Every finding on record at Stratford Manor Rehabilitation and Care Center

Based on interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure a.) the bed hold-policy that was provided to the Resident or Resident's Representative (RR) included information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, and the Resident and/or RR's information for 2 of 2 residents (Residents #2 and #16) reviewed for hospital transfer and b.) the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution, including the discharge summary for 1 of 1 resident (Resident #15) reviewed for transfer.The deficient practice was evidenced by the following: 1.On 9/15/25 at 1:24 PM, Surveyor #1 (S#1) reviewed the electronic medical records (eMR) of Resident #2, and revealed: A review of the admission Record (AR; an admission summary) or face sheet, revealed Resident #2 had been admitted with diagnoses which included but were not limited to; heart failure unspecified, other sequelae following unspecified cerebrovascular disease (stroke), hemiplegia (a neurological condition characterized by paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction affecting right dominant side, and chronic obstructive pulmonary disease (COPD; an ongoing lung condition caused by damage to the lungs) unspecified. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/22/25, reflected a brief interview for mental status (BIMS) score of 13 of 15, indicated that the resident was cognitively intact. A review of the two most recent discharge return anticipated MDS (DRAMDS), revealed that the resident had an unplanned transfer to acute hospital. On 9/16/25 at 10:28 AM, S#1 asked the Licensed Nursing Home Administrator (LNHA) for the facility's Bed Hold Notifications files. On 9/16/25 at 11:28 AM, S#1 reviewed the binder provided by the LNHA with regard to bed hold policy notifications and revealed that the resident had two bed hold notifications, dated 7/1/25 for lethargy and 9/5/25 for shortness of breath (SOB). In addition, the bed hold policy notifications (for dates 7/1/25 and 9/5/25) did not include information about the reserve bed payment policy plan, the explanation of the right to appeal the transfer, and the information to whom the bed hold policy was given. On 9/18/25 at 12:25 PM, S#1 interviewed the Director of Social Services (DSS) in the presence of another Social Worker (SW) about facility's practice and policy with bed hold notification. The DSS informed S#1 the process was when the resident was being transferred to the hospital, it was the responsibility of the social services department to fill out the Notice of Emergency Transfer and Bed Hold Policy notice (paper form) and the same form would be provided to cognitively intact resident or to the RR if the resident was cognitively impaired. The DSS further stated that the filled out form then will be filed to the binder that was provided to the surveyor. On that same date and time, S#1 asked the DSS if there were documentation to whom the bed hold policy notice was given and if the reserve payment was provided to the resident or RR in the language that they were able to understand. The DSS responded that the social services mail the same filled out form or given to the resident and there was no evidence it was sent because it was sent as a regular mail and not as registered mail. The DSS further stated that there was no other documentation about reserve payment and other information except for the filled out. Furthermore, S#1 asked the DSS if she was aware of the regulation about notifying the resident or RR of the reserve payment for bed hold, and she responded that she was unaware. The DSS confirmed that the bed hold policy form in the Notice of Emergency Transfer had no reserve payment and no information whom the form was provided. On 9/19/25 at 12:18 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional Nurse, Chief Nursing Officer (CNO), Director of Operations (DoO), and [NAME] President of Operations (VPoO), and S#1 notified them of the above concerns with Resident #2's bed hold policy notices for 7/1/25 and 9/5/25. On 9/22/25 at 10:33 AM, the survey team met with the LNHA, DON, Regional Nurse, CNO, and the DoO. The LNHA stated that the facility's policy with regard to bed hold was updated to include the rate for bed hold and the opportunity for the resident or RR the explanation of the right to appeal the transfer. A review of the facility's Bed Hold and Ombudsman Notification Policy that was provided by the LNHA, with a reviewed date of 8/2025, revealed, there were no information about reserve payment policy plan, the explanation of the right to appeal the transfer, and the RR's information. 2. On 9/16/25 at 1:31 PM, S#1 reviewed the eMR of Resident #15, and revealed: A review of the AR revealed Resident #15 had been admitted with diagnoses which included but were not limited to; cerebral infarction (stroke), encounter for palliative care, type 2 diabetes mellitus with mild non proliferative diabetic retinopathy without macular edema bilateral, aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction, major depressive disorder recurrent and specified, and unspecified psychosis not due to a subacute or known physiological condition. A review of the current personalized Care Plan (CP) with focus that the resident planned to remain for long term care, that was created and revised on 3/19/23. There was no documented evidence the resident had CP for transfer to another facility. A review of the Social Service quarterly progress notes (PN) with an effective date of 6/12/25, revealed that long term care remained appropriate. A review of the quarterly MDS (qMDS), with an ARD of 9/1/25, reflected C1000. Cognitive Skills for Daily Decision Making was coded #2, indicated that the resident cognition was moderately impaired. The qMDS also reflected that the resident participated in the assessment and goal setting and there was no plan for discharge (d/c). A review of the recent discharge return not anticipate Minimum Data Set (DRNAMDS), revealed that the resident had a planned transfer to hospice institutional facility. A review of the Miscellaneous tab of eMR revealed hospice meeting dates for 7/15/25 and 8/12/25 that were uploaded on 9/10/25, there was no documented evidence about plan to transfer to another hospice facility. A review of the monthly nursing comprehensive summary in the PN dated 9/1/25, reflected that resident observed to be much calmer and cooperative. The PN also include that the resident's sleep pattern was good and no change in ADL (activities of daily living) function. A review of the PN revealed that there was no documented evidence that the physician documented and was aware of the plan to transfer Resident #15 to another facility or hospice facility prior to transfer on 9/11/25. The last physician PN was from 9/1/25 with documentation that there was no new issues with the resident. A review of the Social Service PN created on 9/11/25 at 11:51 AM, reflected that the DSS documented that the resident was scheduled for transfer to another facility, notified the RR of transfer, transportation was arranged for pick up at 1:00 PM, and nursing was made aware of transfer. There was no documented evidence that the physician was notified of the transfer and the order was obtained. A review of the assessment, eINTERACT Transfer Form, revealed: Description: Discharge to Hospital. Date: 9/11/25 1:42 PM. Lock Date: 9/11/25 2:06 PM. Treatment/discharge details: to [name of hospital] date 8/16/22, reason for transfer: behavioral symptoms. Resident Representative: [name of RR and phone number]. A review of the Universal Transfer Form (UTF) revealed, date of transfer 9/11/25 at 3:00 PM, transfer to, code status, reason for transfer, attached documents, sending and receiving facility contacts, form filled and completed by information were blank. The contact person was not the RR identified in the Social Service PN dated 9/11/25 at 11:51 AM, and was not in the Resident's AR or face sheet. A review of the September 2025 Order Summary Report revealed that there was no documented evidence that the physician ordered a transfer for 9/11/25 d/c to another facility. On 9/19/25 at 10:44 AM, S#1 asked the LNHA about the provided closed records of the resident, and the LNHA confirmed that there were four files from 2020 to 2023, and one physical chart. The LNHA informed S#1 that the 2024 and 2025 Resident's medical records were in the computer and nothing else. The LNHA stated that the physician notes should be in the computer (or eMR). Both S#1 and LNHA reviewed the chart and there were no documents. On 9/19/25 at 11:02 AM, S#1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) about facility's d/c and transfer practice and policy. The LPN/UM informed S#1 that there should be an order for transfer from the physician, the nurse would do the transfer assessment and the UTF, the physician or APN (advance practice nurse) would assess the resident before they leave, notify the RR of the transfer, and information should be documented in eMR. On that same date and time, S#1 asked the LPN/UM if she remembered Resident #15, and she responded yes, the resident was alert with confusion. She stated that she did not see or spoken to the RR since she started a week ago when the resident was transferred to another facility due to resident was not thriving here, with incidents with other staff, behavioral, and refused meds. She further stated that it was the responsibility of the SW to obtain an order from the physician the transfer of the resident and notify the physician. She acknowledged that there was no physician order obtained by nursing for the 9/11/25 transfer of the resident. She also acknowledged that there should be a documentation of the reason of transfer. On 9/19/25 at 11:16 AM, the LNHA informed S#1 that there was no other documentation in the chart about the resident's transfer to another facility by the physician and that the resident's physician only documented in the eMR. S#1 notified the LNHA of the above findings and concerns that there was no physician order for transfer to another facility, no documentation from the physician that he was aware of the transfer, and reason of transfer or any assessment from the physician prior to or on the date of transfer. On 9/19/25 at 11:48 AM, S#1 asked the LNHA for facility's policies with regard to planned and unplanned d/c, physician orders, and transfer to another facility. On 9/19/25 at 12:18 PM, the survey team met with the LNHA, DON, CNO, DoO, and the VPoO, and S#1 notified them of the above concerns with Resident #15's concerns with regard to transfer to another facility with no physician order, no physician notes and d/c summary, discrepancies with PN, transfer form and UTF, including missing information from the UTF. S#1 also notified the concern about missing and discrepancies with documentation, communicating these information to the receiving provider was one way the facility can reduce the risk of complications and adverse events during the resident's transition to a new setting. On 9/19/25 at 1:00 PM, the Registered Nurse/MDS Coordinator (RN/MDSC) called back and informed S#1 that the facility practice was for her to ask the SW if the resident's d/c information, the date, where to transfer, and reason for transfer. She also stated that she review the medical records for physician order for d/c or transfer. She confirmed that the information about d/c or transfer should be in the medical records of the resident. She further stated that she was responsible for MDS assessment in Section A for completing information about the d/c or transfer. On that same date and time, the RN/MDSC stated that she remembered the resident who had a planned d/c. The RN/MDSC stated that the resident's d/c was a short notice, I was not sure if the resident was coming off hospice. The surveyor the notified the RN/MDSC of the above findings and concerns that there were no order for transfer, no documentation from the physician that he was made aware of the transfer, the transfer form, UTF, and care plan did not include information about the reason of transfer. The RN/MDSC stated, to be honest with you I did not look for order of transfer and did not look if the physician was made aware. She further stated, I assume that it was done. She also stated, I did not check also the documentation of reason of transfer. On 9/19/25 at 4:09 PM, the resident's physician called back and informed S#1 that he remembered the resident and at that time he was visiting other resident at the facility when a nurse which he could not remember the name, notified him of the plan of transfer to another facility due to behavior issues and being demented. The physician stated that was on actual d/c date 9/11/25, around after 11:30 AM because that was my usual rounds and I said okay. The physician confirmed that he did not have a privilege to another facility where the resident was transferred and that honestly, I did not know that I have to document about the resident's d/c to another facility. He confirmed that the last PN he had for the resident was on 9/1/25, and that there were no prior arrangement or meeting about resident's transfer not until 9/11/25. On 9/22/25 at 8:46 AM, S#1 met with the LNHA for Quality Assurance Performance Improvement (QAPI) meeting and S#1 asked what areas of concerns that the surveyors identified that were not discussed in the facility's most recent QAPI meeting. The LNHA stated the number one was communication, the documentation from nursing stand point, and physicians that we should have a clear pictures of what was going on with the resident with regard to d/c and transfer, and the bed hold procedure. On 9/22/25 at 10:33 AM, the survey team met with the LNHA, DON, Regional Nurse, CNO, and the DoO. The LNHA stated that the facility's policy with regard to bed hold was updated to include the rate for bed hold and the opportunity for the resident or RR the explanation of the right to appeal the transfer. The DON informed the surveyor that the hospice documented an addendum to include the d/c to another facility and attestation from the physician after surveyor's inquiry. At that same time, S#1 notified about the information provided by the physician to S#1 on 9/19/25. The LNHA stated that the physician should have documented the transfer. The surveyor also asked as to why there was no note about the plan of transfer, reason of transfer, and obtained an order transcribed to the resident's medical record, and the facility management team did not respond. A review of the facility's Discharge Plan Policy that was provided by the DON, with a reviewed date of 8/2025, revealed: Policy: The resident's needs pertaining to post-d/c care will be assessed upon admission. The Interdisciplinary care team members will perform the assessment. A plan to meet these needs will be developed and interventions to meet specific d/c planning goals will be designed. The plan will be monitored and revised as necessary throughout the nursing home stay. Procedure:.3. Physicians will inform the resident of the anticipated d/c date and treatments that will take place while in the facility.6. All disciplines will document the resident's progress or lack of progress in the interdisciplinary PN. 7. D/c instructions will be completed by Interdisciplinary team in eMR. The current d/c instruction summary will be completed and given to the resident upon d/c. On 9/22/25 at 12:18 PM, the survey team met with the LNHA, DON, Regional Nurse, CNO, and the DoO for an exit conference, and there was no additional information provided by the LNHA. 3. On 9/15/25 at 10:51 AM, the Surveyor #2 (S#2) observed Resident #16's room with Enhanced Barrier Precaution (EBP-an infection prevention strategy) signage on the door and Personal Protective Equipment (PPE-use of gloves and gowns for direct contact) cart in the hallway. S#2 interviewed the Licensed Practical Nurse (LPN), who stated that the resident was in hospital due to the gallbladder drain that the resident had, and that was why there was an EBP signage on the doorway. On 9/16/25 at 3:02 PM, S#2 reviewed the medical records of Resident #16, and revealed: A review of the resident's AR revealed diagnoses which included but not limited to; acute cholecystitis (inflammation of the gallbladder, a small organ that stores bile from the liver), other mechanical complication of gastrointestinal prosthetic devices, and personal history of other diseases of digestive system. A review of the qMDS, with an ARD of 9/10/25, reflected a BIMS score of 15 out of 15 indicating intact cognition. Further review of the MDS, revealed that the resident was transferred on 6/13/25 to the acute care (hospital) for hypotension (blood pressure significantly lower than normal), on 7/3/25 due to right biliary drain and abdominal pain, and on 7/30/25 for cholecystostomy tube malfunction. On 9/18/25 at 2:30 PM, S#2 reviewed the Social Services and Nursing PN in the eMR regarding the discharge/transfer to the hospital on 6/13/25, 7/3/25, and 7/30/25 which included: On 6/13/25, the resident had a fall while going to the bathroom and was admitted in the hospital for hypotension. There was no documented evidence regarding Resident #16 and the RR were notified (informed) on bed reserve payment. On 7/3/25, the resident was transferred to the hospital due to right biliary drain leakage. There was no documented evidence regarding Resident #16 and the RR were notified on bed reserve payment. On 7/30/25, the resident was transferred to the emergency room due to the Nurse Practitioner (NP) order for cholecystostomy drainage system possible malfunction. There was no documented evidence regarding Resident #16 and the RR were notified on bed reserve payment. A review of the miscellaneous tab in eMR revealed a Notice of Emergency Transfer forms for the three dates above were completed but no information on reserve payment. The form did not contain a signature from the resident or RR that they were informed of the bed hold policy and did not specify who the form was given to. On 9/19/25 at 9:40 AM, S#2 interviewed the DSS in the presence of the assistant Social Worker, and reviewed the bed hold transfer notification transfer binder. S#2 asked the DSS if she was aware of the notification for bed hold reserve payments and that residents and families had to be notified, and she replied, No, I'm not aware. S#2 asked if she was aware of the regulations for reserved payment for bed hold and she replied No. S#2 asked if they had any other documentation, notifications or notes in eMR regarding bed hold transfer notifications for reserve payments, and she replied she did not have other documentation. On 9/19/25 at 12:18PM, the survey team met with the LNHA, DON, Regional Nurse, CNO, DoO, VPoO, and S#2 notified them of the concern regarding bed hold policy that the resident and RR were not informed of reserve payments for the dates of emergency transfers on 6/13/25, 7/4/25, and 7/31/25. The DoO stated that they had on admission packet upon admission for the information needed. S#2 notified the DoO that the regulation specifically explained the reserve bed payment bed hold policy to be submitted upon admission and on every emergency transfer there had to be a reissuance. S#1 also stated that the facility form did not state or include information on who was informed on the bed hold transfer because the form did not specify and there were no resident or RR signatures on the forms. NJAC 8:39-5.1(a); 5.4(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 3 medication carts observed on 1 of 2 nursing units of the facility. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 9/16/25 at 1:55 PM, the surveyor began to inspect selected medication (med) storage areas in the facility and observed the following:The surveyor in the presence of Licensed Practical Nurse (LPN) inspected the med cart identified as the East Cart. The surveyor observed a total of 19 unidentified tablets (tabs) and/or capsules (caps) located in the bottom of the 3rd drawer. The surveyor asked the LPN if they could identify the loose tabs or caps and if they should be stored that way. The LPN stated that they were in the process of cleaning out the cart and could not identify what the med was or who it was for and that it should not be stored that way since it was not clean.The surveyor showed the LPN/Unit Manager (LPN/UN) the loose medications (meds) and asked if the meds should be stored loose. The LPN/UM stated that the meds should not be in the cart that way and thought that the cart had been previously cleaned. The surveyor observed the LPN assigned to the med cart dispose of the unidentified meds in a self-contained drug disposal system. On 9/18/25 at 1:17 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discussed the above findings and concerns.On 9/22/25 at 10:33 AM, the survey team met with the LNHA, DON, Regional Nurse, Chief Nursing Officer (CNO), and Director of Operations (DoO), and the DON provided a copy of staff education for med storage and loose pills.A review of the facility's Medication Storage Policy dated reviewed June 2025, reflected under Policy: .facility to store meds in a safe and proper manner. Procedure: 1. Meds are stored in the containers in which they are received. 7.Meds are stored in an orderly manner in cabinets, drawers or carts.The LNHA did not provide any further pertinent information for med storage.NJAC 8:39-29.4(d)(g)

