Every finding on record at Mystic Meadows Rehabilitation and Nursing Center

Based on observation, interview, review of medical records and other pertinent facility documents, it was determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance or enhancement of their quality of life by maintaining cleanliness and dignified appearance of the resident's motorized wheelchair. This deficient practice was identified in one of one resident (Resident #80) reviewed for dignity and was evidenced by the following:On 12/4/2025 at 10:57 AM, during the initial tour of the facility, the surveyor observed Resident #80 ambulating in the hallway on a motorized wheelchair. The surveyor observed the motorized chair to be heavily soiled with fresh and dried food crumbs, dusts, and other unidentified debris on the bilateral front and rear wheels, all wheel fenders, bilateral seat side rails, footrest, seat board, controller, power base and leg rest hangers. The resident was unable to recall when the chair was last cleaned.The surveyor reviewed the medical record for Resident #80.A review of the admission Record revealed Resident #80 was admitted to the facility with diagnoses which included but not limited to cerebral palsy (a condition marked by impaired muscle coordination) and depression.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/15/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated an intact cognition. The MDS also indicated that the resident had impairments on both upper and lower extremities and that the resident needed clean-up assistance.A review of the resident's comprehensive care plan did not include a focus for usage of motorized wheelchair.On 12/9/2025 at 9:02 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the housekeeping department maintained the cleanliness of the wheelchairs in the facility by power washing them monthly or on as needed schedule. The DON stated that the nurses would let the unit managers know about the need for more frequent cleaning of the wheelchairs and the unit managers would let the housekeeping director know about it. On 12/9/2025 at 12:18 PM, during an interview with the surveyor, the housekeeping director stated that all the wheelchairs in the facility are scheduled on a monthly or on as needed basis. The surveyor asked the housekeeping director for a list of residents whose wheelchairs were cleaned monthly for the past 6 months. A review of the monthly list of units whose wheelchairs were cleaned revealed that Resident #80's wheelchair was last cleaned in October 2025. On the wheelchair cleaning schedule for November and December 2025, a cross mark on the resident's unit was indicated under week 1 with no specific name of the residents whose wheelchairs were cleaned.No further information was provided.A review of the facility-provided undated policy titled Routine Cleaning and Disinfection revealed the following under Policy Explanation and Compliance Guidelines: 4.) Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include but not limited to . i.) Resident chairs. N.J.A.C. 8:39 - 4.1 (a) (11) (12)

Based on observation, interview, review of medical record and other pertinent facility documents, it was determined that the facility failed to respect the resident's right to confidentiality of personal and medical records from unauthorized disclosure without the resident's consent by leaving the resident's private health information exposed on an open and unattended computer screen in an area accessible to the public. This deficient practice was identified for one of four unsampled residents (Resident #21) during medication administration observation.The deficient practice was evidenced by the following:On 12/5/2025 at 7:54 AM, during the medication administration observation in the long-term care unit, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #21. After administering 1 tablet of metformin 500 milligrams and applied prednisolone acetate ophthalmic suspension to both eyes of the resident, LPN #1 returned to the medication cart located in the hallway, to place the ophthalmic suspension bottle inside the top drawer. The surveyor observed LPN #1 leave the medication cart with the computer screen open on the page showing the resident's photograph, name, location, gender, date of birth , age, physician, allergies, code status, physician orders, current vital signs including weight, and medical condition. LPN #1 went inside the resident's room to speak to the resident with their back facing the doorway. The medication cart was not on LPN #1's line of vision. The computer screen on top of the medication cart faced the hallway. There were no residents or staff in the hallway at that time. The surveyor called the attention of LPN #1 and asked the nurse if the computer screen showing the resident's private health information is supposed to be left exposed in the hallway while the medication cart was unattended. LPN #1 stated that the computer screen should be on locked mode at all times while unattended meaning it should be on a blank page and not showing the resident's information.On 12/9/2025 at 8:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that during medication administration, the nurses should be pressing the computer screen lock button to protect the residents' private information from being viewed by other people when they leave the cart.A review of facility- provided policy titled Medication Administration revised on November 11, 2024, included under Policy Explanation and Compliance Guidelines: . 7.) Provide privacy. NJAC 8:39-4.1(a)18NJAC 8:39-35.2(i)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1 of 4 units ([NAME] Unit).This deficient practice was evidenced by the following: On 12/08/2025 at 10:00 AM, in bedroom [ROOM NUMBER] on the [NAME] Unit, the surveyor observed multiple black debris scattered across the A-side wall. On the B-side, the cloth material behind the bed was torn in several places. In the bathroom, the heater vent had unfinished spackling around it, and five holes were noted on the bathroom wall, all with incomplete spackling. On 12/08/25 at 10:00 AM, in the shower room on the [NAME] Unit, the surveyor observed that the entrance door had brown, flaking metal with crumbling edges, and paint was peeling away. Molding on the wall adjacent to the entrance door showed missing and bulging paint, exposing open wall spaces. Additionally, a sharp container was tilted and hanging, filled to the top with multiple blue razors, with its top open, exposing the contents. During an interview with the surveyor on 12/09/25 at 1:20 PM, the Licensed Nursing Home Administrator (LNHA) stated that maintaining a homelike environment was important for residents' dignity and comfort. The LNHA also explained that any environmental issues were addressed promptly by maintenance, with response times prioritized based on the severity of the issue. During an interview with the surveyor on 12/10/25 at 11:15 AM, the Maintenance Director (MD) stated that he completed rounds around the facility three times daily and addressed issues promptly, depending on their severity. He stated that the maintenance department was responsible for emptying sharps containers and monitored them during rounds to determine when they needed to be emptied. The MD explained that he was unaware of the issues in bedroom [ROOM NUMBER], shower room and that the sharps containers should have been emptied for safety reasons. He acknowledged that the environment was not homelike for residents and stated that he would address the issues immediately. A review of the facility's undated policy titled Homelike Environment revealed that Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent as possible. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that the resident was free from physical restraint for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. This deficiency was identified for 1 of 1 resident reviewed for physical restraints (Resident #9).This deficient practice was evidenced by the following: On 12/08/25 at 10:02 AM, the surveyor observed Resident #9 on the [NAME] unit in the day room, seated in a geriatric chair (a wheelchair designed for older adults, providing comfort, safety, and support for limited mobility), watching television with peers. A yellow tab alarm device (a personal alert device used in healthcare that triggers an alarm when a resident attempts to get up from a bed, chair, or wheelchair) was clipped to Resident #9 shirt. According to the admission record, Resident #9 was admitted to the facility with diagnoses including, but not limited to, dementia (a brain condition that affects memory, thinking, and daily functioning, making it difficult to remember, make decisions, or manage everyday tasks). A review of Resident #9's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 09/19/25, included a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated that the resident had severe cognitive impairment. Further review of Section P: Restraints and Alarms revealed that the resident did not use any alarms. A review of Resident #9's individual comprehensive care plan (ICCP) revealed that the facility did not include a focus area or interventions for any personal alarms. A review of Resident #9's medication administration record (MAR) and treatment administration records (TAR), dated as of 12/25, did not contain any physician orders for personal alarms. A review of Resident #9's electronic medical records (EMR) revealed that the facility did not perform a restraint assessment for the use of personal alarms. There was no information in the resident's medical record for any type of assessment related to the use of personal alarms. During an interview with the surveyor on 12/08/25 at 1:10 PM, the Licensed Practical Nurse (LPN) stated that she has worked at the facility for approximately one year and that Resident #9 had always had a tab alarm in place. The LPN stated the resident wore the alarm at all times; however, there was no physician order for its use. The LPN further stated that the resident should not be wearing the alarm because it was considered a restraint, and that the facility did not use restraints. During an interview with the surveyor on 12/08/25 at 1:15 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that Resident #9 had always had a chair alarm. The LPN/UM indicated that she did not consider the tab alarm to be a restraint, but however confirmed that a physician's order, care plan, consent, and MDS documentation should be in the resident's chart for the use of the personal alarm. During an interview with the surveyor on 12/08/25 at 1:25 PM, the Registered Nurse /MDS Coordinator stated that she had been working at the facility completing MDS assessments since 04/2020. She explained that the tab alarm should have been coded as a restraint and noted that there was no physician order in place; therefore, it was not coded. She stated that a comprehensive assessment of the resident was completed quarterly and explained that the tab alarm should have been included in the resident's comprehensive care plan so that it ensured all staff were aware of the required interventions. During an interview on 12/09/25 at 1:20 PM, the Director of Nursing (DON) stated that restraints included anything that prevented a resident from performing activities independently and that the facility did not use physical restraints. The DON explained that the personal tab alarms were used for safety only after physician consultation. She stated that proper documentation should have been included in the care plan, nurse notes, and MDS. The DON stated that Resident #9's tab alarm was previously discontinued on 08/25 because it was no longer needed, and the resident had not had an alarm since. The DON noted that facility staff, including CNAs, could have placed the alarm on the resident because tab alarms were accessible to staff and were stored in the same supply closet as batteries and other equipment. She stated that she unsure why the alarm had been placed on the resident but would continue to investigate and provide staff education. A review of the facility's undated policy titled Use of Restraints revealed that Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. NJAC 8:39-4.1(a)6

