Every finding on record at Accela Rehab and Care Center at Manalapan

COMPLAINT #2963689, 2978806 Based on interviews, review of medical records and other pertinent facility documentation on 5/28/26 and 5/29/26, it was determined that the facility failed to develop a comprehensive care plan to address the resident's discharge plans. This deficient practice was identified for 6 residents reviewed (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7) and was evidenced by the following:1.) A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: chronic kidney disease, hypotension, and mild cognitive impairment. A review of Resident #1's care plan did not reveal a focus related to the resident's preference and potential for future discharge. 2.) A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: congestive heart failure, type II diabetes, and dementia. A review of Resident #2's care plan did not reveal a focus related to the resident's preference and potential for future discharge. 3.) A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: type II diabetes, cognitive communication deficit, and post-traumatic stress disorder. A review of Resident #4's care plan did not reveal a focus related to the resident's preference and potential for future discharge. 4.) A review of the admission Record revealed that Resident #5 was admitted to the facility with diagnoses that included but were not limited to: epilepsy, type II diabetes, and hypertension. A review of Resident #5's care plan did not reveal a focus related to the resident's preference and potential for future discharge. 5.) A review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to: metabolic encephalopathy, secondary parkinsonism, and dementia. A review of Resident #6's care plan did not reveal a focus related to the resident's preference and potential for future discharge. 6.) A review of the admission Record revealed that Resident #7 was admitted to the facility with diagnoses that included but were not limited to: heart failure, atrial fibrillation, and hyperlipidemia. A review of Resident #7's care plan did not reveal a focus related to the resident's preference and potential for future discharge. An interview was conducted on 5/29/26 at 11:53 AM with the Director of Social Work (DSW) who stated that discharge planning for each resident was discussed during initial assessment of a new resident and during their quarterly assessments. During a follow-up interview with the DSW at 2:28 PM, she stated that the purpose of a care plan (CP) was to ensure that each resident's individual needs were explained to ensure involved members were aware of the level of care the resident required. She further stated that she had the ability to update resident's CP and that she did not include the residents' discharge plans as a focus area. An interview was conducted on 5/29/26 at 3 PM with the Director of Nursing (DON), who stated that a CP was a person-centered outline of the care that each resident required. She stated that discharge planning begins at the time of admission and that it was the responsibility of the DSW to ensure that discharge plans were included in the CP. When the surveyor asked the DON if she was aware that the DSW had not included discharge planning, the DON stated that she had come across one CP that did not include it but did not explain what action was taken when she saw it. The DON restated that discharge plans should be a part of each resident's CP. N.J.A.C. 8:39-27.1(a)

COMPLAINT #2963689, 2978806 Based on interviews, record review, and review of facility documentation on 5/28/26 and 5/29/26 it was determined that the facility failed to a.) keep resident's medical information confidential and b.) follow facility policy titled Release of Information on maintaining the confidentiality of residents' information. The deficient practice was identified for one resident reviewed (Resident #6), and was evidenced by the following:A review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to: metabolic encephalopathy, secondary parkinsonism, and dementia. Further review revealed that the resident's address and that of their two contacts including phone numbers, were included in the resident's admission form. A review of Resident #6's care plan did not reveal a focus related to the resident's preference and potential for future discharge from the facility. A review of Resident #6's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 4/21/26, revealed a Brief Interview of Mental Status (BIMS) of 5 out of 15, which indicated that the resident's cognition was severely impaired. A review of an undated facility document, titled: Investigation Summary and Conclusion provided to the surveyor by the Director of Nursing (DON), revealed that an investigation was initiated by the facility after they received an allegation that the, .facility improperly released.[Resident #6's] contact information to an outside facility. The document also confirmed that the facility contacted an outside third party facility and provided them with Resident 6's information, and asked the third party facility to reach out to Resident #6's family without getting permission from the resident's family first. An interview was conducted on 5/29/26 at 12:36 PM with the Licensed Nursing Home Administrator (LNHA) and the DON. The LNHA confirmed the above information. He stated that he identified and contacted an outside third part facility and provided them with Resident #6's information and that he sent a referral to the outside facility. The LNHA stated that he did this in preparation of Resident #6's discharge. The LNHA stated that he did not discuss this with Resident #6 due to their low cognition. He also stated that the resident did not have a Power of Attorney (POA) and that he did not reach out to the family regarding this facility. When asked who he obtained consent from to reach out to the outside facility on behalf of the resident he stated that he was under the impression that the family wanted options. When asked for documentation related to the family's knowledge that the outside facility was being contacted, none was provided. During a follow-up interview on 5/29/26 at 4:08 PM, with the LNHA, the DON, and the Regional Clinical Director (RCD), the LNHA reviewed the facility's Release of Information policy in the presence of the surveyor. When the surveyor asked if the LNHA followed this Policy Interpretation and Implementation, he stated that he had not completely followed the policy. After the survey, on 6/8/26 at 5:39 PM, the surveyor received an electronic message from the LNHA containing attachments. The LNHA indicated that the documents made up the referral packet that was forwarded to the outside facility for Resident #6. The document included Resident #6's Care Plan, Diagnosis Report (dated 3/27/26), admission Record (dated 3/27/26), PN with an effective date range of 2/1/26 to 3/15/26, and the Order Summary Report (dated 3/27/26). A review of the facility's Release of Information policy, revised November 2009, revealed that the facility would maintain resident confidentiality. The policy further revealed, . 3. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative . N.J.A.C. 8:39-4.1(a)18; 27.1(a)

Complaint #: 2708219Based on interviews, review of medical records, and review of other pertinent facility documents on 1/8/2026, it was determined that the facility failed to develop and implement a baseline care plan to address a resident's oxygen therapy and failed to address the resident's known non-compliance with oxygen use. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3), as evidenced by the following: According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: pneumonia and acute respiratory failure with hypoxia.According to the Minimum Data Set (MDS), an assessment tool, Resident #3 did not have a Brief Interview for Mental Status (BIMS) score completed at the time of survey due to recent admission.A review of a document provided by the facility titled Discharge Instructions with a printed date of 12/26/25 at 01:32 P.M., for Resident #3, reveals Oxygen therapy for 2 liters per minute applied via nasal cannula (a device used to supply supplemental oxygen) with a continuous duration of use. The document further reveals Monitor oxygen saturation, supplemental oxygen as needed for goal saturation of 92 number.A review of Resident #3's Admission/readmission comprehensive nursing assessment dated [DATE] reveals under 1. Nursing Assessment. 5. Most Recent O2 sats [oxygen saturation] 98.0% via nasal cannula.A review of Resident #3's medical record revealed that a formal physician order for oxygen was not placed until 12/28/25.A review of Resident #3's MEDICATION ADMINISTRATION RECORD dated 12/1/2025 - 12/31/2025 reveals 02 @ 3LPM VIA NASAL CONTINUOUS [oxygen delivery in the nose of 3 liters of oxygen per minute to be given continuously] every shift.-Start Date- 12/28/2025 2300.A review of Resident #3's Care Plan (CP), revealed a focus of the resident has altered respiratory status related to respiratory failure as evidenced by hypoxia with an initiated date of 12/29/2025. However, review of the associated interventions revealed no interventions addressing the use of oxygen, no interventions addressing Resident #3's non-compliance with wearing oxygen, and no monitoring plan for oxygen saturation.During an interview on 1/8/2026 at 12:06 P.M., with the Unit Manager (UM), the UM states Resident #3 was on oxygen and was non-complaint with oxygen. The UM further states that the UM and supervisors update the CP and put them in, and that if a resident is non-compliant with oxygen there would be a CP in place.During an interview on 1/8/2026 at 2:08 P.M., with the Director of Nursing (DON), the DON states, [Resident #3] did not have a care plan for oxygen. The DON acknowledges there should have been a CP for oxygen as well as a CP for non-compliance with oxygen.A review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed under Policy Statement that a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed.NJAC 8:39- 11.2 (d)

Complaint #: 2708219Based on interviews, review of medical records, and review of other pertinent facility documents on 1/8/2026, it was determined that the facility failed to obtain a physician's order for oxygen therapy, upon admission, for a resident that was identified as needing continuous oxygen therapy.This deficient practice was identified for 1 of 3 residents reviewed (Resident #3), as evidenced by the following:According to the admission Record (AR), Resident #3 was admitted with diagnoses that included but were not limited to: pneumonia and acute respiratory failure with hypoxia.According to the Minimum Data Set (MDS), an assessment tool, Resident #3 did not have a Brief Interview for Mental Status (BIMS) score completed at the time of survey due to recent admission.A review of a document provided by the facility titled Discharge Instructions with a printed date of 12/26/25 at 01:32 P.M., for Resident #3, reveals Oxygen therapy for 2 liters per minute applied via nasal cannula (a device used to supply supplemental oxygen) with a continuous duration of use. The document further reveals Monitor oxygen saturation, supplemental oxygen as needed for goal saturation of 92 number.A review of Resident #3's Admission/readmission comprehensive nursing assessment dated [DATE] reveals under 1. Nursing Assessment . 5. Most Recent O2 sats [oxygen saturation] 98.0% via nasal cannula.A review of Resident #3's MEDICATION ADMINISTRATION RECORD dated 12/1/2025 - 12/31/2025 reveals 02 @ 3LPM VIA NASAL CONTINUOUS [oxygen delivery in the nose of 3 liters of oxygen per minute to be given continuously] every shift.-Start Date- 12/28/2025 2300.During an interview on 1/08/2026 at 12:22 P.M., with the Director of Nursing (DON), the DON states an oxygen order should start on admission when a resident needs it, for [Resident #3] it started on 12/28/26. The DON acknowledges that Resident #3 was wearing oxygen but the order for oxygen was not placed into the medical record until 2 days after the resident was admitted . The DON further states the facilities policy was not followed by the nurse because there was no order for oxygen from admission.A review of the facility's policy for Oxygen Administration with a revised date of October 2010, reveals under Preparation 1. Verify that there is a physician's order for this procedure.NJAC 8:39- 11.2 (a), (d)

Complaint # 2672054 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 12/9/25, it was determined that the facility Nursing staff failed to notify the Resident's family when a Resident had a change in condition for 1 out of 4 sampled residents (Resident #2). This deficient practice is evidenced by the following: According to Resident #2's MR, the Resident had diagnoses which included but were not limited to: Crohn's Disease and Ulcerative Colitis. According to the Minimum Data Set (MDS) an assessment tool utilized to facilitate the care of a resident, dated 10/31/25, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating the Resident was moderately impaired. A review of Resident #2's Progress Notes (PN) documented by the Nursing Supervisor dated 11/01/25 at 9:50 AM, revealed: Resident with a Medical diagnosis of Ulcerative Colitis was observed during the AM shift with an episode of bloody diarrhea. Upon assessment, resident stated 'I already called my son'. Resident appeared anxious at the time of evaluation. Further review of the PN revealed that the Nurse Practitioner was notified, the doctor was called, but did not answer, and a voicemail was left regarding the resident's condition and transfer. There was no documentation that the resident's family was notified regarding the resident's change in condition. An attempt was made to reach the assigned nurse for Resident #2 on 12/9/25 at 1:21 PM but was unsuccessful. During an interview with the surveyor on 12/9/25 at 1:44 PM, the Certified Nursing Assistant (CNA #1) stated that on 11/1/25, she received report from Resident #2's assigned nurse, that the resident had a medical emergency and needed to leave as soon as possible. CNA #1 stated that she received Resident #2 in their bathroom and that there were blood clots on the floor leading to the bathroom and on the bathroom floor. CNA #1 stated that there were other staff prepping the resident to go to the hospital. CNA #1 stated that the Emergency Medical Transport (EMT) and the resident's representative were already at the facility when she arrived. CNA #1 stated that she provided care to Resident #2 and the resident's son assisted her to put the resident in their chair. During an interview with Director of Nursing (DON) on 12/9/25 at 2:11 PM, the DON stated, The resident was bleeding I believe that night after midnight on 11/1/25. The Nursing Supervisor reported a bleeding episode with the resident, they did not know where the bleeding was coming from. They reached out to the Nurse Practitioner (NP) to get further instruction.There was no documentation in Resident #2's MR that the Resident's family was made aware of the Resident's change in condition. A review of the facility's policy titled Change in a Resident's Condition or Status with a Revised date of 2021, revealed:Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental or psychosocial status; NJAC 8:39-13.1(c)

Based on review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 28 days reviewed.This deficient practice was evidenced by the following:According to the Nursing Staffing Reports completed by the facility, the facility provided no RN services on 7/20/25. NJAC 8:39-25.2(h)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate and easily accessible for 1 of 30 residents reviewed (Resident #116). This deficient practice was evidenced by the following:On 8/12/2025 at 8:41 AM, the surveyor reviewed the closed electronic medical record for Resident #116. A review of Resident #116's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD, a lung disease characterized by ongoing inflammation and narrowing of the airways, leading to difficulty breathing), hypertensive heart disease (heart conditions caused by long-term high blood pressure), and benign prostatic hyperplasia (BPH, enlarged prostate, is a common condition in older men where the prostate gland enlarges, potentially causing urinary problems). A review of Resident #116's progress notes and miscellaneous section of uploaded documents did not reveal any documented attending physician progress notes. The surveyor requested from the Director of Nursing (DON) the paper medical record. A review of Resident #116's additional hybrid (paper and electronic) medical record that was provided by the facility did not reveal any documented attending physician progress notes for the residents stay from 9/30/24 until 7/4/25. On 8/12/2025 at 11:08 AM, the surveyor interviewed the DON regarding physician visits. The DON stated that the expectation was that the primary physician visited monthly but that a Nurse Practitioner could visit alternate months. The surveyor asked the DON where the physician documented their visits. The DON stated that the expectation was for the physician to document the notes in the electronic record but that they could be in the paper chart. The surveyor asked the DON to review Resident #116's paper and electronic record that was provided to the surveyor. The DON confirmed that there were no attending physician visit notes documented in Resident #116's hybrid medical record. The DON stated that she was going to reach out to the attending physician. The surveyor asked the DON if the attending physician's visit should be part of the resident's medical record. The DON stated that they should be part of the medical record. The DON confirmed that she was contacting the attending physician after surveyor inquiry. On 8/12/2025 at 2:57 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, the [NAME] President of Nursing (VPoN) and the [NAME] President of Operations (VPoO) of the concern that Resident #116 did not have any documented attending physician visits in the hybrid medical record. On 8/13/2025 at 8:00 AM, the VPoN provided a copy of multiple visits that were performed by the attending physician during Resident #116's stay at the facility. A review of the documents revealed a printed date of 8/12/25 5:30 PM. On 8/13/2025 at 1:04 PM, the DON stated that the VPoN received the attending physician visit notes from the attending physician after surveyor inquiry and that the notes should have been in the medical record.The LNHA did not provide any additional information.A review of the facility provided policy titled Physician Services with a revised date of February 2021, included the following:Policy Statement The medical care of each resident is supervised by a licensed physician.Policy Interpretation and Implementation6. Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy. 7. Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. A review of the facility provided policy titled Electronic Medical Records with a revised date of March 2014, included the following:Policy Statement Electronic medical records may be used in lieu of paper records when approved by the administrator.N.J.A.C. 8:39-35.2

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the facility-wide assessment (used to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) was updated to address the care and needs of a resident with a LVAD (a left Ventricular Assist Device-a mechanical pump that helps a weakened heart pump blood).On 8/7/2025 at 11:00 AM, during a resident council meeting, which included unsampled Resident #67 and two surveyors, Resident #67 stated they had a LVAD. The surveyor reviewed the electronic Medical Record for unsampled Resident #67. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage heart failure (the heart can no longer pump enough blood to meet the body's needs) and presence of a heart assist device. A review of the Order Summary Report revealed a physician order for Monitor pump parameters q-shift.LVAD team.start date 2/14/2024. The surveyor reviewed the facility provided facility assessment (FA), date of assessment or update of 9/5/24. The review did not reveal an LVAD was included in the care or services provided. On 8/7/2025 at 1:12 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), reviewed and verified the above-mentioned FA was the most recent and up to date. He stated the FA was updated at least yearly or if there was a change. On 8/13/2025 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON), who stated the FA was a break down of the history of what residents need in the building. She reviewed the above-mentioned FA in the presence of the surveyor and verified it did not include the care of a resident with an LVAD. She stated, I know we can take them (resident with an LVAD) but was unable to show the surveyor in the FA or how she knew that. At that time, the DON called the [NAME] President of Nursing (VPN) on speaker phone and questioned the VPN on the FA. The VPN stated we (the LNHA and VPN) would go to the office right now and review it. The surveyor observed the LNHA, and the VPN enter the LNHA's office and sit at the computer. The surveyor entered the office and asked if LVAD care was included in the FA. The LNHA stated he would print a new one (FA) right now. The surveyor declined a new one to be printed and asked if the care of a resident with an LVAD should be in the facility assessment, the VPN shook her head yes and stated, it should be included in the facility assessment.A review of the facility's policy Facility Assessment revised 10/2018, revealed Policy Statement: A Facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation:3. The facility assessment includes a detailed review of the resident population. This part of the assessment includes; a. resident census data from the previous 12 months. c. factors that affect the overall acuity of the residents.5. Conditions or diseases that require specialized care (eg., dialysis, ventilators, wound care). N.J.A.C. 8:39-5.1(a), 27.1(a)(b)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a refrigerated controlled medication (Lorazepam oral concentrate solution) was removed from active inventory when the controlled medication was discontinued on [DATE] and when six (6) of the 15 Lorazepam oral syringes were expired on [DATE]. The deficient practice was identified when one (1) of two (2) medication room refrigerators were inspected and evidenced by the following: On [DATE] at 1:37 PM, the surveyor inspected the 200 Unit medication room refrigerator in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed six (6) of 15 oral syringes of Lorazepam oral concentrate 0.5 milligram per 0.25 milliliters labelled for Resident #30 with a use by date of [DATE]. LPN/UM stated the six (6) Lorazepam oral syringes with the use by date of [DATE] should have been removed from the refrigerator. The LPN/UM added that she would have to bring the Lorazepam oral syringes to the Director of Nursing (DON) for destruction. The surveyor then reviewed the corresponding Controlled Drug Administration Record provided by the LPN/UM which reflected 15 oral syringes of Lorazepam 0.5 MG/0.25 ML were received on [DATE]. The surveyor reviewed the medical record for Resident #30.A review of the current physician's orders (PO) for Resident #30 which reflected there was no PO for Lorazepam.A review of the August electronic medication administration record (EMAR) revealed that there was no PO for Lorazepam.On [DATE] at 9:15 AM, the surveyor interviewed the DON, who stated Resident #30 was on hospice and thought there would be a PO for the Lorazepam and it would have been indicated on the EMAR. The DON added that she would have to check.On [DATE] at 11:50 PM, the DON provided the surveyor with the May and [DATE] EMARs, which revealed Resident #30 had a PO for Lorazepam with a start date of [DATE] for 14 days. The DON stated that the Lorazepam had not been used and should have been removed from the refrigerator when the PO was discontinued. The DON stated she would look for the discontinued date for the Lorazepam.On [DATE] at 12:20 PM, the DON provided the surveyor with a PO for the Lorazepam with a start date of [DATE] and an end date of [DATE].A review of the facility policy Storage of Medications dated as revised [DATE] provided by the DON reflected Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. NJAC 8:39-29.4(g)(h)(k)

NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 1 of 10 residents (Resident #43) reviewed for tray accuracy during dining and was evidenced by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli. The surveyor observed a sign that hung over the resident's bed which indicated, No Straws and Thickened liquids, do not leave thickener packets with the resident. The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool dated 5/23/25, 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 indicated that the resident required a mechanically altered diet (e.g., pureed food, thickened liquids), and a therapeutic diet (e.g., low salt, diabetic, low cholesterol) and had no identified weight loss or weight gain. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/30/25, that the resident had a swallowing problem r/t (related to) oral dysphagia (difficulty swallowing); I am on Nectar thick liquids. Interventions included: Instruct me to eat in an upright position, to eat slowly, to chew each bite thoroughly, refer for Swallowing Evaluation as needed.A review of the Order Summary Report (OSR), dated as of 3/26/25, including the following Physician's Order (PO):A PO, dated 3/26/25, for a No Concentrated Sweets (NCS) diet Ground texture, Nectar consistency.A review of a Speech Therapy Discharge summary dated [DATE], included: Skill: Interventions Provided: .instruction in no straw precautions.On 8/6/25 at 12:50 PM, the surveyor observed Resident #43 seated in a wheelchair eating independently accompanied by another resident. The surveyor reviewed the resident's meal ticket which indicated, NCS-Ground, Nectar Thick Liquids. Further review of the meal ticket specified, NO STRAW at the bottom of the resident's meal ticket. A straw that was sealed in paper was placed to the left of the resident's meal tray. At that time, Registered Nurse (RN) #1 presented to the resident's table. When the surveyor asked RN #1 why the resident was provided with a drinking straw when the meal ticket specified otherwise RN #1 stated, But, it was not opened. RN #1 further stated that the resident needed to be assisted with meal set up but could feed themselves independently. On 8/7/25 at 11:28 AM, the surveyor interviewed RN #1, who stated that the aides were informed of the resident's care needs and there were signs on the resident's wall in their room which indicated thick liquids, no straw. RN #1 stated that the resident could aspirate (food or fluids get into the airway), so a straw should not have been given to the resident if it specified no straw on the resident's meal ticket. On 8/7/25 at 11:54 AM, the surveyor observed Resident #43 seated in a wheelchair in the main dining room with a drinking straw on his/her place mat. On 8/7/25 at 11:57 AM, the Infection Preventionist (IP) walked over to Resident #43's table and removed the straw from the resident's place mat. When interviewed at that time, the IP stated that he removed the straw from the resident because the resident was on a list of residents who received thickened liquids. On 8/7/25 at 12:00 PM, the surveyor interviewed Activity Aide (AA) #1, who stated that the dietary department put the place mat, napkin and straw on each table. On 8/7/25 at 12:03 PM, the surveyor interviewed the Registered Dietician (RD), who stated that the meal ticket specified no straw if the resident were ordered thickened liquids. The RD further stated that the aide, or the nurse could identify if the ticket specified no straw upon review for tray accuracy and remove it at that time if indicated. On 8/7/25 at 12:08 PM, the surveyor interviewed the Food Service Director (FSD), who stated that the staff usually fed the resident, and the nurse should have noticed the straw at that time. The FSD stated that the resident should not have been provided with a drinking straw because the resident was ordered thickened liquids. The RD who was present at that time, stated that the reason that the resident was not permitted to have a straw had something to do with their swallowing, but she did not know the correct answer. On 8/7/25 at 1:41 PM, the surveyor informed the Director of Nursing (DON) of the concerns with Resident #43 who received a drinking straw on their tray during the lunch meal service on 8/6/25 and 8/7/25, despite the meal ticket indicating No Straw.A review of the facility's undated Tray Accuracy included:.Routine tray line audits to confirm tray accuracy will be conducted by the Food Service Director or designated employee.A review of the facility's Preparing the Resident for a Meal policy, revised September 2010, included: .Review the resident's care plan and provide for any special needs of the resident.NJAC 8:39-17.4(a)1

Complaint #401653, #401655Based on observation, interview and record review, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 7 residents reviewed for medication management, (Resident #9, #120 & #57), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.On 8/7/2025 at 11:00 AM, during a resident council meeting which included Resident #9 and two surveyors, Resident #9 stated they had not received their pain patch or pain gel that morning. The surveyor reviewed the electronic medical record (EMR) for Resident #9. A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; general anxiety disorder, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life), schizoaffective disorder, bipolar type (characterized by the presence of mood episodes, including mania or mixed mania and depression, along with psychotic symptoms such as delusions or hallucinations), pain in left knee and low pack pain unspecified. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/9/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. Further review reviewed the resident received a scheduled pain medication regiment. A review of the individual comprehensive care plan (ICCP) revealed a Focus: has (acute/chronic) pain r/t (related to) RHEUMATOID ARTHRITIS; Unspecified osteoarthritis, unspecified site…Date Initiated: 11/2/2023 and included Interventions: Administer analgesia as per orders . Date Initiated: 11/02/2023 Revision on: 1/26/2024 and anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/2/2023. A review of the Order Summary Report (OSR) revealed physician orders (PO) for the following: - Voltaren External Gel 1 % (Diclofenac Sodium (Topical)) Apply to left knee topically one time a day for pain Apply 4grams to left knee one time a day, Dated 10/23/24. -Lidocan External Patch (Lidocaine) Apply to Lower Back topically one time a day for Lower Back Pain 4% Lidocaine Patch and remove per schedule; Dated 2/27/25. A review of the August 2025 electronic Medication Administration Record (eMAR) revealed the above POs for the Voltaren External Gel had been signed as administered as ordered on 8/7/25 at 0900 (9:00 AM), site: Lknee (left knee) and the Lidocan External patch had been signed as applied as ordered on 8/7/25 at 0900 by Licensed Practical Nurse (LPN) #1. On 8/7/2025 at 1:55 PM, the surveyor interviewed LPN #1, who stated that she had given Resident #9 all their medications that morning. The surveyor asked if the resident received anything for pain, any gels or patches? LPN #1 responded “Yes, I didn’t put them on yet. I am getting to my treatments now.” She stated the medications were in the treatment cart not the medication cart. LPN #1 reviewed the EMR in the presence of the surveyor and stated all the medications in green meant that they were given. She verified the orders for the Lidocan patch and the Voltaren gel were green, but stated they were not given. The surveyor asked if the physician was informed that the medications were not given, and she stated “I haven’t gotten to it yet. It’s not an important medication so I don’t think anything should be done.” On 08/7/2025 at 2:01 PM, the surveyor interviewed LPN/Unit Manger (LPN/UM) #1, who stated her expectation for a 9 AM medication was the medication could be given an hour before or after the time and if it was within the parameters, it should be given. She stated if a medication was not in the cart, then the nurse should check the backup medications. She verified the Lidocaine patch 4 percent and the Voltaren gel was available in the back up. LPN/UM #1 stated, “I know 100 percent both are in stock in the back up.” She stated if the nurse signed the eMAR for the medication, it meant it was given. The surveyor made LPN/UM#1 aware LPN #1 said she didn’t give the medications, but she signed she did. LPN/UM #1 stated, “It is a medication error and the nurse should be written up for it and a medication error sheet should be done.” On 8/7/2025 at 2:11 PM, LPN #1 informed the surveyor, in the presence of LPN/UM#1, that she had retrieved the medications and reported to the physician that the medications were not given this morning. On 8/7/25 at 2:50 PM, the surveyor interviewed the Director of Nursing (DON), who stated 9 AM medications can be given up to an hour before or up to an hour after. She stated if they (medications) are not given within the time period, then the physician should be called. She further stated if medications were not in the medication cart, the nurse should check the back up system and contact pharmacy. She confirmed if a medication was in green it meant the medication was given at the correct time and that medication should not be signed as given if it was not given. On 8/12/2025 at 2:48 PM, the surveyor, in the presence of the survey team, made the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Nursing (VPN), the DON, and the [NAME] President of Operations aware of the above concerns. 2. The surveyor reviewed the electronic closed medical record for Resident #120. A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Rheumatoid Arthritis (RA) (chronic inflammatory disorder affecting the joints). A review of the resident's electronic medication administration record (EMAR) for November revealed on 11/12/25 a physician’s order dated 11/12/25 for “Voltaren External Gel 1 % (Diclofenac Sodium (Topical) Apply to knees, hands, shoulder topically every shift for arthritis pain apply 4 grams.” The “Night” dose was not administered and was indicated by LPN #2 with the number “5” which corresponded to “Hold/see progress notes.” A review of the resident’s electronic progress notes (EPN) revealed there was no corresponding progress note to correlate with the number “5” for Voltaren gel not being administered on 11/12/25 at night. Further review of the EPN revealed on 11/13/25 at 6:24 AM there was a nursing note from the LPN #2 “Resident alert and oriented. At 5:45 am resident complain [redacted] did not get [redacted] last night medicine writer explain to [redacted] that [redacted] only medication [redacted] take at this time is for GERD (gastroesophageal reflux disease-irritation caused by stomach contents flowing back up into the esophagus), resident get upset saying [redacted] did not get [redacted] evening medication and night medication steroid….” Further review of the EMAR revealed a PO dated 11/13/24 for “Methylprednisolone oral 4 MG (Methylprednisolone) Give 2 tablet by mouth at bedtime for arthritic pain.” There was no time of administration indicated on the EMAR for the evening of 11/12/24. According to an After Visit Summary from an emergency room hospital visit dated 11/11/24, the resident had instructions to start 11/12/24 Methylprednisolone 4 MG tablet, commonly known as Medrol Dosepak, take as directed on package. Indications: pain with history of RA, start tomorrow 11/12/24. On 8/7/25 at 10:00 AM, the surveyor requested from the DON any investigations regarding Resident #120. On 8/12/2025 at 9:20 AM, the surveyor attempted to interview LPN #2 via the telephone and left a voicemail. On 8/12/2025 at 9:55 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the CP for approximately a year. The CP stated that if a medication was not available the nurses should check the backup supply, call the pharmacy provider and call the physician for follow up. The CP added that the nurses cannot just document that the medication was not available. On 8/12/25 at 11:00 AM, the surveyor interviewed LNHA regarding Resident #120. The LNHA was unable to speak to any concerns or investigations regarding Resident #120. On 8/12/2025 at 1:24 PM, the surveyor interviewed the DON, who stated for a new admission there was a backup supply for some medications and there was also the possibility to call an emergency pharmacy if the provider pharmacy could not deliver a medication right away and the provider pharmacy also made multiple deliveries at different times of the day. In addition, the DON stated that medications if brought from home in a prescription vial or properly labelled were verified then the facility would be able to use the medications brought from home. The DON was unable to speak to Resident #120 not receiving their medications on the night of 11/12/24 because she was not the DON at that time. In addition, the DON was unsure if LPN #2 was still employed. On 8/12/25 at 2:48 PM, the survey team met with the LNHA, DON, VPN and [NAME] President of Operations. The DON stated she would expect to see in the progress notes why medications were not administered and any follow up from a physician. The VPN provided a timeline for Resident #120 which indicated Resident #120 was admitted at the end of the day shift on 11/12/25 and “Medications finished around 6:00 pm.” There was no explanation for the evening dose of Voltaren gel not being administered or the PO for Methylprednisolone not being administered the evening of 11/12/25. There was no further documentation provided for Resident #120. 3. On 8/6/25 at 11:30 AM, the surveyor observed Resident #57 in their room with a staff member cleaning out the resident’s personal refrigerator. The surveyor was unable to interview the resident. The surveyor reviewed the electronic medical record for Resident #57. A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, dementia, major depressive disorder, recurrent, in partial remission and gastro-esophageal reflux disease without esophagitis (stomach acid irritates the lining). A review of the most recent comprehensive quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 14 out of 15, indicating that the resident had an intact cognition. A review of the resident's EMAR for August 2025 revealed the following: 1. A PO with a start date of 7/28/25 for “Cefuroxime Axetil Oral Tablet 250 MG (Cefuroxime Axetil) Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 6 days 2 tabs=500 MG. Notify MD (physician) of signs and symptoms adverse reaction.” On 8/1/25 at the time of administration for 1700 (5 PM) indicated the number 9 by LPN #3 which corresponded to “other/see nursing progress notes.” 2. A PO with a start date of 7/29/25 for “Escitalopram Oxalate Oral Tablet 5 milligrams (MG) (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Depression 1 tab=5 MG.” The time of administration was 9:30 AM and on 8/12/25 the medication was not signed as administered and there was the number 9 noted by LPN #4 which corresponded to “other/see progress notes.” 3. A PO with a start date of 7/29/25 for “Pantoprazole Sodium Oral Tablet Delayed release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD 1 tab=40 MG, Do not crush.” The time of administration was 9:00 AM and on 8/12/25 the medication was not signed as administered and there was the number 9 noted by LPN #3 which corresponded to “other/see progress notes.” A review of the electronic progress notes (EPN) for Resident #55 revealed the following eMAR administration notes: 1. On 8/1/25 at 18:29 (6:29 PM) the LPN #3 documented “awaiting delivery” for the Cefuroxime 500 MG dose. 2. On 8/12/25 at 9:02 AM the LPN #4 documented “awaiting delivery” for the Escitalopram 5 MG dose. 3. On 8/12/25 at 9:03 AM the LPN #4 documented “awaiting delivery” for the Pantoprazole 40 MG dose. There were no progress notes regarding the physician being notified. On 8/13/2025 at 11:02 AM, the surveyor interviewed LPN #5 who stated that she was the nurse administering medications to Resident #55 that day but was not here yesterday. LPN #5, in the presence of the surveyor, reviewed the medication cart and removed Escitalopram 5 MG and Pantoprazole 40 MG labelled for Resident #55. LPN #5 stated they were in the bottom drawer of the medication cart. LPN #5 added that sometimes agency nurses do not look for the medications. On 8/13/2025 at 11:25 AM, the surveyor interviewed Resident #55 in their room. The resident stated that the nurses brought their medications and had no concerns. The resident added that they had a lot of medications and was unable to speak to which medications or what times the nurses gave them their medications. On 8/13/2025 at 11:50 AM, the surveyor interviewed the DON, who stated that she would have to educate the nurses who indicated “awaiting delivery” for Resident #55’s medications. The DON stated that Cefuroxime, Escitalopram and Pantoprazole were medications stocked in the back up supply and should have been administered. The DON added that she would expect the nurses to notify a supervisor if a medication was not available and there would be follow up such as getting the medication from the backup system, calling the provider pharmacy, or emergency pharmacy. The DON stated that the goal was to get the medication and administer it and if that was not possible then the physician needed to be notified for follow up. A review of the electronic medication back up supply list reflected that Cefuroxime 250 MG tablets, Escitalopram 10 MG tablets and Pantoprazole 20 MG tablets were available. A review of the facility policy dated as revised April 2019 for “Administering Medications” provided by the DON reflected “Medications are administered in a safe and timely manner, and as prescribed.” In addition, the policy interpretation and implementation included but not limited to; “4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).” NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 8/7/25, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 35 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 8.57 %. The deficient practice was identified for two (2) of five (5) residents, (Resident #30 and #55), that were administered medications by two (2) of two (2) nurses. The deficient practices were evidenced as follows: 1.On 8/7/25 at 8:24 AM, the surveyor observed the Registered Nurse (RN) #1 administer four (4) medications to Resident #30. The resident then stated that they wanted their cough medicine.On 8/7/25 at 8:29 AM, the surveyor observed RN #1 measure 10 milliliters (ML) of Gertussin DM (Guaifenesin Dextromethorphan) liquid. RN #1 stated Guaifenesin DM was an over-the-counter/house stock (OTC/HS) medication meaning that the facility was responsible for providing those medications to any resident with a physician's order (PO). RN #1 added the resident had an as needed (PRN) PO for the cough medicine. At that time, the surveyor with RN #1 reviewed the electronic medication administration record (EMAR) which revealed a PO for Guaifenesin liquid 100 milligrams (MG)/5 milliliters (ML), Give 10 ML by mouth every 6 hours PRN for cough. RN #1 stated that the Gertussin DM was the cough medicine that was ordered.The surveyor reviewed the electronic medical record for Resident #30.A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, Huntington's Disease (a hereditary disorder which damages brain cells).A review of the resident's Order Summary Report (OSR) reflected a corresponding PO with a start date of 7/26/25 for Guaifenesin liquid 100 milligrams (MG)/5 milliliters (ML), Give 10 ML by mouth every 6 hours PRN for cough.On 8/7/25 at 12:29 PM, the surveyor interviewed RN #1, who stated that she only had the Gertussin DM in the medication cart as the OTC/HS cough medicine. RN #1 added that OTC/HS medications were ordered by the central supply person.At that time, the surveyor, with RN #1 reviewed the EMAR and PO which indicated Guaifenisen liquid in addition to the bottle of Gertussin DM. RN #1 acknowledged that the OTC/HS had the ingredients of Guaifenesin and DM. RN #1 stated the Gertussin DM was the only OTC/HS cough medicine that she had and thought that was the correct medication. RN #1 then stated that since the PO had not indicated DM she would have to call the physician and have the PO changed. (ERROR #1)On 8/7/25 at 12:38 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the PO must match the medication being administered. The DON added the Staffing Coordinator was in charge of the central supply and ordering of the OTC/HS medications. The DON also stated the facility had a list of OTC/HS and could order and provide OTC medications to the residents. In addition, the DON stated there were no substitutes and the physician would have to be called for an order.On 8/7/25 at 12:43 PM, the surveyor interviewed the Staffing Coordinator (SC) who stated she had the responsibility of ordering the OTC/HS medications for the facility. The SC added that she ordered according to a list that she was provided by the facility on a weekly or monthly basis to keep an inventory. The SC added if there was a need for an OTC/HS that was not on the list then she would have to order it when it was needed. The surveyor, with the SC, reviewed the OTC/HS medications stored in the central supply room and the SC stated that the only cough medicine that was available at that moment was Gertussin DM. The SC also stated that she used three different vendors depending on who had the OTC/HS that was needed. The SC added that she would have to be told to order an OTC/HS that was not on the list and could not speak to whether Guaifenesin without the DM was ordered. The surveyor was provided an OTC/DNS List by the Director of Nursing and Guaifenesin Solution 100 MG/5 ML was on the list.A review of a Medication Pass Observation (med pass) form for RN #1 dated 6/23/25, completed by the Consultant Pharmacist (CP) revealed that an observation was completed by the CP and that RN #1 had a 4% error rate.On 8/12/25 at 12:32 PM, the surveyor interviewed the CP via telephone who stated she has been the CP for approximately a year and could not speak to the OTC/HS medications the facility purchased. The CP added she had done individual nurse med pass observations but had not done an inservice for all nurses recently. The CP also stated she reviewed the Med Pass Observation form with the nurse after the observation and would do a 1:1 inservice on any errors or findings and would also review the entire form to cover any areas that were not observed. The CP added that she would give a Medication Pass handout to the nurse. The CP also stated the PO for the OTC/HS had to match the drug, dose, formulation before administering. The CP added the nurse would have to call the physician to change the PO to match the OTC/HS medication.A review of the CP Medication Pass inservice handout reflected for accuracy Right Drug-Compare the pharmacy label/package to the MAR/eMAR-the medication and strength must match exactly what is ordered.On 8/12/25 at 10:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, [NAME] President of Nursing (VPN) and VP of Operations (VPO). The surveyor reviewed the above concern that occurred during the medication pass.A review of the facility policy dated as revised April 2019 for Administering Medications provided by the DON reflected, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 2. On 8/7/25 at 9:02 AM, the surveyor observed the RN #2 administer 11 medications to Resident #55, which included a Ferrous Sulfate 325 MG tablet and a Lidocaine 4% patch. RN #1 stated that according to the EMAR, the resident had a PO for the Ferrous Sulfate and Lidocaine 4% patch and both were OTC/HS medications.The surveyor reviewed the electronic medical record for Resident #55.A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to, anemia (low red blood cells) and atherosclerosis with gangrene of left leg (thickening of the arteries with tissue death due to the lack of blood flow).A review of the resident's OSR revealed the following POs: Ferrous Sulfate Oral Tablet Delayed Release 325 (65 Active Fe) Give 1 tablet by mouth two times a day for supplement 1 tab=325 MG with a start date of 6/3/25 and Lidocaine-Menthol External Patch 4-1% (Lidocaine-Menthol) Apply to Left knee topically one time a day for pain and remove per schedule with a start date of 6/4/25.A review of the EMAR revealed corresponding POs for the above Ferrous Sulfate Delayed Release and Lidocaine-Menthol External Patch 4-1%.On 8/7/25 at 1:37 PM, the surveyor interviewed RN #2 who stated that she administered the OTC/HS medications that she had in the medication cart. The surveyor, with RN #2, reviewed the EMAR for Resident #55 for the Ferrous Sulfate Delayed Release and Lidocaine-Menthol 4-1% against the OTC/HS medications that she had administered. RN #2 was unable to speak to the Ferrous Sulfate OTC/HS medication not matching the PO for a delayed release formulation. In addition, RN #2 was unable to speak to the OTC/HS Lidocaine 4% not containing Menthol 1 %. (ERROR #2 and ERROR #3)On 8/7/25 at 12:38 PM, the surveyor interviewed the DON, who stated that the PO must match the medication being administered. The DON added the SC was in charge of the central supply and ordering of the OTC/HS medications. The DON also stated the facility had a list of OTC/HS and could order and provide OTC medications to the residents. The DON also stated there were no substitutes and the physician would have to be called for an order. On 8/7/25 at 12:43 PM, the surveyor interviewed the SC who stated she had the responsibility of ordering the OTC/HS medications for the facility. The SC added that she ordered according to a list that she was provided by the facility on a weekly or monthly basis to keep an inventory. The SC added if there was a need for an OTC/HS that was not on the list then she would have to order it when it was needed. The surveyor with the SC reviewed the OTC/HS medications stored in the central supply room and SC stated that there was Ferrous Sulfate 325 MG tablets and had no other Ferrous Sulfate tablets and only had Lidocaine 4% patches. The SC also stated that she used three different vendors depending on who had the OTC/HS that was needed. The SC added that she would have to be told to order an OTC/HS that was not on the list and could not speak to any other Ferrous Sulfate or Lidocaine patch being ordered. The surveyor was provided an OTC/DNS List by the DON and Slow Fe 45 MG tablets were on the list. In addition, Lidocaine 4% patches were not listed.A review of a Medication Pass Observation form for RN #2 dated 6/23/25, completed by the CP revealed that an observation was completed by the CP and the RN #2 had a 4% error rate.On 8/12/25 at 12:32 PM, the surveyor interviewed the CP via telephone who stated she has been the CP for approximately a year and could not speak to the OTC/HS medications the facility purchased. The CP added she had done individual nurse med pass observations but had not done an inservice for all nurses recently. The CP also stated she reviewed the Med Pass Observation form with the nurse after the observation and would do a 1:1 inservice on any errors or findings and would also review the entire form to cover any areas that were not observed. The CP added that she would give a Medication Pass handout to the nurse. The CP also stated the PO for the OTC/HS had to match the drug, dose, formulation before administering. The CP added the nurse would have to call the physician to change the PO to match the OTC/HS medication. A review of the CP Medication Pass inservice handout reflected for accuracy Right Drug-Compare the pharmacy label/package to the MAR/eMAR-the medication and strength must match exactly what is ordered. On 8/12/25 at 10:50 AM, the survey team met with the LNHA, DON, VPN and VPO. The surveyor reviewed the above concerns that occurred during the medication pass. A review of the facility policy dated as revised April 2019 for Administering Medications provided by the DON reflected The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. NJAC 8:39-11.2(b), 29.2(a)(d), 29.4(c)

Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 27 residents reviewed (Resident #10 and Resident #13). This deficient practice was evidenced by the following:1.On 8/6/25 at 11:54 AM, Resident #10 refused to speak with the surveyor. The resident refused to speak with the surveyor for the duration of the survey. On 8/12/25 at 10:59 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1, who stated that Resident #10 had specific CNAs that they want and only allowed them to provide care and would shout, yell, curse, and refuse everything for others. The surveyor reviewed the Comprehensive admission MDS dated [DATE], which indicated that Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had an intact cognition, no behaviors or rejection of care were noted, and diagnoses included diabetes (high blood sugar), anxiety, and post-traumatic stress disorder. A review of the electronic health record (EHR) revealed a progress note dated 5/26/25, which indicated Resident #10 refused morning medications, a progress note dated 5/27/25, which indicated weekly weight was refused, and a progress note dated 5/28/25, which indicated a physician/provider visit and all medications were refused.On 8/12/25 at 11:19 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that Resident #10 did refuse care and yelled at the staff. 08/12/2025 at 3:03 PM, the surveyor interviewed the (MDSC) via phone, who she stated that the Social Worker would have completed the MDS section regarding the refusals and behaviors of Resident #10 and that the MDS should reflect what was documented in the nursing notes. She further stated that the Social Worker in question was no longer at the facility. On 8/13/2025 at 12:04 PM, the surveyor interviewed the Regional MDSC, who stated that Section E of the MDS was completed by the Social Worker who was no longer at the facility. She acknowledged that there was documentation of the resident's behaviors and refusals and stated that the Social Worker did not capture the behaviors and miscoded the MDS for Resident #10. 2.On 8/6/2025 at 11:41 AM, the surveyor observed Resident #13 in their room, in bed and dressed. The resident stated their hearing aids broke but was unsure if they told anyone. The surveyor observed Resident #13 trying to put a hearing aid in their ear and showed the surveyor the battery came out.On 8/7/25 at 11:12 AM, the surveyor reviewed the Comprehensive admission MDS dated [DATE], which indicated adequate hearing, no hearing aid, a BIMS score 15 out of 15 which indicated the resident had an intact cognition and diagnoses including schizophrenia (a mental disorder that affects how people think, feel, and behave). The quarterly MDS dated [DATE], indicated moderate difficulty with hearing, no hearing aid, and a BIMS score 15 out of 15. A review of the EHR revealed the Accela Quarterly, Annual, or Significant change 7-IDT-V2 dated 1/12/24, 4/14/24, 7/14/24, 1/14/25, 4/12/25, and 7/9/25 all indicated hearing aids were in use.A review of the individual comprehensive care plan (ICCP) included a focus area initiated 2/29/24, that the resident had a communication problem related to hearing difficulty. Interventions included hearing aids that are kept at the bedside and cared for by the resident.On 8/7/25 at 12:15 PM, the surveyor interviewed the RN/UM who stated that Resident #13 was admitted with hearing aids, but these hearing aides were relatively new and that she called the vendor to come and repair the hearing aid of which the battery compartment was in disrepair. On 8/08/2025 at 11:13 AM, the surveyor interviewed the MDS Coordinator (MDSC) who stated she was unaware the resident had hearing aids. She acknowledged the care plan for them and stated she would do a modification of the MDS.Review of facility policy Electronic Transmission of the MDS, revised November 2019 included:Policy StatementAll MDS assessments (e.g., admission, annual, significant change, quarterly review, etc) and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. N.J.A.C 8:39-11.1

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 2 residents (Resident #18) reviewed for timing of assessments and was evidenced by the following: This deficient practice was evidenced by the following: On 8/8/25, a review of the electronic health record (EHR) revealed that Resident #18 was admitted to the facility on [DATE]. The Comprehensive admission MDS, with an assessment reference date (ARD) of 2/27/25, was noted to be signed as completed on 3/18/25. On 8/8/25, the surveyor interviewed the MDS Coordinator who stated this admission MDS should have been completed by March 6th (3/6/25). She further stated that she did not have an explanation as to what happened.Review of facility policy MDS Completion and Submission Timeframes, revised July 2017 included:Policy StatementOur facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.Policy Interpretation and Implementation2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.Review of facility policy, Resident Assessments, revised March 2022, included:1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments - conducted for all residents in the facility:1. admission Assessment (Comprehensive)2. Quarterly Assessment3. Annual Assessment (Comprehensive)2. The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments.According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2024, page 2-17, the Comprehensive admission assessment must be completed no later than admission date + 13 calendar days. NJAC 8:39-11.2 (e)

NJ401661, NJ401667, NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow appropriate infection control procedures during the provision of incontinence care for a resident who was previously identified to have been at risk for recurrent urinary tract infection.This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for bladder and bowel incontinence and was identified by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli.The surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: urinary tract infection, site not specified, overactive bladder, other specified noninfective gastroenteritis and colitis (conditions that affect the gastrointestinal tract). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 5/23/25, 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 that the resident was frequently incontinent of urine and was always incontinent of bowel. On 8/6/25 at 10:42 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that she was assigned to eleven residents today and she had not yet provided any care to Resident #43 yet because she planned to give the resident a shower today and the resident required assistance from two staff members to get out of the bed. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, with a revision date of 7/18/25, that the resident had bowel incontinence related to dementia. Interventions included: Check resident every two hours and assist with toileting as needed and provide peri care after each incontinent episode. Further review of the ICCP included a focus area, with a revision dated of 7/18/25, that the resident was at risk for chronic urinary tract infection related to incontinence. Interventions included: Resolved: Check at least every 2 (two) hours for incontinence. Wash, rinse and dry soiled areas (resolved date 3/19/25), and encourage adequate fluid intake, and monitor/document/report to MD (medical doctor) PRN (as needed) for s/sx (signs and symptoms) of UTI: Frequency, urgency, malaise (a general feeling of discomfort), foul smelling urine, dysuria (painful or difficult urination), fever, nausea and vomiting, flank (side) pain, supra-pubic (lower part of the abdomen above the genitals) pain, hematuria (presence of blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes (date initiated 6/30/25). A review of the Order Summary Report, included the following physician order (PO):A PO dated, 7/24/25, for Macrobid oral capsule 100 MG (milligrams) (Nitrofurantoin Monohyd Macro) Give 1 (one) capsule by mouth two times a day for UTI for 10 (ten) days.A review of an Incident Note dated 7/24/25 at 11:07 PM, indicated that the resident was on Macrobid Oral Capsule 100 MG for UTI for 10 days. No c/o (complaint of) pain or discomfort noted during the shift. PO (oral) fluids encouraged.Safety precautions in place. On 8/6/25 at 11:07 AM, the surveyor observed CNA #1 and CNA #2 as they prepared to assist Resident #43 with incontinence care. CNA #1 stated that she did not know when the resident's brief was changed last. CNA #1 then stated that CNA #2 went to get supplies to change the resident. At that time, CNA #2 returned to the room without any supplies to change the resident. The resident wore a green brief that was opened by CNA #2, who then assisted the resident to turn towards the right side of the bed towards CNA #1. The resident had a small amount of urine and liquid stool in their brief. CNA #2 stated that the stool looked fresh. CNA #2 then proceeded to use the brief to cleanse both the stool and urine from the resident's skin. When the surveyor asked if it were permissible to use the brief to clean the resident with the soiled brief instead of a washcloth CNA #1 stated that it was okay since the resident was going to get a shower anyway. CNA #2 then continued to clean the resident with the soiled brief and prepared the resident to shower. On 8/7/25 at 10:30 AM, the surveyor interviewed CNA #3 who stated that Resident #43 was changed today at 9:30 AM and was not saturated with urine. CNA #3 stated that he obtained all supplies needed before he rendered care to the resident. CNA #3 stated that the facility offered both disposable and washable wash cloths for incontinence care. CNA #3 stated that two wash cloths were needed for incontinence care for a female, and it was important to clean from front to back so that it would not get contaminated. CNA #3 stated that if we used a soiled brief to wipe a resident it was not appropriate for infection control purposes because the resident could get an infection. On 8/7/25 at 11:19 AM, the surveyor interviewed CNA #2 who stated that she used the resident's soiled brief to clean Resident #43's urine and stool because it was there, and CNA #1 wanted to clean the resident in the shower. CNA #2 stated that there were wipes that were not used and the resident was not properly cleaned. CNA #2 further stated that by using the brief to clean the resident instead of a wipe the resident could get an infection. On 8/7/25 at 11:28 AM, the surveyor interviewed Registered Nurse (RN) #1 who stated that the aides could have pressed the call bell and called for wash cloths to cleanse the resident. RN #1 further stated that there was a potential for infection because the resident had a history of urinary tract infection. On 8/7/25 at 11:36 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1, who stated that a soiled brief should not be used to do incontinence care because you must use a wet washcloth to clean the resident appropriately. The LPN/UM #1 stated that it could cause an infection if a soiled brief were used instead. The LPN/UM #1 further stated that Resident #43 has had UTIs since day one and had been going to the urologist, but they have not specified the cause of the resident's UTIs. On 8/7/25 at 12:20 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that even if a section of the resident's brief that was not soiled were used to clean the resident it was still soiled and dirty. The IP stated that he would have instructed the aides to wait and get the appropriate supplies to clean the resident because there was a concern for infection, and it could cause a potential UTI. On 8/7/25 at 1:41 PM, the surveyor interviewed the Director of Nursing (DON), who stated that it was not appropriate to use a soiled brief to clean the resident. The DON stated a clean diaper maybe, or a washcloth, wipe or toilet tissue could be used to clean the resident but not a soiled diaper, until the aides showered the resident. The DON stated, A soiled brief was not clean, and it is an infection issue because there was both urine and bowel movement in the diaper and it can cause an infection. The DON stated that the doctor has deemed the resident chronic for UTI. A review of the facility's Urinary Continence and Incontinence-Assessment and Management policy, revised September 2010, included: The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines.A review of a staff in-service that was provided to staff which included CNA #2 on 7/2/25, revealed the following:.Nurses and CNA play a key role in UTI prevention through patient education and promoting healthy habits.Female Patients: Spread the labia majora and wipe down the center, using a clean part of the washcloth for each stroke. Then, clean each side, rinsing and drying the area thoroughly. Finally, have the patient turn on their side to clean the anal area.Male Patients: For circumcised males, start cleaning at the top of the penis and move downwards in a circular motion to the base. For uncircumcised males, gently retract the foreskin before cleaning and remember to reposition it afterward. NJAC 8:39-19.4