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 3 of 7 licensed staff of the total 10 newly hired staff reviewed, Staff Member (SM) #6, #7 and #8. The deficient practice was evidenced by the following:On 9/18/25 at 12:40 PM, the surveyor reviewed the facility provided employee files of 10 randomly selected newly hired employees of which 7 were licensed staff which included the following: 1. A review of Staff Member #6 (SM#6), a Certified Nursing Assistant (CNA), hired on 6/12/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which was not dated. There was no documented evidence that SM#6's license was verified prior to the date of hire (doh).2. A review of Staff Member #7 (SM#7), a CNA, hired on 10/2/24, had a NJDOH online Public Registry license verification printout which was not dated. There was no documented evidence that SM#7's license was verified prior to the doh.3. A review of Staff Member #8 (SM#8), a CNA, hired on 5/1/25, had a NJDOH online Public Registry license verification printout which was not dated. There was no documented evidence that SM#8's license was verified prior to the doh.4. A review of Staff Member #9 (SM#9), a CNA, hired on 12/31/24, had a NJDOH online Public Registry license verification printout which was dated 12/29/24. There was documented evidence that SM#9's license was verified upon hire.On 9/18/25 at 1:16 PM, the surveyor interviewed the Human Resources Manager (HRM), in the presence of the Director of Operations (DoO) regarding the process for new hires and license verification. The HRM stated that she would make sure their license was active and in good standing on the New Jersey website prior to the hire date. The surveyor showed the HRM and DoO the 3 SM's license verification printout that did not have a date. The DoO stated that the printer did not always print the date on it. The surveyor then showed the HRM and DoO SM #9's license verification printout that had a date on it. The DoO confirmed that SM #6, #7 and #8's license verification printouts did not have a date on them. The DoO stated that the verification was done before the doh. On 9/19/25 at 12:18 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, Chief Nursing Officer (CNO), DoO and [NAME] President of Operations (VPoO) the concern that three CNAs did not have documented evidence that their license verification was done prior to their doh.On 9/22/25 at 10:50 AM, in the presence of the DON, Regional Nurse, CNO and DoO, the LNHA stated that staff were educated on the new hire process and that moving forward to have all proper documentation upon hire.The LNHA did not provide any additional information.A review of the facility's New Hire Policy and Procedure with a reviewed date of 2/2025, included the following:1. Upon a successful completion of the facility's pre-screening process for a new hire (including but not limited to, background checks, interviews, reference checks, etc.) only than will the new hire be able to move forward with the onboarding process. A review of the facility's Resident Abuse/Neglect Misappropriation of Property Policy with a reviewed/revised date of 4/1/25, included the following:Hiring Practices/Screening of Potential Employees and VolunteersThe facility will not knowingly employ any individual who has a history of abusing other persons. Potential employees and volunteers shall be screened thoroughly through structured interviews, personal and employment reference checks, criminal background checks, and contact with State licensing boards and registries, when applicable.For any individual applying for employment as a certified nursing assistant, the New Jersey Nurse Aide Registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals and/or theft of property have been entered in the applicant's file.For any licensed professional applying for a position that may involve direct contact with a resident, his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. N.J.A.C. 8:39-43.15

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 1 resident (Residents #4) reviewed for timing of assessments.This deficient practice was evidenced by the following:Reference: According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-17, the Comprehensive admission assessment must be completed no later than the admission date + 13 calendar days.On 9/22/25 at 9:09 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #4, reflected that the resident was admitted to the facility on [DATE]. The Comprehensive (and modified) admission MDS with an assessment reference date (ARD) of 8/12/25, was completed on 8/21/25, and transmitted and accepted on 9/7/25. The MDS was completed more than 14 days of the required timeframe.On 9/22/25 at 9:33 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), who stated that the MDS assessment on a new admission was due within 14 days of admission. She further stated that she was responsible for the MDS assessments of all residents in the facility while the Lead MDS who left two months ago was responsible for scheduling MDS. She also stated that she was not at the facility for three weeks in the July 2025. She acknowledged that the admission MDS for ARD 8/12/25 was completed late and should have been completed on 8/18/25.On 9/22/25 at 10:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, Chief Nursing Officer (CNO), and the Director of Operations (DoO), and the surveyor notified them of the above concerns with late MDS of Resident #4.A review of facility's MDS Policy that was provided by the RN/MDSC, with a reviewed date of 12/2024, reflected:Policy: It is the policy and procedure of this facility to follow the latest version of the Resident Assessment Manual and CMS regulations and requirements.Purpose:1. To outline the procedure of identifying and addressing residents' strengths and needs through the RAI process.2. To provide information on the resident's condition3. To facilitate development of a comprehensive care plan (CP).4. To ensure care delivery that enhances the resident's quality of life.5. To help achieve the highest and practical level of self-sufficiency.Procedure:MDS Department1. Schedules MDS and CP Meeting in accordance to existing regulations governing RAI process.3. Assures the completeness and accuracy of the information in the MDS.5. Coordinates, signs and certifies the completion of the MDS.6. Submits MDS data in required format to CMS.8. Reviews and corrects errors with the MDS Coordinator.9. Files final validation submission report.On 9/22/25 at 12:18 PM, the survey team met with the LNHA, DON, Regional Nurse, CNO, and the DoO for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.1; 11.2(e)(h)

Based on interview and record review, it was determined that the facility failed to ensure that the residents Attending Physician visited and documented monthly visits, every other month when the Advanced Nurse Practitioner (ANP) visited on the subsequent month for 1 of 28 residents reviewed (Resident #11). This deficient practice was evidenced by the following:On 9/17/25 9:31 AM, the surveyor reviewed Resident #11's hybrid (paper and electronic) medical record which revealed that the resident's attending physician had no documented visit from 5/1/24 through 12/31/24. The remaining documented visits in the resident's electronic medical record were done by the ANP for the same time frame.A review of Resident #11's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; cerebral infarction (a stroke, where blood flow to part of the brain is blocked), atherosclerotic heart disease (a condition of progressive narrowing and hardening of coronary arteries), and essential hypertension (high blood pressure).Further review of the resident's medical record also reflected that they were receiving hospice care, which was a specialized form of healthcare designed to provide comfort, support, and dignity to individuals in the final stages of a terminal illness.On 9/17/25 at 10:40 AM, the surveyor interviewed the Unit Manager (UM), who stated that the Medical Doctor (MD) comes in once in a while or once in a blue moon, usually probably in the evenings. The UM also stated that the ANP and the Hospice Nurse visited the resident.On 9/18/25 at 9:56 AM, the surveyor interviewed the APN, who stated that they were a contracted vendor with the facility for two years and visited three days a week. The APN further stated that they supplement physician visits, and usually sees Resident #11 alone, without the MD. The surveyor asked the APN if they recall the last time that the resident was seen and evaluated by the MD, and the APN responded that they believed it was last year.On 9/22/25 at 9:26 AM, the surveyor interviewed the UM and asked if there was anywhere else that Resident #11's MD documented other than the paper chart. The UM stated no, other than a note that was entered into the electronic medical record (EMR) on 9/4/25. On 9/22/25 at 10:58 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), The Regional Nurse, the Chief Nursing Officer (CNO), and the Director of Operations. The surveyor showed the DON Resident #11's paper chart and asked if they could locate any MD notes for the period of 5/1/24 through 12/31/24. The DON stated that they could not locate any. The surveyor asked if Resident #11's MD documents anywhere else other than the paper chart. The DON stated that the MD documented in the paper chart and only recently in the EMR.At that same time, the DON stated that APN and Hospice Nurse both see the resident and document. The surveyor asked the DON if they were aware of the regulations for MD and non-physician practitioners that reflect that an APN could only alternate with the MD every other month. The DON agreed that that was the regulation. The surveyor showed the DON and LNHA the recently provided MD notes for January 2025 through September 2025, that reflected the MD had documented monthly, not alternating as was suggested. The surveyor asked the DON if any of the notes from January 2025 through September 2025 reflected as being comprehensive progress notes. The DON stated no that they do not look like comprehensive notes. The MD notes for January 2025 through September 2025 did not reflect the resident's name or any other identifier.On 9/22/25 at 11:54 AM, the survey team met with the LNHA and DON, and the LNHA provided documentation of a Quality Assurance Performance Improvement (QAPI) report dated 9/5/25, titled Physician Visit Documentation Compliance. The facility did not provide MD progress notes for the period of 5/1/25 through12/31/25 as requested.The LNHA did not provide any further pertinent information.A review of the facility's Physician Visits Policy, dated as reviewed 12/24, reflected under Policy: It is the policy and procedure of this facility that the Attending Physician must make visits in accordance with applicable state and federal regulations. Procedure: 1. The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admissions, and then at least every sixty (60) days thereafter. 2.an alternate schedule of visits may be established, but not to exceed every sixty (60) days. A .nurse practitioner may make alternate visits. N.J.A.C. 8:39-23.2(d)

