Every finding on record at Alaris Health at Cedar Grove

COMPLAINT #2734880Based on observation, interview, medical record review, and review of pertinent facility documentation on 4/7/26 and 4/8/26, it was determined that the facility failed to consistently auscultate (listen for sounds) for Resident #5's bowel sounds prior to the administration of the resident's medications and tube feeding (a form of nutrition that is delivered into the digestive system through a tube). The deficient practice was identified for 1of 1 resident reviewed (Resident #5) and was evidenced by the following: Resident #5 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #5 was admitted to the facility with diagnoses that included but were not limited to: dementia, chronic kidney disease, and gastro-esophageal reflux disease. Review of Resident #5's comprehensive Assessment Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/9/25, indicated that Resident #5 was rarely/never understood and was severely cognitively impaired. Further review of the MDS revealed that the resident required a feeding tube for nutrition. A review of Resident #5's care plan (CP) indicated that Resident #5 had a focus related to the resident's reliance on tube feedings (TF) to meet their nutritional needs. Interventions for this focus, indicated that the resident was to be provided with TF and flushes as ordered. A review of Resident #5's Medication Administration Record (MAR) for January 2026 revealed that Licensed Practical Nurse (LPN #1) administered the following medications through tube feed to the resident on 1/28/26 at 9 AM:- Ascorbic Acid Liquid 500 MG/5ML- BusPIRone HCl Tablet 5 MG- QUEtiapine Fumarate Tablet 200 MG- Valproic Acid Oral Solution 250 MG/5ML- Ativan Oral Tablet 0.5 MG The MAR further revealed that Resident #5 also received the following on 1/28/26 at 10 AM:- Enteral Feed Order five times a day flush tube with 150ml of H2O after every bolus feed- Enteral Feed Order for Jevity 1.5 liquid via bolus feeding, five times a day. The MAR further revealed that LPN #1 signed off on the tube feed as administered to the resident on 1/28/26 at 7 AM as follows:-Enteral Feed Order flush tube with 30 ml [water] before and after each med pass and after completion of formula. A review of Resident #5's progress notes (PN) revealed a PN written by the Nurse Practitioner (NP), and dated 1/28/26 at 12:40 PM, which stated, .severe abdominal distention and absence of bowel sound on auscultation. A review of Resident #5's New Jersey Universal Transfer Form revealed that on 1/28/26, Resident #5 was transferred to a hospital for further evaluation due to altered mental status and abdominal distention. An interview was conducted on 4/7/26 at 12:21 PM with LPN #2 who stated that residents with enteral feeding (Tube feeding) should be checked for the presence of bowel sounds, and that if there were no bowel sound present, the tube feeding should be held and a supervisor notified.During a follow-up interview with the LPN #2 on 4/7/26 at 1:33 PM, he stated that he assessed residents for bowel sounds once a shift. He further stated that he recalled Resident #5, but that he did not remember any specifics related to the resident's care. An interview was conducted on 4/7/26 at 1:53 PM with LPN #1. She stated that there was no protocol for residents with TF to be assessed for bowel sounds, and that she assessed residents for bowel sound based on her own independent understanding. LPN #1 confirmed that she was assigned to Resident #5 on the morning of 1/28/26, and that she administered the resident's medications and feeding through the FT. She further stated that when she went back to the resident's room, [she could not recall the time], she heard the resident groaning, and that she informed the NP who was on the unit at the time. LPN #1 stated that she did not recall checking Resident #5's bowel sounds the morning of 1/28/26. An interview was conducted on 4/7/26 at 2:24 PM with the Registered Nurse Unit Manager (RN/UM). She stated that although she expected nurses to assess residents with tube feed for bowel sounds prior to administration of medications and/or nutrition, checking for bowel sounds were not included in the physician orders or a part of facility policy. She further stated that the presence of bowels sounds meant that the bowel was functioning which was important to assess in residents that required TF. An interview was conducted on 4/8/26 at 11:12 AM with the NP. The NP stated that she expects nursing staff to listen for bowel sounds prior to administering any TF. She further stated that checking bowel sound was important to ensure that the bowel is functioning, especially for those residents that cannot express their needs. An interview was conducted via telephone on 4/8/26 at 11:55 AM with the Medical Director (MD) who stated that it was important to ensure that bowel functionality was present through the auscultation of bowel sounds. The MD stated that he expected that staff follow all policies and/or protocols that are in place. An interview was conducted on 4/8/26 at 2 PM with the Director of Nursing (DON) who provided a copy of the facility's Pre-enteral Administration Protocol. She stated that the protocol was supposed to be implemented prior to the administration of any medication and/or feeding through the TF. The DON stated that the protocol included auscultating for the presence of BS. When the surveyor informed the DON of what nursing staff stated regarding facility protocol and not auscultating for bowel sound before medication/feeding administration, the DON stated that the protocol was included in all new hire and annual trainings. She further stated, they will have to be re-inserviced. A review of the facility's policy titled: (use the title of policy) Tube Feeding, Medication Administration via revised 7/2025, revealed that tube placement and patency were to be verified, per facility protocol. A review of the facility's protocol titled: Pre-Enteral Administration (Medication and Feeding), revised 7/2025, revealed that the protocol was developed to ensure that enteral nutrition and mediations were administered safely. The protocol further described the steps on how to assess a resident, which included auscultating for bowel sounds.N.J.A.C. 8:39-27.1(a)

Based on interviews, review of medical records and other pertinent facility documentation on 4/7/26, and 4/8/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice when staff failed to consistently bladder and bowel continence in the Documentation Survey Report v2 (DSR). This deficient practice was identified for 3 of 3 residents reviewed (Resident #1, Resident #2, & Resident #5) and was evidenced by the following:a). A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: traumatic subdural hematoma, gastrotomy status, and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). Review of Resident #1's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 3/21/26, indicated that Resident #1 was rarely/never understood. Further review of the MDS revealed that the resident was dependent on staff in all areas of ADL care. A review of Resident #1's care plan (CP) indicated that Resident #1 had a focus related to the resident having a self-care performance deficit. A review of Resident #1's Documentation Survey Report v2 (DSR) for January 2026 included that the following should be documented during each shift. There was no evidence of documentation on the following dates and shifts: -Bladder Continence:1/1/26 Evening & Night shifts1/16/26 Day shift1/19/26 Day shift1/25/26 Evening & Night shifts -Bowel Continence and Movements:1/1/26 Evening & Night shift1/16/26 Day shift1/19/26 Day shift1/25/26 Evening & Night shifts1/31 /26 Night shift b). A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: protein-calorie malnutrition, gastrotomy status, and hypertension. Review of Resident #2's comprehensive MDS, dated [DATE], indicated that Resident #2 was rarely/never understood. Further review of the MDS revealed that the resident was dependent on staff in all areas of activities of daily living (ADL) care. A review of Resident #2's care plan (CP) indicated that Resident #2 had a focus related to the resident having a self-care performance deficit. A review of Resident #2's Documentation Survey Report v2 (DSR) for January 2026 included that the following should be documented during each shift. There was no evidence of documentation on the following dates and shifts: -Bladder Continence:1/1/26 Night shift1/2/26 Night shift1/11/26 Day shift1/12/26 Night shift1/15/26 Night shift1/16/26 Day & Night shifts1/19/26 Night shift1/20/26 Day & Night shifts1/22/26 Night shift1/27/26 Day shift1/31/26 Night shift -Bowel Continence and Movements:1/1/26 Night shift1/2/26 Night shift1/11/26 Day shift1/12/26 Night shift1/15/26 Night shift1/16/26 Day & Night shifts1/19/26 Night shift1/20/26 Day & Night shifts1/22/26 Night shift1/27/26 Day shift1/31/26 Night shift c). A review of the admission Record revealed that Resident #5 was admitted to the facility with diagnoses that included but were not limited to: dementia, chronic kidney disease, and gastro-esophageal reflux disease. Review of Resident #5's comprehensive Assessment Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 11/9/25, indicated that Resident #5 was rarely/never understood. Further review of the MDS revealed that the resident was totally dependent on staff to provide toileting hygiene and required partial assistance with toilet transfers. A review of Resident #5's care plan (CP) indicated that the resident had a focus related to incontinence and that the resident was totally dependent on staff to assist with toileting needs. A review of Resident #5's New Jersey Universal Transfer Form revealed that on 1/28/26 Resident #5 was transferred to a hospital for further evaluation due to, altered mental status and abdominal distention. A review of Resident #5's Documentation Survey Report v2 (DSR) for January 2026 included that the following should be documented during each shift. There was no evidence of documentation on the following dates and shifts: -Bladder Continence:1/4/26 Day shift1/11/26 Day shift1/16/26 Day shift1/19 /26 Day shift1/20/26 Day shift1/22/26 Night shift1/24/26 Day shift1/25/26 Day, Evening, & Night shifts1/27/26 Day shift -Bowel Continence and Movements:1/4/26 Day shift1/11/26 Day shift1/16/26 Day shift1/19/26 Day shift1/20/26 Day shift1/22/26 Night shift1/24/26 Day shift1/25/26 Day, Evening, & Night shifts1/27/26 Day shift An interview was conducted on 4/8/26 at 11:12 AM with the Nurse Practitioner (NP) who stated that all care provided by staff should be documented in each resident's medical record. She further stated that that documentation was important to ensure that everyone was aware of a resident's status. An interview was conducted via telephone on 4/8/26 at 11:55 AM with the Medical Director (MD) who stated that monitoring a resident's bowel and bladder function was an important factor that confirmed that the resident's body was functioning properly. He further stated that he expected that documentation be fully completed and accurate. An interview was conducted on 4/8/26 at 1:01 PM with the Certified Nursing Assistant (CNA #1) who stated that all care provided should be documented in each resident's electronic medical record to confirm that it was done. She further stated that there are times when they get so busy providing the care that they forget to document. An interview was conducted on 4/8/26 at 2 PM with the Director of Nursing (DON) who stated that CNAs were responsible for providing and documenting all ADL care in each resident's medical record. She expected that there would be no blanks. The DON further stated that signing off was their way of showing proof that care was provided. A review of the facility's Incontinence Care Management Policy revised 07/2025, revealed that residents would be provided with .individualized and clinically appropriate care. The policy further revealed that staff would document the care provided in each resident's medical record. A review of the facility's Documentation, General policy, dated 07/2025, revealed that the facility would ensure that all care provided to residents would be documented .accurately, timely, and completely. N.J.A.C. 8:39-27.1(a)

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to maintain and provide readily accessible medical documents for 1 (one) of 32 residents (Resident #4) reviewed for medical records. This deficient practice was evidenced by the following: On 9/11/25 at 11:42 AM, the surveyor observed Resident #4 in bed, awake, and able to answer the surveyor's inquiry. On 9/16/25 at 10:54 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #4, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #4 was admitted with diagnoses that included but were not limited to diabetes mellitus (increased blood sugar level) due to underlying conditions. A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) on 7/19/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. A review of medical records revealed that there was no documented evidence that the Physician Progress Notes (PPN) were done by the primary physician or by an alternating advanced practice nurse from February 2025 through July 2025. On 09/15/2025 at 11:47 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) in the pink unit, who stated that she would get the medical records from the medical record room. The RN/UM added that the PPN should be in the medical record, but cannot tell why it is not in the resident's hybrid medical records. The RN/UM did not provide the PPN record to the surveyor. On 9/16/2025 at 12:56 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional RN regarding the concern above. But did not provide further information. On 9/17/2025 at 10:19 AM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN regarding the concern above. The LNHA stated that all the PPN from February to July 2025 of Resident #4 is now available in the electronic record under the miscellaneous tab. The LNHA added that she got the PPN from the doctor's office and uploaded it to the system after the surveyor's inquiry. A review of the facility policy titled Subject: Medical Records with a reviewed date in January 2025, under Procedures: 1. The facility shall maintain medical records on each resident that are: c. Readily accessible. NJAC 8:39- 35.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 1 (one) of the 32 residents (Resident #13) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: On 9/10/2025 10:42 AM, the surveyor observed Resident #13 in bed, awake, unable to answer the surveyor's inquiry. The surveyor observed that the call device was located between the siderails and away from the resident's reach. On 9/11/2025 at 10:45 AM, the surveyor observed that the resident's call device was hanging on the side of the resident's bed and not within the reach of the resident. On 9/11/2025 at 11:15 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to Alzheimer's disease (loss of memory), unspecified. A review of the significant change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 8/29/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the SC/MDS, as reflected in section GG, revealed that the resident was dependent on staff for daily living activities. A review of the Care Plan (CP) report initiated on 8/16/24 focused on the resident's use of oxygen therapy related to respiratory illness. Interventions included, but were not limited to, encouraging the resident to call for assistance, but did not indicate that the call device should be within the reach of the resident. On 9/11/2025 at 10:48 AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that after she gives care to the resident, she will put the call device within the resident's reach, but did not provide further information on why Resident #13's call device is not within reach. On 9/11/2025 at 10:51 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the call device must have been put there by the CNA when he was giving care to the resident. The call device should be placed within the reach of the resident. On 9/11/2025 at 11:01 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that the call device should be within the resident's reach so they can call the staff if they need help. On 9/17/2025 at 1:03 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN to discuss the above concern, but did not provide further information. A review of the facility policy titled Subject: Call Bells with the revision date in January 2025, revealed under Procedure: 9. Call bells should be within reach of resident. NJAC 8:39-31.8(c)9

NJ 2594265 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an incident/accident on 6/14/25 and 6/15/25, related to an allegation of being dropped by transport for Resident #182. This deficient practice was identified for one (1) of three (3) residents reviewed for accidents and was evidenced by the following:A review of the reportable event record/report (FRE; Facility Reported Event) was called in on 6/16/25 at 11:37 AM, with an event date of 6/14/25 and 6/15/25 at 12:24 PM. The incident was reported as an allegation of being dropped by ambulance transport and involved two (2) personnel on 6/14/25 and 6/15/25. The event was described as follows: On 6/14/25 the resident reported to the nurse while reaching for their urinal, the resident heard a pop and immediately experienced pain on their elbow and shoulder. The notified physician ordered to transfer the resident to the hospital. The transport [name redacted transport #1] arrived at the facility at 8:49 PM and transported the resident to the hospital. The hospital report did not reflect inconsistent injury from their current diagnosis. The resident returned to the facility on 6/15/25 at 3:47 AM, via Transport #2. On 6/15/25 after lunch the resident informed a staff member that they were dropped by both transport on to the floor and did not inform the facility staff because they did not want to get someone in trouble. The surveyor reviewed the closed medical record for Resident #182. The admission Record (AR; or face sheet; an admission summary) reflected that the resident had been admitted with diagnoses which included multiple myeloma (a type of cancer which affects the white blood cells that produces antibodies to fight infection) , fatigue fracture of the vertebrae (small crack on the bone due to repetitive, excessive stress), pathological fracture (bone fracture due to underlying condition that weakens the bone rather than external trauma) in neoplastic disease, malignant neoplasm of the bone (cancerous tumor that originated from the bone tissue). The Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 7/18/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Section E. of the MDS did not reflect behaviors related to rejection of care. Further review of the SCMDS developed by the facility to identify resident's needs and implement care interventions, revealed that Resident #182 was dependent for all activities of daily living including all surface transfers. The individualized comprehensive Plan (CP) revealed a focus that included, Resident #182 was at risk for falls related to generalized weakness initiated on 1/7/25. The interventions included to anticipate and meet the resident's needs, initiated on 1/8/25. The goals were to the resident would be free of falls through the review date, initiated on 1/8/25. A review of the investigation revealed that after reporting a fall from transport the resident received a skin assessment by a Licensed Practical Nurse. The investigation and the medical record did not reflect that a Registered Nurse assessed the resident immediately after the fall was reported. Further review of the investigation did not reflect an effort was made to contact Transport #2 to completely investigate the incident/allegation of a fall during transport. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern regarding the resident's missing assessment from a Registered Nurse and evidence that Transport #2 was contacted as part of the investigation of the alleged fall. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern regarding the missing assessment after the reported fall and the missing statements from Trasport #2 as part of the investigation On 9/18/25 at 10:57 AM, during a meeting with the survey team, the DON, and the LNHA, the R/RN stated that they had tried to contact the former LNHA to learn more information regarding the investigation and if an interview had occurred. The R/RN also stated that Transport #2 was contacted and confirmed of the transport that occurred on 6/15/25 and would send information regarding the concern. The facility team acknowledged that the information received by the survey team and the investigation conducted by the previous LNHA was in-fact incomplete. A review of the facility policy for Accident/Incident Investigation dated/revised 1/2025 included that investigation would include interviewing staff, resident, and witness statements.The witness statements would be attached to the incident report and kept on file at the DON's office. No further information was provided. NJAC-8.39-4.1(a)5

