Every finding on record at Abigail House for Nursing & Rehabilitation

This is a repeat deficiency. Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On [DATE] from 9:39 AM until 10:37 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1. The FSD lifted the lid of the ice machine to display its contents. The surveyor noted that the ice release cover had multiple areas of brown and gray debris on it. The surveyor asked the FSD to wipe the area with a paper towel. The FSD wiped the ice release cover and then showed the surveyor the paper towel which was then soiled with a brown substance. The FSD stated that if the substance were mold, it would be black, not brown in color. The FSD stated that the ice machine was not sanitary and might be unsafe for use. The FSD stated that the ice machine should be cleaned every month, but he was unsure when it was last cleaned. There was no maintenance log maintained on the ice machine to demonstrate how frequently it was cleaned. 2. The FSD removed the cap from the juice gun which was covered with a brown, moist substance. The FSD maintained that the juice gun was cleaned last night, and if it were dirty, there would be fruit flies around it. 3. On the drying rack in the Pot Room, the surveyor noted that there were three plastic cutting boards with deep nicks and scratches in them. The FSD stated, These are going in the trash. The FSD further stated that the cutting boards were not safe for use because bacteria could stay on them. 4. In the three compartment sink inside of the Pot Room, the surveyor noted that there were multiple gnats flying out of the drain. The FSD stated that the three compartment sink was not used, and the pots and pans were washed in the dish machine. 5. In the galley of the kitchen, the surveyor noted a scoop inside of a two gallon container of instant mashed potatoes. The FSD stated that it was unsanitary to store the scoop directly inside of the container. 6. In the galley of the kitchen, on a shelf below the prep area, there was a bucket of detergent with a rag stored inside of it. The surveyor asked to view the sanitation log for the detergent for the measurement of the sanitation levels. The FSD stated that he did not keep a log, but then proceeded to demonstrate that the water to detergent ratio was ample for sanitization with the use of a test strip. The FSD stated that he did not maintain a log, but checked the sanitizer level in the bucket each morning prior to use. 7. In the galley of the kitchen, the surveyor observed an insect that ran across the top of the stove. The FSD stated that it was a fruit fly. 8. On the second shelf of a five tiered wired rack, an opened packet of one pound chicken base was noted. The FSD stated that the packet should not have been stored opened because insects and bacteria could get inside of the packet. The FSD then proceeded to take the opened packet of chicken base to the food preparation area in the galley of the kitchen where he indicated it would be used to prepare the luncheon meal. 9. On the top shelf of a five tiered wired rack, a two pound container of thyme with a received date of ,d+[DATE], had an opened date of ,d+[DATE], with no year indicated on the label. And a two pound container of cilantro with a received date of ,d+[DATE] had a checked date of ,d+[DATE], with no year specified. The FSD stated that spices were good for two to three years after opening. The FSD stated that he did not have a policy for the shelf life of spices after opening. 10. In the walk-in refrigerator, a rolling cart had four trays of canned pears that were stored in individual clear plastic containers, that were not labeled or dated. 11. On the second shelf of a three-tiered wired rack, an opened eight ounce container of salsa was not labeled or dated. The FSD stated that it was from the last taco Tuesday and should have been dated so that you knew when it expired. 12. On the second shelf of a three-tiered wired rack, a hotel pan of cooked breakfast sausage links were not labeled or dated. The FSD stated that they were left over from this morning and should have been labeled and dated. 13. In the dry storage room, there were two ten pound containers of sugar and flour and both of the containers had their scoops stored directly inside of the bins. The FSD stated that the scoops should not have been stored inside of the bins for sanitary reasons. 14. Inside of the ice cream freezer, there was no thermometer present, and there was no temperature log to indicate when the temperature was last checked. The ice cream was hard to touch, but there was water running down the back of the freezer wall. The FSD stated that he wanted to ensure that the ice cream was hard, and was not melted. 15. In the galley of the kitchen, the FSD pulled the table mounted can opener from its' sheathe and the exposed the can opener blade that had a dried, brown debris on it. The FSD stated that it was important to clean the can opener after use or the debris may get in the food. 16. In the galley of the kitchen, there was a soiled two-tiered rolling rack with scoop dishes and bowls on it in the tray line area. The bowls had solid, black debris on them. The Assistant Food Service Director (AFSD) stated that the rolling cart should have been cleaned after the breakfast meal. On [DATE] at 8:40 AM, the surveyor interviewed the Director of Maintenance (DM) who stated that he cleaned the ice machines in the facility on a quarterly basis, but he cleaned the ice machine more frequently in the kitchen, and documented it on a piece of paper in his own records the day that it was completed. The DM stated, they told me there was mold in there. The DM stated, from what I know, you can get sick from it, and I would not drink it. The DM stated that the facility informed him verbally that the ice machine was dirty prior to him cleaning it. On [DATE] at 12:35 PM, in the presence of the survey team the surveyor informed the Licensed Nursing Home Administrator (LNHA) of all concerns related to the kitchen observations. The LNHA stated that the FSD reported directly to him and he was responsible to provide oversight over the kitchen. The LNHA stated that the DM had to clean the ice machine more frequently and keep a log of it. A review of the facility policy Food Storage And Handling Policy undated, included: Dry food and food supplies shall be stored in a clean, dry location not exposed to splash, dust, or other contamination. .Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. .Food inventories shall be rotated on a first-in, first-out (FIFO) basis. Each product shall be marked with date of entry and expiration date. .The temperature of all freezer units shall be kept at 0 F (Fahrenheit) or lower. .Temperatures shall be monitored in all refrigeration and freezer units, checked daily (or more often if there is a problem), and recorded . .All food-contact equipment and utensils shall be stored in a sanitary manner. .Food Service Equipment shall be: .Kept clean and free of debris, breaks, open seams, cracks, chips, pits, inclusions, or similar imperfections .Kept in good repair and in operation. Any equipment not in use shall be removed, repaired, or replaced. .Cutting boards and blocks shall be made from plastic washable materials or hard maple that is not absorbent, meets all code requirements, and is free of seams and cracks .Cutting boards should be replaced when boards become excessively worn or develop hard-to-clean grooves . NJAC 8:,d+[DATE].4

REPEAT DEFICIENCY Based on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 2 of 2 nurses on 2 of 3 units (A Wing and C Wing) administering medications to 2 of 6 residents (Resident #137 and #231) making 2 errors out of 26 medication opportunities which resulted in a medication error rate of 7%. This deficient practice was evidenced by the following: 1.) On 4/7/25 at 8:30 AM, the surveyor observed Licensed Practical Nurse (LPN) #3 administer medications to Resident #231. The LPN dispensed four medications, including one tab of multivitamin with minerals. After administering the medications, the LPN signed off an order for plain multivitamin as administered (Error #1). A review of the Order Summary Report (OSR), as of 4/7/25, included a physician's order for Thera Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for vitamin deficiency, with a start date of 3/29/25. A review of the April 2025 Medication Administration Record (MAR) included the aforementioned order scheduled at 9:00 AM was signed out as administered on 4/7/25. On 4/7/25 at 11:47 AM, the surveyor interviewed LPN #3 who reviewed Resident #231's physician's orders and verified the order was for plain multivitamin, not multivitamin with minerals. The LPN then opened her medication cart and verified there was no plain multivitamin in her medication cart. The LPN stated she should have given the plain multivitamin as ordered. On 4/9/25 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurse should check the physician's orders to verify which type of multivitamin is ordered prior to administration. The LPN/UM explained that if the order was for Thera Oral Tablet that it was the plain multivitamin, and that Thera-M was the order for multivitamin with minerals. On 4/9/25 at 12:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) for the facility who stated a nurse should not administer multivitamin with minerals if the physician's order was for a plain multivitamin. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated the nurses should check the physician's order to verify which type of multivitamin to administer so that the resident received the correct medication. 2.) On 4/7/25 at 9:40 AM, the surveyor observed LPN #5 administer medications to Resident #137. The LPN dispensed seven medications, including a Fluticasone Propionate nasal spray 50 mcg/act (micrograms per actuation). After entering the resident's room, the nurse donned gloves and prepared to administer the nasal spray, but the resident took the nasal spray from the LPN's hands and administered one spray to each nostril. The resident then asked the LPN, one spray in each side, right? to which the LPN acknowledged as correct. After administering Resident #137's medications, the LPN signed off the Fluticasone Propionate order as administered. A review of the OSR, as of 4/7/25, included a physician's order for, Fluticasone Propionate Nasal Suspension 50 mcg/act 2 sprays in both nostrils one time a day for allergies, with a start date of 4/25/24 (Error #2). A review of the April 2025 MAR included the aforementioned order was scheduled at 9:00 AM was signed out as administered on 4/7/25. On 4/7/25 at 11:38 AM, the surveyor interviewed LPN #5 who reviewed Resident #137's physician's orders and verified the order for Fluticasone Propionate was for two sprays in each nostril. The LPN then confirmed that only one spray was administered to each nostril during the medication pass and stated she should have instructed the resident to administer two sprays to each nostril so that the medication would have the correct effectiveness. On 4/9/ 25 at 11:26 AM, the surveyor interviewed LPN/UM #1 who stated the nurse should follow the physician's order for the correct number of nasal sprays for each nostril. On 4/9/25 at 12:28 PM, the surveyor interviewed the CP who stated nurses should be following the physician's order and administer the number of nasal sprays as ordered. On 4/9/25 at 1:12 PM, the surveyor interviewed the DON who stated the nurses should check the physician's order to verify the correct number of nasal sprays to administer so that the resident received the right dose. A review of the facility's Administering Medications policy, undated, included the following: General rules for administering medications 1. Observe the five rights in giving each medication a. The right resident b. The right time c. The right medication d. The right dose e. The right method of administration 4. Check the MAR with the label on the medication three times, reading the name of the medication, the route of administration, and the strength of dosage. NJAC 8:39 - 29.2(d)

