Every finding on record at Adroit Care Rehabilitation and Nursing Center

Complaint #: 3131839Based on observation, interview and record review, it was determined that the facility failed to; a.) notify the resident's physician to ensure that there was a physician order to discharge a resident and b.) notify the resident's legal guardian (LG) about discharge planning to ensure sufficient preparation for a safe and orderly discharge from the facility. This deficient practice was identified for 1 of 3 residents, (Resident #2) reviewed for discharge process.The deficient practice was evidenced by the following: A review of the admission Record (AR) revealed that the resident was admitted to the facility with diagnosis which included but not limited to: dementia (decline in mental abilities), essential hypertension (high blood pressure that has no clear, single medical cause), and muscle weakness (lack of physical strength where extra effort is needed to move your arms, legs, or other muscles).A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 02/12/2026, revealed a Brief Interview Mental Status (BIMS) score of 14 out of 15, which indicated that the resident was cognitively intact.A review of the hospital Progress Note (PN) dated 02/08/2026, at 4:46 PM, the physician documented: Resident #2 consistently refused subacute rehab, home health, and outpatient services, and was ultimately found to lack medical decision-making capacity on repeated psychiatric evaluation, prompting initiation of guardianship proceedings for discharge planning. By 02/05/2026, temporary guardianship was established and Resident #2 was discharged to a subacute rehabilitation facility.A review of the nursing PN dated 02/10/2026, at 11:19 AM, the Licensed Practical Nurse (LPN #1) documented: Resident #2 refused vital sign readings and medication despite education and encouragement x2 [twice], the Medical Doctor (MD) and legal guardian (LG) made aware. No new orders at this time.A review of the nursing PN dated 02/17/2026, at 1:59 PM, LPN #1 documented: Resident #2 refused vital sign readings and medication despite education and encouragement x2, MD and LG made aware. No new orders at this time.A review of the nursing PN dated 02/23/2026, at 2:54 PM, LPN #1 documented: Resident #2 refused vital sign readings and medication despite education and encouragement x2, MD and LG made aware. No new orders at this time.A review of the nursing PN dated 02/25/2026, at 2:58 PM, LPN #1 documented: Resident #2 discharged at 11:45 AM in stable condition.During an interview on 07/31/2026 at 10:21AM, the Unit Manager (UM)/LPN #1 stated, the MD should be notified by the nurse and social worker of a discharge. There should be a doctor's order for all discharges. The UM/LPN #1 further stated, the resident's responsible party should be notified of the discharge plans prior to discharge.During an interview on 07/31/2026 at 11:27AM, the Director of Social Work (DSW) stated, For all residents with a responsible party and LG, I have to reach out to them concerning discharge planning. He further stated, I did not reach out to Resident #2's LG, I should have reached out. I did not look at the paperwork correctly to see that Resident #2 had a LG listed.During an interview on 07/31/2026 at 12:21 PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), stated the resident's physician should be notified by the nurse and obtain a discharge order. The nurse should also notify the resident's responsible party or LG about discharge planning. The DON further stated, for Resident #2, there was no discharge order or notification to the LG about the discharge. The DON acknowledged the facility's discharge policy was not followed for Resident #2.On 07/31/2026 at 10:30 A.M., the surveyor attempted to conduct a phone interview with LPN #1, however; LPN #1 could not be reached for the interview.A review of the facility's policy titled: Discharge Policies and Procedures dated 02/20/2017, revealed under Policy: residents shall be discharged from the facility only in accordance with a physician's order and in compliance with all applicable federal, state and local regulations. Under Purpose revealed: the purpose of this policy is to ensure that residents are discharged safely from the facility with appropriate planning, continuity of care, and necessary arrangements to support the resident's ongoing health and well-being. Under Physician's Order revealed: the resident's attending physician must issue a written and signed discharged order. The order shall include, when applicable, medication instructions and disposal instructions. Under Discharge Procedure revealed: 1. Explain the discharge process to the resident and family or the responsible party. NJAC 8:39-4.1; 27.1 (a)

Based on observations, interviews, and record review on 5/6/26, it was determined that the facility failed to ensure that a cognitively impaired resident (Resident #1), who required care assistance, was free from verbal abuse by staff. This deficient practice was identified for 1 of 2 residents reviewed for abuse. The deficient practice was evidenced by the following: A review of Resident #1's Face Sheet (FS), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses, which included but are not limited to, metabolic encephalopathy (a brain dysfunction caused by systemic illness, organ failure, or chemical imbalances in the blood, rather than a direct physical injury to the brain), altered mental status, muscle weakness, cognitive communication deficit, depression, anxiety disorder, and osteoarthritis (a degenerative joint disease where the protective cartilage on the ends of bones wears away over time, causing joint pain, stiffness, and reduced mobility). A review of the resident's care plan activity report (CP) revealed the following: Under Focus, BIMS/Brief Interview for Mental Status, initiated 3/9/26, revealed moderate cognitive impairment BIMS score 0-7. Under Focus, ADLs (Activities of Daily Living), initiated 3/9/26, revealed interventions, included but not limited to, transfer, chair transfer: supervision or touching; support: one person physical assist; modes of transfer: pivot with one person assist. A review of the local police department [name redacted] Incident Report (IR), dated 4/12/26 revealed that Resident #1's family member reported inappropriate comments were made by facility staff to Resident #1. A review of the Reportable Event Record/Report (FRE) dated 4/13/26 revealed the following: The date and time of the event as 4/12/26 at 1:09 PM. The FRE further revealed under Narrative that on Sunday, 4/12/26, Resident #1's family member called police claiming an allegation of abuse. The family member had left their phone on record under the bed since 4/9/26 and was alleging the recording indicated that staff were verbally inappropriate during care on Thursday, 4/9/26, between 7 PM and 8 PM. Staff were suspended pending investigation. CNA #1's statement obtained 4/15/26 via a phone interview revealed that during care, Resident #1 stated No and resisted, but care was continued. CNA #2's statement obtained 4/15/26 via a phone interview revealed that Resident #1 was resisting and that CNA #1 made an inappropriate comment about Resident #1. A facility document titled Report of Investigation (ROI) indicated under 3. Investigation Process. The investigation began immediately with the suspension of the 2 staff who provided care to [Resident #1] on the 3 to 11 pm shift on Thursday 4/9/26. Head to toe assessment was completed, no bruises or redness noted. [ .] 6. Conclusion of Investigation. In conclusion, this was verbal abuse/ inappropriate language towards a resident. Resident will be monitored closely for any untoward behavioral changes. Staff involved are, terminated, Staff in-services continue. On 5/6/26 at 1:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA denied there were any grievance filed by Resident #1's family member. The LNHA stated that the audio recording was reviewed and even though CNA #1 denied the allegation we recognized CNA #1's voice making inappropriate comments to Resident #1. The LNHA further stated that CNA #3 stated the incident should have been reported to the supervisor or the nurse. A review of the facility's policy on Abuse Prevention & Reporting with a revised date of 1/28/26 and review date of 4/12/26 revealed under Policy: 1. Residents of this center will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations. Under Definitions revealed: Verbal Abuse, defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within hearing distance regardless of their age, ability to comprehend, or disability. Under Training: 2. Training will include direct teaching regarding: How to report allegations or suspected cases [ .]. Under Responsibility and Actions: All licensed employees are responsible to 1. Notify their supervisor immediately. 2. Notify Administration of same. 3. Will complete written statement to aid in investigation. Under Allegation of Abuse, neglect, exploitation or mistreatment and injuries of unknown source: 1. All alleged violations of abuse are to be reported immediately but no later than 2 hours if the alleged violation involve abuse or results in serious bodily injury. N.J.A.C. 8:39-4.1(a)5