Based on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on long-term use of insulin medication. This deficient practice was identified in 1 (one) of the 32 residents (Resident#11) reviewed for CP.This deficient practice was evidenced by the following: On 9/10/2025 at 10:16 AM, the surveyor observed Resident #11 out of bed to the wheelchair, able to propel themselves, and able to answer questions appropriately. On 9/15/25 at 1:18 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #11, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #11 was admitted with diagnoses that included but were not limited to hemiplegia (weakness of one body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a blood vessel in the brain was blocked) affecting the right dominant side and type 2 diabetes mellitus (elevated blood sugar). A review of the quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) on 8/18/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that the resident had impaired cognition. Further review of Q/MDS reflected in Section N recorded that Resident #11 is taking insulin injection and anticoagulant medications. A review of the Order Summary Report (OSR) is as follows: 1. Insulin glargine 100 unit/ml (milliliter) inject 10 units subcutaneously (SQ, fatty layer of the skin) one time a day, with the start date of 8/8/25. 2. Heparin sodium 5000 unit/ml inject 5000 unit SQ every 8 hours with a start date of 8/7/25. A review of Resident #11's comprehensive CP report revealed no CP for the use of insulin and anticoagulant medication. On 9/15/2025 at 11:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the above concern. The LPN stated that there should be a CP for insulin and anti-coagulant medications. On 9/15/2025 11:52 AM, the surveyor interviewed the Registered Nurse/ Unit Manager (RN/UM) in the blue unit, who stated that the CP should include using insulin injections and anticoagulant medications. The RN/UM did not provide further information on why insulin and anticoagulants are not in the CP for Resident #11. On 9/17/2025 at 1:06 PM, the team of surveyors discussed the above concern with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional RN, but did not provide further information. A review of the facility policy titled Subject: Plan of Care and IDCP Team Meeting Policy with a reviewed date in January 2025 revealed under Procedures: The plan of care shall be individualized, based on the diagnosis, resident assessment, and personal goals of the resident and his/her family. NJAC 8:39-11.2(d)

NJ 404793 Based on observations, interviews, records review, and review of other facility documentation, it was determined that the facility failed to ensure Resident #178's care plan was individualized, reflective of the resident's assessment, consistently provided full assistance to a resident who was dependent when eating, and the nutritional status was monitored by following the weekly weights intervention. This deficient practice was identified for one (1) of one (1) resident reviewed for nutrition (Resident #178) and was evidenced by the following: The surveyor reviewed the medical record of Resident #178 The resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included dementia (decline in cognitive abilities), diabetes (high blood sugar), congestive heart failure (a condition of weakened, stiffened heart muscle causing the heart to ineffectively pump blood leading to fluid buildup in the lungs and other parts of the body) and pulmonary embolism (clot travels from one part of the body and blocks an artery in the lungs. The resident's most recent comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 10/014/24, reflected that a Brief Interview for Mental Status was not conducted since the resident was rarely/never understood. The resident had no indicators of hallucination and delusion. Section GG revealed that the resident was dependent (wherein the helper is required for the resident to complete the activity) for activities of daily living that included eating. Section K reflected that the resident complained of difficulty or pain when swallowing. The resident received mechanically altered diet (a change in texture of food or liquids such as pureed food, thickened liquid). A review of the resident's comprehensive individualized Care Plan (CP) included a focus on the resident's nutritional problem related to diagnoses, impaired mobility, advanced age, textured modified diet, body mass index (measurement used to assess a person's weight status and potential health risk) and underweight (UW) status, started on 10/4/24. The interventions included to monitor, record, and report to MD signs and symptoms of malnutrition, emaciation, muscle wasting significant weight loss of three (3) pound (lbs.) a week. Further review of the CP reflected that the resident required assistance with meals as needed, which was inconsistent with the comprehensive assessment that reflected the resident was dependent when eating. A review of the electronic Medical Record (eMR) reflected one weight measurement; (wheelchair) on 10/3/2024 that equaled to 113.8. No other weights were recorded for this resident. A review of the Documentation Survey Report (the report of the electronic point-of-care system (POCS) where the Certified Nursing Assistants (CNAs) electronically document patient care activities). The POCS revealed that during the resident's stay, 24 of the 73 shifts the CNAs documented the resident was independent while eating and 3 of the 49 shifts, the resident received set-up or clean-up assistance. On 9/11/25 during an interview with the surveyor, the Speech-Language Pathologist (SLP) stated that the resident from admission was on puree and nectar thick and had not changed Resident #178's diet texture. On 9/15/25 at 12:29 PM, during an interview with the surveyor the Registered Dietician (RD) stated that all residents admitted received a nutritional assessment, medical record review to ensure a resident was on a proper diet. The RD stated the hemodialysis and CHF residents are monitored for diet, food consumption, labs, signs of fluid overload. At that time, the surveyor and the RD reviewed the formed RD's progress note that indicated the previous RD spoke with the resident's family who requested nutrition supplement for Resident #178. The record reflected the RD increased the resident's nutritional supplement from twice a day to three times a day. At that time, the RD stated that the assessment for Resident #178 was made by the former RD. The RD confirmed and acknowledged the record reflected the resident was underweight, was on puree and thickened liquid, had dementia, diagnosis of CHF and had an increase of nutrition as part of the family's request. At that time, the RD stated that the increase of supplement was reflective of the resident's status of not eating well and acknowledged that the record did not reflect how the effectiveness of the nutritional intervention was measured. On 9/16/25 at 1:22 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse, the surveyor discussed the concern regarding the care plan that reflected the resident required assistance with meals, opposed to the assessment that reflected the resident was dependent for activities of eating and the POCs that reflected the resident did not receive full assistance 27 out of 73 shifts. Additionally, the surveyor discussed the concern that the former RD increased the resident's nutritional supplement with no method of measurement for the effectiveness of the intervention, and the care plan intervention to monitor, record and report greater that three (3) pound weight loss to the Medical Doctor (MD) was not followed. On 9/17/25 at 10:15 AM, during a meeting with the survey team, the R/RN, the DON and the LNHA, the RD stated that the care plan was generic and should have been individualized. The RD acknowledged that the CP of weekly weight monitoring was not followed and should have been. The DON stated in-services were given to staff that the care plan should follow the assessment and the POC documentation should be accurate. A review of the undated facility policy for Weights reflected that monthly, and weekly weights per the discretion of the dietician and/or physician) shall be obtained by the CAN and record on the weight sheet form. A review of the job description for the dietician included to assess the nutritional status of residents that included weight maintenance, resident's independence and overall nutritional well-being. A review of the provided facility policy dated 1/2025 included that the care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development foals for the resident that are reasonable and measurable. NJAC 8:39-27.1(a),27.2(a)

Based on observation, interview, and record review it was determined that the facility failed ensure consistent provision of care/services in accordance with professional standards, consistently assess residents' vital signs and dialysis access site before dialysis treatments and provide ongoing communication with the dialysis center regarding a medication that was held. This deficient practice was identified for 1 of 2 residents (Resident #12) reviewed for dialysis and was evidenced by the following: Reference: According to the manufacturer's specifications for Midodrine under Mechanism of Action; Standing systolic blood pressure is elevated by approximately 15 to 30 mmHg at 1 hour after a 10-mg dose of midodrine, with some effect persisting for 2 to 3 hours. On 9/10/25 at 11:06 AM, during the initial tour of the facility the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that Resident #12 was at the hemodialysis (HD) center and picked up on Monday, Wednesday and Friday at 10:15 AM. On 9/15/25 at 9:13 AM, the surveyor observed the resident in their room with their eyes closed. The surveyor reviewed the medical record of Resident #12. According to the admission Record face sheet, an admission summary, reflected that Resident #12 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool dated 7/3/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #12 was cognitively intact. Section O reflected the resident received hemodialysis during their stay at the facility. A review of the individualized comprehensive care plan reflected a focus that the resident received HD and had an access site arteriovenous fistula (AV; an irregular connection between an artery and a vein) at the left upper arm. The interventions included ensure the resident reports to HD, monitor bruit and thrill (indicator of proper functioning of an AV fistula). Monitor labs and report to the doctor as needed. A review of the electronic Treatment Administration Record (eTAR) for September 2025 included the following physician's orders:-Check left arm AV fistula for bruit and thrill, initiated on 4/26/24 reflected charting blanks.-Assess dressing site for bleeding upon return form dialysis and removal, initiated on 4/26/24, reflected charting blanks. -Remove dialysis access dressing 4 hours post dialysis treatment every evening and night shift initiated 4/26/24 reflected a charting blank. A review of the Nurse's Progress Notes from August to September 2025 reflected that on the following dates the resident was not assessed prior to attending HD treatment-9/1/25-8/29/25-8/22/25 no documented vital signs prior to leaving the facility-8/20/25-8/18/25-8/15/25 no documented vital signs prior to leaving the facility-8/13/25 no documented vital signs prior to leaving the facility-8/8/25-8/6/25-8/1/25 no documented vital signs prior to leaving the facility A review of the resident's electronic Medication Administration Record (eMAR) for September 2025 included a PO for 10 milligrams (mg) of Midodrine (a medication use to treat orthostatic hypotension, a condition wherein the blood pressure drops significantly upon standing from sitting or lying position, with effects from 1 hour up to 3 hours) with a scheduled administration time of 9:00 AM; Give 1 tablet one time a day every Monday, Wednesday and Friday prior to dialysis. Hold for systolic blood pressure higher than 140. Further review of the Midodrine reflected the following:-9/1/25 not administered; blood pressure not documented-9/3/25 not administered; blood pressure not documented-9/5/25 not administered; blood pressure not documented-9/8/25 administered; 122(systolic)/78(diastolic) millimeters of mercury (mmHg)-9/10/25 administered; 132/67 mmHg-9/12/25 not administered; blood pressure not documented -9/15/25 not administered; blood pressure not documented-9/17/25 not administered; 144/85 mmHg A review of the Dialysis Progress Notes (DPN) for August to September 2025 did not reflect documentation was made regarding the dose of the Midodrine that were held or the assessment conducted prior to HD treatment. On 9/17/25 at 9:53 AM, during an interview with the surveyor, the RN/UM stated that the facility had a communication form, DPN that was sent with the resident for the HD center to fill out. The RN/UM stated that they did not send information with the resident and stated that no information meant that there were no issues with the resident. An issue would result into a phone call made to the HD center. If no information was sent that is to say, the resident is fine. At that time, the surveyor and the RN/UM reviewed the resident's electronic Medical Record (eMR) together. The eMR reflected that the resident had Midodrine that was scheduled for administration on HD treatment days prior to treatment and had parameters for when to administer based on the resident blood pressure condition. The RN/UM could not show evidence that communication with the HD center was made when the Midodrine was held or administered. The RN/UM stated that the communication form did not have an area or requirement for her or the nurses on duty to document that information for the HD center. On 9/17/25 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) and the Regional Registered Nurse (R/RN), the surveyor discussed the concern that Resident #12's pre-dialysis assessment were inconsistent and the missing proof of communication of the resident's pre-assessment and the administration or the holding of the Midodrine dose prior to HD treatment, in order to better manage and assess the changing blood pressure of the resident during and after the HD treatment. On 9/18/25 at 10:57 AM, in the presence of the survey team, the LNHA and the DON, the R/RN stated that the facility used the Dialysis Progress Notes as a communication form for the HD center to communicated with the facility and documented their assessment in the eMR [which the HD had no access to review for shared communication]. The R/RD stated the form has been updated to include the pre-assessment and ancillary information such as medication(s) initiated, administered, held or discontinued which would be available for the HD center to review. A review of the provided facility policy dated/revised did not reflect a process for shared communication between the nursing home and the HD facility. NJAC 8:39 - 27.1 (a)

