Every finding on record at Allendale Rehabilitation and Healthcare Center

Complaint #3092316 Based on interviews and review of pertinent facility documentations on 8/27/26, it was determined that the facility failed to conduct a thorough investigation following an unwitnessed fall of a resident (Resident #1). This deficient practice was identified for 1 of 5 residents reviewed for incidents and accidents and was evidenced by the following:The surveyor reviewed the medical record of Resident #1.A review of the admission Record (AR), an admission summary, revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes mellitus, malignant neoplasm of the brain (brain cancer), aphasia (difficulty speaking), muscle wasting, and other mechanical complication of the ventricular intracranial (communicating) shunt. A review of the Minimum Data Set (MDS), an assessment tool dated 6/8/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which meant a severely impaired cognition. The MDS further revealed that the resident required assistance from staff to complete their activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (CP) included a focus area dated 6/1/26 , which indicated that the resident was at risk for falls related to generalized weakness. Interventions included but were not limited to assist in change of position, be sure call light was within reach, and keep personal items and frequently used items within reach. A review of the resident's Progress Notes (PN) included a Physician's Progress Notes (PPN) dated 7/3/26 at 4:40 PM. Under chief complaints, PPN indicated, established patient presents for follow-up evaluation and management, yesterday slide from bed - no dizziness, no head injury, vitals stable.Fall and Aspiration precautions discussed. Further review of the resident's PN revealed no other documentations dated 7/1/26 or 7/2/26 pertaining to Resident #1's fall or slide from bed. The surveyor requested for a list of residents' incidents and accidents from 5/1/26 to 8/26/26. The Assistant Director of Nursing (ADON) provided a facility's document titled: Incident List which revealed that Resident #1 had no incidents of falls from 5/1/26 to 8/26/26. On 8/27/26 at 2:34 PM, the surveyor interviewed Resident 1#'s Resident Representative (RR) on the telephone. The RR stated that she arrived at the facility around 2:30 PM on 7/2/26, and found the resident on the floor near the bed. RR further stated that the resident was not hurt, no broken bones, and that she called for help immediately and that the head nurse, Registered Nurse Unit manager (RN /UM) and two aides came and helped her get the resident up from the floor and into the bed. RR stated that Resident #1 was trying to get out of their wheelchair and had no access to call light.On 8/27/26 at 3:19 PM, the surveyor interviewed the registered nurse unit manager (RN/UM) in the presence of the Licensed Nursing Home Administrator (LNHA) and ADON. When asked about the resident's fall incident, RN/UM stated that he did not recall much detail about the incident, and he acknowledged that he notified the resident's physician about the fall. RN/UM confirmed that he did not initiate an incident report of the unwitnessed fall. During follow up interview at 4:25 PM, RN/UM stated that the resident's assigned nurse checked the resident's vital signs, evaluated the resident for pain, and neuro completed was completed. He also stated that he should have completed an incident report. On 8/27/26 at 5:16 PM during exit conference, the ADON stated that an incident report (IR) should have been completed according to facility protocol. A review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, with revision date 7/2017, under Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident ore incident. N.J.A.C. 8:39-4.1(a)5

Based on observations, interviews, record reviews, and reviews of facility policies, the facility failed to ensure Infection Control measures were maintained 1. during incontinent care for one resident (Resident (R) 5) of one resident reviewed for incontinent care in a total sample of 29 residents, 2. during separation of clean and soiled laundry, and 3. in a water management program for Legionella bacteria. These failures placed residents at risk of cross-contamination of bacteria and increased health complications.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with a diagnosis of a non-traumatic brain injury. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/29/25 revealed R5 was assessed by staff to be severely impaired in cognition and was incontinent of bowel and bladder. During an observation on 11/24/25 at 9:57 AM, Certified Nursing Assistant (CNA) 3 entered R5's room to provide morning cares. After CNA3 removed a urine-soaked brief and provided peri care she did not remove her soiled gloves or use hand hygiene before continuing on to clean her legs. During an interview on 11/24/25 at 10:18 AM, CNA3 was asked if she had changed her gloves or used hand hygiene after providing incontinent care to R5. CNA3 stated, No, I didn't. During an interview on 11/25/25 at 8:44 AM, the Director of Nursing (DON) was informed of the lack of hand hygiene and change of gloves when performing incontinent care for R5. The DON stated, CNA3 is very aware of infection control and incontinent care. I have in-services all the time, she knows better. 2. Observation on 11/25/25 at 3:35 PM with Laundry Aide (LA)1, the Housekeeping Supervisor, and Director of Environmental Services, revealed that the laundry room was one large room with the three washing machines located nearest the door and the two dryers were located at the back of the room. The folding area was located across the hall in another room. The Housekeeping Supervisor stated, The soiled laundry is sorted on the unit and then brought to the laundry room and then placed into the washer. After washing, the laundry then goes to the dryer area at the back of the room. After the laundry is dried, it is placed into a bin and then transferred across [the soiled area] to the folding room across the hall. In addition, the soiled area of the laundry room did not contain gowns, gloves, or masks and the bottle of disinfectant, used to clean the bins and doors to the washing machines, was located in a bin, under clean items and on top of clean linen. When asked about having to go across a soiled area with clean laundry, the Housekeeping Supervisor and the Director of Environmental Services stated they understood this could be an issue. During an interview on 11/25/25 at 4:30 PM, Infection Preventionist (IP) was asked if she was aware of the situation in the laundry with the clean linen having to pass the soiled linen area to go to the folding area. The IP stated, No, I was not aware. 3. On 11/25/25 at 6:18 PM, the Maintenance Director was asked for his water management plan including documentation of a floor plan which indicated where the water from the city entered the facility and how the water moved through the facility and areas where standing water may pool and any testing being done. The Maintenance Director stated he did not designate potential sites of pooling water or water sources to be tested if needed. Review of the facility procedure titled, Departmental (Environmental Services)-Laundry and Linen dated January 2014 revealed, .The purpose of this procedure is to provide a process for the safe and aseptic handline, washing, and storage of linen .Employee sorting or washing linen must wear a gown and gloves .Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times . Review of the facility policy titled, Legionella Water Management Program dated September 2022 revealed, .Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella .The water management program includes the following elements .A detailed description and diagram of the water system in the facility, including the following: Receiving; Cold water distribution; Heating; Hot water distribution; and Waste .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: Storage tanks; Water heaters; Filters; Aerators; Showerheads and hoses; Misters, Atomizers, Air washers, and Humidifiers .and Medical devices such as CPAP machines . NJAC 8:39-19.4

