a little better. The RN informed the resident that she made an error and had not administered the Methadone and informed the resident that she would be administering it at that time. The surveyor and the RN exited the resident's room. On 10/4/24 at 11:20 AM, during a follow-up interview with the surveyor the RN stated that she would call the physician and inform her supervisor. The surveyor reviewed the medical record for Resident #367. According to the Admission Record, Resident #367 was admitted to the facility with diagnosis that included but was not limited to pulmonary hypertension (a chronic condition that occurs when blood pressure in the lungs is higher than normal). Review of the incomplete Admission Minimum Data Set (MDS), an assessment tool with an Assessment Record Date of 9/25/23, reflected a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident was cognitively impaired. The pain asssessment section of the MDS was incomplete. Review of the eMAR for Resident #367 included a physician order for Methadone 5mg, give 1 tablet by mouth every 12 hours for pain management. The administration was scheduled at 9:00 AM and 21:00 [9:00 PM]. On 10/8/24 at 1:45 PM, during an interview with the surveyor, the MDS-Director stated that the MDS for Resident #367 was incomplete, the section for pain assessment was incomplete and the comprehensive person-centered care plan for pain was also incomplete. On 10/4/24 at 1:26 PM, in the presence of the survey team, the Licensed Practical Nurse/ Infection Preventionist (LPN/IP), the DON, and the Regional Nurse, the surveyor discussed the concern regarding RN #1 who failed to obtain a parameter for Resident #131 prior to administration of the high blood pressure medication, in accordance with the physician's order and professional standards of practice. At that time, the surveyor also discussed the concern regarding Resident #367's routine Methadone physician's order that was documented as administered, but was not and was documented removed from the IPCDR, but was not. On 10/7/24 at 10:44 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator, and the Regional Nurse, the DON stated that education was given to the nurses for medication administration, parameters, and an investigation was conducted for the missed administration of the Methadone. The resident was assessed, and the physician was notified. A review of the provided facility policy, Medication Pass dated/revised 6/24/24, included the following: -Medication Preparation; Hold parameters: Check blood pressure and/or pulse rate immediately prior to pouring. -Signing for Medications; Sign the MAR/eMAR immediately after the administration of the medication to each resident. NJAC 8:39-27.1(a), 29.2(d)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift; (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties; and (3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum . A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the period of 9/15/24 to 9/28/24 (2 weeks prior to the standard survey of 10/10/24) and the period of 5/5/24 to 5/11/24 (the time period covering complaint investigations) revealed the following: For the 2 weeks of staffing prior to survey from 09/15/2024 to 09/28/2024, the facility was deficient in CNA staffing for residents on 13 of 14 day shifts as follows: -09/15/24 had 18 CNAs for 170 residents on the day shift, required at least 21 CNAs. -09/16/24 had 20 CNAs for 170 residents on the day shift, required at least 21 CNAs. -09/17/24 had 16 CNAs for 170 residents on the day shift, required at least 21 CNAs. -09/19/24 had 19 CNAs for 170 residents on the day shift, required at least 21 CNAs. -09/20/24 had 19 CNAs for 174 residents on the day shift, required at least 22 CNAs. -09/21/24 had 18 CNAs for 174 residents on the day shift, required at least 22 CNAs. -09/22/24 had 19 CNAs for 174 residents on the day shift, required at least 22 CNAs. -09/23/24 had 21 CNAs for 174 residents on the day shift, required at least 22 CNAs. -09/24/24 had 21 CNAs for 178 residents on the day shift, required at least 22 CNAs. -09/25/24 had 21 CNAs for 178 residents on the day shift, required at least 22 CNAs. -09/26/24 had 20 CNAs for 177 residents on the day shift, required at least 22 CNAs. -09/27/24 had 21 CNAs for 177 residents on the day shift, required at least 22 CNAs. -09/28/24 had 19 CNAs for 177 residents on the day shift, required at least 22 CNAs. For the week of Complaint staffing from 05/05/2024 to 5/11/24, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: -05/05/24 had 21 CNAs for 181 residents on the day shift, required at least 23 CNAs. -05/06/24 had 21 CNAs for 179 residents on the day shift, required at least 22 CNAs. -05/07/24 had 21 CNAs for 179 residents on the day shift, required at least 22 CNAs. -05/08/24 had 20 CNAs for 179 residents on the day shift, required at least 22 CNAs. -05/11/24 had 20 CNAs for 176 residents on the day shift, required at least 22 CNAs. On 10/8/24 at 12:15 p.m., the surveyor informed the Director of Nursing and Licensed Nursing Home Administrator (LNHA) of the staffing ratio and resident care concerns. 36419 On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed a strong unpleasant odor in the resident's room. On 10/1/24 at 11:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been assigned to Resident #59's care for the 7AM-3:00 PM shift. During the interview, the CNA stated that she had 10 residents on her assignment and that this was the first opportunity she had to provide care to Resident #59. The surveyor asked the CNA how often she provided incontinence care to the residents on her assignment. The CNA replied she would usually provide incontinence care 3 times a shift, but today it would be only twice since it was already so late. On 10/1/24 at 11:45 AM, the CNA exposed Resident #59's incontinence brief. The surveyor and CNA observed that the Resident's incontinence brief had a bladder absorbency pad inserted within the adult brief. The adult brief, pad and pad under the resident were all saturated with urine. On 10/7/24 at 10:35 AM, in the presence of the survey team, the DON stated that despite the number of residents the CNAs have on their assignments, incontinence care should be provided to the residents three times on the night shift and every 2 hours on the day shift. Refer to F677D NJAC 8:39-5.1(a); 27.1(a); 27.2(d); 27.2(h)

Based on observation, interview, and record review it was determined that the facility failed to assess residents' vital signs and dialysis access site for complications upon return from the renal dialysis (RD) center for 2 of 2 residents reviewed for dialysis care, Resident #90 and 134. Evidence of the deficient practice is as follows. 1. The surveyor interviewed Resident #90 on 10/1/24 at 1:09 PM. The resident stated they had RD appointments on Monday, Wednesday, and Friday at 5:30 AM. The resident stated they are not assessed promptly when returning from RD. A review of the electronic medical record revealed the following information. The 8/15/24 quarterly Minimum Data Set (MDS) assessment tool, Section C - Cognitive Patterns, indicated the resident was cognitively intact (Brief Interview for Mental Status score 15 of 15). Section I - Active Diagnoses triggered for renal disease. Section O - Special Treatments, Procedures, and Programs indicated the resident received RD. The physician's 10/2024 Order Summary Report included the following RD-related orders. RD Monday, Wednesday, Friday chair time 5:30 AM. Enhanced Barrier Precautions related to the presence of an arterio-venous fistula (RD access site). Monitor left arm fistula for signs and symptoms of infection and active bleeding. The surveyor interviewed the nurse Unit Manager (UM) on 10/04/24 at 8:02 AM. The UM stated the nurses should be documenting promptly in the electronic progress notes vital signs and assessment of the RD access site when the resident returns from RD. The UM was unable to locate the documentation in the electronic record when asked to do so by the surveyor. The Director of Nursing (DON) spoke with the surveyor on 10/07/24 at 10:41 AM. The DON stated the post dialysis assessments were not done consistently on the resident. She stated the vital signs and the access site monitoring must be done post dialysis and documented in the progress notes. 