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that food stored in residents' personal refrigerators was maintained in a safe and sanitary manner by failing to a.) ensure thermometers were present in residents' personal refrigerators to monitor internal temperatures, b.) routinely monitor and document refrigerator temperatures on a temperature log, c.) maintain food items at the appropriate internal temperatures, d.) discard food items in accordance with manufacturers' expiration or by the used by dates, and e.) routinely monitor and clean refrigerators.This deficient practice was identified in 6 of 6 residents' rooms (Rooms 302, 304, 314, 319, 330B, and 330C) reviewed for the use of personal refrigerators and was evidenced by the following:On 3/19/26 at 10:20 AM, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM), the surveyor toured the rooms of residents with personal refrigerators. During the tour, the following observations were made:room [ROOM NUMBER] contained a personal refrigerator; however, no thermometer was present to monitor internal temperatures, and no temperature log was available to document routine monitoring. The surveyor and LPN/UM reviewed the contents of the refrigerator and identified multiple expired food items, including vanilla pudding (expired 2/20/26), mixed fruit (expired 3/16/26), and three turkey sandwiches (expired 3/15/26, 3/16/26, and 3/17/26).room [ROOM NUMBER] contained a personal refrigerator but lacked a thermometer to monitor internal temperatures. A medication temperature log dated 2023 was affixed to the front of the unit; however, the log was blank, indicating that routine temperature monitoring was not being performed. The refrigerator also contained spilled food and visible debris at the bottom, suggesting inadequate cleaning concerns. Inspection of the refrigerator contents revealed multiple expired food items, including Dijon mustard (expired 2/7/26), soda (expired 11/17/25), sliced cheese (expired 8/15/25), two packages of blue cheese (expired 3/13/25), cream cheese (expired 3/12/25), tomato ketchup (expired 1/18/24), French dressing (expired 10/23/23), and Dijon mustard (expired 7/3/23).room [ROOM NUMBER] revealed the presence of a personal refrigerator equipped with a thermometer to monitor internal temperature; however, no temperature log was available to document routine monitoring. At the time of observation, the thermometer displayed a temperature of 50 F., and visible residue was observed at the bottom of the unit. Inspection of the refrigerator contents revealed multiple expired food items, including: two (2) turkey and cheese sandwiches (expired 3/15/26 and 3/17/26), sandwich meat (expired 3/5/26), rum punch (expired 3/1/26), and lemon Jell-O (expired 3/10/26) Additionally, one (1) sandwich was observed to be undated and unlabeled.room [ROOM NUMBER] revealed the presence of a personal refrigerator with a thermometer to monitor internal temperature. The thermometer displayed a temperature of 9 F at the time of observation and the food items inside were frozen. There was no temperature log present to document routine monitoring of refrigerator temperatures. The LPN/UM stated that the resident's family adjusts the temperature control.room [ROOM NUMBER]B revealed the use of a personal refrigerator; however, no thermometer was present to monitor internal temperatures, and no temperature log was available to document routine monitoring. Inspection of the refrigerator contents revealed expired food items, including four turkey and cheese sandwiches (expired 3/15/26) and apple juice (expired 11/21/25).room [ROOM NUMBER]C contained a personal refrigerator in use; however, the unit lacked a thermometer to monitor internal temperatures, and there was no temperature log available to document routine monitoring. The interior of the refrigerator was warm to the touch, indicating a potential failure to maintain required temperature control.During the tour of residents' rooms with personal refrigerators, the surveyor interviewed the LPN/UM, who acknowledged that thermometers were not routinely placed in residents' personal refrigerators and that staff did not monitor or document temperatures. The LPN/UM also stated that residents, rather than staff, checked for expiration dates and cleaned the refrigerators. When asked about safety concerns associated with the warm internal temperatures, the LPN/UM responded by obtaining the residents' permission and discarded the hazardous food. On 3/20/26 at 12:00 PM, the surveyor interviewed the Director of Maintenance (DOM), who stated that the Certified Nursing Assistants (CNAs) were responsible for monitoring residents' refrigerators, including checking and cleaning them daily and ensuring that expired food items were discarded. On 3/23/26 at 12:17 PM, during a meeting with the Licensed Nursing Home Administrator (LNHA), Regional Clinical Nurse (RCN), and the Director of Nursing (DON), inconsistencies were identified regarding the placement of thermometers, monitoring and cleaning of residents' refrigerators, and the labeling, dating, and routine inspection of residents' food items. The LNHA stated that the facility was not responsible for residents' personal refrigerators and that no specific policy existed regarding their use. However, the RCN noted that the DOM periodically checked residents' refrigerator temperatures using thermometer guns. When asked for documentation, the RCN was unable to provide temperature logs and stated that the temperatures were not recorded. The surveyor asked the team about the expected temperature range for personal refrigerators. The RCN stated that temperatures should be maintained between 36 F and 40 F. When questioned about the appropriateness of periodic monitoring, given that temperatures outside this range were observed, the team did not provide a response and was unable to report how often the temperatures were out of range, acknowledging that this represented a safety concern. On 3/20/26 at 11:40 AM, the surveyor was provided a copy of the facility policy titled Use and Storage of Food Brought to Residents by Visitors, dated 1/3/24 and reviewed 2/7/26. Under the Procedure section, the policy indicated that: 2. All food items are to be labeled with the resident's name, room number, and date; 4.b. Food past the manufacturer's expiration date will be discarded by nursing staff; 5. Nursing staff will monitor . refrigeration units for food and beverage disposal; and 7. All resident room refrigerator units will be checked daily and cleaned weekly. A review of the facility policy titled Foods Brought by Family/Visitors, dated 6/13/22 and reviewed 1/28/26, indicated under Policy Interpretation and Implementation that nursing staff are responsible for discarding perishable foods on or before the use-by date. NJAC 8:39-17.2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide residents with a clean environment by failing to a.) appropriately dispose of soiled materials and personal protective equipment (PPE) and b.) provide clean bed linen and incontinence supplies maintained in sanitary condition to prevent cross-contamination. This deficient practice was identified in room [ROOM NUMBER] and Resident #16 reviewed for environmental concerns and was evidenced by the following:1). On 3/18/2026 at 11:19 AM, surveyor #1 toured room [ROOM NUMBER] and observed the following: Enhanced Barrier Precautions (EBP) signage posted on the door. Soiled materials including bed linen with other items wrapped inside and a blue disposable chuck) disposed of on top of the garbage receptacle. A disposable glove turned inside-out and discarded on the floor. On 3/20/26 at 9:45 AM, surveyor #1 observed EBP signage posted on the door of room [ROOM NUMBER] and a pair of disposable gloves turned inside-out discarded on the floor. On 3/20/26 at 9:51 AM, surveyor #1 interviewed the Certified Nursing Assistant (CNA), who stated that the soiled bed linen should be discarded inside the trash bin, not placed on top of it. The CNA further stated that gloves and other PPE should not be discarded on the floor, but instead placed in a designated trash receptacle. The CNA also reported that proper disposal of trash and PPE is important for infection control. On 3/20/26 at 10:08 AM, surveyorc#1 interviewed the Licensed Practical Nurse (LPN), who confirmed that soiled linen should be placed inside the garbage receptacle and not on top of it. The LPN acknowledged that PPE should not be discarded on the floor and stated that used gloves and other PPE should be disposed of in a designated red trash bin for infection control purposes. On 3/20/26 at 12:00 PM, surveyor#1 interviewed the Director of Maintenance (DOM), who confirmed that it was not acceptable to place trash on top of a garbage receptacle and that all waste should be placed in a bag inside the receptacle. The DOM stated that trash is emptied daily and more frequently as needed to support proper infection control practices. On 3/20/26 at 1:05 PM, surveyor #1 interviewed the Registered Nurse/Infection Preventionist (RN/IP), who stated that staff were expected to discard used PPE in a red trash bin or in a regular trash receptacle lined with a red bag if a red trash bin was unavailable. The RN/IP further stated that staff were expected to perform hand hygiene immediately after disposal of trash. The RN/IP agreed that placing PPE on top of the trash bin and on the floor was unacceptable. The RN/IP stated that staff who failed to adhere to the facility's policy were provided with individualized, one-on-one reeducation. A review of the facility's Personal Protective Equipment policy, dated 11/29/21 and reviewed 1/28/26, included that personal protective equipment should be disposed of appropriately in designated receptacles inside residents' rooms. The Personal Protective Equipment – Using Gloves section indicated to discard gloves in the designated waste receptacle inside the room. NJAC 8:39-31.4 (a) 2.) On 3/18/2026 at 9:18 AM, Surveyor #2 observed Resident #16 in bed. At the foot of the resident's bed was a covered red plastic trash bin. The surveyor observed the following sitting directly on top of the trash bin cover: folded blue disposable chuck, folded cream-colored incontinence brief, and several layers of folded linen and garments. There was an Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes), signage posted on the door. A plastic bin containing PPE (Personal Protective Equipment) was located along the doorway. The surveyor reviewed the medical record for Resident #16. A review of the admission Record revealed Resident #16 was admitted to the facility with diagnoses which included but not limited to local infection of the skin and subcutaneous tissue, dementia, and muscle weakness. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/6/2026, reflected the resident had an unhealed stage 4 pressure ulcer on the left hip. A review of the Physician Orders active as of 3/24/2026, revealed an order for Santyl 250 unit/gram topical ointment every day and as needed for the diagnosis of Other skin changes. A review of the resident's individualized comprehensive care plan effective on 1/1/2026, indicated a focus for pressure ulcer stage 4 on the left ischium (hip). One of the goals in the care plan included the following: I will show no signs of infection to site. On 3/20/2026 at 9:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that nursing staff cannot put clean linens on top of the trash bin for infection control. On 3/23/2026 at 10:02 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that red trash bins are for soiled PPE of residents on EBP. The IP also stated that clean linens should be bagged and not be left on top of trash bins. A review of the facility-provided policy titled Linen Storage reviewed on 11/22/2025, did not include how clean linen should be stored inside the room of residents on EBP. N.J.A.C. 8:39 - 31.4 (a)

Based on observations, interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents receiving enteral feedings were provided appropriate care and services to prevent complications by failing to complete formula labels for residents receiving feedings. This deficient practice was identified for 2 of 3 residents (Residents #49 and #114) reviewed for tube feeding. The deficient practice was evidenced by the following:1.) On 3/18/26 at 11:24 AM, Surveyor #1 observed Resident #114 lying asleep in bed while receiving a continuous tube feeding (TF). Observation revealed that the TF bag was not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate per hour. Surveyor #1 reviewed the electronic medical record (EMR), for Resident #114. A review of the admission Record (admission summary) indicated that the resident had diagnoses which included but were not limited to dysphagia (difficulty swallowing), aphasia (a disorder affecting communication), and gastrostomy status (presence of a tube in the stomach for the administration of nutrition, fluids, and medications). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of the resident's care, dated 1/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating that the resident's cognition was severely impaired. Further review of Section K (Swallowing/Nutritional Status) of the MDS indicated that the resident was receiving nutrition via a feeding tube while residing in the facility. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, initiated on 8/22/24 and revised on 9/3/24, that the resident required tube feeding related to (r/t) dysphagia, failure to thrive, malnutrition, and at risk for aspiration. Interventions included providing or enteral feeding per medical doctor (MD) orders and tube feed formula and water flushes as ordered. A review of the Order Summary Report of active orders, renewed 1/15/26, included a physician's orders (PO) for enteral feeding, Peptamen 1.5 cal. liquid via gastrostomy (GT) to run at 60 mL/hr. via a pump. Total volume to be infused, 1000 mL/24 hrs. The order further directed that the feeding be initiated at 4:00 PM and discontinued when total feeding volume infused. The order directed the staff to document the feeding start time each shift and to verify and ensure the accuracy of the infusion rate and feeding each shift. On 3/20/26 at 10:08 AM, surveyor #1 interviewed the Licensed Practical Nurse (LPN), who confirmed that the TF bag should have been labeled with the resident's name, room number, date and time the feeding was initiated, and the prescribed infusion rate. The LPN further stated that proper labeling of the TF bag was important to ensure safety and accuracy, as well as to prevent contamination by ensuring the feeding bag is changed daily. On 3/20/26 at 10:53 AM, Surveyor #1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). When asked what information should be applied to a TF bag, the LPN/UM stated that the label should include the date, time, TF rate, as well as the resident's name and room number. The LPN/UM was unable to explain why the TF bag was missing this information. The LPN/UM further stated that labeling the TF bag with the resident's information was important for resident safety and infection control. On 3/23/26 at 12:17 PM, Surveyor #1 interviewed the Director of Nursing (DON), who confirmed that the tube feeding TF bag should have been labeled with the resident's name, room number, date and time the feeding was started, formula, and rate. The DON stated that staff were expected to apply a new label with the required information each day to ensure resident safety and adherence to infection control practices. The facility policy and procedure titled Tube Feedings, dated 6/14/21 and reviewed on 2/10/26, indicated that tube feedings will be given per physician's order. Under the Action section, step 3 directed staff to fill in information on the label (i.e. resident's name, room start time and rate) . 2.) On 03/18/2026 at 9:54 AM, during initial tour of the facility Surveyor #2 observed Resident #49 asleep in bed while receiving a continuous tube feeding (TF). At that time Surveyor #2 observed the TF bag was not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate per hour. A review of Resident #49's admission record revealed that Resident #49 was admitted with but not limited to Gastrostomy status (presence of a tube in the stomach for the administration of nutrition, fluids and medication). A review of Resident #49's annual Minimum Data Set (MDS) dated [DATE] revealed in Section K (Swallowing/Nutritional Status) that the resident received 51% or more of their total calories through TF while residing at the facility. A review of Resident #49's Electronic Medical Record (EMR) revealed a physician's order for tube feeding, Glucerna 1.2 at a rate of 75 milliliters per hour (ml/hr) via pump. Total volume to be infused of 1,550 milliliters. The order further directed the TF to be initiated at 5:00 PM and discontinued when the total volume infused. A review of Resident #49's Care Plan revealed that the resident included a focus area for Tube feeding effective 03/25/2025. Interventions included .will administer your feedings: as ordered. On 03/23/2026 at 12:05 PM during an interview the Director of Nursing (DON) indicated that it was necessary to have the TF bags properly labeled to ensure that the residents are receiving the correct nutrition. A review of the policy titled Tube Feedings reviewed on 2/10/2026revealed under the section Action under step 3, fill in information on the label (i.e. residents name, room, start time and rate). N.J.A.C. 8:39-27.1(a)

REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store medications securely inside the medication cart by keeping it locked when unattended and b.) failed to ensure that medications were stored under proper temperature controls by failing to maintain unopened insulin vials in the refrigerator. The deficient practice was identified in 2 of 5 medication carts (B side 2nd floor cart and the 2nd floor central medication cart) observed during tour of the facility and medication storage and labeling task inspection.The deficient practice was evidenced by the following: A.) On 3/18/2026 at 9:09 AM, during the initial tour of the facility, Surveyor #1 observed a medication cart labeled B- Side unlocked along the B side hallway of the 2nd floor. The lock of the cart faced the hallway. There were no medications on top of the cart. There were no residents, visitors, or staff present in the hallway. The surveyor stayed within the line of sight of the medication cart. On 3/18/2026 at 9:12 AM, the surveyor observed Registered Nurse #1 (RN #1) came out of a resident's room near the B side medication cart. RN #1 approached the unlocked medication cart and locked the cart. On 3/18/2026 at 9:14 AM, during an interview with the surveyor, RN #1 confirmed that they were in charge of the medication cart. RN #1 stated that medication carts need to be locked at all times. RN #1 apologized to the surveyor for leaving the cart unlocked. On 3/20/2026 at 9:57 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that nurses must lock the medication carts if they are not behind them because they do not want anybody to open the carts. A review of facility- provided policy titled Medication Storage reviewed on 1/28/2026, did not include keeping medication carts locked when not being attended to. B.) On 03/20/2026 at 11:50 AM, the Surveyor observed the Central Medication Cart in the presence of Licensed Practical Nurse (LPN) # 1 located on the second floor. At that time, the Surveyor observed the top drawer of the cart and found one multi-dose vial of insulin lispro 100 units, one insulin glargine 100 units/milliliter, and one unopened box of a lantus multi-dose vial 100 units. Each medication is prescribed to treat blood-sugar levels within the body. Two of the insulin multi-dose vials had the protective cap intact and the lantus multi-dose vial was still in a sealed, unopened box. At that time, the surveyor reviewed the instructions located on each box for each of the insulin multi-dose vials. The instructions revealed that, DO NOT FREEZE. Store refrigerated at 36 degrees F to 46F [2 to 8 C] until time of use. Store in-use vials refrigerated at 36 degrees F to 46 degrees F [2* C to 8 degrees C]. If refrigeration is not possible store at room temperature (up to 88 degrees F [30 degrees C]) . The second floor medication room did contain a refrigerator for medications. At that time, the surveyor interviewed LPN # 1. LPN # 1 confirmed that the insulin multi-dose vials should be refrigerated. LPN # 1 both confirmed that the three insulin multi-dose vials were sealed by the protective cap and the lantus multi-dose vial box was unopened. A review of the facility policy titled Medication Storage-Insulin last reviewed 1/28/26. The policy revealed that, It is the policy of [Facility Name] to follow the manufacturer's recommendations for the proper storage and temperature controls of all medications including but not limited to INSULIN. N.J.A.C. 8:39-29.4(h) N.J.A.C. 8:39-29.4(a)

Based on observations, interviews, review of medical records and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection in accordance with the Center for Disease Control & Prevention (CDC) guidelines and standards of clinical practice by ensuring, a.) respiratory device tubing, masks, and mouthpiece were stored in protective covering between uses identified for 1 of 5 residents (Resident #50) reviewed for respiratory care, b.) proper use of personal protective equipment (PPE) for 1 of 1 residents reviewed under contact precautions (Resident #75). This deficient practice was identified in 1 out of 2 nursing units (third floor unit) and was evidenced by the following:a.) On 03/19/2026 at 09:36AM, the surveyor observed Resident #50's bedside table had oxygen tubing hanging from the bedside table. With the permission of Resident #50, the surveyor requested a staff member to open the top draw revealing Resident #50's nebulizer (a machine that aerosolizes medications for inhalation) with the nebulizer mask on top open to air. A review of Resident 50's admission record revealed that Resident #50 was admitted with but not limited to chronic obstructive pulmonary disease (COPD), (a progressive lung disease that makes it difficult to breathe).A Review of Resident #50's annual Minimum Data Set (MDS) dated [DATE] revealed under section O that the resident received oxygen therapy. A review of Resident #50's Electronic Medical Record (EMR) revealed a physician's order for Sodium Chloride (inhalant) 0.9% solution for nebulization, inhale 1 unit four times per day for shortness of breath. A review of the Care Plan in the EMR revealed a nursing focus of respiratory disorder with intervention that included nebulizer treatments as ordered. During an interview on 03/20/2026 at 09:57 the Director of Nursing (DON) stated that when nebulizers were not in use they should be stored in a plastic bag. b.) On 03/18/2026 at 10:31 AM during initial tour, the surveyor observed signage on Resident #75's door that read Contact Precautions that included instruction to Put on gown before room entry. At that same time, a Certified Nurse's Aide (CNA) was observed entering Resident #75's room without a gown. At that time the surveyor observed the CNA remove a basin from Resident #75's room and then was observed entering another resident room. The CNA confirmed that the basin was removed from Resident #75's room and indicated that she did so because Resident #75's water took too long to warm. Review of Resident #75's EMR revealed a physician's order for Contact Precautions dated 01/07/2026. A review of the Care Plan in the EMR revealed a focus titled Contact Precautions. Etiology C. Auris (an infectious organism) swab positive 11/12/2025, with an effective date 11/14/2025. On 03/23/2026 at 10:03 AM during an interview, the Infection Preventionist (IP) indicated that PPE should be applied prior to entering the resident's room. The IP indicated that residents on contact precautions should have dedicated supplies that should not go in and out of the residents' room. Review of the policy titled Infection Prevention and Control Program last review dated 01/28/2026 revealed under the section titled Contact Precautions, that 5. Gown; a. wear a disposable gown upon enter the contact precautions room. The same policy under the section titled Contact Precautions revealed, 7. Resident-care Equipment; .dedicate the use of non-critical resident-care equipment items . to a single resident (or cohort of residents) to avoid sharing between residents.N.J.A.C. 8:39-19.4(a)

Complaint: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to a.) implement a resident's (Resident #1) comprehensive care plan for out on pass with escort only which resulted in the resident eloping and b.) develop a care plan for a resident post elopement. On 8/22/2025, Resident #1 was sitting outside the facility unescorted and was found wandering on a multi-lane highway by a passerby who brought the resident to the police precinct and had a syncopal episode (loss of consciousness) and was transferred to the emergency room.This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According to Resident #1's face sheet, the resident was admitted to the facility with a diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., which indicated the nurse saw Resident #1 around 3:10 P.M., well dressed with a cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside. The nurse said okay, and documented that the physician was informed to get an out on pass order. Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct. The Director of Nursing (DON) and the writer were contacted. Due to a syncopal episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the Physician's Orders (PO) on 08/29/2025, did not include a PO for the Resident #1 to go out on pass at the time of the incident. On 8/29/2025, the surveyor reviewed Resident #1's Care Plan (CP) dated 5/29/2025, with no revision date. The CP's focus revealed Nursing: Community Pass As Evidenced By: Community pass with escort only. The CP further revealed a focus of Nursing Communication Etiology: Confusion Additional Detail: Resident has a POTENTIAL for alteration in communication secondary to: Another CP dated 5/30/2025, with no revision date, revealed a focus of Nursing: Disorders of the Brain Etiology: Dementia As Evidenced By: Confusion Additional Detail: Resident exhibits alteration in brain functioning due to: Resident has POTENTIAL for alteration in brain functioning due to: Dementia. The CP did not include the incident on 8/22/2025, where the resident was found wandering on a multi-lane highway and had a syncopal episode.During a telephone interview with the Police Sergeant (SGT) on 8/29/2025 at 11:49 A.M., he stated the police precinct received calls around 4:20 P.M. on 8/22/2025, for an elderly [person] who looked confused and wandering on the shoulder of the highway. When Resident #1 arrived at the police precinct [they] were confused and only knew [their] name and that [they] were coming from work and was on the way home. The SGT stated that the resident looked out of breath. The SGT further revealed he called the facility who were unaware of the resident's departure. The SGT stated Resident #1 then had a loss of consciousness while sitting in a chair speaking to other officers. Then the ambulance was called, and Resident #1 was transferred to the emergency department.During a telephone interview on 8/29/2025 at 12:36 P.M., the Registered Nurse/Nursing Supervisor (RN/NS) stated that he had called the physician that day and obtained an order for Resident #1 to go out on pass, but I forgot to put in the order and write the note. The RN/NS acknowledged it was important to document the order because it made everyone aware that the resident was allowed to go out on pass. During an interview on 9/02/2025 at 2:41 P.M., the DON stated that the nurses initiated CPs on admission and with any incidents to ensure the plan of care was accurate for the resident. At that time, the DON reviewed Resident #1's CP in the presence of the surveyor and acknowledged the resident had an intervention for out on pass with escort only. The DON stated that the Unit Manager should have updated the CP post MDS assessment when the resident's BIMS score changed.A review of the facility's policy titled ACCIDENTS/INCIDENTS INVESTIGATION PROCESS dated 6/05/2025, revealed under PROCESS.Review previous interventions in the care plan, establish new intervention for this specific incident and write it in the incident report and update the care plan.A review of the facility's policy titled COMPREHENSIVE CARE PLAN DATE 6/05/2025, revealed under Policy Statement: C. Each resident's comprehensive care plan shall be reviewed and updated by the interdisciplinary team as per MDS 3.0 schedule: quarterly, annually, significant in condition and if the resident's condition warrants it. At the time of the survey the CPs were dated from the time of admission and not updated with the quarterly MDS or after the elopement occurred.NJAC 8:39-27.1 (a)

Complaint: 2600629, 2601350Based on interviews, medical records review, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., that the nurse saw Resident #1 around 3:10 P.M., well dressed with cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside. The nurse said okay, and documented that the physician was informed to get an out on pass order. Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct. The Director of Nursing (DON) and the writer were contacted. Due to a syncopal (loss of consciousness) episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the facility's undated REPORT OF INVESTIGATION revealed under 6. Conclusion of investigation: It was concluded that [Resident #1] who is alert and oriented BIMS 12 verbalized desire to go for a walk and sit outside for a while. Order for Out on Pass obtained and signed by [Resident #1] .During out on pass [they] walked away.Returned to facility later in the evening, safe. Body check done, no signs of injury. Wander guard was placed on [Resident #1] for extra safety. Care plan updated.During an interview on 8/29/2025 at 1:14 P.M., with the Licensed Nursing Home Administrator (LNHA) and DON, the surveyor asked if the elopement was reported to the NJDOH. The DON stated that after reviewing the incident they determined that reporting to the NJDOH was not necessary since they had a physician's order and an out on pass signed.A review of the medical record did not include a physician's order at the time of the incident for the resident to go out on pass unescorted. A review of the facility's policy titled ACCIDENTS/INCIDENTS INVESTIGATION PROCESS dated 6/05/25, revealed under REPORTABLE EVENTS that The results of all investigations will be reported to the administration of his or her designated representative and to other officials in accordance with State law, including the State Agencies, within 5 working days of the incident with appropriate corrective action taken as a result of the investigation.NJAC 8:39-9.4(f)