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to meet professional standards of nursing practice with respect to following physician's orders. This deficient practice was identified for one (1) of thirty-four (34) residents reviewed, Resident #56. This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. 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 well-being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 12/4/2025 at 10:56 AM, the surveyor observed Resident #56 sitting in their wheelchair (W/C) outside of the day room. The Resident was not wearing the derma-legs, paperless gloves, or Geri-sleeves. The resident was not able to be interviewed due to cognitive deficits. On 12/4/25, at 10:20 AM, the surveyor reviewed the medical record for Resident #56 which revealed the following information: Review of the admission Record (admission summary) dated 9/18/24, reflected that Resident #56 was admitted to the facility with diagnoses which included but were not limited to: systemic inflammatory response syndrome (SIRS), [a life-threatening medical emergency characterized by inflammation throughout the body], protein-calorie malnutrition (inadequate intake of nutrients), and heart failure (inability of the heart to pump blood effectively). Review of the quarterly Minimum Data Set (MDS), an assessment tool utilized to manage a resident's care dated 10/1/25, indicated that the resident displayed both short-term and long-term memory problems. Review of the Individual Comprehensive Care Plan (ICCP) reflected a focus area, dated 2/3/25, that Resident #56 was at risk for bruising/bleeding/skin tear related to (r/t) aspirin therapy and physiological changes in skin secondary to aging. Interventions included: always apply derma-legs to both legs except during care, apply derma-sleeves at all times except during (activities of daily living) ADLs, apply Geri-sleeves to both arms at all times except during ADLs, and encourage resident to keep Geri and derma sleeves on, reapply when removed. Subsequently, the surveyor observed Resident #56 not wearing the prescribed skin protectors on multiple occasions: 12/4/25 at 10:56 AM, 12/8/25 at 10:56 AM, 12/8/25 at 12:58 PM, and 12/9/25 at 8:53 AM. The physician Order Summary Report (OSR), dated as of 12/9/25, included the following physician orders (PO): (1). A PO dated 4/2/25, for derma-sleeves at all times except during care, every shift for skin protection.(2). A PO dated 2/3/25 for Geri-sleeves at all times except during care, every shift for skin protection.(3). A PO dated 10/10/25 for fingerless gloves every shift for skin protection. The Treatment Administration Record (TAR) for December 2025 indicated the skin protectors were documented as applied every shift. However, the surveyor observed Resident #56 multiple times not wearing the skin protectors. On 12/8/2025 at 1:10 PM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated that the Resident should wear the derma-legs, paperless gloves, and Geri-sleeves at all times. On 12/8/25 at 1:20 PM the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the Resident should wear the derma-legs, paperless gloves, and Geri-sleeves at all the times. The LPN further reported that the resident sometimes removed the skin protectors. When asked about documentation to support the Resident's removal of the skin protectors, the surveyor did not find any documentation verifying the Resident's removal of the skin protectors. On 12/9/2025 at 9:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who confirmed that the Resident should wear the derma-legs, paperless gloves, and Geri-sleeves at all times. The RN/UM further stated that if the Resident removed the skin protectors they should be reapplied, and staff should document any removal. On 12/9/25 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the skin protectors should be applied as ordered by the physician. The DON further agreed that staff should reapply the skin protectors if the Resident removes them and document the removal in the Progress Notes. A review of the facility's policy Dressings, Dry/Clean, revised 9/23, indicated that staff were to verify that there was a physician's order, review the resident's care plan, current orders, and diagnoses and check the treatment record. NJAC 8:39-27.1(a)

Based on observation, interview, review of the medical record, and other facility documents, it was determined that the facility failed to ensure that a resident who was identified as having a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) received recommended services to prevent further decreased in range of motion (ROM). This deficient practice was identified for 1 of 1 resident reviewed for positioning and mobility, (Resident #4) and was evidenced by the following:On 12/4/2025 at 9:45 AM, during the initial tour of the facility, the surveyor observed Resident #4 in bed while being rendered morning care.On 12/4/2025 at 10:34 AM, the surveyor observed Resident #4 ambulating in the hallway using their left hand to move the wheelchair. The resident's right leg was up on the leg rest on immobilizer boot. The resident's right arm was bent on the elbow and kept close to the body. The resident's right hand was flexed and being held by the left hand. The resident did not wear a splint or hand roll on the right arm and the right hand. The surveyor did not see any hand splint or hand roll in the resident's room.On 12/8/2025 at 9:40 AM, the surveyor observed Resident #4 ambulating in the hallway using their left hand to move the wheelchair. The resident's right leg was up on the leg rest on immobilizer boot. The resident's right arm was bent on the elbow and kept close to the body. The resident's right hand was flexed and being held by the left hand. The resident did not wear a splint or hand roll on the right arm and the right hand. The surveyor did not see any hand splint or hand roll in the resident's room.The surveyor reviewed the medical record for Resident #4.A review of the admission Record revealed Resident #4 was admitted to the facility with diagnoses which included but not limited to hemiplegia (paralysis) affecting right dominant side and personal history of transient ischemic attack and cerebral infarction (stroke).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/24/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated an intact cognition. The MDS also reflected that the resident had impairment on one side of the upper and lower extremities and was dependent on staff for their activities of daily living.A review of the Clinical Physician Orders (CPO) active as of 12/4/2025 did not include any order addressing the resident's right upper extremity's mobility. An order for right hand anti-spasticity hand roll splint to be worn as needed, on in the AM, off in the PM, remove for hygiene was ordered on 12/12/2024 and discontinued on 2/15/2025.A review of the resident's comprehensive care plan included a focus for the resident's decreased passive range of motion on the right wrist/ hand due to contractures revised on 10/28/2025. Interventions included the following: To wear right resting hand splint for 4 hours during daytime after morning care.A review of the occupational therapy evaluation and plan of treatment dated 10/24/2025 included recommendations for resting hand splint, as tolerated, remove for hygiene for right hand contracture.On 12/9/2025 at 9:05 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the Director of Rehabilitation (DOR) issued orders for assistive devices.On 12/9/2025 at 9:45 AM, during an interview with the surveyor, the DOR stated that they issue the orthotics (artificial devices such as splints and braces) orders and had access to the resident's electronic medical record to write orders which would need to be confirmed and approved by the resident's physician.On 12/09/2025 at 11:10 AM, the surveyor observed Resident #4 inside their room facing the dresser. On top of the dresser was a blue-colored hand splint. The resident pointed to the hand splint and stated to the surveyor that they were handed the blue- colored splint today.A review of the CPO active after the surveyor's inquiry about the resident's orthotics, revealed an unconfirmed physician order for applying right resting hand splint on daytime as tolerated created on 12/9/2025 by the DOR but was backdated to 10/24/2025 by the DOR.A review of the facility-provided policy titled Provision of Rehab Services created in 2025, included the following under Policy: 2.) Physician orders are required, or there is a change in the resident/ patient's condition, the interdisciplinary team will contact the physician. Any changes in the plan of care must be approved by the physician and documented in the resident/ patient's record. N.J.A.C. 8:39 - 27.2 (m)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to follow facility policy and procedure for weekly weights for 1of 2 residents (Resident #1) on 1 of 3 units (Comfort Care). This deficient practice was evidenced by the following: On 12/05/2025 at 7:59 AM Resident#1 was observed in bed. Resident #1 was slightly agitated and did not prefer to communicate with the surveyor. The breakfast tray was observed on the over the bed table. The tray was observed to be untouched. Resident 31 stated that he/she was in pain and had no appetite. Resident #1 would not tell the surveyor how long their appetite had been poor, then stated, yesterday. Staff were observed to attend to Resident#1 after the surveyor had left the room. Staff were observed by the surveyor to provide assist with setting resident up to eat and opening cold cereal and pouring milk.A review of Resident #1's admission Record revealed that Resident #1 was admitted to the facility with the following but not limited to diagnoses: Congestive heart failure (a chronic condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the lungs, legs, and other areas, causing shortness of breath, swelling, and fatigue), sepsis (blood infection), malignant neoplasm of unspecified female breast, dementia, anxiety disorder, edema, and cachexia (a severe, involuntary loss of muscle and fat mass).A review of Resident #1's comprehensive Resident Assessment Instrument Minimum Data Set (MDS, an assessment tool, dated 11/14/2025 revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. According to Section F of the MDS, Resident #1 required supervision or touching assistance with eating. Section K of the MDS revealed that Resident #1 had complaints of difficulty or pain with swallowing, received a mechanically altered diet while a resident and received a therapeutic diet while a resident. Section K did not reveal that Resident #1 had significant weight gain or decline. Section indicated that Resident #1 received a daily diuretic and opioid medication.A review of Resident #1's Order Summary Report with active orders as of 12/09/2025 revealed Resident #1 had the following physician orders: No Added Salt diet, chopped texture, regular fluid consistency, order date: 11/07/2025. House Supplement Shake, one time a day for nutrition support provide 4 oz (ounce) by mouth, order date: 11/14/2025. Weekly weights every day shift every Wednesday for monitoring after weight loss for 3 weeks, order date: 12/03/2025. Dietary/Dietician consult cachexia, order date: 11/10/2025. Weight on admission and Weekly x 4 weeks every day shift every Friday for weight protocol for 28 days, order date: 11/07/2025. Furosemide Oral Tablet 40 MG (milligrams) (Furosemide) give 1 tablet by mouth one time a day for leg edema, order date: 11/07/2025. Spironolactone Tablet 25 MG give 1 tablet by mouth one time a day for hypertension/CHF (congestive heart failure), order date: 11/23/2025.A review of the Medication Administration Record (MAR, dated 11/1/2025-11/30/2025 revealed the following weekly weights: 11/14: 126.2, 11/21: 129, and 11/28: 128.A review of the comprehensive, person-centered care plan revealed the following care plan Focus: I have a nutritional problem or potential nutritional problem r/t (related to) need for therapeutic diet, need for mechanically altered diet, congestive heart failure, malignant neoplasm of breast, atrial fibrillation (an irregular and often very rapid heartbeat), hypertension, dementia, osteoarthritis, COPD (chronic obstructive pulmonary disease), anxiety, depression, GERD (gastroesophageal reflux disease), malignant pleural effusion, and history of significant weight changes. Interventions/tasks included but were not limited to the following: Weigh weekly x 4 weeks post weight loss, then monthly per protocol. Date Initiated: 11/10/2025. On 12/05/2025 at 12:54 PM, the surveyor reviewed the medical record for Resident #1. The following weights were documented: 11/7/2025: 133.0, 11/14/2025: 126.2, 11/21/2025: 129.0. 11/28/2025: 128.0 and 12/2/2025: 122.2. Resident #1 had a 6.8-pound weight decrease over a one-week period from 11/7/2025 to 11/14/2025.On 12/09/2025 at 9:38 AM, the surveyor conducted an interview with the Certified Nursing Assistant (CNA #). When asked what her responsibility was concerning weekly weights, CNA # told the surveyor that she was responsible for obtaining the weekly weight of Resident #1. CNA # further explained that I get the weight and write it down on a piece of paper and give it to the nurse on the unit.On 12/09/2025 at 9:47 AM, the surveyor conducted an interview with the Unit Manager/Registered Nurse (UM/RN #) assigned to Resident #1's unit. When asked to explain the weekly weight process UM/RN # told the surveyor that the CNA's and nurses are responsible for obtaining weekly weights. Once the weight is obtained it is entered into PCC (Point Click Care, an electronic medical record) and it would then populate on the TAR (Treatment Administration Record) and in the weights/vitals section. UM/RN # further explained that they would compare the weight to the previous weeks weight. If there was a +/- 3 -pound change in one week we will conduct a re-weight that day or the in the next 24 hours and document the re-weight. If the weight decline was accurate then I notify the dietitian verbally because I see him every day. The dietitian will evaluate, and we also evaluate as a team. The surveyor then asked UM/RN # if a weight decline of 6.8 pounds in one week would require a reweight. UM/RN # stated, Yes. A loss of 6.8# pounds in a week would generate a reweight. The surveyor then asked UM/RN # why a reweight was not conducted for Resident #1 for the documented weight loss of 6 pounds from 11/7/2025 to 11/14/2025. UM/RN # told the surveyor that the reweight was done but I didn't document it. The surveyor asked UN/RN # if the reweight should have been documented and UM/RN # replied Yes, it should have been documented so we can address the issue (weight decline) right away. On 12/09/2025 at 10:46 AM, the surveyor conducted an interview with the facility Registered Dietitian (RD). The RD told the surveyor that Resident #1 was on weekly weights which we do for all new admissions. He further stated that the nursing staff reports outlying weights to him, and I also review the weights myself for those who are on weekly weights. The surveyor asked the RD if Resident #1 should have had a reweight conducted for the documented 6.8-pound weight decline from 11/7 to 11/14/2025. The RD replied, Yes, Resident #1 had a weight change of greater than 3 pounds and it should have been a reweight and documented. The RD also explained that he also did re-weights, so it was not all on the nursing staff. The surveyor then asked the RD what the importance was of an accurate reweight and the RD responded that it was important so we can intervene and evaluate the resident to help prevent further weight decline.On 12/09/202 at 1:10 PM, the surveyor conducted an interview with facility administrative staff. The surveyor asked the facility Director of Nursing (DON) about the weekly weight process. The DON told the surveyor that we go over the residents on weekly weights and we have a weekly weight meeting. She further explained that nursing was responsible, and the dietitian was responsible for documenting the weights in the medical record. The surveyor asked the DON if a reweight should have been conducted and documented for the 6.8-pound weight decline in one week from 11/7 to 11/14/2025. The DON responded, I agree that we did not document the re-weight on 11/14/2025 when Resident #1 had a 6.8# weight discrepancy.The surveyor reviewed the facility provided policy titled Weight Assessment and Intervention, Revision Date: December 1, 2025. The following was revealed under Weight Assessment:Residents are weighed upon admission and at intervals established by the interdisciplinary team.Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5lbs (pounds) or more (in 1 month) or 3lbs or more (in 1 week) will be retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing.NJAC 18:39-27.1(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) ensure respiratory tubing was maintained in sanitary condition while being used by the resident and a nebulizer (a machine used to administer medication in the form of a mist inhaled into the lungs) mask was stored in protective covering to prevent the spread of infection and b.) follow physician orders and provide oxygen (O2) tubing to accommodate the respiratory needs of a resident ordered O2 in accordance with professional standards of practice. This deficient practice was identified for two of three residents (Resident #83 and Resident #56) reviewed for respiratory care.This deficient practice was evidenced by the following: 1.) On 12/4/2025 at 11:02 AM, during the initial tour of the facility, Surveyor #1 observed Resident #83 from the hallway, sleeping in bed connected to an oxygen concentrator running at 2 lpm (liters per minute) via a nasal cannula (NC) (a tube used to deliver oxygen though the nostrils). The surveyor observed the middle part of the oxygen tubing inside the trash bin located on the left side of the resident's bed. The oxygen tubing was observed touching the trash inside the trash bin. The oxygen tubing was unlabeled. There was no signage inside or outside the resident's room indicating oxygen is being used. On 12/5/2025 at 12:42 PM, the surveyor observed the resident in bed connected to the oxygen concentrator via a nasal cannula. The surveyor observed an unbagged nebulizer mask on the bedside table, lying sideways exposing it to air. The surveyor reviewed the medical record for Resident #83. A review of the admission Record revealed Resident #83 was admitted to the facility with diagnoses which included but not limited to chronic obstructive pulmonary disease (COPD) and heart failure. A review of the resident's most recent Minimum Data Set (MDS), an assessment tool dated 11/23/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated an intact cognition. The MDS also reflected that the resident received respiratory treatment which included oxygen therapy. A review of the Clinical Physician Orders (CPO) active as of 12/4/2025 included the following orders: Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) mg/ 3 ml, 3 ml inhale orally 3 times a day for COPD ordered on 11/6/2025 and started on 11/7/2025. Oxygen PRN (as needed) via NC at 2 liters per minute as needed for SOB (shortness of breath). A review of the corresponding Medication Administration Record (MAR) in December 2025 revealed that nebulization on the following dates and times was signed administered on 12/5/2025 at 9:15 AM, 1:00 PM, and 5:15 PM. The order for oxygen treatment as needed was not signed administered for the month of December 2025. A review of the comprehensive care plan revised on 6/27/24 reflected a focus for oxygen therapy related to anxiety. The interventions included the following: Give medications as ordered by physician. I, use oxygen therapy, 2 liters per minute via nasal cannula while sleeping. On 12/9/2025 at 8:58 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that nebulization mask should be stored in plastic bag when not in use. The DON also stated that oxygen tubing should not touch the trash bin. A review of facility provided policy titled Oxygen Administration revised in October 2010, indicated under Steps in the Procedure: .2.) Place an Oxygen in Use sign on the outside of the room entrance door. Close the door. 3.) Place an Oxygen in Use sign in a designated place on or over the resident's bed. Under Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record; 1.) The date and time that the procedure was performed, 2.) The name and title of the individual who performed the procedure. The policy did not address nebulization treatment and storage. 2.) On 12/5/2025 at 7:56 AM, the surveyor observed Resident #56 sitting in their wheelchair (W/C) in their room. No O2 tubing was observed in the Resident's room. On 12/4/25, at 10:20 AM, the surveyor reviewed the medical record for Resident #56. A review of the admission Record (admission summary) dated 9/18/24, reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to: Systemic Inflammatory Response Syndrome (SIRS), [a life-threatening condition involving widespread inflammation], protein-calorie malnutrition (inadequate intake of nutrients), and heart failure (inability of the heart to pump blood effectively). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates the management of a resident's care, dated 11/1/25, indicated that the Resident had both short-term & long-term memory problems. A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 11/5/25, that the Resident was to have O2 therapy as needed for shortness of breath. The ICCP did not include any interventions related to O2 tubing. A review of the physician Order Summary Report (OSR), dated 12/9/25, included the following physician orders for Resident #56 (PO): A PO dated 11/4/25, for AHC: O2 tubing storage. Keep tubing in a bag when not in use, every shift, for low O2 less than 92%. A PO dated 11/4/25, for AHC: respiratory bag change. Change and date bag every night shift, every Tuesday, for O2 less than 92%. A review of the Treatment Administration Record (TAR) for December 2025 showed that the O2 tubing tasks were documented as completed every shift. However, during observations conducted on 12/5/25 at 7:56 AM, 12/8/25 at 1:30 PM, and 12/9/25 at 8:56 AM, the surveyor did not observe any O2 tubing in Resident #56's room. On 12/9/2025 at 9:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who confirmed that Resident #56 had an active order for O2 tubing but did not have the tubing in their room. When asked about the O2 tubing task being signed off on the TAR, the RN/UM stated that the task should not have been signed off because the Resident did not have O2 tubing in their room. On 12/8/25 at 1:20 PM the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that based on PO, Resident #56 should have O2 tubing stored in a bag in the room. When asked about the importance of following the PO for O2 tubing, the LPN responded that it was important to have the O2 in the Resident's room in case of an emergency, particularly because the Resident is on hospice. On 12/9/25 at 12:12 PM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged that the oxygen (O ) tubing should have been stored in the Resident's room as ordered and agreed that staff should not document completion of the O2 tubing task on the TAR as the tubing was not present. The DON also affirmed that it is especially important for a hospice resident to have O2 tubing readily accessible in the event of an emergency. A review of the facility's policy and procedure titled Oxygen Administration, revised October 2024, indicated that the purpose of the procedure was to provide guidelines for the safe oxygen administration. N.J.A.C. 8:39 - 27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medications securely inside the medication cart by keeping it locked while unattended. The deficient practice was identified for 1 of 4 unsampled residents (Resident #21) observed during medication administration. The deficient practice was evidenced by the following:On 12/5/2025 at 7:54 AM, during the medication administration observation in the long-term care unit, the surveyor observed Licensed Practical Nurse (LPN) #1 administer medications to Resident #21. After administering 1 tablet of metformin 500 milligrams and applied prednisolone acetate ophthalmic suspension to both eyes of the resident, LPN #1 returned to the medication cart located in the hallway, to place the ophthalmic suspension bottle inside the top drawer. The surveyor observed LPN #1 push the drawer close but did not lock the medication cart. LPN #1 went inside the resident's room to speak to the resident with their back facing the doorway. The medication cart was not on LPN #1's line of vision. The opening of the medication cart faced the hallway. There were no residents or staff in the hallway at that time. The surveyor called the attention of LPN #1 and asked the nurse if the medication cart is supposed to be left unattended unlocked in the hallway. LPN #1 stated that the medication cart should be locked at all times.On 12/9/2025 at 8:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that medication carts should be locked at all times.A review of facility- provided policy titled Medication Storage revised on 5/30/2023, included under Policy General Guidelines: a.) All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) .c.) During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/ cart. N.J.A.C. 8:39 - 29.4 (h)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure a safe, and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to provide residents with appropriate products for hand hygiene during mealtime, and staff did not follow hand hygiene practices consistent with accepted standards of practice. This deficiency was identified in 1 of 4 dining room observations ([NAME] Unit dining room).This deficient practice was evidenced by the following: On 12/08/25 at 11:10 AM, the surveyor observed dining for lunch on the [NAME] Unit dining room. The Certified Nurse Assistant (CNA) assisted two residents with hand hygiene before lunch using a folded wet napkin for each resident. However, the CNA did not perform hand hygiene herself between assisting each resident. During an interview with the surveyor on 12/08/25 at 11:14 AM, the CNA stated that during mealtimes she uses folded wet napkins, which do not contain alcohol, to perform hand hygiene for residents. She further reported that she also uses the same folded wet napkins to perform hand hygiene on herself. During an interview with the surveyor on 12/09/25 at 1:20 PM, the Licensed Nursing Home Administrator (LNHA) stated that hand hygiene should be performed using soap and water when hands are visibly soiled and alcohol-based hand sanitizer when appropriate, including between contact with residents. During an interview with the surveyor on 12/10/2025 at 11:02 AM, the Infection Preventionist (IP) stated that the folded wet napkins used by the CNA did not contain alcohol. She explained that hand hygiene wipes should contain at least 70% alcohol. The IP noted that the CNA should not have performed hand hygiene on residents using the folded wet napkins and should have used either 70% alcohol-based hand gel or soap and water between residents for proper infection control. A review of the facility's undated policy titled Infection Prevention and Control Program revealed that All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. N.J.A.C. S 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 09:29 AM until 10:17 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1.) The surveyor requested to view the dish machine that was in service at that time. The FSD stated that the wash cycle gauge was broken, and the temperature was obtained manually. The FSD then placed a manual thermometer in the water in the base of the dish machine after the wash cycle to demonstrate the wash cycle temperature which was 178 degrees Fahrenheit (F) (manufacturers instructions that were posted on the front of the dish machine indicated expected parameters for the wash cycle temperature was 160 F and the rinse cycle temperature was 180 F). The rinse cycle gauge reading was 180 F during the rinse cycle. The surveyor requested to view the dish machine temperature log at that time. Review of the Record of Dish Machine Temperature log revealed that the breakfast reading for the wash cycle temperature was recorded at 162 F and the rinse cycle was recorded at 183 F. Further review of the log revealed that the lunch service was already filled in with a wash cycle of 162 F and 183 F for the rinse cycle. The FSD stated that only the breakfast dish machine cycle should have been recorded at that time as lunch had not yet been served. 2.) The surveyor asked the Dietary Aide/Dishwasher (DA/DW) to demonstrate the sanitizer level in the three-compartment sink. The FSD proceeded to place a test strip into the sanitizer compartment and held it in the water for two seconds. The FSD stated that the color of the test strip when compared to the test strip legend was orange, which indicated an insufficient sanitizer level. The DA/DW who was present stated that the test strip was required to be submerged in the sanitizer for fifteen to thirty seconds. The DA/DW then placed the test strip into the sanitizer level for 15 seconds and stated the test strip was still orange which indicated the sanitizer level was zero and that he needed to add more sanitizer. The DA/DW stated the desired sanitation level was between 200 and 400 PPM (parts per million). The surveyor requested to view the Sanitizing Sink Testing log which revealed the following: Procedure: 1. Fill sink to marked level 2. Add Sanitizer 3. Take a piece of the test strip and hold it under water for ten (10) seconds 4. Read immediately 5. Chart results below 6. Range must be between 100 and 200. When the surveyor reviewed the legend on the side of the vial of test strips used to test the sanitizer level, there were color coded numeric readings in PPM of 0 orange, 150 brown, 200 dark brown, 400 green and 500 dark green). Review of the Sanitizing Sink Testing log revealed that the breakfast meal sanitizer level was documented as 187 PPM (not reflected as a possible value on the test strips) and the lunch result had already been recorded at 200 PPM, prior to the lunch meal service. 3.) In the food preparation area, the surveyor observed a meat slicer that was covered with plastic. The surveyor asked the FSD to remove the plastic. The surveyor noted that there was debris on the base of the food slicer. The FSD stated the meat slicer was used last night and there should not have been anything on there. 4.) In the food preparation area, the surveyor observed a free-standing mixer that was not covered with plastic. The FSD stated that the mixing bowl was replaced this morning and should have been covered. 