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurately documented, readily accessible, and systematically organized medical records. This deficient practice was identified for 2 of the 28 residents reviewed (Residents #2 and #15). This deficient practice was evidenced by the following:1.On 9/15/25 at 1:24 PM, The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #2, and revealed:A review of the admission Record (AR; an admission summary) or face sheet, revealed Resident #2 had been admitted with diagnoses which included but were not limited to; heart failure unspecified, other sequelae following unspecified cerebrovascular disease (stroke), hemiplegia (a neurological condition characterized by paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction affecting right dominant side, and chronic obstructive pulmonary disease (COPD; an ongoing lung condition caused by damage to the lungs) unspecified.A review of the comprehensive Minimum Data Set (MDS), with an assessment reference date (ARD) of 7/22/25, reflected a brief interview for mental status (BIMS) score of 13 of 15, indicated that the resident was cognitively intact.A review of the neurology (neuro) consult (paper consult) dated 4/25/25, revealed recommendations for CT (computed tomography scan is a non-invasive imaging procedure that uses X-rays to create detailed images of the brain and surrounding structures, helping diagnose various medical conditions) brain and neuro follow up in two months.A review of the cardiology consult (paper consult) dated 6/18/25, revealed recommendations for five day [NAME] (a portable device that continuously records the heart's electrical activity for 24 to 48 hours, helping to diagnose irregular heart rhythms) monitor given, follow up in a month, continue medications including metoprolol and apixaban. Further review of the above neuro and cardiology consults revealed that there were no documented evidence that Resident #2's physician was notified of the above recommendations for CT scan of brain and follow up with neuro in two months and the recommendations for five day [NAME] monitor and follow up in a month were followed, or as to why it was not followed.On 9/16/25 at 11:04 AM, the surveyor asked the Registered Nurse (RN) if the recommendations were followed and where were the results for 4/25/25 and 6/18/25 consults, and the RN responded that it should be with the Unit Manager (UM). The Unit Clerk (UC) who was in the nursing station also responded that the CT of the brain was not done because the resident was in and out of the facility and hospital, and the follow up was not done as well for the neuro because the CT of the brain was not done. The UC also stated that the five day [NAME] was not sent yet for results because of the same thing, the resident was in and out of the hospital. The UC confirmed that the [NAME] monitor was still at the facility and was not sent over (or returned to the office of the neurologist who provided the device). On 9/16/25 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the facility's process with regard to physician consultations. The LPN/UM stated that recommendations would be relayed to the resident's primary physician, and if the physician agreed with the recommendations, it would be carried out. She further stated, if the physician declined the recommendations, it would be documented in the progress notes (PN). The surveyor asked for documentation if the recommendations were carried out or not for neuro consult dated 4/25/25, and cardiology consult on 6/18/25, and she stated that she would get back to the surveyor.On 9/16/25 at 11:47 AM, the LPN/UM informed the surveyor that the resident's CT brain was done on 6/19/25 at the hospital. The surveyor asked where the result was and the follow up appointment notes, and the LPN/UM stated that the resident was out of the hospital that time in June 2025. The surveyor notified the LPN/UM that according to the resident's MDS, the resident was in the hospital 7/1/25, and not June 2025. The LPN/UM informed the surveyor that the [NAME] monitor was done at the facility and that she would follow up the results. The surveyor also asked where were the consult notes that the resident was seen by cardiologist and neurologist as follow up according to the recommendations, and the LPN/UM responded that she would follow up and check.On 9/16/25 at 1:05 PM, the LPN/UM provided a copy of CT head from hospital dated 6/19/25, which she confirmed that was due to resident had swelling of eyelid due to multiple falls and not due to recommendation of the Neurologist on 4/25/25. The LPN/UM stated that the [NAME] monitor and CT scan of the brain recommendations were not approved by the primary doctor. The LPN/UM confirmed that there was no documentation from the physician and the nurse that the recommendations were relayed and declined by the physician. She also stated that she was unsure why the follow up with the two consultants were not followed. She further stated that it was the facility's practice to document all those information the resident's medical records.On 9/19/25 at 12:18 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Chief Nursing Officer (CNO), Director of Operations (DoO), the [NAME] President of Operations (VPoO), and the surveyor notified them of the above concerns with Resident #2's medical records and consults that were not followed.2. On 9/16/25 at 1:31 PM, the surveyor reviewed the discharge hybrid medical records of Resident #15, and revealed:A review of the AR revealed Resident #15 had been admitted with diagnoses which included but were not limited to; cerebral infarction (stroke), encounter for palliative care, type 2 diabetes mellitus with mild non proliferative diabetic retinopathy without macular edema bilateral, aphasia (a language disorder that affects a person's ability to communicate) following cerebral infarction, major depressive disorder recurrent and specified, and unspecified psychosis not due to a subacute or known physiological condition.A review of the current personalized Care Plan (CP) with focus that the resident planned to remain for long term care, that was created and revised on 3/19/23. There was no documented evidence the resident had CP for transfer to another facility.A review of the Social Service quarterly PN with an effective date of 6/12/25, revealed that long term care remained appropriate.A review of the quarterly MDS (qMDS), with an ARD of 9/1/25, reflected C1000. Cognitive Skills for Daily Decision Making was coded #2, indicated that the resident cognition was moderately impaired. The qMDS also reflected that the resident participated in the assessment and goal setting and there was no plan for discharge.A review of the recent discharge return not anticipate Minimum Data Set (DRNAMDS), revealed that the resident had a planned transfer to hospice institutional facility.A review of the Social Service PN created on 9/11/25 at 11:51 AM, reflected that the Director of Social Services (DSS) documented that the resident was scheduled for transfer to another facility, notified the Resident Representative (RR) of transfer, transportation was arranged for pick up at 1:00 PM, and nursing was made aware of transfer. There was no documented evidence that the RR had prior notice of transfer and/or was notified of the reason of transfer to another facility.On 9/19/25 at 11:02 AM, the surveyor interviewed the LPN/UM about facility's discharge and transfer practice and policy. The LPN/UM stated that all information about resident's transfer should be documented in electronic medical records (eMR) including the notification of the RR about the reason of transfer.On 9/19/25 at 12:18 PM, the survey team met with the LNHA, DON, CNO, DoO, and the VPoO, and S#1 notified them of the above concerns with Resident #15's concerns with regard to transfer to another facility, that there was no documented evidence that the RR was notified of the transfer prior to 9/11/25 transfer and was aware of the reason of transfer. The surveyor also notified the facility management of the concerns that CP did not include information about plan to transfer the resident.On 9/22/25 at 8:46 AM, the surveyor met with the LNHA for Quality Assurance Performance Improvement (QAPI) meeting and the surveyor asked what areas of concerns that the surveyors identified and were not discussed in the facility's most recent QAPI meeting. The LNHA stated the concern of the surveyor with regard to medical records and documentation were not identified from the most recent QAPI meeting.On 9/22/25 at 11:48 AM, the survey team met with the LNHA and DON. The DON stated that she obtained a copy of the Interdisciplinary team meeting dated 9/8/25, informing the RR of the transfer. The surveyor asked why it was not presented or provided by the Director of Social Services (DSS) at the time of interview and when the surveyor asked for it on 9/19/25. The DON stated she did not know where she found the copy and shy it was not provided by the DSS. The surveyor asked for the facility's medical records policy.A review of the facility's Medical Records and Confidentiality of Information and Personal Privacy Policy that was provided by the LNHA, with a reviewed date of 6/2025, revealed there was no information about the regulation that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-(i) Complete;(ii) Accurately documented;(iii) Readily accessible; and(iv) Systematically organized.On 9/22/25 at 12:18 PM, the survey team met with the LNHA, DON, Regional Nurse, CNO, and the DoO for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-23.2 (a)(b); 34.1(a); 35.2

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/18/24 at 9:52 AM, in the presence of the Dietary Director (DD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed seven of seven oven knobs and the oven handle soiled with a brown colored substance, which was able to be lifted with the tip of a pen. In the food preparation area, the surveyor also observed 1 of 2 handles of the convection oven soiled with a brown colored substance, which was also able to be lifted with the tip of a pen. The DD stated that these areas should be cleaned. 2. In the dry storage room, the surveyor observed the following cans with dents, which were in rotation for use: - A number 10 sized can of butterscotch pudding which had a 1/2 inch dent on the upper lip of the can, - A number 10 sized can of tapioca pudding which had a 1 inch dent to the upper lip of the can, The DD stated that the cans on this shelf are in rotation for use and that there should not be any dents in them. On 4/18/24 at 1:50 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing. NJAC 8:39-17.2(g)

REPEAT DEFICIENCY Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of a medication Alendronate Sodium (Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. This occurred for one (1) of 11 residents, (Resident #25), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 4/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones. The resident added that she received his/her early morning medications all together. The surveyor reviewed the medical record for Resident #25. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture. A review of the resident's Order Summary Report reflected a physician's order (PO) dated 4/24/23 for Alendronate Sodium (Fosamax) (a medication to oral tablet 70 milligrams (MG), Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x [for] 30 minutes. A review of the April electronic medication administration record (EMAR) revealed the above PO for Fosamax had a time of administration every Monday at 6:30 AM. Further review of the EMAR revealed that there was a PO dated 3/6/24 for Pantoprazole (Protonix) (a medication used to reduce acid in the stomach) that had a time of administration of 6:30 AM and was administered every day at that time. In addition, there was a PO dated 10/12/2023 for Ferrous Sulfate (Iron) (a medication used to increase red blood cells) that had a time of administration of 6:00 AM. On 4/18/24 at 1:30 PM, the surveyor interviewed the CP via the telephone. The CP acknowledged that Fosamax had specific instructions for administration and should be administered as the first medication in the morning with no other medications for at least 30 minutes and that a recommendation should be made regarding these instructions. The CP acknowledged that the Fosamax instructions for administration were not being followed because the iron supplement had a time of administration of 6 AM. On 4/18/24 at 1:38 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON acknowledged that Fosamax had specific administration instructions that it was the first medication to be administered in the morning with no other medications. The DON also stated that she thought there would have been a recommendation from the CP and then the nurses would have to change the medication times. The DON acknowledged that the nurses were to follow cautionary warnings. The DON added that she would have to check. On 4/22/24 at 7:18 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) via telephone. The LPN stated that she had worked the 7 PM to 7 AM shift and was responsible for administering the early morning medications to Resident #25. The LPN was unsure which medications she had administered and had to check the EMAR. The LPN then stated that she had checked the EMAR and had administered all three of the resident's medications at the same time that morning because they were timed together. The LPN could not speak to the cautionary warning. On 4/22/24 at 11:50 AM, the surveyor interviewed the owner of the CP company (OCP) who acknowledged the Fosamax manufacturer's administration instructions. The OCP also stated that the cautionary warning was on the Fosamax package. The OCP added that the iron supplement time of 6 AM would have to be changed and that the Protonix could be administered without regard to meals so the 6:30 AM time should also be changed. A review of the Fosamax packaging labeled for Resident #25 that was in the medication cart reflected a cautionary warning on a red colored sticker Take 8 ounces of water at least 30 minutes before first food/beverage/drug of the day. On 4/22/24 at 1:02 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should have been aware of the instructions for Fosamax as per the PO. The DON also acknowledged the administration times on the EMAR for the resident's early morning medications had administration times that were not able to follow the specific instructions for Fosamax administration and should have been changed. A review of the facility policy for Medication Administration revised 10/2023 provided by the DON reflected for accuracy Right Drug-Compare the pharmacy label/package to the EMAR . and Right Time-Medications are scheduled to avoid drug/food interactions and per manufacturer recommendations. In addition, for medication administration general instructions included Cautionary warnings followed. A review of the manufacturer's specifications reflected Take Fosamax first thing in the morning, at least 30 minutes before you eat or drink anything or take any other medicine. The specifications also reflected, Take with a full glass (6 to 8 ounces) of plain water. Do not use coffee, tea, soda, juice or mineral water. Do not eat or drink anything other than plain water. In addition, For at least 30 minutes after taking Fosamax: Do not lie down or recline. Do not take any other medicine including vitamins, calcium or antacids. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(b)(3)