Complaint: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 08/29/2025 and 9/02/2025, it was determined that the facility failed to follow acceptable standards of nursing practice by a.) not documenting a physician's order for a resident (Resident #1) to leave the facility on pass (out on pass) and b.) not following a physician's order for a psychiatric consultation and psychological consultation for a resident (Resident #1) that was ordered at admission to the facility.This deficient practice was identified for 1 of 3 sampled residents (Resident #1) 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 response to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist. 1. The surveyor reviewed the medical record for Resident #1. According to Resident #1's face sheet, the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., that the nurse saw Resident #1 around 3:10 P.M., well dressed with a cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside. The nurse said okay, and documented that the physician was informed to get an out on pass order. Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct. The Director of Nursing (DON) and the writer were contacted. Due to a syncopal (loss of consciousness) episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the physician's orders (PO) on 8/29/2025, did not include a PO for the Resident #1 to go out on pass at the time of the incident. During a telephone interview on 8/29/2025 at 12:36 P.M., the Registered Nurse/Nursing Supervisor (RN/NS) stated that he had called the physician that day and obtained an order for Resident #1 to go out on pass, but I forgot to put in the order and write the note. The RN/NS acknowledged it was important to document the order because it made everyone aware that the resident was allowed to go out on pass. During an interview on 8/29/2025 at 1:14 P.M., with the Licensed Nursing Home Administrator (LNHA) and the DON, the DON stated the RN/NS did not write the order, so I immediately did a one-to-one in-service with the [RN/NS] and other nursing staff. The DON also stated that she called the physician who confirmed that an order was obtained. The DON confirmed the nurse did not document the physician's order for Resident #1 to go out on pass. 2. The surveyor reviewed the medical record for Resident #1. According to Resident #1's face sheet, the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the physician's orders (PO) on 8/29/2025, for Resident #1, included a PO dated 5/30/2025, for a consultation (consult) for a psychiatry evaluation with [name redacted group]. A review of an additional PO dated 5/30/2025, included a psychology consult. A review of the medical record included a psychiatric consult that was completed almost three months later on 8/25/2025, after the resident eloped from the facility. A further review did not include that a psychology consult was obtained as ordered. During an interview on 9/2/2025 at 2:41 P.M., the DON stated that upon admission to the facility, there were certain consultations that were a standard order for all residents, which included the psychiatric and psychological consults. The DON stated the orders should have been for as needed psychiatric and psychological consults. The DON confirmed the PO's were not followed as written for Resident #1; that there was no psychological consult obtained, and the psychiatric consult was done on 8/25/2025. A review of the facility's policy titled Out on pass dated 7/1/2025, revealed under PROCEDURE: 6. Nursing Supervisor will notify Physician & obtain an order for Out on Pass with Responsible Party or independently if deemed appropriate. A review of the facility's policy titled DOCUMENTATION in the EMR dated 6/5/2025, revealed POLICY: It is the policy of this center to document all information related to the patients medical care in the Electronic Medical Record.NJAC 8:39- 27.1(a)

COMPLAINT #NJ185510 Based on interviews, record reviews, and review of other facility documentation, on 05/08/25 and 05/09/25, it was determined that the facility failed to provide a requested medical record for a discharged resident within 2 days of a written request. This deficient practice was identified for 1 of 3 residents, reviewed (Resident #6), and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the Resident Face Sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease, Dementia, Respiratory Disorder, and Chronic Pulmonary Obstructive Disease. The face sheet also revealed that a family member (FM) requesting the Resident's medical record was listed in the Contacts section as Primary, listed the FM's relationship to the resident, and under designation PHI: [protected health information] Full. According to the admission Minimum Data Set (MDS), an assessment tool dated 04/03/25, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated that Resident #6 was severely cognitively impaired. The surveyor reviewed a timeline provided by the facility Administrator (ADM) on 05/09/25 regarding a FM's written request for the medical record for Resident #6. According to the timeline, on 4/07/2025, the FM requested the medical records. The contracted provider of the medical record informed the facility ADM they required documentation demonstrating the requestor was the personal representative of the resident and had the authority to request the records. According to the timeline, the next communication was on 4/21/2025 at 5:03 pm from the ADM to the FM that supporting documentation was required. The facility did not follow up with the FM in a timely manner with this new request for information to ensure receipt of the medical record within 2 days of the 4/07/2025 request. The surveyor reviewed emails provided by the Administrator for review: -4/7/25 at 4:04 P.M.: Email sent from facility to the Contracted Provider containing the medical record request from the family. -4/7/25 at 4:21 P.M.: Email sent from the Contracted Provider to the facility advising that additional documentation was needed prior to approving the release of records. The current Medicaid Coordinator (MC), whose role was Medical Records personnel at the time of the FM request on 4/07/2025, was interviewed on 5/08/2025 at 4:37 PM. The MC stated she was aware the FM filed a request for the resident's medical record. The MC further stated she did not deal directly with the family regarding the medical record request but was copied on the emails regarding the request. On 05/08/25 at 5:08 P.M., the surveyor interviewed the Administrator (ADM), who stated that to obtain a resident's medical record, a form must be completed, and then the facility would send the request to [Contracted Provider Name]. The ADM further explained that this provider was the facility's legal consultant who reviewed each request and informed the facility if the person requesting was legally entitled to the information or if additional documentation was needed. According to the ADM, the request for the medical record was received from Resident #6's FM and was sent to the Contracted Provider for review on 04/07/25. The Administrator also stated that he received a response from the Contracted Provider on the same day, 04/07/25 and that the provider advised that additional documentation was needed prior to releasing the records. The Administrator stated that he informed the family of the need for additional documentation on 04/21/25 when he next returned to the facility. When the surveyor asked why the facility did not send the request for additional information to the family member sooner, the Administrator stated that he could have delegated the task to someone else but that he did not. N.J.A.C. 8:39-35.2(h)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 shower rooms. The deficient practice was evidenced by the following: On 11/06/2024 at 10:58 AM, the surveyor entered the shower room on the second floor and observed tiles on the floor and various hygienic products left in the whirlpool tub. On 11/07/2024 at 09:49 AM, the surveyor entered the shower room on the second floor and observed tiles picked up and placed on the window sill, and items remained in the whirlpool tub. On 11/07/2024 at 1:05 PM, the surveyor entered the shower room on the third floor and observed brown stains on the wall and floor tiles, an empty can of aftershave on the floor, a leaking shower head in a plastic bag, and a broken faucet. On top of the linen cart was one loose, blue incontinent pad and one open bag of incontinence briefs. On 11/08/2024 at 09:35 AM, the surveyor entered the shower room on the third floor and observed in the shower area a leaking shower head in a plastic bag with towels around it. Clothing on the shower bed and tissues on the floor under the shower bed. Trash in the trash can with no bag lining. On 11/08/2024 at 09:39 AM during an interview with the housekeeper (HK # 1), the surveyor asked who is responsible for cleaning the shower rooms. HK # 1 replied, Housekeeping is responsible for emptying the trash, mopping the floors, and cleaning the shower room. Certified Nurse Aides (CNAs) are responsible to clean up behind the residents after showering. On 11/08/2024 at 09:44 AM during an interview with the Director of Housekeeping (DOH), the surveyor asked what are the brown stains in the shower area on the third floor, who is responsible to clean the shower rooms, and do the residents use the shower area. The DOH replied, The staining in the shower area is caused by the harshness of the water. Housekeeping is responsible for cleaning the area. The area is difficult to maintain due to the water quality. The Regional Director of Housekeeping (RDOH) was notified yesterday for guidance on addressing the water stains. The RDOH brought in lime spray today to clean the area, and the stains have now been removed. The shower area is currently non-functional and has not been used for the resident showers in over a year. On 11/12/2024 at 12:27 PM during an interview with the Licensed Nursing Home Administrator (LNHA), the surveyor asked what are the brown stains in the shower area on the third floor. The LNHA replied, The staining in the shower area is due to the harshness of the water, and the shower area should have been cleaned. A review of a facility provided policy, with a review date of 06/04/2024, titled Environmental Services revealed under the section titled Procedure Bathroom and Toilets #4 that, Sanitation: Bathrooms are high-risk areas for pathogen transmission, so extra attention is needed. Toilets, sinks, and faucets should be sanitized with appropriate disinfectants. Shower Areas: Cleaning and disinfecting showers, bathtubs, and other wet areas to prevent mold and mildew buildup is essential. A review of a facility provided policy, with a review date of 06/04/2024, titled Environmental Services revealed under the section titled Environmental Cleaning Audits #11 that, Monitoring and Evaluation: Facilities should implement regular audits or inspections to assess the effectiveness of cleaning practices. These audits can be used to identify areas for improvement and ensure that standards are met. Feedback Loop: Providing ongoing feedback to housekeeping staff is crucial for continuous improvement and maintaining high standards of cleanliness. S 8:39-31.4 (a)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a resident's activities of daily living (ADL) care in a dignified manner. This deficient practice was identified for 1 of 3 residents reviewed for activities of daily living (Resident #102), and was evidenced by the following: On 11/07/2024 at 10:58 AM, the surveyor observed Resident #102 in their private room accompanied by Certified Nursing Assistant (CNA #1), who assisted the resident transfer from a wheelchair to the bed. While laying in bed, the surveyor observed CNA #1 remove Resident #102 pants exposing the resident's lower body and their incontinence briefs. At that time, the surveyor left and asked the RN Supervisor-in-training (RN #1) to check on Resident #102. Upon returning to the room, Resident #102 was under the blankets and covered. When CNA #1 exited the room, the surveyor inquired how ADLs are to be performed in the room. CNA #1 acknowledged that the curtain was not pulled for privacy. RN #1 confirmed that all ADL care should be provided in the room with either the door shut or curtain pulled for privacy. The surveyor reviewed Resident #102's medical Record: A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/21/24 reflected the resident was admitted to the facility with diagnoses which included fracture of the humerus and ribs. The MDS also reflected that the resident brief interview for mental status (BIMS) score of 11 out of 15, which indicated that the resident had moderately impaired cognition. On 11/12/2024 at 12:19 PM, in the presence of the Licensed Nursing Home Administrator, Regional Nurse, the Director of Nursing (DON), acknowledged it was the expectation of staff to have the door closed or close the privacy curtain closed to ensure privacy and dignity to the residents. A review of the facility policy titled, Resident Rights, last reviewed June 11, 2024, revealed that: Resident's Rights include, but are not limited to the following: treated with respect, dignity [ .] NJAC 8:39-4.1(a)12

Complaint # NJ00176124 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain treatment records that were complete with staff signatures according to professional standards of clinical practice for Resident # 72, 1 of 24 residents reviewed for professional standards. The deficient practice was evidenced by the following: A review of Resident # 72's Admission Record indicated Resident # 72 was admitted to the facility with diagnoses which included but were not limited to Quadriplegia (partial or total loss of function in all for limbs and the torso) and Peripheral Vascular Disease (a condition that occur when blood vessels outside the brain and heart narrow, reducing blood flow to organs and tissues). A Review of Resident #72's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate care, dated 09/24/2024 revealed a Brief Interview for Mental Status score of 15/15, indicating Resident #72 was cognitively intact. A review of Resident #72's Treatment Administration Record (TAR) for the months of July 2024, August 2024, September 2024, and October 2024 revealed several blanks. For the treatment to the left 3rd toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 09/30/24 day shift For the treatment to the left great toe blanks were noted for: 07/04/24 day shift 07/08/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 09/30/24 day shift For the treatment to the right calf blanks were noted for: 07/04/24 day shift 07/08/24 day shift 07/13/24 day shift 07/14/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 10/04/24 day shift For the treatment to the right 3rd toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift For the treatment to the Right 4th toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift For the treatment to the right great toe blanks were noted for: 07/04/24 day shift 07/13/24 day shift 07/14/24 day shift 07/24/24 day shift 08/08/24 day shift 08/13/24 day shift 08/18/24 day shift 08/21/24 day shift 08/23/24 day shift 09/29/24 day shift 10/04/24 day shift For the treatment to the left lower leg blanks were noted for: 09/30/24 day shift For the treatment to the right buttock blanks were noted for: 09/30/24 day shift 10/04/23 day shift During an interview on 11/08/2024 at 09:56 AM with the surveyor, Resident #72 said they feel like when there are only 2 nurses on the floor their wound care doesn't get done. During an interview on 11/12/2024 at 12:19 PM with the surveyor, The Director of Nursing (DON) said when there are blanks on the TAR it means the nurse didn't sign it and you don't know if it was done. The DON also said there should not be any blanks on the TARS. A review of a facility provided policy last reviewed 06/04/2024 titled Documentation in the EMR revealed under section Purpose that, To maintain all information regarding the resident's care and treatment in an organized manner to ensure residents receives appropriate medical care with appropriate documentation. The also revealed under General information that, Documentation about treatments received will be located in the TAR. This will include the treatment ordered, frequency and location to administer treatment as well as the date/time administered and who performed the treatment. Any refusal should be documented accordingly, and MD should be informed. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that expired vaccines were removed from active inventory upon expiration. The deficient practice was identified in 1 of 2 medication rooms and was evidenced by the following: On [DATE] at 11:30 AM, in the presence of the Licensed Practical Nurse Unit Manager (LPNUM #1), the surveyor inspected the second floor medication room on the sub-acute unit. In the refrigerator, the surveyor observed a brown bag that had identification stickers which identified it as Covid-19 vaccines with an expiration date of [DATE]. Inside the bag were five (5) prefilled Intramuscular (IM) Moderna Covid 19 vaccine syringes with an expiration date of [DATE]. At this time, LPNUM #1 stated that the overnight shift is responsible for checking the expiration dates and confirmed that the bag should not be in refrigerator. On [DATE] at 1:40 PM during an interview with the surveyor, the Assistant Director of Nursing (ADON) confirmed that the Covid 19 vaccines were expired and should not have been in the refrigerator. On [DATE] at 11:12 AM, during an interview with the surveyor, the Infection Preventionist (IP) confirmed that the overnight staff are responsible for checking expiration dates in the medication rooms and that the Covid 19 vaccines should have been removed from the medication room. When asked why it is important to remove vaccines that are expired, the IP responded that vaccines might not be effective past that date. On [DATE] at 12:19 PM, in the presence of the Licensed Nursing Home Admistrator, Regional Nurse, Director of Nursing (DON), acknowledged that the expired vaccine in the medication room refrigerator. A review of the facility policy titled, Medication Storage, last reviewed [DATE], revealed under, Responsibility that: 1.[Licensed Nurse] Checks medication storage at least monthly to ensure all meds and supplies are checked for labels, expiration dates and to ensure the labels are legible. 2. Any meds that will be expiring should be removed before the expiration date. If pending expiration, it will determine if the supply will be completed before expiration date. NJAC-8:,d+[DATE].4