5.) In the galley of the kitchen, the surveyor observed a table mounted can opener. The surveyor asked [NAME] #1 to remove the can opener from its sheath to expose the blade. At that time, the surveyor observed a dried brown substance on the blade. [NAME] #1 stated that she just used it that morning. [NAME] #1 then proceeded to scrape the brown matter off with her fingernail. The FSD stated that if the blade of the can opener were not cleaned prior to use, it could have resulted in cross-contamination. 6.) In the dry storage area, the surveyor observed a three-pound container of vanilla frosting that was previously opened and was dated ,d+[DATE]. The FSD stated the date indicated the month and year the item was received. The surveyor asked when the vanilla frosting was opened and what the use-by date was and the FSD stated, That is a good question. The FSD was unable to describe the facility policy for labeling and dating when asked. The FSD then proceeded to discard the frosting. 7.) In the walk-in refrigerator, on the top shelf of a three-tiered wire rack, the surveyor noted a pan of leftover meatloaf that was not fully covered with clear wrap that was exposed to air. The FSD stated that the meatloaf should have been fully covered. 8.) In the food prep area, the surveyor asked the FSD to remove the cover of the cap that covered the juice machine gun. When the FSD removed the cap, the surveyor noted a brown substance. The FSD stated she did not know what the brown substance was. The FSD further stated that the juice gun should have been soaked in boiling water and cleaned nightly. 9.) The table refrigerator temperature was confirmed by the FSD on two separate thermometers with a reading of 70 F. The FSD stated that the temperature should have been below 40 F. The FSD further stated the refrigerator held multiple potentially hazardous foods such as: egg salad sandwiches, lunch meat sandwiches, and dairy items such as milk and supplements which were made this morning and needed to be thrown out. 10.) The surveyor returned to the three-compartment sink and interviewed the DA/DW who demonstrated the sanitizer level. The DA/DW dipped the test strip into the sanitizer for eight seconds. The DA/DW then proceeded to place the test strip up against the vial of test strips and compared the test strip to the legend on the side of the bottle and stated that the color indicated that the sanitizer level had reached the desired level of sanitation, between ,d+[DATE] PPM. The DA/DW stated that he ensured that he dipped the test strip into the sanitizer level for ten seconds by counting from ten to fifteen. After the kitchen tour, the surveyor interviewed the FSD regarding her hair net which did not fully cover her hair. The surveyor noted that strands of her hair hung from both the right side and the back of her hair net during the tour. The FSD stated that if her hair were not fully covered, there was a potential for the hair to go into someone's food. When the surveyor asked the FSD to explain why both the dish machine and the three-compartment sink logs were filled in prior to the lunch meal, the FSD stated she did not know why the logs were filled in for lunch when it was not completed. The FSD stated she thought that the staff were nervous because the surveyor was there. The FSD stated the logs for the dish machine must not be pre-filled in because things could change. The FSD stated if the sanitizer strip was not maintained in the sanitizer within the three-compartment sink for the required 10 seconds per manufacturer directions, then it may not show the correct amount of sanitizer level. 11.) On [DATE] at 10:23 AM the surveyor observed the nourishment room in the Harbor Unit in the presence of the Regional Director of Nursing (RDON). The surveyor observed a jar of French onion dip that had an expiration date of [DATE], that was only marked with someone's initials, and was not labeled or dated. The RDON stated the item should have been properly labeled and dated. She further stated that she was not sure if the items were required to be discarded after 48 or 72 hours. 12.) On [DATE] at 10:33 AM the surveyor observed the nourishment room in the [NAME] Unit in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) #1. The surveyor observed that the freezer temperature was 20 F and the refrigerator temperature was 51 F. LPN/UM #1 stated the temperatures were too warm. The surveyor observed two resident take-out containers that were stored on the bottom shelf of the refrigerator. LPN/UM #1 stated that the containers should have been marked with the resident's room number and date because food was not permitted to be kept in the refrigerator for more than three days. LPN/UM #1 then opened the door to the microwave and the surveyor noted that the microwave was heavily soiled with dried, brown matter on all sides. The LPN/UM #1 stated the microwave looked like it needed to be cleaned as it appeared that something exploded inside and was not wiped afterward. LPN/UM #1 was not sure who was responsible to clean the microwave. 13.) On [DATE] from 11:23 AM until 11:49 AM during a follow-up visit to the kitchen, the surveyor observed the following in the presence of the FSD: The surveyor observed [NAME] #1 who washed his hands and dried them with a paper towel. [NAME] #1 then proceeded to lift the lid to the trash can with his bare hands and discarded the paper towel rather than using the trash can beside the sink which had a foot pedal. [NAME] #1 then donned (put on) gloves and proceeded to the food preparation area. When interviewed at that time, [NAME] #1 stated he should have used the trash can with the foot pedal instead of touching the lid of the trash can. The surveyor observed the tray line during the meal service and noted a Dietary Aide (DA) who had both a mustache and beard but only covered his beard with a beard restraint, and left his mustache exposed as he plated food. When interviewed, the DA stated that he normally worked on the evening shift. The FSD was present at that time, stated that she had not noticed the DA's mustache was not covered. The FSD stated that there was a potential for hair to get into the food if all the DA's facial hair was not covered. On [DATE] at 12:22 PM, the surveyor interviewed the Licensed Practical Nurse/ Infection Preventionist (LPN/IP) who stated that all hair should be pulled back to the best of their ability to ensure that it did not fall into the food. The LPN/IP further stated that if the cook opened the trash can with his bare hands before he donned gloves, then his hands were contaminated. The LPN/IP also stated that if both the dish machine temperature log and the three-compartment sink logs were filled in prior to meal service, the temperature may not be accurate, and the sanitizer level may not be up to par. Review of the facility policy, Food Safety Requirements (Reviewed/Revised ,d+[DATE]) revealed the following: Food safety practices shall be followed throughout the facility's entire food handling process .Elements of the process include the following: .Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms, Preparation of food ., Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. Employee hygienic practices. .Monitoring food temperatures and function of the refrigeration equipment daily and at routine intervals during all hours of operation; .Labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and Keeping foods covered or in tight containers . .All equipment used in handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination. Staff shall follow facility procedures for dishwashing and cleaning fixed equipment. .Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. .Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Review of the facility policy, Date Marking for Food Safety (Reviewed/Revised [DATE]) revealed the following: .Refrigerated, ready-to-eat, time/temperature for food safety (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 (seven) days. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing the food shall be responsible for date marking the food at the time the food is opened or prepared. Review of the facility policy, Sanitation Inspection (Reviewed/Revised [DATE]) revealed the following: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. .Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. Review of the facility policy, Dietary Employee Personal Hygiene (Reviewed/Revised [DATE]) revealed the following: It is the policy of this facility to utilize the following guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. .Hands must always be washed after .engaging in other activities that contaminate the hands . Review of the facility policy, Dishwasher temperature (Reviewed/Revised ,d+[DATE]) revealed the following: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. .Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or re-filled for cleaning purposes. Review of the facility policy, Use and Storage of Food Brought in by Family or Visitors (Reviewed/Revised ,d+[DATE]) revealed the following: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. .All food items that are already prepared by the family or visitor brought in from home must be labeled with content and dated. The facilty may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within 3 (three) days. If not consumed within 3 (three days), food will be thrown away by facility staff. Review of the facility policy, Nourishment Room Procedures (Revised February 2024) revealed the following: To promote the health of residents and staff by maintaining clean and sanitary conditions. The Housekeeping and Dietary Department cleans nourishment rooms as determined by the cleaning log. The area includes all nourishment rooms throughout the building. The items included are all kitchen appliances, cabinets, counter tops and high touch areas. .Storage: All food items in the Nourishment room must be labeled with content and dated .It is the responsibility of the facility representative to check and discard undated and expired food items. NJAC 8:,d+[DATE].2 (g)

Based on interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 residents (Resident #56) reviewed for Beneficiary Protection Notification. The deficient practice was evidenced by the following: On 07/01/24 at 9:25 AM, the Regional Director of Case Management (RDCM) provided the SNF Beneficiary Protection Notification Review form for Resident #56, which indicated the resident started on Medicare Part A Services on 11/13/23 and was discharged from Medicare Part A Services on 12/26/23. The form further indicated the resident did not receive the SNF ABN or NOMNC beneficiary notices because he/she did not want to participate in therapy. The RDCM stated that the resident should have received the SNF ABN and NOMNC when the resident was discharged from Medicare Part A Services and remained in the facility. On 07/01/24 at 10:45 AM, the Director of Social Services (DSS) stated that residents on Medicare Part A Services were reviewed at the weekly Utilization Review meetings. The DSS further stated that when a resident was discharged from Medicare Part A Services, the resident would receive a NOMNC which notified the resident that they are being cut from Medicare Part A Services and provided information on how to appeal the decision. The DSS further stated that if the resident remained in the facility, the resident would also receive the SNF ABN which notified the resident of the private pay costs of services not covered by Medicare Part A Services if the resident chose to continue those services in the facility. The DSS also stated that if a resident initiated the discharge from Medicare Part A Services, it would be documented in the resident's progress notes, therapy notes, or on the NOMNC form. On 07/01/24 at 10:55 AM, the Director of Rehabilitation (DOR) stated that she leads the weekly Utilization Review meeting which reviews the residents' current progress in therapy so that the interdisciplinary team can decide as a team when a resident will be discharged from therapy services. The DOR further stated that the Social Worker was responsible for issuing the NOMNC and then setting the resident's discharge date . When asked about Resident #56, the DOR stated that the resident was discharged from Physical Therapy (PT) services on 12/08/24 because the resident had met his/her prior level of functioning, but continued on Occupational Therapy (OT). The DOR added that OT discharge was decided as a team for 12/26/23 because [Resident #56] had reached his/her maximum potential at that time. Review of Resident #56's progress notes, dated 11/13/23 through 12/26/23, did not indicate the resident initiated a discharge from Medicare Part A Services or that the SNF ABN or NOMNC beneficiary notices were provided when the resident was discharged from Medicare Part A Services. Review of the Service Log Matrix, dated 06/28/24, revealed Resident #56 refused PT one time on 11/17/23, and OT one time on 12/22/23. There were no other refusals documented from 11/13/23 through 12/26/23. Review of the PT Discharge Summary, for Dates of Service 11/14/23 through 12/08/23, included, D/C [discharge] Reason: Highest Practical Level Achieved. Further review revealed, Patient has reached maximum potential with skilled services. Review of the Speech Therapy Discharge Summary, for Dates of Service 11/14/23 through 12/20/23, included, D/C Reason: Highest Practical Level Achieved. Further review revealed, Patient has reached maximum potential with skilled services. Review of the OT Discharge Summary, for Dates of Service 11/14/23 through 12/26/23, included, D/C Reason: Highest Practical Level Achieved. Further review revealed, Patient has made consistent progress with skilled interventions and patient has reached maximum potential with skilled services. Review of the facility's Advance Beneficiary Notices policy, reviewed/revised 08/2022, included, For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, and, A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. NJAC 8:39-4.1(a)(8)