Based on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to a.) properly secure medication within the medication cart for 2 of 2 nurses observed during the medication administration pass, and b.) store medications within acceptable temperature ranges for 2 of 3 medication storage areas (B Wing and C Wing) reviewed for medication storage. This deficient practice was evidenced by the following: 1.) On 4/7/25 at 8:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #3 prepare medications for Resident #30. When the nurse entered the resident's room to administer the resident's medications, she did not lock the medication cart before leaving the medication cart unattended. On 4/7/25 at 8:30 AM, the surveyor observed LPN #3 prepare medications for Resident #231. When the nurse entered the resident's room to administer the resident's medications, she did not lock the medication cart before leaving the medication cart unattended. On 4/7/25 at 9:00 AM, the surveyor observed LPN #3 prepare medications for Resident #232. When the nurse entered the resident's room to administer the resident's medications, she did not lock the medication cart before leaving the medication cart unattended. On 4/7/25 at 9:15 AM, the surveyor interviewed LPN #3 who stated that should have locked the medication cart before leaving it unattended for the residents' safety and to prevent anyone from removing medications from the cart. On 4/7/25 at 9:35 AM, the surveyor observed LPN #5 prepare medications for Resident #134. When the nurse entered the resident's room to administer the resident's medications, she did not lock the medication cart before leaving the medication cart unattended. On 4/7/25 at 9:50 AM, the surveyor interviewed LPN #5 who stated she should have locked the medication cart before leaving it unattended to make sure no one could get into the cart. On 4/9/25 at 11;26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurses should make sure to lock the medication cart before leaving the cart unattended so that no staff, residents, or visitors could go into the cart. On 4/9/25 at 12:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated the nurses should ensure their medication carts were locked when unattended because otherwise someone could access the medications. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when the nurses leave their medication carts unattended, they should make sure to lock the cart to prevent anyone from going into the medication cart. A review of the facility's Storage of Medications in Rooms and Carts policy, dated 8/2024, included, Unless ordered by the physician, medications shall be stored in a locked area unless under the supervision of a licensed personnel. 2.) On 4/9/25 at 9:17 AM, the surveyor inspected the B Wing medication room in the presence of Registered Nurse/Unit Manager (RN/UM) #1. Upon opening the medication refrigerator, the surveyor observed the temperature on the thermometer read 26 F (degrees Fahrenheit). Stored in the refrigerator was a vial of Retacrit (a medication used to help make more red blood cells), a bottle of omeprazole (a medication to treat reflux), and three insulin pens. At that time, the RN/UM stated the medication refrigerator should be between 36 F and 46 F, but was unsure the reasoning. The surveyor reviewed the B Wing Temperature Monitoring Sheet for the medication refrigerator which revealed a recorded temperature of 34 F on 4/2/25 at 6:00 AM. On 4/9/25 at 9:38 AM, the surveyor inspected the C Wing medication room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) #3. Upon opening the medication refrigerator, the surveyor observed the temperature on the thermometer read 32 F. Stored in the refrigerator were nine bags of insulin pens, two insulin vials, and a COVID-19 vaccine vial. At that time, the LPN/UM stated the medication refrigerator should be between 36 F and 46 F so that the medications did not freeze. The surveyor reviewed the C Wing Temperature Monitoring Sheet for the medication refrigerator which revealed the following recorded temperatures: 30 F on 4/1/25 at 6:00 AM 30 F on 4/2/25 at 6:00 AM 32 F on 4/3/25 at 6:00 AM 30 F on 4/9/25 at 6:00 AM On 4/9/25 at 12:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that the medication refrigerator should be kept between 36 F and 46 F because medications could be destroyed at temperatures outside of that range. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated the medication refrigerator should be kept between 36 F and 46 F because the medications could go bad if stored at the incorrect temperature. A review of the facility's Storage of Medications in Rooms and Carts policy, dated 8/2024, included, Medications should be kept in the facility in accordance with the manufacturer's guidelines. That is, medications requiring refrigeration should be stored between 36 and 46 degree Fahrenheit . NJAC 8:39-29.4(h)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individual comprehensive care plan after psychotropic medications were discontinued for 1 of 3 residents (Resident #38) reviewed for mood and behavior. This deficient practice was evidenced by the following: On 4/4/25 at 10:13 AM, the surveyor observed Resident #38 lying in bed. The resident was not experiencing any behaviors at that time. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, unspecified dementia and unspecified psychosis. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/30/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the only psychotropic medication the resident received in the last seven days was an antipsychotic. A review of the individual comprehensive care plan (ICCP) included a focus area, initiated 2/5/25, that the resident was on an antidepressant medication (Remeron) related to depression. Further review of the ICCP included a focus area, initiated 2/5/25, that the resident was on an antianxiety medication (Buspar) related to anxiety disorder. A review of the Order Summary Report (OSR), dated as of 4/9/25, included the following physician orders (PO) for psychotropic medications: A PO, dated 2/5/25, for Seroquel 50 milligrams (mg) give one tablet by mouth at bedtime for unspecified psychosis. There were no active orders for antidepressant or antianxiety medications. A review of the discontinued medications listed in the resident's Electronic Medical Record (EMR) revealed the following: The PO for Remeron was discontinued with an end date of 12/12/24. The PO for Buspar was discontinued with an end date of 6/19/23. On 4/9/25 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the UMs were responsible for updating the residents' care plans. When asked about discontinued psychotropic medications, the LPN/UM stated the care plan should be revised the same day the medication was discontinued. The LPN/UM explained that it was important for the care plans to accurately reflect the residents for continuity of care and so the staff know how to take care of the resident as a whole. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated the UMs were responsible for updating the residents' care plans. When asked about discontinued psychotropic medications, the DON stated the care plan should be revised the same day the medication was discontinued. The DON explained that it was important for the care plans to accurately reflect the residents to make sure the resident received appropriate care. A review of the facility's Care Plans policy, dated July 2024, included, Assessments of the resident are ongoing and care plans are revised as information about the residents and the residents' conditions change. Further review of the policy also included: The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted ; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to: a.) administer medications according to manufacturers' instructions for 1 of 2 nurses observed during the medication administration pass, b.) ensure the accountability of the narcotic shift to shift count logs were completed for 1 of 3 medication carts inspected, and c.) complete and maintain copies of Federal narcotic order forms (DEA 222 forms) for 3 of 3 DEA 222 forms reviewed. This deficient practice was evidenced by the following: 1.) On 4/7/25 at 9:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #5 prepare medications for Resident #95. The LPN dispensed six medications, including a ferrous sulfate elixir 220 mg (milligrams)/5 ml (milliliters). The LPN poured 7.5 ml into a medicine cup and administered the medication to the resident without diluting it in water or juice. When the resident drank the ferrous sulfate elixir, he/she grimaced. A review of the Order Summary Report (OSR), dated as of 4/7/25, included a physician's order for Ferrous Sulfate Oral Solution 220 mg/5 ml Give 7.5 ml by mouth two times a day for anemia, with a start date of 4/1/25. On 4/7/25 at 11:38 AM, the surveyor interviewed LPN #5 who stated she was not aware of any special instructions for ferrous sulfate elixir but reviewed the bottle of ferrous sulfate which included instructions to mix with water or juice to prevent staining of the teeth. The LPN then stated she should have mixed the ferrous sulfate elixir with water or juice. On 4/9/25 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated ferrous sulfate elixir should be mixed with juice because it could stain the resident's teeth. On 4/9/25 at 12:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that ferrous sulfate elixir could be mixed with water or juice because it has a taste to it. A review of the manufacturer's instructions for Ferrous Sulfate Elixir, provided by the facility, included directions to mix with water or fruit juice to avoid temporary staining of the teeth . A review of the facility's Administering Medications policy, undated, included, Occasionally oral liquid medications must be diluted prior to administration. The specific directions for the individual medication should be followed carefully to prevent untoward effects due to administration of an improperly diluted medication. 2.) On 4/7/25 at 9:40 AM, the surveyor observed LPN #5 prepare medications for Resident #137. The LPN dispensed seven medications, including a Trelegy Ellipta 100-62.5-25 mcg/act (milligrams per actuation) inhaler. The LPN donned gloves and administered the inhaler to the resident without offering the resident water to rinse his/her mouth afterwards. A review of the OSR, dated as of 4/7/25, included a physician's order for Trelegy Ellipta 100-62.5-25 mcg/act 1 inhalation inhale orally in the morning for COPD [Chronic Obstructive Pulmonary Disease] with a start date of 4/2/25. On 4/7/25 at 9:50 AM, the surveyor interviewed LPN #5 who stated she was unsure if she was supposed to offer Resident #137 a rinse after administering the inhaler but reviewed the Trelegy Ellipta box which included instructions on the label to rinse mouth thoroughly after each use. The LPN then stated she should have offered water for the resident to rinse his/her mouth because the inhaler could cause thrush (a fungal infection caused by the yeast Candida albicans). On 4/9/25 at 11:26 AM, the surveyor interviewed LPN/UM #1 who stated the nurse should instruct the residents to rinse their mouths with water after administering an inhaler to prevent thrush. On 4/9/25 at 12:28 PM, the surveyor interviewed the CP who stated after administering Trelegy Ellipta, the nurse should offer the resident water to rinse their mouth with to prevent thrush. On 4/9/25 at 1:12 PM, the surveyor interviewed the DON who stated nurses should offer residents water to rinse their mouths after administering an inhaler to remove any aerosol films in the resident's mouth. A review of the manufacturer's instructions for Trelegy Ellipta, provided by the facility, included under Warnings and Precautions, Candida albicans infection of the mouth and pharynx [throat] may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. A review of the facility's Administering Medications policy, undated, included, After administering oral inhalation medications, the resident may experience dry mouth and hoarseness. Gargling and rinsing the mouth with water after each dose may help lessen the discomfort. 3.) On 4/9/25 at 9:00 AM, the surveyor inspected the A Wing medication cart in the presence of LPN #2 and LPN/UM #1. Upon reviewing the narcotic binder kept on the medication cart (Cart 2), the surveyor observed there were blanks where the nurse did not sign the shift to shift narcotic count log on the following dates: -4/4/25 7:00 AM Incoming Nurse -4/4/25 3:00 PM Incoming Nurse -4/4/25 3:00 PM Outgoing Nurse -4/4/25 11:00 PM Outgoing Nurse -4/8/25 11:00 PM Incoming Nurse On 4/9/25 at 9:17 AM, the surveyor interviewed LPN/UM #1 who acknowledged the omitted signatures on the narcotic shift to shift count log and stated the nurses were supposed to sign the narcotic shift to shift count log every shift to ensure the narcotic count on the medication cart was accurate. On 4/9/25 at 12:28 PM, the surveyor interviewed the CP who stated the nurses should sign the narcotic shift to shift count log because the nurses were responsible for ensuring the narcotic medications were accounted for. On 4/9/25 at 1:12 PM, the surveyor interviewed the DON who stated the nurses should sign the narcotic shift to shift count log located on the medication carts every shift. A review of the facility's Controlled Substances policy, dated 4/2024, included, An inventory of controlled substances retained in each nursing unit must be made at the termination of each shift. This record will be signed by both the outgoing and incoming nurse who meet the criteria for handling controlled substances. 