Based on observation, interview, record review, and facility policy review, the facility failed to ensure hair washing was provided during showers for one resident (Resident (R) 49) of four residents reviewed for ADLs (Activities of Daily Living) in a total sample of 29 residents. This failure placed the residents at risk of a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R49 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, and anxiety disorder. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/06/25 revealed R49 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated R49 was severely impaired in cognition and required moderate assistance with bathing/showering. Review of the 09/29/23 ADL Self Care Performance Care Plan located in the Care Plan tab of the EMR revealed, I have an ADL Self Care Performance Deficit r/t limited mobility secondary to (L) [left] hip fracture. The Care Plan did not contain documentation of approaches/interventions for bathing/shower or hair washing assistance. During an observation on 11/23/25 at 2:52 PM, R49 was observed to have significant greasy hair in which it was separated and hung down across her face. R49 was asked if staff wash her hair when they give her a shower. She stated, Yes, they wash my hair. During an interview on 11/23/25 at 2:55 PM, Certified Nurse Aide (CNA) 2 was asked if R49 was receiving ADL assistance. CNA2 stated, When I shower her, she is pleasant, but you have to explain what you are doing with her. I can't speak to anyone else though. CNA2 further stated, They [CNAs] are supposed to wash hair when a shower is given. During an interview on 11/25/25 at 5:15 PM, the Director of Nursing (DON) stated, After you told me about R49's greasy hair, I went to check on her. The DON confirmed that R49's hair had not been washed. The DON further stated, Some of the aides use grease in the residents' hair, even though they are not African American. R49 is white and does not need grease in her hair. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting dated 2001 revealed, .Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with .hygiene (bathing, dressing, grooming, and oral care) . NJAC 8:39-4.1(a)22

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)68) reviewed for side rails out of 29 sampled residents. The lack of alternate side rail measures and proper assessment/consent increased the potential for restraint or side rail entrapment. Findings include: Review of R68's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis of muscle weakness. Review of R68's admission Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/16/25 revealed a Brief Interview for Mental Status (BIMS), score of eight out of 15 indicating severe cognitive impairment. This MDS revealed that R68 was able to self-transfer. Review of R68's Care Plan located under the Care Plan tab of the EMR dated 09/16/25, revealed no care plan for side rail use. Review of R68's Physician Orders located under the Orders tab in the EMR dated 09/16/25 revealed no order for side/bed rail use. Review of R68's MQS Admission/readmission Evaluation located under Assessments tab in the EMR dated 09/16/25 stated bedrail assessment bed/side rails were not used. Interview and observation on 11/23/25 at 11:40 AM and 11/25/25 at 10:10 AM revealed R68 in bed with side rails up on the right side. R68 stated the side rails had been on her bed since she was admitted , and that the right side was always in the up position, and the left side was at times. R68 stated that she did not use the side rails as an enabler when moving in bed or transferring herself from the bed. During an interview on 11/25/25 at 10:06 AM Licensed Practical Nurse (LPN)5 verified the facility did not get informed consent prior to bedrail use or explore alternatives before implementing bedrail use. During an observation and interview on 11/25/25 at 10:20 AM, Registered Nurse/Unit Manager (RN)1 stated he was unaware that R68 had bedrails on her bed and he was not sure if there was signed informed consent for the resident to have bedrails. He observed R68 in bed with her bedrails. He also stated he was unaware that her admission assessment/bedrail use indicated she did not use bedrails. RN1 stated that he considered bed rails a safety risk. He confirmed there was no signed informed consent for the bedrail use. During an interview on 11/25/25 at 12:33 PM, the Director of Nursing (DON) stated that on the subacute unit where new residents were admitted all beds had bedrails. She stated she expected staff to evaluate and screen any resident prior to implementing bedrails and to obtain informed consent. Review of the facility policy titled Bed Safety and Bed Rails revised August 2022 revealed, resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic used during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternative interdisciplinary evaluation, resident assessment, and informed consent. NJAC 8:39-27.1(a)