Complaint #: NJ169593 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records. This deficient practice was identified for 1 of 23 resident (Resident #248) medical records reviewed and was evidenced by the following: The surveyor reviewed the medical record for Resident #248. A review of the Admission Record face sheet reflected that the resident had diagnoses that included, but were not limited to, cramp and spasm, urinary tract infection, and chronic pain. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 12/30/224, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had an intact cognition. Further review of the MDS included in Section H: Bladder and Bowel, that the resident had an indwelling catheter (urinary catheter) and in Section J: Health Conditions, under pain management, that the resident received scheduled pain medications. A review of the Order Summary Report (OSR) for December 2023, reflected the following: -Start date 06/30/23: Flush catheter with 10 milliliters (ml) normal saline (NS) every shift to prevent catheter blockage. -Start date 04/14/23: Diazepam 10 milligrams (mg) give 1 tablet by mouth every 8 hours for spasms. -Start date 10/17/23: Tizanidine 4 mg give 3 tablets by mouth every 8 hours for muscle spasms. A review of the Care Plan for Resident #248 revealed, a focus area of the resident to use anti-anxiety medication Valium [Diazepam] for muscle spasms, date initiated 03/30/23, with interventions that included to give anti-anxiety medication ordered by physician. Further review revealed a focus area of an alteration in bladder elimination related to neurogenic bladder (lack of bladder control) with indwelling urinary catheter, date initiated 3/30/23, with interventions that included catheter care per protocol, and another focus area for risk for a urinary tract infection (UTI) related to urinary catheter use, date initiated 5/15/23, with an intervention of keep urinary catheter patent and intact at all times. A review of the November 2023 Treatment Administration Record (TAR) revealed the physician's order, Flush [urinary] catheter with 10ml NS every shift to prevent catheter blockage, was not signed as completed and left blank on: -11/02/23 evening shift -11/21/23 day shift A review of the December 2023 TAR revealed the physician's order, Flush [urinary] catheter with 10ml NS every shift to prevent catheter blockage, was not signed as completed and left blank on: -12/17/23 day shift -12/20/23 day shift -12/24/23 day shift -12/26/23 day and evening shifts -12/27/23 day shift -12/28/23 day shift A review of the December 2023 Medication Administration Record (MAR) revealed the physician's order for, Tizanidine 4 mg give 3 tablets by mouth every 8 hours for muscle spasms, was not signed as administered and left blank on: -12/06/23 2200 (10pm) A review of the Progress Notes for November 2023 and December 2023 reflected there was no documentation related to the blanks on the MAR and TAR. On 07/02/24 at 09:39 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that she was responsible for emptying the urinary bag the bag and to ensure it was clean. Shen then stated that she documented the urinary output in electronic medical record (EMR), which was documented every shift. The CNA stated that she was not sure if the nurses had to flush the catheter. On 07/02/24 at 09:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was responsible to empty the urinary bag, to ensure it does not get full, and ensure the resident was comfortable. LPN #1 stated that the nurse or the CNA would document the urinary output. She further stated that the nurses were responsible to document the urinary output in the TAR, monitor the output and document the care. LPN #1 explained that flushes depended on the resident but there would be an order for it and if there was an order then the nurse would document in the TAR to indicate that the catheter was flushed. LPN #1 stated that it was important to flush the catheter because it could back flow and could cause too many complications if it was not flowing properly. She then stated if there was an order the nurses should follow the order and flush the catheter. At that time, the surveyor asked what the numbers on the MAR and TAR indicated, and LPN #1 stated that if the nurses document a number 5 then it meant hold and the number 9 meant other and was followed up with a progress note. LPN #1 stated that the MAR and TAR should not be left blank because there needs to be an explanation of why. On 07/02/24 at 09:59 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated, in the presence of the survey team, that for catheter care, the CNAs were responsible for emptying the catheter, changing the bag to a leg bag if the resident was getting out of bed, and ensuring that the privacy cover was in place The LPN/UM stated that the nurses were responsible for changing the catheter and explained catheter care included ensuring that the catheter worked appropriately and observing the catheter bag to ensure there were no sediment in the bag. The LPN/UM further stated that the nurses flushed the catheter depending on the physician's order and that it was important to flush catheters to prevent infections. The LPN/UM stated that the nurses document in the MAR or TAR because it would be an order to flush the catheter. At that time, the surveyor asked what the numbers on the MAR and TAR indicated and the LPN/UM stated that the number 5 indicated the physician's order was held and number 9 indicated other which prompted the nurse to write a progress note on it. The LPN/UM stated that the blanks on the MAR and TAR indicated that it was not filled out and not done. She stated the expectation was for staff to document on the MAR and TAR or to write a progress note. On 07/02/24 at 10:22 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the CNAs were responsible to ensure the catheter was clean, that it was emptied, and that the privacy cover was place. She stated that the CNAs documented the urinary output in the EMR, and they also informed the nurses so the nurse could document it in the TAR. The DON stated that the nurses were responsible to ensure the catheter was flowing correctly, cleaned, checking the urinary output, and that it was documented. The DON stated that flushing the catheter depended on the physician's order. She stated that if the physician ordered for the catheter to be flushed every shift, the expectation would be for the catheter to be flushed as ordered. She then stated that it was important flush the catheter to prevent infections and clogging of the catheter. At that time, the surveyor asked what the numbers on the MAR and TAR indicated and the DON stated that the number 5 indicated to hold, and the number 9 indicted to follow up with a progress note to document the rationale. The DON stated that the blanks on the MAR and TAR indicated the nurse did not sign off on the order. The DON further stated that the expectation was the nurses followed the physician's order and to document, because if it is not documented it's not done. The DON stated that she could not speak to the blanks but then stated that the resident could refuse and was at times noncompliant but the nurse could have not documented it. On 07/02/24 at 11:00 AM, the surveyor interviewed the primary Medical Doctor (MD) for the resident via the phone in the presence of the DON. The MD stated that there was an order to flush the catheter because the resident had a history of blood in it. The MD stated that the expectation would be for the nurses to follow the order of the flushes. He further stated that it was important to flush the catheter to prevent it from getting clogged which could cause pain and kidney issues. He concluded that they wanted to ensure that the catheter was functioning properly. On 07/02/24 at 11:59 AM, the surveyor interviewed the Interim Licensed Nursing Home Administrator (LNHA), who also identified as a Registered Nurse (RN), who stated the agency nurses would get backed up and so she would go and flush Resident #248's catheter, but that she was not on the cart, so did not sign off on the order. She stated that she did not write a progress note or sign the TAR and that it was on me. The interim LNHA stated that she should have signed the TAR and wrote a progress note that she did it. She stated that the resident would ask why the nurse was not doing it and she stated that she would inform the resident that she was assisting the nurse with the catheter care since the nurse was behind. She stated as a nurse it was in her nature to help. The Interim LNHA then stated it was during the holidays and that was why she remembered the blanks in the TAR because they had agency staff, and they were falling behind because the resident needed a lot of care. She stated the importance of flushes was prevent the catheter from getting clogged because the resident had a history of blockage and granulates, and sediment would get into it. The Interim LNHA stated the importance of documentation was to validate that it was done. She again stated she should have documented in the EMR that she flushed the urinary catheter but since she was generally not on the floor, it was not done. The Interim LNHA concluded she was generally good for documenting and should have done it. On 07/03/24 at 10:54 AM, the DON, in the presence of the LNHA, the interim LNHA, the Regional Director of Case Management, and the survey team, stated that an incident report was done related to the blank on the MAR. She stated that the nurse informed her she gave the medication, but did not remember not signing the MAR. The DON acknowledged that staff should be signing the MAR and TAR and not leave it blank. On 07/03/24 at 10:57 AM, the Interim LNHA acknowledged, in the presence of the LNHA, the DON, the Regional Director of Case Management, and the survey team, that there were blanks on the MAR and TAR that should not have been left blank. A review of the facility's Charting and Documentation policy, dated reviewed 5/2024, included, 2. The following information is to be documented on the resident medical record: b. Medications administration, c. Treatment or services performed. 7. Documentation of procedures and treatments will include care-specific details, including: g. the signature and title of the individual documenting. NJAC 8:39-35.2 (d)

Based on observation, interview, and review of facility documents it was determined that the facility failed to practice proper hand hygiene for 1 of 2 nurses observed during medication administration. The deficient practice was evidenced by the following: On 6/27/24 at 8:36 AM, the surveyor observed Licensed Practical Nurse (LPN #2) take the Blood Pressure (BP) of an unsampled resident. LPN #2 then cleaned the BP cuff with a disinfectant wipe, removed his gloves, and proceeded to the medication cart to prepare the unsampled resident's medication. At that time, LPN #2 did not perform hand hygiene. On 6/27/24 at 9:08 AM, LPN #2 donned (put on) gloves, administered the unsampled resident's medication and then doffed (removed) his gloves. At that time, LPN #2 did not perform hand hygiene. On 06/27/24 at 09:39 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that hand hygiene should be performed when donning and doffing gloves. When asked, when should hand hygiene be performed? The LPN/UM stated it should be before and after all care. She then explained it should be performed before and after donning and doffing gloves. When asked should hand hygiene be performed after cleaning equipment. The LPN/UM replied, definitely, yes. On 6/28/24 at 11:17 AM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) regarding hand hygiene. The LPN/IP stated that staff should perform hand hygiene anytime they are in contact with the resident. She explained staff should performed hand hygiene before donning gloves and after doffing gloves. She further stated that staff could either use alcohol-based hand rub (ABHR) or perform handwashing. A review of facility's policy titled Hand Hygiene, Date Reviewed/Revised 6/2023, included, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. N.J.A.C 8:39-19.4(a)

Based on interview and record review, it was determined that the facility failed to consistently document the administration of a treatment in the electronic Treatment Administration Record (eTAR) in accordance with the facility policy. This deficient practice was identified for 1 of 2 residents (Resident # 29) reviewed for nutrition and for 2 of 3 residents (Residents #90 and #195) reviewed for urinary catheter and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. According to the Admission Record, Resident #29 was admitted to the facility with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease, a condition causing difficulty breathing), hypertension (high blood pressure) and Dementia. According to the Quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care dated 09/02/22, Resident #29 had a Brief Interview for Mental Status (BIMS) score of four, which indicated the resident was severely cognitively impaired. The MDS further reflected that Resident #29 was at risk for skin breakdown, sustained one fall with no injury since the last MDS assessment and received oxygen. A review of Resident #29's electronic medical record revealed the following physician orders (PO): - An order dated 04/10/22 oxygen tubing/water bottle/wash filter: change and date tubing, water bottle if applicable, wash filter every night shift every Wednesday. - An order dated 04/11/22 to monitor tab alarm for placement/function every shift for fall risk. - An order dated 09/26/22 for Nystatin Powder Apply to under right breast topically every shift for redness. - An order dated 06/23/33 to offload heels while in bed every shift for left heel is dark, red and soft. - An order dated 06/23/ to apply skin prep for left heel is dark, red and soft. Discontinued 10/30/22. - An order dated 04/08/22 for Zinc Ointment to sacrum every shift for preventative - An order dated 07/07/22 for Zinc Oxide Ointment 10% apply to right upper buttocks topically every shift to promote skin integrity due to incontinence. A review of Resident #29's August, September and October 2022 eTAR reflected blanks for the following POs, indicating that the nurse did not document in the eTAR when the treatment was rendered: - For the order dated 04/10/22 oxygen tubing/water bottle/wash filter: change and date tubing, water bottle if applicable, wash filter every night shift every Wednesday order, blanks were noted on 08/10/22, 08/31/22 and 10/12/22 for night shift. - For the order dated 04/11/22 