45449 2. On 10/2/24 at 9:25 AM, the surveyor observed Resident #134 asleep, covered with a blanket, and did not rouse to the voice of the surveyor. On 10/2/24 at 9:33 AM, the surveyor observed Registered Nurse/Unit Manager verbally requested permission from Resident #134 to assess their arteriovenous (AV) fistula (a surgically created connection between the artery and the vein to provide access for dialysis). At that time the RN/UM and the surveyor observed the AV fistula shunt was intact. The surveyor reviewed the medical record for Resident #134. According to the Admission Record, Resident #134 was admitted with diagnoses that included, end stage renal disease and congestive heart failure. Review of the Admission Minimum Data Set (MDS), an assessment tool used to manage care dated 8/27/24, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact and while a resident received dialysis services. Review of Resident #134's medical record revealed that the resident was scheduled for hemodialysis (HD) on Monday, Wednesday, and Friday at 1:00 PM. During an interview with the surveyor on 10/2/24 at 9:36 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the process for communication with dialysis was that the nurses would fill out a pre-dialysis communication log prior to the HD appointment which would be kept in the dialysis communication book. The log contained information such medications sent with the resident, meals sent, labs drawn, weight and vitals. The HD communication book would go with the resident to the HD center. After dialysis the HD center would fill out the post dialysis communication log that contained information such as completion of treatment as ordered, pre dialysis weight and post dialysis weight, treatment complications, when a physician was notified, the AV shunt report and the Registered Nurse completing the report. The HD communication book traveled back with the resident to the facility. The LPN/UM stated that when the resident returned to the facility, the receiving nurse would assess the resident's AV fistula's thrill (vibration or buzzing when fingers are place on the fistula) and bruit (a swooshing sound heard near fistula when using a stethoscope), obtain vital signs and write the result of the assessment on the bottom of the HD communication log. A review of the September 2023 HD communication log reflected the following: - 9-2-24 the post dialysis communication to be filled out by the HD center was blank, and did not include pre-weight post dialysis weight, treatment complication. The AV fistula assessment completed by the facility staff was documented as positive however no vitals were documented after returning to the facility. - 9-20-24 the post dialysis communication to be filled out by the HD center was blank, and did not include pre-weight post dialysis weight, treatment complication. The AV fistula assessment completed by the facility staff was documented as positive however no vitals were documented after returning to the facility. - 9-25-24 the pre-dialysis communication log did not contain information such medications sent with the resident, meals sent, labs drawn, weight and vitals. the post dialysis communication to be filled out by the HD center was blank, and did not include pre-weight post dialysis weight, treatment complication. The AV fistula assessment completed by the facility staff was documented as positive however no vitals were documented after returning to the facility. - 9-27-24 The AV fistula assessment completed by the facility staff was documented as positive however no vitals were documented after returning to the facility. - 9-30-23 The AV fistula assessment completed by the facility staff was documented as positive however no vitals were documented after returning to the facility. On 10/4/24 at 1:26 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Practical Nurse/Infection Preventionist (LPN/IP) and the Regional Nurse, the surveyor discussed the concerns regarding the failure to consistently and completely assess Resident #134's vitals upon return from the HD center as reflected on the HD communication log. On 10/7/24 at 10:44 AM, in the presence of the survey team, the DON acknowledged that the communication log was not always done and would be addressed, A review of the facility provided policy End-Stage Renal Disease, Care of a Resident dated/revised 1/28/24 reflected that Agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care will be managed, including how information will be exchanged between the facilities. The general medical nurse should document in the resident's medical record every shift as follows: location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given and observation post dialysis. NJAC 8:39 - 27.1 (a)

Based on observation, interview, and record review it was determined that the facility failed to accurately assess: a) a resident's oral health; b) a resident's use of a hand splint; c) a resident's use of an indwelling urinary catheter; and d) a resident's skin condition in the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 4 of 38 residents reviewed for MDS accuracy (Resident #88, 77, 129, 25) and evidenced by the following. 1. The surveyor interviewed Resident #88 on 10/2/24 at 9:53 AM. The resident was observed with multiple broken and missing teeth. The surveyor interviewed the Registered Dietician (RD) on 10/4/24 at 8:46 AM regarding the resident's oral health. The RD referred the surveyor to the Speech Language Pathologist's (SLP) admission evaluation. The surveyor reviewed the 9/12/24 Speech Therapy SLP Evaluation and Plan of Treatment. In the document, the SLP noted pt with poor natural dentition, many missing/broken teeth. The 9/17/24 Admission MDS assessment, Section L - Oral/Dental Status failed to identify broken or missing teeth. The surveyor interviewed the RN Assessment Coordinator on 10/4/24 at 12:00 PM. She stated the broken or missing teeth should have been triggered in the Admission MDS. 2. The surveyor observed Resident #77 on 10/1/24 at 11:19 AM. The resident had a blue hand splint on the over bed table. A review of the electronic medical record revealed a 1/10/24 physician's order for a right-hand roll with a wrist support (an orthopedic device used for muscle contractures). The 8/9/24 Annual MDS assessment, Section O - Special Treatments, Procedure, and Programs failed to address the daily placement of a splint or brace. The surveyor interviewed the RN Assessment Coordinator on 10/04/24 at 12:00 PM. She stated the splint should have been identified in Section O. 3. Resident #129 was admitted to the facility with an indwelling urinary catheter for chronic urinary bladder outlet obstruction as noted by the nurse in the 7/2/24 electronic Admission Summary Note. The 7/8/24 Admission MDS assessment Section H failed to identify that the resident used an indwelling urinary catheter. The surveyor interviewed the RN Assessment Coordinator on 10/4/24 at 12:00 PM. She stated the catheter should have been coded in the Admission MDS. The facility policy titled Certifying Accuracy of the Resident Assessment, revised 12/2009, contained the following Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. 45449 4. On 10/1/24 at 11:45 AM, during the initial tour, Resident #25 was not in their room. A staff member identified Resident #25 in the dayroom asleep, not roused by the surveyor's voice, seated on a geri chair (geriatric chair or medical recliner; a large, padded chair with wheels, designed to assist seniors with limited mobility) with legs elevated and heels off-loaded (practice of reducing or removing pressure on a part of the body to help with healing or prevent wounds). The surveyor reviewed the medical record for Resident #25 According to the electronic Medical Record, Resident #25 had diagnoses which included, but were not limited to, unstageable pressure ulcer of unspecified site. Review of the quarterly Minimum Data Set, an assessment tool dated 6/28/24, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated a severely impaired cognition. Further review of the qMDS revealed Resident #25 had an unstageable deep tissue injury (DTI) that was not present upon admission. Review of the Admission MDS dated [DATE], under section M. Skin Conditions revealed the resident had 1 unstageable DTI that was present upon admission. Review of the Wound Physician's Note dated 8/16/22, reflected Resident #25 had an unstageable DTI of the right heal. On 10/4/24 at 12:37 PM, the surveyor interviewed the Registered Nurse /MDS Director (RN/MDS-D) who stated she signed the submissions for the MDS and that the signature was an attestation that she had checked all the areas for accuracy to the best of her knowledge. At that time, the surveyor and the RN/MDS-D reviewed Resident #25's medical record. The RN/MDS-D confirmed that the MDS submitted was inaccurate and that the accuracy of the MDS was important because the assessment can affect the care given to the resident. On 10/4/24 at 1:26 PM, during a meeting with the survey team, the Director of Nursing (DON), Licensed Practical Nurse/Infection Preventionist (LPN/IP) and the Regional Nurse, the surveyor discussed the concern regarding the inaccuracy of the MDS for Resident #25. On 10/7/24 at 10:44 AM, during a meeting with the survey team, the License Nursing Home Administrator, and the DON, the Regional Nurse, stated the MDS coding should be accurate. A review of the facility provided policy, Certifying Accuracy of the Resident Assessment, dated /revised on 1/5/24 included: All personnel who complete any portion of the MDS assessment, tracking form or correction request form must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment. NJAC 8:39-11.2(e)1