REPEAT DEFICIENCYBased on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's primary physician accurately dated their Physician Progress Notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 1 (one) of 32 residents (Resident #13). This deficient practice was evidenced by the following: On 9/10/2025 10:42 AM, the surveyor observed Resident #13 in bed, awake, unable to answer the surveyor's inquiry. The surveyor observed that the call device was located between the siderails and away from the resident's reach. On 9/11/2025 at 10:45 AM, the surveyor observed that the resident's call device was hanging on the side of the resident's bed and not within the reach of the resident. On 9/11/2025 at 11:15 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to Alzheimer's disease (loss of memory), unspecified. A review of the significant change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 8/29/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the SC/MDS, as reflected in section GG, revealed that the resident was dependent on staff for daily living activities. A review of the PPNs in the eHR reflected the following Effective Date, Created Date, and/or Late Entry (any documentation that is recorded in the eHR beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated the PPN of medical doctor (MD) was not documented on the effective date (Date of Service): 1. PPN with an effective date of 1/5/25 and a created date of 3/5/25. 2. PPN with an effective date of 1/12/25 and a created date of 3/5/25. 3. PPN with an effective date of 1/18/25 and a created date of 3/5/25. 4. PPN with an effective date of 2/2/25 and a created date of 3/5/25. 5. PPN with an effective date of 2/9/25 and a created date of 3/5/25. 6. PPN with an effective date of 2/16/25 and a created date of 3/5/25. 7. PPN with an effective date of 2/23/25 and a created date of 3/5/25. 8. PPN with an effective date of 5/11/25 and a created date of 5/4/25. 9. PPN with an effective date of 4/30/25 and a created date of 5/4/25. 10. PPN with an effective date of 5/8/25 and a created date of 5/22/25. 11. PPN with an effective date of 3/9/25 and a created date of 5/27/25. 12. PPN with an effective date of 3/10/25 and a created date of 5/27/25. 13. PPN with an effective date of 3/14/25 and a created date of 5/27/25. 14. PPN with an effective date of 3/15/25 and a created date of 5/27/25. 15. PPN with an effective date of 3/17/25 and a created date of 5/27/25.16. PPN with an effective date of 3/19/25 and a created date of 5/27/25. 17. PPN with an effective date of 3/20/25 and a created date of 5/27/25. 18. PPN with an effective date of 3/31/25 and a created date of 5/27/25. 19. PPN with an effective date of 4/6/25 and a created date of 5/27/25. 20. PPN with an effective date of 4/13/25 and a created date of 5/27/25. 21. PPN with an effective date of 4/19/25 and a created date of 5/27/25. 22. PPN with an effective date of 4/27/25 and a created date of 7/19/25. 23. PPN with an effective date of 5/9/25 and a created date of 7/19/25. 24. PPN with an effective date of 5/11/25 and a created date of 7/19/25. 25. PPN with an effective date of 5/13/25 and a created date of 7/20/25. 26. PPN with an effective date of 5/15/25 and a created date of 7/20/25. 27. PPN with an effective date of 5/19/25 and a created date of 7/20/25. 28. PPN with an effective date of 5/20/25 and a created date of 7/20/25. 29. PPN with an effective date of 5/22/25 and a created date of 7/22/25. 30. PPN with an effective date of 5/26/25 and a created date of 7/22/25. 31. PPN with an effective date of 5/29/25 and a created date of 7/22/25. 32. PPN with an effective date of 6/1/25 and a created date of 7/22/25. 33. PPN with an effective date of 6/2/25 and a created date of 7/22/25. 34. PPN with an effective date of 6/4/25 and a created date of 7/22/25. 35. PPN with an effective date of 6/8/25 and a created date of 7/22/25. 36. PPN with an effective date of 6/10/25 and a created date of 7/22/25. 37. PPN with an effective date of 6/15/25 and a created date of 7/22/25. 38. PPN with an effective date of 6/20/25 and a created date of 7/22/25. 39. PPN with an effective date of 7/8/25 and a created date of 7/22/25. 40. PPN with an effective date of 6/25/25 and a created date of 8/24/25. 41. PPN with an effective date of 7/9/25 and a created date of 8/24/25. 42. PPN with an effective date of 7/10/25 and a created date of 8/24/25. 43. PPN with an effective date of 7/21/25 and a created date of 8/25/25. 44. PPN with an effective date of 7/23/25 and a created date of 8/25/25. 45. PPN with an effective date of 7/24/25 and a created date of 8/25/25. 46. PPN with an effective date of 7/28/25 and a created date of 8/25/25. 47. PPN with an effective date of 7/30/25 and a created date of 8/25/25. 48. PPN with an effective date of 8/4/25 and a created date of 8/25/25. 49. PPN with an effective date of 8/7/25 and a created date of 8/25/25. 50. PPN with an effective date of 8/12/25 and a created date of 8/25/25. 51. PPN with an effective date of 8/19/25 and a created date of 8/25/25. On 9/15/2025 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the physician comes into the facility regularly and writes their notes in the eHR. On 9/15/2025 11:33 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) from the pink unit, who stated that the physician visits their residents regularly and documents the progress notes in the computer. The RN/UM did not provide further information on why the PPN has a late entry. On 9/17/2025 at 11:30 AM, the surveyor called the primary physician and left a message to call back for an interview, but the primary physician did not return the call. A review of the facility policy titled Subject: Physician Visits and Services, with a reviewed date in January 2025, under Procedure: 5. Progress notes and orders must be written, signed, and dated at each physician visit, which may be done in a physical or electronic chart. NJAC 8:39-23.2(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure consistent accountability and reconciliation of narcotic medication for Resident #95's and 151's narcotic medications. These deficient practices were identified for one (1) of five (5) medication carts inspected and was evidenced was as follows:On 9/16/25 at 11:57 AM, in the presence of the Licensed Practical Nurse (LPN) the surveyor began the narcotic medication inspection, stored in a mounted, double locked portion of the medication cart (narcotic box) located on the high side of the pink unit. A review of the facility's Controlled Medication Accountability Sheet (a shift-to-shift count/sign in sheet, used to account for the narcotics and syringes within the medication cart) for September 2025, reflected that the inventory counts were performed on three shifts (7:00 AM, 3:00 PM and 11:00 PM), daily from 9/1/25 at 7:00 AM, to at 9/15/25 at 7:00 AM by the two nurses, the outgoing shift and the incoming shift. At that time, the surveyor and the LPN observed Resident #95's Clonazepam 0.5 milligram, tablets (a narcotic psychotropic indicated for anxiety, seizure and panic disorder; mg) bingo cards (a multidose card containing individually packaged medications) contained a total of 47 tablets. At that time, the surveyor compared the count of the bingo card against the Individual Patient Controlled Substance Administration Record (declining inventory log) for Resident #95's Clonazepam 0.5 mg tablet which reflected a balance of 48 tablets and was last signed by the administering nurse on 9/15/25 at 21:00 PM (9:00 PM). At that time, the surveyor questioned the one (1) tablet discrepancy of the Clonazepam count. The LPN stated she administered the Clonazepam that morning to Resident #95 and forgot to sign that she removed the medication from the inventory against the facility's policy. At that time, the surveyor and the LPN reviewed the declining inventory log for Resident #95's Morphine 20 mg/ml which reflected a balance of balance of 26 milliliters and was last signed by the administering nurse on 9/15/25 at 9:00 PM. At that time, the surveyor and the LPN reviewed the electronic Medication Administration Record (eMAR) for Resident #95's Morphine which reflected an administration on 9/16/25 for the 9:00 AM dose. This administration was not reflected on the declining inventory log. At that time, during an interview with the surveyor, the LPN stated that she also administered the Morphine that morning to Resident #95 and forgot to sign that she removed the medication from the inventory because she was distracted. On 9/16/2025 at 12:10 PM, in the presence of the LPN, the surveyor observed Resident #'151's Alprazolam 0.5 mg, tablets (a narcotic psychotropic indicated for anxiety) bingo cards contained a total of 69 tablets. At that time, the surveyor compared the count of the bingo card against the declining inventory log for Resident #151's Alprazolam 0.5 mg tablet which reflected a balance of 70 tablets and was last signed by the administering nurse on 9/16/25 at 8:00 AM. At that time, during an interview with the surveyor, the LPN could not explain why the discrepancy was not identified during the shift-to-shift count earlier that day. At that time, during a meeting with the Registered Nurse/Unit Manager (RN/UM) the surveyor discussed the concerns regarding the discrepancy for the accountability of Resident #95's narcotic medications (Clonazepam and Morphine) and the failed reconciliation of Resident #151 Alprazolam that resulted in a discrepancy of one (1) pill. At that time the RN/UM stated an in-service would be provided to the nurses, an investigation for the shortage would be initiated and the Director of Nursing (DON) along with the Assistant Director of Nursing (ADON) would be informed. On 9/16/25 at 1:22 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Regional Nurse, the surveyor discussed the concern regarding the failure to ensure that the declining logs were signed upon removal from active inventory and implement reconciliation of the narcotic inventory during the shift-to-shift counts. On 9/17/25 at 10:15 AM, during a meeting with the survey team, the LNHA, and the Regional Nurse, the DON stated that in-services were provided regarding signing the declining sheet upon removal and ensuring that the counts were conducted during the shift-to shift counts. An investigation was conducted regarding the shortage of Resident #151's Alprazolam and found that the outgoing nurse from the 11 to 7 shift destroyed a loose pill in the medication cart and destroyed the pill in the drug buster without a witness since he did not realize it was a controlled substance. The DON stated that the nurse should have tried to identify the loose pill prior to destroying the narcotic medication and should have been done in the presence of another nurse as a witness of the destruction/disposal. A review of the provided policy for Inventory of Controlled Substances dated/revised on 1/2025 included that the controlled substances are counted by the oncoming nurse and outgoing nurse at the change of each shift and documented.a documentation of any discrepancy must be reported to the Director of Nursing. Further review of the policy reflected that all medication destructions in the facility must be witnessed by at least two persons, each of whom shall be the registered professional nurse, licensed practical nurse or pharmacist consultant. NJAC 8:39-11.2(b), 29.2(d), 29.4(g)(i) .

Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for three (3) of five (5) newly hired licensed staff reviewed, (Staff #5, #8 and #10). This deficient practice was evidenced by the following: 1. On On 6/27/24 at 12:00 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Staff #5, a Social Worker, hired 8/21/23, had a New Jersey Division Consumer Affairs license verification printout was dated 10/02/23. The verification was completed after the staff member was hired. There was no documented evidence that Staff #5's license was verified prior to the date of hire (doh). On 6/28/24 at 10:00 AM, the surveyor interviewed the Business Office Manager (BOM) regarding license verification. The BOM stated that she would check the license and print a copy and that it had to be done before orientation. The surveyor showed the BOM Staff #5's license verification dated after the doh. The BOM stated that she was not employed at the facility at that time. She added that the license should be verified prior to doh. On 6/28/24 at 10:04 AM, the surveyor interviewed the Director of Nursing (DON) regarding license verification. The DON stated that the BOM checked the license prior to doh. On 6/28/24 at 12:06 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Operations (VPoO) the concern that Staff #5's license was not verified prior to the doh. The LNHA stated that he was the stand in BOM and that he missed it. On 7/01/24 at 10:04 AM, in the presence of the survey team, DON and VPoO, the LNHA confirmed that the license should have been verified prior to the doh. 49078 2. On 6/27/24 at 10:30 AM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Staff #10, a Certified Nurse Aide (CNA), hired 10/23/23, had a New Jersey Division Consumer Affairs license verification printout that had no date the verification was completed visible on the printout. There was no documented evidence that Staff #10's license was verified prior to the doh. On 6/27/24 at 12:15 PM, the surveyor reviewed five of ten randomly selected new employee files. The review for license verification for one of the new licensed employees revealed the following: Staff #8, a Registered Nurse, hired 8/25/23, had two New Jersey Division Consumer Affairs license verification printouts that were dated 10/02/23 and 11/14/23. The verification was completed after the staff member was hired. There was no documented evidence that Staff #8's license was verified prior to the doh. On 7/01/24 at 9:48 AM, the LNHA provided another copy of Staff #10's printout. The printout reflected handwriting that was highlighted printed on 6/28/24 print no date shown. The License verification printout did not reflect any other date that it was printed. There was no documented evidence that Staff #10's license was verified prior to the doh. A review of the facility provided policy titled, New Hires with a reviewed date of 01/2024, included the following: 1. All new hires shall complete the following paperwork and the paperwork will have to be reviewed by the BOM: . f. Original licenses/certification with verification by the BOM (if applicable) A review of the facility provided policy titled, Abuse Prevention Program with a revised date of 02/08/2023, included the following: .Part III-Screening . Potential hires of professional staff will have their license verified by their licensing boards prior to hire NJAC 8:39-43.15(a,b)

Based on interviews, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every sixty days from January 2024 through June 2024 according to the facility's policy and procedure. This deficient practice was identified for one (1) of 28 residents, Resident #134 was reviewed for physician visits and was evidenced by the following: On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134. Resident #134's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder. The most recent Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had moderately impaired cognition. There was no documented evidence that the physician visited and examined Resident #134 at least every 60 days from January 2024 through June 2024. On 6/26/24 at 11:14 AM, the surveyor called the physician of the resident and the surveyor spoke to the receptionist of the physician's office. The receptionist informed the surveyor that the physician was not available and would let the physician know to call the surveyor for an interview. On 6/26/24 at 12:03 PM, the surveyor interviewed the Registered Nurse Coordinator (RNC) of the Peach unit (Behavioral unit). The surveyor asked the RNC what was the facility's protocol regarding the physician visit notes, and the RNC responded that he would get back to the surveyor. On that same date and time, the surveyor notified and showed to the RNC that the resident's visits notes for dates 01/25/24 (History and Physical) and 3/10/24 (Progress Notes) were both done by the Advance Practice Nurse (APN), and there were no further notes found in the resident's hybrid medical records. On 6/28/24 at 11:29 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), [NAME] President of Operations (VPoO), and Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns. The surveyor asked the facility management if that was the facility's policy and practice that the primary physician does not write visit notes. The LNHA stated no, and that the physician should see the resident once every 60 days, the APN can come in between months and do the alternating visits and notes. A review of the facility's Physician Visits and Services Policy with a reviewed date of 01/2024 that was provided by the LNHA included that the attending physician shall visit the resident at least once during the 30 days following admission and/or as required by the resident's needs. The attending physician shall visit the resident in accordance with the resident's needs, but at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter and as needed. On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings. NJAC 8:39-23.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. This deficient practice was identified in behavioral unit for four (4) of six (6) residents rooms, one (1) of one (1) shower room, and one (1) of two (2) unit rooms. This deficient practice was evidenced by the following: On 6/25/24 at 10:08 AM through 10:49 AM, the surveyor conducted a Behavioral Unit (BU) tour with the Licensed Nursing Home Administrator (LNHA) and Registered Nurse/Unit Coordinator (RN/UC) in the presence of a second surveyor. The following was observed during the tour: 1. At 10:08 AM, the surveyor entered into room [ROOM NUMBER] and observed a gray-black colored substance on the air vent cover on the ceiling of the room. The LNHA stated, the gray/black substance was an accumulation of dust. The LNHA was unable to state when the air vent was last cleaned. The surveyor observed one ceiling tile near the window area with a large circular, brownish colored stain in the middle of the tile. The LNHA responded that it was probably due to condensation, and he was unsure when that had happened. The RN/UC stated, the tile should not be there. The surveyor entered the bathroom and observed a laundry bin with one piece of black colored clothing inside of it. The RN/UC stated, the clothing was probably from other resident who was transferred to another room last Friday. The RN/UC acknowledged that the room and the dirty clothing should have been cleaned immediately after the resident was moved to another room. 2. At 10:15 AM, the surveyor entered into room [ROOM NUMBER] and observed dry debris hanging from the upper area of the window. The RN/UC confirmed that it was dust. The LNHA and RN/UC acknowledged that the window should have been cleaned. 3. At 10:21 AM, the surveyor entered into the bathroom of room [ROOM NUMBER] and observed two toilet paper holders with brownish discoloration. The RN/UC acknowledged it was rust and stated it should not be like that. The surveyor observed a white hat [a plastic container for urine collection] on the floor. The RN/UC stated, it was a urine collection container, and it should not be on the floor for infection control. It was used to measure the resident's urine output. The RN/UC further explained that there was currently no resident in the room and the resident was transferred to the hospital yesterday. 4. At 10:27 AM, the LNHA opened the unlocked door of the Motor Access Room and informed the surveyors that it was an electrical room. The surveyor observed a brown colored, dried-up substance on the floor. There was a blanket on the floor with brownish discoloration. The LNHA acknowledged that the room door should have been locked. 5. At 10:30 AM, the surveyor entered into room [ROOM NUMBER] and observed that the smoke detector on the ceiling. The smoke detector was detached and hanging from the ceiling. The LNHA stated, it should have been fixed and attached to the ceiling. 6. At 10:43 AM, the surveyor entered the room labeled the Eyewash Station. Inside the room there were three shower stalls on the right side. The surveyor observed in the second shower stall, a square shaped opening on the right wall of the shower where there was a knob to control the water. The RN/UC acknowledged that the part to close the opening was missing. The surveyor observed an air vent on the ceiling which had no cover. The RN/UC stated that it should have been covered and acknowledged that there was an accumulation of dust, and it should have been cleaned. On 6/27/24 at 8:53 AM, the surveyor interviewed the Director of Housekeeping (DoH) who stated that the housekeeping staff were supposed to clean the resident rooms and hallway daily. The DoH stated he was responsible to make daily rounds on the units to ensure that housekeeping staff were completing their responsibilities. He further stated that he did not have any logs or documentation to account for the cleaning of vents and windows, or for his daily rounds. On 6/27/24 at 12:41 PM, the survey team met with the LNHA, Director of Nursing (DON), and [NAME] President of Operations (VPoO). The surveyors notified the facility management of the above concerns and findings regarding the resident rooms, bathrooms, shower room, and motor access room. On 6/28/24 at 11:29 AM, the LNHA, DON, and VPoO met with the survey team. The VPoO stated in-service was provided to housekeeping staff regarding environmental concerns and high dusting issues. The LNHA stated that the valve in the middle shower stall was temporarily covered and closed until a new cover was received. The LNHA further explained the air vent cover in the shower room was replaced and the smoke detector was properly mounted to ceiling. A review of the facility provided Facility Environment policy with a revised date January 2024, included: Policy: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Procedure: 1. The facility shall provide a safe, clean, comfortable and homelike environment, allowing the resident to use their personal belongings to the extent possible. 2. Housekeeping and maintenance shall maintain a sanitary, orderly and comfortable environment. NJAC 8:39-31.4 (a)(b)(f)