REPEAT DEFICIENCY Based on observation, interviews, record review and a review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding a.) a rationale for the length of therapy for a medication (Enoxaparin)(a medication used to reduce the risk of blood clots) from August 2023 until surveyor inquiry, b.) the appropriate documentation of vital sign parameters for a medication (Metoprolol)(a medication used to treat high blood pressure) as ordered by the physician according to standards of clinical practice and facility practice, c.) a rationale for the continued off-label use of a medication (Flomax) (a medication used to treat urinary retention usually in males) from January 2024 until surveyor inquiry and d.) following a cautionary warning for a medication (Alendronate)(Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. The deficient practices were identified for three (3) of 11 residents, (Resident #72, #103 and #25 ) reviewed for medication management. The deficient practice was evidenced by the following: 1. On 4/17/24 at 10:20 AM, the surveyor observed Resident #72 laying on the bed with eyes closed and there was one Certified Nursing Aide (CNA) inside the room. The surveyor reviewed the medical record of Resident #72. Resident #72's Admission Record (AR; or face sheet, an admission summary) reflected that the resident had diagnoses that included but were not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities), anemia (refers to low levels of healthy red blood cells), and essential hypertension (high blood pressure that doesn't have a known cause). The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an ARD (assessment reference date) of 01/04/24, included in Section C Cognitive Patterns a BIMS (brief interview for mental status) score of 4 which indicated that the resident's cognitive status was severely impaired. The qMDS showed that the resident was on an anticoagulant. The April 2024 Order Summary Report (OSR) included a physician's order (PO) with a start date of 4/04/24 for Metoprolol Tartrate tablet (tab) 25 MG (milligrams) to give one tab by mouth two times (2x) a day for HTN (hypertension), hold for SBP (systolic blood pressure) less than 110 and HR (heart rate) less than 60. A review of the resident's Pharmacy Review 2024 (or MRR) by CP#1, located in a binder which was provided by the Licensed Practical Nurse/Unit Manager (LPN/UM), revealed the last MRR date was on 4/11/24. The 4/11/24 report did not identify the irregularities regarding the absence of documentation of the resident's SBP and HR in the eMAR for April 2024. Further review of the April 2024 OSR showed that there was PO with a start date of 8/19/23 for Enoxaparin sodium injection solution prefilled syringe 40 MG/0.4 ML (milliliters), inject 0.4 ML subcutaneously one time a day for dvt (deep vein thrombosis, a blood clot in a deep vein, usually in the legs) prophylaxis. The above order for Enoxaparin was transcribed into the eMAR from August 2023 through April 17, 2024. A review of the resident's Progress Notes (PN) showed that there was no physician's documentation about indications of continued use of Enoxaparin. The Consultant Pharmacist's Reports for 2023 and 2024 revealed that the med Enoxaparin was not identified in the MRR for any irregularities. On 4/17/24 at 10:28 AM, the surveyor interviewed the Registered Nurse (RN) in the nursing station. The RN informed the surveyor that she was the assigned nurse of Resident #72. The RN stated that residents with blood pressure (bp) meds with parameters for SBP and HR should be obtained before administering meds and document the SBP and HR in the eMAR according to the facility's practice. She further stated that the SBP and HR can be seen also in the Weights & Vitals section of the electronic medical record (eMR). On that same date and time, the surveyor asked the RN if the nurse should follow the PO for Metoprolol for the resident about the SBP and HR and she responded Yes. The surveyor then asked the RN again, why the resident's April 2024 eMAR did not have documentation of the resident's SBP and HR 2x a day for the Metoprolol order. The RN stated she did not know why it was not documented. Later on, the RN acknowledged there should be documentation of 2x a day SBP and HR in the April 2024 eMAR. The RN stated that she would fix the eMAR in order for nurses to document the required SBP and HR. She indicated that when the order was entered, there was a dropdown that should have been checked to include supplemental documentation of SBP and HR. She further stated that was the reason why the SBP and HR were not documented 2x a day as supposed to be. On 4/17/24 at 10:39 AM, the surveyor interviewed the LPN/UM. The LPN/UM stated that per facility protocol, SBP, and HR parameters should have been documented in the eMAR. She further stated that the CP comes to the facility on ce a month to do MRR and it was her responsibility as a UM to act upon the CP's review and recommendations. On 4/17/24 at 01:36 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns for Enoxaparin and Metoprolol. On 4/18/24 at 9:09 AM, the surveyor called CP#2 in the presence of the survey team. CP#2 informed the surveyor that she was the CP that went to the facility monthly until January 2024 and now it was CP#1. CP#2 stated that CP#1 was unavailable and that CP#2 would answer surveyors' inquiries on behalf of CP#1. CP#2 informed the surveyor that it was her responsibility as CP to identify irregularities with meds and notify the physician and the facility, and this included the meds with parameters and justification of continued use of meds. At that same time, the surveyor notified CP#2 of the above findings and concerns. The surveyor asked CP#2 why the CPs did not identify the irregularities with Enoxaparin without indications for continued use of med from the physician and APN, and the Metoprolol parameters. CP#2 did not respond. On 4/18/24 at 11:01 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The DON and the LNHA did not provide additional information and responses for the above concerns and findings. A review of the facility's Medication Administration Policy that was provided by the DON with a reviewed date of 10/2023 included that it is the policy and procedure of the facility to provide the nursing staff with an understanding of proper med administration. On 4/19/24 at 12:25 PM, the surveyor met with the LNHA and DON. The DON and the LNHA stated that there was no additional information. 49078 2. On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status. The surveyor reviewed the electronic medical record (EMR) for Resident #103. A review of the 4/10/24 quarterly Minimum Data Sheet (MDS) ,an assessment tool used to facilitate the management of care, reflected the resident was unable to complete a brief interview for mental status (BIMS) due to cognitive impairment. The MDS section H also reflected use of an indwelling urinary catheter and was not on any toileting or weaning program. A review of the resident's active diagnoses included, Alzheimer's disease, retention of urine and infection and inflammation reaction due to indwelling urethral catheter. The surveyor reviewed the resident's medications in the EMR. The EMR reflected an order for tamsulosin, also known as Flomax, (a medication used to treat urinary retention, usually in males) with an initial date of 1/2/2024 that coincides with a readmission from the hospital. On 4/17/24 at11:09 AM the surveyor interviewed the RN who was assigned to the resident. The RN stated that the resident is scheduled to be discharged home soon and will have the catheter removed. The surveyor reviewed the manufacturer package insert for tamsulosin. The section labeled Indications and Usage did not indications for off-label use. A further review of the EMR, including the physician's progress notes, had not revealed any documentation of urinary retention or the use of tamsulosin with or without a urinary catheter. On 4/17/24 at 12:15 PM, the surveyor reviewed the CP reports from 10/23/23 to present for Resident #103. Review of the CP notes had not revealed any recommendation directed to the facility or physician requesting clarification or additional documentation regarding the rationale for use of tamsulosin with or without a catheter or in an approved indication for use or off-label use. On 4/18/24 at 9:09 AM, the surveyor interviewed CP#2 by telephone in the presence of the survey team. The CP #2 stated she comes to the facility on ce a month and was doing the medication reviews until January 2024. CP#1 now did the reviews. However, she could speak to the facility issues. The CP#2 stated she reviewed records for appropriate diagnosis and indications and was familiar with the medication tamsulosin. The CP#2 stated she would not necessarily comment on off label or unapproved use depending on what the physician was using it for. The CP#2 stated that there are studies where tamsulosin is used in an unapproved manor effectively. She also stated other studies reviewed use of the medication when weaning off a catheter to facilitate urine flow. She stated this was a common use. The CP#2 provided no further information regarding irregularities for use of tamsulosin for an off-label use with or without a catheter. On 4/18/24 at 11:06 AM, the surveyor interviewed the DON. The DON stated she had a discussion with the CP#2 and thought there were studies for an off-label indication. The DON stated that the medication was started at the hospital. The DON agreed that a continued off-label use of a medication without supportive documentation from the physician would be considered an irregularity. 34033 3. On 4/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones. The resident added that she received his/her early morning medications all together. The surveyor reviewed the medical record for Resident #25. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture. A review of the resident's Order Summary Report reflected a physician's order (PO) dated 4/24/23 for Alendronate Sodium (Fosamax) oral tablet 70 milligrams, Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x (for) 30 minutes. A review of the April electronic medication administration record (EMAR) revealed the above corresponding PO for Fosamax with a time of administration every Monday at 6:30 AM. Further review of the EMAR revealed that there was a PO dated 3/6/24 for Pantoprazole (Protonix) (a medication used to reduce acid in the stomach) that had a time of administration of 6:30 AM and was administered every day at that time. The same time of administration as Fosamax. In addition, the EMAR revealed that there was a PO dated 10/12/2023 for Ferrous Sulfate (Iron) (a medication used to increase red blood cells) that had a time of administration of 6:00 AM. The administration time was before the administration of Fosamax. A review of the Consultant Pharmacist's reports from 10/2023 to 4/2024 revealed that there was no recommendation made regarding Fosamax for Resident #25. On 4/18/24 at 1:30 PM, the surveyor interviewed the CP#2 via the telephone. The CP#2 acknowledged that Fosamax had specific instructions for administration and should be administered as the first medication in the morning with no other medications for at least 30 minutes and that a recommendation should be made regarding these instructions. The CP#2 stated that she had been the CP who was completing the reports a while ago but recently another CP#1 had been doing the reports so she could not speak for anyone else. CP#2 stated that CP#1 was unavailable for interview. On 4/18/24 at 1:38 PM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON acknowledged that Fosamax had specific administration instructions that it was the first medication to be administered in the morning with no other medications. The DON also stated that she thought there would have been a recommendation from the CP and then the nurses would have to change the medication times on the EMAR. The DON added that she would have to check. On 4/22/24 at 11:50 AM, the surveyor interviewed the owner of the CP company (OCP) who stated that there was a recommendation made on 2/13/24 regarding the Fosamax instructions for administration. The OCP provided a copy of the CP's Nursing Summary Report dated 2/13/24. The report had not been initialed by a facility staff member or had a completed date by the facility. The recommendation reflected Fosamax must be given as the first med of the day and given alone. Schedule all other meds at least 30 minutes after the administration of Fosamax (alendronate). On 4/23/24 at 9:19 AM, the survey team met with the DON who stated that the OCP had shown her the CP report with the Fosamax recommendation dated 2/13/24 but that according to her portal the facility had not received that recommendation. On 4/23/24 at 10:06 AM, the surveyor, in the presence of another surveyor, interviewed the DON and OCP. The DON stated that when she received the computerized CP report, she would print it out and give the report to the corresponding Unit Manager (UM). The DON added that the UM would complete the CP report and give back the report initialed and dated. The OCP then explained that she had a new employee who ran the report in February and that the facility had not received the whole report. The OCP also stated that the next month when the CP had reviewed the EMAR and saw that the timing of the Fosamax was not acted upon then the CP should have repeated the comment regarding Fosamax. The OCP acknowledged that there was no other recommendation made by the CP regarding Fosamax for Resident #25. The surveyor requested a Policy and Procedure for the Consultant Pharmacist reports. There was no policy and procedure provided. NJAC 8:39-29.3(a)(1)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by failing to document on the effectiveness, appropriate indication, or benefit vs risk statement for an unapproved use for one (1) of eleven (11) residents reviewed for medication management (Resident #103). The deficient practice was evidenced by the following: On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status. The surveyor reviewed the electronic medical record (EMR) for Resident #103. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 4/10/24, reflected the resident was unable to complete a brief interview for mental status (BIMS) test due to cognitive impairment. The MDS section H also reflected use of a urethral catheter (a medical device inserted into the urinary tract to allow urine to flow freely) and was not on any toileting or weaning program. A review of the resident's active diagnoses included, Alzheimer's disease, retention of urine and infection and inflammation reaction due to indwelling urethral catheter. The surveyor reviewed the resident's medications in the EMR. The EMR reflected an order for tamsulosin, also known as Flomax, (a drug used to treat the signs and symptoms of benign prostatic hyperplasia which can include urinary retention, primarily in men) with an initial date of 1/2/2024 that coincides with a readmission from the hospital. On 4/17/24 at11:09 AM the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN stated that the resident is scheduled to be discharged home soon and will have the catheter removed. The surveyor reviewed the manufacturer package insert for tamsulosin. The section labeled Indications and Usage reflected, Flomax is an alpha1 adrenoceptor antagonist indicated for treatment of the signs and symptoms of benign prostatic hyperplasia. A review of the EMR, specifically the physician's progress notes for the dates of 1/1/24 through 4/18/24 inclusive, did not reveal any notation of urinary retention, or use of tamsulosin with or without a catheter until 4/18/24 in a discharge note after it was brought to the facility's attention by the surveyor. A further review of the EMR, specifically the physician's progress notes entered and signed by the Advance Practice Nurse (APN) for the dates of 1/1/24 through 4/18/24 inclusive, did not reflect any use of tamsulosin. The surveyor reviewed the resident's care plan (a summary of a resident's health conditions, specific care needs and current treatments). The care plan reflected that the resident had urinary retention, an indwelling urethral catheter and impaired cognitive function/dementia. On 4/18/24 at11:06 AM the surveyor interviewed the Director of Nursing (DON). The DON stated that she was aware of the resident receiving tamsulosin and that the medication was started at the hospital. The DON agreed that the physician should document about continued unapproved use of tamsulosin in the resident's chart and that she had contacted the physician and asked him to provide documentation. N.J.A.C. 8:39-11.2(b)

Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 6 of 24 residents (Resident #12, #16, #22, #111, #13, and #62) reviewed and occurred over several months. This deficient practice was evidenced by the following: 1. A review of the hybrid medical record for Resident #12 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 2. A review of the hybrid medical record for Resident #16 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 3. A review of the hybrid medical record for Resident #22 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for February 2024 and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature. 19106 4. A review of the hybrid medical record for Resident #111 revealed there were no monthly orders signed by the Physician for the months of January 2024, February 2024 and March 2024. 34421 5. A review of the hybrid medical record for Resident # 13 revealed there were no monthly orders signed by the Physician for the months of January 2024, February 2024 and March 2024. 6. A review of the hybrid medical record for Resident # 62 revealed there were no monthly orders signed by the Physician for the months of January 2024 and February 2024. On 4/22/24 at 11:25 AM, the surveyor interviewed License Practical Nurse (LPN) #1, who was also the Unit Manager (UM) for North and [NAME] Wing Units and has been working in the facility for two years. The UM stated, The primary physicians come in every 1-2 weeks or monthly. The Director of Nursing (DON), who was also present stated, The doctors have started signing orders in the Electronic Health Records (EHR) since last year, they used to come in and sign on paper but now they come in to sign orders in EHR. On 4/22/24 at 11:44 AM , the surveyor interviewed LPN # 2, who stated that the Physicians should be signing the residents' orders monthly in the electronic health record. On 4/22/24 at 1:05 PM, the survey team met with the Administration: License Nursing Home Administrator (LNHA) and the DON, regarding missing physician monthly orders review and signature from January 2024 through March 2024. The administration acknowledged that the physicians should be coming in monthly to sign orders. On 4/23/24 at 9:00 AM, the DON provided the facility policy and procedure for Physician Orders dated 12/23. The Physician Orders policy reflected, All verbal or written orders must be signed by the prescriber monthly. NJAC 8:39-23.2(b)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient practice was identified for 1 resident (Resident #5) of 24 reviewed for the reasonable accommodations of needs/preferences as evidenced by the following. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed awake, able to answer the surveyor's inquiry. The surveyor asked the resident if she could reach her call light cord. The resident tried to reach for it three times and said they still could not get it. The call light cord was under the resident's right chest on both days. A review of the medical record revealed the following information. The admission record documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set, an assessment tool dated 3/12/24, reflected that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognition. On 4/16/24 at 9:10 AM, the surveyor called the Registered Nurse (RN) to check the resident's call light cord. The RN stated that it should be on top of the blanket so she could reach for it; the nurse repositioned the call bell. On 4/17/24 at 1:45 PM, the surveyor team discussed the inaccessibility of the call light cord for Resident #5 with the Administrator and the Director of Nursing (DON). On 4/18/24 at 9:40 AM, the DON provided a policy titled Call Bell Audit. However, it was noted that the policy does not specifically address the call light cord being within the resident's reach. NJAC 8:39-27.1(a); 4.1

Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 24 residents (Resident #2, 5, 35, and #225). This deficient practice was evidenced by the following: 1. Resident #2 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/15/24, which was due to be transmitted to CMS no later than 1/29/24. However, the QMDS was not submitted to CMS until 2/9/24. 2. Resident #5 was observed to have a QMDS with an ARD on 12/12/23, which was due to be transmitted to CMS no later than 12/26/23. However, the QMDS was not submitted to CMS until 1/10/24. 3. Resident #35 was observed to have an Entry MDS (EMDS) with an ARD on 10/2/23. The EMDS was due to be transmitted to CMS no later than 10/16/23. However, the EMDS was not submitted to CMS until 10/17/23. 4. Resident #225 was observed to have an Annual MDS (AMDS) with an ARD on 9/22/22, which was due to be transmitted to CMS no later than 10/6/22. However, the AMDS was not submitted to CMS until 10/20/22. A review of discharged Return Not Anticipated (DRNA), with an ARD on 10/10/22, was due to be transmitted to CMS by 10/24/22. The DRNA was not submitted to CMS until 11/7/22. A review of the undated Final Validation Report for Residents #2, 5, 35, and 225 by the MDS Coordinator/Registered Nurse (MDSC/RN) revealed that The submission date is more than 14 days after Z0500B on this new assessment. On 4/18/24 at 12:59 PM, the surveyor interviewed the MDSC/RN, who stated that she started working in February 2023 and added that she is not responsible for all those MDS submitted late. The only thing that she is responsible for is Res. #5. She is aware that the submissions were all late. The MDSC/RN stated that she follows the RAI manual. On 4/18/24 at 1:39 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing. The surveyor notified the facility management of the above findings and concerns. NJAC 8:39 - 11.1

Based on interview and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 2 of 24 residents reviewed, Residents #13 and #25 as evidenced by the following: 1. The surveyor reviewed Resident #13's electronic medical records (EMR). Resident #13 was admitted to the facility with diagnoses which included Myocardial Infarction (heart attack). A review of the Physician's Orders (PO) for Resident #13 revealed that the resident had an order for Eliquis 5 mg 1 tablet by mouth twice daily for blood clot prevention. The surveyor reviewed the resident's current care plans. There was no care plan developed regarding the resident's PO for the anticoagulant medication. On 4/22/24 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN stated that a care plan for the anticoagulant medication should have been created 34033 2. On 04/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones. The surveyor reviewed the medical record for Resident #25. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture. A review of the resident's Order Summary Report reflected a physician's order dated 4/24/23 for Alendronate Sodium (Fosamax) oral tablet 70 milligrams (MG), Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x (for) 30 minutes. A review of the resident's current Interdisciplinary Plan of Care (IDCP) had not included a plan of care that had been initiated for osteoporosis. On 4/23/24 at 9:19 AM, the survey team met with the Director of Nursing (DON) who stated that the Unit Managers were responsible for creating and updating the resident's care plans. In addition, the DON stated that she also was responsible for inputting resident care plans. The DON acknowledged that Resident #25 was actively being treated for osteoporosis and should have had a care plan completed. A review of the facility policy for Care Plans Comprehensive with a revised date of 6/2023 provided by the DON reflected that An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. In addition, the facility policy reflected that The comprehensive care plan is based on a thorough assessment that includes not limited to the MDS. Each resident's comprehensive care plan is designed to: i. incorporate identified problem areas; . The policy also reflected that Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. And that The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: .iv. at least quarterly. NJAC 8:39-11.2(e)(1)(2)(f)(h)

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following physician orders for 2 of the 24 residents reviewed (Residents #5 and #35). The deficient practice was evidenced by the following: 1. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed, awake, and able to respond to the surveyor's questions. The resident was not wearing a left-hand elbow resting splint on both days. A review of electronic medical record revealed the following information. The Admission Record (AR or face sheet, an admission summary) documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set (QMDS), an assessment tool dated 3/12/24, reflected that Resident #5 had a Brief Interview for Metal Status (BIMS) score of 10 out of 15, indicating moderate cognition impairment. A review of the resident's Order Summary Report (OSR) reflected a Physician's Order (PO) dated 3/13/24 for left hand elbow resting splint and on 4/1/22 for Don left hand and left elbow splints after AM care, doff before PM care. A review of the April 2024 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) under Unscheduled 'Other' Orders revealed that the above-corresponding PO for left hand and left elbow resting splints were not specified in either the eMAR or eTAR. On 04/17/24 at 12:11 PM, the surveyor interviewed the Certified Nurse Assistant (CNA#1), who had worked in the facility for [AGE] years, and stated that she was assigned to Resident #5. CNA#1 opened the resident's drawer; the surveyor observed the splints inside. CNA#1 said the residents should wear the splints aftercare in the morning. On 04/17/24 at 12:17 PM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who had worked in the facility for [AGE] years. The LPN#1 said the physical therapist should put the elbow and hand splint on the resident. On 04/17/24 at 12:20 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) and stated that the CNA should put the splint on the resident's after providing care. The LPN stated the nurse should sign in the eTAR after checking that the resident was wearing the splints. The LPN/UM added that the order for the elbow and hand splints was not in the eTAR and there was no specific order for how long they should be placed. On 04/17/24 at 12:30 PM, the surveyor interviewed the Rehab Director (RD) who stated that Resident #5 is in the therapy program and needs the elbow and hand splints. The rehab will order the splints, and then they train nurses, including the aide, on how to apply it to the resident. They screen quarterly and revise. Resident #5 was revised on March 18, 2024. The next review is scheduled in May 2024. She added that Nursing is responsible for applying the splint. On 4/17/24 at 1:25 PM, the surveyor team discussed the above findings and concerns with LNHA and DON. 2. On 4/15/24 at 10:00 AM, the surveyor observed Resident #35 lying in bed awake, watching television, alert and oriented, able to answer the surveyor's inquiry. Resident #35 stated that they have been in the facility for over five years. The resident stated they do not wear anything on their feet while in bed. A review of electronic medical record revealed the following information. The AR documented that Resident #35 was admitted to the facility with diagnoses that included but were not limited to primary osteoarthritis (conditions that affect the tissues in the joint) and cellulitis (skin infection) of the left toe. The recent QMDS, dated [DATE], reflected that Resident #35 had a BIMS score of 14 out of 15, indicating intact cognition. A review of the resident's OSR reflected a PO dated 3/13/24 for bunny booties while in bed and a PO dated 10/2/23 for heel pads to both heels while in bed every shift for protection. Further review of the April 2024 OSR shows no PO for surgical shoes. A review of the April 2024 eMAR and eTAR under Unscheduled 'Other' Orders revealed that the above-corresponding PO for bunny booties and heel pads was not specified in either the eMAR or eTAR. On 4/22/24 at 11:40 AM, the surveyor observed the resident out of bed in a wheelchair. The resident stated that they wore surgical shoes on both feet when attending therapy. On 4/22/24 at 11:47 AM, CNA#2 was observed caring for the resident. She stated that she did not see any booties or heel pads in the resident's room. On 4/22/24 at 12:07 PM, the surveyor interviewed LPN #1 who stated that she was unaware that the resident had bunny booties or heel pads while in bed. LPN #1 stated that when the resident was attending therapy they wore surgical shoes. On 4/22/24 at 12:10 PM, the LPN/UM stated that bunny booties and heel pads are ordered in bed and should be taken off during care. The surveyor asked if surgical shoes were ordered and the nurse manager said there was no order. On 4/22/24 at 12:17 PM, the surveyor interviewed the RD, who stated that the she didn't order bunny booties and added that the resident wore surgical shoes for protection when out of bed. On 4/22/24 at 12:20 PM, the Registered Nurse (RN) was observed entering the resident's room with green bunny booties wrapped in plastic. The surveyor asked the RN where the booties came from. The RN stated that they came from the laundry. On 4/22/24 at 1:05 PM, the surveyor team met with the Administrator and Director of Nursing (DON). The DON stated that she thought it was understood that if the resident has a full bath while in bed, the heel booties should be removed during care and a skin check for for skin integrity should be performed. She added that bunny booties and heel pads shouldn't have been ordered simultaneously. A review of the facility policy titled Specialty Devices stated under Policy: It is the policy and procedures of this facility that residents who require preventative measures and positioning devices (i.e., foam finger spreader, etc.) will be provided with these devices in order to prevent contractures or problems associated with contractures. These measures or devices will be provided in accordance with an order from a physician, nursing, occupational therapy, and/or physical therapy. NJAC 8:39 27.2(m)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and c.) ensure respiratory tubing and cannula was stored properly. This deficient practice was identified for one (1) of one (1) resident (Resident #425) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/17/24 at 10:23 AM, the surveyor observed the Rehab Aide (RA) propell Resident #425's wheelchair into the resident's room. Inside the resident's room, the oxygen (O2) concentrator (which can be used as an alternative to compressed gas cylinders) was on at 3 LPM (liters per minute), and the nasal cannula (n/c, a device that delivers extra O2 through a tube and into the nose) was wrapped around the half side rail of the bed. The half-side rail of the bed had a pool noodle (an extra layer of padding on a metal frame) on which the n/c was wrapped around. The n/c was not being used at that time and was not properly stored. At that same time, the surveyor interviewed the resident after the RA left the room. The resident informed the surveyor that he/she was a subacute resident at the facility and came from the hospital due to a breathing problem. Resident #425 stated that O2 use was something new to the resident and was being used in the facility as needed (PRN). During an interview, the resident stated that he/she did not need the O2 at that time. The resident appeared to be in no distress. On 4/18/24 at 10:07 AM, the surveyor asked the assigned Licensed Practical Nurse #1 (LPN#1) to go with the surveyor inside the resident's room. In the room, both the surveyor and the LPN observed Resident #425 seated in a regular chair, the O2 was ongoing with the n/c attached to the O2 concentrator while the other end of the n/c was wrapped around the padded half-side rail of the bed directly touching the pool noodle padding. The resident appeared to be in no distress. On that same date and time, the surveyor asked LPN#1 to check the O2 flow rate at which the concentrator was running. The LPN checked the concentrator and informed the surveyor that the resident order for O2 was at 2 LPM. The LPN confirmed that the concentrator was at 2 liters (L). The LPN stated that the n/c should have been placed inside a plastic bag when not in use for infection control. She further stated that she would remove the n/c and change it with a new one. The surveyor observed that LPN detached the n/c and turned off the O2 concentrator. At that same time, the LPN assessed the resident and the resident was stable. The surveyor reviewed the medical record for Resident #425. The Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included acute on chronic diastolic (congestive) heart failure, other seizures, essential hypertension (abnormal blood pressure), presence of prosthetic heart valve (an artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly), and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, showed the admission MDS was in progress (not completed) for an ARD (assessment reference date) of 4/15/24. A review of the individualized person-centered Care Plan (CP) initiated on 4/09/24 for a focus on shortness of breath (SOB) related to decreased energy and fatigue, decreased lung expansion, acute hypoxic respiratory failure, and CHF (congestive heart failure) had an intervention that included but was not limited to patient is on O2 at 1 L PRN. Further review of the CP did not include respiratory care on how to store the O2 cannula and supplies when not in use. The Social Service Admission/Readmission Evaluation with an effective date of 4/09/24 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated that the resident's cognitive status was moderately impaired. A review of the Order Summary Report included a physician's order (PO) dated 4/09/24 for O2 at 1 LPM via n/c for SOB PRN. The above order for PRN O2 was transcribed into the eMAR for April 2024. Upon review of the April 2024 eMAR showed that there was no documentation that the nurses signed that the PRN O2 as administered. A review of the Weights & Vitals in the electronic medical record (eMR) revealed the following dates that the resident had O2 via n/c with O2 saturation (Sats): O2 Sats (noninvasive method of measuring the saturation of O2 in a person's blood) Summary: Date Time Sats Nurse 4/16/2024 00:03 95.0% Oxygen via Nasal Cannula LPN#2 4/13/2024 23:25 95.0% Oxygen via Nasal Cannula LPN#2 4/12/2024 14:38 97.0% Oxygen via Nasal Cannula LPN#3 4/11/2024 23:10 95.0% Oxygen via Nasal Cannula LPN#2 4/10/2024 22:36 95.0% Oxygen via Nasal Cannula LPN#2 4/10/2024 11:38 95.0% Oxygen via Nasal Cannula LPN#3 4/09/2024 22:42 94.0% Oxygen via Nasal Cannula LPN#2 Further review of the eMR revealed that on dates 4/09/24, 4/10/24 (twice), 4/11/24, 4/12/24, 4/13/24, and 4/16/24 the eMAR should have been signed by nurses indicated the PRN O2 was administered. On 4/18/24 at 10:17 AM, LPN#1 informed the surveyor that the order for O2 was 1 LPM and not 2 LPM. The LPN asked the surveyor to go again with LPN#1 to the resident's room and check that it was on 1 LPM now. In the resident's room both the surveyor and the LPN observed that the O2 was below 1 LPM and there was a yellow light on. LPN#1 stated that she had to replace the O2 concentrator because the yellow light meant that there was a problem with the concentrator. LPN#1 acknowledged that it was probably broken. At this time, the surveyor notified LPN#1 of the surveyor's observation on 4/17/24 that it was at 3 L and wrapped around the half-side rail. On 4/18/24 at 01:39 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns regarding O2 observations, orders not followed, and nurses not signing the eMAR when O2 was administered as evident in the O2 Sats records in the Weights & Vitals (7 x the resident was on O2). On 4/19/24 at 10:10 AM, the surveyor interviewed the Registered Nurse (RN) who worked on 4/17/24 at the 7 AM to 3 PM shift. The RN informed the surveyor that Resident #425 was cognitively intact with some forgetfulness and was on 1 LPM O2 PRN. The RN stated that if the nurse administered the PRN O2, the nurse should document and sign the eMAR. At that same time, the surveyor notified the RN of the above findings and concerns. The surveyor asked the RN why the resident's O2 on 4/17/24 during the observation was at 3 L wrapped around the half-side rail, not properly stored when not in use, and the eMAR was not signed. The RN had no response. On 4/19/24 at 10:19 AM, the surveyor called and left a message to LPN#2. On 4/19/24 at 12:01 PM, the surveyor interviewed the Infection Preventionist Nurse/RN (IPN/RN). The IPN/RN informed the surveyor that she was responsible for in-service/education regarding infection control including respiratory care and use of O2 and nebulizer (neb) supplies on how to properly store when not in use. The IPN/RN stated that it was an expectation that the nursing staff store O2 and neb supplies like tubing and masks inside a plastic bag when not in use and change it once a week for infection control because bacteria can accumulate in the tubing and mask when exposed to resident's environment. On that same date and time, the surveyor notified the IPN/RN of the above findings and concerns regarding O2 n/c wrapped around the half-side rail on two observations. The IPN/RN stated that it was not appropriate that the O2 n/c was not stored when not in use and that was not the facility's practice. On 4/19/24 at 12:11 PM, the surveyor interviewed LPN#3 via phone conference. LPN#3 informed the surveyor that she remembered Resident #425 with an O2 and the LPN thought the order for O2 was continuous. The LPN stated that if the order was PRN for O2, then the PRN O2 should have been signed. The LPN further stated that she was unable to remember why the PRN O2 in the April 2024 eMAR was not signed but it should have been signed. A review of the facility's Respiratory Tubing Storage Policy with an updated date of 9/2023 that was provided by the IPN/RN included that it was the policy and procedure of the facility to ensure the sanitation of all O2 accessories for residents' care. The procedure included but was not limited to when the mask or n/c is not in use, it will be stored in the bag. A review of the facility's Oxygen Administration Policy with an updated date of 12/2023 that was provided by the RN Supervisor included that it was the policy and procedure of the facility to provide O2 to residents in compliance with their physician order. On 4/19/24 at 12:25 PM, the surveyor met with the LNHA and DON. The LNHA stated that the facility management acknowledged the concerns and that the facility would continue to monitor the O2. NJAC 8:39-11.2(b); 19.4(a); 27.1(a)