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 10 residents (Resident #59, #82 and #29), observed for incontinence care on 1 of 2 units (B1 Unit). This deficient practice was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed a strong unpleasant odor in the resident's room. On 10/1/24 at 11:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had been assigned to Resident #59's care for the 7AM-3:00 PM shift. During the interview, the CNA stated that she had 10 residents on her assignment and that this was the first opportunity she had to provide care to Resident #59. The surveyor asked the CNA how often she provided incontinence care to the residents on her assignment. The CNA replied she would usually provide incontinence care 3 x daily, but today it would be only twice since it was already so late. On 10/1/24 at 11:45 AM, the CNA exposed Resident #59's incontinence brief. The surveyor and CNA observed that the Resident's incontinence brief had a bladder absorbency pad inserted within the adult brief. The adult brief, pad and pad under the resident were all saturated with urine. A review of Resident #59's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body, dysphagia and gastrostomy status (surgical procedure creating an opening into the stomach through the abdominal wall to provide nutrition). A review of Resident #59's Annual Minimum Data Set (MDS) an assessment tool dated 7/25/24 revealed Resident #59 had a long- and short-term memory problem and had a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident 59's Individualized Care Plan (ICP) initiated on 2/5/20, with a revision date of 9/12/24 included the resident was totally dependent on staff with activities of daily living (ADLs) with Interventions which included but were not limited to: providing incontinence care every 2 hours and as needed. On 10/4/24 at 7:20 AM, the surveyor completed an incontinence tour on the B1 Unit and observed the following: On 10/4/24 at 7:26 AM, the surveyor accompanied by the CNA observed Resident #82 in bed. The surveyor and CNA noted a strong urine odor in the resident's room. The surveyor observed that Resident #82's incontinence brief was saturated with urine and feces. The pad under the resident was also saturated with urine. The CNA acknowledged the brief and under pad were saturated with urine and feces and stated that the resident could not have received incontinence care recently due to the extent of the saturation. A review of Resident #82's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to bipolar disorder, dementia, and dysphagia. A review of Resident #82's Quarterly MDS dated [DATE] revealed Resident #82 had a had a long and short-term memory problem and had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident 82's ICP initiated on 12/5/22, with a revision date of 8/12/24, revealed the resident had an ADL self-care performance deficit with interventions which included but were not limited to the resident required extensive assistance of 1 staff for personal hygiene; and to keep skin clean and dry. On 10/4/24 at 7:38 AM, the surveyor accompanied by the CNA observed Resident #29 in bed with a strong unpleasant odor in the resident's room. The CNA exposed Resident #29's incontinence brief which was saturated with urine and feces. At that time when the CNA exposed the incontinence brief the surveyor observed that the Resident's gown and bed pad were also saturated. The CNA stated that the resident could not have received incontinence care at 5:00 AM, due to the saturated brief, gown and pad. On 10/4/24 at 7:40 AM, the unit manager accompanied the surveyor to Resident #29's room. The unit manager acknowledged that the resident was saturated with urine and feces and stated that it was unacceptable. A review of Resident #29's Admission Record revealed Resident #29 was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, acute kidney failure, psychosis and major depressive disorder. A review of Resident #29's Annual MDS dated [DATE] revealed Resident #29 had a Brief Interview for Mental Status (BIMS) of 3 of 15 indicating a severe cognitive impairment. MDS further assessed Resident #29 was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of Resident #29's ICP initiated on 12/24/19 with a revision date of 9/19/24 revealed that the resident had an ADL self-performance deficit and required extensive assistance of staff for personal hygiene. On 10/4/24 at 12:35 PM, the survey team met with the administration to discuss the above observations and concerns. On 10/7/24 at 6:50 AM, the surveyor attempted an interview with the assigned 11 PM-7 AM CNA for Resident's #82 and #29. The Registered Nurse (RN) stated that the 11-7 CNA had called out. The surveyor attempted a phone interview and left a message, with no return call. The surveyor asked the Director of Nursing (DON) to contact the CNA. On 10/7/24 at 7:00 AM, the surveyor interviewed the RN who stated that the CNAs should perform incontinence rounds and provide incontinence care 3 times per shift at 11:30 PM, 2:30 AM and again between 4:30-5:00 AM. The RN/UM stated that on 10/4/24 one of the CNAs left their shift early around 6:00 AM and there was only 1 CNA on the floor from 6:00 AM-7:00 AM. On 10/7/24 at 10:35 AM, in the presence of the survey team, the DON stated that despite the number of residents the CNAs have on their assignments, incontinence care should be provided to the residents 3 times on the night shift and every 2 hours on the day shift. On 10/7/24 at 11:30 AM, the DON stated that the 11-7 CNA did not return her call and therefore was not available for an interview. A review of the facility's Urinary and Fecal Incontinence Care policy dated as revised 6/24/24 reflected .residents must be cleaned after each episode of incontinence. NJAC 8:39-27.1 (a), 27.2 (h)

Complaint NJ 177694, NJ 176286 Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure an abnormal urine lab result was communicated to the physician, received treatment and care, in a timely manner, and in accordance with professional standards of practice that meet the resident's physical, mental and psychosocial needs. This deficient practice was identified for one (1) of two (2) residents reviewed for abuse and neglect, (Resident #319) and was evidenced by the following: The surveyor reviewed the closed record for Resident #319. According to the Admission Record, Resident #319 was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease (gradual loss of kidney function), heart failure (a condition when the heart does not pump enough blood to meet the body's needs) and hyperparathyroidism (excessive secretion of parathyroid hormone resulting in abnormally high levels of calcium). Review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 8/11/23, reflected the resident's Brief Interview for Mental Status (BIMS) score of three (3) out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident did not exhibit behaviors associated with rejection of care. Resident #319 had occasional urinary and fecal incontinence. Review of Resident #319's person-centered care plan (CP) included a focus that the resident had a potential for impairment to skin related to impaired mobility, incontinence, and poor safety awareness. The interventions included to provide prompt toileting needs for incontinence care, that was initiated on 11/9/22. Further review of the CP for activities of daily living reflected the resident required a Hoyer lift (mechanical lift) with two (2) to three (3) staff member assistance. The CP did not reflect an intervention to monitor for signs and symptoms of urinary tract infection (UTI). Review of the facility provided, Antibiotic Order Listing Report for October 2023, reflected Resident #319 had a physician order on 10/26/23, for a facility acquired cystitis (a type of UTI that causes inflammation of the bladder). Review of the Nurse's progress notes (NPN), dated 11/29/23 at 12:22 PM, included that a urinalysis (UA; a test to detect urinary tract infection, kidney disease or diabetes), with culture and sensitivity (C&S; a test to identify the cause of an infection) was collected from Resident #319. Review of the NPN, dated 11/30/23 at 1:03 AM, reflected Resident #319 received intravenous (IV) hydration (formulated liquid injected into the vein) and that the UA C&S was pending. Review of the NPN note dated 11/30/23 at 2:36 PM included that the UA/C&S was still pending. Review of the abnormal urine lab report, with a reported date of 11/30/23 at 9:07 PM, included a preliminary report of gram-negative rods, and colony count of over 100,000. Review of the final abnormal urine lab report for Culture and Sensitivity, with a final report date on 12/2/23, included the following: Colony count 100,000+ Gram negative rods Organism identification: Pseudomonas Aeruginosa Review of the Infectious Disease Note, dated 12/6/23 at 4:22 PM, included that the resident was seen for UTI evaluation of reported positive urine culture. The assessment plan included an order for renal ultrasound and an antibiotic, IV Cefepime that was renally dosed. On 10/8/24 at 8:45 AM, during an interview with the surveyor, the Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated that if a resident had frequency in urination, with or without a fever, and an altered mental status, a UA/C&S was ordered by the physician. When the UA result showed colony counts greater than (>) 100,000, and either gram positive (+) or gram negative (-). The physician usually orders an antibiotic when the culture and sensitivity report is available. At that time, the LPN/IP also stated that any abnormal labs were reported to the physician, by any of the nurses or the supervisors. The standard of practice was to document the communication into the electronic medical record (eMR). On 10/8/24 at 9:24 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) could not provide evidence that the physicians were made aware of the final abnormal urine lab report for culture and sensitivity result that returned on 12/2/24. The communication was not documented in the eMR. The LPN/UM stated she would look into the matter further, discuss with the supervisors and care team regarding the surveyor's concern. On 10/8/24 at 11:49 PM, during an interview with the