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary and comfortable environment that helped prevent the development and transmission of communicable diseases and infections. The deficient practice was evidenced by the following: On 11/06/24 at 10:58 AM, upon initial tour of the second-floor sub-acute unit, the surveyor observed room [ROOM NUMBER] with an Enhanced Barrier Precautions sign along the doorframe. The surveyor observed inside the room Personal Protective Equipment (PPE) Gown discarded in the resident's personal trash bin. On the same date and time, the surveyor observed room [ROOM NUMBER] with a Contact Precautions Sign along the doorframe. The surveyor observed inside the room a discarded Personal Protective Gown on the resident's floor. On 11/07/2024 at 11:13 AM, during an interview with the surveyor, Licensed Practical Nurse Unit Manager (LPNUM #1) stated that facility expectation was to bring a red biohazard disposable bag into the resident room and place all discarded PPE into the bag and throw it away in the soiled trash room. LPNUM #1 confirmed that PPE is not to be discarded in the resident trash bin or on the floor. On 11/12/24 at 10:22 AM, the surveyor observed in room [ROOM NUMBER] with an Enhanced Precautions Sign along the doorframe. The surveyor observed inside the room PPE discarded in the resident's personal trash bin. On 11/12/2024 at 10:26 AM, during an interview with the surveyor, Certified Nursing Assistant (CNA #1) stated that upon the start of their day, they receive report of residents with a change in status and any resident that is on enhanced barrier protection and/or contact precautions. CNA #1 confirmed that upon entering a room with a precaution sign, they are to bring a red trash bag and discard the PPE in that bag upon exiting the room then bring the bag to the soiled trash room. CNA #1 confirmed that PPE is not to be discarded in resident trash bin or on the floor. On 11/12/2024 at 11:12 AM, during an interview with the surveyor, the Infection Preventionist (IP) acknowledged that PPE disposal was to be in a red bag and brought to the trash room. The IP confirmed that PPE is not to be discarded in resident trash bin or on the floor. On 11/12/2024 at 12:19 PM, in the presence of the Licensed Nursing Home Administrator, Regional Nurse, Director of Nursing (DON), acknowledged that the PPE should not be discarded on the floor or in resident trash bins. A review of the facility document titled Infection Control Manual, last reviewed June 4, 2024, revealed under Isolation- Initiating Transmission Based Precautions that When transmission based precautions are implemented, the infection preventionist or designee shall: C. Ensure that appropriate linen barrel/hamper and waste container with appropriate liner are placed in or near the resident's room. A review of the facility document titled Infection Control Manual, last reviewed June 4, 2024, revealed under Personal Protective Equipment- Using Gown that After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. A review of the facility document titled Certified Nursing Assistant Job Description, revealed under safety and sanitation to follow established procedures in the use and disposal of personal protective equipment. A review of the facility document titled Licensed Practical Nurse Job Description, revealed under safety and sanitation to Ensure that CNAs and other nursing personnel follow established procedures in the use and disposal of personal protective equipment. NJAC 8:39-33.1(b)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately obtain a blood pressure and accurately document the site, b.) accurately document the refusal of medications, d.) dispose of medications in a safe manner, c.) clarify and accurately administer a medication (Midodrine) according to a physician's order and d.) remove and dispose of controlled substances from active inventory when discontinued from March of 2023 until surveyor inquiry. The deficient practices occurred for two (2) of seven (7) residents, (Resident #56 and #75) reviewed for medication management and for two (2) of two (2) medication refrigerators inspected. 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. This deficiency was evidenced by the following: 1. On 8/30/23 at 8:00 AM, during the morning medication pass, the surveyor observed the Licensed Practical Nurse (LPN #1) obtaining a blood pressure (BP) for Resident #56. The LPN#1 placed the BP cuff on the resident's right leg below the knee. The LPN #1 stated that this was the best way to obtain the BP because the resident was very thin. The LNP#1 then stated that she received an error indication on the digital BP machine, the surveyor observed her reposition the BP cuff on the same area and immediately restarted the BP machine. The LNP#1 then stated that she had obtained a BP of 187/147 and a heart rate (HR) of 63. The LPN#1 added that the resident's BP was usually high and would check the BP again later. After removing the BP cuff, the LPN#1 asked the resident if he/she wanted the Iron pill and the resident shook their head in the yes direction. The LNP#1 explained to the surveyor that the resident did not always like the Iron pill because it turned the applesauce black and would refuse to take it. On 8/30/23 at 8:07 AM, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), for Resident #56. On 8/30/23 at 8:16 AM, upon returning to the medication cart, the LPN #1 indicated on the EMAR the BP of 187/147 was obtained in the sitting position to the right arm. The LPN#1 stated she had not seen another way to enter the site the BP was taken. The surveyor reviewed the medical record for Resident #56. A review of the resident's Admission Record (AR) revealed diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (HTN)(high blood pressure). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 7/14/2023, reflected the resident had a brief interview for mental status (BIMS) score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed physician orders (PO) dated 7/25/23 for Metoprolol Tartrate oral tablet 100 MG, give one tablet by mouth two times a day for HTN-give with food hold if systolic BP less than 110 millimeter of mercury (mmhg) and HR less than 60. A review of the vital sign recordings for BP for August 2023 had the following dates which indicated the site for the BP was other; 8/3/23 at 7:14 PM, 8/4/23 at 8:43 AM, and 8/8/23 at 8:01 AM. All other entries for the site of the BP were to the right or left arm. A review of the August EMAR reflected the above PO and revealed that the vital sign recordings for 8/4/23 and 8/8/23 were entered by LPN#1. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that she was familiar with Resident #56 but had not taken a BP on the resident's leg. The UM/LPN could not speak to if that was the correct method because she had not taken the BP that way. The UM/LPN stated that a BP of 187/147 had not sounded accurate and would retake the BP to be sure. The UM/LPN added that when she would retake the BP that she would change the arm in order to get an accurate reading. The UM/LPN also stated that she used her own digital BP machine because there was only one BP machine on the unit and there were two nurses who would be administering medications at the same time, so it was easier to use her own. At that time, the UM/LPN was unable to locate the facility BP machine that was on the unit. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that a BP of 187/147 had not sounded accurate and would recommend retaking the BP and if the BP was accurate than the physician should be called. The IP explained that if an error or inaccurate reading of a BP was obtained then the nurse should retake the BP. The IP further explained that retaking a BP would mean changing the site such as going from right to left arm or if the same site was going to be used again then the nurse would have to wait at least five (5) minutes because retaking the BP on the same site could give an inaccurate reading. The IP stated that she would prefer the nurses using the facility BP machines because they were calibrated and remained in the facility. The IP further stated that when nurses used their own BP machines there was the possibility that they were not always calibrated and accurate. The IP also stated that she knew there was one BP machine on each unit and that there were additional BP machines that were being purchased. On 8/31/23 at 11:30 AM, the IP provided the surveyor with a Medication Pass Audit Tool dated 5/2/23 for LPN #1 completed by the Consultant Pharmacist (CP) which revealed that there were areas indicating a No, which meant that a technique was not performed appropriately. On 8/31/23 at 2:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, ADON and IP. The IP stated that when a medication pass audit was performed if there were indications that proper procedures were not followed then another observation and in servicing would be followed up. The DON stated that she would check if there were any other medication observations performed for LPN #1. On 9/1/23 at 8:58 AM, the DON provided the surveyor with an In-service on medication pass dated 5/10/23 completed by the ADON and signed by LPN #1 was performed and a Competency Validation: Medication Pass was completed by the ADON on 7/26/23 that indicated the LPN#1 Meets Standard for all the Performance Criteria. In addition, the DON provided a Medication Observation Form dated 6/9/23 for LPN #1 completed by the provider pharmacy which revealed that there was zero (0) % error rate. On 9/1/23 at 9:38 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the consultant for the facility for approximately a year. The CP stated that she had performed medication observations with the nurses and verified that she used a Medication Pass Audit Tool but was unable to speak to the actual form that she had completed for LPN#1. The CP stated that she would add to the form Discussed tips & tricks for med pass observation by Department of Health (DOH), etc. because as she performed the medication observation, she would review different areas to help the nurses understand what the correct procedure that should be done during the medication pass. The CP added that the completed Medication Pass Audit Tool was left with the DON and if there were issues, she would review them, and the DON would decide the next step. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that It is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner. In addition, The EMAR is the form onto which all medication orders are transcribed from physician electronic orders, from which medications are poured and administered and on which medication doses are documented. A review of the facility policy dated as reviewed 3/1/23 for Vital Signs provided by the DON reflected that Vital signs are documented in the medical records. Vital signs can be taken manually or obtained electronically. Physician's or Nurse Practitioner's should be notified about changes in vital signs including any symptoms identified, in accordance with parameters ordered. 2. On 8/30/23 at 8:05 AM, during the morning medication pass, the LPN#1 asked the resident if he/she wanted the Iron pill and the resident shook their head in the yes direction. The LNP#1 explained to the surveyor that the resident did not always like the Iron pill because it turned the applesauce black and would refuse to take it. On 8/30/23 at 8:07 AM, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 20 milligram (MG) tablet of Famotidine (Pepcid) (a medication used to treat excess stomach acid), one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), one (1) 150 MG capsule of Polysaccharide-Iron Complex (Ferrex)(a medication used to treat iron deficiency), one (1) 500 MG tablet of Ascorbic Acid (Vitamin C)(a supplement) and two (2) 325 MG tablets of Acetaminophen (Tylenol)(a medication used for pain relief) for Resident #56. On 8/30/23 at 8:14 AM, the surveyor observed the LPN #1 crush four (4) of the five (5) medications together in a pouch and then poured the crushed medications into a 30 milliliter (ML) medication cup with applesauce. The LPN#1 then opened the Ferrex capsule and mixed the contents into the medication cup that had the four (4) medications and filled the medication cup with applesauce. The applesauce then turned a black color. On 8/30/23 at 8:16 AM, the surveyor observed the LPN#1 approach the resident to administer the five (5) medications in the applesauce and the resident was shaking their head in the no direction. The LPN #1 explained that the applesauce contained the resident's medication and that it was important to take the medications. The LPN#1 scooped a spoonful of the applesauce and administered the spoonful to the resident. The resident took the spoonful and shook their head in the no direction repeatedly. The LPN#1 explained again the importance and told the resident there was just another spoonful left. The LPN#1 was unable to administer the remaining applesauce containing the medications. Upon returning to the medication cart, the LPN#1 discarded the remaining applesauce and stated that the resident had swallowed more than half of the applesauce, so she felt that the resident had received the medications. The LPN#1 then indicated on the electronic administration record (EMAR) that the resident had received the five (5) medications. The LPN#1 had not documented any refusal of medication by the resident. The surveyor reviewed the medical record for Resident #56. A review of the resident's Admission Record (AR) revealed diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking), hypertension (HTN)(high blood pressure), severe protein-calorie malnutrition and gastro-esophageal reflux disease (acid reflux). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 7/14/2023, reflected the resident had a brief interview for mental status (BIMS) score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed physician orders (PO) for the following: Famotidine tablet 20 MG, give 1 tablet by mouth in the morning for acid indigestion with a start date 1/13/23. Metoprolol Tartrate oral tablet 100 MG, give one tablet by mouth two times a day for HTN-give with food hold if systolic BP less than 110 millimeter of mercury (mmhg) and HR less than 60 with a start date of 7/25/23. Polysaccharide Iron Complex capsule 150 MG, give 1 capsule by mouth one time a day for deficiency with a start date of 1/13/23. Ascorbic Acid tablet 500 MG, give 1 tablet by mouth one time a day for supplement with a start date of 1/13/23. Acetaminophen tablet 325 MG, give 2 tablet by mouth every 6 hours as needed for pain with a start date of 2/24/23. A review of the August 2023 EMAR revealed consistency with the above POs. In addition, the EMAR had not revealed any refusals by the resident for medications. A review of the resident's progress notes had not indicated that there were any refusals of medications. A review of the resident's Interdisciplinary Care Plan had not revealed that there was a Focus area for the resident refusing medications. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that she was familiar with Resident #56 and was unaware of any medication refusals. The UM/LPN stated that when a resident refused medications the physician would be notified and there would be documentation in the progress notes. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that the nurses would have to document that a medication was refused because the whole dose would not have been administered and the physician should be notified. The IP also stated that the nurses should try to figure out why the resident was refusing medications and put interventions in place such as changing the medication if the taste were an issue or possibly changing the time. In addition, the IP provided the surveyor with a Medication Pass Audit Tool dated 5/2/23 for LPN #1 completed by the Consultant Pharmacist (CP) which revealed that there were areas indicating a No, which meant that the technique was not performed appropriately. On 8/31/23 at 2:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, ADON and IP. The IP stated that when a medication pass audit was performed if there were indications that proper procedures were not followed then another observation and in servicing would be followed up. The DON stated that she would check if there were any other medication observations performed for LPN #1. On 9/1/23 at 8:58 AM, the DON provided the surveyor with an In-service on medication pass dated 5/10/23 completed by the ADON and signed by LPN #1 was performed and a Competency Validation: Medication Pass was completed by the ADON on 7/26/23 that indicated the LPN#1 Meets Standard for all the Performance Criteria. In addition, the DON provided a Medication Observation Form dated 6/9/23 for LPN #1 completed by the provider pharmacy which revealed that there was zero (0) % error rate. On 9/1/23 at 9:38 AM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that she had been the consultant for the facility for approximately a year. The CP stated that she had performed medication observations with the nurses and verified that she used a Medication Pass Audit Tool but was unable to speak to the actual form that she had completed for LPN#1. The CP stated that she would add to the form Discussed tips & tricks for med pass observation by Department of Health (DOH), etc. because as she performed the medication observation, she would review different areas to help the nurses understand what the correct procedure that should be done during the medication pass. The CP added that if a resident was refusing a medication or was unable to receive the entire dose then the physician should be notified, and the nurses should review the possible reason the resident was refusing to possibly make a change. The CP added that the completed Medication Pass Audit Tool was left with the DON and if there were issues, she would review them, and the DON would decide the next step. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that Documents administration of medication in the EMAR immediately following administration. Notes in EMAR medications not administered (i.e., refused, etc.) and identifies reason. The policy also reflected that Documents all held or refused medications on EMAR. Uses prudent professional judgement by informing Physician in a timely manner when medications held, refused, or otherwise unavailable for administration. 3. On 8/30/23 at 8:07 AM, during the morning medication pass, the surveyor observed the LPN#1 preparing five (5) medications which included one (1) 20 milligram (MG) tablet of Famotidine (Pepcid) (a medication used to treat excess stomach acid), one (1) 100 MG tablet of Metoprolol Tartrate (Lopressor)(a medication used to treat high blood pressure), one (1) 150 MG capsule of Polysaccharide-Iron Complex (Ferrex)(a medication used to treat iron deficiency), one (1) 500 MG tablet of Ascorbic Acid (Vitamin C)(a supplement) and two (2) 325 MG tablets of Acetaminophen (Tylenol)(a medication used for pain relief) for Resident #56. On 8/30/23 at 8:14 AM, the surveyor observed the LPN #1 crush four (4) of the five (5) medications together in a pouch and then poured the crushed medications into a 30 milliliter (ML) medication cup with applesauce. The LPN#1 then opened the Ferrex capsule and mixed the contents into the medication cup that had the four (4) medications and filled the medication cup with applesauce. The applesauce then turned a black color. On 8/30/23 at 8:16 AM, the surveyor observed the LPN#1 approach the resident to administer the five (5) medications in the applesauce and the resident was shaking their head in the no direction. The LPN #1 explained that the applesauce contained the resident's medication and that it was important to take the medications. The LPN#1 scooped a spoonful of the applesauce and administered the spoonful to the resident. The resident took the spoonful and shook their head in the no direction repeatedly. The LPN#1 explained again the importance and told the resident there was just another spoonful left. The LPN#1 was unable to administer the remaining applesauce containing the medications. Upon returning to the medication cart, the LPN#1 discarded the remaining applesauce in the garbage that was attached to the medication cart. On 8/30/23 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Infection Preventionist (IP) and Assistant Director of Nursing (ADON) were the staff educators for medication pass. On 8/30/23 at 1:08 PM, the surveyor interviewed the Unit Manager (UM)/LPN who stated that when any medication had to be disposed there was a medication disposal system on each medication cart. The UM/LPN added that if the medication were a controlled medication, then the DON or ADON would be given the controlled medication for a witnessed destruction. The surveyor with the UM/LPN looked in the medication cart that the UM/LPN was using and were unable to find the medication disposal system in that medication cart. The UM/LPN stated that she would have to get one for the cart. On 8/30/23 at 1:16 PM, the LPN#1 showed the surveyor that she had a medication disposal system on the medication cart that she was using. The LPN #1 stated that because the medications were crushed for Resident #56, she could throw them in the garbage that was attached to the medication cart. On 8/31/23 at 9:30 AM, the surveyor interviewed the IP who stated that she was employed at the facility approximately less than two (2) months and could speak to medication pass techniques because she helped with orientation and educating the nurses on medication pass techniques. The IP stated that when the nurses had to dispose of a medication that was not a controlled medication then they would use the medication disposal system that was on each cart. The IP further explained that the safest method for medication disposal even if the medications were crushed was to use the medication disposal system. On 9/1/23 at 9:38 AM, the surveyor interviewed the CP via the telephone who stated that the nurses were to use the medication disposal system when a medication needed to be discarded. The CP added that even if the medication was crushed that the medication disposal system should be used and thought there was one on each medication cart. A review of the undated facility policy for Discarding and Destroying Medications provided by the DON reflected that Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. 4. On 8/28/23 at 11:42 AM the surveyor observed Resident #75 in bed, the surveyor attempted to interview the resident, but the resident was unable to answer any questions. The surveyor reviewed the medical record for Resident #75. A review of the resident's AR revealed diagnoses which included dementia, neurocognitive disorder with [NAME] bodies (a mental health disorder that primarily affect cognitive abilities), syncope and collapse and HTN. A review of the admission MDS, an assessment tool used to facilitate the management of care, with an assessment reference date of 8/30/2023, reflected the resident had a BIMS score of zero (0) out of 15, indicating that the resident had a severely impaired cognition. A review of the August and September electronic medication records (EMAR) revealed a PO dated 8/23/23 for Midodrine Hydrochloride oral tablet 5 MG, give 5 MG by mouth every 8 hours (Q8H) as needed (PRN) for low BP, give if BP less than 110. There was no documentation that the medication was administered. A review of the vital sign recordings for the resident's BP for August 2023 had the following dates with BP recordings that had a BP less than 110; on 8/29/23 at 5:26 PM 82/52, on 8/30/23 at 7:47 PM 107/70 and on 9/1/23 at 10:40 AM 107/60. Further review of the August and September EMARs revealed a PO dated 8/24/23 for Metoprolol Tartrate (Lopressor) (a medication used to slow the heart rate and lower BP). oral tablet 25 MG, give 25 MG by mouth two times a day for HTN hold for systolic BP less than 110 or HR less than 60. There was documentation on 8/29/23 that the BP was 82/52 and on 8/30/23 the BP was 107/70 and the Lopressor medication was held. There was documentation on 9/1/23 that the Lopressor medication was held but no documentation of the BP results. On 9/5/23 at 11:23 AM, the surveyor interviewed LPN #2 who stated that she was the medication nurse for Resident #75. The LPN #2 stated that the resident had been readmitted at the end of August. The surveyor with the LPN#2 reviewed the EMAR regarding the PRN Midodrine and the LPN#2 stated that if the resident's BP was less than 110 then the Midodrine should have been administered. The LPN#2 stated that she had not administered the Midodrine because she had not had a BP less than 110 for the resident. The LPN#2 acknowledged that the PRN Midodrine had no documentation as being administered and also acknowledged that there was documentation of BP's less than 110. The LPN#2 also stated that the resident had no PO for a BP to be obtained every 8 hours (Q8H) and that a BP was obtained twice a day for the medication Lopressor. On 9/6/23 at 9:49 AM, the surveyor interviewed the DON who stated that she thought the PO for Midodrine was a PRN PO and was allowed to be administered three times within a 24-hour period and that a BP was not needed Q8H. On 9/6/23 at 10:05 AM, the surveyor further interviewed the DON. The surveyor with the DON reviewed the EMAR for Resident #75. The DON acknowledged that the Midodrine was not administered when the BP was less than 110. The DON also acknowledged that when the BP was taken for the Lopressor PO and was less than 110, the Lopressor was held but there was no indication to administer the PRN Midodrine. The DON acknowledged that the PO for PRN Midodrine should be clarified. A review of the facility policy dated as reviewed 6/22/23 for Medication Administration and Documentation provided by the DON reflected that It is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner. In addition, the policy reflected, Monitors vital signs when appropriate prior to medication administration. Administers med according to parameters ordered by physician (if any). 37791 5. On 8/30/23 at 11:25 AM, the surveyor inspected the 3rd floor medication room refrigerator in the presence of Licensed Practical Nurse (LPN#1). The surveyor observed a narcotic lock box that contained five syringes of Ativan (medication of anxiety) 0.5 mg topical gels for Resident #88. The surveyor observed the narcotic box was affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#2 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included hypertension (elevated blood pressure), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activity), and mood disorder (general emotional state or mood is distorted or inconsistent and interferes with your ability to function). A review of the Order Summary (OS) (physician's order) dated 3/8/23 revealed a physician order (PO) for Ativan 0.5mg, apply to the inner wrist topically every 8 hours as needed for severe agitation. A further review of the PO revealed that the medication was discontinued on 3/23/23. A review of the March 2023 electronic Medication Administration Record (eMAR) revealed an order dated 3/8/23, for Ativan 0.5mg (Lorazepam), apply to inner wrist topically every 8 hours as needed for severe agitation with a discontinued date of 3/23/23. On 3/30/23 at 12:30 PM, the surveyor inspected the 3rd floor medication room refrigerator narcotic box in the presence of LPN#1. LPN#1 acknowledge that the Ativan gel was discontinued and should be remove from active medication and will be destroyed per facility policy. b). On 8/30/23 at 11:35 AM, the surveyor inspected the 2nd floor medication room refrigerator in the presence of LPN#2. The surveyor observed a narcotic lock box that contained twenty-six (26) capsules of Marinol (appetite stimulant) 2.5 mg capsules for Resident #64. The narcotic box was observed affixed to the medication refrigerator, but the narcotic box was unlocked. The surveyor interviewed LPN#2 who acknowledge that the narcotic box was unlocked, and she further stated that it was the facility policy that all narcotics must be double lock. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses that included hypertension (elevated blood pressure), metabolic encephalopathy (chemical imbalance of the brain), and failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition). A review of the Order Summary Report (OSR) (physician's order) dated 7/17/23 revealed PO for Marinol (Dronabinol) 2.5mg, give 1 capsule by mouth two times a day for appetite stimulant. A review of the August 2023 eMAR revealed an order dated 07/17/23, for Marinol (Dronabinol) 2.5mg, give 1 capsule by mouth two times a day for appetite stimulant with a discontinued date of 8/18/23. A review of a Progress Note dated 8/18/23 at 5:10 PM revealed that Resident #64 was discharged home. On 3/30/23 at 12:30 PM, the surveyor inspected the 2nd floor medication room refrigerator narcotic box in the presence of LPN#2. LPN#2 acknowledge that the Marinol 2.5 mg belonged to Resident #64 and that the resident was discharged from the facility. The surveyor observed LPN#2 place the Marinol back in the narcotic box and then lock the box. LPN#2 stated that she will destroy the medication during shift change because she will need another nurse to witness the destruction. On 8/31/23 at 1:00 PM, the surveyor discussed the above concerns with the Administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for Controlled Medications Accountability and storage that was dated 01/07/23 and was provided by the DON included the following: Narcotic ordered for residents are stored in a locked narcotic box of the medication cart. If the narcotic medication is to be refrigerated, the narcotic is stored in the locked box within the refrigerator. The refrigerator has a lock on the door as well. A review of the facility's policy Medication Storage that was dated 05/26/23 and was provided by the DON included the following: 4. Any discontinued medications should be removed from the refrigerator, med room or med cart and returned to pharmacy or discarded no later than 14 days. A review of the facility's policy Discarding and Destroying Medications that was undated and was provided by the DON revealed the following: 5 (c). Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by a resident. NJAC 8:39-11.2 (b), 29.2(a), 29.2 (d), 29.3(a)(5), 29.4(g)