monitor tab alarm for placement/function every shift for fall risk order, blanks were noted on 09/09/22, 10/26/22 evening shift, and on 08/10/22, 08/31/22, 09/13/22, and 10/12/22 night shift. - For the order dated 09/26/22 for Nystatin Powder Apply to under right breast topically every shift for redness order, blanks were noted on 10/26/22 evening shift and on 10/12/22 night shift. - For the order dated 06/23/22 to offload heels while in bed every shift for left heel is dark, red and soft, blanks were noted on 09/09/22 and 10/26/22 on evening shift and on 08/10/22, 08/31/22, 09/13/22 and 10/12/22 on night shift. - For the order dated 06/23/22 to apply skin prep for left heel is dark, red and soft, blanks were noted on 09/09/22, 10/26/22 and 10/30/22 on evening shift and on 08/10/22, 08/31/22, 09/13/22, and 10/12/22 on night shift. Order was discontinued 10/30/22. - For the order dated 04/08/22 for Zinc Ointment to sacrum every shift for preventative, blanks were noted on 09/12/22 on day shift, 09/09/22 and 10/26/22 on evening shift, and 08/10/22, 08/31/22, 09/13/22, and 10/12/22 on night shift - For the order dated 07/07/22 for Zinc Oxide Ointment 10% apply to right upper buttocks topically every shift to promote skin integrity due to incontinence, blanks were noted on 09/09/22 and 10/26/22 on evening shift, and on 08/10/22, 08/31/22, 09/13/22 and 10/12/22 on night shift. During an interview with the surveyor on 11/01/22 at 9:16 AM, Licensed Practical Nurse #1 (LPN) stated that after she provided a treatment to a resident, she signed the eTAR. LPN #1 stated that it was important to sign the eTAR so that everyone would know that a treatment was completed and that the resident would not receive duplicate treatments. During an interview with the surveyor on 11/01/22 at 10:23 AM with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS), the DON stated that blanks in the electronic Medication Administration Records (eMAR) and eTARs were reviewed during the clinical meeting held Monday through Friday, by Nursing Management, consisting of the Unit Managers and the DON, where they will review for any missing documentation in the eMARs and eTARs. We try to address each concern and call each nurse who had missed documentation and tell them they have 24 hours to enter the documentation. We do not have a policy to this effect. The RDCS stated that the electronic medical record computer program will allow you 30 days to make corrections; but the facility tells nurses that they only have 24 hours to complete the documentation. During a follow up interview with surveyor on 11/02/22 at 11:55 AM, the DON, in the presence of the RDCS, stated that she expected that the eMARs and eTARs should be signed by the end of the shift. 41072 2. On 10/21/22 at 12:13 PM, the surveyor observed Resident #90 awake and alert sitting in a wheelchair in his/her room. The surveyor observed a urinary catheter drainage bag in a blue privacy bag attached to the wheelchair. According to the Admission Record, Resident #90 was admitted to the facility with diagnoses that included acute kidney failure (kidney damage), chronic kidney disease, urinary tract infection and schizophrenia. According to the most recent MDS, dated [DATE], Resident #90 had a BIMS score of 12, which indicated the resident had mildly impaired cognition. Section H reflected that Resident #90 had an indwelling urinary catheter. A review of Resident #90's PO dated 09/23/22 revealed an order for foley catheter output every shift. A review of Resident #90's October 2022 eTAR revealed a PO for foley catheter output every shift with a start date of 09/23/22. A review of Resident #90's Care Plan (CP), initiated 09/23/22, included a focus that I have a catheter secondary to urinary retention. The CP included interventions, initiated on 09/23/22, to Monitor and document intake and output as per facility policy. A review of Resident #90's October 2022 eTAR revealed that the aforementioned PO, with the administration time of day, evening, and night shifts. The TAR reflected no documentation for the foley catheter output on the following dates and times: Day shift:10/10/22, Evening Shift:10/08/22, 10/12/22, 10/14/22, 10/15/22 Night Shift: 10/02/22, 10/08/22, 10/11/22, 10/12/22,10/16/22, 10/17/22, 10/18/22 38679 3. On 10/21/22 at 12:13 PM, the surveyor observed Resident #195 in bed watching television. The surveyor observed a foley drainage bag, covered with a blue flap, attached to the resident's bed. When interviewed, Resident #195 had no concerns with the care being provided for his/her foley catheter. According to the Admission Record, Resident #195 was admitted with diagnoses that included, but were not limited to, hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine,) dementia, obstructive uropathy (a condition in which the flow of urine is blocked) and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney,) and retention of urine. A review of the Admission MDS, dated [DATE], revealed Resident #195 had a BIMS score of 10 which indicated that the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had a catheter and required extensive assistance with toilet use. A review of Resident #195's CP, initiated 10/14/22, included a focus that I have an indwelling foley catheter due to obstructive uropathy and urinary retention. The CP included interventions, initiated on 10/14/22, to Monitor and document intake and output as per facility policy and catheter output. Review of Resident #195's October Order Summary Report (OSR), for active orders as of 10/28/22, revealed an PO, dated 10/14/22, to Monitor Catheter output every shift. every shift for monitoring. Review of Resident #195's October 2022 eTAR revealed the aforementioned PO, with the administration time of day, evening, and night shifts. The eTAR reflected no documentation for the foley catheter output on the following dates and times: Day shift: 10/17/22, 10/18/22 and 10/24/22 Evening Shift: 10/25/22 and 10/26/22 Night Shift: 10/16/22, 10/17/22, 10/18/22, 10/20/22, and 10/25/22. During an interview with the surveyor on 10/27/22 at 12:27 PM, the Certified Nursing Assistant (CNA) stated she would empty the catheter drainage bag and give the amount to the nurse who would document the amount in the electronic medical record (EMR). During an interview with the surveyor on 10/28/22 at 11:01 AM, LPN #2 stated the nurse should add up the resident's total urine output for their shift and document the total amount in the eTAR by the end of their shift. The LPN further stated is was important to monitor and record the resident's output to ensure the resident was not dehydrated and was getting enough fluids. During an interview with the DON on 11/01/22 at 10:23 PM, the DON stated that she reviewed the resident's EMR and confirmed the blanks noted in the October 2022 eTAR. The DON stated the CNAs documented the resident's output on their assignment sheet, which were kept in a binder on the unit. The DON added that she expected the nurse to communicate with the CNA to get the resident's output and then document the output amount in the eTAR by the end of their shift. The DON added that late documentation should be completed within 24 hours. The surveyor reviewed the facility's Documentation of Treatment Administration policy, revised April 2022, revealed that a nurse or Certified Aide (where applicable) shall document all treatments administered to each resident on the resident's TAR. The policy further reflected that administration of a treatment must be documented after (never before) it is given. Documentation of procedures and treatments will include care-specific details, including g: the signature and title of the individual documenting. NJAC 8:39-11.2 (b); 27.1(a)

Based on interview and record review, it was determined that the facility failed to accurately complete an Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for a resident. This deficient practice was identified for 1 of 25 residents reviewed (Resident #73) and was evidenced by the following: Review of the 08/07/22 Annual MDS for Resident #73 reflected in Section C Cognitive Patterns, that Subsections C0100, C0200, C0300, C0400, C0500 C0600, C0700, C0900, and C1000 were not assessed. The MDS further reflected in Section Q Participation and Goal Setting that Subsections Q0100, Q0300, Q0490, Q0500, Q0550 were not assessed. Review of Section Z Assessment Administration in subsection that Subsection Z0400 Signature of Persons Completing the Assessment reflected that the MDS Coordinator completed Sections C and Q. During an interview with the surveyor on 11/01/22 at 9:01 AM, the MDS Coordinator stated that at the time the MDS assessment was completed, the facility did not have a Social Worker who would usually completed Sections C, D and Q of each MDS. The MDS Coordinator reviewed Resident #73's 08/07/22 Annual MDS, in the presence of the surveyor, and stated that Sections C, D and Q should have been completed. The MDS Coordinator added that she was working remotely and could not complete the resident interview. The MDS Coordinator stated that it was the responsibility of each department to complete their assigned sections; and if not completed, she gave them reminders to complete them. The MDS Coordinator further stated that each department should be looking daily at MDS in progress tabs to make sure their sections were completed. She added that the MDS program did not alert her when a section was not assessed. During an interview with the surveyor on 11/01/22 at 10:50 AM, the Social Worker stated that she started her position as Social Worker on 08/08/22. She confirmed that she did not complete this assessment and normally she completed Sections C, D and Q of each MDS. During an interview with the surveyor on 11/02/22 at 11:25 AM, the Director of Nursing (DON), in the presence of the Regional Director of Clinical Services, stated the MDS Coordinator was working remotely and was ultimately responsible for the completion of the MDS. The DON added that sections C and Q were normally done by Social Worker but the Unit Manager was new and completed those sections. The DON stated that she expected the MDS Coordinator to let her know that the sections were not assessed. The DON further stated she expected the Sections of the MDS to be completed. Review of the facility's RAI Process Operational Manual - Administrative Policies policy, reviewed 03/22, reflected that the facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS [Centers for Medicaid] RAI MDS 3.0 Manual. The policy further reflected that all information recorded within the MDS Assessment must reflect the resident's status. NJAC 8.39 - 11.1

Based on observation, interview, review of medical record and the review of other facility documentation, it was determined that the facility failed to ensure that Personal Protective Equipment (PPE) was utilized in accordance with facility policy and in accordance with the Center for Disease control and Prevention (CDC) and New Jersey Department of Health (NJDOH) guidelines to prevent the spread of Covid-19. This deficient practice was identified for 7 of 9 staff members observed on 2 of 3 residents' units, during the Focused Infection Control Survey on 2/3/2021 and was identified by the following : On 2/3/21 at 09:47 AM, the surveyors conducted an entrance conference with the facility administrative team which included: the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Assistant Director of Nursing (ADON) who was also the Infection Preventionist (IP). The IP informed the surveyors that the entire facility was on Transmission Based (TBP) Precautions and that they used N95 or KN95 masks with goggles/face shield for eye protection. The IP further stated that staff used face shield if they wore the KN95 mask and could use goggles if they wore N95 mask on all the units. The DON and the IP stated that the facility had three residents' units which included: Mallard, Harbor and Comfort Zone units. The IP stated that Mallard and Harbor units were the negative, non Covid-19 units, and that Harbor Comfort Zone unit was separated into three areas that included; Covid-19 area, Observation unit and an area designated for Persons Under Investigation (PUI). The IP added that all staff members were expected to don N95/KN95 masks, goggles or face shield and gloves when they go into residents's rooms on Harbor and Mallard, non-Covid-19 units. She stated that staff were expected to don N95/KN95 masks, goggles or face shied, gown and gloves when they go into the rooms of residents on the observation, PUI and Covid-19 positive units (Comfort Zone). 1. On 2/3/21 at 10:15 AM, the surveyor went to the Mallard unit and observed a staff member in the hallway as she moved clean linen from the laundry cart onto the unit linen cart. The surveyor interviewed the staff member who identified herself as a housekeeper and laundry aide (HK/LA). The surveyor noted that the HK/LA wore a KN95 mask and her prescription eyeglasses instead of the face shield as required. The HK/LA was not wearing any other PPE, and according to facility policy, HK/LA did not need to wear other PPE because she was outside of a resident's room and on non-Covid-19 unit. When questioned about the use of prescription eyeglasses, she stated that was not aware that she was supposed to wear a face shield with the KN95 mask. The HK/LA added that she had training and was in-serviced in infection control measures and that she thought that her eye prescription eyeglasses was an appropriate eye protection with the KN95 mask. 2. At 10:35 AM, the surveyor observed another staff member as he approached the nurses' station on the Mallard unit. The surveyor noted that he wore a surgical mask with regular prescription eyeglasses. Upon interview, he identified himself as an Assistant Director of Maintenance (ADM#1). The ADM#1 was not wearing any other PPE which was in accordance with the facility policy. When questioned about his wearing a surgical mask with regular prescription eyeglasses, the ADM#1 stated that he believed that was the proper PPE for him to wear because he did not work with residents and because he was on Mallard unit which was a non-Covid-19 unit. 3. At 10:38 AM, the surveyor observed a Licensed Practical Nurse (LPN), who was standing by the medication cart near a resident's room in the hallway on the Mallard unit. The surveyor noted that the LPN wore a KN95 mask with her prescription eyeglasses instead of a face shield as required. When interviewed, she stated that she usually wore a KN95 mask with her prescription eyeglasses to go into residents' rooms because she was on the non-Covid-19 unit, and that she was told that eyeglasses were an appropriate eye protection on negative, non-Covid-19 unit. The LPN was not wearing any other PPE. 4. At 10:51 AM, the surveyor observed as a staff member wheeled Resident #5 out of the bathroom in their room on the Mallard unit. The surveyor noted that the staff member wore a KN95 mask with a prescription eyeglasses instead of a face shield as required. When interviewed, she identified herself as a Certified Nursing Assistant (CNA#1). The surveyor noted that CNA#1 was not wearing any other PPE. She stated that the facility gave her goggles but the goggles do not fit over her prescription eyeglasses. CNA #1 then reached into her pocket, pulled out the goggles and showed to the surveyor. She stated that she had not informed the IP or the DON that the goggles did not fit. According to facility policy, CNA#1 was supposed to wear a KN95 with a face shield in a resident's room on the Mallard unit. Review of the medical record and test results showed that Resident #5 tested negative for Covid-19 on a rapid Covid-19 test done on 2/1/21. At 11:05 AM, the surveyor interviewed the IP. She stated that CNA#1 should not have used her prescription eyeglasses in place of goggles or face shield and that regular prescription eyeglasses was not an appropriate eye protection for staff. 