4.) On 4/9/25 at 1:45 PM, the DON provided copies of the facility's DEA 222 forms for the last year. The following forms did not have PART 5: TO BE FILLED IN BY THE PURCHASER filled out which would have indicated the number received and date received for each Schedule I and II narcotic drug that was ordered by the facility: -Order Form Number: 220095970 dated 3/15/24 -Order Form Number: 220095965 dated 1/23/25 -Order Form Number: 240815653 dated 3/31/25 On 4/10/25 at 8:10 AM, the surveyor interviewed the DON who stated the facility did not keep the packing slips when the Schedule I & II narcotic drugs were delivered to the facility. On 4/10/25 at 9:51 AM, the surveyor conducted a follow-up interview with the DON who stated she was responsible for filling out the DEA 222 forms, but that she only completed PART 1 and PART 2. When asked about the importance of PART 5 of the form, the DON stated that it showed the number of narcotic drugs received and the date they were received. The DON further stated that PART 5 was to be filled out when the narcotic drugs were received by the facility. The DON explained that it was important to fill out PART 5 to prevent drug diversion. On 4/10/25 at 12:00 PM, the DON provided the copies of the packing slips for each DEA 222 form and stated she had to obtain the copies from the pharmacy. The DON further stated that the facility was not keeping copies of the DEA 222 forms after sending them to the pharmacy, and that the copies provided to the surveyor were also provided by the pharmacy after surveyor inquiry. The DON explained that the facility did not have the copies of the DEA 222 forms upon receipt of the narcotic drugs to complete PART 5 at that time. A review of the Instructions for DEA Form 222, located on the back of each DEA 222 Form, included the following: PART 5. CONTROLLED SUBSTANCE RECEIPT 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item. 3. Purchaser must keep its copy of each executed order form and all copies of unaccepted or defective forms and any attached statements or other related documents available for inspection for a period of two years. NJAC 8:39-27.1 (a) NJAC 8:39-29.7 (c)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure a) fall interventions were in place for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #382) On 4/4/25 at 10:43 AM, the surveyor observed Resident #382 awake and alert lying in bed. The surveyor observed two blue floor mats folded and stored at the head of the bed leaning against the wall. The resident stated he/she has had falls and stated, That's why I am here. On 4/7/25 at 9:00 AM, the surveyor observed Resident #382 lying in bed with his/her eyes closed. The resident had a floor mat in place to the resident's left side, but the floor mat for the resident's right side was folded up and not in place. On 4/9/25 at 8:18 AM, the surveyor observed Resident #382 in bed with their eyes closed. The resident had a floor mat in place to the resident's left side, but the floor mat for the resident's right side was folded up and not in place. The surveyor reviewed the medical record for Resident #382. A review of the Admission Record face sheet, an admission summary, revealed the resident had diagnoses which included but were not limited to, syncope (another word for fainting or passing out) and collapse, unspecified dementia, abnormalities with gait and mobility and weakness. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/30/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident had a fall in the last month prior to admission to the facility. A review of the individualized comprehensive care plan (ICCP) included a focus area that the resident was at risk for falls and had a fall on 3/17/25. Interventions included: Continue the use of safety alarm and floor mats both sides of the bed. A review of the Order Summary Report (OSR) dated as of 4/1/25, included the following physician's order (PO): -A PO dated 1/24/25, for Fall Precautions: Low bed. Fall mats. A review of the April 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include the above physician's order for nursing staff to sign off that the floor mats were being checked for proper placement. On 4/9/25 at 12:30 PM, the surveyor interviewed Certified Nursing Assistant (CNA #4), who stated Resident #382 sometimes needed moderate assistance for transfers but today needed maximal assistance. CNA #4 further stated that the resident was on fall precautions and that both floor mats should be in place when the resident was in bed. On 4/9/25 at 12:34 PM, the surveyor interviewed Licensed Practical Nurse (LPN #3), who stated that every time the resident was in bed, that both floor mats should be in place. LPN #2 also stated that there should be a physician's order for floor mats and the nurse would document that the floor mats were in place in the TAR. On 4/9/25 at 12:39 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that residents with floor mats should have mats down in place any time the resident was in bed. LPN/UM #1 confirmed that there was not a PO in the TAR that the nurses could document the placement of the mats. On 4/9/25 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) who stated residents should have floor mats in place whenever the resident was in bed. The DON further stated that residents should have a PO on the TAR so the nurses could document that the floor mats were in place. A review of the facility's Fall Prevention Intervention policy, revised 4/13/24, included the facility's policy is to ensure residents who have the potential to fall, and /or has a history of falls, they will be identified at the time of admission by way resident history and the nursing fall risk assessment; Interventions include: Bed and chair alarm, positioning the bed, floor mats at the bedside, low bed and persona; items and call bell within reach of the resident. NJAC 8:39-27.1 (a)

Based on interviews and a review of facility provided documents, it was determined that the facility failed to provide Saturday mail services to residents. This deficient practice was identified for one (1) of one (1) resident interviewed during the Resident Council group meeting (Residents #50) and was evidenced by the following: On 4/7/25 at 10:44 AM, the surveyor conducted the Resident Council (RC) meeting with Residents #50, #74, #115, #137, and #152. During RC, the surveyor asked the residents if they received mail on Saturdays and Resident #50 stated that he/she never received mail on a Saturday while living at the facility. Residents #115 and #137 stated they did not normally receive mail on a regular basis because nobody sent them mail. Residents #74 and #152 did not reply when asked if they received mail on Saturdays. On 4/10/2025 at 12:20 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and the survey team, stated that he was not sure if the facility received mail on Saturdays. He further stated that the mail was delivered to the business office, which was closed on Saturdays. The LNHA stated that he stopped the mail from coming on Saturdays because the mail was getting lost. On 4/11/2025 at 9:55 AM, the LNHA, in the presence of the survey team stated that there were times that the facility did not get mail. He further stated that he was not sure if it was placed on hold because they were considered a business. The LNHA acknowledged the issue should have been looked into but none of the residents complained. On 4/11/25 at 10:28 AM, the surveyor interviewed the Business Office Manager (BOM), who stated that mail was received in the business office, sorted, given to the Activities staff to be distributed to the residents. She stated that the facility had never received mail on Saturdays in the [AGE] years she has been employed there. She further stated that after surveyor inquiry, she called the post office to see if they could deliver mail to the facility on Saturdays. A review of the facility's undated Resident Mail policy, included, Residents . have the right to send and receive mail privately. .N.J.A.C. 8:39-4.1 (a)(19)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's room in a sanitary and homelike manner. This deficient practice was evidenced on 1 of 3 resident units (C-Wing) and was evidenced by the following: On 4/4/25 at 10:10 AM, during the initial tour, the surveyor entered an unsampled resident's room (room [ROOM NUMBER]-B). The bed remote was noted to have a buildup of a hard brown substance. The bed frame contained a buildup of dust and small particles. The windowsill was also noted to have a buildup of dust. On 4/8/25 at 10:41 AM, the surveyor interviewed the Housekeeper (HSK), who stated that she cleaned the bed frames and windowsills every day. On 4/8/25 at 12:34 PM, the surveyor interviewed the Environmental Services Director (EVSD), who stated that she was fully staffed. She further stated that the high-touch areas in the resident rooms were cleaned daily, and any areas that were visibly dirty should be cleaned. She also stated that the bed frames were cleaned each month when the room was carbolized (sanitizing or disinfecting equipment or surfaces to kill germs and prevent the spread of infection). The EVSD stated that room [ROOM NUMBER]-B was last cabolized on 3/6/25 and the next carbolization was scheduled for 5/6/25. At that time, the EVSD confirmed that each room was not scheduled to be carbolized monthly. At that time, the surveyor showed the EVSD a photo of the dirty areas in the resident's room, she confirmed that it was dirty and should have been cleaned. On 4/8/25 at 12:47 PM, during a follow-up visit to room [ROOM NUMBER]-B, the surveyor observed the bed remote, the bed frame, and the windowsill were still not cleaned. On 04/10/25 at 12:23 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, stated each resident's room was carbolized once a month. He further stated high touch areas should be cleaned daily and as needed. A review of the facility's undated Resident Room Cleaning policy included, Steps in the Daily Cleaning of a Resident .2. Clean and dust all horizontal surfaces, including furniture, over-bed tables, floormats A review of the facility's undated Complete Room Cleaning policy included, 1. Complete room cleaning is performed monthly. Each housekeeper will be responsible for one per day.3. Complete room cleaning includes moving of all furniture away from walls and cleaning underneath and behind. 4. Complete room cleaning includes disinfection of furniture and any beds or floormats located within the room. NJAC 8:39 - 31.4 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to administer pain medication according to the physician prescribed pain scale for 1 of 3 residents (Resident #33) reviewed for pain. This deficient practice was evidenced by: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/8/25 at 10:19 AM, the surveyor observed Resident #33 sitting in the dayroom participating in an activity. The resident was not available for interview, but had no visible signs or symptoms of pain. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, unspecified psychosis, opioid dependence, and chronic pain syndrome. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident had pain almost constantly and rated the intensity of his/her worst pain as severe. A review of the individual comprehensive care plan (ICCP) included a focus area, revised 6/21/13, that the resident had chronic back pain related to spinal stenosis and had a long history of opiate dependency. Interventions included: Assess for pain on ongoing basis, and Administer pain medication as ordered. A review of the Order Summary Report (OSR), dated as of 4/9/25, included the following physician orders (PO): A PO, dated 1/17/25, for Tramadol 50 milligrams (mg) give 0.5 tablet by mouth every eight hours for pain (0.25 tablet = 25 mg). A PO, dated 11/21/21, for Tylenol 325 mg give two tablets by mouth every four hours as needed for mild pain; pain scale 1-3. A review of the April 2025 Medication Administration Record (MAR) included the PO for Tylenol. The Tylenol was administered for pain greater than 3 on the following dates: On 4/1/25 at 4:40 AM, Tylenol was given for a pain rating of 7. On 4/1/25 at 4:26 PM, Tylenol was given for a pain rating of 10. On 4/1/25 at 9:56 PM, Tylenol was given for a pain rating of 9. On 4/3/25 at 5:00 AM, Tylenol was given for a pain rating of 9. On 4/4/25 at 4:48 AM, Tylenol was given for a pain rating of 8. On 4/5/25 at 11:13 AM, Tylenol was given for a pain rating of 5. On 4/6/25 at 4:01 PM, Tylenol was given for a pain rating of 7. On 4/6/25 at 8:46 PM, Tylenol was given for a pain rating of 7. On 4/7/25 at 4:45 AM, Tylenol was given for a pain rating of 7. On 4/9/25 at 6:00 AM, Tylenol was given for a pain rating of 8. On 4/9/25 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that if the resident's pain level was greater than the pain scale for the as needed pain medication, the nurse should call the physician for clarification and further recommendations. The LPN/UM explained that it was important to administer pain medication according to the physician's order so the resident could have relief and ensure the pain medication was effective. On 4/9/25 at 12:28 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated the nurse should clarify the as needed pain medication order prior to administering the medication if the resident's pain level did not match the physician's order. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated if a resident's pain level did not match the PO for as needed pain medication, the nurse should notify the physician. The DON explained it was important to administer pain medication according to the physician's order so the resident is being taken care of. A review of the facility's Pain Management policy, dated September 2024, included the following: 2. The best modality for pain relief will be established and ordered by the physician. 3. Modality and/or medication will be changed in accordance with need to control discomfort. 4. Modality and/or medication will be utilized, as needed, to enhance maximum level of functioning. 5. Pain management will be addressed as an approach to a problem/need or plan of care. NJAC 8:39-27.1(a)