Based on observation, interview, and relevant document review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of three (3) medication carts and one (1) one of two (2) medication storage rooms inspected on two (2) of two (2) units. This deficient practice was evidenced by the following: On 4/16/24 at 10:56 AM the surveyor in the presence of another surveyor and the Licensed Practical Nurse (LPN#1) assigned to the medication cart inspected the medication cart identified as the northwest cart. The surveyor observed one (1) brown package containing one (1) vial of latanoprost eye drops (a medication used to treat glaucoma). The brown packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 3/29/24. There was no date when the vial was opened observed on the packaging or on the vial. The surveyor observed one (1) package containing Fluticasone/salmeterol discus 500/50 (a medication used to treat asthma and chronic obstructive pulmonary disease). The packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 4/11/24. The medication device which is used to administer the medication was observed to have an automatic dosage counter that reflects the number of doses used/remaining. The counter reflected fifty-five (55) out of sixty (60) uses. There was no date when the medication was opened observed on the packaging or on the medication device. The surveyor observed one (1) package containing Fluticasone/salmeterol discus 250/50 that reflected a date when opened of 2/23/24. The surveyor observed that the medication cart contained a separate lockable box that contained controlled substances. The surveyor observed that the box was not locked by lifting the lid without the use of a key. The surveyor observed on closing the lid that it was blocked from fully closing by excess medication packages outside the box. The surveyor discussed the above areas of concern with LPN#1. LPN #1 agreed that the latanoprost and fluticasone/salmeterol should have a date when opened, the fluticasone/salmeterol dated 2/23/24 was opened more than 30 days, and that the lock box containing controlled substances should always be locked when not in use. The surveyor in the presence of another surveyor entered the northwest medication room with assistance from a nurse. The surveyor observed a locked refrigerator with a temperature log on the door that reflected documentation of refrigerator temperatures twice a day. The surveyor observed that the temperature log had blank spaces for the dates of 4/12/24 AM, 4/12/24 PM and 4/13/24 AM. The surveyor reviewed the manufacturer package insert for latanoprost. The section labeled storage reflects: Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks. The surveyor reviewed the manufacturer package insert for fluticasone/salmeterol. The section labeled 16 How Supplied/Storage reflects: The device should be discarded 1 month after removal from the moisture-protective foil overwrap pouch or after all blisters have been used (when the dose indicator reads 0), whichever comes first. On 4/16/24 at 1:33 PM, the surveyor in the presence of the survey team discussed the concerns with the Administrator and Director of Nursing (DON). The DON stated that she had removed the medications of concern the previous day and educated the staff. On 4/17/24 at 1:15 PM the DON provided to the surveyor a policy for medication storage. The policy reflects on line nine (9) All controlled drugs are stored under double-lock and key. NJAC 8:39-29.4(g)(h), 8:39-29.7(c)

Based on observation, interview, and record review, it was determined that the facility failed to establish appropriate infection control practices for environmental cleaning for 1 of 24 residents (Resident #5). This deficient practice was evidenced by the following: On 04/15/24 at 10:40 AM, the first day during rounds in Resident #5 room, the surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The Registered Nurse (RN) stated that it looked like a tube feeding milk on that wall and added that she would ask housekeeping to clean it. On 4/17/24 at 1:25 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about the concern regarding the splash of creamy milk-like substance on the wall. The LNHA stated it was already clean and did not provide further information. NJAC 8:39-19.1(a)