5. On 2/3/21 at 11:27 AM, while the surveyor was on the Mallard unit near the plastic curtain demarcation between the negative, non-Covid-19 unit and the observation unit, a staff member exited through the plastic curtain from the observation unit and walked onto the hallway of the negative, non-Covid-19 unit, wearing a KN95 mask and no other PPE. When interviewed, the staff member identified herself as a housekeeper (HK) and stated that she removed her gown and gloves before she left the Observation unit. At that time, she reached inside her pocket, retrieved her prescription eyeglasses and put them on. When asked about goggles or face shield , she stated that she had goggles and that it might be in my car. The HK stated that she did not have a face shield and that she had not asked for one. She added that she thought prescription eyeglasses was proper eye protection with the KN95 mask. She also acknowledged that she did receive training on infection control practices. The HK stated that she was going to the housekeeping room to obtain a new mop head and clean water. She did not enter into a resident's room. 6. At 11:50 AM, on the PUI unit, the surveyor observed a staff member (CNA#2) as she exited Resident#6's room wearing an N95 mask with no gown and no eye protection or goggles. When interviewed, she stated that she removed her gown in the resident's room and that she had worn her prescription eyeglasses which she had just placed in her pocket. CNA#2 then reached into her pocket and retrieved her eye glasses. She stated that she only wore goggles or face shield if she was going into the Covid-19 unit. Review of the medical record and test results showed that Resident #6 tested negative for Covid-19 on 1/27/21. At 11:58 AM, the surveyor toured the Covid-19 unit and observed a housekeeper in the hallway as she prepared to clean residents' rooms. The surveyor noted that she wore full PPE appropriately - gown, gloves, N95 mask and face shield. 7. At 12:05 PM, the surveyor observed a staff member on the observation unit hallway. The surveyor noted that the staff member wore KN95 mask with a cloth mask covering the KN95. She was not wearing any other PPE. When interviewed, the staff member identified herself as a non - Certified Nursing Assistant (NA). She stated that she just started to work at the facility two days ago and that she was on orientation with CNA #2. The NA stated that she normally wore goggles but because she was wearing her prescription eye glasses, the goggles did not fit over the glasses. She stated that she did not know that she was not supposed to use her prescription eyeglasses with the KN95 mask. Review of the facility's policy dated 8/2020 and titled: Equipment- Using Eye glasses indicated to use masks and eye protection devices such as goggles or glasses with solid side shields or chin-length face shield. The policy further reflected that eyeglasses should not be considered as adequate protective eye wear. 8. On 02/03/21 at 11:43 AM, the surveyor observed Resident #1's room on the Comfort Cove (observation PUI unit). There was a sign on the wall next to the door to the resident's room noting that the resident was on respiratory/droplet precautions. The surveyor also observed a second sign on the wall which indicated that the required Personal Protective Equipment (PPE) to enter the room included; N95 mask or higher respirator, face shield or goggles, clean non-sterile gloves, and an isolation gown. The surveyor observed a staff member enter the room wearing a KN95 mask and prescription eyeglasses without gown or gloves. The surveyor observed the staff member use his bare hands to take the television remote control from the resident's table and start to work on the resident's television (TV). The surveyor also observed the staff member place his bare left hand directly onto Resident #1's dresser. When the staff member finished fixing the resident's TV, he washed his hands and left the room. The staff member did not enter any other resident's room and went directly to the maintenance area. During an interview at 11:46 AM, the staff member identified himself as a maintenance worker (Assistant Director of maintenance-ADM#1). ADM#1 stated that the Comfort Cove unit, which was the PUI/Observation unit, had no isolation precautions. ADM#1 further stated if a resident was on precautions, there would be signs at the room and a plastic bin containing PPE needed to be worn in the room. The surveyor then walked with ADM#1 back to Resident#1's room entrance. At that time, ADM#1 saw the signs and PPE bin. He then stated that he had not noticed the plastic bin of PPE nor the isolation signs at the resident's room door. He stated that he was aware of the plastic barrier at the end of the hall that separated the Covid area from the other residents and that he was the one who hung the plastic barrier up. He added that he recently had an in-service about two weeks ago on how and when to wear PPE and that he only had to wear full PPE (gown, gloves and face shield) if he was on the Covid-19 positive unit. He acknowledged that he directly touched the resident's environment with his bare hands and stated that he should have worn gloves. Review of the Admission Record for Resident #1 revealed that Resident #1 was readmitted to the facility the day before and had a negative rapid Covid-19 test on 2/2/2. The medical records also showed that another Covid-19 test was collected from the resident and sent out to the laboratory with results pending. The surveyor noted that Resident #1 had a physician's order dated 2/2/21 for respiratory and droplet isolation precautions until 2/16/21. Resident #1's care plan revealed a focus for isolation precautions for respiratory/droplet and contact isolation with interventions that included but not limited to; staff to wear proper PPE- gown, mask, face shield, goggles and gloves in the resident's room. During an interview at 11:58 AM, the Registered Nurse Unit Manager (RN/UM) for the Observation/PUI unit stated that the unit housed residents who were admitted from the hospital and were on respiratory and droplet precautions for 14 days. The RN/UM stated that staff should wear masks, goggles or face shield, gowns and gloves in the residents' rooms and that regardless of discipline, all staff members must wear full PPE. The RN/UM stated that regular prescription eyeglasses was ok to be worn in the residents' rooms. During an interview at 12:03 PM, the IP stated that staff were required to wear gowns, gloves, and eye protection in the rooms on the Observation/PUI unit. The IP also acknowledged that prescription eyeglasses were not acceptable to wear in the respiratory and droplet precaution rooms because there are no solid sides to the glasses, and that glasses do not offer full protection. The IP added that she in-serviced all staff members on proper PPE to done and that staff probably misunderstood what eye wear meant. The IP and the DON did not address how staff were monitored to ensure they wore proper PPE consistently. The surveyor reviewed in-service education that was provided by the IP, and it showed that the above staff members received in-service education on infection control/PPE. During an interview at 12:17 PM, the staff member responsible for PPE supplies stated that the facility had multiple cases of face shields, goggles, N95 masks, disposable PPE gowns, surgical masks, gloves, and coveralls and that they did not have any issues with PPE supply. The surveyors inspected two supply rooms for PPE and noted that the facility had adequate PPE supplies. Review of the facility signage on the PUI unit and the Observation unit revealed that all employees who enter into PUI/Observation units must wear appropriate PPE and eye protection in the form of goggles or face shield, and N95 mask and to wear gowns and gloves when entering a resident's room. Review of the facility policy titled: Coronavirus, Prevention and Control policy dated 8/21/20, indicated that staff will don an N95 mask or equivalent when entering the room of a resident with suspected or confirmed coronavirus. And that Face shields will be utilized during procedures that generate splash or aerosol. Review of the facility policy titled: Infection Control Protective Equipment-Using Gowns, dated 8/20, revealed to use gowns when indicated or instructed. NJAC 8:39-19.4; 27.1

Based on interview and record review, it was determined that the facility failed to a.) follow acceptable standards of nursing practice by administering the wrong medication to a resident and b.) consistently document the administration of an as-needed (PRN) medication in the electronic Medication Administration Record [REDACTED]. This deficient practice was identified for Resident #45, 1 of 27 residents reviewed for medication and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. According to the Admission Record, Resident #45 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Record further revealed that the resident was allergic to [MEDICATION NAME] (a form of narcotic medication used to treat pain). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/24/19, Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #45's March 2020 Order Summary Report (OSR) revealed a physician order, dated 02/17/20, for [MEDICATION NAME] 5-325 mg (milligram) two tablets orally every four hours PRN for severe pain. A review of Resident #45's March 2020 eMAR indicated the resident was administered two [MEDICATION NAME] tablets on 03/07/20 at 1:33 PM. A review of Resident #45's Progress Notes revealed a Nurse Note (NN), dated 03/07/20, that the resident was given two tablets of Tylenol with [MEDICATION NAME] instead of two tablets of [MEDICATION NAME] 5-325 mg and that the resident was allergic to [MEDICATION NAME]. The NN further revealed Resident #45's physician was notified and ordered for the resident to be monitored. Resident #45's progress notes also revealed that the resident was monitored per the physician order [REDACTED]. The surveyor reviewed the Medication Administration Error form (Report), provided by the Director of Nursing (DON), which confirmed that the Licensed Practical Nurse (LPN #1) administered two tablets of Tylenol with [MEDICATION NAME] instead of two tablets of [MEDICATION NAME] 5-325 mg. The Report revealed that LPN #1 did not correctly check medication bingo card (a card that holds individual doses of a medication). The Report further revealed that Resident #45 had no adverse reactions to the Tylenol with [MEDICATION NAME]. The surveyor reviewed Resident #9's (an unsampled resident) Individual Patient's Controlled Drug Record form (narcotic declining inventory sheet) which reflected that two tablets of Tylenol with [MEDICATION NAME] were removed for Resident #45 on 03/07/20 at 1:30 PM. During an interview with the DON on 03/11/20 at 11:49 PM, the DON stated she was called by LPN #1 and informed of the medication error on 03/07/20. The DON further stated that LPN #1 pulled the wrong medication bingo card by mistake and realized she gave the wrong medication during the change of shift narcotic count. During a follow-up interview with the DON on 03/11/20 at 2:04 PM, the DON stated she expected the nurses to check the medication bingo card against the physician's orders [REDACTED]. 2. A review of Resident #45's declining inventory sheet for [MEDICATION NAME] revealed the following: 1. [MEDICATION NAME] was documented as administered on 03/07/20 at 6:00 PM. A review of Resident #45's eMAR reflected that there was no documentation of the 03/07/20 at 6:00 PM administration. 2. [MEDICATION NAME] was documented as administered on 03/08/20 at 8:45 AM. A review of Resident #45's eMAR reflected that there was no documentation of the 03/08/20 at 8:45 AM administration. 3. [MEDICATION NAME] was documented as administered on 03/08/20 at 2:00 PM. A review of Resident #45's eMAR reflected that there was no documentation of the 03/08/20 at 2:00 PM administration. 