Based on interview and document review, it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) received a written notification. This deficient practice was identified for all residents who maintained Personal Needs Accounts at the facility and was evidenced by: A review of the Patient Fund Balances Report through 4/4/2025 revealed a list of 171 active resident names with a balance of $104,879.71. There were nine (9) residents listed with PNA funds that range from $2,014.77 to $2,723.14. There were ten (10) residents listed with PNA funds that range from $1,801.93 to $1,965.65 On 4/7/25 at 12:02 PM, the surveyor interviewed the Business Office Manager (BOM) in the presence of the survey team who stated her role regarding the PNA was that she reviewed the monthly balances and completed the transfers and maintained the trust account. The BOM stated that she tried to maintain each resident's PNA balance under $2000.00. She stated that if she noticed the account was close to $2000.00, she would reach out to the resident to see what they needed or wanted. The BOM stated that she went to the units twice a week and resident were also able to come to her office. At that time, the BOM stated Resident #40 had just received the $50.00 for the month and was over by $14.00; for Residents #42, #45, #46, and #63 she would find out what they needed; for Resident #79 they were recently transferred to the facility with a high amount but would speak with the resident; for Resident #165 their social security benefits were deposited into the account and needed to be refunded; for Resident #109 there were on hospice and would speak with the family; and for Resident #12 the resident saved their money as they went on a trip with their family once a year. On 4/8/25 at 11:06 AM, the surveyor conducted a follow-up interview with the BOM and when asked to provide copies of the notices for residents whose balances were within or approaching $200 of the maximum allowed, the BOM stated she did not provide written notices, nor does she document in the resident's medical record that the resident/representative was notified. She stated, I don't have that capability in my system. On 4/10/25 at 12:22 PM, the surveyor presented the concerns regarding the PNA balances to the facility administration. On 4/11/24 at 9:43 AM, the facility administration had no further information to provide regarding the PNA balances. On 4/11/25 at 10:25 AM, the BOM stated that she rectified each one that was over the $2000.00. The BOM stated that she provided quarterly statements and when requested but reiterated she did not provide a written statement to residents whose balances were within or approaching $200 of the maximum allowed. She stated she was aware the balance was supposed to be under $2000.00 but was not aware of the written notification to the residents. A review of the facility's Job Description - Business Office Employee included, 2. PNA funds a. To post the PNA balances timely. A review of the facility's undated Personal Needs Accountants Disbursements policy did not include the process for residents whose balances were within or approaching $200 of the maximum allowed. NJAC 8:39-9.5(c)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 2 of 4 residents (Resident #28 and #57) reviewed for respiratory care. This deficient practice was evidenced by the following: 1.) On [DATE] at 10:31 AM, the surveyor observed that Resident #28 was not in their room. The surveyor observed a nebulizer mask (a device used with a nebulizer machine to deliver medication in the form of a mist directly to the lungs through the nose and mouth) was lying directly on the nebulizer machine located on the bedside table, uncovered and not stored in a plastic bag. The surveyor observed oxygen tubing not in use lying directly on the floor. On [DATE] at 8:15 AM, the surveyor observed Resident #28 awake and alert lying in bed. Resident #28 had an intact tracheostomy (an opening created in the neck to insert a tube into the trachea (windpipe) This allows air to flow directly into the lungs, bypassing the mouth and nose) clean and dry and on room air (not using oxygen) The surveyor observed the nebulizer mask lying directly on the nebulizer machine located on the bedside table and the oxygen tubing lying directly on the floor, both uncovered and not stored in a plastic bag. Resident# 28 stated that he/she did not use oxygen at that time and only received the nebulizer by way of the facial mask. On [DATE] at 10:11 AM, the surveyor observed the nebulizer mask lying directly on the nebulizer machine located on the bedside table and the oxygen tubing lying directly on the floor, both uncovered and not stored in a plastic bag. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (not receiving enough oxygen), and chronic obstructive pulmonary disease (COPD). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had tracheostomy care and did not use oxygen A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated [DATE], that the resident has oxygen therapy but refuses to wear oxygen. Interventions included: to give medications as ordered physician. A review of the Order Summary Report (OSR), dated as of [DATE], included the following physician orders (PO): A PO, dated [DATE], for oxygen every shift as needed (PRN) at six (6) liters (L) via humified Trach collar to keep oxygen saturation (SpO2) at 92% or greater as need for shortness of breath (SOB). A PO, dated [DATE], for Ipratropium-Albuterol Solution 0XXX,d+[DATE].5(3) milligram/ 3milliliters (mg/ml) give 3 ml via trach every 8 hours as needed for COPD. A review of the [DATE] Medication Administration Record (MAR) revealed that Resident #28 had received the nebulizer per physician's order three times a day. A review of the March and [DATE] Treatment Administration Record (TAR) revealed that the resident had not used the oxygen as needed. On [DATE] at 11:56 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that when a nebulizer mask and oxygen tubing was not in use, the mask and tubing should be stored in a plastic bag. LPN #1 stated that it was important to keep the nebulizer mask and oxygen tubing, when not in use, in a plastic bag for infection control reasons. On [DATE] at 12:08 PM, the surveyor interviewed LPN #2 who was Resident #28's assigned nurse for that day. LPN #2 stated that when a nebulizer mask or oxygen tubing was not being used, the mask and tubing should be stored in a plastic bag. At that time, LPN #2 and the surveyor went to Resident #28's room and LPN #2 confirmed that the nebulizer mask was not stored in a plastic bag and the nasal oxygen tubing was lying directly on the floor and not stored in a plastic bag. On [DATE] at 12:23 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manger (LPN/UM #1) who stated that the nebulizer mask and oxygen tubing should be stored in a plastic bag when not being used. LPN/UM #1 further stated that the oxygen tubing should not be touching the floor. LPN/UM #1 stated that it was important to store respiratory equipment in a plastic bag when not being used so the resident would not get an infection, and dust would not get on the equipment. On [DATE] at 1:06 PM, the surveyor interviewed the Director of Nursing (DON) who stated that oxygen tubing should not be on the floor and the nebulizer mask and tubing should be stored in a plastic bag when not being used. This was important so that dust, germs or bacteria did not get on the tubing or mask. On [DATE] at 12:38 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, the Assistant DON, the Administrator in Training (AIT) and the survey team, acknowledged that the oxygen and nebulizer mask should have been stored in a plastic bag when not being used. 40041 2). On [DATE] at 9:50 AM, during the initial tour, the surveyor observed Resident #57 awake and alert, sitting on the bed with oxygen (O2) infusing at 2 liters via a nasal cannula (n/c). The oxygen tubing was connected to a concentrator and did not contain a date on the tubing. At that time, a BiPAP machine (a machine that delivers oxygen while asleep) was observed on the nightstand with the mask uncovered lying on top of the machine. On [DATE] at 11:52 AM, during a follow-up visit with Resident #57, he/she was alert and awake, sitting upright on the bed, receiving oxygen via a nasal cannula. The oxygen tubing remained undated. Resident #57 stated that he/she requested that the oxygen tubing be changed and was told that the facility did not have the long tubing that allowed him/her to walk to the bathroom while receiving oxygen. The resident removed the nasal cannula from their nose to show the surveyor. The nasal prongs and reservoir were light brown and no longer clear. At that time, Resident #57 had a nebulizer machine (a machine that converts liquid medication into a fine mist, allowing for inhalation into the lungs and respiratory system) on their overbed table. The nebulizer mask was lying on top of the nebulizer machine and was noted to be uncovered and not in use. The resident stated that they used the nebulizer when they walked to the bathroom and planned to use it shortly. At that time, the surveyor observed the BiPAP mask was again uncovered and lying on the BiPAP machine on the resident's nightstand. A review of the Admission Record, revealed the resident had diagnoses which included but were not limited to, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), chronic respiratory failure, chronic congestive heart failure, and generalized anxiety disorder. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed that the resident was on continuous oxygen therapy and used a BiPAP. A review of the resident's individual comprehensive care plan (ICCP), dated [DATE], included a focus area that the resident had COPD and OSA. Interventions included: giving aerosol or bronchodilators as ordered, applying BiPAP as ordered, and oxygen at 2 liters. A review of the Order Summary Report (OSR), dated as of [DATE], included the following: A physician's order (PO) dated [DATE], for continuous oxygen via nasal canula at 2 liters for shortness of breath every shift. A PO dated [DATE], to apply BiPAP at ,d+[DATE] settings at bedtime. The OSR did not include an order to change and date the oxygen tubing. On [DATE] at 12:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated, the oxygen tubing was changed on Wednesdays. LPN #1 further stated the tubing should be dated when it was changed. On [DATE] at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2, who stated that the oxygen tubing was changed weekly and should be dated when it was changed. LPN/UM #2 further stated that a schedule was posted at the nurses' station indicating when the oxygen tubing should be changed. LPN/UM #2 also stated that the BiPAP and nebulizer mask should be covered when not used for infection control. At that time, LPN/UM #2 accompanied the surveyor to the resident's room and confirmed that the oxygen tubing was undated and that the nebulizer and BiPAP mask were uncovered. On [DATE] at 2:01 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the oxygen tubing should be changed weekly and dated when it was changed. Further review of the PO revealed an incorrect PO dated [DATE] for Ipratropium-Albuterol inhalation solution 0XXX,d+[DATE].5 (3) milligram(mg)/3 milliliter (ml) (Ipratropium-albuterol): 1 puff (error), inhale orally every 6 hours as needed for SOB. A review of the Consultant Pharmacist Review NON PHYSICIAN REPORT (CPRR - a report generated by the pharmacist after reviewing the resident's medications to ensure safe and effective medication therapy) dated [DATE] indicated no irregularities. A review of the CPRR dated [DATE] and [DATE], did not include recommendations regarding ipratropium-albuterol. On [DATE] at 9:51 AM, the surveyor conducted a follow-up interview with the DON regarding the albuterol order. The DON stated that the order was incorrect and should have indicated that one (1) vial should be given instead of 1 puff. The DON further stated that the nurse should have immediately clarified the order and called the doctor for any discrepancy. On [DATE] at 10:16 AM, the surveyor interviewed the Pharmacy Consultant (PC), who stated that he reviewed each resident's medication regimen every month and sometimes more often. He further stated that the order for ipratropium-albuterol was incorrect, and the PO should have been clarified and indicated that 3 mls or 1 ampule should be administered. A review of the facility's C-pap/Bi-pap Machine Cleaning and Maintenance policy, dated [DATE], included that masks should be wiped down daily after each use and place mask in a plastic bag. A review of the facility's Infection Control and Prevention Program, revised [DATE], included that the program objective was to minimize the risk of transmitting infections associated with the use of procedures, medical equipment and medical devices. N.J.A.C. 8:39- 19.4(a); 27.1(a)

Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to a.) obtain a physician's order b.) obtain consent, c.) perform a side rail safety assessment, and d.) follow the facility's policy for side rail assessment and protocol prior to the application of two half side rails and two quarter side rails to a resident's bed. This deficient practice was identified for 1 of 1 resident (#13), reviewed for restraints and was evidenced by the following: On 4/4/25 at 11:15 AM, during the initial tour of the facility, the surveyor observed Resident #13 lying in bed with two bilateral half side rails and two bilateral quarter side rails in the raised position on the resident's bed. When interviewed, the resident stated that he/she used the upper side rails to reposition in bed. The resident was unable to state when the side rails were placed on the bed. On 4/7/25 at 10:31 AM, the surveyor reviewed the medical record for Resident #13. A review of the Admission Record (an admission summary), revealed the resident had diagnoses which included, but were not limited to: Unspecified Dementia, moderate with mood disturbance, morbid (severe) obesity due to excess calories, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke) affecting non-dominant side, and contracture (a condition of shortening and hardening of muscles, tendons, often leading to deformity and rigidity of joints) unspecified hand. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/25/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired and had impairment on one side of the body in both the upper and lower extremities. Further review of the the MDS revealed that bed rails were not coded on the assessment as a physical restraint (defined: physical restraints are any manual or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual can not remove easily which restricts freedom of movement or normal access to one's body). A review of the resident's individual comprehensive care plan (ICCP) included a focus area, with a revision date of 5/17/21, that the resident had an ADL (activities of daily living) self-care performance deficit r/t (related to) hemiplegia. Interventions included .Side Rails: half rails up as per Dr.s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition Q 2 H (every two hours) and as necessary to avoid injury . A review of the Order Summary Report (OSR) revealed an order dated 7/12/19, for Siderails x 2 (two) Both sides for improved bed mobility. Further review of the OSR revealed that there was no documented evidence of an order for quarter side rails to both sides of the resident's bed. A review of the progress notes failed to include any documentation regarding the resident's use of side rails. A review of a Side Rail Assessment with an effective date of 1/25/25, included that the use of side rails was recommended to provide safety, with side rails on both the left and the right side of the bed, half rails were specified. Further review of Rails portion of the assessment included when full rails (four rails) were used (Must complete Restraint Assessment). Further review of the medical record failed to indicate that a Restraint Assessment was completed as indicated on the Side Rail Assessment form. On 4/7/25 at 11:18 am, the surveyor observed Resident #13 self-propelling in their wheelchair in the hallway. The surveyor observed that the resident's bed was made and all four side rails were maintained in the upright position. On 4/8/25 at 10:39 AM, the surveyor observed Resident #13 lying in bed fully dressed with all four side rails up on the bed. The resident stated that he/she was waiting for assistance to get out of bed. On 4/8/25 at 10:40 AM, the surveyor observed three Certified Nursing Assistants (CNA) enter Resident #13's room with a mechanical lift (a device used to assist a dependent resident out of bed) and closed the door to render care to the resident. On 4/8/25 at 10:50 AM, the surveyor interviewed CNA #3 who stated that she had worked at the facility for [AGE] years. CNA #3 stated that Resident #13 had four side rails on the bed to prevent falls and used the side rails to hold onto while he/she turned in bed. CNA #3 was unable to state when the side rails were placed onto the bed. At that time, the resident had already been assisted out of bed to the wheelchair and only the left upper half side rail had been lowered while the three remaining side rails were noted to be maintained in a raised, upright position. On 4/8/25 at 10:58 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that he worked at the facility for two years. LPN #1 stated that the resident required four side rails on the bed because he/she placed their legs off of the side of the bed. LPN #1 stated that the resident used the side rails to assist themselves and the staff with mobility and the side rails were not considered a restraint. On 4/8/25 at 1:04 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that the lower side rails were only placed in the upright position during care for safety. LPN/UM #2 stated that the side rails were not a restraint and were used so that the resident did not roll out of bed. LPN/UM #2 further stated that the bottom side rails should have been lowered when the resident was not receiving care. On 4/8/25 at 1:24 PM, the surveyor interviewed the MDS Coordinator who stated that the facility did not use restraints, so she would not code the MDS for side rails to be considered as a restraint. The MDS Coordinator stated that the facility was only permitted to use bilateral half rails to promote balance or safety and mobility. The MDS Coordinator stated that if two half rails and two quarter rails were permitted to be upright simultaneously, that was a restraint, and it was not permitted. The MDS Coordinator stated that she observed the resident quarterly and only saw two bilateral top half rails were used to aid in mobility. The MDS Coordinator further stated that she reviewed the Care Plans quarterly for new admissions and readmissions and would have expected to see that both two half rails and two quarter rails were implemented on the resident's Care Plan because it was part of their care. The MDS stated that there absolutely should have been an order for all four side rails to be used. On 4/8/25 at 1:42 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility only used four side rails with care to prevent falls and did not use four side rails as a restraint. The DON stated that a physician's order was only necessary for the quarter rails if the side rails were up all of the time. The DON stated that she would have expected for the use of four side rails to be care planned. The DON stated that the Care Plan was updated as needed, and quarterly. The DON stated that she would check with medical records to determine if a consent was obtained prior to all side rail initiation. The DON stated that she was not aware and should have been advised of the implementation of the use of four side rails in the daily clinical care meeting. The DON further stated that Maintenance would have put the side rails on the resident's bed. On 4/8/25 at 2:00 PM, the surveyor interviewed the Director of Maintenance (DM) who stated that he placed both the upper and lower side rails on the resident's bed to prevent falls. The DM was unable to state when he put the side rails on the bed. The DM was also unable to provide the surveyor with documented evidence of any requests for side rail placement. On 4/9/25 at 10:20 AM, the surveyor reviewed both the resident's electronic health record and paper chart both of which failed to contain a consent for side rail usage. The surveyor interviewed LPN/UM #2 at that time, who stated that she was not aware of the facility policy for side rail use off of the top of her head. LPN/UM #2 stated that the resident's family member was responsible to sign consent on behalf of the resident when indicated. LPN/UM #2 stated that she would look into the matter further to determine if a consent for side rail application was obtained prior to application. On 4/9/25 at 1:32 PM, the surveyor interviewed the DON who stated that she would not find a consent in the resident's medical records because the four side rails should not have been up, because the facility was a restraint free building. The DON stated that she would have expected there to be a signed consent if the side rails were in use. On 4/9/25 at 1:44 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the resident had half rails for many years, but she had no knowledge of the lower rails being applied to the bed. The ADON stated that consents were not required when the side rails were used for bed mobility. The ADON stated that an order should have been obtained when the quarter rails were added, they should have been added to the care plan and a consent should have been obtained prior to use. The ADON confirmed that there was never an order, side rail safety assessment, consent, or care plan entry for the addition of quarter side rail use, or the use of four side rails to be used simultaneously, but there should have been. On 4/10/25 at 12:40 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the quarter rails had to be removed since there was no order for use. The LNHA stated that the facility administration did weekly walking rounds inspections of the resident's rooms, but the use of four side rails was missed. A review of the facility's Side Rails Assessment Protocol/Rational policy reviewed July 2024, included: Residents of this facility, shall have the right to be free from any physical restraint. .Alternate methods are investigated and side rail usage is determined to be necessary, and side rails meet the definition of a restraint (restricts movement), a physicians' order should be obtained and the side rail should be assessed as an approach to a problem/need on the resident's care plan. If side rails are raised, staff should allow residents the opportunity to toilet and assist with repositioning at least every two hours. However, if residents are independent in bed mobility and have not demonstrated a need to be toileted during the night and are not incontinent, the residents may choose not to be disturbed every two hours while asleep for the purpose of lowering the side rails. Each resident's decision must be documented. NJAC 8:39-27.1 (a) (1)(3)(i)

Based on observation, interview and record review, it was determined that the facility failed to ensure that as-needed (PRN) psychotropic medications were ordered for no more than 14 days. This was identified for 1 of 5 residents (Resident #40) reviewed for psychotropic medication use . This deficient practice was evidenced by the following: On 04/10/2025, at 11:35 AM, the surveyor observed Resident #40 sitting quietly and calmly in the day room, smiling. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dementia, and major depressive disorder with psychotic symptoms. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/15/2024, that the resident is at risk for injury related to psychotropic drug use. Interventions included: Psychiatrist to evaluate and attempt gradual dose reduction as clinically appropriate and psychiatric evaluations as needed. A review of Resident # 40's Physician Order Sheet (POS) included an order with a start date of 12/9/2024 for Xanax oral tablet 0.5 MG, give 1 tablet by mouth every 6 hours as needed for restlessness/agitation. The order did not include an end date. A review of the Medication Administration Record (MAR) for December 9th, 2024, through April 10th, 2025, revealed that Resident #40 was not administered Xanax. A review of the Consultant Pharmacist Review PHYSICIAN REPORT dated 1/12/2025 revealed, please eval (evaluate) prn Xanax per CMS (Centers for Medicaid Services) 14 d (day) rule. Suggest order include an end date. It further revealed that the nurse obtained a Telephone Verbal Order (TVO) from the psychiatrist that he would evaluate the Xanax order. A review of the Consultant Pharmacist Review PHYSICIAN REPORT dated 3/21/2025 revealed, please eval (evaluate) prn Xanax per CMS (Centers for Medicaid Services) 14 d (day) rule. Suggest order include an end date. It further revealed that the nurse obtained a Telephone Verbal Order (TVO) from the psychiatrist that he would evaluate the Xanax order. On 4/10/2025 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 who stated, that when the resident does not use the PRN (as needed) medication, the nurse would call the psychiatrist and inform them that the resident has not been using the medication. He further stated that the doctor would come and speak with the resident, and sometimes, the doctor would discontinue the medication and then reassess the resident in a couple of months. On 4/10/2025 at 10:33 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) # 2, who stated that if the resident is not using the PRN psychotropics, the nurse would contact the doctor to see if they want to discontinue the medication and document it in the medical record. The LPN/UM #2 further stated that she would give the Consultant Pharmacist Review PHYSICIAN REPORT to the psychiatrist to decide to continue or discontinue the medication, and a lot of times, the psychiatrist would tell the nurse that he would re-evaluate the need for the medication on the next weekly round. On 4/10/2025 at 10:56 AM, the surveyor interviewed the Psychiatrist who stated that he did not recall seeing the Consultant Pharmacist PHYSICIAN REPORT dated January 12, 2025, however he was aware of the CMS 14 day rule for PRN psychotropics. He further stated that he believed that when he wrote a PRN order such as Xanax, it would automatically expire after 2 weeks. He also stated that he reviewed the resident's medical record this morning (4/10/2025) and noted that the resident has not been taking the Xanax; therefore, he does not see any reason why he should be on it and plans to discontinue it. On 4/10/2025 at 11:16 AM, the surveyor interviewed the Director of Nursing (DON) who stated that if the resident does not use a PRN medication in three to four months the nurse should have called the doctor and have it discontinued. The DON further stated that the PRN Xanax should have had a 14-day duration in accordance with CMS (Center for Medicare and Medicaid Services) requirements. A review of the facility's Psychotropic Usage undated policy revealed, PRN psychotropic usage is allowed per CMS regulation if certain documentation is met. All initial prn psychotropics must contain an end date not to exceed 14 days. After 14 days, the prescribers must reassess the resident to renew the medication. Justification is needed in the medical record to document further use.There are no exceptions to the above policy for prn psychotropics including residents on hospice. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to ensure residents' records were kept confidential for 3 of 6 residents (Resident #30, #231, and #232) observed during the medication administration pass. This deficient practice was evidenced by the following: On 4/7/25 at 8:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #3 prepare medications for Resident #30. When the nurse left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's record displayed on the nurse's laptop. On 4/7/25 at 8:30 AM, the surveyor observed LPN #3 prepare medications for Resident #231. When the nurse left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's record displayed on the nurse's laptop. On 4/7/25 at 9:00 AM, the surveyor observed LPN #3 prepare medications for Resident #232. When the nurse left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's record displayed on the nurse's laptop. On 4/7/25 at 9:15 AM, the surveyor interviewed LPN #3 who stated that should have put up the privacy screen when she left her medication cart unattended to protect the residents' privacy. On 4/9/25 at 11;26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurses should make sure the privacy screen was on when they leave their medication cart unattended so that no one could read the residents' information on the laptop. On 4/9/25 at 1:12 PM, the surveyor interviewed the Director of Nursing (DON) who stated that when the nurses leave their medication carts unattended, they should make sure to turn on the privacy screen so that no one sees the residents' information. A review of the facility's Confidentiality of Medical Records, policy, dated 8/2024, included, It is the policy of [NAME] House to respect and protect resident's rights to confidentiality of clinical and personal information. NJAC 8:39-4.1 (a)(18)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to ensure: a.) kitchen staff performed hand hygiene at the appropriate times and adhered to proper food handling procedures during the tray line observation b.) staff performed appropriate hand hygiene during meal service for 1 of 3 dining rooms observed (A Wing). This deficient practice was evidenced by the following: 1. On 4/9/25 at 12:16 PM, during a follow-up visit to the kitchen to observe the lunch meal tray line service, the surveyor observed [NAME] #1 who washed her hands at the handwashing sink for 21 seconds. [NAME] #1 then proceeded to donn (put on) a pair of gloves prior to preparing to obtain food temperatures from the steam table. [NAME] #1 placed several scoops and ladles in direct contact with the surface of the preparation area of the steam table. As [NAME] #1 proceeded to obtain food temperatures, her right arm brushed up against the scoops and ladles which caused them all to fall onto the floor. At 12:25 PM, the Food Service Director (FSD) observed the scoops and ladles that laid on the floor and directed [NAME] #1 to pick them up and run them through the dish washer. [NAME] #1 picked up the scoops and ladles with her gloved hands and took them over to the dish washer to be cleaned. [NAME] #1 then proceeded to doff (remove) her gloves and donned clean gloves without first performing hand hygiene. At 12:32 PM, [NAME] #1 began plating food. At 12:37 PM, [NAME] # 1 was observed using her right gloved hand to move a sausage and oven roasted potatoes around on the plate in order to redistribute the food. At 12:45 PM, the FSD accompanied the surveyor and observed [NAME] #1 who continued to use her right gloved hand to move both sausages and potatoes around on the plate in order to accommodate additional food items that were added to the plates. At that time, the FSD stated that [NAME] #1 should have washed her hands after she doffed her gloves and before donning new gloves prior to plating food. The FSD stated that there was a concern for contamination. On 4/9/25 at 12:52 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that hand hygiene should occur after you doff your gloves. The IP further stated that there was a concern for contamination if [NAME] #1's hands were not washed after she touched the soiled utensils and then touched food on the tray line. On 4/9/25 at 1:20 PM, the surveyor interviewed [NAME] #1 who stated that she should have washed her hands after she doffed her gloves and before she donned new gloves and started plating food on the tray line. [NAME] #1 further stated that if she failed to wash her hands and then touched food with her gloved hands it may result in food borne illness or contamination. On 4/10/25 at 12:35 PM, in the presence of the survey team the Licensed Nursing Home Administrator (LNHA) was made aware of the surveyors findings. 41072 2. On 4/9/25 at 12:48 PM, the surveyor observed the lunch meal service in the A Wing dining room. At that time, the surveyor observed Certified Nursing Assistant (CNA) #1 touch Resident#382's slice of white bread, and then proceeded to place the meat inside of the slice of bread and folded the bread over to make a sandwich with her ungloved hands. CNA # 1 then obtained a tray from the lunch cart and served the lunch tray to Resident # 100 without first performing hand hygiene. On 4/10/25 at 09:19 AM, the surveyor interviewed CNA #2 who stated that when assisting residents at mealtime you don't touch the food with bare hands. On 4/10/25 at 09:23 AM, The surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) #1 for A Wing who stated that when CNAs are assisting residents during meal service, the CNAs should wear gloves when touching a resident's food and should not touch food with their bare hands. The LPN/UM #1 further stated that the staff should perform hand hygiene between serving meal trays to each resident. On 4/10/25 at 10:09 AM, the surveyor interviewed CNA #1 who confirmed that she was the CNA who assisted Resident #382 and Resident #100 with their lunch trays the previous day. CNA #1 stated that hand hygiene should be performed before and after assisting a resident with their meal tray and you don't touch residents' food with your bare hands. On 4/10/25 at 10:51 AM, the surveyor interviewed the Director of Nursing (DON) who stated that hand hygiene should be performed before and after serving a resident their meal tray. The DON further stated that a staff member should not use their ungloved (bare hands) to touch a residents' food. The DON stated that the staff should have worn gloves when touching a resident's food and this was important so that you do not pass any germs on to the resident. A review of the facility's Food Storage and Handling, undated, included: All employees shall ensure proper hand-washing techniques are used .If food servers' hands must be in direct contact with food, the <designated person> shall ensure food servers are wearing single-use gloves. A review of the facility's Handwashing policy, review date 2/2025, included: employees must thoroughly wash their hands when: . before handling food/medications . And including: immediately before touching a resident, .after touching a resident or the resident's immediate environment ., immediately after glove removal NJAC 8:39-19.4(n)

Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program, including ongoing monitoring and use of a nationally recognized surveillance criteria when antibiotics were being prescribed. This deficient practice was identified for 3 of 3 residents (Resident #50, #78, and #124) reviewed for antibiotic stewardship. This deficient practice was evidenced by the following: On 4/9/2025 at 11:04 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she had worked at the facility full-time since February 24, 2025. The IP stated that she used the McGeer criteria (clinical and laboratory findings used to define and track infections in long-term care facilities). At that time, the surveyor reviewed the IP Checklist (a list of residents prescribed antibiotics). The IP checklist indicated the following: Resident #50 was prescribed antibiotics for a urinary tract infection (UTI) 3/31-4/5/2025, and he/she met the criteria for antibiotics. Resident #78 was prescribed antibiotics for a left foot toe infection from 4/2 to 4/12/2025, and he/she met the criteria for antibiotics. Resident #124 was prescribed an antibiotic for osteomyelitis (an infection of the bone), and he/she met the criteria. When the surveyor asked the IP how she determined that the resident met the criteria, she stated that she was aware of the requirements. The IP further stated that she had no documented evidence of the McGreer Criteria Assessment usage and had not completed the assessment form since she started working there. On 4/10/25 at 12:23 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team, who stated that the McGeer Criteria for Infection Checklist should have been completed for each resident to ensure that the resident met the criteria for antibiotic usage. A review of the facility's Antibiotic Stewardship policy, reviewed 9/2024 revealed: POLICY: To promote appropriate use of antibiotics, while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotics use. NJAC 8:39-19.4(c) (d)