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide food that accommodated a resident's known food allergy to eggs and egg-derived products. This deficient practice was identified for 1 of 18 residents (Resident #32) reviewed for meal observations. On 02/27/24 at 8:32 AM, Resident #32 was observed eating a hard-boiled egg. The meal ticket on their breakfast tray had documented allergies to eggs and egg-derived products. This posed the likelihood of serious harm to the health and wellbeing of Resident #32. This resulted in an Immediate Jeopardy (IJ). The IJ was identified and began on 02/27/24 and the IJ template was given to the Licensed Nursing Home Administrator (LNHA) on 02/27/24 at 12:48pm. An acceptable removal plan was received on 02/28/24 at 2:20 PM and was verified on-site on 02/29/24 at 9:13 AM. The evidence was as follows: A review of the facility policy for Food Allergies and Intolerance's, revised August 2017, included but was not limited to: Residents with food allergies Are identified upon admission . Steps are taken to prevent resident exposure to the allergen(s). Assessment and Interventions: 1. Residents are assessed for a history of food allergies upon admission and as part of the comprehensive assessment. 2. Resident food allergies . are documented in the assessment notes and incorporated into the resident's care plan. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 01/31/24, reflected the resident had a brief interview for mental status (BIMS) of 09 out of 15, indicating that the resident had moderate cognitive impairment. Section GG, was coded as 04 which indicated that the resident required supervision for eating. On 02/23/24, the surveyor reviewed Resident #32's electronic medical record. A review of the Admission Record dated 07/21/23, documented that Resident #32 had Allergies: Erythromycin (an antibiotic), Eggs or Egg-derived products, Penicillin's (an antibiotic), Citric Acid, Melon. The Admission Record revealed diagnoses which included but were not limited to legal blindness and need for assistance with personal care. The Physician's Order Summary Report dated 02/27/24, indicated Allergies: Erythromycin, Eggs or Egg-derived products, Penicillin's, Citric Acid, Melon. A review of the resident's current Comprehensive Care Plans documented the resident's diagnosis, date of birth, physician's name, admitted , room location and allergies which included Erythromycin, Eggs or Egg-derived products, Penicillin's, Citric Acid, Melon. A review of the February 2024 Certified Nursing Aide (CNA) Task record (a guide to care for the resident) included but was not limited to: Allergies Erythromycin, Eggs or Egg-derived products, Penicillin's, Citric Acid, Melon. A review of the Physician's Assistant Progress Notes (PN) dated 02/20/24, included but was not limited to: Allergies Erythromycin, Eggs or Egg-derived products, Penicillin's, Citric Acid, Melon. A review of the Dietitian's PN dated 01/22/24, included but was not limited to: Allergies Erythromycin, Eggs or Egg-derived products, Penicillin's, Citric Acid, Melon. A review of the Endocrinology consult dated 01/05/24, revealed Resident #32's documented allergy list as citric acid, eggs or egg-derived products, Penicillin's, Erythromycin, melon. On 02/27/24 at 8:15 AM, the surveyor observed Resident #32's meal ticket which indicated allergies: eggs. On 02/27/24 at 8:32 AM, the surveyor observed Resident #32 sitting up in bed with the meal in front of the resident. The surveyor observed the meal ticket next to the resident's plate. Resident #32 stated [he/she] wanted pancakes. The resident then raised their right hand, which had a half-eaten hard-boiled egg, and ate the rest of the egg in the presence of the surveyor. The surveyor did not observe an allergic reaction. The surveyor then went into the hallway outside of Resident # 32's room and interviewed the MDS/LPN nurse and Licensed Practical Nurse (LPN). The MDS/LPN stated she had delivered the meal tray to Resident #32. The surveyor inquired what the process was regarding meal tray delivery. The MDS/LPN stated she would check for the correct diet. She also stated she does not normally pass out meal trays and that she does not look down at the allergies on the meal ticket. The MDS/LPN confirmed that there were two hard-boiled eggs on the resident's meal tray. On 02/27/24 at 8:33 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who verified that Resident # 32 had food allergies to eggs via the electronic medical record (EMR). On 02/27/24 at 8:54 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the MDS/LPN should have looked for allergies on the meal ticket. The DON acknowledged that Resident #32's EMR and meal ticket documented an egg allergy. On 02/27/24 at 8:57 AM, the surveyor interviewed the Food Service Director (FSD) and a Dietary Aide (DA). The FSD stated the facility used a meal tracker system to print out the resident's food order and a list of allergies. The DA preparing the tray was responsible to review the allergies to ensure the resident was not receiving those foods. On that same date and time, the DA stated that she would always read the meal tickets and be mindful about food allergies. The DA acknowledged the resident's meal ticket indicated pancakes and that she should have provided pancakes. The DA stated, It is my fault. On 02/27/24 at 10:03 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that Resident #32 should not have been served eggs given that eggs were listed as a food allergy on the resident's meal ticket. On 02/27/24 at 10:46 AM, the surveyor, in the presence of two other surveyors, conducted a telephone interview with Resident #32's Medical Doctor (MD). The MD confirmed he had been the resident's MD since January 2024. He stated I would expect [he/she] did not get any eggs if there was an egg allergy noted on Resident #32's meal ticket. He further stated he had never clarified what Resident #32's reaction was to any of the allergies documented in the medical record. On 02/29/24 at 8:27 AM, the surveyor interviewed the DA again regarding why eggs were placed on Resident #32's meal tray. The DA stated she thought she could give it to her so she did eventhough the meal ticket documented an egg allergy. An acceptable removal plan was received on 02/28/24 at 2:20 PM indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: 1) assessment and monitoring of the resident for an allergic reaction; 2) a physician order for Benadryl (a medication that treats pain and itching caused by allergic reactions) to be given if the resident had an allergic reaction; and 3) facility education to the nursing and dietary staff regarding meal tray accuracy and delivery including attention to documented allergies. The survey team verified the removal plan on-site on 02/29/24 and determined the IJ for F806 was removed as of 02/29/24 at 9:13 AM. NJAC 8:39-17.4; 27.1 (a)

Complaint #159956 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement interventions to prevent urinary tract infections (UTIs) for a resident with a history of chronic UTI's (from 06/17/2022 through 01/03/2024) which required oral and intravenous (IV) antibiotic therapy, and required hospitalization . This deficient practice was identified for 1 of 2 Residents (Resident #51) reviewed for Urinary Tract Infections and was evidenced by the following: On 02/23/24 at 6:15 AM, Surveyor #5 completed an incontinence care tour on the 200 Unit, a strong urine odor permeated in the hallway of the low side of the 200 Unit. Surveyor #5, in the presence of a Certified Nurse Aide (CNA #1), observed Resident # 51 was wearing two incontinent briefs that was saturated with urine. On that same date and time, a nurse was also present, who stated that some of the residents wore double briefs. At that same time, Surveyor #5 interviewed the CNA who stated that if a resident was a heavy wetter, a pad would be placed inside the diaper. A review of the current Electronic Medical Record (EMR) revealed that Resident #51 was admitted to the facility with diagnoses including but not limited to; Type 2 diabetes mellitus, dementia, overactive bladder, urinary tract infection (UTI), acquired absence of left great toe and coronary angioplasty implant and graft (a treatment used to widen and open narrowed or blocked arteries supplying your heart muscle). The Annual Minimum Data Set (MDS), as assessment tool used to facilitate the management of care dated 11/30/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating that the resident had severe cognitive impairment. Further review of the MDS indicated the resident required maximum assistance for toileting, hygiene, was always incontinent of urine, had a UTI in the last 30 days and was non-ambulatory. A review of Resident #51's comprehensive care plan and interventions, initiated on 11/02/23, with a target date of 12/21/23, revealed the resident had a UTI with a goal of the resident's urinary tract infection will resolve without complications by the review date. The care plan interventions included to encourage adequate fluid intake; give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness; give antipyretics, analgesics and antispasmodics as ordered/PRN [as needed]; monitor/document for side effects and effectiveness; monitor/document/report to MD [medical doctor] PRN for signs and symptoms of UTI: Frequency, Urgency, Malaise, foul smelling urine, dysuria, Fever, nausea and vomiting, flank pain, Supra-pubic pain, Hematuria, Cloudy urine, Altered mental status, Loss of appetite, Behavioral -initiated 11/02/23. The care plan did not include any updated interventions after each UTI or to prevent further UTIs. There was no focus for activities of daily living self care performance deficit (ADLs) related to incontinence care. A review of the current EMR revealed the following physician's orders (PO) and corresponding progress notes: On 11/15/23 a PO for Keflex (an antibiotic used to treat bacterial infections) 500 milligram (mg) 1 capsule orally three times a day for Extended Spectrum Beta-Lactamase (ESBL- enzymes produced by some bacteria that may make them resistant to some antibiotics) for 7 days. A nurses noted dated 11/15/23 at 11:44 PM, reflected that the resident was started on an antibiotic for UTI treatment. On 12/26/23 a PO for Macrobid (an antibiotic used to treat UTI's) 100 mg give 1 capsule by mouth. A review of 12/26/23 Nurse Practitioner's (NP) note revealed that Resident #51 had a UTI that was positive for two organisms and was currently being managed with Macrobid. Review of the medical record revealed a nurses note dated 01/02/24, that Resident #51 had an intermittent reproductive cough, the doctor was notified and an order for Levaquin, cough medicine and a chest X-ray was obtained. On 01/03/24 a PO for Levaquin 250 mg tablet, 1 tablet by mouth once daily for 7 days; and a NP note, dated 01/04/24 at 1:20 PM, revealed that the resident had Methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used) in the urine, was on isolation precautions and was currently being managed with Levaquin, and was previously on Macrobid. On 02/28/24 at 9:29 AM, the Director of Nursing/Infection Preventionist (DON/IP) provided a timeline of Resident #51's UTI's from 2022 through 2023 which revealed the following: 06/17/22- MD ordered Ciprofloxacin 500 mg twice a day for 5 days (an antibiotic commonly used for UTI's). 10/18/22- Resident admitted to the hospital with a UTI. 11/28/22- [NAME] blood cell's (WBC's) elevated, order to collect urine culture and sensitivity (UA C&S) then start Cipro 500 mg twice a day for 5 days. 12/01/22- Urine culture positive for ESBL and infection disease consult ordered. 12/2/22- the Cipro was discontinued and IV antibiotic Invanz (an antibiotic used to treat a wide variety of bacterial infections)1 gram every 24 hours times 3 days was ordered for ESBL(extended spectrum beta-lactamase -an enzyme found in some strains of bacteria) in the urine and osteomyelitis of the left great toe. 12/19/22- admitted to the hospital with colitis (an infection in the colon). 12/22/22- readmitted to the facility on Cipro 500 mg twice a day for 5 days for a UTI. 03/28/23- Urine culture positive, resident received Rocephin (an antibiotic used to treat many bacterial infections) 1 gm times one dose. 04/18/23- resident was admitted to the hospital after a fall and admitted with a UTI. 04/26/23- resident readmitted to facility with a UTI and an order for Invanz 1 gm IM (intramuscularly) times one dose. 06/11/23- urine culture positive for ESBL, Macrobid 100 mg twice a day times 7 days ordered. 08/04/23- urine culture positive, Rocephin 500 mg twice a day for 6 days ordered. 11/14/23- Keflex 500 mg three times a day for 7 days for UTI 12/22/23- Cipro for UTI 12/25/23- Cipro discontinued and Macrobid started. A review of hospital records, dated 10/18/22, revealed Resident #51 presented with a UTI and was ordered IV Cipro antibiotic. On 02/28/24 at 10:29 AM, the surveyor interviewed CNA#2 who stated that if a resident was left in a wet diaper for long periods of time, they can get a UTI. On 02/28/24 at 10:44 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who stated that ways to prevent a resident from getting a UTI would include checking and changing the resident every 2 hours, monitor for any changes in mental status, increase fluids and make sure they remain dry. If a resident is left wet in a diaper for long periods of time, it can cause a UTI. It is important to provide incontinence care every 2 hours or as needed in order to prevent UTI's. On 02/28/24 at 10:31 AM, the surveyor interviewed the DON/IP who stated that it was important to change a resident's incontinent brief every two hours, if not changed, and if the resident was heavily soiled with urine, it could lead to an infection. The DON/IP further stated, If urine is sitting there it can cause UTI's for the ladies. If residents are not changed in a timely manner, it can be serious. On 02/29/24 at 1:49 PM, the Licensed Nursing Home Administrator (LNHA) and the DON/IP were made aware of the above concerns. On 03/06/24 at 1:35 PM, the LNHA, DON/IP, [NAME] President of Nursing (VPN) and [NAME] President of Operations for the management company met with the survey team. The VPN stated that the resident had chronic UTIs and the facility did not offer any additional information regarding interventions to prevent UTIs. A review of the facility's policy titled Urinary Tract Infections/Bacteriurua-Cimical Protocol, revised April 2018, revealed that when a resident has a persistent or recurring urinary tract infection after treatment with antibiotics, the physician will review the situation with the nursing staff and consider other or additional issues (such as urinary obstruction or indwelling catheter) before prescribing additional courses of antibiotics. A review of the facility's policy titled Urinary Continence an Incontinence-Assessment and Management, revised September 2010, revealed that the physician and staff will provide appropriate services and treatment to help resident restore or improve bladder function and prevent urinary tract infections to the extent possible. The staff and physician will identify the presence of any UTI that may be related to incontinence. A review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revision date of 03/2018, indicated the following: Policy statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs.) Residents who are unable to carry out activities of daily living independently, will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. A review of the facility provided, Certified Nursing Assistant Job Description undated, included but was not limited to; Purpose: to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. Personal Nursing Care Functions: Assist residents with bowel and bladder functions. Keep incontinent residents clean and dry. Check each resident routinely to ensure personal care needs are being met. NJAC 8:39-19.4(a), 27.2(d)