Based on observation, interview, and record review it was determined that the facility failed to provide a homelike and dignified dining experience to residents on 2 of 2 nursing units on 3 consecutive days. The deficient practice was evidenced by the following. The surveyor observed the lunchtime meal at the following locations and days/times: Second floor dining room - 8/28/23 at 12:00 PM; 8/29/23 at 12:17 PM; 8/30/23 at 11:57 AM. Third floor dining room - 8/28/23 at 11:45 AM; 8/29/23 at 12:19 PM; 8/30/23 at 12:00 PM. During each of the observations, staff served residents' meals on plastic trays. The trays remained in place throughout the residents' mealtime. Additionally, staff placed each plate dome lid upside down on residents' tables and used them as a trash container for wrappers and debris from the meal tray. The dome lids remained in place on the tables throughout the mealtime. On 8/30/23 at 12:02 PM the surveyor interviewed the Licensed Practical Nurse (LPN) who supervised the second floor dining room. The LPN stated it was the practice of the facility to leave meal plates on the plastic trays and to leave the dome lids on the table during the entire dining period. On 8/30/23 at 1:26 PM the surveyor told the Director of Nursing (DON) and the Administrator of observed concerns with dining practices that were not homelike or dignified. On 8/31/23 at 10:05 AM the DON stated to the surveyor leaving plates on plastic serving trays and using dome lids for trash was a dignity concern. On 9/6/23 the DON provided the surveyor with the facility Policy and Procedure for Meal Service, last reviewed 1/10/23. The document did not contain information for steps to set up the meal in a dignified and homelike manner. NJAC 8:39-4.1(a)12