Based on the interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure residents who were discharged to the community had a discharge summary that was completed by the physician. This deficient practice was identified for 1 of 1 resident, (Resident #179), reviewed for discharge. This deficient practice was evidenced by the following: On 4/7/25 at 10:16 AM, the surveyor reviewed the medical record for Resident #179. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but not limited to, high blood pressure, diabetes, and complications of amputation stump. A review of the most recent Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/31/24, revealed in Section A Identification Information that the discharge (d/c) status was coded 01 (home/community). Further review of the medical records revealed that there was no documented evidence that the physician completed a d/c summary. On 4/7/25 at 12:39 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the physicians completed a discharge summary and documented in the electronic medical record (EMR) within 72 hours of the resident being discharged . On 4/8/25 at 8:35 AM, the surveyor conducted a follow up interview with the DON who stated that the physicians did not complete a discharge summary but completed weekly visit notes. She further stated the only time the physician would complete a discharge summary was if the discharge day fell on the same day as the weekly visit. On 4/10/25 at 10:13 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1) who stated for the discharge summary the nurses ensure they received the orders from the physician. She stated that all departments completed a section on the discharge summary, and anything related to care the nurses filled out. RN/UM #1 stated that the physician wrote a discharge summary in the Progress Notes (PN) and that every resident should have a discharge summary. On 4/10/25 at 10:16 AM, the surveyor interviewed the Physician for Resident #179 in the presence of the Advance Practice Nurse (APN) who stated that residents who were scheduled to be discharged would have a discharge summary which included what was done during the resident's stay at the facility and medications that were ordered for post-discharge. He stated that the notes were done in a separate system from the facility and had to be uploaded into the EMR. The Physician stated that there should be a discharge summary for every resident that was discharged to the community to ensure they were discharged in stable condition. The Physician stated that the APN could also complete a physician's discharge summary. On 4/10/25 at 10:20 AM, the APN stated that she was the APN for the Physician. She stated that she remembered Resident #179's name but did not remember if a discharge summary was completed. At that time, both the Physician and the APN reviewed the EMR. On 4/10/25 at 10:21 AM, upon review of the EMR, the Physician stated that it was probably one they missed. At that time, they both stated they were away during the timeframe the resident was discharged . The Physician stated they had coverage but did not have anyone to complete the discharge summaries. The Physician confirmed there was no physician's discharge summary for the resident. He stated he would have to add a note in there now. He further stated they tried to complete and upload the discharge summary into the EMR within 30 days. They both acknowledged it was longer than 30 days and that it should have been completed prior to surveyor inquiry, On 4/11/25 at 9:52 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), the Assistant DON (ADON), and the survey team stated that the physician's discharge summary should have been completed. The DON and the ADON confirmed it was not done prior to surveyor inquiry. The DON acknowledged it should have been done within 30 days of the resident's discharge. A review of the facility's Interdisciplinary Discharge Summaries policy dated reviewed September 2024, included, 4. The Unit Manager will notify the Physician. The Physician will supply necessary orders and scripts. The Physician will also write his/her Physician Discharge Summary/Progress Note to be put in the patient's chart. A review of the facility's Transfer and Discharges policy dated reviewed September 2024, included, 4. Documentation a. the attending physician will document the reason for the transfer/discharge in the resident's medical records. NJAC 8:39-4.1(a)(31); 36.1(b)(c)

Complaint #: 165979 Based on observation, interviews, review of the medical record, and other pertinent facility documentation on 12/29/23, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) care as being provided to Resident #3 on the ADL Documentation form. This deficient practice was identified for 1 of 5 residents (Resident #3) reviewed for ADL care and evidenced by the following: Review of the Admission Record revealed that Resident #3 was admitted to the facility on ,d+[DATE] with medical diagnoses which included but were not limited to: Unspecified Dementia, Cerebral Palsy (a condition marked by impaired muscle coordination), Cerebral Infarction (disrupted blood flow to the brain), and Anxiety. Review of Resident #3's comprehensive Minimum Data Set (MDS) an assessment tool, dated 7/6/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated severe cognitive impairment. The MDS also indicated Resident #3 needed extensive assistance with ADL tasks including toileting, personal hygiene, transfers, dressing and bed mobility. Review of the Resident #3's Care Plan (CP) dated 6/26/23, under the Focus section, revealed Resident #3 required extensive assistance with ADLs due to multiple strokes. Under the Goals section, revealed to be dressed appropriately, well groomed, and comfortable daily. Under the Interventions/Tasks section, revealed incontinent of both bowel and bladder and unable to use bedpan. Check and change every 2 hours and as needed. Review of Resident #3's ADL Documentation form for 6/27/23 through 7/12/23 revealed blank spaces indicating the tasks were not documented as being completed as follows: Eating on the day shift on 7/1/23. Transfers, toilet use, and personal hygiene on the evening shift on 7/2/23. Transfers, toilet use, personal hygiene, eating, and bed mobility on the evening shift on 7/3/23. Transfers, toilet use, personal hygiene, eating, and bed mobility on the overnight shift on 7/1/23, 7/2/23, 7/3/23, 7/5/23 and 7/11/23. During an interview with the surveyor on 12/29/23 at 9:12 AM, the Assistant Director of Nursing (ADON) stated the Certified Nursing Assistants (CNAs) were responsible for recording ADL care, when completed, by the end of their shift. The ADON stated if there were blank spaces on the ADL form, it indicates it's not recorded in the kiosk. The ADON further stated, It is important to record ADL care, so we know ADL care was being done. If it's not recorded, it's not done. During an interview with the surveyor on 12/29/23 at 9:43 AM, the Director of Nursing (DON) stated that the CNAs were responsible for documenting ADL care immediately after care was provided. The DON stated if ADL care was not documented, there was really no proof that it was done. The DON stated it was important to document ADL care to keep a record and follow-up of any changes in the future. The DON further stated, If ADL care was not provided, the CNAs should have recorded a not applicable (n/a) in the blank spaces. All blank spaces should be filled in. During an interview with the surveyor on 12/29/23 at 9:50 AM, the Licensed Practical Nurse (LPN) stated the CNAs were responsible for ADL care and it should be documented in the kiosk. The LPN stated that if it was not documented on the ADL documentation sheet in the kiosk, it meant ADL care wasn't rendered. The LPN, in the presence of the surveyor, reviewed the ADL documentation sheets for Resident #3. The LPN stated, I wouldn't know if ADL care was completed if there were blank spaces on the ADL documentation sheet. The LPN further stated, It is important to document on the ADL documentation sheet because it is used as a communication tool for the nurses. The facility policy, ADL Documentation dated 9/2023 indicated under the Procedure section, 1. CNA staff responsibility is to chart ADLs in Point Click Care (PCC) for residents who they are assigned, 2. CNA staff are prompted by PCC in each category of ADLs, 3. Staff should indicate level of assistance and/or if the ADL did not occur on their shift, 4. Documentation is to be completed each shift, and 5. Unit Managers (UMs), supervisors and nurses are responsible for completing audit checklist for point of care (POC) monitoring each shift to ensure that all documentation is done. NJAC 8:39-27.1 (a) 8:39-35.2(g).

Based on observation, interview, record review, and policy review, the facility failed to: a. sanitize glucometers between uses for 10 (Resident (R)54, R92, R25, R110, R143, R13, R133, R139, R30, and R152) of 10 residents observed receiving fasting blood sugar tests (FSBS) out of a total sample of 47 residents; b. perform hand hygiene and or wear gloves during FSBS for two residents (R61 and R150). The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-K: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. On 04/04/23 at 7:43 PM, the Administrator, Director of Nursing (DON), and Infection Control Preventionist were notified of the Immediate Jeopardy (IJ) at F880-K Infection Control related to multi-use glucometers not being cleaned and sanitized between each resident including residents identified with blood borne pathogen concerns. The facility submitted an acceptable removal plan on 04/06/23 at 9:31 AM. The removal plan included educating the DON on system management and education of staff, sanitizing all glucometers, retraining, and ensuring competency of all Licensed Practical Nurses (LPN), and Registered Nurses (RN) on the use and sanitization of glucometers, securing hepatitis C screenings for all residents receiving FSBS tests, and updating the policy on blood sampling and glucometer sanitization to include using a manufacturer's approved sanitizing method. Through interviews with facility staff, observations of FSBS tests, review of staff in-services and facility policy, the survey team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ, effective 04/06/23 at 10:39 AM. The deficient practice remained at an E (pattern of potential for more than minimal harm) scope and severity following the removal of the immediate jeopardy. Findings include: a. The facility failed to sanitize glucometers according to manufacturer's instructions. 1.Review of R54's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R54 had diagnoses that included diabetes mellitus and human immunodeficiency virus (HIV) disease. 2. Review of R92's Admission Record, located under the Profile tab of the EMR, revealed R92 had diagnoses that included diabetes mellitus and viral hepatitis C (infectious disease of the liver that can lead to liver disease). 3. Review of R25's Admission Record, located under the Profile tab of the EMR, revealed R25 had diagnoses that included diabetes mellitus. 4.Review of R110's Admission Record, located under the Profile tab of the EMR, revealed R110 had diagnoses that included diabetes mellitus. 5. Review of R143's Admission Record, located under the Profile tab of the EMR, revealed R143 had diagnoses that included diabetes mellitus. Observation on 04/04/23 at 11:02 AM revealed Licensed Practical Nurse (LPN)6 performed hand hygiene and donned gloves to obtain a glucose reading on R110. The nurse did not clean or sanitize the glucometer after she removed it from the medication cart. Once LPN6 performed the accucheck she wiped the glucometer with an alcohol wipe and placed it back in the cart. On 04/04/23 at 11:13 AM LPN 6 next used the glucometer on R92 who has a diagnosis of Hepatitis C. The nurse removed the glucometer from the medication cart and performed hand hygiene but did not sanitize the glucometer. LPN6 obtained the blood glucose reading and removed her gloves. The nurse placed the glucometer in her uniform jacket pocket. When the nurse returned to the medication cart, she removed the glucometer from her pocket and wiped it with an alcohol wipe and placed the glucometer in the medication cart drawer. Observation on 04/04/23 at 11:42 AM LPN6 removed the glucometer from the medication cart drawer to obtain a blood glucose reading on R146. The nurse performed hand hygiene and donned gloves; however, she did not clean or sanitize the glucometer. After obtaining the resident's blood glucose reading the nurse put the glucometer in her jacket pocket, performed hand hygiene and returned to the medication cart. The nurse put the glucometer in the medication cart without cleaning or sanitizing the unit. The nurse was asked if she had used the glucometer since she used it on R92 and she stated no. LPN6 stated that she uses alcohol wipes to clean the glucometer and the Super Sani-Cloth germicidal wipes are to clean spills and the medication cart. During the interview, the nurse opened the container of Sani wipes and started wiping down her medication cart. An additional interview with LPN6 on 04/04/23 at 2:11 PM revealed she uses the Sani-wipes to wipe down the glucometer before the start of her shift, and in between each resident. However, the nurse admitted today she used alcohol wipes on the glucometer after testing R92, R110, and R146. LPN6 also stated she was not aware of R92's diagnosis of viral hepatitis C. On 04/04/23 at 11:21 AM, Registered Nurse (RN) 2 was observed to remove a glucometer from the medication cart to perform a blood glucose reading on R54, who has a diagnosis of HIV. LPN2 did not clean or sanitize the glucometer and entered the resident's room and obtained a blood glucose reading. After obtaining the blood glucose reading LPN2 returned the glucometer to the medication cart without cleaning or sanitizing it at all. Continuing observation on 04/05/23 at 11:21 AM, RN2 then moved to R25's room and prepared to obtain a blood glucose reading on R25. RN2 removed the same glucometer from the cart without cleaning or sanitizing the unit. RN2 obtained the blood reading from R25 and returned the unit to the medication cart without cleaning or sanitizing the unit at all. During an interview on 04/04/23 at 2:05 PM with RN2, he stated that used the Santi Cloth wipes before and after each resident uses the glucometer. RN2 was asked to show the container of Santi Cloth germicidal wipes that he used to clean the glucometer. The nurse opened the cart and could not find the container of Santi Cloth wipes. RN2 went to the closet behind the nurses' station and brought a container of Santi Cloth wipes stating he used that container to clean the glucometer. LPN6 was also at the nurses' station listening to the interview. I was asked was that not the same container of Sani Cloth wipes that she had just opened, and she replied yes. RN 2 did not say anything else. 25225 6. Review of R13's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R13 had diagnoses that included diabetes mellitus type 2. Review of R13's Physician Order, dated 01/24/23 and located under the Orders tab of the EMR, revealed R13 was to receive a fingerstick blood sugar (FSBS) test twice daily. 