surveyor, the NP stated that he did not treat infections until the culture and sensitivity came back. In the case of Resident #319, who had renal failure, the NP stated he had to involve the infectious disease ID/physician or the ID/NP to renally dose the resident. At that time, the NP stated that the expectation was the ID prescriber would see the resident within 2 to 3 days of the requested consult. The NP was asked if it was an acceptable standard of practice for Resident #319 not to be evaluated, and treated until 12/6/23, four (4) days from when the culture and sensitivity was available on 12/2/24. The NP stated that it was not an acceptable standard of practice however he had no control of when the ID prescriber saw the resident. On 10/8/24 at 12:52 PM, during a follow-up interview with the surveyor, the LPN/UM stated that she was on vacation prior to 12/6/23 and was the one who called the ID/NP to see Resident #319 that day. At that time, the LPN/UM stated that the nurses or the supervisors should have followed-up preliminary result and communicated with the NP when the finalized abnormal urine lab culture and sensitivity results was available and documented into the eMR. Review of the provided policy, Facility assessment dated [DATE], reflected: It is the policy of [name redacted] to conduct, document and annually review a facility-wide assessment, which included both resident population and the resources the facility needs to care for the residents. Review of the provided policy, Test Results dated 2/5/24, included that Attending physicians will be notified promptly of the the test results provided to the facility. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review it was determined that the facility failed to consistently follow a physician's order for placement of an orthopedic device for 1 of 3 residents reviewed for positioning and mobility, Resident #77. The deficient practice is evidenced by the following. The surveyor observed the door to Resident #77's room was closed on 10/1/24 at 11:19 AM. The surveyor knocked and entered the room to see the resident had completed receiving morning care from the Certified Nursing Assistant (CNA). The CNA stated she was done with care and left the room. The surveyor observed a blue hand splint placed on the over bed table. The surveyor returned to the resident's room later the same day at 1:03 PM. The splint was observed on the over bed table. The resident was seated in a geri-chair (a reclining lounge-type chair) at the bedside. A review of the electronic medical record revealed the following information. An Admission Record noting the resident was admitted with a diagnosis of a right-hand contracture. A 4/26/24 Physician's Order for the application of a right-hand roll with a wrist support (an orthopedic device used for muscle contracture) to be placed on the resident during AM care and removed during PM care daily. A 10/1/24 Treatment Administration Record (TAR) contained a nurse signature indicating the splint was placed at AM care and removed at PM care on 10/1/24. The surveyor interviewed the nursing Unit Manager on 10/4/24 at 8:36 AM. She stated if the splint was not put on the resident during AM care, the nurse should not have documented that it was in place. The Regional Registered Nurse stated on 10/7/24 at 11:04 that if the nurse documented the placement of the splint, it should have been on. The facility policy titled Orthotic Devices, revised 4/2007, included the Standard as follows: Residents receive appropriate services and interventions in response to physical and functional needs. 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 administer oxygen therapy according to the physician's order for 2 of 4 residents, (Resident #29 and #136). This deficient practice was evidenced by the following: 1. On 10/1/24 at 12:46 PM, the surveyor observed Resident #29 in bed. The resident did not respond to the surveyor. The surveyor observed Resident #29 wearing a nasal cannula (NC) with a portable oxygen tank on and the gauge was set at 2 liters per minute (LPM). On 10/4/24 at 7:38 AM, the surveyor observed Resident #29 in bed with the head of the bed positioned at approximately 45 degrees with a tube feeding running via a machine at 65 mililiters (mls) per hour. The resident did not respond to the surveyor. The surveyor observed Resident #29 was wearing a NC with a portable oxygen tank on and the gauge was set at 1 LPM. A review of Resident #29's Admission Record revealed Resident #29 was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, acute kidney failure, psychosis and major depressive disorder. A review of Resident #29's Annual Minimum Data Set (MDS), an assessment tool, dated 6/7/24 revealed Resident #29 had a Brief Interview for Mental Status (BIMS) of 3 of 15 indicating a severe cognitive impairment. A review of the resident's comprehensive person-centered care plan initiated on 10/3/24 reflected that Resident #29 had altered respiratory status/difficulty breathing related to hypoxia (low levels of oxygen in body tissues.) The interventions included Oxygen via nasal cannula at 2 LPM continuously. A review of the September 2024 Order Summary Report (OSR) revealed an active physician order (PO) with an order date of 9/30/24 for Oxygen 2 LPM via NC for hypoxemia. On 10/4/24 7:40 AM, the surveyor asked the UM/LPN to accompany her to Resident #29's room. The surveyor and the UM/LPM entered Resident #29's room, and both observed the resident in the bed at approximately 45 degrees with tube feeding running via a machine. The resident was wearing a NC and the oxygen tank was on with the gauge set at 1LPM. The UM/LPN confirmed the oxygen tank was on and the gauge was set at 1LPM. On that same day at the same time, the surveyor and the UM/LPN reviewed the electronic medical record (EMR) for the resident's order for oxygen. The UM/LPN stated that the resident's PO was for 2LPM, not 1LPM and she did not know who changed the oxygen to 1LPM. The UM/LPN acknowledged the order should have been followed. On 10/4/24 at 12:35 PM, the survey team met with the administration to discuss the above observations and concerns. 45449 2. On 10/1/24 at 10:53 AM, the surveyor observed Resident #136 in bed asleep, wearing a nasal cannula with the oxygen (O2) concentrator (a medical device used for delivering oxygen) set at 1.5 liters per minute (LPM) and the head of the bed was elevated. On 10/2/24 at 9:12 AM, the surveyor observed Resident #136 asleep, who did not rouse from the surveyor voice. The resident was wearing a nasal cannula and the O2 concentrator was on and set to 1.5 LPM. The surveyor reviewed the medical record for Resident #136. According to the Admission Record, an admission summary, the resident was admitted to the facility with diagnoses that included but was not limited to palliative care. The significant change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 8/22/24, reflected a Brief Interview for Mental Status (BIMS) score that was blank, and that the resident was rarely/never understood. Further review of the SCMDS reflected the resident required respiratory treatment. A review of the residents comprehensive person-centered care plan reflected Resident #136 had altered respiratory status/difficulty breathing related to hypoxia (a condition when the respiratory system cannot adequately provide oxygen to the body). The interventions included Oxygen via nasal cannula at 2 LPM continuously, initiated on 4/17/24. The goal reflected that the resident would maintain normal breathing [NAME] as evidenced by normal respirations, normal ski color and regular respiratory rate/pattern through the review date. A review of the Treatment Administration Record (TAR) reflected an order for October 2024 included a physician's order for O2 at 2 LPM via nasal every shift. The O2 order start date was on 8/15/24. Further review of the TAR revealed the administration of oxygen was signed on all three shifts on 10/1/24 and on the day shift of 10/2/24. On 10/2/24 at 12:40 PM, during an interview with two surveyors, the Licensed Practical Nurse (LPN) informed the surveyors that he was assigned to Resident #136. The LPN stated that Resident #136 was on hospice and had a hospice aide, but the aid did not provide care involving the resident's oxygen. The LPN also stated that he checked the resident's oxygen that morning and ensured the head of the bed was elevated. On 10/2/24 at 12:42 PM, the surveyor and the LPN entered the Resident #136's room who was asleep and observed the O2 concentrator was on and set at 1.5 LPM. The LPN observing the O2 concentrator was set at 1.5 LPM, the surveyors and the LPN exited the resident's room. On 10/2/24 at 12:44 PM, the surveyor and the LPN reviewed the electronic medical record for Resident #136 which reflected the physician's order for O2 saturation was 2 LPM. At that time, the LPN acknowledged the order should have been followed. On 10/2/24 at 12:47 PM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) entered Resident #136's room. Resident #136 was awake, conversant and did not want to eat. The LPN/UM adjusted the setting on the O2 concentrator to 2 LPM while speaking with the resident. The LPN/ UM explained to the resident that she needed to use a pulse oximeter to measure the amount of oxygen in their blood. The resident was agreeable, and pulse oximeter reading was 99, which indicated the O2 saturation was normal. On 10/2/24 at 12:55 PM, the LPN/UM stated the physician's order should have been followed. The LPN/UM informed the surveyor that she would check the functionality of the machine and provide education to the nurses. All nurses on all shifts were responsible to ensure the O2 saturation for Resident #136 was correct. A review of the facility provided policy for Oxygen Administration, dated/revised on 5/13/24, included the following: The purpose of this procedure is to provide guidelines for safe oxygen administration. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to start, complete and transmit the Minimum Data Set (MDS) for a Death in facility and a Discharge Return not Anticipated in accordance with federal guidelines. This deficient practice was identified for two (2) of 38 residents reviewed for Resident Assessment (Resident #144, and 54) and was evidenced by the following: 1. The surveyor reviewed the closed medical record for Resident #144. A review of the resident's Admission Record (an admission summary) reflected that Resident #144 was admitted to the facility with diagnoses that included but was not limited to heart failure. On [DATE] at 10:14 AM, the surveyor reviewed the electronic Medical Record, Minimum Data Set (MDS) tab that reflected a Death in the facility tracking discharge was not completed and was 102 days overdue. On [DATE] at 10:28 AM, during an interview with the surveyor, the MDS-Director stated that the facility had 14 days to submit the death in the facility tracking. At that time the MDS- Director confirmed Resident #144 expired on [DATE] and the Death in the facility was not started, and was over 102 days overdue. A review of the facility provided policy Resident Assessment Instrument (RAI), dated [DATE], reflected that the Assessment Coordinator was responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: within 14 days of the resident's admission; when there is a significant change; at least quarterly, and once every 12 months. 19106 2. Resident #54 was discharged from the facility to home on [DATE] as noted in a [DATE] electronic Nurses Note and the electronic Census. The resident was not expected to return to the facility. A review of the completed MDS assessments revealed the following submissions: A [DATE] Entry and a [DATE] Admission/Medicare 5 Day assessment. The surveyor interviewed the RN Assessment Coordinator on [DATE] at 11:50 AM. She stated the MDS Discharge/Return Not Anticipated assessment should be done within 14 days of the discharge date . She stated the assessment was not done and was late. On [DATE] at 10:44 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator, and the Regional Nurse, and the DON, the surveyor discussed the concern Regarding the Death in the facility tracking discharge for Resident #144 that was not started and was 102 days overdue. A review of facility policies regarding resident MDS assessments failed to address discharge assessment, however the RN Assessment Coordinator stated the facility follows the Resident Assessment Instrument (RAI) 3.0. NJAC 8:39 - 11.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 38 residents reviewed for accommodation of needs (Resident #59 and #127), and was evidenced by the following: On 10/1/24 at 11:34 AM, the surveyor observed Resident #59 in bed on a specialty mattress, with his/her eyes open. Resident #59 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was intertwined with their roommates call bell cord and entangled in the bed electrical cords, not within his/her reach. The surveyor reviewed the medical record for Resident #59. A review of Resident #59's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body, dysphagia and gastrostomy status (surgical procedure creating an opening into the stomach through the abdominal wall to provide nutrition). A review of Resident #59's Annual Minimum Data Set (MDS) an assessment tool dated 7/25/24 revealed Resident #59 had a long- and short-term memory problem and had a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident 59's individualized comprehensive care plan (ICCP) initiated on 2/5/20, with a revision date of 9/12/24 included the resident had a communication problem r/t history of intercranial hemorrhage with aphasia, she is non-verbal. The interventions included but were not limited to; ensure/provide a safe environment: keep call light in reach. On 10/1/24 at 11:34 AM, the surveyor observed Resident #127 in bed. The resident did not respond to the surveyor's greeting. The surveyor observed the resident's call bell was intertwined with their roommates call bell and twisted together in the bed electrical cords not within his/her reach. A review of Resident #127's Admission Record reflected that the resident was admitted to the facility with diagnoses which included dementia, insomnia and dysphagia. A review of the most recent quarter MDS dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated a severe cognitive impairment. A further review indicated they required supervision and contact guard from staff for transfers and toileting. A review of the ICCP initiated 6/26/23 revised 7/12/24 reflected, resident has potential for activities of daily living (ADL) self-care performance deficit r/t cognitive deficits secondary to dementia with interventions that included but not limited to: encourage resident to use bell to call for assistance. On 10/4/24 at 8:00 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who had Resident #59 and Resident #127 on their assignment on 10/1/24. The CNA acknowledged that the call bells should be kept within the resident's reach at all times and could not speak to why she did not ensure that the resident's call bells were within their reach. On 10/7/24 at 10:35 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Regional Director of Nursing (RDON) and DON acknowledged that all residents should have their call bells within reach. A review of the facility's Call Light Use policy revised 1/5/24 included .the purpose is to respond promptly to resident's call for assistance .when providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light .be sure call lights are placed on the bed as all times never on the floor or bed side. A review of the facility's Certified Nursing Assistant job description included .answers all call bells and places them in reach of the resident . NJAC 8:39- 31.8 (c)(9)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to prevent a severe weight loss of 8.6 pounds (lbs) which was 9.6% in 50 days from 3/2/21 through 4/21/21, a 7.7 lbs loss which was 9.5% in 14 days from 4/21/21 through 5/5/21, and an additional 2.1 lb loss from 5/5/21 through 6/2/21. The facility failed to a.) identify significant weight losses and obtain reweights in a timely manner, b.) implement and monitor weekly weights, c.) ensure prescribed fortified foods were provided, d.) evaluate and adjust nutritional interventions, e.) comprehensively assess the resident after a significant weight change and f.) revise the nutritional care plan. This was identified for 1 of 9 residents (Resident #30) reviewed for nutrition. The evidence was as follows: On 6/8/21 at 1:10 PM, two surveyors observed Resident #30 in his/her room in a reclined chair with eyes closed. The lunch tray was on an overbed table. Review of the lunch tray meal ticket listed pureed Philly cheese steak on a bun, pureed peppers & onions, mashed potatoes (not identified on the meal ticket as fortified), pureed cauliflower, pudding (not identified on the meal ticket or labeled as fortified), four-ounce whole milk, coffee, salt, pepper and sugar. On 6/9/21 at 9:15 AM, the surveyor observed the residents breakfast tray on an overbed table. Review of the breakfast tray meal ticket listed grits (not identified on the meal ticket or labeled as fortified cereal), one slice of puree French toast, puree breakfast sausage, four-ounce orange juice, eight-ounce whole milk, coffee, margarine, salt, pepper, sugar packets and maple syrup. On 6/10/21 at 8:40 AM, two surveyors observed the residents breakfast tray on an overbed table. Review of the breakfast tray meal ticket listed farina cereal (not identified on the meal ticket or labeled as fortified), pureed scrambled eggs, four-ounce orange juice, eight-ounce whole milk, coffee, margarine, salt, pepper, sugar packet and jelly. The resident's assigned Certified Nurse Aide (CNA) #1 was present. She stated that the resident needed to be fed and had a varied consumption of the pureed meals but consumed 100% of fluids, the supplement Two Cal HN and typically preferred fluids and sweets. On 6/11/21 at 9:25 AM, the surveyor observed the residents breakfast tray on an overbed table. Review of the breakfast tray meal ticket listed Maypo cereal (not identified on the meal ticket or labeled as fortified), pureed Western omelet, puree wheat toast, four-ounce orange juice, eight-ounce whole milk, coffee, margarine, salt, black pepper, sugar, and jelly. CNA #1 was present and stated the resident consumed 25% of meal, mainly hot cereal, and drank 100% of the liquids. The surveyor reviewed the medical record for Resident # 30. The resident's Face Sheet (an admission record) reflected the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/27/21 reflected a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident cognition was severely impaired. A review of the Order Summary Report reflected a physician's order (PO) dated 8/21/20 for a puree diet with