Complaint NJ #s 154702, #154763 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a) antipsychotic medications were administered daily per physician orders for two residents, Resident #19 who missed 8 daily doses, and Resident #45 who missed 9 daily doses. This resulted in increased combative and hallucinatory behaviors that necessitated transfer to Crisis via 911 (emergency) for both residents, and b) behaviors were monitored and documented and appropriate interventions were developed and implemented for Resident #76 who required antipsychotic medication. This deficient practice was identified for 2 of 3 residents (Resident #19 and #45) reviewed for change in condition and for 1 of 4 resident (Resident #76) reviewed for use of psychotropic medications. The deficient practice was evidenced by the following. 1.) On 02/20/24 at 11:50 AM, the surveyor reviewed Resident #45's Electronic Medical Record (EMR) which revealed diagnoses which included but were not limited to; Type 2 diabetes mellitus, schizoaffective disorder, unspecified mood disorder, anxiety disorder, muscle weakness (generalized), and extrapyramidal movement disorder (impaired motor control-often associated with antipsychotic medication use). On 02/22/24 at 10:05 AM, the surveyor reviewed Resident #45's EMR which revealed the following documention: Review of the March 2022 Medication Administration Record (MAR) revealed a physicians order for a antipsychotic medication for Clozapine 200 mg (milligrams) at bedtime (9:00 PM) for the diagnosis of schizophrenia. Review of the March 2022 MAR revealed the resident did not receive the Clozapine 200mg as ordered by the physician on 03/11/22, 03/12/22, 3/14/22, 3/17/22, 3/18/22, 3/19/22, 3/20/22, 3/22/22 and 3/23/22 (9 days). There was no documented evidence why the Clozapine 100 milligrams (mg) was omitted for 9 days. A review of Resident #45's comprehensive resident-centered care plan included but was not limited to; a focus area on psychotropic drug use for management of schizophrenia dated 1/28/20; goal will continue to benefit from medication use without complication through next review. Mood and behavior will remain stable within baseline through next review. Will exhibit decreased episodes of anxiety; interventions administer psychotropic medication as ordered. Observe for side effects of medication. Educate staff to report any concerns. Notify Medical Doctor (MD) of abnormalities. Review of the Licensed Practical Nurse (LPN) Progress Note (PN) dated 3/14/22 at 10:09 PM, indicated, The resident refused all medication and finger sticks, stating unhappy with room. Review of the LPN's PN dated 3/17/22 at 11:11 PM, indicated the following documention: Resident refused his/her finger sticks and medication despite multiple attempts by this writer. When asked why, he/she kept saying Leave me alone, I don't want it. Review of the LPN's PN dated 3/22/22 at 3:04 PM, indicated, 7:04 AM Resident refused Q (every) 2 week CBC (Complete Blood Count) for clozapine refill. The resident was aggressive and yelled at this author and the lab technician to get out of his/her room and leave him/her alone. Doctor made aware of resident's behaviors. No new orders given at this time. Lab re-draw scheduled for this Thursday. Pharmacy in need of updated labs for clozapine refill. Review of the LPN's PN dated 3/23/22 at 3:59 PM, indicated, Resident is observed talking to self, episode of auditory hallucinations, cursing yelling at the staff, redirected 1:1 numerous times unsuccessful, MD was made aware left voicemail to office to be sent out to Crisis. Review of the Registered Nurse (RN) PN dated 3/23/22 at 10:10 PM, indicated, The resident started yelling and swinging his/her arms at staff, 911 called due to the resident being a danger to self and others. When the EMS (Emergency Medical Services) arrived, the resident continued with yelling and swinging his/her arms and after verbal redirection, the resident did not resist. 2.) On 02/27/24 at 8:29 AM, the surveyor interviewed Resident #19. He/she was observed seated upright eating breakfast in bed. The resident stated he will be leaving today, the resident was looking over his/her shoulder with poor eye contact stating he/she cannot discuss where he/she will be going, and said that is all I have to say and the surveyor exited the residents room. The surveyor reviewed Resident #19's EMR which revealed the following documentation: Review of the Admission Summary, revealed diagnoses which included but were not limited to; schizophrenia, other specified anxiety disorders, unspecified intellectual disabilities, insomnia, hypertensive heart disease without heart failure. Review of the March 2022 MAR revealed the physicians order for antipsychotic medication for Clozapine 100 mg at bedtime (9:00 PM) for the diagnosis of schizophrenia (a mental disorder commonly characterized by psychosis and hallucinations). Review of the March 2022 MAR revealed the resident did not receive the Clozapine 100 mg as ordered by the physician on 03/16/22, 03/18/22, 03/19/22, 03/20/22, 03/22/22, 03/29/22, 03/30/22, and 03/31/22 (8 out of 31 days). There was no documented evidence why the Clozapine 100 mg was omitted for 8 days. Review of Resident #19's comprehensive resident-centered care plan included but was not limited to; a focus area on psychotropic drug use for management of schizophrenia dated 4/29/21, managed with use of Clozapine-target behaviors: delusion/paranoia; goal will exhibit no delusions and or hallucinations; interventions administer psychotropic medication as ordered. Observe for side effects of medication. Educate staff to report any concerns. Notify MD of abnormalities. Monitor for and document changes in mood/behavior noting any precipitating factors, interventions attempted, and effectiveness of interventions. Keep MD informed of concerns. Review of the LPN PN dated 3/22/22 at 11:09 AM, indicated the following documention: The resident continued with his/her paranoid behaviors and speech. Stated that staff and his roommate are out to get him/her. He/she was observed placing a chair in front of the doorway to block entry into the room. Resident was experiencing visual and auditory hallucination. He/she was observed talking to self and yelling loudly and aggressively towards staff. The LPN's PN further indicated, By the afternoon the resident was yelling loudly and aggressive towards redirection. Attempted music therapy but the resident continues to talk to him/herself. Spoke with pharmacy, states the resident needs to be enrolled into the REMS (Risk Evaluation and Mitigation Strategy) program for clozapine refill. Attempted to reach psychiatrist Doctor several times. Unable to leave message online. Spoke with MD [medical doctor], states he is not enrolled in the REMS program and cannot enroll the patient. New order given for Ativan 0.5 mg po (by mouth) BID (twice a day) x 14 days PRN (as needed) for aggression and difficult behaviors until able to reach psychiatry for patient enrollment. Order carried out. Resident sitting in his/her room with music, no issues observed at this time. Will continue to monitor. Review of the RN PN dated 3/22/22 at 9:43 PM, indicated the resident was received in his/her wheelchair by the front door with paranoid behaviors, visual and auditory hallucinations. He/she was observed talking to self and stated that the staff and roomate are out to get me and that his/her family member took the house that was inherited by him/her from the dead parents. He/she stated the lawyer will be called to place his family member in jail. Several attempts made to redirect the resident were unsuccessful. The physician was contacted and the resident received Ativan 0.5 mg po PRN for anxiety disorder, the medication had mild effect. The resident continued to talk to self and have auditory and visual hallucinations. The resident accepted all scheduled medication. Review of the RN's PN dated 3/31/22 at 10:34 PM, indicated, Resident remains alert and oriented x 3 with periods of forgetfulness noted. No complaint of pain noted. Resident refused dinner after several attempts and educating resident and the importance of eating his/her meals for nutritional benefits, he/she stated that he/she understands but does not want to eat, bedtime snack also was offered and he/she refused. The resident accepted all PM medication, medication well tolerated. Review of the RN's PN dated 4/1/22 at 7:13 AM indicated, The resident was awake most of the night playing music in bed. At 4:00 AM the resident left his/her room to walk around, after redirected to go back to his/her room the resident said no. The resident walked to the 100's unit and refused to come back to his/her unit to the 200 unit. The staff attempted to redirect the resident and was noted to have comabtive and aggressive behaviors, fighting staff and refused to get up off the floor. The resident threatened to hurt the staff if they assisted him/her to get up. Resident continued with his/her combative behaviors, becoming a danger to self and others. The resident was offered Ativan 0.5mg at 5:30AM, but refused and 911 was called to send the resident to Crisis for evaluation. The emergency transport arrived and resident departed at 6:40 AM. The family and medical doctor were notified. On 02/27/24 at 2:13 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA). The surveyor requested any investigations for Resident #19 and #45 for March and April of 2022. On 02/28/24 at 9:32 AM, the Director of Nursing (DON) confirmed that the surveyor was provided with everything that was available for Resident #19 and #45. There was no additional information provided. On 02/28/24 at 1:03 PM, the surveyor interviewed the DON in the presence of the survey team regarding both Resident #19 and #45 not receiving physician ordered antipsychotic medication. The DON stated, It was a big mess, regarding the residents not receiving their medications. The DON further stated, I am sure the medical doctor could have overridden it [ordering the antisphychotic medication] but he is not familiar with psych meds [psychiatric medications]. On 3/1/24 at 10:21 AM, the surveyor interviewed the LPN #1 on the 200's Unit. The LPN stated she does not have any resident on Clozapine, but she does have other residents on antipsychotic medication. The LPN stated that if patient refused a medication, it should be documented in the EMR, the rationale for refusal and interventions that were attempted to encourage the patient to take the medication. The LPN stated if a medication was held, it could be for numerous reasons. One reason could be the criteria to administer the medication was not met, for example parameter to follow to administer blood pressure medications. Another reason could be the medication not available. Regardless of the rationale for a prescribed medication not to be administered, the physician must be notified and the nurse must have an order to hold the medication. On 3/1/24 at 10:35 AM, the surveyor interviewed the LPN #2 on the 100's Unit. The LPN stated if a patient refused the medication, the nurse would assess the patient, identify the rationale for refusing the medication, and notify the physician and the resident's representative. The LPN further stated, If a medication was held, the physician must be notified, and the nurse should document the rationale for not administering the medication. On 3/1/24 at 12:41 PM, the surveyor interviewed the Psychiatric Mental Health Nurse Practitioner (PMHNP). The PMHNP stated that Clozapine is classified as an antipsychotic and is used in patients that have schizophrenia. The PMHNP confirmed that Clozapine should not be abruptly stopped or started. The PMHNP stated, if you stop abruptly, it can have a reverse reaction and the patient will have a relapse and more positive symptoms of schizophrenia will occur which will lead the patient to decompensate [a decline in mental health often with increased negative behaviors]. The PMHNP confirmed that the nurse was to notify the PMHNP of any missed doses that have not been administered or refused. She further stated that the nurse and staff need to document in the EMR the behavior exhibited to ensure that symptoms were not worsening. On 03/06/24 at 11:03 AM, the [NAME] President of Operations and Nursing for the management company, the DON and LNHA met with the survey team. There was no additional information provided regarding the above concerns. Review of the facility provided Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, which included but were not limited to: The facility will provide and residents will receive behavioral health service as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. Review of the facility provided Change in a Resident's Condition or Status policy, revised February 2021, which included but were not limited to: the nurse will notify the resident's attending physician or physician on call when there has been a(an): d.) significant change in the residents. 38079 3.) On 02/20/24 at 10:01 AM, during tour of the facility 100-unit, Resident #76 was observed in bed, awake and alert. Resident #76 was continually observed during the day staying in [his/her]bed. A review of the Admission Record revealed that Resident #76 had diagnoses which included but were not limited to; subarachnoid (area of the brain) hemorrhage, alcohol abuse, muscle wasting and atrophy multiple sites, and cognitive communication deficit. A review of the Admission Minimum Data Set (MDS) an assessment tool dated 01/17/24, included but was not limited to; the resident was assessed as sometimes understood or sometimes understand others. The resident had a BIMS score of 00 out 15, indicating the resident had severe impaired cognition. Review of Section M revealed High risk drug classes: Use and Indication indicated the resident was on an antipsychotic and antidepressant medications. Review of the Antipsychotic Medication section indicated antipsychotics were received on a routine basis; a gradual dose reduction (GDR) had not been attempted; and no GDR was documented as clinically contraindicated. A review of the March 2024 Order Summary Report, revealed a physician's order dated 01/10/24, for Zoloft (an antidepressant) 100 milligram (mg) give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, unspecified. A physician's order dated 01/10/24, for Seroquel (medication used to treat behaviors such as mental/mood disorders, episodes of mania) 25 mg give 1 tablet by mouth in the evening for psychosis. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 01/01/24 through 01/31/24, reflected Seroquel 25 mg give 1 tablet by mouth in the evening for psychosis monitor for hallucinations and aggressive behavior. The MAR and TAR further documented Zoloft 100 mg give 1 tablet one time a day related to major depressive disorder. The MAR and TAR had no documented evidence that monitored the presence and/or absence of specific target behaviors or possible side effects associated with the use of antipsychotic and antidepressant medications to determine the efficacy and adverse consequences. A review of the MAR and TAR dated 02/01/24 through 02/29/24, documented the Seroquel 25 mg give 1 tablet by mouth in the evening for psychosis monitor for hallucinations and aggressive behavior. The MAR and TAR further documented Zoloft 100 mg give 1 tablet one time a day related to major depressive disorder. The MAR and TAR had no documented evidence that monitored and document the presence and/or absence of specific target behaviors or possible side effects associated with the use of antipsychotic and antidepressant medications to determine the efficacy and adverse consequences. A review of the comprehensive resident-centered care plan included but was not limited to; a focus area on psychotropic medication for management of depression date initiated 01/11/24. The goal indicated, will have minimal side effects from psychotropic medications. Interventions included but limited to: administer medications as ordered by MD (medical doctor), assess, and monitor for side effects, counseling as ordered and PRN (as needed), and psych (psychiatric) consult as ordered. All interventions were initiated on 01/11/24. The care plan did not address any evidence of an individualized, non-pharmacological approaches to care that are provided as part of a physical and psychosocial environment, directed toward preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical or psychosocial well-being regarding the antipsychotic medication used for the diagnosis of Psychosis. A review of the Pharmacy consultant recommendation, dated 01/11/24, included but was not limited to; identify and monitor the behavior being exhibited for Seroquel. This was not dated as having been completed. There was no documented evidence in the Progress Notes (PN) that this was addressed with the doctor. A review of the Nurse Practioners (NP) PN dated 01/12/24, included but was not limited to; Signs/symptoms: memory loss, confusion, anxiety, depression. Plan: 1. Always consider supportive interventions, including redirection, support/reassurance, comfort measures, reduced stimulation, expression of feelings, family involvement. A review of the PNs dated 01/10/24 through 03/04/24, revealed no consistent documented evidence of behaviors or lack of behaviors to summarize and monitor the residents. On 03/05/24 at 9:07 AM, the Director of Nursing (DON) and Registered Nurse Unit Manager (RN/UM) were interviewed on the 100-unit. The DON stated that Resident #76 doesn't get behavior monitoring because [he/she] does not have behaviors. On 03/05/24 at 10:30 AM, the DON in the presence of four surveyors, stated that the consultant pharmacy review would be completed on admission and then monthly. The DON was provided the pharmacy consultant recommendation dated 01/11/24, to identify and monitor the behaviors for the use of Seroquel. The DON was unable to explain why it was not initiated. On 03/05/24 at 11:08 AM, the DON was again interviewed and shown the RN/UM note dated 01/12/24, Psych NP in to evaluate use of Seroquel. Stated pt (patient) was on in the hospital for psychosis and severe agitation. When pt [patient] shows continuous lack of behaviors, GDR can be started. The DON stated that a GDR wouldn't be considered except for every 3 months. The surveyor requested a policy to address this, but the facility was unable to provide any policy or additional information. On 03/05/24 at 12:43 PM, the surveyor conducted a telephone interview with the Psychiatric Nurse Practitioner (NP) in the presence of the survey team. The NP stated it would be her expectation that the staff would document behaviors so that she would be able to review the documentation and examine the resident to determine GDR. She further stated, I read the documentation and base any symptoms on my assessment. The NP further stated she had not been back to the facility yet to evaluate Resident #76. On 03/06/24 at 12:01 PM, after surveyor inquiry, the facility prvided a note from the NP dated 03/05/24, which included but was not limited to; I will plan to GDR Seroquel at the next visit on 03/08/24, and eventually discontinue Seroquel if patient continues to be without symptoms. Antipsychotics are indicated for use in the management of psychiatric disorders, and other brief psychotic episodes such as alcohol withdrawal related psychosis, or other metabolic related triggers such as delirium. The surveyor requested the facility policy on Psychotropic Medication use and the Director of Nursing (DON) provided the policy Identifying Involuntary Seclusion and Unauthorized Restraint policy dated 4/21, which included but was not limited to; If psychotropic medication is used to treat a medical symptom, the use of the medication is supported by a documented rationale for its use, administered at the correct dose and duration, and with adequate monitoring. Review of the facility provided Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, included but were not limited to: The facility will provide and residents will receive behavioral health service as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Guidelines: 1. Behavior is the response of an individual to a variety of factors which may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. 1.a. behavior is regulated by the brain and influenced by past experiences, personality traits, environment, and interactions with others. b. behavior may be a way for an individual in distress to communicate unmet needs, discomfort, or express thoughts that cannot be articulated. 2. As part of the comprehensive assessment, the staff will evaluate . a. the resident's patters of cognition, mood, and behavior. c. typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers. d. previous patterns of coping with stress, anxiety, and depression. 3. The nursing staff will identify, document, and inform the physician about specific detains regarding changes in an individual's mental status, behavior, and cognition, including: a. onset, duration, intensity, and frequency of behavior symptoms; b. any recent precipitating or relevant factors or environmental triggers c. appearance and alertness of the resident and related observations. Monitoring: 4. If antipsychotic medications are used to treat behavioral symptoms, the IDT (Interdisciplinary Team) will monitor the indication . a. the IDT will monitor for side effects and complications related to psychoactive medications example: lethargy, abnormal involuntary movements, anorexia, recurring falls. Review of the facility provided Change in a Resident's Condition or Status policy, revised February 2021, included but were not limited to, the nurse will notify the resident's attending physician or physician on call when there has been a(an): d.) significant change in the residents physical/emotional/mental condition f.) refusal of treatment or medications two (2) or more consecutive times. NJAC 8:39-27.1 (a); 28.1(c)