Based on observation, interview, and record review it was determined that the facility failed to provide full visual privacy when providing wound care treatment, for one (1) of 28 residents, Resident #103. The deficient practice was evidenced by the following: On 6/27/24 at 10:15 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a treatment to the sacral wound of Resident #103. The Certified Nurse Aide (CNA) was assisting the LPN with the positioning of Resident #103 during the wound treatment. On 6/27/24 at 10:31 AM, during the wound treatment, Resident #103 with the assistance of the CNA was lying on their left side on the bed facing away from the door. The back of the resident's body was exposed. The privacy curtain was partially pulled, around the foot of the resident's bed. The resident's bed was visible to the door of the room, which was closed. The LPN after cleansing the resident's wound, removed her gloves and went to the door of the room. LPN #1 fully opened the door, went to the treatment cart positioned in front of the door to get gloves from the box on top of the cart. The back side of the resident's body was visible to the hallway as the privacy curtain was not closed fully and the resident's door was widely open. LPN #1 retrieved the gloves from the top of the treatment cart, came back in room, put the gloves on the bedside table, next to the resident's bed and then closed the door of the resident's room. On 6/27/24 at 10:50 AM, the surveyor interviewed the LPN after the wound treatment about privacy for residents. The LPN stated visual privacy should be provided and maintained for residents. The surveyor discussed the observation during the wound treatment. The LPN acknowledged that she should have drawn the resident's curtain further or closed the door of the room when she went to the treatment cart to ensure that the resident was not visible from the hallway. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #103 which revealed the following: According to the Admission Record (an admission summary), Resident #103 had diagnoses that included but were not limited to, urinary tract infection, sacral pressure ulcer wound, and epilepsy (a seizure disorder). An Annual Minimum Data Set (MDS), an assessment tool to facilitate management of care, dated 5/10/24, indicated the facility assessed the resident's cognition using a Brief Interview for Mental Status (BIMS) test. Resident #103 scored a 9 out of 15, which indicated the resident had moderate cognitive impairment. On 6/27/24 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the [NAME] President of Operations (VPoO). The surveyor notified the LNHA, DON, and VPoO of the concern observed during the wound treatment of the resident's full visual privacy not being maintained. There was no verbal response by the facility at this time. On 6/28/24 at 11:30 AM, the LNHA, DON, and VPoO met with the survey team. The VPoO stated in-service education about resident's privacy was being provided to all staff. There was no additional information provided by the facility. A review of the facility's Resident Rights To Privacy and Confidentiality with a reviewed date of 01/2024. Under Procedure it read, Every nursing home resident has the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations and personal care. A review of the facility's Resident's Rights, which was undated. Under I. Each resident shall be entitled to the following rights .16) To have physical privacy. The resident shall be allowed, for example, to maintain the privacy of his or her body during medical treatment and personal hygiene activities, such as bathing and using the toilet, unless the resident needs assistance for his or her own safety . NJAC 8:39-4.1(a)12,16

Based on interview, record review and review of other pertinent facility documents, it was determined that the facility failed to provide the resident and the resident's representative written notification of the reason for transfer to the hospital and also send a copy to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for two (2) of three (3) resident's (Resident #195 and #41) reviewed for hospitalization . This deficient practice was evidenced by the following: 1. A review of Resident #195's electronic medical record included the following: Resident #195's discharge return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, for the three DRAMDS, reflected that the resident was transferred to the hospital. A review of Resident #195's hybrid (a combination of paper, scanned, and computer-generated records) medical record did not include a written notification of the reason for transfer to the resident or resident representative (RR) and a copy to the LTCO for each transfer to the hospital. 46049 2. The surveyor reviewed the hybrid medical records of Resident #41 which revealed the following: A New Jersey Universal Transfer Form (NJUTF) and nurse progress notes documented that Resident #41 was transferred to an acute care hospital in May 2024. According to the DRAMDS in May 2024, Resident #41 was discharged (d/c) to an acute care hospital with a return anticipated to the facility. There was no documentation in the hybrid medical record of Resident #41 to indicate that the facility provided written transfer notification to the resident or RR. Additionally, there was no documentation in the hybrid medical records to indicate written transfer notification was provided to the Ombudsman's office. On 6/25/24 at 9:52 AM, the surveyor interviewed the Director of Social Services (DSS) about written emergency transfer notifications. The DSS stated social services department was not responsible for providing written emergency transfer notifications and did not provide notice to the Ombudsman's office. The DSS stated he was not sure who was responsible for providing the notifications. On 6/25/24 at 9:57 AM, the surveyor interviewed the Admissions Director and Regional Director of Case Management and Admissions (RDCMA) about written emergency transfer notification. The RDCMA stated nursing was responsible for providing the written transfer notification to the resident or RR. On 6/25/24 at 11:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated written emergency transfer notification was not provided by nursing. The DON further stated she was not sure which department was responsible for providing and would follow up to provide further information. On 6/25/24 at 12:01 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the medical records department was responsible for providing written emergency transfer notification to resident and/or RR and the Ombudsman's office. On 6/25/24 at 12:07 PM, the surveyor interviewed the medical records staff (MRS) who stated she was not responsible for providing any written emergency transfer notification. The MRS further explained that she would complete a monthly spreadsheet of residents that were d/c and send directly to the LNHA. The MRS stated she had no knowledge about written emergency transfer notifications and did not know who was responsible for providing. On 6/27/24 at 12:41 PM, the survey team met with the LNHA, the DON, and the [NAME] President of Operations (VPoO). The surveyors notified the facility of the concerns that there was no written emergency transfer notification provided to the resident/RR and no notification provided to the Ombudsman's office. There was no verbal response by the facility at this time. On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The VPoO stated in-service education was provided to staff to put the process of providing emergency written transfer notifications back into place as it was not being completed. There was no additional information provided by the facility. The surveyor reviewed the facility provided policy titled Emergency Transfer Notification with a reviewed date of 01/2024. Under Policy it read It is the policy of this facility to provide guidelines for the notification requirements when transferring residents to an acute care facility on an emergent basis. Under Procedure it read: 1. When a resident is temporarily transferred to an acute care facility a notice of the temporary transfer will be provided to the resident and/or RR as soon as practicable .2. A copy of the notice will also be sent to the Ombudsman when practicable, such as a list of residents on a monthly basis .3. The notice will contain: a. The reason for transfer; b. The effective date; c. The location to which the resident is transferred; d. Contact information . NJAC 8:39-5.3; 5.4

Based on interview, record review and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for one (1) of three (3) residents, Resident #142 reviewed for closed records. This deficient practice was evidenced by the following: On 6/26/24 at 12:58 PM, the surveyor reviewed the closed medical chart for Resident #142 whose discharge MDS was coded for discharge (dc) to an acute hospital. Review of Resident #142's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder, unspecified, and essential (primary) hypertension (high blood pressure). Review of A section of the 4/27/24 Discharge MDS for Resident #142 revealed that section A2105 DC Status documented, 04. Short-Term General Hospital. The Order Summary Report (OSR) reflected a physician order dated 4/27/24 - dc home with home care services. The Progress Notes dated 4/27/24 at 9:30 AM that was electronically signed by Licensed Practical Nurse (LPN) included resident was seen this morning in their wheelchair no signs of distress or discomfort noted. Vitals taken and recorded; due medications (meds) tolerated. Resident dc, left the building at 9:30 AM, with resident representative. Resident has been educated on their meds and oxygen use; list of meds had been faxed to [name redacted] pharmacy. The dc Summary, with effective date 4/27/24 12:44 PM revealed under section 103 Social Services documented, 2. dc Status - dc home, family support. Ref (referred) to [name redacted] Home Care for home services. On 6/27/24 at 11:28 AM, the surveyor interviewed the MDS Coordinator (MDSC). MDSC explained, I do remember him/her, that Resident was dc to home. I made a mistake and entered their information transferred to hospital. The MDSC acknowledged that the MDS was coded inaccurately and Resident #142 went home and did not go to the hospital. On 6/28/24 at 11:28 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and [NAME] President of Operations (VPoO) regarding the above concerns. The VPoO stated, she [the MDSC] made an error in MDS. She further stated that the resident was dc home and did not go to the hospital. No further information provided. NJAC 8:39-33.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow the physician's orders for medications with parameters for two (2) of 28 residents, Residents #44 and #134, reviewed for physician orders according to standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #44 which revealed the following: The Admission Record (AR, an admission summary) revealed that Resident #44 had diagnoses that included but were not limited to, end stage renal disease, hypotension (low blood pressure), and anemia. A Quarterly Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 4/03/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #44 scored a 15 out of 15, which indicated the resident was cognitively intact. A physician's order (PO) dated 5/10/24 read: Midodrine HCl Oral Tablet (tab) 10 MG (milligram) (Midodrine HCl) Give 1 tab by mouth two times a day for hypotension hold for BP [blood pressure] > [greater than] 120. A review of the June 2024 electronic Medication Administration Record (eMAR) revealed the nurses signed for midodrine medication (med) being administered on 6/04/24 at 1700 [5 PM], 6/10/24 at 1700, 6/11/24 at 0900 [9 AM], 6/16/24 at 0900, 6/18/24 at 1700, 6/19/24 at 1700 and 6/24/24 at 1700. On these entries the BP was documented to be a BP greater than 120 and the midodrine med should have been held per the PO. On 6/27/24 at 11:12 AM, the surveyor interviewed a Licensed Practice Nurse (LPN) #1 (LPN #1) assigned to care for Resident #44 about medications (meds) with parameters. The LPN stated a PO should be followed. If the BP results were outside the parameters of the med order, the med should be held and not administered to the resident. On 6/27/24 at 12:41 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Operations (VPoO) of the concerns that the PO for the midodrine med with parameters was not being followed. The facility was to follow up and provide additional information. On 6/28/24 at 11:30 AM, the LNHA, the DON, and the VPoO met with the survey team. The DON acknowledged the nurses did not follow the parameters ordered by the physician for the midodrine med and nurse in-service education was ongoing. 38327 2. On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid medical record for Resident #134. Resident #134's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified, traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder. The most recent Significant Change MDS (SCMDS) dated [DATE], reflected that the resident had a BIMS score of 09 out of 15, which indicated the resident had moderately impaired cognition. A review of the OSR for May and June 2024 reflected a PO dated 3/07/24 for the following: Hydralazine HCL (hydrogen chloride) oral tab 25 mg give one tab orally every 12 hours (hrs) to treat high blood pressure hold if SBP (systolic blood pressure [the top number measures the pressure in the arteries when the heart beats]) less than 120. Toprol XL (extended-release) oral tab 50 mg give one tab by mouth one time a day for HTN (hypertension) hold for SBP less than 100 and HR (heart rate) less than 60. The above orders for Hydralazine and Toprol Xl were plotted in the eMAR for May and June 2024, were administered by nurses (checked mark), and did not follow the PO: Toprol XL hold for SBP less than 100: Date Time BP Nurse 6/22/24 8 PM 96/61 [SBP 96] Registered Nurse#1 (RN#1) HydrALAZINE HCl hold for SBP less than 120: Date Time BP Nurse 6/09/24 9 AM 115/73 [SBP 115] LPN#2 6/12/24 9 PM 112/68 [SBP 112] LPN#2 6/19/24 9 PM 18/67 [SBP 118] LPN#2 6/20/24 9 PM 103/64 [SBP 103] LPN#2 6/22/24 9 PM 105/70 [SBP 1050 LPN#3 5/03/24 9 AM 113/96 [SBP 113] RN#1 5/10/24 9 PM 116/72 [SBP 116] LPN#2 5/14/24 9 PM 116/68 [SBP 116] LPN#2 On 6/25/24 at 9:54 AM, the surveyor interviewed RN#1 who informed the surveyor that she was a regular full time per diem nurse for a year now in the Behavioral Unit (BHU). The RN informed the surveyor that the meds with parameters like the BP meds should follow the order of the physician if needed to hold, then it should be followed. She further stated that she checked BP first prior to administering the BP meds, and documented the BP in the eMAR. The RN also stated that the checkmark in the eMAR means it was administered. The RN further stated that it was considered a med error if BP meds were administered beyond the parameters. On that same date and time, the surveyor notified RN#1 of the above concerns and findings regarding the Toprol she administered on 6/22/24 and Hydralazine on 5/03/24 not following the parameters. The surveyor with another surveyor and RN#1 went to the BHU nursing station. RN#1 checked the eMAR and acknowledged that she was the nurse that administered the BP meds and it should not administered due to parameters. She further stated that she did not know why it was administered and did not follow the PO for parameters. On 6/25/24 at 11:22 AM, the surveyor called and left a message to an agency nurse, LPN#3. On 6/25/24 at 11:23 AM, the surveyor called and spoke to LPN#2 regarding the above concerns and findings. LPN#2 informed the surveyor that she was from an agency and had been working in the facility since June 2023 as a float nurse. On that same date and time, LPN#2 stated that meds with parameters example the BP meds should follow the PO for parameters. She further stated that she checked BP first prior to administering meds and documented the BP in the eMAR. LPN#2 admitted that she usually works the 3-11 shift. At that time, the surveyor notified LPN#2 of the above findings regarding her administered Hydralazine on 6/09/24, 6/12/24, 6/19/24, 6/20/24, 5/10/24, and 5/14/24 not following the parameters. She further stated that the above meds should not be administered due to parameters. LPN#2 had no answer as to why she did not follow the PO for parameters. On 6/25/24 at 11:38 AM, the DON provided a copy of the Med Administration Policy with a reviewed date of 01/2024. The DON stated that the policy about meds with parameters was incorporated in this policy (Medication Administration Policy with a reviewed date of 01/2024) and the DON pointed to Procedure #3: Meds must be administered in accordance with the orders, including any required time frame. The surveyor did not receive a call back from LPN#3. On 6/27/24 at 9:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM stated that she notified the physician yesterday about the concerns with the parameters, the physician had no new order and instructed the nurse to continue the parameters. She further stated that there was no adverse effect on the resident. On 6/27/24 at 12:41 PM, the survey team met with the LNHA, the VPoO, and the DON. The surveyor notified the facility management of the above concerns and findings. On 6/28/24 at 11:29 AM, the survey team met with the LNHA, DON, and the VPoO. The DON stated that one-to-one education was provided to LPN#2 regarding following the PO for parameters. The DON acknowledged and stated that meds were given beyond the parameters and that should have been held for both meds Toprol and Hydralazine. A review of the facility provided policy titled, Medication Administration Policy, with a reviewed date of 01/2024. Under Policy it read: Meds shall be administered in a safe and timely manner, as prescribed. Under Procedure it read: .3. Meds must be administered in accordance with the orders, including any required time frame .7. The following information must be checked/verified for each resident prior to administering meds .b. Vital signs, if necessary . NJAC 8:39-11.2(b); 29.2(d)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a discharge summary was completed for two (2) of two (2) residents, Residents #13 and #142 reviewed for discharge to home, according to the facility policy and procedure . This deficient practice was evidenced by the following: 1. On 6/26/24 at 10:10 AM, the surveyor reviewed the hybrid (combination of paper and electronic) closed record of Resident #13 and revealed the following: The Admission Record (AR, or face sheet, an admission summary) showed that the resident was admitted to the facility with a diagnosis that included but was not limited to urinary tract infection (UTI, an infection) site not specified, hypothyroidism (underactive thyroid), chronic obstructive pulmonary disease with acute exacerbation (COPD, group of lung diseases that block airflow and make it difficult to breathe), depression unspecified, anxiety disorder unspecified, and fibromyalgia (long-term condition that involves widespread body pain and tiredness). A review of the modified Comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/27/24 showed a brief interview for mental status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. The CMDS also showed that the overall goal for the resident was to be discharged (DC) to the community. Further review of the MDS revealed that the most recent DC Return Not Anticipated ARD was on 6/20/24 and was export-ready (which means it was completed but was not submitted to the Centers for Medicare and Medicaid Services or CMS). The Order Summary Report (OSR) for June 2024 showed a physician's order (PO) dated 6/20/24 for DC home with home care services. The Progress Notes (PN) dated 6/20/24 at 02:43 PM that was electronically signed by Licensed Practical Nurse #1 (LPN#1) included that patient (resident) DC to a private home, left in the company of the resident's representative (RR). Further review of the PN showed that the last note of the physician was on 6/19/24 and did not include the DC information and plan for the resident. The DC Summary in the electronic medical records (EMR), assessment tab showed that it was In Progress date 6/20/24 and the lock date was blank. The DC Summary dated 6/20/24 showed the following were left blank and no documented information found: SECTION 103. Social Services 1. Admission Status=left blank SECTION 104. Rehab 1. Admission Status=left blank 2. Discharge Status=left blank SECTION 105. Dietary 1. Admission Status=left blank SECTION 106. Activities 1. Admission Status=left blank Further review of the DC Summary showed that there was no physician DC summary. On 6/27/24 at 12:20 PM, the Director of Nursing (DON) with the Registered Nurse/Unit Manager (RN/UM) met with the surveyor. The RN/UM notified the surveyor that the facility did not have a DC summary from the physician, and it was not the facility's practice. The RN/UM also stated that the only requirement from the physician was to have an order for DC and the facility to document that the physician was notified of the DC of the resident. He further stated that that was the reason why there was no DC summary from the physician in the EMR and the actual paper closed chart. On 6/27/24 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Operations (VPoO), and the DON. The surveyor notified the facility management of the above concerns and findings. The surveyor also notified the facility management of the RN/UM interview in the presence of the DON. On 6/28/24 at 11:29 AM, the survey team met with the LNHA, DON, and the VPoO. The VPoO stated that we have to put back the system for DC summaries, and moving forward that would be done, the DC summaries of the physician. The VPoO acknowledged that the DC summary of the physician was not something new in the requirements, and should have been done. On that same date and time, the surveyor also notified the facility management that the DC Summary that was in the Assessment tab of the EMR was still in progress and was not completed, where multiple areas were blank. On 7/01/24 at 11:09 AM, the survey team met with the LNHA, DON, and the VPoO. There was no additional information provided with regard to the above concerns. A review of the facility's DC Policy with a reviewed date of 01/2024 by the LNHA included that when a resident's DC is anticipated, a DC plan, summary, and instructions will be developed to assist the resident to adjust to his/her new living environment. The IDT (interdisciplinary team) will document the DC summary in the EMR. On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings. 48423 2. On 6/26/24 at 12:58 PM, the surveyor reviewed the hybrid closed record of Resident #142 and revealed the following: The AR showed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder, unspecified, and essential (primary) hypertension (high blood pressure). A review of the DC MDS reflected BIMS score of 15 out of 15 which indicated that the resident was cognitively intact. Further review of the MDS section A0310F. revealed that MDS assessment was coded 10. DC assessment- return not anticipated. A review of OSR showed a PO dated 4/27/24 for DC home with home care services. A review of PN dated 4/27/24 at 9:30 AM that was electronically signed by LPN#2 included resident was seen this morning in their wheelchair no signs of distress or discomfort noted. Vitals taken and recorded; due medications (meds) tolerated. Resident DC, left the building @ 9:30 AM, with RR. Resident has been educated on his/her meds and oxygen use; list of meds had been faxed to [name redacted] pharmacy. Further review of the PN showed that the last physician note titled as H&P was on 4/15/24 and did not include the DC information and plan for the resident. Further record review did not reveal a physician DC summary for Resident #142. NJAC 8:9-36.1(b)