Fortified foods (cereal/mashed/pudding); a PO dated 8/20/20 for Two CAL HN (a nutrient dense supplement) eight ounces two times a day with med pass at 9 AM and 6 PM. Further review of the order summary reflected a PO dated 10/15/20 to Monitor behavior every shift (crying/screaming/physically aggressive with staff during am care) every shift. A review of the March 2021 electronic Medication Administration Record (eMAR) did not reflect the above corresponding PO for fortified foods. There was no documented evidence of monitoring for prescribed fortified foods. Further review of the eMAR revealed that the resident consumed 100% of the Two Cal HN eight ounces 53 times and four ounces of the Two Cal HN eight times and only refused once. Review of the March 2021 behavior monitoring in the eMAR record reflected the resident did not exhibit any behaviors. Review of the April 2021 eMAR did not reflect the above corresponding PO for fortified foods. There was no documented evidence of monitoring for prescribed fortified foods. Further review of the eMAR revealed that the resident consumed 100% of the Two Cal HN eight ounces 48 times and four ounces of the Two Cal HN 12 times. Review of the April 2021 behavior monitoring indicated the resident exhibited behaviors on 4/1/21, during the 11-7 shift. The behavior exhibited was not documented. There was no other documented evidence of the resident exhibiting behaviors until the 23 rd of the month for the 7-3 and the 3-11 shift. Review of the May 2021 eMAR did not reflect the above corresponding PO for fortified foods. There was no documented evidence of monitoring for prescribed fortified foods. Further review of the eMAR revealed that the resident consumed 100% of the Two Cal HN eight ounces 43 times and four ounces of the Two Cal HN 19 times. Review of the May 2021 behavior monitoring indicated the resident exhibited behaviors on 5/7/21, during the 7-3 shift, 5/14/21, during the 3-11 shift, and on 5/16/21, during the 7-3 shift. There was no other documented evidence of behaviors exhibited by the resident for the month of May 2021. Review of the June 2021 eMAR did not reflect the above corresponding PO for fortified foods. There was no documented evidence of monitoring for prescribed fortified foods. Further review of the eMAR revealed that the resident consumed 100% of the Two Cal HN eight ounces 21 times and four ounces of the Two Cal HN four times. Review of the June 2021 behavior monitoring indicated the resident exhibited behaviors on 6/3/21 during the 3-11 shift, and 6/9/21 through 6/11/21 during the 7-3 shift. The surveyor reviewed the weight record in the electronic medical record (EMR). Weights documented were as follows: 3/2/21 89.2 lbs 4/21/21 80.6 lbs 5/5/21 72.9 lbs 5/24/21 72.6 lbs 6/2/21 70.8 lbs Review of the Registered Dietitian's (RD) Quarterly Nutrition Note dated 3/25/21, reflected the resident was on a puree diet with fortified foods (cereal, mashed and pudding) at meals and eight-ounces of Two cal HN twice a day each of which provided 475 calories and 20 grams (gm) of protein. The RD's note reflected that the resident's meal intake was between 26-50% and supplement intake was 76-100%. She further indicated that the resident was receiving an appetite stimulant [MEDICATION(S)], had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD questioned the effectiveness of the [MEDICATION(S)] and indicated that the resident may benefit from the discontinuation of [MEDICATION(S)]. The RD made no nutritional recommendations. Review of the RD's Weight Change Note dated 4/21/21, indicated she had witnessed the resident's weight obtained on 4/21/21. The resident weighed 80.6 lbs. The RD documented It suggests significant weight loss of 8.6 lbs (9.6%) x 30 days and 10.4 lbs (11%) x 6 months. Weight loss is not desired and seems to be due to suboptimal PO [by mouth] intake. Resident was taken off [MEDICATION(S)] (3/25/21) in lieu of no weight gain, however, [MEDICATION(S)] may have been keeping resident weight stable. [Resident] is fed regular puree thin liquid diet at meals with noted decrease in po intake- now consuming 25-70 %. Fortified foods (cereal/mashed and pudding) provided as well as 8 oz [ounce] Two Cal HN bid [twice a day]. No recent labs and skin currently intact. Recommend to restart [MEDICATION(S)] 10 ml [milliliters] bid to stimulate appetite. The RD made no nutritional recommendations. Further review of the EMR and paper chart, revealed no documented evidence that the facility addressed the 5/5/21 severe weight loss of 7.7 lbs (5.6%) since 4/21/21 (15 days). The resident weighed 80.6 lbs on 4/21/21 and weighed 72.9 lbs on 5/5/21. The RD did not address the residents severe weight loss until 5/24/21 (19 days later). Review of the EMR and paper chart did not reveal that the physician was notified on 5/5/21 of the resident's severe weight loss of 5.6% within 15 days. Review of the RD's Weight Change Note dated 5/24/21, indicated (4/21) 80.6 lbs (5/5) 72.9 lbs. Re-weight requested to verify this May monthly weight. I witnessed weight taken (5/24) 72.6 lbs indicates significant weight loss of 17 lbs (19%) x 6 months and 8 lbs (10%) x 30 days. Weight loss not desired and is due to suboptimal po intake. Resident is fed regular puree thin liquid diet at meals. Appetite fluctuates with anywhere from 0-100% consumed. Appetite stimulants provided- currently on [MEDICATION(S)], as well as [MEDICATION(S)] to tx [treat] dx [diagnosis] depression with possible s/e [side effects]of increasing appetite. Nursing staff reports that his/her refusal of po is 'behavioral.' In order to meet estimated nutritional needs, 8 oz Two Cal provided BID [twice a day] (also accepted with fluctuation) and po fluids encouraged .Reviewed resident status with ADON [Assistant Director of Nursing.] Family will be informed, and plan of care options discussed. Recommend d/c [discontinue] [MEDICATION(S)] at this time due to ineffective. The RD made no nutritional recommendations. Review of the RD's Weight Change Note dated 6/9/21, indicated March-89.2 lbs, May-72.9 lbs, June-70.8 lbs indicates significant weight loss of 18.2 lbs (20%) x 6 months. Weight loss not desired and is due to suboptimal po intake. Resident has been on appetite stimulants [MEDICATION(S)] and [MEDICATION(S)] with no effect. He/she remains on [MEDICATION(S)] for depression with possible s/e [side effect] of stimulating appetite. Resident is fed regular puree thin liquid diet at meals. Despite encouragement, appetite fluctuates with anywhere from 0-100% consumed. No noted difficulty chewing/swallowing. Fortified foods (cereal at breakfast, mashed and pudding at lunch/dinner) provided. In addition, 8 oz TwoCalHN (475 kcal [calories]/19.9 gm [grams] protein) provided bid to better meet estimated nutritional needs. Resident also accepts this with fluctuation. Po fluids encouraged. No new labs and skin intact. MD aware of resident decline. Resident family has been informed of weight loss. Awaiting family to return calls to make decision of plan of care. The RD made no nutritional recommendations. Review of the Physicians note dated 4/6/21, indicated Weight not yet recorded this month. It also reflected that the residents baseline weight was 120 lbs and the resident's order for [MEDICATION(S)] was recently discontinued. It further reflected dietitian following. Review of the Physicians note dated 5/4/21, indicated Weight not yet recorded this month. It also reflected that the residents baseline weight was 120 lbs and the resident's order for [MEDICATION(S)] was increased. It further reflected dietitian following. Review of the Physicians note dated 6/1/21, indicated that the residents baseline weight was 120 lbs and was down to 72 lbs. It also reflected that the recent increase of [MEDICATION(S)] showed no improvement. It further reflected dietitian following and patient's family discussing hospice care. Review of the Physicians note dated 6/13/21, indicated that the Physician's Assistant (PA) and the ADON discussed the options of Hospice verse the risks and benefits of peg tube placement (nutrition support whereby liquid formula is delivered directly to the gastrointestinal tract via a tube) with the family post surveyor inquiry. Documentation reflected the family decided to proceed with the peg tube placement. A review of the resident's individual nutritional comprehensive Care Plan initiated on 12/26/19 and revised 3/25/21, reflected the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan Goal area had not been revised since 3/25/21 and reflected that the resident would show improved nutritional status as evidenced by maintaining weight with no continued significant weight loss. The Care Plan Interventions area reflected to monitor for significant weight loss which included a three lb weight loss in one week. This parameter could not be used since weekly weights were not implemented for monitoring. On 6/11/21 at 10:25 AM, the surveyor, in the presence of another surveyor interviewed the residents Licensed Practical Nurse (LPN) #1. She stated that the resident had dementia and had a varied meal intake and takes the supplement Two Cal HN well. The LPN also stated that the resident drinks better than eating the puree food and preferred sweet items. She further stated that she thought the resident received fortified foods and confirmed there was an order in the electronic medical Record (EMR), but it was not on the eMAR and acknowledged