Based on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure: a.) 2 of 3 anti-[CONDITION(S)] medications ([MEDICATION(S)] and [MEDICATION(S)]) ordered upon discharge from the hospital were appropriately discussed with the Physician for re-order, reconciled, received from the Provider Pharmacy, and administered in accordance with hospital discharge instructions for a resident with recent [CONDITION(S)] activity (Resident #163), and b.) an anti-[CONDITION(S)] medication ([MEDICATION(S)]) was available and administered as ordered for a second resident with a history of [CONDITION(S)] disorders (Resident #27). This deficient practice was identified for 2 of 3 residents reviewed for anti-[CONDITION(S)] medication management (Resident #27 and #163). Resident #163, who had a severe cognitive impairment, was admitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was not administered for ten days from 2/7/21 until 2/17/22 at the 9:00 AM dose. Further, the hospital discharge instructions indicated to continue on another anti-[CONDITION(S)] medication ([MEDICATION(S)]) but the resident was never started on the medication at the facility. There was no documented evidence as to why the [MEDICATION(S)] was not re-ordered from admission to the facility on [DATE] through 3/1/22 when the resident was subsequently re-hospitalized , and there were no labs drawn to determine therapeutic levels. Interviews with the Director of Nursing (DON) who reconciled the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was not seen by the Attending Physician or a Nurse Practitioner until 2/24/22. Resident #163 was never monitored for [CONDITION(S)] activity while the medications were omitted, an alternate anti-[CONDITION(S)] medication or other intervention was never discussed with the Physician or implemented while [MEDICATION(S)] was not available and while [MEDICATION(S)] was not being given to prevent rebound [CONDITION(S)] activity. A second resident, Resident #27, who had severe cognitive impairment had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was neither available nor administered from 1/31/22 at 9:00 PM until 2/8/22 at 9:00 AM and again from 2/10/22 at 9:00 PM until 2/12/22 at 9:00 AM. There was no documented evidence that the physician was made aware that the medication was unavailable. Interviews and review of records revealed that some nurses were falsely documenting for the administration of the medication when it was not available, never sent from the pharmacy and it was not kept in a back-up supply of medications. There was no documented evidence of [CONDITION(S)] monitoring, monitoring of side effects for omitted dosage, or an alternate anti-[CONDITION(S)] medication or other intervention discussed with the Physician as a means to prevent rebound seizures. The facility's failure to ensure all residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an Immediate Jeopardy (IJ) situation that began on 1/31/22. The facility Administration was notified of the IJ on 3/4/22 at 2:44 PM. The facility submitted an acceptable written Removal Plan (RP) on 3/4/22 at 5:25 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/7/22. The non-compliance remained on 3/6/22 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The evidence was as follows: A review of the Manufacturer specifications for the anti-[CONDITION(S)] medication and controlled drug [MEDICATION(S)] included, Highlights of Prescribing Information: WARNINGS AND PRECAUTIONS . [MEDICATION(S)] should be gradually withdrawn to minimize the potential of increased [CONDITION(S)] frequency. 5.5 Withdrawal of Antiepileptic Drugs (AEDs) As with all AEDs, [MEDICATION(S)] should be withdrawn gradually (over a minimum of 1 week) to minimize the potential of increased [CONDITION(S)] frequency in patients with [CONDITION(S)] disorders. A review of the Manufacturer specifications for the anti-[CONDITION(S)] medication, [MEDICATION(S)] included, Antiepileptic drugs, including [MEDICATION(S)], should be withdrawn gradually to minimize the potential of increased [CONDITION(S)] frequency. 1. On 2/23/22 at 10:59 AM, the surveyor observed Resident #163 with his/her eyes closed in bed, appearing to be asleep. The surveyor observed that the bed was positioned low, floor mats were on both sides of the bed, and the resident was wearing a helmet on their head. The next day on 2/24/22 at 9:56 AM, the surveyor observed the resident with their eyes closed in a bed positioned low with floor mats on either side on the bed. The surveyor observed that the resident was not wearing the helmet but it was placed on a nightstand next to the bed. The surveyor observed that the resident had a bandage applied to the right side of the forehead. On 2/25/22 at 11:43 AM, the surveyor observed the resident with his/her eyes closed in bed appearing to be asleep. The bed was in the low position with floor mats on either side of the bed. The surveyor observed that the resident was not wearing the helmet and there was still bandage to the right side of the forehead. The surveyor reviewed the medical record for Resident #163. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility on [DATE] following a hospitalization . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the hospital records for Resident #163 prior to the resident's admission to the facility which revealed the following: A review of the Neurosurgery Health and Physical Noted dated 1/17/22 included that the [resident] has a past history of seizures and convulsions with a fall/[CONDITION(S)] (temporary loss of consciousness caused by a fall in blood pressure) on 1/14/22 and was sent to the emergency room . The [resident] had a right forehead hematoma (pool of blood outside of blood vessels) from a previous fall and had a computed tomography scan (CT scan; multiple x-rays to create pictures of the head) which revealed an enlargement of the hematoma; the Neurosurgeon was consulted for possible intervention. A review of a Nursing Note dated 1/17/22 at 5:49 AM, reflected that the [resident] was found sitting on the floor in the room with a big hematoma to the right side of the face and blood on the floor. The [resident] could not recall what happened, and a CT and x-ray were ordered. A review of a Nursing Note dated 1/17/22 at 1:50 PM, reflected that the [resident] had neurosurgery at the bedside. A review of a Nursing Note dated 1/21/22 at 8:15 AM reflected that at 6:21 AM, the [resident] started twitching, not responding to verbal commands. Blood sugar was rechecked, and vital signs were taken. At 6:45 AM, laboratory tests were drawn, and the physician ordered [MEDICATION(S)] (anti-[CONDITION(S)] medication) 2000 milligrams (mg); the first bag was hung [via the intravenous route]. A review of a Nursing Note dated 1/22/22 at 10:00 PM reflected that the resident had electroencephalography (EEG; method to record an electrogram of electrical activity on the scalp) and neurological checks (an assessment of an individual's neurological functions and level of consciousness to determine if a person is functioning correctly and reacting appropriately to tests) every two hours. A review of a Nursing Note dated 1/25/22 at 8:05 AM, reflected that the resident had video EEG monitoring in progress with no observed [CONDITION(S)] activity during the shift. A review of the hospital discharge medications included the following anti-[CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] ([MEDICATION(S)]) 10 milligram/milliliter (mg/mL) solution; give 10 mL (100 mg total) by feeding tube (FT) two times a day. Maximum daily dose 200 mg. 2. [MEDICATION(S)] 500 mg tablet; give 2.5 tablets (1,250 mg total) by FT two times a day. 3. [MEDICATION(S)] ([MEDICATION(S)]) 250 mg/5 mL oral liquid; give 15 mL (750 mg total) by nasogastric route (a tube that delivers food and medicine to the stomach from the nose) two times a day. The surveyor continued to review the facility's medical record for Resident #163 upon admission to the facility on [DATE]. A review of the Progress Notes reflected an Admission Progress Note dated 2/7/22 at 7:37 PM, which included that the resident was newly admitted to the facility from the hospital with slurred speech and severe cognitive impairment with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted for sub-acute rehabilitation with sutures to [his/her] right temporal lobe and helmet to be worn out of bed. A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/14/22, reflected a Brief Interview for Mental Status (BIMS) score could not be determined, so staff conducted a cognitive assessment for the resident which determined that the resident had a short and long-term memory problem with a severely impaired decision-making capacity. A review of the resident's individualized comprehensive Care Plan reflected a focus area initiated on 2/8/22 that the resident was at the facility for a short term stay with a goal to discharge to the community upon completion of sub-acute rehabilitation. A further review reflected a focus area for seizures initiated on 2/10/22 due to a history of subdural hematoma, which was evacuated status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was to remain free of injuries related to [CONDITION(S)] activity during the facility stay. Interventions included to give medications as ordered, and monitor/document for effectiveness and side effects; nurse will obtain and monitor laboratory/diagnostic work as ordered; and [CONDITION(S)] precautions: do not leave alone during [CONDITION(S)], protect from injury if out of bed help to the floor to prevent injury, remove or loosen tight clothing, don't attempt to restrain during a [CONDITION(S)] as this could make the convulsions more severe, protect from onlookers, draw curtain, etc. (etcetera; and the rest). A review of the current physician Order Summary Report reflected the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. A PO dated 2/8/22 for [MEDICATION(S)] ([MEDICATION(S)]) solution 10 mg/mL; give 10 mL via FT two times a day related to traumatic subdural hemorrhage. 2. A PO dated 2/7/22 for [MEDICATION(S)] ([MEDICATION(S)]) solution 250 mg/5 mL; give 15 mL via FT two times a day related to traumatic subdural hemorrhage. The Order Summary Report did not include a PO for the [MEDICATION(S)] tablets in accordance with the hospital discharge medication list. A review of the Medication Administration Record (MAR) for February 2022 reflected the following for order for the [MEDICATION(S)]: A PO dated 2/7/22 and discontinued 2/8/22 at 2:28 PM, for [MEDICATION(S)] 10 mg/mL; give 100 mg via FT two times a day. The nurses signed that the resident allegedly received the [MEDICATION(S)] on 2/7/22 at 9:00 PM and 2/8/22 at 9:00 AM. A review of the corresponding MAR for PO dated 2/8/22 reflected that from 2/8/22 at 9:00 PM through the 2/15/22 at 9:00 PM dose, the nurses signed a code 9, which indicated the medication was not given and other/see Nurse Notes. The same MAR reflected that the resident allegedly received the next doses of [MEDICATION(S)] beginning on 2/16/22 at 9:00 AM. A review of the corresponding electronic Progress Notes (PN) for the above dates reflected the following Nurse Notes (NN): For the 2/8/22 at 9:00 PM - NN at 9:07 PM that Pharmacy call, awaiting prescription delivery and Physician #1 made aware. For the 2/9/22 at 9:00 AM - NN at 3:06 PM that needs a prescription. For the 2/9/22 at 9:00 PM - NN at 10:29 PM awaiting delivery. For the 2/10/22 at 9:00 AM - NN at 11:44 AM called Physician #1's office for a prescription. For the 2/10/22 at 9:00 PM - NN at 10:47 PM with no additional information. For the 2/11/22 at 9:00 AM - NN at 1:57 PM with no additional information. For the 2/11/22 at 9:00 PM - NN at 10:56 PM, that medication ordered will administer upon delivery. For the 2/12/22 at 9:00 AM - NN at 1:49 PM that medication not administered, and Pharmacy called. For the 2/12/22 at 9:00 PM - NN at 11:05 PM awaiting a prescription. For the 2/13/22 at 9:00 AM - no NN or additional information. For the 2/13/22 at 9:00 PM - NN at 9:35 PM awaiting a prescription. For the 2/14/22 at 9:00 AM - NN at 7:24 PM, no additional information. For the 2/14/22 at 9:00 PM - NN at 10:13 PM, no additional information For the 2/15/22 at 9:00 AM - NN at 12:01 PM that Physician #1 needs to send a prescription. An additional NN at 2:50 PM that Physician #1 was called due to needing a prescription and awaiting a callback. The NN further indicated that helmet must be worn at all times. For the 2/15/22 at 9:00 PM - NN at 10:58 PM for awaiting delivery. There was no documentation that the resident was being monitored for [CONDITION(S)] activity or monitored for side effects of missing dosages of anti-[CONDITION(S)] medications or that the Medical Director was notified in an effort to promptly communicate with a physician, when Physician #1 was not available. A review of the Individual Patient Controlled Substance Administration Record (a declining inventory record used for the accountability of controlled drugs) reflected that 300 mL of [MEDICATION(S)] 10 mg/mL solution was filled on 2/16/22 and received by the facility on 2/17/22. The sheet reflected the first documented dose was on 2/17/22 (not on 2/16/22 at 9 AM as the MAR was allegedly signed). The time was not recorded when the 10 mL was administered on 2/17/22 and there was no balance remaining documented. The declining inventory record revealed there was only one dose removed from inventory on 2/17/22 and not two doses in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Individual Patient Controlled Substance Administration Record further reflected that the next dose that was signed out was on 2/18/22 for 10 mL. The space to record the time of removal was left blank, and the balance remaining was also left blank. The third time the medication was removed from inventory was 2/19/22 at 9:00 AM for 10 mL for a remaining balance of 270 mL. (This revealed that even when the facility had the medication available for the resident on 2/17/22, the resident only received one dose on 2/18/22, instead of the two doses daily as ordered). On 3/3/22 at 12:09 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), DON, Assistant Director of Nursing (ADON), and Corporate Nurse and requested for additional information regarding the blanks on the Individual Patient Controlled Substance Administration Record for the [MEDICATION(S)] delivered on 2/17/22. On 3/4/22 at 10:12 AM, the LNHA stated in the presence of the DON, ADON, Corporate Nurse, and the survey team, that the facility completed an audit upon surveyor inquiry of the Individual Patient Controlled Substance Administration Record for the [MEDICATION(S)] received on 2/17/22, which revealed that the dose signed out on 2/17/22 with no recorded time and the 2/18/22 dose removed with the no recorded time were both signed by the evening nurses who gave the 9:00 PM doses. The LNHA stated that the nurses allegedly administered the 2/17/22 at 9:00 AM and 2/18/22 at 9:00 AM, but they forgot to document it on the Controlled Substance Administration Record. (There was no explanation as to why the remaining balance would indicate 270 mL total on 2/19/22 at 9 AM, which reflected only 30 mL was removed, instead if the resident received those doses then it should have have reflected 50 mL total was removed with a balance of 250 mL remaining as of 2/19/22 at 9 AM). On 3/4/22 at 11:22 PM, the surveyor reviewed with the LNHA and the DON the Progress Notes written from 2/8/22 through 2/15/22 regarding the [MEDICATION(S)] and the conflicting documentation of waiting for the Pharmacy to deliver the medication and waiting on the prescription. The LNHA responded that he thought poor verbiage by the nurse was waiting for a prescription and not delivery. At this time, the surveyor reviewed the February 2022 MAR for [MEDICATION(S)] with the LNHA and DON, which reflected that the nurses signed that the resident allegedly received [MEDICATION(S)] on 2/7/22 at 9:00 PM, 2/8/22 at 9:00 AM, 2/16/22 at 9:00 AM and 9:00 PM (which did not correspond with any declining inventory logs and the availability of the medication from the Pharmacy Provider). The DON stated that the resident did not receive those doses because the facility did not have the [MEDICATION(S)] until 2/17/22 at 4:30 AM. The DON also confirmed that the facility did not have [MEDICATION(S)] in their emergency back-up supply of controlled medications. The LNHA stated that the [MEDICATION(S)] was included in the resident's admission PO, and the facility was unable to reach Physician #1 to obtain a prescription for the [MEDICATION(S)]. When asked what the nurse should do in a situation where they cannot contact the physician, the LNHA stated that they should try to contact another Physician, including the Medical Director. When asked if any adverse reactions could occur from not receiving the [MEDICATION(S)], the DON responded that it was an anti-[CONDITION(S)] medication that was being administered to the resident for a hematoma and craniectomy. The DON confirmed that a person could have a [CONDITION(S)] without observed physical activity or if staff were not present but stated that the resident had no observed [CONDITION(S)] activity. When asked if the resident was placed on one-to-one supervision during this time, the DON responded no and acknowledged that the resident could have had an unobserved [CONDITION(S)], and delaying treatment or suddenly stopping an anti-[CONDITION(S)] medication could trigger an adverse reaction or rebound seizures. On 3/4/22 at 12:48 PM, the surveyor interviewed the resident's Registered Nurse (RN #1), who stated that the process for residents with seizures was to make sure side rails were padded, the head of the bed was elevated for safety, and make sure they have their [CONDITION(S)] medications as prescribed. RN #1 stated that residents who did not receive their [CONDITION(S)] medications could relapse and have a rebound [CONDITION(S)], and a resident could have a [CONDITION(S)] without anyone knowing. RN #1 stated that there was no specific monitoring for residents with seizures, such as monitoring/checks at a certain time. RN #1 stated that Resident #163 was never observed out of bed or by the Nurse's Station that the resident always remained in bed. RN #1 stated that if you could not get in touch with the physician for a prescription, she would have to let the Supervisor know, and she confirmed that there were times she could not get in touch with the physician and told the Supervisor. On 3/4/22 at 12:50 PM, the surveyor attempted to call Physician #1 via telephone with no response and a voice message system that indicated that the call was missed or do not want to speak with you. On 3/4/22 at 12:55 PM, the surveyor confirmed Physician #1's phone number as dialed with the DON. The DON stated that since she had been at the facility, she had yet to meet Physician #1. The surveyor asked who transcribed and reconciled the resident's admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/4/22 at 12:57 PM, the surveyor team reviewed the resident's discharge PO from the hospital with the DON. The DON stated that the check next to the medication indicated that the physician wanted to continue with the medication and that she verified that the medication was in the computer. The surveyor showed the DON the checkmark next to the [MEDICATION(S)] order, and the DON confirmed that the [MEDICATION(S)] was ordered based on her documentation. At this time, the surveyor showed the DON the February 2022 MAR and asked her to find where the [MEDICATION(S)] was transcribed for nurses to know it needed to be administered. The DON confirmed that the [MEDICATION(S)] was not appearing on the MAR nor was it administered, and she would need to look into why. When asked if she would document if a Physician would not want to continue on a specific medication for the hospital discharge medication list such as [MEDICATION(S)] or other therapeutic drug, the DON stated no. When asked if she entered an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor continued to review the resident's medical record. A review of the Physician's Progress Notes revealed that the Nurse Practitioner saw the resident for the first time on 2/24/22 (7 days after the [MEDICATION(S)] had been delivered on 2/17/22) and there was no documentation regarding the omitted doses of [MEDICATION(S)] or why [MEDICATION(S)] was not reordered. The Nurse Practitioner also saw the resident on 3/1/22 and she again did not address the omitted doses of the anti-[CONDITION(S)] medications or the plan regarding monitoring the resident's [CONDITION(S)] activity including obtaining therapeutic labs if doses were omitted. There was no documentation that the resident was seen by Physician #1 or their Nurse Practitioner within the forty-eight hours of admission. A review of the resident's Admitting Evaluation History which was completed on 2/25/22 and signed (illegibly) where indicated Signature of Physician, which reflected that the resident was admitted post status right craniectomy post fall with a history of [CONDITION(S)] disorder. A review of the PN reflected a NN dated 3/1/22 at 8:09 PM, that the resident was noted with diaphoretic (sweating heavily), coughing and congested, noted with difficulty breathing. Upon auscultation (listening to sounds of heart, lungs, or other organs with a stethoscope), wheezing was noted to left lower lungs. The physician was made aware and ordered to be transferred to the emergency room for evaluation. A NN dated 3/1/22 at 3:32 AM reflected that the resident was admitted to the hospital with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of [CONDITION(S)] monitoring or increased [CONDITION(S)] monitoring specifically during the time in which there were omitted doses of anti-[CONDITION(S)] medications, and there was no documentation as to why [MEDICATION(S)] was not ordered and no evidence that therapeutic laboratory tests were ordered for the resident's [MEDICATION(S)] levels. On 3/4/22 at 1:15 PM, the surveyor attempted to interview the Nurse Practitioner via telephone but there was no response. The surveyor left a message to call back. On 3/4/22 at 1:16 PM, the surveyor attempted to interview the facility's Provider Pharmacy Representative (PPR) via telephone with no response. The surveyor was unable to leave a message because the mailbox was full. On 3/4/22 at 1:19 PM, the surveyor attempted to interview the Medical Director via telephone with no response. The surveyor left a message to call back. On 3/4/22 at 1:25 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone, who confirmed that the manufacturer recommended that [MEDICATION(S)] was weaned off and not abruptly stopped. The CP acknowledged that there are various [CONDITION(S)] types that may not be visible to another person. The facility's failure to ensure all residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an Immediate Jeopardy situation. The IJ was identified on 3/4/22, and the LNHA, DON, ADON, and Regional Administrator were notified of the IJ at 2:44 PM. An acceptable written Removal Plan was accepted on 3/5/22 which included identifying all residents with [CONDITION(S)] diagnoses; audit of charts for residents with [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/7/22 at 9:15 AM, the surveyor interviewed Resident #163's Representative (RR) via telephone, who confirmed that the resident was still in the hospital. The RR stated that the resident had seizures for the past three years and has been on two to three [CONDITION(S)] medications for the past few years. The RR could not recall which anti-[CONDITION(S)] medications the resident had been taking. The RR stated that he/she visited the resident while at the facility, and the resident was always in their room in bed during those visits. On 3/7/22 at 2:48 PM, the surveyor interviewed the Provider Pharmacy Representative (PPR) via telephone, who stated that the facility received medication deliveries twice a day with a delivery that leaves the Pharmacy at noon and midnight. The PPR stated that if the facility ordered new medications, the cutoff time was 10:00 AM for noon deliveries, and all refill medication was delivered at midnight. The facility could also order a STAT or emergency order that the facility paid an additional fee for but received the medication within four hours. The PPR stated that the prescription was entered into the facility's [electronic medical system] for controlled medications. The prescription was faxed to the Pharmacy; the physician could send an electronic prescription directly to the Pharmacy; or the physician can call a three-day supply directly into the Pharmacy. The PPR stated that medications were generally not delayed from the Pharmacy unless the facility missed the order cutoff time or the order needed to be clarified. At this time, the surveyor requested a timeline regarding Resident #163's [MEDICATION(S)] for February 2022. On 3/7/22 at 4:49 PM, the PPR emailed the surveyor the following timeline regarding Resident #163's [MEDICATION(S)]: The resident was admitted to the facility on [DATE], and the facility did not fax the order from the [electronic medical system] the day the [resident] was admitted . All C2-5 medications (class of controlled medications) must be printed out from [electronic medical system] and faxed to the Pharmacy. Customer Service received a phone call from the facility on 2/10/22. Please see attachment. (*nurse will follow-up with physician for prescription) On 2/10/22, physician wrote the wrong strength; instead of 10 mL wrote 10 mg on D-letter. On 2/11/22, Pharmacy sent clarification to the physician and the facility. On 2/11/22, Pharmacy sent blank D-letter to Physician's office. On 2/14/22, Pharmacy paged the physician and left a voice message. On 2/15/22 and 2/16/22, Pharmacy reached out to the physician's office and faxed D-letter. On 2/16/22, the physician corrected D-letter to read 10 mL and was faxed to Pharmacy. On 2/16/22, medication was sent to the facility on Midnight delivery. On 3/8/22 at 9:56 AM, the surveyor interviewed the Medical Director via telephone, who stated that his role was to ensure compliance was met and attended quarterly meetings. The Medical Director stated that he was at the facility almost daily and was available 24-hours a day for any issues. The Medical Director stated that he did not involve himself with other physician's residents and does not like to interfere with other Physicians. The Medical Director stated if the physician was not returning their calls to the facility, he would expect to be notified. The Medical Director stated that for a prescription for a controlled substance, he preferred that the resident's physician wrote their own prescription. The Medical Director stated that if the facility was trying to contact the physician for several days with no response, he would then write a prescription for the resident for a few days. When asked how many days were acceptable for the resident to wait for their medications, the Medical Director stated that there is no answer. The surveyor reviewed the resident's hospital records from their staying beginning on 3/1/22. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Neurology Consultation Final Report dated 3/5/22 included that at the present time, neurological evaluation is limited; I would suggest having a CT scan of the head to evaluate for any acute or chronic intracranial processes [existing or occurring within the cranium]; I would suggest having routine EEG .[he/she] has a history of [CONDITION(S)] disorder, treated with [MEDICATION(S)]; I would suggest having blood work for [MEDICATION(S)] level .further management will be determined on above-mentioned test results. A review of a Video Electroenchalography (Video-EEG) Report included on date of study dated 3/7/22 from 7:00 AM to 3/8/22 7:00 AM, that abnormal VEEG. The above findings are c/w [consistent with] nonconvulsive focal status with epileptogenic zone Rt F-T-C region [a prolonged [CONDITION(S)] that manifests primarily as altered mental status as opposed to dramatic convulsions]. Further adjustment of AEDs [antiepileptic drugs] is recommended. During the sample expansion of reviewing residents receiving anti-[CONDITION(S)] medications on 3/7/22, the survey team identified a second resident (Resident #27) who did not receive their anti-[CONDITION(S)] medication ([MEDICATION(S)]) for a prolonged period of time because it was not available. The findings were as follows: 2. On 3/7/22 at 10:32 AM, the surveyor observed Resident #27 in bed with [MEDICATION(S)] 1.5 (nutrition formula) being administered via a feeding tube. The resident was unable to be interviewed. The surveyor reviewed the medical record for Resident #27. A review of