Based on observation, interview and review of the medical record and other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received consistent daily treatment of a hand splint to prevent contractures or further contraction for one (1) of two (2) residents reviewed for position and mobility (Resident #94). This deficient practice was evidenced by the following: On 6/24/24 at 10:45 AM, the surveyor observed Resident #94 seated in a wheelchair and wore a splint on their left hand. Resident #94 stated that he/she wore the splint during the day. On 6/25/24 at 11:48 AM, the surveyor reviewed Resident #94's electronic medical record. Resident #94's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to flaccid hemiplegia affecting left nondominant side (affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), type 1 diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) and unspecified disorder of thyroid (medical condition that keeps your thyroid from making the right amount of hormones). Resident #94's electronic physician order set (POS) included the following active order: *FMP* (Functional Maintenance Program) PROM L UE (passive range of motion left upper extremity) in all planes as tolerated 3-5x/WK (week) 10-20 reps (repetitions). Donn (to put on) L (left) hand orthotic after AM care and doff (to take off) before PM care daily. Further view of the order indicated POS only and did not transfer to the TAR (Treatment Administration Record) for staff signatures. A review of Resident #94's care plan included the following focus area with an initiated date of 01/23/2023: Restorative Nursing Program: Passive ROM (range of motion) left upper extremity 3-5x/week 10-20 reps, Donn left hand orthotic device (splint) on after AM care and off before PM care daily. A review of Resident #94's January 2024 through June 2024 TAR did not have a physician's order for the splint for nurses to sign as administered. There was no documented evidence in Resident #94's hybrid (a combination of paper, scanned, and computer-generated records) medical record that the physician's order or care plan was being carried out. On 6/26/24 at 9:18 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) regarding splints. The CNA stated that everyone could do the splint and that it was documented in the computer. The CNA stated that Resident #94 was currently receiving therapy and that therapy was doing the splint now. She added that when the resident was not in therapy that nursing staff would do the splint and document it. A review of Resident #94's Documentation Survey Report (CNA documentation for interventions or tasks) for January 2024 through June 2024 did not include any documentation regarding splints. On 6/26/24 at 9:23 AM, the surveyor interviewed the Director of Rehab (DoR). The DoR stated that the Restorative Nurse Aid (RNA) documented on paper when she applied the splint. On 6/26/24 at 9:33 AM, the surveyor interviewed the RNA. The RNA stated that she had a binder that she documented in for Resident #94. On 6/26/24 at 12:09 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of Pink unit regarding the process of splints and documentation. The RN/UM requested that the DoR be present. On 6/26/24 at 12:50 PM, in the presence of the DoR, the RN/UM stated that there was a physician order in the computer that was on the TAR and that the nurse would sign it but that it was only when resident was not on therapy. She added that when the resident was on therapy the RNA would leave the binder for the other staff to document. The surveyor requested to see the documentation. On 6/27/24 at 10:06 AM, the DoR provided the surveyor a copy of Resident #94's RNA's documentation for the splint. A review of the provided Functional Maintenance Program Flow Record for Resident #94's Splinting/Brace program included the following: June 2024 had 18 days that the RNA signed that Resident #94's splint was donned and doffed by the RNA. There were 8 days that were blank. May 2024 had 19 days that the RNA signed. There were 12 days that were blank. April 2024 had 20 days that the RNA signed. There were 10 days that were blank. March 2024 had 21 days that the RNA signed. There were 9 days that were blank. February 2024 had 19 days that the RNA signed. There were 9 days that were blank. January 2024 had 21 days that the RNA signed. There were 10 days that were blank. The surveyor asked the DoR about the blanks. The DoR stated that he did not know how nursing documented the splint. There was no documented evidence that Resident #94's splint was applied on the days that the RNA was not at the facility. On 6/27/24 at 10:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the process for splint. The LPN stated that the RNA applied the splint when she was working. She added that when the RNA was not here that the CNA or the nurse would apply the splint and that here was a section in the TAR that they signed. The surveyor asked the LPN if the CNA also documented the splint applied. The LPN stated that she believed that the CNA also documented in the computer but was not sure. She added that she did not think that the CNA documented in a binder and that the RNA only had a binder. At that same time, the surveyor then showed the LPN the forms that the DoR provided and she confirmed that there were blanks and that the CNA's were not documented on that form. The LPN then viewed the TAR and confirmed that there was a new order placed in the TAR on 6/26/24, after surveyor inquiry, for Resident #94's splint. The surveyor asked the LPN what the importance of having the order in the TAR. The LPN stated that it was to ensure that the splint was applied each day and to prevent further contractures. On 6/27/24 at 10:24 AM, the surveyor interviewed the RNA regarding the binder that she documented in. The RNA stated that she did not leave the binder for the CNA's when she was not here. There was no documented evidence that Resident #94's splint was applied on the days that the RNA was not at the facility. On 6/27/24 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for splinting. The DON stated that the RA documented the splint in a binder. The surveyor then asked if the RA was at the facility seven days a week. The DON stated that the RA was not at the facility seven days a week and that the nurses documented the splint in the TAR. The surveyor then asked the DON about the missing documentation of the splint for Resident #94. The DON stated that she was informed after surveyor inquiry and that they failed to have the documentation. On 6/27/24 at 01:10 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON and [NAME] President of Operations (VPoO) the concern that Resident #94 did not have any documented evidence that the splint was applied on the days that the RA was not there. On 6/28/24 at 11:41 AM, in the presence of the survey team, LNHA and DON, the VPoO stated that the staff was inserviced on documentation for splints. The facility did not provide any additional information. A review of the facility provided policy titled, Functional Maintenance Program with a revised/reviewed date of 01/2024, included the following: The facility's Functional Maintenance Program (FMP) is designed to assist residents to achieve and maintain an optimal level of function. When a resident is discharged from skilled therapy to FMP, the following steps are followed: The treating therapist will initiate recommendations for FMP and notify nursing of these recommendations with appropriate instructions and training of recommendations. An FMP order will be placed in the resident's electronic chart and care planned. The care plan shall be written with nursing interventions which will give direction to the CNA's for assisting the resident in the program. CNA's shall aid the residents in performing the recommended FMP. These CNA's will be under the direction of a licensed nurse who will collaborate their activities with PT/OT (physical therapy/occupational therapy). The CNA's shall document daily in the FMP log. This log will be reviewed monthly by the nursing and rehab team and monthly nursing summary will be completed to evaluate the current program. The policy did not contain any information in regards to splints and documentation while a resident received skilled therapy. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the incontinence care plan was developed according to the resident's assessment to provide appropriate treatment and services for the care of the resident who had frequent urine and occasional bowel incontinence according to the facility's policy and procedure, for one (1) of one (1) resident, Resident #134, reviewed for bowel and bladder incontinence. This deficient practice was evidenced by the following: On 6/24/24 at 11:39 AM, the surveyor observed Resident #134 seated in a wheelchair in the Therapy room (also known as the dining area) with other five residents for early lunch. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #134. Resident #134's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypotension unspecified (low blood pressure), traumatic subdural hemorrhage (caused by a traumatic head injury) without loss of consciousness, cerebral infarction (also known as a stroke) due to embolism of a left posterior cerebral artery, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiplegia (paralysis) and hemiparesis (muscle weakness) following cerebral infarction affecting right dominant side, other secondary hypertension (elevated blood pressure), depression unspecified, and anxiety disorder. The most recent Significant Change Minimum Data Set (SCMDS), an assessment tool used to facilitate the management of care, dated 3/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had moderately impaired cognition. The SCMDS also showed that the resident was coded for frequently incontinent of urine and occasionally incontinent of bowel. Also, the SCMDS revealed that the resident was not on a bladder and bowel toileting program. Further review of the SCMDS revealed that on Section V Care Area Assessment (CAA) Summary, #6 Urinary Incontinence and Indwelling Catheter that area was triggered and was checked to proceed with Care Plan (CP). The CAA included that the urinary incontinence was an actual problem, and the nature of the problem: Resident is noted more B & B (bladder and bowel) accidents. Resident is assisted with his/her toileting for safety. The CP's consideration was to address the problem to proceed with CP, with an overall objective to slow or minimize the decline. A review of the personalized CP showed that there was no focus CP, goals, and interventions for B & B incontinence. Further review of the medical records showed that the above SCMDS CAA for #6 was not followed to proceed with CP for B & B incontinence. A review of the Tasks for the Certified Nursing Aide (CNA) in the electronic medical records revealed that the task description for bladder continence and bowel continence, frequency was every shift. On 6/25/24 at 9:54 AM, the surveyor interviewed the Registered Nurse (RN). The RN stated that the resident was alert with some forgetfulness with behavior of verbally abusive to staff and other residents at times. She further stated that Resident #134 with periods of B & B incontinence, staff assisted the resident in toileting. On 6/28/24 at 8:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that Resident #134 was incontinent of B & B. The RN/UM stated that she was responsible for initiating, reviewing, and revising the CP. She added that RN Coordinator (RNC) was also responsible for the resident's CP. The RN/UM further stated that she was unsure if incontinence should be care planned for. At that time, the surveyor notified the RN/UM of the above concerns. On 6/28/24 at 9:13 AM, the surveyor interviewed the assigned CNA of Resident #134. The CNA stated that the resident was alert with periods of confusion, with periods of incontinence in both B & B. The surveyor asked the CNA how often she checked on the resident for incontinence and what kind of care and assistance was provided to the resident. The CNA responded that at least every two hours or more. The surveyor then asked again the CNA, how she knew the resident should be checked for two hours or more, the CNA responded that based on her experience as a CNA. On 6/28/24 at 9:20 AM, the surveyor interviewed the MDS Coordinator/RN (MDSC/RN). The MDSC/RN stated that she was responsible for the CAA in the MDS for the nursing side including the Continence/incontinence. At that same date and time, the surveyor notified the MDSC/RN about the above findings and concerns including the CAA for #6 that there was no CP. The MDSC/RN stated that there should be a CP for incontinence and that she will check on it and get back to the surveyor. On 6/28/24 at 10:21 AM, the MDSC/RN in the presence of the survey team informed the surveyor that she did not see a CP for incontinence and that should have been care planned. On 6/28/24 at 11:29 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the [NAME] President of Operations (VPoO). The surveyor notified the facility management of the above findings and concerns. A review of the facility's Incontinence Care Policy with a reviewed/revised date of 01/2024 that was provided by the LNHA included that the facility shall provide care for all incontinent residents. The Procedure included that the check residents at least every two hours. A review of the facility's Plan of Care and IDCP Team Meeting Policy with reviewed date of 01/2024 that was provided by the LNHA included that the facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, and goals. Procedures: -The plan of care shall be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as appropriate. -the plan of care shall be documented in the facility's EMR (electronic medical record) system. Interdisciplinary Care Plan (IDCP) Team meeting: -The IDCP Team meeting shall be held after completion of the comprehensive assessment, quarterly or more frequently, as needed. On 7/01/24 at 11:58 AM, the survey team met with the LNHA, DON, and VPoO for an Exit Conference. No additional information was provided by the facility management, and the facility did not refute findings. NJAC 8:39-11.1, 11.2 (e)(1,2), 27.1(a)