there was no documented evidence to ensure the resident received and consumed the items. The LPN stated that the resident had weight loss and that the supervisor, the family, the physician, and the RD were typically notified. She also stated that the RD would usually recommend a three-day calorie count, weekly weights and a change in supplementation, however she acknowledged that the RD did not do this for Resident #30. On 6/11/21 at 10:45 AM, the surveyor, in the presence of another surveyor interviewed the Food Service Director (FSD), the Food Service Supervisor (FSS), and the Dietary Secretary (DS). The FSD stated that they received diet change information which included the addition of fortified foods via email notification as well as in writing on a designated form which they kept on file over the last two years. The DS looked through these files and stated that there were no communication forms for Resident #30. The DS then gave the surveyor a copy of an email from the RD dated 6/9/21 which indicated Please update Prime to reflect the following: [Prime was the FS software program which was used to print the residents tray tickets]. Resident #30 was listed as should have been receiving fortified cereal at breakfast, mashed and pudding at lunch/dinner. The DS stated, this was the first time we got this. The FSD provided the surveyor with the fortified food recipes which reflected that oatmeal was the hot cereal specifically used to make the fortified cereal. On 6/11/21 at 11:23 AM, the surveyor interviewed the (Licensed Practical Nurse/Assistant Director of Nursing) (LPN/ADON #2) and LPN #3 in the presence of the survey team. They both stated that they would have notified the FS department about an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 had signed for Resident #30's fortified food order in the EMR on 8/21/20. The LPN and the surveyor reviewed the EMR together. LPN #3 acknowledged she had signed for the fortified food order but could not remember if she communicated the order to the FS department. LPN/ADON #2 and LPN #3 stated that the fortified foods would not have been reflected on the eMAR and could not speak to how there would have been accountability to ensure the resident had received the fortified food items. On 6/11/21 at 11:30 AM, the surveyor, in the presence of the survey team interviewed LPN/ADON #2 who stated that Resident # 30 had a significant weight loss last year and the physician contributed the significant weight loss to Covid-19. However, the resident had further significant weight loss since. LPN/ADON #2 stated that she worked with the RD for all the interventions for Resident #30 but could not speak to nutritional interventions. She stated there were medication changes as well as psychiatric interventions related to behaviors which were now managed. She further stated that since the resident continued to lose weight despite interventions, she contacted the family regarding Hospice versus a feeding tube. This occurred post surveyor inquiry. She added that the family called back today and had decided they wanted the facility to proceed with a feeding tube. She could not speak to whether a significant change MDS was completed. On 6/11/21 at 1:15 PM, the surveyor, in the presence of the survey team interviewed the RD who stated that monthly weights should be completed by the 10th of the month and that reweights were taken when there was a significant change from the previous weight. She further stated that reweights were not always documented in the weight section; at times it was documented in her progress notes. The RD could not speak to why the resident's monthly weight for April 2021 was not documented in the EMR until 4/21/21. She stated, I don't know why it took so long to get a weight. She also stated, I have to chase them to get weights and the resident has behavior issues. She could not speak to whether the behavior issues were in relation to obtaining weights. The RD stated that she did not recommend weekly weights for the resident because the April 2021 weight obtained was so close to May 2021. She further stated she couldn't get a reweight of the resident for May 2021 until 5/24/21 and by then it was so close to June 2021 that she again did not recommend weekly weights. The RD stated that weekly weights were typically implemented when a resident has a significant weight loss and could not speak to whether she notified anyone from nursing or administration regarding her inability to ascertain the resident weights in a timely manner. She stated that she asked LPN/ADON #2 to speak with the residents family about the weight loss and that we did everything we could on this end so the options are hospice or a feeding tube because he/she was still declining despite everything we were doing. The RD stated that she had not reassessed or adjusted the resident's nutritional needs after the significant weight losses or the continued weight loss this month since she assessed the resident's nutritional needs in the December 2020 annual assessment. She further stated that the resident's nutritional needs would not have changed since she based this on the resident's desirable body weight. The RD further stated that she had not seen the need to change the resident's nutritional interventions because I didn't think the weight loss was related to calories; I do not reassess specifically. She stated that she felt the resident's April weight loss was due to the discontinuation of the [MEDICATION(S)] in March 2021 and her April 2021 intervention was to restart the [MEDICATION(S)]. The RD acknowledged that the resident had an additional significant weight loss in May 2021 despite the restart of [MEDICATION(S)] and stated that was the reason the resident needed hospice or a feeding tube. The RD acknowledged that the resident was consuming the Two Cal HN well but did not recommend increasing it because I didn't think calories was the problem. The RD stated that she was responsible to update the nutritional care plan when there were changes and acknowledged she had not updated the residents care plan since 3/25/21. She stated, I did not update that. She acknowledged the care plan did not reflect the significant change weight losses, that the goals were not met and were not measurable as there was no target weight range. The RD further acknowledged that she was unable to implement the monitoring intervention of a three lb weight loss within a week parameter, since she had not implemented weekly weights for Resident #30. She also stated that she did not inform the MDS Coordinator about the resident's significant weight loss because the resident only had one decline in activities of daily living (ADLs), and two or more were required to proceed with a significant change MDS. She stated, I don't know when I would tell the MDS Coordinator about a significant weight loss. The RD stated that the resident received a puree diet and fortified foods which consisted of hot cereal at breakfast and mashed potatoes and pudding at lunch and dinner. She stated that she notified the FS department via an email about the addition of fortified foods but could not speak to why the surveyors had not observed fortified foods on the resident's breakfast and lunch meal trays. She stated that each fortified item provided approximately 250-400 calories each. The RD stated that she did meal rounds but I did not ask the residents regular CNAs what the resident likes to eat or drink. She stated that she did not see the need for further nutritional interventions prior to proceeding with a feeding tube and could not speak to why a feeding tube was not discussed with the resident family earlier. On 6/11/21 at 1:50 PM, the surveyor, in the presence of the survey team interviewed the MDS Coordinator #1. She stated that a significant change MDS would not have been done for weight loss alone and that more than one decline in ADLs was required to qualify. She further stated that the Resident Assessment Instrument (RAI) manual guided the process for a significant change MDS which included an assessment step and a team meeting. On 6/11/21 at 2:15 PM, the surveyor, in the presence of the survey team interviewed the residents PA. She stated that along with the Physician, they see the resident monthly. The PA stated that the resident had Covid-19 last year and had end stage dementia and was pretty healthy otherwise. She stated that the resident lost weight again after the new year and had a profound weight loss this month. She stated that appetite stimulants were tried, and psychiatry was involved for a while. The PA acknowledged that the facility just recently spoke with the resident's family about a feeding tube. She stated that when she documented in the progress notes dietitian following that it was both her and the physician's expectation that the RD was reassessing the resident's nutritional needs and implementing and adjusting nutrition interventions. She stated that we rely on and defer to the RD. She further stated that the expectation was that other nutritional interventions should have been tried before opting for a tube feeding. On 6/14/21 at 9:50 AM, the surveyor, in the presence of another surveyor interviewed CNA #2 assigned to care for Resident # 30. The CNA stated that they usually finish taking monthly weights by the third of the month and give the weights to LPN #1. She stated she would be given a list if a resident needed