Based on observation, interview, record review and review of other pertinent documents, it was determined that the facility failed to a) ensure adequate supervision to prevent falls, b) ensure current documented fall prevention interventions were consistently implemented, and c) ensure the Falls Policy was consistently followed to complete an assessment of the causal factor and identify and implement pertinent fall prevention interventions to prevent further falls, . This deficient practice was identified for 1 of 5 residents (Resident #5), reviewed for accidents. Resident #5 was identified as a fall risk for falls. Sustained 13 falls from 09/11/22 through 02/25/24, including falls with major injuries on 09/11/22 (72 hours after admission) sustained a hematoma to the right forehead and pain to the right shoulder. On 09/15/22, sustained a non-displaced fracture of the medial malleolus of left tibia (bony prominence of the left ankle). On 10/27/23, Resident #5 had an unwitnessed fall, required emergent 911 transfer and resulted in a left wrist fracture. The deficient practice was evidenced by the following: On 02/20/24 at 9:57 AM, the surveyor observed Resident #5 being transferred to the room in a wheelchair by a Certified Nursing Assistant (CNA). On 02/21/24 at 10:30 AM, during an interview with the CNA, she stated that Resident #5's dominant language was a [foreign language redacted] but was able to understand and follow commands and required assistance with transfers. On 02/28/24 at 8:35 AM, the surveyor observed Resident #5 in the room and observed a large yellow and purple bruise that extended from the top of the forehead to the right jaw area and with bruises to both wrists. A visitor was in the room and informed the surveyor that the resident had a fall on 02/25/24, and was transferred to the hospital, then returned to the facility last night (02/27/24). On 02/28/24 at 10:00 AM, the surveyor conducted an initial review of the electronic medical record (EMR) for Resident #5. The EMR did not contain any medical records prior to 11/2023. The surveyor requested all medical records from 2022 from the Licensed Nursing Home Administrator (LNHA). According to the current Admission Record (an admission summary), Resident #5 was readmitted to the facility on [DATE], with diagnoses which included Fracture of Unspecified Part of Neck of Left Femur, subsequent encounter for closed fracture with routine healing. Other diagnoses included but were not limited to; need for assistance with personal care, unspecified fall, unspecified dementia without behavioral disturbances. Review of the Admission/Re-admission nursing assessment dated [DATE] timed 10:45 PM, indicated that Resident #5 was admitted to the facility from another Long Term Care facility, was alert and oriented with intermittent confusion. Admitting diagnosis: S/P [status post] left hip ORIF related to fall from home prior to admission. The assessment indicated that Resident #5 required extensive assistance with transfer, bed mobility and toileting, supervision with meals, incontinent of bowel and bladder. Review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 09/18/2023, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating that the resident had severe cognitive impairment. Review of the Incident /Accident Report dated 09/11/22 timed 2:12 PM, indicated that the CNA called the nurse to the room. Resident #5 noted to be lying on the floor next to the bed. Resident confused but stated that [he/she] needed to get out of the bed. Resident noted with swelling and darkened area above right eyebrow, reported mild shoulder pain. MD [Medical Doctor] aware, and right shoulder X-Ray ordered. Neuro [neurological] check in progress. Kept at nursing station for close supervision. Resident has new bed with side rails at this time. Family called and updated on plan of care. Call bell in place. X-ray done at 10:00 PM. On 02/28/2024 at 11:00 AM, the surveyor requested all 2022 medical records for Resident #5 from the Director of Nursing (DON). Review of the facility provided care plan revealed a Care Plan (CP) for falls Established 03/24/22. The CP Problem indicated the following: Falls r/t [related to] history of falls, impaired mobility, psyche and pain med use [psychotropic and pain medication use], poor safety awareness, [diagnosis] hypertension, DM-2 [Diabetes Type 2]. Goals: I will have no incidents and will remain free of injury [related to] falls. Started 03/24/22 with a Target Date of 06/22/22. The DON provided a CP for Fall CP that was from a prior admission to the facility and was Discontinued on 03/24/22. A Care Plan for Fracture-Site 1, Established 09/08/22 and Discontinued 06/28/2023, revealed Problem Alteration in musculoskeletal system [status post] Left Hip Fracture with interventions that included 09/09/22 Medicate for pain prior to activities, i.e. [example] physical therapy, ADL [Activities of Daily Living] care, transfers. Review of the Physician Progress Notes dated 09/12/22, revealed Impaired mobility, and self care due to mechanical fall. Resident was transferred to the facility on [DATE]. Admission course complicated by mechanical fall out of the bed. Pain right shoulder and elbow, pain at worst 8 out of 10 at best 2 out of 10. Pain aggravated with movement and touch. The physician progress notes continued: Repeated falls, probably due to confusion, decreased safety awareness, impaired balance and muscle strength. Review of the History and Physical (H&P) dated 09/22/22, completed by the physician, indicated that Resident #5 had a past medical history of anemia, left hip fracture, non-displaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture, with routine healing. New probably/ no additional work-up: likely due to recent fall, seen by podiatrist who recommended air-cast. Patient can resume partial weight bearing to the left lower extremity. Continue Physical therapy (PT) and Occupational therapy (OT) to focus on strategies to decrease pain and promote safety during functional mobility and ADLs. The surveyor was unable to locate evidence in the resident's medical record that reflected Resident #5 was assessed as a high fall risk upon readmission on 09/08/22, or that a CP for falls was developed upon readmission to include interventions to prevent further falls. The focus for falls that was provided was from the 03/24/22 with the prior admission. Resident #5 was discharged home on 05/06/22 and readmitted to the facility on [DATE]. No care plan for fall with interventions was initiated on 09/08/22. The surveyor reviewed the facility form titled, Incident/Accident Report dated 09/11/22 timed 2:12 PM, which reflected that Resident #5 had an unwitnessed fall at 2:12 PM. According to the report, the assigned CNA heard Resident #5 calling out for help and observed the resident was on the floor. The nurse then interviewed Resident #5 and the resident stated that [he/she] wanted to get out of the bed. A fall risk assessment which indicated that the resident was a high fall risk. Resident #5 received a score of 15. According to the fall risk assessment a score of 10 or higher was considered a high fall risk. Review of the Post Incident Review dated 09/12/22, reflected that Resident #5 was referred to Physical Therapy (PT) on 09/11/22. The Therapy Screen dated 09/12/22 made the following recommendations: Patient (referring to Resident #5) will need: Bed Alarm and Chair Alarm for safety. Patient education to call for assistance as needed. The Screening Form dated 09/11/22 indicated, Cognition: decrease safety awareness, history of falling, long history of non compliance. Recommendations: Continue with skilled therapy to increase safety and function. Patient requires Bed and Chair Alarm. The surveyor could not locate where these recommendations /interventions were added on the care plan. Review of the nurse's notes dated 09/12/22 timed 12:17 (12:17 PM), revealed the following: . S/P [status post], large purple discoloration and bump noted to R [right] eyebrow, L [large] purple discoloration noted to [R] right shoulder . Right shoulder X-Ray pending result. Review of the Nurse's notes dated 09/12/22 timed 5:45 PM, revealed: Right eyebrow still noted with bruises and swelling. Fall precaution maintained. Resident encouraged to use safety whenever help is needed. Bed placed to lowest position, call bell with personal items within reach. X-Ray done result still pending. Review of the nurses notes dated 09/13/22, indicated that Resident #5 was moved to room [ROOM NUMBER]-2 to be closer to the nursing station. X-Ray result negative. The facility was unable to provide the X-Ray report of the right shoulder ordered on 09/11/22. An X-ray report of the right shoulder dated 10/22/22 was attached to the Incident Report dated 09/11/22. Review of the nurses notes dated 09/15/22, revealed the following documentation: MD ordered X-Ray of the left foot due to bruise to site. Resident reported pain to the left ankle. X-Ray of the left ankle was positive for a nondisplaced fracture of the medial malleolus of left tibia. Further review of the medical records revealed that on 09/19/22, the resident was referred to the podiatrist who ordered that an air cast be applied to mobilize the fracture. Review of the Nurse's Progress notes dated 09/30/22 at 2:40 PM, indicated documentation of an unwitnessed fall. Resident noted to be sliding out of the bed, onto the floor next to the bed. The resident did not have a bed or a chair alarm to alert the staff. According to Incident /Accident statement, Resident #5 was trying to reach for the phone. The phone was not within reach. The post incident review indicated in the post incident interventions that the phone should be on the over bed table, as well as other items frequently used. Continue with PT and OT. The facility determined on 09/11/22, after reviewing the incident /accident report that the call bell and personal items would be within reach. Review of the Incident /Accident Report dated 11/17/22 at 11:25 AM, indicated resident was found sitting on the floor inside the bathroom. Resident went to the bathroom unassisted, the wheelchair was not locked. There was no documented evidence that the alarm sounded and alerted the staff, or that the alarm was present. The staff was unaware that the resident was in the bathroom and could not determine how long the resident had been on the floor. Review of the CNA statement dated 11/17/22 timed 11:25 AM, indicated that she assisted the resident with care and placed the resident in the wheelchair. The CNA did not indicate that she offered or assisted the resident to the bathroom prior to or after breakfast. The post interventions were to reeducate to lock the wheelchair prior to transfer. Reminded the resident to call for assistance to the bathroom. Therapy referral, Reeducate to call for assistance. Review of the Incident /Accident Report dated 09/30/23 at 10:30 AM, indicated Resident #5 had another unwitnessed fall. Resident #5 was found on the floor. The resident reported pain in the lower back. On the fall investigation tool, for the question if a safety monitor was in place and was activated, the bed, chair alarm was checked No. Review of the Incident /Accident Report dated 10/01/23 timed 12:50 PM, revealed that Resident #5 had another unwitnessed fall. Resident #5 was observed sitting on the floor next to the bed on the right side. Resident later reported lower back pain. Bruises noted to right lower leg measuring 3 centimeters (cm) x 4 cm. Right chest 1 cm x 3 cm , upper back 2 cm x 2 cm. Review of the Incident /Accident Report dated 10/04/23 timed 9:45 AM, revealed Resident #5 noted sitting on the floor. There was no documented evidence that the alarm sounded and alerted the staff. Interventions: Educate on using call bell. Frequent rounding by staff, keep bed at the lowest position, Physical therapy referral. Review of the Incident /Accident Report dated 10/13/23 9:40 AM, indicated Resident # 5 was observed sitting on the floor next to the bed. Resident stated [he/she] was going to the bathroom. Upon assessment, Resident #5 was noted to be incontinent of stool. Post incident interventions: Incontinent care, offer to take resident to the bathroom frequently. Remind resident to use call bell for assistance. Continue with PT/ OT. Review of the Incident /Accident Report dated 10/27/23 at 6:30 PM, indicated resident lost balance while ambulating from bathroom, hit the wall, and landed on the left side. The incident/accident supervisor's statement form indicated that the roommate reported that the resident went to the bathroom unassisted. No alarm sounded to alert the staff that the resident was in the bathroom. The Fall assessment revealed swelling to the left wrist, and hematoma to upper back. Pain level 8 out of 10. Resident remained on the floor until paramedics arrived. Resident #5 was transferred to the Emergency Department for evaluation and treatment. Resident #5 was diagnosed with left wrist fracture and Urinary Tract Infection (UTI). After the fall of 10/27/23 the Interdisciplinary met and decided to add a bed and a chair alarm. The recommendations from a Nursing Communication to Therapy Form and dated and signed by a Physical Therapist on 09/12/22 revealed, Patient will need bed and chair alarm for safety. The Care Plan revealed an intervention, initiated on 11/10/23, Resident uses bed alarm while in bed. This intervention was added to the care plan 14 months after the initial fall on 09/11/22. Review of the Incident /Accident Report dated 12/07/23 timed 7:40 AM, indicated Resident # 5 unplugged bed alarm and tried to get out of the bed, resident slide down to the floor on the right side. There was no statement attached to the fall incident report. The facility could not explain how the resident was able to pull the pad and disconnect the alarm. Review of the Incident /Accident Report dated 01/10/24, revealed that during a transfer the resident slid to buttocks on the floor. Scratch marks observed to lower back. Small lump observed to right side of the head. Review of the Incident /Accident Report dated 02/25/24, indicated an unwitnessed fall out of bed. The nurse documented: Heard alarm sounded off, upon checking the room, observed resident sitting leaning on the right side. Observed a small bump on the forehead, unable to explain what happened, probably hit the forehead on the side of the bed. No statement attached to the incident/ Accident report. Resident #5 was transferred to the emergency room for evaluation and treatment. The resident was admitted for observation and UTI. CT Scan (Computed Tomography) diagnostic imaging of the head was negative. The resident returned to the facility on [DATE] with large bruise which extended from the forehead to the jaw area, and bruises on both wrists. Review of the Nurse's Notes dated 02/25/24 timed 21:01 (9:01 PM), indicated that the resident was alert, responsive, denied any pain and able to move upper and lower extremities, ice applied on site. There was no documented evidence for new interventions listed for fall prevention or injury reduction based on the causal factor after each fall. On 02/26/24 at 10:30 AM, the facility provided a care plan from the new EMR which was initiated on 11/02/2023 with a target date of 01/31/24. The care plan had a Focus for: I am at risk for falls related to history of falls, impaired mobility, poor safety awareness . The goal was for Resident #5 to be free from injury through the review date. The Interventions initiated on 11/02/2023 included: Anticipate and meet my needs; Be sure the call light is within reach and encourage to use call light for assistance as needed. Additional interventions initiated on 11/10/2023, included [Resident #5] uses bed alarm while in bed; Ensure the device is in place and functional; [Resident #5] has memory problems and unable to remember or learn safety needs. I need frequent cues and reminders. Additional interventions initiated on 02/09/2024, included Line of site when out of bed. On 02/28/24 at 9:30 AM, the surveyor reviewed the falls incident dated 09/11/22 and 11/17/22, with the Licensed Practical Nurse/Unit Manager (LPN/UM) and requested the care plan for 2022. The LPN/UM stated that she did not remember any details of the incident and was not able to speak any further. She informed the surveyor that she would print the care plan. On 02/28/24 at 10:30 AM, the surveyor requested a timeline of all the falls and explained to the DON that the timeline should include, date, time, location, causal factor and interventions implemented after each fall. On 02/28/24 at 1:15 PM, the surveyor met with the Assistant Director of Nursing (ADON) and inquired regarding the care plan for the readmission of 09/08/22 and requested a timeline for all of the falls. The ADON provided a Comprehensive Care Plan with a focus for falls that was initiated on 03/24/22. The surveyor in the presence of the ADON reviewed the care plan for falls initiated on 03/23/2022, which indicated that the care plan for falls was not initiated when the resident was readmitted on [DATE], after the fall with the hip fracture. The ADON did not have any additional information to provide. On 03/05/24 at 8:47 AM, the DON provided the fall timeline with no interventions. The causal factor was not identified. The DON confirmed that he was unable to locate a fall care plan for 2022. The DON further stated, that he started working for the facility on 10/18/23, and could not account for the missing documents. On 03/05/24 at 11:04 AM, during a pre-exit meeting held with the survey team and current facility Licensed Nursing Home Administrator (LNHA), the DON and Executive Nursing Management, the surveyor discussed the concerns regarding Resident #5's multiple falls, including fall with major injury and the Comprehensive Care Plan not updated after the falls. The administrator added that the nursing department was responsible to review the recommendations and implemented them. On 03/06/24 at 1:30 PM, there was no additional information provided. Review of the facility policy titled: Accidents and Incidents-Investigating and Reporting last revised July 2017, revealed under Policy Statement that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy interpretation: The nurse supervisor/charge nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Falls - Clinical Protocol, Revised March 2018, revealed under Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. a. Often, multiple factors contribute to a falling problem. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Under Treatment/Management; 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to to to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Under Monitoring and Follow-Up, 1a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 3. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed . NJAC 8:39-27.1(a)