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) administer oxygen therapy according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for 5 of 7 residents (Resident #35, Resident #51, Resident #57, Resident #69, and Resident #363) reviewed for respiratory care and the evidence was as follows: 1. On 2/23/22 at 11:25 AM, the surveyor observed Resident #35 sitting in a wheelchair in their room watching television. The resident was being administered oxygen from a concentrator alongside their bed that was set to one liter per minute (1 lpm) via an undated nasal cannula (tubing used to deliver oxygen through the nose). The resident appeared to be in no distress. The surveyor reviewed the medical record for Resident #35. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility in January of 2017 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/10/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. A further review reflected the resident was not on oxygen therapy at the time of this assessment. A review of the individualized person-centered Care Plan initiated on 10/3/19, did not include that the resident received oxygen or respiratory therapy. A review of the Order Summary Report included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/22 at 10:07 AM, the surveyor observed the resident in bed with the oxygen concentrator set to 1 lpm being delivered to the resident by an undated nasal cannula tube. The resident appeared to be in no distress. On 2/24/22 at 10:34 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident's SPO2 was checked that morning at 8:05 AM, and it was at 91%. The LPN stated that the PO was to administer oxygen at 2 lpm when the SPO2 was less than 92%. The LPN also stated that oxygen tubing was changed once a week and should be dated when changed. At this time, the surveyor accompanied by the LPN observed Resident #35's oxygen concentrator and tubing. The LPN confirmed the oxygen tubing was not dated, and the concentrator was not set to the ordered 2 lpm. The surveyor observed the LPN replace the oxygen tubing and dated it 2/24/22. On 2/25/22 at 1:04 PM, the surveyor observed the resident's oxygen tubing connected to the concentrator that was not in use was dated 2/20/22 and not the 2/24/22 date observed yesterday. On 2/25/22 at 1:46 PM, the surveyor interviewed the LPN regarding the resident's oxygen tubing who confirmed that she dated the tubing 2/24/22 yesterday, and she was unable to explain why the tubing was now dated 2/20/22. The LPN called the Assistant Director of Nursing/Infection Preventionist (ADON/IP) over to the resident's room. The ADON/IP confirmed that she was aware of the tubing being changed and dated the previous day on 2/24/22, and she confirmed the current tubing was now dated 2/20/22. The ADON was unable to speak to this discrepancy. On 3/4/22 at 10:11 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LHNA), ADON/IP, and the survey team, stated that oxygen tubing was changed and dated weekly on Sundays during the 11:00 PM to 7:00 AM shift by nursing staff and as needed if the tubing was on the floor. The DON also acknowledged that oxygen should be administered according to the PO. The DON was unable to speak to the discrepancies in the oxygen tubing dates. 2. On 2/23/22 at 11:14 AM, the surveyor observed Resident #69 in their room resting in bed with no distress. The resident was being administered oxygen from a concentrator alongside their bed that was set to 1 lpm via an undated nasal cannula. The surveyor reviewed the medical record for Resident #69. A review of the Admission Record reflected that the resident was admitted to the facility in December of 2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 5 out of 15, which indicated a severe cognitive impairment. A further review reflected the resident was on oxygen replacement therapy and had shortness of breath or trouble breathing when lying flat. A review of the individualized person-centered Care Plan initiated on 5/12/21, included a focus area for shortness of breath related to [CONDITION(S)] and asthma. Interventions included to administer bronchodilators (medication used to open airway) in a timely manner and to position resident with proper body alignment for optimal breathing. A review of the active Order Summary Report included a PO dated 1/21/22 for oxygen to be administered at 2 lpm via nasal cannula for shortness of breath. On 2/24/22 at 11:06 AM, the surveyor in the presence of the LPN observed the resident in bed with the oxygen concentrator set to 1.5 lpm being delivered to the resident via a nasal cannula that was dated 2/22/22. The LPN confirmed the PO was for the concentrator to be set at 2 lpm but did not make the adjustment at that time. On 2/25/22 at 1:02 PM, the surveyor observed the resident's oxygen concentrator was set to 2 lpm and the oxygen tubing was dated 2/20/22 which contradicted the 2/22/22 date observed the day before. On 2/25/22 at 1:52 PM, the surveyor interviewed the ADON/IP confirmed the tubing was dated 2/20/22 and stated that she will have to look into this issue. On 3/4/22 at 10:11 AM, the DON in the presence of the LNHA, ADON/IP, and the survey team, stated that oxygen tubing was changed and dated weekly on Sundays during the 11:00 PM to 7:00 AM shift by nursing staff and as needed if the tubing was on the floor. The DON also acknowledged that oxygen should be administered according to the PO. The DON was unable to speak to the discrepancies in the oxygen tubing dates. 3. On 2/23/22 at 10:50 AM, the surveyor observed Resident #363 in their room resting in bed. The resident was being administered oxygen from a concentrator alongside their bed that was set to 2 lpm via an undated nasal cannula. The surveyor reviewed the medical record for Resident #363. A review of the Admission Record reflected that the resident was admitted to the facility in March of 2016 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 9 out of 15, which indicated a moderate cognitive impairment. A further review reflected the resident was on oxygen replacement therapy and had shortness of breath or trouble breathing when lying flat. A review of the individualized person-centered Care Plan initiated on 7/18/19, included a focus for oxygen therapy related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to administer oxygen by nasal prongs/mask at 2 lpm as needed for shortness of breath. A review of the active Order Summary Report included a PO dated 3/26/21 for continuous oxygen at 2 lpm via nasal cannula for shortness of breath. An additional PO dated 1/17/22 for oxygen at 2 lpm as needed for a pulse oximeter less than 92% or shortness of breath. On 2/25/22 at 12:44 PM, the surveyor observed the resident's oxygen tubing not in use and hanging wedged between the nightstand table and wall with most of the tubing length lying directly on the floor. At this time, the surveyor interviewed the resident who stated that he/she needed the oxygen. On 2/25/22 at 12:49 PM, the DON came to the resident's room and informed the surveyor that the tubing should not be stored like that; it should be in a bag when not in use. The DON also stated that the tubing should not be on the floor like that because it can cause infection control issues and needed to be changed. 4. On 2/23/22 at 11:01 AM, the surveyor observed Resident #57 in bed with an oxygen concentrator at their bedside which was turned on and set to 2.5 lpm. The surveyor observed that the undated nasal cannula was connected to the concentrator and hanging from the resident's bed side rail with the nasal prongs lying directly on the floor. The surveyor reviewed the medical record for Resident #57. A review of the Admission Record reflected that the resident was admitted to the facility in March of 2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 12 out of 15, which indicated a moderate cognitive impairment. A further review reflected the resident was not on oxygen therapy at the time of this assessment. A review of the individualized person-centered Care Plan initiated on 4/23/2020, included a focus area for oxygen therapy related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to give oxygen therapy as ordered by the physician. A review of the active Order Summary Report included a PO dated 11/8/21 for oxygen to be administered at 2 lpm via nasal cannula for shortness of breath as needed for SPO2 less than 90%. On 2/24/22 at 10:34 AM, the surveyor along with the LPN observed the resident in their room not receiving oxygen. The LPN stated that the resident received oxygen as needed for an SPO2 less than 90%. The LPN stated that she checked the resident's SPO2 that morning and the level was above 90% so the resident did not need oxygen. On 3/4/22 at 10:11 AM, the DON in the presence of the LNHA, ADON/IP, and the survey team, stated that oxygen tubing should be stored in a bag when not in use. 5. On 2/23/22 at 11:02 AM, the surveyor observed Resident #51 awake lying in bed. The surveyor observed a nebulizer machine (a device used to create a mist out of liquid respiratory medications to transport to the lungs) with connected tubing and a face mask lying directly on the floor underneath the resident's bed. The surveyor reviewed the medical record for Resident #51. A review of the Admission Record reflected that the resident was admitted to the facility in October of 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the active Order Summary Report reflected a PO dated 2/10/22, for [MEDICATION(S)] solution 0.5-2.5 (3) milligram/3 milliliters (mg/3 mL); 3 mL inhale orally via nebulizer every six hours every Monday, Wednesday, Friday, Sunday for respiratory treatment on non-[CONDITION(S)] days. A review of the individualized person-centered Care Plan included a focus area initiated 2/12/2020, for altered respiratory status/difficulty breathing with regards to congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should). Interventions included to administer medications as ordered; monitor for effectiveness and side effects. On 2/28/22 at 11:05 AM, the surveyor observed Resident #51 awake lying in bed with the nebulizer machine with the connected tubing and mask lying directly on the floor underneath the resident's bed. On 2/28/22 at 11:05 AM, the surveyor accompanied by the Registered Nurse (RN) entered Resident #51's room and the RN confirmed that the resident's nebulizer machine with connected tubing and mask was lying directly on the floor underneath the resident's bed. The RN stated that she needed to change the tubing and mask and proceeded to pick up the nebulizer machine with the attached tubing and mask and placed them in bed with the resident. The RN removed the tubing and mask and stated that she needed to grab new tubing and mask since it was on the floor for infection control purposes. The RN changed the tubing and mask, leaving the nebulizer machine in bed with the resident and exited the room. At this time, the surveyor interviewed the RN in the hallway who confirmed that the tubing and mask on the floor would be an infection control concern, so she changed them. When asked about the nebulizer machine that was on the floor and now in bed with the resident was okay, the RN acknowledged that she should have changed the nebulizer machine or wiped it down with alcohol. The RN stated that she would now change the nebulizer machine, tubing, and mask. On 2/28/22 at 11:20 AM, the surveyor interviewed the resident who stated that the Certified Nursing Aide (CNA) placed the nebulizer machine, tubing, and mask on the floor when they performed care, and the CNA had not placed the nebulizer back in bed. The resident confirmed that the nebulizer machine was usually placed in bed with them. On 2/28/22 at 11:30 AM, the surveyor interviewed the CNA who stated that she had not performed care on the resident yet, and she had not placed the nebulizer machine on the floor. On 2/28/22 at 11:38 AM, the surveyor re-interviewed the resident who confirmed that the CNA had not placed the nebulizer machine, tubing, and mask on the floor, and they were unable to speak to who did. On 3/1/22 at 9:19 AM, the surveyor interviewed the ADON/IP who stated that the nebulizer machine should not be on the floor or in bed with the resident. The ADON/IP stated that the nebulizer machine should be placed on a table, and the tubing and mask should be stored in a bag when not in use to prevent contamination. On 3/4/22 at 10:12 AM, the LNHA in the presence of the DON, ADON/IP, Corporate Nurse, and survey team acknowledge that the nebulizer, tubing, and mask should not be placed on the floor. A review of the facility's Oxygen Administration policy dated updated 12/2021 included it is the policy and procedure of [NAME] Manor to provide oxygen to residents in compliance with their physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Tubing and other accessories will be changed weekly and dated. A review of the facility's Respiratory Tubing policy dated updated 11/2021, included . respiratory tubing will be properly dated, maintained, and stored to prevent infection .when not in use, store respiratory tubing in an oxygen bag that is labeled with the date the tubing was changed. NJAC 8:39-11.2(b); 19.4(a); 27.1(a)