to be reweighed or weighed weekly. CNA #2 stated that Resident #30 was combative during weighing at times; however, she weighed the resident on a Hoyer lift (an assistive device) with another CNA and they were always able to get a weight for the resident. On 6/14/21 at 10:05 AM, the surveyor, in the presence of another surveyor interviewed LPN #1 who stated that monthly weights were done by the fifth of the month, and that weights were taken on the 7 -3 and 3-11 shifts. She also stated that the monthly weights were reviewed by the RD who informed her of which resident's required reweights or weekly weights. LPN #1 could not remember if the RD requested a reweight for Resident #30. She acknowledged that the resident was not on weekly weights and could not speak to why the April 2021 weight was not entered into the EMR until 4/21/21. When asked about nutritional interventions for this resident, LPN #1 stated that the RD was on top of it. On 6/14/21 at 11:10 AM, the surveyor, in the presence of the survey team interviewed the MDS Coordinator #1. She stated she had spoken to the Long-Term Care (LTC) MDS Coordinator #2 who stated that she had not been informed of Resident #30's significant weight loss. On 6/14/21 at 12:56 PM, the surveyor, in the presence of the survey team interviewed the MDS Coordinator #1 who stated that she spoke with the LTC MDS Coordinator #2 again who sent her copies of the form she used to meet with the team on 4/22/21 and 5/5/21 which indicated a decision not to proceed with a significant change MDS for weight loss for Resident # 30. Review of the 4/22/21, IDT (interdisciplinary team) determination on whether significant change in status assessment will occur or not indicated sig [significant] change will not occur secondary to inability to facilitate useful strategy to improve sig wt loss. Pt [patient] remains a feeder. No decline noted in any other areas. Collective decision has made not to proceed with sig change assessment. Further review of the IDT document indicated that K0300 Emergence of unplanned weight loss (5% in 30 days or 10% in 180 days) was marked as checked. Review of the 5/5/21, IDT determination on whether significant change in status assessment will occur or not indicated Sig [significant] change will not occur as PT [patient] remains a feeder. No decline noted in any other areas. Decision was made by IDT team not to proceed with sig change assessment. Further review of the IDT document indicated that K 0300 Emergence of unplanned weight loss (5% in 30 days or 10% in 180 days) was marked as checked. The MDS Coordinator #1 could not speak to the meaning of the verbiage on the form and could not speak to why the form was not part of either the EMR or the paper chart. On 6/14/21 at 2:05 PM, the surveyor attempted to conduct a telephone interview with the LTC MDS Coordinator #2 but was unable to complete the interview. On 6/14/21 at 2:34 PM, the surveyor, in the presence of the survey team interviewed the RD who stated that she sent a list of resident's who were on fortified foods via an email to FS on 6/9/21 to confirm they had the correct information. The surveyor asked the RD if she conducted tray audits for fortified foods to ensure residents received the items. The RD stated she did not conduct any tray audits. The RD provided the surveyor with the nutritional information for the fortified foods which revealed the following: Supercereal, a six-ounce portion was 427 calories and 9 gm of protein. Supermashed, a four-ounce portion was 286 calories and 9.7 gm of protein. Super Pudding, a four-ounce portion was 216 calories and 5.62 gm of protein. On that same date and time, the RD further stated that she did not conduct weight audits or weight meetings. She then stated that she had notified MDS Coordinator #2 regarding the resident's weight losses on 4/21/21 and 5/5/21. She stated that I don't recall why I told you I didn't tell the MDS Coordinator about the weight losses last week. The RD further stated that they met to decide if they were going to proceed with a significant change MDS or not and did not because there was only one decline in ADLs. The surveyor and the RD together reviewed the IDT determination on whether significant change in status assessment will occur, dated 4/22/21 and 5/5/21. She stated that she could not speak to or explain the rationale that was written on IDT documentation forms and did not remember the content discussed. She acknowledged that she signed the forms and stated, my lesson is to read what I sign before I sign it, now I've learned. The RD could not speak to what tools she used to monitor the resident. She again stated that weeks went by quickly and I couldn't get reweights. She stated that she couldn't speak to if she or anyone documented that a weight could not be obtained due to the residents behaviors; but stated that it should have been documented, you know what, from now on I will. The RD again acknowledged that she had not revised the resident's nutritional care plan and stated, I should have updated it. She also stated, I would have approached the family a lot quicker if I knew the appetite stimulants didn't work again. When asked about why nutritional interventions were not adjusted the RD stated, I didn't think anything else should have been done. On 6/14/21 at 3:27 PM, the surveyor, in the presence of the survey team interviewed the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Administrator in Training (AIT). The DON stated that she was not involved with the MDS and would have to talk to the MDS coordinator regarding significant changes. On 6/14/21 at 4:01 PM, the surveyor, in the presence of the survey team interviewed the DON, the LNHA and the AIT. The DON stated that she could not speak to why the April 2021 monthly weight was not documented until 4/21/21. She also stated that she could not speak to what if any nutritional interventions were implemented and how the resident was being monitored related to the severe weight losses. The DON stated that the resident was consuming the supplements, well I think 75%. She acknowledged she did not see documented evidence of the RD monitoring the resident, how the resident was responding to the order for [MEDICATION(S)], or staff unable to weigh the resident due to combative behavior. She further stated that once a significant weight loss was identified on 4/21/21 and 5/5/21, nutritional interventions should have been implemented even without a reweight. The DON stated that she assumed the RD would have implemented nutritional interventions, increased the supplements and recommended weekly weights. She stated that they rely on the RD. The DON stated she could not speak to why the resident had weight losses and could not recall team conversations about the same. She stated that the RD was responsible to update and revise the nutritional care plan and should have done so since the resident had a decline. The DON also acknowledged that the intervention for monitoring for a three lb weight loss in a week as significant was not possible since weekly weights were not implemented. On 6/15/21 at 9:36 AM, the surveyor, in the presence of the survey team interviewed the DON who stated that the order for fortified foods should have been on the eMAR for accountability. On 6/15/21 at 1:13 PM, the surveyor, in the presence of the survey team interviewed the DON, LNHA and AIT. The DON stated that the RD was unable to provide documentation that her method of estimating nutritional needs using desirable body weight were based on an accredited source. Review of the facility policy for Weight Assessment and Intervention with a revised date of 4/23/21, reflected that the policy statement was that the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss. It also reflected that there was a weight change of 5% or more since the last weight a reweight should be taken and if confirmed the RD would be notified immediately and would respond within 72 hours. The policy reflected that the RD would review the weight records by the 15th of the month and that a 5% loss would be considered significant and greater than 5% would be considered severe. It further reflected that the team would meet and implement a care plan for weight loss and nutrition, including time frames and parameters for monitoring and reassessment. In addition, it reflected that interventions for undesirable weight loss should be based on careful consideration of the residents preferences, nutrition needs and the use of supplements. Review of the facility policy for MDS 3.0 Completion dated 1/1/21, reflected that residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Review of the facility policy MDS Completion and Submission Timeframes with a revised date of 4/23/21, reflected that the facility would conduct and submit resident assessments in accordance with current federal and state submission guidelines. It further reflected that the Assessment Coordinator or designee were responsible for ensuring that resident assessments were submitted, and Significant Change in Status (SCSA) assessments were to be completed by the 14th calendar day after determination of a significant change in status. Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, updated October 1, 2019. Indicated that the Guidelines for Determining a Significant Change in a Resident's Status: Note: this is not an exhaustive list. Some Guidelines to Assist in Deciding I[TRUNCATED]