Complaint #s NJ 152910, 152911, 159956 Based on observation, interview and document review, it was determined that the facility failed to ensure that all residents were treated with respect and dignity by ensuring the facility acted promptly to respond to ongoing residents grievances affecting quality of life by failing to consistently and uniformly address grievances regarding: a) ensuring residents had consistent access to their personal needs account funds (PNA), b) food complaints identified on 02/28/2022 when the resident council was alerted to the menu being changed to kosher style, and c) the menu not being posted, not having access to menus to select meal choices and the repetitiveness of the menu. This deficient practice was identified by 6 of 6 residents who attended a resident council meeting and affected all residents who resided on 2 of 2 units. The deficient practice was evidenced by the following: Refer to: 567F and 568F On 02/20/24 at 9:41 AM, during the initial tour of the kitchen with the Food Service Director (FSD), the surveyor asked if the kitchen was a kosher kitchen and the FSD stated it was kosher style. On 02/20/24 at 12:07 PM, during the tour of the facility, the surveyor observed a large bulletin board affixed to the wall and labeled, Daily Menu, with five empty slots. The board was in the central area of the 200 unit. The surveyor observed a Licensed Practical Nurse (LPN) and asked where the menu would be posted. The LPN stated the menu was not posted. On 02/20/24 at 1:30 PM, the surveyor received the 81-page facility Admission Agreement provided by the Licensed Nursing Home Administrator (LNHA) as part of the entrance documents. A review of the document revealed 3. Services Provided: a. Services Included in the Daily Basic Rate. The facility agrees to provide the following basic services, all of which are included in the daily basic rate: (i) Board, including food and drink that is palatable, attractive, and at a safe and appetizing temperature, drinks consistent with Resident needs and preferences and in quantities sufficient to maintain Resident hydration, therapeutic or modified diets, as prescribed by a physician or other licensed health professional, and menus meeting the nutritional needs of Residents in accordance with established national guidelines, taking into account religious, cultural, and ethnic needs of the Resident groups, that accommodates Resident allergies, intolerance's, and preferences. Food shall be stored, prepared, distributed, and served in accordance with professional standards for food service safety. (The kosher style menu was not included as part of the Admission Agreement) On 02/21/24 at 11:17 AM, the LNHA provided the surveyor with a copy of the current four-week menu cycle. Upon review, the surveyor observed that the breakfast meals listed only Vegetarian Sausage Links as a breakfast item three times per week, no pork products were listed on the menu and chicken was listed as a lunch entree on 21 of 28 days and fish as a dinner entree 23 out of 28 days. On 02/23/24 at 6:36 AM, the surveyor again toured the kitchen, and the breakfast meal was in progress. The surveyor interviewed the Cook regarding what the kosher style menu was. The cook stated, we don't have pork, meat and dairy together and no meat for breakfast. The Cook stated the kosher style menu started about 1-1/2 years ago and it changed with the new owners that wanted that kind of menu. The cook stated, we used to have bacon and sausage all of the time and now we don't have it. The surveyor asked about the chicken that was observed in the walk-in refrigerator. The cook stated, there is quite a lot of chicken on the menu. On 02/23/24 at 6:43 AM, the FSD entered the kitchen, and at 6:48 AM, the surveyor asked the FSD if he created the menus and he stated that they came from a company. The surveyor asked the FSD to explain what a kosher style menu was. The FSD stated, it is kosher style, and he was not sure why it was changed. The surveyor asked the FSD if he met with the residents regarding the menu. The FSD stated he attended a Food Forum meeting at the resident council. The surveyor asked the FSD to provide any meeting minutes or documentation regarding what was discussed at the meeting. The FSD stated he had none to provide. The surveyor asked the FSD if he was provided with anything in writing, including meeting minutes that he had to respond to or change regarding resident menu concerns. He stated, I'm not handed anything regarding meeting minutes. On 02/23/24 at 11:14 AM, a surveyor conducted a resident council meeting with 6 residents. All 6 of 6 residents stated that they were made aware that the meals are from a kosher style kitchen, and they do not have any pork products. The resident's confirmed that they used to get pork products but only get vegetable sausage now. All six residents confirmed that they have asked for pork products before, and the facility told them it is a kosher style kitchen, and they only serve chicken and fish mostly. One resident stated they would only get chicken and they don't ask for pork products because they won't get them, and all 6 of 6 residents confirmed that menus have not been provided to review or make selections. The surveyor asked the residents about their PNA account and 6 of 6 residents stated they were not able to access their PNA when they want. All six residents confirmed they were only allowed to remove $ 25.00 at a time. Resident #10 stated they always say they have to go to the bank for it, and the money goes to fast. The resident also stated that you can't get it when you want it or need it, they say they have to get someone to go to the bank to get the cash, and the person responsible doesn't drive. Resident #25 stated, I can't get my money right away, I also have to wait like everyone else. Resident #18 stated, when I say I need money, they say we don't have it or some [NAME] [exploitive redacted] excuse that they can't. Main excuse they use is that they are too busy. Resident #30 stated, they still owe me $ 25.00; I've been to [Human Resources Director's] office seven times and she told me yesterday she would bring it to me and still haven't seen it. I will be going to her office today. Resident #17 stated, I never receive my money on time either and they only give $25 at a time. Resident #49 stated, when I first came here in [date redacted] I asked for money, and they told me no. I used to have it in [Facility Name Redacted] and they would give me $50.00 every month. When I went, they said I don't have an account. I have not received any money since I've been here. An unidentified resident stated, there was no receipt provided when getting any money and only $25.00 increments allowed at a time. The LNHA provided the surveyor with the following Resident Council Meeting Minutes which revealed: -02/28/22; 20 Residents in attendance. Dietary: New Business: [Staff name redacted] met with residents to explain the new kosher style menu and to give them copies of the week's rotation. Residents voiced their concerns with the new diet and many of the substitutes. [Resident name redacted] stated that most residents don't want kosher and that she is speaking for them not herself. The other residents present did not confirm this. [Staff name redacted] said she would ask about the possibilities of substitutes and get back to them. They came back and said she was told she may give milk at the evening meals but that she could not do anything about pork or bacon. The residents voiced having the option of switching lunch to meat and dinner to dairy. Administrator: Our new Administrator introduced himself and took questions mostly concerning the new menu. He left to inquire to the owners about their concerns. He came back shortly after to tell the council that they will make any allowances they require such as milk in the evenings and cheese for hamburgers. The Administrator confirmed that if the general consensus of the residents was to switch the menu, we most definitely can. We agreed to convene next meeting to go over any concerns. -There were no Resident Council minutes provided for a 3/2022 meeting, and no follow- up regarding reconvening with the Administrator to review concerns regarding the menu. - 04/25/22; 17 Residents in attendance. Dietary: Past Issues: Residents are happy with meat served at the midday meal (No response included regarding the concerns about the menu change to a kosher style menu). -05/31/22; 19 Residents in attendance. Past Issues: Residents would still like a menu posted somewhere. Response: [New Food Service Director] will post them on the wall to the right as everyone enters the dining room .Residents are reminded that if they would prefer they can order from the always menu: chicken, hot dogs, burgers and grilled cheese. (No response included regarding the concerns about the menu change to a kosher style menu, or posting the menu). -06/27/22;19 Residents in attendance. Dietary: New Business: Food Committee meeting to review the menu just prior to this meeting. Residents state they love the new spring/summer menu that just started on June 19th. (No Food committee meeting minutes attached, and no response included regarding the concerns about the menu change to a kosher style menu or posting the menu). -There were no Resident Council minutes provided for a 07/22 meeting, (No response included regarding the concerns about the menu change to a kosher style menu or posting the menu). -08/31/22; 20 Residents in attendance. Dietary: Past Issues: No past issues mentioned. (No response included regarding the concerns about the menu change to a kosher style menu or posting the menu.) New Business: Food committee meeting prior to this meeting. Resident stated too much chicken is on the menu and the Food Service Director agreed and will make changes. -09/19/22; 13 Residents in attendance. Past Issues: Residents are requesting a daily menu so they can choose what they would like to eat. (This is a repeat concern, there was no follow-up to the Food Service Director confirming there was too much chicken on the menu and no response included regarding the concerns about the menu change to a kosher style menu or posting the menu.) -10/24/22; 12 Residents in attendance. Dietary: Past Issues: Resolved (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: Dietary Director has left, will have Food Forum when a new director is hired .Residents are requesting daily menus (Repeat concern without resolution). Residents would like to be aware of other alternatives they may choose from. -11/22/22; 7 Residents in attendance. Dietary: Past Issues: Residents would like weekly menus delivered to them. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: New Dining Director was introduced. Residents asked about a breakfast meat and Dining Director told them they can do turkey bacon or sausage. Residents would like to be aware of other alternatives they may choose from (Repeat concern without resolution). -12/23/22; 6 Residents in attendance. Dietary: Past Issues: Residents requesting winter menu. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu.) New Business: New Dining Director was introduced. Residents asked about a breakfast meat and Dining Director told them they can do turkey bacon or sausage. Residents would like to be aware of other alternatives they may choose from. (Repeat concern without resolution). -01/30/23; 11 Residents in attendance. Dietary: [left blank] Past Issues: Winter menu still not finalized. (No responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or the winter menu). -02/27/23; 9 Residents in attendance. Dietary: They are waiting too long for missing items. -03/28/23; 13 Residents in attendance. Concerns: Dietary: better. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu). Administration: There is a need for PNA (personal needs account) money to be available on weekends. -04/25/23; 10 Residents in attendance. Dietary: Resident would like sausage and bacon added to the menu for breakfast. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu). Administration: Not listed and there was no follow-up regarding the concern regarding PNA money not being available on the weekends. 05/23/23; 6 Residents in attendance. Activities: Resident requesting trip to a restaurant. Also want to make sure they receive money before going. Dietary: Coffee is sometimes not hot enough. Patient requesting for variety other than fish or chicken (no resolution-repeat complaint nine months prior). Residents are requesting turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. (No specific follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not being provided with a menu or winter menu) 06/26/23; 8 Residents in attendance. Dietary: No Concerns: (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). Administration: No follow-up regarding the concern regarding PNA money not being available on the weekends. Residents were informed that we are in the process of switching to a new company with the goal of improving our service. 07/31/23; 6 Residents in attendance. Dietary: Notes of Resident preferences were recorded by Dietary Director. Residents liked the summer menu. (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -08/31/23; 10 residents in attendance. Dietary: Food is cold sometimes. Food forum was held, and resident's preferences will be honored. (No follow up for cold coffee. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -09/31/23; 11 Residents listed in attendance. Dietary: Concerns: No concerns, Food forum was held and resident's preferences will be honored. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. -10/31/23; 20 Residents listed in attendance. Dietary: Concerns: Food forum was held and resident preferences made, new food company has been contracted to improved food quality. Response: Residents are looking forward to new recipes and new culinary experiences. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken ( and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, [Repeat Complaint] and not being provided with a menu or winter menu). -11/28/23; 16 Residents listed in attendance. Dietary: Resident chose the menu for the holidays, went over new items in the menu and requested their preferences. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu and not being provided with a menu or winter menu). No follow-up regarding the concern regarding PNA money not being available on the weekends. 12/26/23; 15 Residents listed in attendance. Dietary: No issues, food has improved, residents shared their preferences, and there are no complaints. (No follow up for cold coffee and food. No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken [identified 16 months prior] on the menu, and not receiving a menu.) No follow-up regarding the concern regarding PNA money not being available on the weekends. 1/30/24; 14 Residents listed in attendance. Dietary: .occasionally food is not warm enough .(No follow up for cold coffee and food [repeat complaint] No follow up for requests for variety other than fish or chicken and other requested items that included turkey burgers, meatloaf, stuffed peppers, corn beef, pepper steak, turkey legs and bologna. There was no follow up and no responses provided regarding the menu changed to kosher style, too much chicken on the menu, and not receiving a menu.) No follow-up regarding the concern regarding PNA money not being available on the weekends. On 02/26/24 at 1:09 PM, interviewed the Food Service Director (FSD) regarding the facility menu development. The FSD stated he is not responsible with the menu development; a company provides the menu. I asked the FSD who signs off on the menu to ensure it meets the residents needs and is nutritionally adequate and he stated, I am not sure. I asked the FSD to elaborate on the kosher style menu, and he stated it started about two years ago, I am not sure, and I don't know why. The FSD stated, it wasn't always kosher. On 02/26/24 at 1:26 PM, the surveyor interviewed the LNHA about facility policies and procedures. The LNHA stated they are reviewed on an annual basis. The surveyor asked the administrator when the menu was changed to kosher style and he stated, I believe it was changed a few months ago, I don't know exactly when it was changed. The surveyor asked the LNHA regarding the company who was responsible for the menu development per the FSD. The LNHA stated he was not sure if the contract for the menu company was still in effect. On 02/29/24 at 9:51 AM, the surveyor interviewed, in the presence of the surveyor team, the Registered Dietitian [NAME] President (VPRD) Of Clinical Services for the Consultant Dietitian Company. The VPRD stated she was responsible for the clinical nutrition for the residents. The surveyor asked what her menu functions were and she stated we don't create the menu, and we don't do menu development, but we review it. She stated, I look to make sure there is a variety and to make sure there is different fruits and vegetables and entrees. Asked the VPRD to provide information regarding if chicken should be served 7 days per week. The surveyor asked if she attended resident council and she said the FSD will attend and and if there are concerns that are brought up in resident council we can make adjustments to the menu. The surveyor asked about the menu and she stated it was a kosher style menu. The surveyor asked about the kosher style menu and the VPRD stated it does not have meat served with dairy and they don't serve pork or shellfish. The surveyor asked if the residents were notified if the menu was changed to kosher style. The VPRD stated, I believe normally, they do notify the residents if they implement a kosher style menu. The surveyor asked if the menus should be posted for the residents and the VPRD stated, yes, for the residents. On 02/29/24 at 10:29 AM, the surveyor conducted an interview with Resident #18, who served in the role as the Resident Council President (RCP). The surveyor asked the RCP how the meals were, and the RCP stated the quality went down. The surveyor asked about receiving pork breakfast meats. The RCP stated, we don't get it anymore, we don't get any bacon. The RCP stated we get vegetable sausage and it [exploitive redacted]. The RCP stated that grits used to be on the menu also, and they no longer provide them. The surveyor asked the RCP if the facility provided anything in writing when the menu was changed to no longer include pork products, and the RCP stated, no. The surveyor asked the RCP if the council decided to not allow any residents to take out $25.00 at a time from their PNA. The RCP stated, no, we never decided on only $25.00, no, that was not our decision, not ever!. The RCP stated even when he/she was not the RCP, that he/she still attended the Resident Council and stated, we want all our money. Asked if all the money was available, no, we cannot get it, maybe $15.00 or $25.00 at a time. The surveyor asked if a receipt was provided when a transaction was made. The RCP stated, no, never, we barely get the money, and if you don't get the money and the Human Resources Director (HRD) goes home, you are [exploitive redacted] out of luck! The RCP stated, they don't have money on the weekends, they used to have money. The RCP stated, there is no money on the weekends, none, [NAME], [NAME] ever. The RCP stated that the HRD sometimes doesn't have money during the week either. The surveyor asked if the LNHA ever conducted a meeting with the residents regarding the changes to the menus. The RCP stated, he comes, stands there for like five minutes and leaves and stated, no we never had a meeting. The surveyor asked the RCP if a menu was provided to make selections and the RCP stated, we would have to ask for it, it is not distributed and it should be left at the nurses station. On 02/29/24 at 1:27 PM, the surveyor conducted a follow up interview with the VPRD. The VPRD stated there is no kosher policy and stated residents could request anything. The surveyor asked is that including pork and bacon, and she stated she cannot speak to that. The VPRD did not provide any information regarding why there is chicken often 7 days per week on the menu. On 02/29/24 at 1:41 PM, the surveyor interviewed the LNHA and DON, in the presence of the survey team. The surveyor asked if bacon was provided to the residents, and the LNHA stated only if a resident asks they can provide bacon. The surveyor asked about the admission agreement, not specifying a kosher style menu. The LNHA stated, a resident can ask and there are no, non-kosher items on the menu. The surveyor asked, are there any pork products in the kitchen and the LNHA stated, no. On 03/01/24 10:00 AM, the LNHA, in the presence of the survey team, provided the surveyor with the Resident Council minutes from 05/31/22 and stated that in the minutes it was documented that if the general consensus was to switch the menu, we most definitely can. The LNHA also provided five random food receipts for unidentified bacon and stated that the bacon was for people who requested it. The LNHA did not provide any documented evidence that the concerns were addressed with the resident council. On 03/01/24 10:52 AM, the surveyor observed an Always Available Menu posted on a bulleting board on the 200's unit. The Menu Please notify our dietary food service department if you prefer and of the alternate options below. Included for Breakfast- French Toast, Scrambled Eggs, Hard Boiled Egg, Assorted Cold Cereal, Hot Cereal of the Day; Bacon, sausage, or any alternate breakfast meats were not listed, and were not listed for Lunch or Dinner. On 03/01/24 at 10:56 AM, the surveyor interviewed the Social Worker (SW) regarding the grievance process. The SW stated if she received the grievance, she would fill out a grievance form and then provide it to the department head and notify the staff. The surveyor asked about grievances at resident council. The SW stated she would sit in on Food Forum, it would be when the residents in attendance would discuss their food preferences, and the Activity Director handled that process. On 03/01/24 at 11:30 AM, the surveyor interviewed the AD about the Food Forum. The AD stated that would be held right before resident council and conducted by the FSD. The surveyor asked if she would receive a copy of the minutes from the Food Forum. The AD stated, no it was a note thing and the FSD would review the always available menu. The surveyor asked the AD if the residents brought up that they wanted pork breakfast meats. The AD stated the FSD told the residents they could have turkey sausage. The surveyor asked the AD if the FSD had ever informed the residents that they could select pork bacon and the AD stated, no the FSD would tell the residents that they could request turkey bacon. The AD confirmed that there were no documented minutes for the Food Forum. On 03/05/24 at 11:10 AM, the surveyor interviewed the LNHA in the presence of the survey team. The surveyor asked if the LNHA documented responses regarding resident grievances. The LNHA stated he did not document responses to resident grievances and that would be the social worker's responsibility. On 03/05/24 at 1:35 PM, the survey team conducted a pre-exit conference with the Director of Nursing (DON) and LNHA. The surveyor reviewed the above concerns. On 03/06/24 at 11:55 AM, the LNHA, provided the surveyor with a Resident Council Concern Form dated 10/24/23. Concern was crossed out and listed was proposing plant-based sausage, cheese blend souffle, residents expressed personal preferences, introducing turkey pastrami, kielbasa, turkey burgers and soup will be added, brisket, tortellini Alfredo. Another form was dated 02/01/23 and was for a specific resident for coffee all meals and another resident would like bacon (type not indicated), Resolution: Resident would receive coffee all meals and other resident would start receiving (unidentified) bacon for breakfast. The LNHA did not provide any information regarding responding to the documented resident council concerns. There LNHA provided eight pages of a handwritten documents titled Daily PNA Disbursements with handwritten resident names and 16 highlighted names/dates that the LHNA stated were weekends. The highlighted amounts revealed, $1.00- $25.00 amounts and 1 of 16 named had a documented $50.00 amount. No additional information was provided. Review of the Resident Rights policy Revised February 2021, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: u. voice grievances to the facility . v. have the facility respond to his or her grievances . NJAC 8:39-4.1(a)(8)(9)(10)(33)