Based on interview, record review and review of pertinent documents, it was determined that the facility failed to protect a resident (Resident #182) from abuse by a Certified Nurse Aide (CNA #1) by failing to ensure: a.) the facility policy was followed to identify an allegation of abuse, b.) that upon receiving an allegation of abuse on 01/17/23 during the 7:00 AM to 3:00 PM shift, the facility immediately protected Resident #182, and other residents from potential abuse, and c.) a thorough investigation was immediately initiated. This deficient practice occurred for 1 of 2 residents reviewed for abuse, and on 1 of 4 resident units. The facility's failure to ensure the abuse policy was followed to protect a resident from abuse, and ensure a process was in place to protect all residents from potential abuse resulted in an Immediate Jeopardy (IJ) situation that began on 01/17/23 when a family member of Resident #182 informed the facility that CNA #1 was not nice to Resident #182, and had and attitude, and the facility failed to immediately initiate an investigation and CNA #1 proceeded to work on the same resident unit the following day, 01/18/23, and was assigned to nine residents. The facility administration was notified of the IJ situation on 01/19/23 at 2:56 PM. The facility submitted an acceptable removal plan on 01/20/23 at 9:00 AM. On 01/20/23 at 9:00 AM, the removal plan was verified as implemented by the survey team during the survey. The non-compliance remained on 01/20/23 for no actual harm with the potential for more than minimal harm, that is not Immediate Jeopardy, based on the following: The evidence was as follows: On 01/19/23 at 8:27 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a written memo that she had received regarding a request to speak with a family member. On 01/19/23 at 8:46 AM, the surveyor contacted the family member (FM) of Resident #182 and conducted a telephone interview. The FM stated Resident #182 had an issue with CNA #1 who had walked into Resident #182's room and was nasty to Resident #182 on 01/17/23. The FM stated CNA #1 told the resident that she was not going to have to change (provide incontinence care) the resident again, since Resident #182 was not her only resident. CNA #1 told Resident #182 that she was on her break at the time, and CNA #1 refused to change Resident #182. CNA #1 then proceeded to throw down the food plate lid with force on Resident#182's over bed table. The FM stated that he/she had made the Director of Social Services (DSS) aware of what happened on the same day, 01/17/23. On 01/19/23 at 8:50 AM, the surveyor interviewed Resident #182 while the resident was in bed. Resident #182 stated that he/she had a problem with a female Certified Nurse Aide (CNA #1) on Tuesday (01/17/23). Resident #182 stated that CNA #1 told him/her that he/she was not her only resident, and CNA #1 also threw the meal tray down. Resident #182 stated that CNA #1 had seemed mad at the time because CNA #1 stated she was on her break. Resident #182 stated he/she had informed the DSS what happened on the same day, 01/17/23. On 01/19/23 at 8:54 AM, the surveyor reviewed the CNA assignment sheet for 01/19/23, with the Unit Manager (UM). The assignment sheet for 01/19/23, revealed that there were two CNAs listed to care for the residents on the unit. The surveyor inquired to the UM what the current resident census was for the unit. The UM stated thirty-eight residents were on the unit, and the surveyor asked what the staffing typically was, and if any of the CNAs that had worked on 01/17/23 were removed from the schedule for any reason. The UM stated that there was usually five or six CNAs staffed on the unit, and he was not sure who had called out sick. The UM then stated no, CNAs had been removed from the schedule for any reason and stated there were three CNAs that had scheduled days off (which included CNA #1). On 01/19/23 at 9:23 AM, the surveyor conducted an interview with the DSS and inquired if there were currently any investigations in progress. The DSS stated that he had received a grievance from Resident #182 on 01/17/23. At that time the DSS provided the surveyor with the copy of the [Facility Name], Grievance/Missing Item Report, which revealed: Date: 01/17/23 (untimed), Resident: [#182], Room: [Resident #182's room number]. Complaint Made By: Patient, Complaint Made to: DSS, Statement of Complaint:, On 01/17/23, at about lunch time, the patient stated a CNA threw the lid cover on the food/tray table. A handwritten Addendum documented directly below the 01/17/23 Statement of Complaint revealed On 01/18/23, on the date above, the Patient stated that the same CNA, while on the total lift machine, wanted to be placed in bed .The statement continued on a blank page which revealed . and in need of a change of [his/her] disposable brief, the CNA stated, Your [sic.] not my only patient, there's no way I'm doing this tomorrow. While in bed, [he/she] was not changed by that CNA. After a while, [he/she] was changed by someone else. The DSS stated that he completed his portion on 01/17/23, when the FM of Resident #182 brought him into the resident's room to speak with Resident #182, and he confirmed that he took the statement from Resident #182 and stated, the complaint was made to me. The DSS stated he brought the initial complaint, on 01/17/23, to the Director of Nursing (DON), because when the complaint involved nursing the DON was responsible for getting statements. The DSS stated that the DON was responsible for the investigation, along with the LNHA, who was the facility abuse coordinator. The DSS stated I would imagine the Director of Nursing has followed up on it [the complaint made by Resident #182]. The DSS stated that he conducted a follow-up interview with Resident #182 on 01/18/23, and at that time, the resident provided an additional statement that he also documented on the form. At that time, the surveyor requested and the DSS provide the surveyor with a copy of the facility abuse policy. The surveyor inquired to the DSS if what Resident #182 stated to the DSS would fall under the abuse category. The DSS stated, yes, that it is verbal abuse, neglect, and it touches many bases. The DSS stated again, he immediately informed the DON of the allegation made by Resident #182 on 01/17/23. The surveyor inquired to the DSS what the process was when an allegation of abuse occurred, and what his involvement was. The DSS stated he was not involved with the abuse investigation, he assisted with grievances, and missing items, and because the allegation received from the FM and Resident #182 was related to abuse. The DSS stated I immediately told the DON and stated, I would imagine that the DON has followed up on it. The surveyor asked the DSS if this allegation would be a priority, and he stated, yes, and the first thing that would be done would be [CNA #1] would be removed from providing care, and stated if it is alleged abuse, then she cannot come to the facility until the investigation is completed, because you would not want someone who was alleged to have performed an abusive act working because it could happen again. The DSS stated when he took the initial complaint from Resident #182, he had initially thought it was an allegation of abuse and neglect because CNA #1 failed to perform care for the resident, and then slammed the lid down which was aggressive and possibly violent. The DSS stated he was instructed by the DON to provide the UM with blank statement forms on 01/17/23, which he had done, and he instructed the UM to get the statements per the DON's instructions. The DSS stated he provided the copy of the grievance form to the UM on 01/18/23. The surveyor asked the DSS what further involvement he had in the abuse investigation process, and had he received any further communication regarding the allegation provided by the DON/ LNHA, and he stated, no, not to me. An initial review of the Facility Policy/ Procedure, Abuse Prevention Program, Original Issue Date: 2/2014, Revised: 10/21/22, in the presence of the DSS revealed under Part V, Investigation, Procedure: The administrator who is the Abuse Prevention Program Coordinator, and the DON will initiate investigations of any allegations of abuse, determine necessary response, and report to the office of the Ombudsman and the Department of Health and Senior Services, as necessary. The scope of the investigation shall be determined by the Administrator and/or the DON. The Protection Procedure revealed, When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor, notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. On 01/19/23 at 9:50 AM, the surveyor conducted an interview with the UM for the unit that Resident #182 resided on. The surveyor inquired to the UM if he had received any complaints or was currently involved in any investigations regarding any residents. The UM stated that the FM of Resident #182, came to him on 01/17/23 and informed him that CNA #1 had an attitude, and she was not nice to the resident. The UM stated that he informed the DON and the DSS the same day of the FM's complaints. The surveyor inquired if the UM had been instructed to do anything because of the complaint. The UM stated, I was told to take statements, but because the UM found out late in the afternoon on 01/17/23, CNA #1 had already left for the day and he was unable to obtain a statement. The UM confirmed to the surveyor that CNA #1 was the CNA assigned to Resident #182, and then stated he obtained a statement from CNA #1 on 01/18/23, which was the following day after the allegation The UM stated that CNA #1 worked her full resident assignment on 01/17/23 and again on 01/18/23. At that time, the surveyor reviewed the 01/18/23, 7:00 AM-3:30 PM assignment sheet for the CNAs, and CNA #1's assignment included nine residents. Resident #182's room had both beds crossed off, and it was replaced with two other beds in another room. The UM stated that when CNA #1 arrived to work on 01/18/23, that she had started her assignment first, and then he had spoken to her (time not provided by UM) regarding the reason for being removed from providing care to Resident #182. However, the UM confirmed that CNA #1 continued to work and was assigned to a resident care assignment which included nine residents. The assignment was located on the same unit where Resident #182 still resided and had access to Resident #182, and all other residents. The surveyor asked the UM if he had been provided a copy of the grievance from the DSS, and he stated, yes. The surveyor asked the UM if what was written on the form represented abuse and neglect, and the UM stated, yes, and stated CNA #1 told him, it never happened, and that Resident #182 was happy with the care she had provided. The surveyor asked the UM if he had interviewed anyone else regarding the allegation. The UM stated he had interviewed the four CNAs (including CNA #1) that worked on the unit on 01/17/23, the date when the allegation was received, and the surveyor asked if the UM had interviewed anyone else in addition to the CNAs. The UM stated, no, and the surveyor then asked if the UM had interviewed any residents. The UM stated, no, and that he provided the statements he collected to the DON. The surveyor inquired to the UM if it was still an ongoing investigation, and the UM stated yes. On 01/19/23 at 10:46 AM, the surveyor, in the presence of the survey team, interviewed the DON and LNHA. The surveyor asked what the process was if there was an allegation of abuse. The DON stated the process was, if there was an allegation of abuse, an investigation would be started immediately, and stated right away after she received the complaint. The surveyor inquired if there had been any recent complaints, or allegations of abuse. The LNHA stated there was a grievance provided by the DSS, and the DON and LNHA confirmed it was provided to both on 01/17/23, and the LNHA stated she had been made aware by the UM on 01/17/23 at 4:00 PM. The surveyor asked what the process was when a grievance was received. The DON stated as soon as she received it, that she would identify the caregiver and nurse assigned to the patient, and then she would obtain a statement from the staff that were involved with the resident, including the family, doctor, nurses, and other residents assigned to the staff. The DON stated that the assigned aide to the person who had the complaint would be suspended while the investigation was ongoing, because we don't want any incident to happen, we want to protect the resident and any other resident assigned. The surveyor informed the DON and LNHA that CNA #1 worked on 01/18/23, despite the DON stating the staff would be suspended during the investigation, and the surveyor informed the DON and LNHA that the UM had confirmed he was made aware of the allegation on 01/17/23 and CNA #1 was allowed to work and provide resident care the following day. The surveyor asked about Resident #182's allegation that CNA #1 threw the lid cover, and the DON stated, I would say that was an attitude, and the DON stated based on that assumption she took CNA #1 off Resident #182's assignment. The surveyor asked where attitude would fall in the abuse policy and the LNHA stated it was just sensitivity, and the DON stated the employee could have burnout but may not have intended to be insensitive to the resident. The DON stated we would have to investigate to see if there was an intention of abuse. The DON was asked if there had to be intention for abuse and the DON responded to the survey team, no. The DON then stated that we spoke with the aide on 01/17/23 (no time provided), after the complaint was made. When the surveyor inquired to the DON when she was informed about the incident from the UM, the DON stated, I could not even remember what he told me on 01/17/23, because it was late in the afternoon. The surveyor inquired to what time the DON received the statement from CNA #1, and the LNHA stated we found out at 4:00 PM about the allegation, and that was when the statement was written. At that time, the surveyor inquired to the LNHA who had the facility received statements from, and the LNHA confirmed she had a statement from CNA #1, and three other CNAs who worked that day. The DON stated we didn't get statements from the nurses that worked that day and then stated that they received statements from the four CNAs that worked on 01/17/23, and the UM. The surveyor inquired to the DON if she had interviewed the resident when she had found out about the allegation on 01/17/23, the DON stated yes, at 3:00 PM, but that was late in the afternoon. The surveyor asked what the DON had asked the resident, and the DON stated, how are you today and no other specific questions per the DON. The DON stated the UM also spoke with the resident on 01/17/23 and confirmed there was no documented evidence when inquired by the surveyor. The DON stated that other alert and oriented residents would still need to be interviewed to obtain statements, and confirmed the investigation was not complete yet, that they cannot just let it go, and we don't tolerate that. The surveyor asked was anything done for residents who were not alert and oriented and the DON stated we would do a body assessment. The surveyor inquired if that was done and the DON stated no, and the LNHA stated we could ask the family members about any concerns with the caretaker. The LNHA stated yesterday was really when the investigation began, and the other day was just a comment. The surveyor inquired if the investigation was completed on 01/18/23, and the DON stated, no. The surveyor then asked if it the investigation was not completed, was CNA #1 supposed to work and have a resident assignment on 01/18/23. The DON stated, this was given to us late, and the DON and LNHA did not offer an explanation as to why CNA #1 worked on 01/18/23 and provided resident care. The surveyor asked why it was important to interview other staff, and the LNHA stated to make sure other residents are safe. The surveyor asked what kind of an allegation the statements made by Resident #182 represent, the DON stated, a complaint. The surveyor asked if the allegation was an allegation of abuse, and the LNHA stated, yes. The surveyor asked is there anything else that should be done when an allegation of abuse was made. The LNHA stated I have to report it to the State and Ombudsman within two hours, and confirmed it was reported to the State Department of Health on 01/19/23, two days later, and not within two hours. On 01/19/23 at 12:00 PM, the surveyor reviewed the medical record for Resident #182 which revealed the following: An Admission Record revealed the resident had diagnoses which included, but were not limited to; respiratory failure, chronic obstructive pulmonary disease, and pneumonia. The Admission Minimum Data Set, an assessment tool, dated 01/14/23, revealed the resident was totally dependent on one person for toileting, and had no behavioral symptoms. The Care Plan included a Focus: date initiated 01/11/2023 for an ADL (Activity of Daily Living) deficit r/t (resulted to) general weakness, Goal: Resident will improve current level of function in (bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score) through the review date, a Focus: date initiated 01/11/23 for Resident is at risk for falls r/t general weakness, osteoarthritis, Goal: Resident will not sustain serious injury through review date, Interventions: Anticipate and meet needs, Anticipate toileting needs, Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance, Monitor effects of medications, a Focus: date initiated 01/11/23, Resident has a potential for skin breakdown secondary to limited mobility in bed, Goal: Resident will have care needs met as evidenced by no skin breakdown, Interventions included: keep skin clean and dry, sheets as wrinkle free as possible, observe skin during bathing, turning, and incontinence care for early signs of breakdown, turn and reposition resident every 2 hours and as needed, use proper positioning, transferring, and turning techniques to minimize skin injury due to friction and shear force (all interventions date initiated 01/11/2023). On 01/19/23 at 12:21 PM, the surveyor requested a copy of the investigation file from the LNHA and the LNHA stated the DSS was still in the process of collecting interviews. On 01/19/23 at 12:23 PM, the LNHA provided the surveyors with an incomplete copy which included page one and three of the Reportable Event Record that was submitted to the Department of Health, Dated 01/19/23 and Timed, 9:55 AM, along with a copy of a statement from CNA #1, dated 01/17/23 (untimed), a statement, dated 01/17/23 (untimed) from CNA#2, a statement from CNA #3, dated 01/18/23 (untimed), and a statement from CNA #4, dated 01/17/23 (untimed). The statements also included the Grievance/Missing Item Report from the DSS with additional information added in the Department Responsible for Resolution section statement, dated 01/18/23 and a statement dated, 01/17/23 from the DON (untimed), and a statement from the UM, dated 01/17/23 (untimed). The handwritten statement dated 01/17/23 and signed by the UM revealed .8:00 AM During rounds, pt [patient] was in bed eating breakfast and watching TV [television], 10:20 AM pt was helped with his/her am [morning] care and went to rehabilitation gym for pt/ot [therapy], 12:00 PM pt in bed having lunch, 2:00 PM CNA's helped with diaper change spouse at the side, 3:00 PM Pt [patient] was in bed resting. Pt did not voiced [sic.] any complaint to me. The statement written by the UM failed to include the allegations confirmed by the UM that he had received from the FM of Resident #182 on 01/17/23, who had informed him that CNA #1 had an attitude, and she was not nice to the resident, and the statement failed to document any follow-up from the allegations the UM received from the DSS which the UM confirmed had confirmed receiving, and failed to document any follow-up regarding the allegations that the UM confirmed he received from the DSS. The statement provided from CNA #1 on 01/17/23 contradicted what the UM stated regarding not being able to obtain a statement from CNA #1 because she had already left for the day, and he stated he informed her of the allegations on 01/18/23. On 01/19/23 at 1:02 PM, the surveyor, in the presence of another surveyor, interviewed Resident #182 with the FM present. The surveyor asked Resident #182 about the incident that occurred with CNA #1, and how it made the resident feel. Resident #182 stated it made him/her feel not good, and he/she was upset and shocked, and the resident was concerned for how he/she would receive care the following day after the incident. Resident #182 stated CNA #1 was mad and left the room and then stated there was no one present when the CNA was not nice to the resident. The FM stated they now had to hire private care to ensure Resident #182 would receive care. On 01/19/23 at 1:30 PM, the DON provided the Time Card Report, for CNA #1 which revealed CNA #1 worked 01/17/23 from 6:55 [AM] to 15:30 [3:30 PM], and on 01/18/23 from 6:53 [AM] to 15:47 [3:47 PM]. On 01/19/23 at 1:36 PM, Surveyor #2 conducted an interview with the UM. Surveyor #2 asked the UM when he was first made aware of the allegations made by Resident #182. The UM stated the FM of Resident #182 told the UM on 01/17/23, and the UM immediately informed the LNHA and DON. Surveyor #2 asked the UM if he had interviewed Resident #182, and he stated I just asked how [he/she] was and [he/she] stated fine. The UM failed to document the allegation received from the FM, failed to document any interviews with Resident #182 regarding the allegations made by Resident #182, nor with the resident's spouse or FM. A further review of the Policy/Procedure: Abuse Prevention Program, Original Issue Date: 2/2014 revealed Policy: This facility prohibits abuse, neglect, involuntary seclusion, and misappropriation of property from residents and will utilize the abuse prevention program to effectively prevent occurrences, screen and train staff, identify, investigate, report, and respond to any occurrences .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Forms of resident abuse: Active Forms of Abuse: .2. Verbal Abuse: Talking to residents in a demanding manner, shouting, cursing, and name-calling ., Passive Forms of Abuse: 1. Emotional Abuse: Deliberately ignoring a resident's request, denying a resident water, food, a bedpan, a call bell, etc. for a period of time., 2. Neglect: The failure of the facility, it's employees, or service provides to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress (ex: [example] allowing a resident to lie in urine or feces, ignoring a resident, not providing daily cleanliness, personal hygiene, proper mouth care, shaving, hair washed and combed, dressing a resident inappropriately and or in dirty clothing. Leaving resident exposed during bathing, dressing, changing etc .). Neglect of goods or services may occur when staff are aware of residents' care needs, based on assessment and care planning, but are unable to meet the identified needs due to other circumstances, such as lack of training to perform an intervention (Example-suctioning, transfers, use of equipment. Lack of sufficient staffing to be able to provide the services, lack of supplies, or lack of knowledge of the needs of the resident. Abuse Prevention Program-Part VII- Protection, Procedure: When a potential abuse incident is reported to a supervisor, the immediate priority is the safety of the resident, who is to be removed from potential danger. After the supervisor notifies the administrator and the DON after ensuring the temporary safety of the resident, the administrator and the DON will make permanent arrangements for the resident's safety. Staff members being investigated for possible involvement in abuse will be removed from contact with the resident, such as suspended pending results of the investigation, as necessary. Abuse Prevention Program-Part V1- Identification, Procedure: .Any unusual occurrence, which may potentially constitute abuse, neglect, or involuntary seclusion, will be identified as a potential abuse incident and investigated as such .Abuse Prevention Program-Part V11 Reporting/Response .When an incident is reported to the supervisor, the supervisor is responsible for ensuring that the resident is safe and will notify the administrator as well as the DON, or their designees The administrate and DON will initiate the investigation of the potential abuse incident, determine the necessary response and report to the Department of Health and Senior Services and/or the office of the Ombudsman (if applicable) as per regulations including Peggy's Law. Alleged violates involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .The scope of the investigation shall be determined by the administrator and/or the DON . N.J.A.C. 8:39-4.1 (a)5,12; 27.1(a)