7. Review of R133's Admission Record, located under the Profile tab of the EMR, revealed R133 had diagnoses that included diabetes mellitus type 2. Review of R133's Physician Order, dated 12/06/21 and located under the Orders tab of the EMR, revealed R133 was to receive a FSBS test twice daily. 8. Review of R139's Admission Record, located under the Profile tab of the EMR, revealed R139 had diagnoses that included diabetes mellitus type 2. Review of R139's Physician Order, dated 01/23/23 and located under the Orders tab of the EMR, revealed R139 was to receive a FSBS test twice daily. 9. Review of R30's Admission Record, located under the Profile tab of the EMR, revealed R30 had diagnoses that included diabetes mellitus. Review of R30's Physician Order, dated 08/31/22 and located under the Orders tab of the EMR, revealed R30 was to receive a FSBS test twice daily, every three days. 10. Review of R152's Admission Record, located under the Profile tab of the EMR, revealed R152 had diagnoses that included diabetes mellitus type 2. Review of R152's Physician Order, dated 10/11/22 and located under the Orders tab of the EMR, revealed R152 was to receive a FSBS test twice daily, every two days. Observation on 04/04/23 at 4:07 PM revealed Licensed Practical Nurse (LPN) 7 removing a basket of FSBS testing supplies, including a glucometer, lancets, and alcohol wipes, from the top drawer of the medication cart used on the back portion of Hall 100. LPN7 placed the basket of supplies on top of the medication cart. Continuing with the observation on 04/04/23 at 4:09 PM, LPN7 obtained the glucometer from the basket and completed a FSBS test for R13. LPN7 returned to the medication cart and placed the glucometer on top of the medication cart. LPN7 did not sanitize the glucometer appropriately prior to or after use. Continuing with the observation on 04/04/23 at 4:11 PM, LPN7 obtained the glucometer, wiped the glucometer with an alcohol wipe, and completed a FSBS test for R54. LPN7 returned to the medication cart, wiped the glucometer with an alcohol wipe, and placed the glucometer on top of the medication cart. Continuing with the observation on 04/04/23 at 4:15 PM, LPN7 obtained the glucometer, completed a FSBS test for R133, returned to the medication cart, and placed the glucometer on top of the medication cart. LPN7 did not sanitize the glucometer appropriately prior to or after use. Continuing with the observation and a concurrent interview on 04/04/23 at 4:17 PM, LPN7 obtained the glucometer, wiped the glucometer with an alcohol wipe and completed a FSBS test for R139. LPN7 returned to the medication cart, wiped the glucometer with an alcohol wipe, and placed the glucometer on top of the medication cart. LPN7 confirmed she was wiping the glucometer with an alcohol wipe. LPN7 did not sanitize the glucometer appropriately prior to or after use. Continuing with the observation on 04/04/23 at 4:22 PM, LPN7 7 obtained the glucometer and completed a FSBS test for R30. LPN7 returned to the medication cart, wiped the glucometer with an alcohol wipe, and placed the glucometer on top of the medication cart. LPN7 did not sanitize the glucometer appropriately prior to or after use. Continuing with the observation on 04/04/23 at 4:25 PM, LPN7 obtained the glucometer, wiped the glucometer with an alcohol wipe, and completed a FSBS test for R152. LPN7 returned to the medication cart and placed the glucometer back in the basket with the other supplies. LPN7 did not sanitize the glucometer appropriately prior to or after use. During an observation and concurrent interview on 04/04/23 at 4:31 PM, LPN7 confirmed a container of Super Sani-Cloth sanitizing wipes was in the bottom left drawer of the medication cart. During an interview on 04/04/23 at 5:29 PM, the Director of Nursing (DON) confirmed staff should be using sanitizing wipes, such as Sani-Cloth wipes when sanitizing the glucometer and the glucometer should be sanitized between each use. During an interview on 04/05/23 at 3:19 PM, LPN7 stated she had used alcohol wipes to clean the glucometer because that is what she thought they were supposed to do. An interview with the DON 04/04/23 at 5:29 PM revealed she was not aware of any problems with staff not cleaning and sanitizing the glucometers before and after each resident's use. ICP nurse joined the interview and was surprised at the observations. Both DON and ICP stated the Pharmacy Consultant last rounds in December 2022 and that he did not identify any problems; however, he did recommend training for nurses on cleaning and sanitizing the glucometers. The ICP nurse provided an In-service sheet dated 12/19/22 and 12/21/22 in which she discussed how to clean and sanitize the Assure Prism Glucose Monitoring Unit according to manufacturer's instructions Neither DON nor the ICP could explain what monitoring system was in place to ensure the staff were following glucometers disinfectant procedures as trained. Both staff members were aware that the facility had some residents with diagnoses of viral hepatitis C and HIV. But the issue of transmission of blood borne pathogens and the number of residents with the diagnosis had not been discussed in the QA/QAPI meetings. A list of residents diagnosed with viral hepatitis C and HIV was requested from the facility. A review of the list revealed the facility had 47 residents that required fingerstick for glucose monitoring: 15 residents with viral hepatitis C and three residents with HIV. On 04/05/23 at 9:48 AM an interview was held with the Medical Director. The Medical Director was unaware of the numbers of residents residing in the facility with the diagnoses of viral hepatitis C and HIV. It was explained to the Medical Director that the failure to clean and sanitize the glucometer after each resident's use had placed the facility in immediate jeopardy situation. The Medical Director stated that he understood the concern and felt the DON and ICP nurse should have been monitoring this situation. The Medical Director also stated he was very concerned about this problem; it should never have happened. 40416 b. Nursing staff failed to wear gloves and/or perform hand hygiene while performing FSBS. 1. Review of R61's Admission Record, located under the Profile tab of the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy and dementia with behavioral disturbance. Review of R61's Physician Order, dated 06/28/22 and located under the Orders tab of the EMR, revealed R61 was to receive a fingerstick blood sugar (FSBS) test two times a day every two days. 2. Review of R150's Admission Record, located under the Profile tab of the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and schizoaffective disorder. Review of R150's Physician Order, dated 01/25/23, indicated R15 was to receive a FSBS test two times a day every seven days. During an observation on 04/04/23 at 4:02 PM, LPN3 performed finger stick blood sugar (FSBS) tests for Residents (R61 and R150). LPN3 retrieved the glucometer from the top drawer of the medication cart. The surveyor observed two brown smears across the screen of the glucometer. LPN3 wiped the glucometer with a Sani-Cloth and placed the glucometer directly onto the top of the medication cart. The Sani-Cloth appeared dirty. When asked about the dirty appearance on the Sani-Cloth, LPN3 stated Oh, that must be my makeup, that's what that is. LPN3 proceeded to the dining room and located R61 at a table sitting with two other residents. LPN3 wiped R61's finger with an alcohol swab, placed the used alcohol swab onto the dining room table, performed the finger stick, and placed the glucometer (containing the used strip) directly onto the dining room table. LPN3 picked up the used alcohol swab from the table and used it to wipe R61's finger. LPN3 gathered all supplies into ungloved hands, proceeded back to medication cart, and placed all supplies onto the top of the cart. LPN3 obtained a clean strip out of the glucose strip bottle with ungloved hands, replaced the used glucose strip with an unused strip, and touched the used strip to the clean strip to transfer a drop of blood. When asked the purpose of this, LPN3 stated, sometimes it doesn't register, and you have to get a new strip to get it to register. LPN3 removed the bloody strip from the glucometer ungloved, discarded both strips and the used alcohol swab into the trash. Continuing with the observation on 04/04/23 at 4:07 PM, LPN3 retrieved a lancet and an alcohol swab from the top drawer of the medication cart, gathered all supplies with ungloved hands, and proceeded back to dining room. LPN3 located R150 sitting at a dining room table with three other residents. LPN3 wiped R150's finger with an alcohol swab, placed the used alcohol swab onto the dining room table, performed the FSBS test, and placed the glucometer (containing the used strip) directly onto the dining room table. LPN3 picked up the used alcohol swab from the table and used it to wipe R150's finger. LPN3 gathered all supplies with ungloved hands, proceeded back to medication cart, and placed all supplies onto the top of the cart. LPN3 obtained a clean strip out of the glucose strip bottle with ungloved hands, replaced with used strip with the unused glucose strip, and touched the used strip to the clean strip to transfer a drop of blood, stating, this one didn't register either. LPN3 gathered both used strips and alcohol swab with ungloved hands to discard into the trash. LPN3 wiped the glucometer with a Sani-Cloth, placed it back into the top drawer of the medication cart and stated, that's it. LPN3 walked over to sit at the nurse's station without performing any type of hand hygiene. LPN3 failed to perform hand hygiene or don gloves throughout the entire observation. LPN3 did not sanitize the glucometer between resident tests. During an interview on 04/04/23 at 4:16 PM, when asked about donning gloves for FSBS procedure, LPN3 stated, Do you think I should be wearing gloves? LPN3 was asked about the facility's policy on wearing gloves during FSBS procedure and before LPN3 answered, the unit manager LPN5 stated, yes, we're supposed to wear gloves. LPN3 stated she did not know she was supposed to wear gloves while performing a FSBS test. LPN3 stated the facility policy was to wash hands before and after performing a FSBS test. LPN3 stated she did not wash her hands before, after, or between performing FSBS test on R61 and R150. LPN3 also stated that she failed to sanitize the glucometer between resident usage. During an interview on 04/06/23 at 12:01 PM, the Director of Nursing (DON) stated the facility's policy on infection control practices during FSBS tests was to sanitize the glucometer with Sani-Cloth before and after use. The DON stated the nurses should don gloves for the procedure and should perform hand hygiene before and afterwards. NJAC 8:39-19.4(a)(l)

Based on interview and record review, the facility failed to have a surety bond in an amount large enough to cover the highest daily balance of the residents' trust fund account. This had the potential to affect 164 of 164 residents whose trust fund monies were held by the facility. Findings include: Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $202,548.31 on [DATE] and the highest daily balance for the period was $278,324.65 on [DATE]. Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $275,915.65 on [DATE] and the highest daily balance for the period was $354,435.91 on [DATE]. Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $350,361.47 on [DATE] and the highest daily balance for the period was $430,027.92 on [DATE]. During an interview on [DATE] at 7:03 PM, the Business Office Manager (BOM) provided a Continuation Certificate surety bond, dated [DATE], for the residents' trust account. The certificate indicated the bond was issued in the amount of $200,000.00 on behalf of [NAME] House for Nursing and Rehabilitation in favor of the US Department of Health and Human Services for the term beginning on [DATE] and ending on [DATE]. The BOM stated the facility's comptroller, who was unavailable for interview, stated it was a continuing bond. The BOM stated she hoped there was another bond as this one was expired. The BOM verified the bond was for $200,000.00 and was not enough to cover the funds in the resident trust account on any day for the last three months. NJAC 8:,d+[DATE].5(c)3