Based on interview and record review, it was determined that the facility failed to complete quarterly and comprehensive Minimum Data Set (MDS) assessments in a timely manner for 5 of 23 residents reviewed (Resident #8, #39, #89, #100 and #254). The MDS is an assessment tool used to guide the resident's plan of care. This deficient practice was evidenced by the following: 1. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #8 which revealed the following. The annual MDS indicated an observation end date or assessment reference date (ARD) of 7/21/23. The status of the annual MDS was listed as in progress.The MDS should have been completed by the 14th day (8/4/23). The MDS was 26 days overdue on the day of the surveyor's record review (8/30/23). 2. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #39 which revealed the following. The quarterly MDS indicated an ARD of 7/21/23. The status of the quarterly MDS was listed as in progress. The MDS should have been completed by the 14th day (8/4/23). The MDS was 26 days overdue on the day of the surveyor's record review (8/30/23). 46889 3. On 08/28/23 at 11:26 AM, the surveyor observed Resident #89, awake, alert lying in bed, responding to the surveyor by nodding his head. The surveyor reviewed the medical records of Resident #89, which revealed the following: Resident #89 was admitted to the facility on [DATE] and readmitted with diagnoses that included but were not limited to Acute and Chronic Respiratory Failure and Dysphagia (difficulty in swallowing). The Admission MDS (AMDS), dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating that the resident's cognition is severely impaired. Resident #89 was observed to have an AMDS with an ARD of 3/22/2023 and was due to be submitted no later than 4/04/2023. The MDS was not submitted until 4/06/2023. 4. Resident #100 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus (increased sugar level) with diabetic chronic kidney disease. The AMDS, dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, indicating that the resident's cognition is intact. Resident #100 was observed to have an AMDS with an ARD of 7/24/2023 and was due to be submitted no later than 8/06/2023. The MDS was not submitted until 8/23/2023. 48781 5. Resident #254 was admitted on [DATE]. The Comprehensive/5 Day MDS had an ARD of 8/16/23 which was completed late on 8/30/23. On 8/31/23 at 2:00 PM, a Validation Report was received from the Regional MDS Coordinator which confirmed the comprehensive assessment was completed late. On 8/31/23 at 2:05 PM, the survey team spoke to the Director of Nursing (DON) and the Administrator regarding late MDS submissions. The DON stated a new MDS Coordinator was hired, however, did not show up for work. A second was hired but has not yet started. The DON stated a Quality Assurance Performance Improvement (QAPI) was started in April 2023 for the timely completion of MDS assessments. The DON voluntarily provided information to the survey team regarding the facility's quarterly QAPI meetings and the MDS submission compliance rates. The surveyors reviewed the facility's QAPI for Timely MDS Completion/Transmission, reporting period April 2023 to July 2023; reviewed 7/28/23 and 8/23/23; next review date 9/29/23. The April 2023 compliance rate of 95.7% had dropped to 31.2% in July 2023. The DON provided the surveyors with the facility MDS policy on 8/31/23. Procedure #4 indicated the RN MDS Coordinator monitors the completion of the scheduled assessments including the Care Area assessments, signs and dates when the MDS is completed. NJAC 8:39-11.2(e)

Complaint # NJ00155894 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered Care Plan (CP) to address the needs for a resident with Diabetes, Epilepsy (a disorder that causes seizures), and that required oxygen (Resident #104), 1 of 24 residents reviewed for CP. This deficient practice was evidenced by the following: According to the Admission Record, Resident #104 was admitted to the facility in May of 2022, with diagnoses that included but were not limited to: traumatic subdural hemorrhage (caused by a blow to the head or fall, causing bleeding inside the brain), Epilepsy, dependence on supplemental oxygen, and Type 2 Diabetes Mellitus. A review of the Admission Minimum Data Set (MDS), an assessment tool dated 5/10/22, revealed a Brief Interview for Mental Status of 00 indicating severe cognitive impairment. Further review of the MDS revealed the resident was total dependence for activities of daily living, had an Active Diagnoses of Diabetes Mellitus, Seizure Disorder or Epilepsy, Respiratory Failure, and dependence of supplemental oxygen. A review of the physician order summary report for May 2022 revealed a physician's order for OXY* Oxygen inhalation (via nasal cannula @-2 lpm (liters per minute)) every shift check every shift; Keppra Tablet 500 MG (milligrams) (levETIRAcetam) give 1 tablet via G-tube two times a day for seizures; HumaLOG Solution 100 unit/ML (milliliters) (Insulin Glargine) inject as per sliding scale . subcutaneously every 6 hours for dm (diabetes); Lantus Solution 100 unit/ML (Insulin Glargine) inject 10 unit subcutaneously at bedtime for dm. A review of the facility provided CP initiated 05/07/22, revealed a Focus for Resident #104; at risk for falls r/t (related to) impaired safety awareness, impaired mobility. Combative behavior. Hx (history) of repeated falls w/ subdural hematoma .Date Initiated: 05/07/2022. Further review of the CP, did not reveal a Focus for epilepsy, Type 2 Diabetes, or supplemental oxygen use. On 08/31/23 at 1:21 PM, during an interview with the surveyors, the Licensed Practical Nurse (LPN) stated that the purpose of the CP was to know what the resident's goals were and what the resident was capable of doing. She then stated that the focus of the CP was guided toward the resident's diagnoses. The surveyor asked the LPN if she would expect to see a CP for a resident with diagnoses of Diabetes, Epilepsy, and oxygen use, she stated, yes, they should all be on the CP. On 09/01/23 at 9:28 AM, during a meeting with the surveyor, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated that the purpose of the CP was to actually meet the needs of the patient and to makes sure the interdisciplinary team, the patient and the responsible party were on same page. The DON stated that it would include the MDS and medical diagnoses. The surveyor asked the DON and the ADON, if they would expect to see a CP for a resident with diagnoses of Diabetes, Epilepsy, and oxygen use, they both stated, yes they should. The surveyor asked the DON and the ADON to review the facility provided CP, for resident #107, for Diabetes, Epilepsy, and/or oxygen use. The DON stated, sad to say, I cannot find those 3 items. They both confirmed that all 3 of the above items should have been addressed on the CP. A review of the facility's policy Comprehensive Care Plan with a last review date of 2/1/23, revealed: Policy Statement: A. A comprehensive care plan for each resident shall be developed and initiated on admission at this facility utilizing and interdisciplinary team approach. The comprehensive care plan will be individualized, defining the problems/needs identified from each discipline's assessment, attainable goals, and interventions. B. The resident's initial comprehensive care plan shall be completed by all disciplines within 14 days of admission. Purpose: A. To provide a system for all disciplines involved to direct resident care to: Identify and assess each resident's problems/needs. Develop, document, and implement a coordinated plan of care. Evaluate the effectiveness of the plan of care and modify plan as needed. N.J.A.C 8:39-11.2 (d) (e) (1) (2) (3)