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to a.) provide adequate supervision, b.) follow the facility accident policy and initiate new fall prevention interventions in response to falls, and c.) implement existing interventions to prevent falls (5 of 6 falls reviewed were determined that the resident was left unsupervised). These failures resulted in Resident #92 sustaining multiple falls including a fall on 11/08/21 that required an emergency room transfer on 11/08/21, when Resident #92 fell out of a wheelchair, hit a tray table, sustained a laceration to the right frontal scalp, and was admitted to the hospital with a mechanical fall with head trauma and laceration without obvious intracranial bleed. This deficient practice occurred for 1 of 1 residents reviewed for falls (Resident #92) with injury and was evidenced by the following: On 01/06/23 at 10:20 AM, the surveyor entered the room and observed Resident #92 in bed, positioned on the right side at the edge of the bed, with no device in place to prevent him/her from sliding off of the bed. The surveyor left the room and alerted the staff that Resident #92 was at the edge of the bed. At 10:30 AM, the Regional Nurse informed the surveyor she had observed the same positioning of the resident and she had placed a cushion to prevent Resident #92 from sliding off of the bed. The surveyor later returned to the room, and observed Resident #92 in a recliner chair inside the room. On 01/09/23 at 11:30 AM, the surveyor observed Resident #92 in the dining room seated at a table. The nurse attempted to assist Resident #92 with the lunch meal, Resident #92 could not open their eyes or his/her mouth to eat. The Licensed Practical Nurse (LPN) attempted to stimulate the resident, she was calling the resident's name and asked the resident to wake up. The LPN was unsuccessful. Resident #92 was transferred to bed and the physician was contacted. On 01/10/23 at 9:15 AM, the Unit Manager informed the surveyor that Resident #92 was transferred to the hospital and was admitted . On 01/10/23 at 12:05 PM, a follow up interview was conducted with the nurse who was observed in the dining room with the resident on 01/09/23. She stated that she was assigned to Resident #92 on 01/09/23 during the day shift. The nurse stated a Certified Nursing Assistant (CNA) was having difficulty getting her/him to eat and drink. Resident #92 would eat a bite or two, and then his/her alertness would come and go. The physician was called and Resident #92 was admitted to the hospital with hypernatremia (elevated levels of sodium in the blood). On 01/10/23 at 12:30 PM, the surveyor requested all fall investigations for Resident #92 and a timeline for review from the Director of Nursing (DON). On 01/10/23 at 1:30 PM, the surveyor reviewed Resident #92's medical record. The Admission Face Sheet reflected that Resident #92 had diagnoses which included but were not limited to; history of falling, major depression disorder, pressure ulcer of sacral region and anxiety disorder. Review of the the most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/05/22, revealed that Resident #92 received a score of 03 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of severe cognitive impairment. A review of the facility provided Fall Risk assessment dated [DATE], revealed Resident #92 scored 15 which indicated the resident was a high fall risk. Review of Resident #92's undated Comprehensive Care plan provided by the facility on 01/09/23, revealed: A focus area: Resident #92 has a history of frequent falls related to poor balance, unsteady gait as evidence by syncope and collapse, had a prior fall prior to hospitalization sustained left humerus fracture. Readmit 10/05/2021, with fall incident at facility 09/29/21, sustained bump forehead, no other abnormalities noted . The goal was that Resident #92 will resume usual activities without further incident through the review date. The interventions /Tasks included: Check range of motion. Continue on the at-risk plan. Keep needed items, water, etc, in reach. Monitor side effects of medication. Monitor/document /report PRN [as needed] x 72 hours to physician for sign/symptoms: pain, bruises, change in mental status, new onset: confusion, inability to maintain posture, agitation. Pharmacy consultant to evaluate medications. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Physical therapy consult for strength and mobility. Rehab [rehabilitation] screen. Sent the Resident to Emergency Department for evaluation. Staff to assist Resident #92 back to bed before 11:00 PM. Anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests. keep residents in common areas for increased observation. Place patient close to the nursing station for monitoring. Further review of the Care Plan revealed that Resident #92 sustained falls at the facility on the following dates: 1. 09/28/21 at 5:45 AM, Found on the floor and had a bump on the forehead. A review of the incident report revealed that Resident #92 received the following medications Xanax , an anti-anxiety medication at 12:48 AM. Tylenol with Codeine an narcotic analgesic for pain at 12:50 AM. Resident #92 was left in the room in the wheelchair unsupervised. According to the facility, the contributing factor was behavior. 2. 11/08/21 at 9:25 PM, fell from wheelchair in the dayroom sustained laceration on the right forehead measuring 4 centimeters (cm) x 0.1 cm. Resident unable to recall what happened. Transfer to hospital for evaluation. Contributing factors: Resident #92 was confused, poor safety awareness. The surveyor reviewed the Medication Administration Record (MAR) and noted that Resident #92 was medicated with Remeron (an antidepressant medication) used as a sleep aid at times, and was left unsupervised in the dayroom in the wheelchair. A review of the history and physical from the hospital record dated 11/09/21, revealed the following: Presented to the Emergency Department (ED) for evaluation after patient fell out of a wheelchair, hitting a tray table, sustained a laceration to the right frontal scalp. The diagnosis was: Mechanical fall with head trauma and laceration without obvious intracranial bleed. The surveyor did not observe any updated interventions on the Care Plan specific for the 11/08/21 fall. 3. 04/25/22 at 11:00 PM, heard resident calling out for help. Was found sitting on the floor leaning on the bed, in front of the wheelchair. Resident #92 informed the staff that he/she was trying to self transfer to bed, but could not do it. Prior to the fall at 9:00 PM , Resident #92 received Depakote a mood stabilizer and Remeron 15 mg. Resident #92 was left unsupervised in the wheelchair in the room. Contributing factors: Behavior, confusion. Interventions: Staff to assist patient back to bed before 11:00 PM. A Drug regimen review completed by the Consultant Pharmacy and dated 04/24/22, documented, Resident found on the floor on 04/25/22 leaning on the bed in front of wheelchair. Resident #92 claimed to have fallen while trying to transfer to bed. Resident is on Depakote and frequently takes Tylenol with Codeine which can both contribute to dizziness and falls. Please encourage to call for assistance when needing to transfer to and from bed. There was no documentation in the medical record that Resident #92 was being monitored after being medicated with the above medications. 4. 05/16/22 at 9:00 PM, Resident #92 slipped out of the wheelchair while in the room. Resident unable to describe what happened. Resident #92 received Remeron 15 mg orally and was left in the wheelchair unsupervised. Interventions: Keep bed in the lowest position, floor mat to the floor. Dycem (non-slip cushion) applied to wheelchair. Rehabilitation screen. 5. 07/21/22 at 11:05 PM, the nurse was sitting at the desk, heard patient screaming, I am on the floor, help me, help me . Resident #92 was found on the floor on the right side next to the wheelchair. The care plan did not include any new interventions in response to this fall, to prevent further falls, or to ensure Resident #92's safety in the event of further falls. A Drug Regimen Review from the Consultant pharmacy dated 07/23/22, again documented, Staff responded to Resident screaming from room, Resident claimed to have slid from wheelchair. Resident is on routine Desyrel/ Depakote which may increase risk for dizziness and falls. Resident also has orders for PRN [As needed] Xanax and Tylenol with Codeine which may further contribute to falls. 6. 11/29/22 at 13:20 PM [1:20 PM], found on the floor mat next to the bed, redness noted to the left hip. Patient transferred to nursing station for close supervision. Resident #92's MAR dated November 2022, revealed that Resident #92 received the following medications at 21:00 [9:00 PM]: Remeron 15 mg, Trazodone 150 mg, Depakote 250 mg, Buspar 10 mg and Gabapentin 300 mg prior the fall The interventions /Tasks included: Check range of motion. Continue on the at-risk plan. Keep needed items, water, etc, in reach. Monitor side effects of medication. Monitor/document /report PRN [as needed] x 72 hours to physician for sign/symptoms: pain, bruises, change in mental status, new onset: confusion, inability to maintain posture, agitation. Pharmacy consultant to evaluate medications. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Physical therapy consult for strength and mobility. Rehab screen. Sent the Resident to Emergency Department for evaluation. Staff to assist Resident #92 back to bed before 11:00 PM. Anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests. keep residents in common areas for increased observation. Place patient close to the nursing station for monitoring. On 01/13/23 at 10:30 AM, the surveyor interviewed the Director of nursing (DON). The DON reported that the Interdisciplinary Team (IDT) which included all the department heads, met once a week to discuss, falls, pressure ulcers, weight loss, and psychotropic medications. She stated that on 11/09/21, the IDT had met and discussed Resident #92's fall that occurred on 11/08/21. She indicated that the IDT team did not discuss the use of the psychotropic medication as a contributing factor for Resident #92's fall nor suggested that Resident #92 should be returned to bed after being medicated for pain/anxiety. The DON stated that Resident #92 would refuse to go to bed, however there was no documented evidence that staff offered Resident #92 to be returned to bed after being medicated, or that he/she had refused. On 04/25/22, the fall investigation documented the following under Resident Description, Patient said, he/she was getting up to transfer to his/her bed and could not do it. On 01/19/23 at 9:30 AM, the surveyor interviewed the Registered Nurse (RN) who worked on the 11:00 PM -7:00 AM shift regarding the protocol after any resident received pain medication and other medications used to facilitate sleep. The RN stated that staff were to check residents after 30 minutes for the effectiveness of the medication and the residents should be in bed to prevent falls. The RN could not remember the exact incident but she remembered she administered Xanax and Tylenol with Codeine to Resident #92, after the surveyor presented her with the investigation report dated 09/23/21 for review. She indicated that Resident #92 reported having pain and was anxious. She stated that she should have documented it in her notes the resident's response after the medication was administered. When asked if she had tried non-pharmacological approach prior to administering the Xanax, she stated that she could not recall. The nurse also stated that she didn't know why she did not document that Resident #92 was reassessed 30 minutes after the medication was administered. On 01/19/23 at 9:42 AM, the surveyor interviewed the Unit Manager (UM) regarding the facility's fall protocol. The UM stated that all residents identified to be high risk for falls, were to be closely supervised. When prompted regarding the protocol after pain medication and psychotropic medications had been administered, she replied, Residents should be in bed and closely monitored for safety. The surveyor then asked the UM who was responsible to monitor the dayroom when residents were in attendance. The UM stated that activity staff were to be with residents in the dayroom. The surveyor then escorted the UM to the dayroom and we both observed 7 residents sitting in the dayroom, and there was no staff monitoring the residents. A review of the facility's policy titled, Accident/ Incident Report dated 02/12 and last revised 12/15/17, reveled the following: Policy: The facility has a system whereby all residents incidents/accidents are reported to the department supervisor and implementation of timely interventions to establish a reduction of repeated incidents/accidents. Procedure: Carry out physician orders and ensure appropriate interventions are in place. Update care plan with new interventions as appropriate. All incident/accident reports are tracked and reviewed by the IDCP team for trends and appropriateness of current interventions. A summary of all incidents/accidents will be reviewed quarterly by the QAPI Committee for trends, locations, times and related hazards. If a trend is identified, the IDCP team will assess the system for additional and necessary interventions. NJAC 8:39-27.1 (a)