Complaint #: NJ 2 Based on observation, interviews, review of the medical record and other pertinent facility documentation, it was determined that the facility failed to provide a safe environment and adequate supervision for a resident who was identified with anxiety and attention seeking behavior. The resident was able to obtain food utensils such as knives, spoons and other sharp items to make cuts on the left arm. The facility failed to evaluate the effectiveness of the interventions developed in the Plan of Care since the resident was still able to continue to find food utensils and other sharp items to harm him/herself while under staff supervision. Despite several transfers to a hospital for evaluations and a short inpatient stay at a psychiatric hospital, the facility continued to accept this resident back instead of implementing their policy Increase Supervision that would provide Resident #4 1:1 supervision until a permanent transfer to a facility more suited for the resident's needs. This placed Resident #4 at risk for Immediate Jeopardy for harm, injury or death. This deficient practice was identified for 1 of 4 residents reviewed for behaviors (Resident #4). The facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Unit Manager (UM) were made aware of the immediate jeopardy situation on 3/13/19 at 5 p.m. However, on the same day at 6 p.m., in the presence of the surveyor and staff, 2 disposable razor blade shavers in a package that was open and 1 razor was partially out of the package were located in the top bedside table of Resident #4. The removal plan was provided by the facility on 3/13/19 at 6:40 p.m. On 3/14/2019 the surveyor came back for a revisit to ensure that the removal plan was implemented. This deficient practice was evidenced by the following: On 3/13/19 at 2:08 p.m., the surveyor reviewed the medical record (MR) for Resident #4. The medical record revealed the following: The resident was originally admitted to the facility in 3/5/2018 and had re-admissions in (MONTH) 2019 and (MONTH) 2019 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 3/8/19 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Additional review of the MDS indicated Resident #4 required supervision and set up for meals. A review of Resident #4's Careplans Behavior (Implemented) on 2/9/19 revealed the following: Resident #4 was observed attempting to cut (his/her) wrist on 2/9/19 with a breakfast knife. The interventions included but were not limited to: Resident #4 was educated regarding danger of using a knife in attempt of cutting (him/herself). A request was sent to the kitchen not to send silver or plastic knife on all meal trays. On 2/11/19, Resident #4 was transferred to the hospital for evaluation. On 2/18/19 the resident was again transferred to the hospital emergency room (ER) for evaluation. Hourly checks were initiated on 2/19/19. On 2/20/19 Resident #4 was transferred to the hospital for an evaluation. On 2/22/19, no utensils at all (plastic or regular), staff to cut food for the resident. Staff to offer sandwiches. On 2/25/19 Resident #4 was transferred to hospital for behavior management. On 3/11/19, no utensils at all for all meals. There was no documented evidence that the facility conducted evaluations of the interventions developed in the Careplans Behavior (Implemented) to determine effectiveness for keeping the resident safe by stopping the recurrences of Resident #4 from obtaining food utensils. During an interview with the surveyor on 3/13/19 at 1:52 p.m., the Licensed Practical Nurse (LPN #1) stated that on 2/11/19, the CNA#3 saw Resident #4 with the knife and took it away. The resident goes up and down the hallway when we are busy collecting the trays. The CNA did not say anything to me when Resident #4 picked up a knife off another tray, however another CNA #2 saw (him/her) and took it away. The third time the resident got a knife and cut (him/herself) and that is when CNA #3 told me and we called the MD and sent (him/her) to the hospital ER for crisis. On 3/9/19, the resident was seen using a spoon and attempted to cut self. LPN #1 also stated that there were no incident reports initiated during this time. During an interview with the surveyor on 3/13/19 at 3:45 p.m., CNA #3 stated that on 2/11/19, she saw Resident #4 in his/her room with a knife and (he/she) said she wanted to cut off (his/her) arm because it was not working. I saw (him/her) previously taking the knife off the food truck in the hallway 2 times on 2 separate days and I took it away from (him/her). (He/she) is so fast, by the time we bring a tray into a resident's room and open things up, (he/she) takes a knife and hides it. As per CNA #3, she reported the incident to the nurse and informed the nurse that she took the knife away from Resident #4, who was by a food truck at the time. On that day I told the nurse and she went to search and found another knife in (his/her) bedside drawer. The resident said Don't blame the aide, I took the knife off the truck. During an interview with the surveyor on 3/13/19 at 3:55 p.m., CNA #2 stated that on 2/11/19 on the 3 p.m.-11 p.m. shift during tray time, she observed Resident #4 holding a knife in (his/her) hand. CNA #2 stated she was not sure where the resident got the knife. The resident was in (his/her) room but Resident #4 did have a roommate in the room at the time when dinner was being served. CNA #2 further stated that Resident #4 was trying to cut self. She took the knife away from the resident and hurried to get the nurse. The resident was sent to the ER. A review of the Progress Notes in the medical record revealed the following: On 2/18/19 at 9:20 p.m. Resident #4 refused to go to bed and the resident's left (L) hand was noted with an abrasion and the abrasion has lines that looked like a knife mark. On 2/18/19 at 9:35 p.m., a CNA entered the resident's room and noticed Resident #4 attempting to cut self with a butter knife. The CNA called the nurse. The supervisor and the Medical Doctor ( MD) were notified and a few minutes later resident was noted using a black plastic comb trying to cut him/herself. The MD ordered Resident #4 to be transferred to the hospital ER for evaluation. At 10:10 p.m., the resident was transferred by ambulance to the hospital ER. On 2/19/19, at 1:10 p.m., Resident #4 was readmitted back to the facility from the hospital. At this time, the resident refused a skin assessment but staff noted an abrasion on the left wrist. A review of the Individual Psychotherapy Progress Note dated 2/19/19, in the Chief Complaint/Reason for visit, indicated the following: Resident appears anxious and worried about health related issues as well as family issues. Has mood swings. Was hospitalized 2 times in past week as (he/she) cut (him/herself) with a knife and caused abrasions to (his/her) skin. A review of the Hourly Checks sheets revealed Resident #4 was placed on hourly checks. This was initiated at 3:00 p.m. on 2/19/19. Also, the hourly check for 11 p.m. was blank. A review of the Progress Notes in the medical record revealed the following: On 2/20/19 at 1:20 p.m., while still on hourly checks, Resident #4 was observed in bed and had refused care. Also, the resident didn't want to be taken out of bed. Resident #4 was observed by a Physical Therapist with a butter knife attempting to cut self. The resident stated at this time that he/she didn't need this arm. The knife was taken away from resident. At 3:20 p.m., the MD was notified. The MD ordered Resident #4 to be transferred to the hospital for evaluation. At 4:20 p.m., Resident #4 was transferred by ambulance to the hospital ER. On the same day at 9:30 p.m., Resident #4 returned back to the facility from the hospital. The staff noted at this time, a dietary slip was sent to the the kitchen that indicated Resident #4 was to have no utensils to be used and sent with meals. Also, hourly checks resumed for Resident #4 at this time. Staff was monitoring for suicidal behaviors and safety. On 2/22/19 at 8:45 p.m., while still on hourly checks, Resident #4 was noted with a butter knife attempting to cut him/herself and the knife was taken away. No documented evidence that physician or family were notified at this time. The staff documented only that risks and benefits were discussed with Resident #4. Also, on this same day, the hourly check for 11 p.m. was blank. On 2/23/19 at 7:15 p.m., while still on hourly checks, Resident #4 reported that he/she had a table knife in his/her dresser draw. When asked where the resident had taken the knife from, the resident stated from another resident's tray. The table knife was removed. A call was placed and messages left for the Nurse Practitioner (NP) and family. On 2/24/19 at 2:15 p.m.,while still on hourly checks, at 11:45 a.m., a Physical Therapist witnessed Resident #4 enter room [ROOM NUMBER] and asked that resident to give him/her their butter knife from his/her lunch tray 2 times. The staff re-directed Resident #4 back to his/her room. The resident came back out of room and went to the food truck in the hallway and the staff had to redirect Resident #4 again. The MD, Nurse Practitioner( NP), family and Optum Nurse who was also following this resident for behaviors were notified. The Optum Nurse was informed that staff were doing monitoring checks every hour. On 2/25/19 at 11:45 a.m., Resident #4 was approved for hospital inpatient admission for the self-injury attempts. The resident was transferred to the behavioral hospital at 6:10 p.m. A review of the Initial Psychiatric Assessment in the medical record revealed, when Resident #4 was an inpatient at the psychiatric hospital dated 2/26/19, the documentation indicated, but was not limited to: I want to cut myself. Resident #4 was, admitted with recent attempt to cut (L) wrist with butter knife. History of Suicidal Attempts. The documentation indicated Resident #4 had Significant HO (History of) Self-harm. In the Medication Management section; the recommendation was for Resident #4 to continue [MEDICATION NAME] and [MEDICATION NAME] and continue to assess behaviors. Further instructions were to taper down and discontinue [MEDICATION NAME]. [MEDICATION NAME] was added on 2/19/19. In the Observation Level section: the resident was placed on every 15 minute checks. On 3/1/19 at 11:42 a.m., Resident #4 was returned back to the facility from the inpatient hospital admission. A review of the Individual Psychotherapy Progress Note dated 3/7/19 in the medical record, in the Chief Complaint/Reason for visit, indicted Resident #4 was hospitalized several times in past week as (he/she) cut (him/herself) with a knife and caused abrasions to (his/her) skin During an interview with the surveyor on 3/14/19 at 11:35 a.m., the Psychiatrist stated that Resident #4 had a borderline personality and the behavior was very difficult to treat. On 3/9/19 at 1:25 PM, it was reported by a CNA that Resident #4 was seen using a spoon trying to cut self. The staff notified Optum Nurse and family. During an interview with the surveyor on 3/13/19 at 2 p.m., the DON stated that Resident #4 indicated that he/she was going to cut him/herself. The doctor, family and dietary were notified that no utensils were to be on the resident's meal tray on 2/9/19 and on 2/22/19 no regular or plastic utensils. On 2/11/19 the resident used a butter knife to cut self. Resident #4 was sent to the ER and returned 2/18/19 and was provided with plastic utensils. On 2/18/19 the resident used a butter knife to cut self and was transferred to crisis ER. Resident #4 returned on 2/19/19 and hourly rounds were started and continued until 2/25/19. On 2/20/19 staff found a butter knife and resident was sent to crisis ER. Resident #4 returned on 2/20/19 from the hospital ER. As per the DON, facility staff were not sure where the resident got the butter knife, as he/she was on hourly rounds. No investigations were done for each of the incidents involving the resident getting the utensils. On 2/21/19, the psychiatrist and the nurse practitioner met with the team to discuss alternate placement to a behavioral psychiatric hospital for in patient admission. The resident was admitted to the hospital on [DATE], but Resident #4 was readmitted back to the facility on [DATE]. During an interview with the surveyor on 3/13/19 at 6:00 p.m., Resident #4 stated, I cut my arm because I can't get it to work. I told them I was frustrated that I wanted to take my hand off. I was using a butter knife, then I started to use a fork and poked a rug burn into my arm. It feels good because I feel like I have control of wanting to feel pain. I like how it feels. I got the butter knife from my roommate. Now they give plastic, because they caught me getting the knives and forks from the food truck and I put it into my pillow case. I used to put lotion and perfume, so it would sting more and I told them about the abrasions were a reaction to the lotion. I tried to tell 5 workers yesterday that I had 2 forks and no one paid attention to me and today this morning they caught me and took it away. I was doing it again to my arm this morning. During the interview Resident #4 showed the surveyor his/her left arm. The surveyor observed a linear abrasion approximately 2 millimeters wide and approximately 20 millimeters long from outer portion of anti-cubital space of left forearm to the medial aspect above the left wrist. The resident continued to state that the staff were not checking his/her bedside drawers. Resident #4 further stated that he/she will continue to cut self. I now am going to use my leg shaver. The surveyor asked what kind of shaver and where the resident kept the razors. The resident indicated the razors were in the top bedside drawer. The surveyor informed a CNA who entered the resident's room and with the resident's permission the CNA checked the drawer. The surveyor observed the CNA took out 2 disposable razor blade shavers in a package that was open and 1 razor was partially out of the package. The nurse was called into the room and made aware and the 2 disposable razor blade shaves were removed from the room. On 3/14/19 the Vice President of Operations provided a written statement which indicated the following: Re (Resident #4), Resident will be placed on one to one supervision upon readmission from the hospital until a transfer to another facility that will be able to accommodate (his/her) needs is arranged. If (he/she) exhibits or verbalizes any intentions of self-harm, (he/she) will be transferred out to the hospital immediately and will not be accepted back to the facility. A review of an undated facility policy entitled Increase Supervision, revealed the following: Procedure 2. If resident needs are identified to require a more intense staffing ratio the facility will implement 1:1 to a specific resident until the team deems it necessary to transfer a resident out for an evaluation or a permanent transfer to a facility more suited for their needs. The IJ was identified for Resident #4 on 3/13/19 at 5:00 PM and corrected at 6:40 PM when the following removal plan was implemented. 1. Resident will be placed one to one supervision immediately Date:3/13/19 2. All residents have the potential to be affected. Date 3/13/19 3. A policy will be written regarding the management of residents with suicidal ideation. date 3/13/19 4. The director of nursing or designee will be notified immediately when a staff member observes a resident expressing suicidal ideation. Results will be brought to the attention of the QA meeting. Date 3/13/19 NJAC 8:39 - 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to develop and revise the Care Plan with new interventions to protect a resident from frequent falls that resulted in major injuries. This deficient practice occurred for Resident #6, 1 of 14 residents reviewed for falls. The evidence was as follows: Resident #6 was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. The resident was first observed on the initial tour on 7/21/14 at 9:10 a.m. lying in bed asleep. The surveyor was told by the Unit Manager (UM) that Resident #6 had a history of [REDACTED]. The surveyor reviewed the medical record for Resident #6 on 7/21/14 at 11 a.m. An initial assessment dated [DATE] indicated that the resident was "extremely forgetful," confused and did not remember to use the call bell to get assistance. The record indicated that less than two weeks after Resident #6 was admitted to the facility, he/she suffered a fall in the room that resulted in three fractured ribs. The interventions in place at that time were a safety alarm on the bed and one on the wheelchair. The record indicated further that Resident #6 had 13 more falls which all occurred in his/her bedroom or bathroom from 10/23/13 through 5/10/14. All but 3 of the 13 falls occurred on the 3 p.m. - 11 p.m. shift. Two of the falls resulted in major injury (bone fractures) and one resulted in a laceration over the left eyebrow. The facility continued to apply only the safety alarms to the bed and the wheelchair despite continued falls, some with major injuries. The surveyor reviewed the Care Plan for Resident #6 on 7/22/14 at 11 a.m. The Care Plan indicated Resident #6 had "dementia - no short term memory." Interventions to prevent falls were to ensure staff respond promptly, keep the bed in the lowest position, attach a safety alarm to the bed and the wheelchair, orient and remind Resident #6 to use the call light and to keep the resident in highly visible areas for close supervision, i.e., in front of the Nursing station. The surveyor interviewed the Unit Manager (UM) on 7/24/14 at 9 a.m. The UM indicated that there were no other interventions put in place other than the bed and wheelchair alarms even though the resident was known to remove the alarms at times. The surveyor and the UM reviewed a physician's progress note dated 7/31/13 that indicated that Resident #6 was a "very high fall risk," the facility's 7/23/13 Initial Assessment which indicated Resident #6 had a history of [REDACTED]. The UM was unable to explain, despite the facility's awareness of the resident's cognition, poor safety awareness and history of non-compliance with the alarms, why the facility continued to use the same ineffective interventions. NJAC 8:39 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to protect a resident from frequent falls that resulted in major injuries. This deficient practice occurred for Resident #6. In addition, the facility failed to implement an identified safety intervention, a bed alarm, for Resident #11. This deficient practice was identified for 2 of 14 residents reviewed for falls. The evidence was as follows: Resident #6 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was first observed on the initial tour on 7/21/14 at 9:10 a.m. lying in bed asleep. The surveyor was told by the Unit Manager (UM) that Resident #6 had a history of [REDACTED]. The surveyor reviewed the medical record for Resident #6 on 7/21/14 at 11 a.m. An initial assessment dated [DATE] indicated that the resident was "extremely forgetful," confused and did not remember to use the call bell to get assistance. The record indicated that less than two weeks after Resident #6 was admitted to the facility, he/she suffered a fall in the room that resulted in three fractured ribs. The interventions in place at that time were a safety alarm on the bed and one on the wheelchair. The record indicated further that Resident #6 had 13 more falls which all occurred in his/her bedroom or bathroom from 10/23/13 through 5/10/14. All but 3 of the 13 falls occurred on the 3 p.m. - 11 p.m. shift. Two of the falls resulted in major injury (bone fractures) and one resulted in a laceration over the left eyebrow. The facility continued to apply only the safety alarms to the bed and the wheelchair despite continued falls, some with major injuries. The surveyor observed incident and accident investigations on 7/22/14 at 9 a.m. and on 7/23/14 at 11 a.m. The following are dates, times and locations of the 13 falls: 10/23/13, 6 p.m. in the bedroom. 11/9/13, 5:45 p.m. in the bedroom which resulted in an impacted fracture of the left radial head (where the arm meets the shoulder) and the left wrist. 11/15/13 at 10:55 p.m. in the bedroom. 11/28/13 at 9:05 p.m. in the bedroom. 12/1/13 at 5:45 p.m. in the bedroom. 12/3/13 at 12:30 p.m. in the bedroom. 12/20/13 at 7 p.m. in the bedroom which resulted in a fractured hip, hospitalization and survey. 12/29/13 at 10:30 p.m. in the bathroom. 1/11/14 at 8:27 a.m. in the bedroom. 2/9/14 at 4:10 p.m. in the bedroom. 3/16/14 at 10:20 p.m. in the bedroom. 4/16/14 at 4:40 p.m. in the bathroom. 5/10/14 at 10:10 a.m. in the bedroom which resulted in a laceration over the left eyebrow. After each fall Resident #6 was screened by Physical Therapy. The therapist's screens reiterated the information that was on the investigation report. This information described the falls. There were no new recommendations from the therapist to prevent further falls. Added by the therapist to the evaluation was that Resident #6 was confused and required assistance with all transfers. The recommendations were to continue the alarms and "remind the resident to ask for help however he/she is forgetful and has poor safety awareness." The surveyor reviewed the Care Plan for Resident #6 on 7/22/14 at 11 a.m. The Care Plan indicated Resident #6 had "dementia - no short term memory." Interventions to prevent falls were to ensure staff respond promptly, keep the bed in the lowest position, attach a safety alarm to the bed and the wheelchair, orient and remind Resident #6 to use the call light and to keep the resident in highly visible areas for close supervision, i.e., in front of the Nursing station. The surveyor interviewed the UM on 7/24/14 at 9 a.m. The UM indicated that there were no other interventions put in place other than the bed and wheelchair alarms. The surveyor and the UM reviewed a physician's progress note dated 7/31/13 that also indicated that Resident #6 was a "very high fall risk," the facility's 7/23/13 Initial Assessment which indicated Resident #6 had a history of [REDACTED]. The UM was unable to explain, despite the facility's awareness of the resident's cognition, poor safety awareness and history of non-compliance with the alarms, why other interventions were not attempted to keep Resident #6 safe from falls. On 7/25/14 at approximately 12:30 p.m. after the Survey Exit the administrator told the survey team that the facility did not attempt other interventions such as a lap buddy because Resident #6 "has always been non-compliant." REFER TO F279 Resident #11 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), the resident was cognitively impaired, required the assist of a staff member to ambulate, was at high risk for falls and was to be toileted every two hours. The resident had orders for a bed alarm when in bed. The care plan addressed the risk of falls due to poor safety awareness and decreased cognition and mobility. Resident #11 was observed on the initial tour on 7/22/2014 at 10 a.m. and according to the nurse the resident was cognitively impaired and a fall risk and will remove the lap buddy. The resident was observed on 7/22/2014 at 3:30 p.m. in the main activity room, seated in a high back wheelchair with leg rests, participating in a bingo game. He was quiet and seemed to enjoy the activity. The resident's lap buddy was removed while in the activity. On 6/2/2014 at 10:55 p.m. the resident was found on the floor between the bed and bathroom wearing only an incontinent brief which was wet with urine. The resident was in bed prior to the fall and was to have a bed alarm in place. The bed alarm never sounded as it was not turned on. Resident #11 sustained a skin tear to the left elbow and a bruise to the left shoulder. The investigative report indicated the steps to be taken to prevent recurrence was to ensure that the bed alarm was in place and functioning and to educate the resident to use the call bell for assistance. During an interview with the nurse on 7/23/2014 at 1:40 p.m., the nurse said that the resident is able to perform transfers with minimal contact guard which is to be done daily. The nurse said that the resident is usually more agitated on the evening shift. According to the facility policy, every incident will be evaluated for the time, place and pattern. If a resident falls from bed, a monitor will be initiated and toileting schedule will be reviewed. If the resident is a frequent faller, the resident will be assessed by the IDT (Interdisciplinary Team). These concerns were discussed with the facility Administration on 7/25/2014 at 12:30 p.m. and they had no additional information to add to the concerns. NJAC-8:39-27.1(a)