4. [MEDICATION NAME] was documented as administered on 03/08/20 at 6:00 PM. A review of Resident #45's eMAR reflected that [MEDICATION NAME] was administered on 03/08/20 at 4:40 PM. During an interview with the DON on 03/11/20 at 12:09 PM, the DON confirmed that the nurse did not sign the eMAR on 03/07/20 at 6:00 PM, 03/08/20 at 8:45 AM, and 03/08/20 at 2:00 PM as documented on the narcotic declining inventory sheet. The DON further stated that the nurse documented the [MEDICATION NAME] administration in the Progress Notes on 03/07/20 for the 6:00 PM administration and on 03/08/20 for the 8:45 AM administration. At which time, the DON stated the nurse did not make a notation in the Progress Notes for the 2:00 PM administration of [MEDICATION NAME] on 03/08/20. The DON stated she expected the nurse to check the physician order [REDACTED]. The nurse would administer the medication to the resident and then return to the medication cart to sign the eMAR. A review of Resident #45's Progress Notes revealed a NN, with the effective date of 03/07/20 at 9:11 PM, which indicated that [MEDICATION NAME] 5-325 mg was administered at 6:00 PM. The Progress Notes also reflected a NN, with the effective date of 03/08/20 at 12:26 PM, which indicated that [MEDICATION NAME] 5-325 mg was administered at 9:00 AM. During a follow-up interview with the surveyor on 03/11/20 at 4:04 PM, the DON stated it was not a practice for the nurse to write a NN instead of signing the eMAR. The DON further stated that the nurses were supposed to sign the eMAR after the medication was administered to the resident. On 03/12/20 at 9:35 AM, the surveyor interviewed LPN #1, who did not sign the eMAR on 03/08/20 at 8:45 AM and 2 PM and who also administered the wrong medication to Resident #45 on 03/07/20. LPN #1 stated she would check the physician's orders [REDACTED]. LPN #1 further stated she would then remove the medication from the medication bingo card and sign the narcotic declining inventory sheet right away. LPN #1 stated she would also check the resident's armband to ensure it was the right resident and then administer the medication. LPN #1 stated she would return to the medication cart and sign the eMAR after administering the medication to the resident. When questioned about not signing the eMAR, LPN #1 stated it was human error. LPN#1 further stated that she self-reported the medication administration error to the shift supervisor, DON, and Medical Director on 03/07/20. During an interview with the surveyor on 03/12/20 at 2:07 PM, Resident #45 confirmed he/she was given the wrong medication but did not have any adverse reactions. The surveyor reviewed the facility's Administering Medications policy, dated February 2019, provided by the DON. The policy revealed that the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The policy also revealed that allergies [REDACTED]. The policy further revealed that the individual administering the medication must initial the resident's eMAR to document administration after giving the medication. NJAC 8:39-11.2 (b); 27.1(a)

Based on interview and record review, it was determined that the facility failed to act on or respond to comments made by the Consultant Pharmacist promptly. This deficient practice was identified for 2 of 27 residents reviewed for physician orders [REDACTED].#205) and was evidenced by the following: 1. According to the Pharmacist's Drug Regimen Review (Pharmacist DRR) progress note, dated 02/14/20, the Pharmacist Consultant (PC) made a recommendation for Resident #16 PRN (as needed) [MEDICATION NAME] used routinely. A review of Resident #16's Order Summary Report (Summary Report) for Active Orders as of 02/01/20 revealed an order, dated 01/21/20, for [MEDICATION NAME] 5-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) every eight hours as needed for pain. A review of the January 2020 Electronic Medication Administration Record [REDACTED]. A review of the February 2020 eMAR revealed Resident #16 received the medication on 02/01/20 at 11:57 AM, 02/03/20 at 8:46 AM and 4:53 PM, 02/04/20 at 8:38 AM and 4:50 PM, 02/05/20 at 9:03 am, 02/07/20 at 8:52 AM, 02/08/20 at 9:08 AM, 02/09/20 at 9:11 AM, 02/10/20 at 9:27 AM, 02/11/20 at 9:12 AM and 5:38 PM, 02/12/20 at 9:12 AM and 5:15 PM, 02/13/20 at 9:16 AM and 6:41 PM, 02/14/20 at 9:23 AM, 02/15/20 at 5:13 PM, 02/16/20 at 8:20 AM and 5:02 PM, 02/17/20 at 9:16 AM, 02/18/20 at 9:24 AM, 02/19/20 at 9:27 AM, 02/20/20 at 8:54 AM and 5:00 PM, 8/21/20 at 8:56 AM and 5:22 PM, 02/22/20 at 8:51 AM, 02/23/20 at 9:21 AM and 6:01 PM, 02/24/20 at 9:43 AM, 02/25/20 at 9:13 AM and 4:44 PM, 02/26/20 at 8:57 AM and 5:03 PM, 02/27/20 at 9:09 AM, 02/28/20 at 8:58 AM and 5:06 PM, and 02/29/20 at 11:58 AM and 8:02 PM. A review of the March 2020 eMAR revealed Resident #16 received the medication on 03/01/20 at 8:11 AM and 4:30 PM, 03/02/20 at 2:09 PM, 03/03/20 at 9:37 AM and 5:50 PM, 03/04/20 at 8:00 AM and 5:06 PM, 03/05/20 at 8:43 AM and 4:42 PM, 03/06/20 at 8:21 AM and 4:22 PM, 03/07/20 at 8:50 AM, 03/08/20 at 8:40 AM and 5:57 PM, 03/09/20 at 9:43 AM, and 03/10/20 at 8:59 AM. A review of the Physicians Progress Note, dated 02/20/20 at 12:43 PM, revealed that the physician did not address the recommendation of the PC. During an interview with the surveyor on 03/10/20 at 11:07 AM, the Unit Manager (UM) and surveyor reviewed the PC recommendation dated 02/14/20. The UM stated that she normally reviewed the PC recommendations with the physician to see if he agreed or disagreed with the recommendation. The UM further stated that she was behind and did not address the PC's 02/14/20 recommendation with the physician. During an interview with the surveyor on 03/11/20 at 10:21 AM, the Director of Nursing (DON) confirmed that Resident #16 had a PRN order for [MEDICATION NAME] during January, February and March 2020 and the medication was used routinely. The DON reviewed the Physicians Note, dated 02/20/20, with the surveyor and confirmed that the physician did not address the PC recommendation. 2. According to the Pharmacist DRR progress note dated 12/20/19, the PC made a recommendation for Resident #205 PRN [MEDICATION NAME] used routinely. Please re-evaluate psych meds. A review of the Summary Report for Active Orders as of 10/01/19 to 03/31/20 revealed that Resident #205 had an order, dated 10/29/19, for [MEDICATION NAME] 0.25 mg every 12 hours as needed for anxiety and an order, dated 01/03/20, for [MEDICATION NAME] 0.25 mg every 12 hours as needed for anxiety. A review of the October 2019 eMAR revealed Resident #205 did not receive the PRN [MEDICATION NAME]. A review of the November 2019 eMAR revealed Resident #205 received the medication on 11/12/19 at 9:04 PM, 11/15/19 at 10:35 PM, 11/20/19 at 2:01 AM, 11/21/20 at 6:45 PM, 11/23/19 at 6:06 PM, 11/25/19 at 1:06 AM, 11/26/19 at 2:30 AM and 11:30 PM, 11/28/20 at 12:37 AM, 11/29/19 at 12:51 PM, and 11/30/19 at 2:51 AM. A review of the December 2019 eMAR revealed Resident #205 received the medication on 12/01/19 at 12:46 AM, 12/02/19 at 1:59 AM, 12/03/19 at 1:54 AM, 12/04/19 at 1:48 AM, 12/05/19 at 12:51 AM, 12/06/19 at 2:24 AM, 12/07/19 at 3:10 AM, 12/08/19 at 2:58 AM and 5:25 PM, 12/09/19 at 11:52 PM, 12/11/19 at 12:45 AM, 12/12/19 at 1:07 AM, 12/13/19 at 12:19 AM, 12/14/20 at 12:35 AM, 12/15/19 at 12:06 AM, 12/16/19 at 12:34 AM and 10:19 PM, 12/18/19 at 3:00 AM, 12/19/19 at 2:51 AM and 7:41 PM, 12/22/19 at 1:19 AM, 12/23/19 at 12:43 AM and 11:07 PM, 12/25/19 at 2:02 AM, 12/26/19 at 2:28 AM, 12/27/19 at 2:07 AM and 11:48 PM, 12/28/19 at 11:50 PM, 12/30/19 at 12:49 AM, and 12/31/19 at 1:30 AM. The December 2019 MAR further revealed that the medication was discontinued on 01/02/20. A review of the January 2020 eMAR revealed Resident #205 received the medication on 01/04/20 at 2:27 AM, 01/05/20 at 2:05 AM, 01/06/20 at midnight, 01/07/20 at 1:28 AM, 01/08/20 at 12:01 AM, 01/09/20 at 2:00 AM and 11:29 PM, 01/11/20 at 4:25 AM, 01/12/20 at 2:37 AM, 01/14/20 at 12:40 AM, 01/15/20 at 12:51 AM and 8:20 PM, 01/16/20 at 11:32 PM, 01/18/20 at 1:57 AM, and 4:28 PM. The January 2020 MAR further revealed that the medication was discontinued on 01/21/20. During an interview with the surveyor on 03/10/20 at 8:20 AM, the Unit Manager (UM) stated that the PC reviewed each resident's medications monthly and made recommendations. The UM stated she reviewed the PC's recommendations and addressed each recommendation with the physician as soon as she could. The UM, in the presence of the surveyor, reviewed the PC's recommendation dated 12/20/19. The UM stated that she was behind and did not address the PC's recommendations. During an interview with the surveyor on 03/10/20 at 8:55 AM, the DON stated that the PC came in monthly to review the resident's medications. The PC would print out his recommendations when he was in the facility and give them to the UM, DON, and the Assistant DON. The UM was responsible for completing and reviewing the PC's recommendations with the physician and it was expected that the recommendations would be reviewed and completed by the UM within a day or two of receipt of the recommendations. During a follow-up interview with the surveyor on 03/11/20 at 10:34 AM, the DON reviewed the Physicians Progress Note completed by the Nurse Practioner (NP) dated 01/14/20. The DON confirmed that the NP did not address the PC's recommendation. During an interview with the surveyor on 03/12/20 at 9:35 AM, the NP stated that she usually addressed the PC's recommendations in her progress notes and that sometimes she and the UM would go through them. The NP stated that she usually ordered a medication for 14 days at a low dosage and then re-evaluated the medication. At 10:19 AM, in the presence of the surveyor, the NP reviewed the Physicians Progress Note dated 01/14/20. The NP confirmed that she did not discuss the risk versus benefit of the medication in the progress note. A review of the facility's Medication Regimen Review policy, revised in April 2007, revealed, The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. Upon receipt of the report, the facility shall address recommendations with a reasonable time frame. NJAC 8:39-29.3

Based on observation, interview and record review, it was determined that the facility failed to maintain clean and sanitary resident rooms for 2 of 23 rooms reviewed, (Residents #60 and #100). This deficient practice was evidenced by the following: During the initial tour of the facility on 03/03/20 at 11:07 AM, the surveyor observed Resident #60 lying in bed. The resident did not respond to the surveyor during this or on subsequent surveyor visits. The surveyor observed that the resident's oxygen concentrator had an accumulation of dust on its surface. Along the floor to wall juncture behind the head of the resident's bed, the surveyor observed a television remote control and packaging from a small piece of medical equipment. There was also a visible white powder along the area where the cove molding met the floor. On the pole and base of the resident's tube feeding pole, there were dried brown spills that were consistent with the color of the resident's tube feeding formula. The surveyor observed these same conditions on room visits on 03/04/20 at 12:32 PM and 03/05/20 at 9:28 AM. On 03/04/20 at 1:22 PM, the surveyor observed Resident #100 in bed. At that time, Resident #100 had two family members visiting, who stated that the resident was almost always in bed. The surveyor observed that the brown-colored laminate of the bed's footboard was torn off on one side. The particleboard on the footboard was exposed and there was black duct tape holding the rest of the laminate in place. The resident's headboard was slanted toward his/her head. The back surface of the headboard had a visible accumulation of dust on its surface. Underneath the resident's bed, near the head of the bed, there were small black disks on the floor. On 03/05/20 at 12:16 PM, the surveyor toured the unit with the Housekeeping Director (HD). At that time, the surveyor pointed out the dust on Resident 100's slanted headboard, which the HD could see and feel. The HD agreed that the headboard was dusty and said he would get housekeeping to take care of it. The surveyor showed the HD the delaminated footboard that was wrapped in duct tape. The HD stated that the condition of the footboard was such that it would not be easily cleanable. Finally, the surveyor pointed out the small black disks beneath the resident's bed. The HD stated that they tend to fall off when the head of the bed gets raised and lowered. The HD indicated that the facility was looking to replace some of the mattresses that shed the black rubber disks. On 03/05/20 at 12:26 PM, the surveyor showed the HD the room where Resident #60 was in bed. The resident's oxygen concentrator was visibly covered in dust. The HD stated that it was housekeeping's responsibility to clean the oxygen concentrators and that he would get someone to attend to it right away. The surveyor pointed out the area behind the bed, along the floor to wall juncture, where there had been a television remote control and a piece of trash for three days. At that time, the remote was placed on the resident's bedside table and the packaging for the medical equipment had been removed. The white powder that was observed along the floor to wall juncture was still visible. The HD stated that it should have been cleaned. The surveyor pointed out the brown, dried drips on the tube feeding pole. The HD stated that the dried spills could be cleaned during Carbolization (thorough cleaning) of the room. On 03/05/20 at 12:45 PM, the HD provided the surveyor with two in-services given to the housekeeping staff on 01/15/20. One described the cleaning of rooms for residents who were discharged and not expected to return to the facility. The other referred to infection control while cleaning rooms. The HD also stated that the rooms were Carbolized once a month. According to the instructions on the Carbolization Form, nursing was requested to have the residents in the room out of bed by 10:00 AM. The HD provided the surveyor with the Carbolization scheduled for February/March 2020. According to this schedule, the room where Resident #60 had been in bed during three days of observations, was to be Carbolized on 03/05/20. On 03/05/20 at 1:45 PM, the surveyor interviewed the housekeeper who was responsible for cleaning Resident #60's room. The housekeeper stated that she Carbolized the resident's room earlier in the week but did not know which day she had cleaned it. On 03/05/20 at 1:48 PM, the HD brought a new tube feeding pole for Resident #60. The surveyor reported to the HD that the housekeeper had stated she Carbolized Resident #60's room earlier this week instead of on 03/05/20 when it was scheduled to be cleaned. The HD stated that he would bring the proof of Carbolization to the surveyor that day. The HD stated that he would speak to the housekeeper and that she should have cleaned the room in accordance with the schedule. On 03/05/20 at 2:12 PM, the HD stated that he did not see a Carbolization sheet for Resident #60's room. The HD stated that he would have Resident #60's room thoroughly cleaned. NJAC 8:39-31.4 (a)(f)