COMPLAINT # NJ Based on interviews, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate nutrition to prevent unplanned weight loss, identify causal factors for a resident's weight loss and implement interventions to prevent further weight loss in a timely manner for 1 of 3 sampled residents (Resident #3). Resident #3 was admitted to the facility and lost 8.6 pounds in 18 days, despite being weighed four times during that time period. In addition, the diet provided to the resident did not meet her nutritional needs and meal intake records for the same time periods differed. This deficient practice is evidenced by the following: 1. According to the facility Face Sheet, Resident #3 was admitted in January, 2012 with [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 1/27/2012, showed Resident #3 was cognitively impaired and needed assistance with all Activities of Daily Living (ADLs), including eating. The MDS indicated the resident's weight was 156 pounds (lbs) and was on a mechanical soft diet. A facility Care Plan (CP), dated 1/15/2012, showed Resident #3 was at risk for weight loss status [REDACTED].#3 "is vegetarian". Interventions included but were not limited to; monitor weights per recommendations, dietary assessment for nutritional needs, offer substitutes PRN (as needed), assess for pain/discomfort as this may affect appetite, family member prefers to fill out select menu, offer feeding assist and cueing, monitor meal acceptance, honor food preferences, monitor labs per MD (physician's) orders and observe for likes/dislikes. On 2/2/2012, a 3 day calorie count was added, and on 2/7/2012 [MEDICATION NAME] 800mg PO (by mouth) and "Two Cal HN", a nutritional supplement 30cc BID (twice daily) were added as interventions. There was no indication in the CP of a "planned" weight loss program. Additionally, another CP, dated 2/2012 documented the problem of a decrease in PO intake which put Resident #3 at increased risk for weight loss. The goal was to have PO intake meet her needs to retard significant loss. Some interventions included; provide mechanical soft diet, monitor wts (weight) and labs, implement 3 day calorie count (CC), modify interventions as needed, provide supercereal, pudding, ice cream, juice with all meals and [MEDICATION NAME] (a medication to increase appetite). The CP indicated that after review of the completed Calorie Count, completed on 2/5/2012, Resident #3's needs were not met and additional interventions, that were not specified, were added. Review of the POS [REDACTED]. On 2/7/2012 [MEDICATION NAME] 800mg PO daily, labs and a nutritional supplement 30cc BID was ordered. On 2/8/2012, the POS showed an order to send the resident to the hospital with a [DIAGNOSES REDACTED]. A nursing, Admission Clinical Assessment, dated 1/15/2012, showed Resident #3's weight at 156.6 lbs. A "Weekly Weight Sheet" (WWS) showed the following; 1/15/2012 156.6 lbs 1/19 153 lbs 1/26 151 lbs 2/2 148 lbs 2/9 discharged to hospital There was no indication in Physician, Nutritional or Nurse's Progress Notes of any documentation regarding Resident #3's weight loss of 3.6 lbs on 1/19/2012, 4 days after admission or the additional 2 lb wt loss on 1/26/2012, for a total weight loss of 5.6 lbs which was a 3.6% weight loss in 11 days after admission. It was not until 2/2/2012, 18 days after admission to the facility, when the resident's weight had decreased by 8.6 lbs, which was a 5.5% loss, that an intervention, a 3 day CC, was initiated. An Admission Nutritional Assessment, dated 1/21/2012, by the Registered Dietician (RD) showed Resident #3's weight for 1/12 was 156.6 lbs. The Estimated Daily Needs for Calories was 1475-1770 calories. The Assessment/Recommendations included the following; a family member of Resident #3 was seen by the food service director (FSD) and was "offered the option to select her menu. She is a vegetarian and specific food preferences were given and noted" in the kitchen. The RD noted that "upon admission PO intake was (decreased) but has improved from fair to good (it fluctuates)...provided with 8 oz milk and juice with all meals". There was no indication the RD was aware of Resident #3's weight loss of 3.6 lbs since admission, even though during an interview on 5/17/2012 at 11:30AM, she told the surveyor she was aware the resident had a lost 3.6 lbs, but had not documented it. There was also no indication of follow up until 2/3/2012 when the RD documented that it was reported to her that the resident had "poor PO intake" and the CC was initiated. Interview with the RD on 5/17/2012 at 1:30PM confirmed the family member was choosing the food/beverage items the resident received for meals. When asked by the FSD for a copy of a menu of what the resident would have received for meals prior to 2/2/2012, she stated they did not keep that information and didn't have meal tickets. However, the RD stated that the menu items the family member selected were skim milk, fruit, vegetables, yogurt and cottage cheese which was consistent with "wt reduction", but there was no indication that she advised the family member at that time that the resident would lose weight on such a diet. Review of a Certified Nurses Aides (CNA) Accountability Record indicated the percentage (%) of food consumed at each meal was to be recorded by the CNA. Poor consumption was equal to (=) 25%, fair = 50% and good = 75%- 100%. Of 19 meals consumed between 1/15/2012 and 1/21/2012, the record showed 10 times 40-50% was consumed and 60-80% was consumed 9 times. From 1/22/2012 through 1/31/2012 the resident consumed 30 meals of which 60% was consumed 5 times and 75-100% was consumed 25 times. Review of the NNs on 1/16/2012 showed a 30% consumption for Breakfast, 50% for Lunch and 60% for Dinner. However the CNA Accountability Record showed 50% consumption for Breakfast, Lunch and Dinner on 1/16/2012. On 1/17/2012 NNs indicated 80% was consumed for Breakfast, Lunch and Dinner, but the CNA Accountability Record showed 40% consumed for Breakfast, 50% for Lunch and 60% for Dinner. On 1/18/2012, the NN at 5PM showed 80% consumed for Dinner, but the CNA Accountability Record appeared to indicate to 75% of dinner was consumed. On 1/22/2012 the NN at 5PM indicated fair appetite was noted for Dinner, but the the CNA Accountability Record showed 75% was consumed at Dinner. On 1/27/2012 NNs documented at 10AM and 12PM that 80% of Breakfast and 60% of Lunch was consumed while the CNA Accountability Record showed 75% of Breakfast and 80% of Lunch was consumed. On 2/3/2012, Nutritional Progress Notes by the RD showed that it was reported Resident #1 had a decrease in PO intake and a CC was initiated. Review of the 3 day CC Summary Sheet, dated 2/3/2012 through 2/5/2012 showed Resident #3 consumed the following: On 2/3/2012 - Breakfast 100% of 1/2 cup fruit juice, 3/4 cup cereal and 2 pieces pancake/french toast Lunch 100% of 6 ounces soup and 4 ounces milk Dinner 20% of entree, 45% of 1/2 cup of starch and 0 of 1 slice bread (not eaten). On 2/4/2012 Breakfast 100% of 1/2 cup fruit juice and 1 ounce of egg. Lunch 100% of 6 ounce soup and 4 ounces milk. Dinner 10% entree and 100% of 4 ounces juice and unspecified amount of soup with crackers On 2/5/2012 Breakfast 100% of 1/2 cup fruit juice and 1 ounce egg. Lunch 100% of 6 ounces of soup, 1 slice bread and 4 ounces milk Dinner 95% of bread, and 100% of 4 ounces juice and and an unspecified amount of soup. The type of entree, soup, juice, cereal, starch and milk was not specified. The CC Summary did not document the amount of calories at the bottom of the sheet where the "intake for the day" was to be noted. Additionally, there was no indication on the CC Summary Sheet that Resident #3 was provided with the 8 oz of milk and juice at every meal per the RD initial assessment on 1/21/2012. During an interview with the surveyor at 11:30AM, the RD was asked how it was determined that the resident's caloric intake didn't equal the amount of calories needed after reviewing the 3 day CC due to the fact there was no indication on it or in the NN of the amount of calories consumed. The RD stated that she "can just tell not enough calories "by items consumed, don't need to calculate it". During the same interview the the surveyor validated with the RD and the FSD if what was written on the CC was all that the resident received on her tray. Both verified that was what she was given and what she ate and if something was on the tray, but not eaten it would be documented as a zero. Review of the CNA Accountability Record from 2/3/2012 to 2/5/201, the same dates as the 3 day CC period showed that on 2/3/2012 25% of breakfast was consumed, 100% lunch and 10% of dinner was consumed. On 2/4/2012 70% of breakfast, 80% of lunch and 10% of dinner was consumed. On 2/5/2012 50% of breakfast, 70% of lunch and 10% of dinner was consumed. The NNs for the same time period differed with the CC and the CNA Accountability Record. The NN, dated 2/3/2012 at 9AM showed "Pt. (patient) ate oatmeal (4 oz), drank 6 oz skim milk and 100% yogurt". On 2/3/2012 at 5PM the NN showed "spoonfed dinner X (with) 1 assist. Consumed all of soup and juice and 15% of main dish. Calorie count in progress". On 2/5/2012 at 5:30PM, NN showed "ate soup, juice and portion of sandwich".. The RD's notes, dated 2/6/2012 showed the CC indicated "resident has (decreased) PO intake and her needs are not met. The daughter was making selections that are for a 'wt. reducing diet'. Skim milk, fruit, vegetables, yogurt, cottage cheese were included and increased calorie foods were excluded. The RD added supercereal, pudding and ice cream and documented that she may benefit from additional supplements. "RD will speak to (family member) and advise her to include (increased) calorie foods" to help meet the resident's needs better. On 2/7/2012, the RD documented; "RD met with (family member) and resident was present. RD informed the (family member) that her menu selections were too low in calories and she may benefit from foods like pudding, ice cream...nutritionally dense foods and supercereal were advised." The "RD explained that needs may not be met since she is "burning up" calories from Physical Therapy...". The RD explained to the family member that it was like going to "weight watchers" then going to the gym. The RD noted the family member after much explaining stated she understood and agreed to select increased calorie items from the menu. Additionally the RD noted a recommendation of a nutritional supplement, multivitamins with minerals and [MEDICATION NAME] (if a candidate) and noted that she "suspects her PO intake will improve when she is given foods she likes". The family member also stated the resident "loves sweets". On 2/8/2012, the RD noted she spoke with the resident's physician regarding the nutritional status and [MEDICATION NAME] and a nutritional supplement was ordered. The RD explained that the family member's "menu selection suggested a wt. reduction diet". The family member "selected items such as cottage cheese, skim milk fruits, vegetables yogurt and did not include pudding, ice cream, cake etc". Additionally, the RD noted that when the family member came in to pick up the resident's belongings because the resident was being discharged to the hospital on [DATE], the family member said "How dare you tell the doctor I had (Resident #3) on a wt reduction diet, I did no such thing." The RD attempted to explain that her selection of low calorie and elimination of increased calorie foods "replicated a weight reduction diet". However there was no indication that the RD had spoken to the family member about this issue prior to 2/7/2012. During an interview with the surveyor on 5/17/2012 at 11:30AM, the FSD stated she met with Resident #3's family member "a lot" to discuss food selection as she did not want sweet desserts so "we made sure it was what she wanted, she was a vegetarian..." She stated she was on a "select" menu which meant the resident/family member could select what they wanted. When asked by the surveyor if anyone in the kitchen monitored what was being ordered met the calorie requirements required, she stated that nursing monitored what was eaten and the kitchen would provide what was chosen. When the surveyor asked the FSD for a copy of a menu that the resident would have consumed during her stay, she stated they did not keep them but she did have a copy of a menu selection that was chosen by the family member for the week after she was discharged from the facility. The surveyor was provided/observed a copy of the menu selection chosen for 2/11/2012, which would have been after the RD and family member had spoken about increasing Resident #3's calorie intake. The menu included apple juice, oatmeal, waffles and syrup for breakfast, cottage cheese, sweet potatoes and italian mix vegetables and cranberry juice for lunch and for dinner cottage cheese, vegetable pasta salad, pineapple and 8 oz skim milk. During the same interview, the surveyor asked the RD if the calories in the above menu selection met the Estimated Daily Needs for Calories noted at 1475-1770 calories in the initial assessment done on 1/21/2012. The RD stated the above menu would be approximately 1200-1400 calories, which would meet 75% of her needs, depending on the amount eaten. She stated she had made rounds and spoken with the resident and family member and the family member had also been bringing in food from home which would have increased her caloric intake. She added that she had not documented any of the foods brought in or if the resident had consumed the food(s) brought in from home. There was no indication that Resident #3 was receiving the calories the RD initially assessed her as requiring on 1/21/2012 and/or did not address the weight loss or low calorie diet selection with the family member prior to 2/2/2012 . Review of Hospital Admission Records, dated 2/8/2012 showed the reason for hospitalization , according to Resident #3, was that she was very weak and had poor appetite. The admitting [DIAGNOSES REDACTED]. NJAC 8:39-27.1 (a) 8:39-27.2 (a&e)