Based on interview and record review it was determined that the facility failed to perform accurate assessments regarding bed mobility and transfer status for a resident who is dependent on staff. The resident developed Stage II pressure ulcers in the facility. This deficient practice was identified in 1 of 3 residents, Resident #8 as evidenced by the following: During the initial tour of the facility on 4/2/13 at 9:30 a.m. the tour nurse identified Resident #8 as staff dependent for care, bed mobility and transfers with a facility acquired pressure ulcer on the right buttock from "shearing." The tour nurse further stated that the shearing most likely had occurred when the resident had been repositioned or transferred. The tour nurse stated that the resident required the assistance of 2 staff members for bed mobility and required a Hoyer lift for transfers since admission. On 4/2/13 at 12:30 p.m. the surveyor reviewed the medical record of Resident #8 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment tools (MDS) of 9/12/12, 10/11/12 and 1/11/13 documented required the total assistance of 1 staff member for bed mobility and transfers. On 4/3/13 at 11:15 a.m. the surveyor questioned the Charge Nurse regarding the discrepancy between what the surveyor had been told on tour and the MDS concerning the method of transfer for Resident #8. The Charge Nurse was not aware of the inaccurate assessments and confirmed that the resident required the total assistance of 2 staff members for bed mobility and Hoyer lift transfers. On 4/3/13 at 2:00 p.m. the Director of Nursing (DON) told the surveyor that the DON was not aware of the inaccurate assessments and confirmed that the resident required the total assistance of 2 staff members for bed mobility and Hoyer lift transfers. On 4/4/13 the DON provided the surveyor with "Correction Requests" to the Minimum Data Sets previously mentioned. Refer to F314 NJAC 8:39- 11.2(e)(1)

Based on interview and record review it was determined that the facility failed to develop and revise care plan interventions to prevent recurrence of shearing incidents for a staff dependent resident. This resident developed facility acquired stage II pressure ulcers. This deficient practice was identified in 1 of 3 residents, Resident #8, reviewed for pressure ulcers and was evidenced by the following: During the initial tour of the facility on 4/2/13 at 9:30 a.m. the tour nurse identified Resident #8 as staff dependent for care, bed mobility and transfers with a facility acquired pressure ulcer on the right buttock from "shearing." The tour nurse further stated that the shearing most likely had occurred when the resident had been transferred or repositioned. The tour nurse stated that since admission the resident required the assistance of 2 staff members for bed mobility and required a Hoyer lift for transfers. On 4/2/13 at 12:30 p.m. the surveyor reviewed the medical record of Resident #8 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Progress (IDP) Notes noted the following: On 11/18/12 at 7 a.m. "Shearing noted on L buttock, measuring 1.5 cm x 1 cm. [MEDICATION NAME] applied and tx ordered, family aware." On 11/21/12 "left buttock shearing wound resolved at this time- tx discontinued. Intact water blister on the R proximal and R distal thigh seen by the wound doctor during wound rounds. Will apply dry protective dressing and will offload blisters." On 1/31/13 7:30 a.m. "While CNA is doing AM care, CNA noted blister on R hip and shearing on L buttock." On 3/24/13 at 8:00 a.m. "While CNA is doing AM care, abrasion on L lower buttock noted, measured 0.2cm x 0.2 cm., abrasion on R lower buttock noted, measured 0.3 cm x 0.3 cm." On 3/25/13 at 8:00 a.m. "Reassessment of her R and L buttocks was done and noted it is reopened old shearing." A review of the 8/30/12 care plan identified the problem "needs total assistance with ADL's." Some of the identified interventions included: "Manual assistance with transfers in and out of bed x 2 persons assistance" and "OOB via Hoyer lift x 2 persons assistance." On 8/30/12 the care plan identified that Resident #8 was considered at "high risk for skin breakdown related to decreased mobility and incontinency." Some of the identified interventions included: "biweekly skin assessment; pressure relieving devices to bed and chair; turn and reposition every 2 hours; administer wound treatment as ordered; offload wounds at all times and heel pads to both heels." On 1/31/13 and 3/24/13 the care plan was updated to identify shearing wounds as a problem. However, the interventions were not revised to prevent recurrence of shearing incidents. On 4/4/13 at 12:30 p.m. the Charge Nurse stated to the surveyor that the resident had been a Hoyer lift transfer since admission to the facility. The Charge Nurse was not aware that the care plan had identified the resident to be a manual assist of 2 for transfer. On 4/4/13 at 1:00 p.m. the Director of Nursing (DON) told the surveyor that the Charge Nurse was responsible for updating and revising the care plan. The DON stated that care plans were to be updated as problems were identified. The DON was not aware that this had not been done for Resident #8. Refer to F 314 NJAC 8:39- 11.2 (e)(2)

Based on observation, interview and record review it was determined that the facility failed to protect the skin of a resident from recurrent shearing incidents and who developed facility acquired stage II pressure ulcers to the buttocks. While the survey was in progress, a new facility acquired left buttock stage II pressure ulcer was discovered by the surveyor. This deficient practice was identified in 1 of 3 residents reviewed for pressure ulcers, Resident #8 as evidenced by the following: During the initial tour of the facility on 4/2/13 at 9:30 a.m. the tour nurse identified Resident #8 as staff dependent for care, bed mobility and transfers. Also that the resident had a facility acquired pressure ulcer on the right buttock from "shearing." The tour nurse further stated that the shearing most likely had occurred when the resident was repositioned or transferred. The tour nurse stated that since admission, the resident required the assistance of 2 staff members for bed mobility and a Hoyer lift for transfers. On 4/2/13 at 12:30 p.m. the surveyor reviewed the medical record of Resident #8 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a stage III pressure ulcer to the proximal right buttock (healed 12/6/12) and a stage II pressure ulcer to the distal right buttock (healed 9/20/12). A review of the Minimum Data Set assessment tools (MDS) of 9/12/12, 10/11/12 and 1/11/13 documented that the resident required the total assistance of 1 staff member for bed mobility and transfers. There was a correction made on 4/3/13 while the survey was in progress to reflect that the resident required the total assistance of 2 staff members for bed mobility and transfers. Surveyor review of the Interdisciplinary Progress (IDP) Notes revealed the following: On 11/18/12 at 7 a.m. "Shearing noted on L buttock, measuring 1.5 cm x 1 cm. [MEDICATION NAME] applied and tx ordered, family aware." On 11/21/12 "left buttock shearing wound resolved at this time- tx discontinued. Intact water blister on the R proximal and R distal thigh seen by the wound doctor during wound rounds. Will apply dry protective dressing and will offload blisters." (resolved 11/28/12). On 1/31/13 7:30 a.m. "While CNA is doing AM care, CNA noted blister on R hip and shearing on L buttock." (resolved 3/14/13). On 3/24/13 at 8:00 a.m. "While CNA is doing AM care, abrasion on L lower buttock noted, measured 0.2cm x 0.2 cm., abrasion on R lower buttock noted, measured 0.3 cm x 0.3 cm." On 3/25/13 at 8:00 a.m. "Reassessment of her R and L buttocks was done and noted it is reopened old shearing." (left buttock resolved 3/28/13). A review of the "Non-Employee Incident Report" for the above mentioned incidents revealed the following: The 11/20/12 report indicated that the resident required the assistance of 2 staff members for transfer. However, the statement obtained from the Certified Nurse Aide (CNA) revealed that the resident only required 1 assist for transfers. The "Conclusionary Statement" revealed "staff has to use diaper which is not too tight; make sure its her size; Hoyer transferring 2 assist for safety; Use drawsheet to pull." The 1/31/13 report indicated that "sensitive skin" was the probable cause for the incident. The steps identified to prevent recurrence were "repositioning q 2 hrs, treatment to shearing and blister twice daily." The "Conclusionary Statement" was that staff needed to be "extra careful in using diapers, not to apply too tight. Elevate both feet with 2 pillows to prevent from sliding down in bed that may cause shearing and blisters." The 3/24/13 report revealed "this is not abrasion, it is old shearing that reopened. Her skin is very sensitive, extra care is needed. Use draw sheet for repositioning in bed and 2 persons are necessary for transfer." A review of the "Wound Care Specialist Evaluation from 1/31/13 to 3/14/13 identified the "etiology" of the left buttock wound to be from "shear." A review of the 8/30/12 care plan identified the problem "needs total assistance with ADL's." Some of the identified interventions included: "Manual assistance with transfers in and out of bed x 2 persons assistance" and "OOB via hoyer lift x 2 persons assistance." On 8/30/12 the care plan identified "high risk for skin breakdown related to decreased mobility and incontinency" as a problem. Some of the identified interventions included: "biweekly skin assessment; pressure relieving devices to bed and chair; turn and reposition every 2 hours; administer wound treatment as ordered; offload wounds at all times and heel pads to both heels." On 1/31/13 and 3/24/13 the care plan was updated to identify shearing wounds as a problem. However, the interventions were not revised to prevent the recurrence of shearing incidents. On 4/2/13 at 11:00 a.m. the CNA told the surveyor that the resident was manually transferred out of bed to the chair with the assistance of 2 staff members. The CNA stated that a Hoyer lift was not consistently utilized since the resident was not heavy. On 4/2/13 at 11:15 a.m. the Charge Nurse (CN) stated to the surveyor that the resident required the assistance of 2 staff members for bed mobility and transfers are with a Hoyer lift since admission to the facility. The CN further stated that the staff did not consistently utilize the Hoyer lift to transfer the resident. The CN stated that she had not observed the staff with the actual repositioning/transferring of Resident #8 to ensure proper methods were being utilized to prevent incidents of shearing. On 4/4/13 at 10 a.m. the surveyor in the presence of the nurse observed the resident's skin. A right buttock stage II pressure ulcer was noted which measured 0.4 centimeters (cm) x 0.4 cm with redness surrounding the ulcer which measured 5 cm x 3 cm. While the survey was in progress, a new left buttock stage II pressure ulcer was noted by the surveyor which measured 0.3 cm x 0.3 cm with redness surrounding the ulcer which measured 2 cm x 1 cm. On 4/4/13 at 1:00 p.m. the Director of Nursing (DON) stated to the surveyor that shearing was not related to pressure ulcers. The DON stated that shearing usually occurred during transfers or repositioning of a resident because of friction. The DON further stated that shearing had not been identified as an issue at the facility. The DON stated that inservicing regarding proper transfer/bed mobility technique to prevent shearing incidents had not been initiated with regards to the resident. The DON further stated that she had not observed the staff during actual repositioning/transferring of the resident to ensure that proper technique was being followed to prevent shearing. A review of the facility's "Pressure Sore Prevention" policy (no date) revealed the following: "Shearing Force Relief Devices: Pillows to support soles of feet to decrease shearing force when head of bed must be elevated; draw sheet to position resident higher in bed to prevent shearing; avoid placing chux directly on skin, as this retains moisture." There was no documented evidence that the policy had been consistently followed. NJAC 8:39-27.1(e)