Based on interview, record review, and facility policy review, the facility failed to ensure an abnormal involuntary movement scale (AIMS-a scoring system which uses a 0-4 rating scale for 12 items to assess the severity of the abnormal involuntary movements) was accurate and completed timely for three residents (Residents (R)10, R15, and R4) reviewed in a sample of29 residents. This failure placed residents at risk of not receiving care and services related to their psychiatric illnesses.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, activity levels, ranging from manic highs to depressive lows), major depressive disorder, and anxiety disorder. Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/01/25 revealed, R10 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R10 was cognitively intact, had rejection of care for four to six days out of seven days, and had been administered an antipsychotic medication during the seven-day observation period. Review of the Order Summary located in the Orders tab of the EMR revealed that R10 was prescribed, Olanzapine [an antipsychotic medication] 20mg [milligrams] at bedtime for bipolar disorder. Review of the 04/25/25 AIMS evaluation, provided by the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN) 1 had signed that he had performed the evaluation for R10. Section EP (examination procedure) revealed no documentation that LPN 1 had assessed R10 for Tardive Dyskinesia (TD-a drug-induced movement disorder characterized by involuntary movements, most commonly affecting the face, tongue, and limbs) as the EP was blank. In addition, there was no documentation to show that the November AIMS evaluation had been completed per the Evaluations tab in the EMR. During an interview on 11/24/25 at 5:29 PM, the DON stated, When I reviewed the Evaluations tab in the EMR, I found no AIMS evaluations for November as it was not triggered to be completed by the nurse assigned as the form was marked that R10 was not administered an antipsychotic medication. After reviewing the 04/25/25 AIMS the DON confirmed that the evaluation was not complete. During an interview on 11/24/25 at 5:56 PM LPN 1 confirmed that he had not received any training on how to perform the AIMS evaluations. LPN 1 further stated, I should have completed the full assessment. 2. Review of the admission Record located in the Profile tab of the EMR revealed that R15 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder, major depressive disorder, and dementia. Review of the annual MDS located in the MDS tab of the EMR with an ARD of 11/20/25 revealed, R15 had a BIMS score of four out of 15 which indicated R15 was severely impaired in cognition, had no behaviors, and was administered an antipsychotic medication during the seven-day observation period. Review of the Order Summary located in the Orders tab of the EMR revealed the following antipsychotic medications for R15:Quetiapine [an antipsychotic medication] 100 mgs daily every 12 hours for bipolar disorder.Quetiapine 300 mgs at bedtime for bipolar disorder. Review of an 04/18/24AIMS located in the Evaluations tab of the EMR revealed that R15 was evaluated for TD. The score documented on the assessment was 21 (the higher the score on a 0-28 score the greater the impact of the movements on the resident). Review of the Order Summary located in the Orders tab of the EMR revealed, Austedo [a medication that helps manage TD symptoms, though it does not cure the TD symptoms] twice daily for TD, dated 04/27/24. Review of the 11/16/23 Comprehensive Care Plan located in the Care Plan tab of the EMR did not show a focus, goal, or interventions for the use of Austedo for R15's abnormal movements. Review of the 09/11/25 AIMS evaluation, provided by the DON revealed Registered Nurse (RN) 1 had signed that he had completed the AIMS evaluation for R15. Review of the EP section of the AIMS revealed R15 was assessed to have had no TD symptoms and the score of 0. During an interview on 11/24/25 at 5:29 PM, the DON stated, I reviewed the AIMS and it appears that in April 2024 an AIMS was performed and the score was 21. September 2024 AIMS was not completed. After January 2025, the AIMS evaluations were moved to the quarterly assessments and were completed. During an interview on 11/24/25 at 6:05PM, RN 1 was asked if the September 2025 AIMS evaluation, which showed that R15 had no TD symptoms despite the previous evaluations and being administered a medication for TD, was correct. RN 1 stated, Yes. RN 1 was asked if he had any training on performing AIMS assessments. RN 1 stated, No, I have not. RN 1was directed to Section F #14 in which he documented that the TD movements did not disappear in her sleep. RN 1 was asked if R15 had no TD movements, why was this marked a No. RN 1 stated, That was wrong. 3.Review of R4's admission Record, located in the EMR under the Profile tab, revealed R4 was readmitted to the facility on [DATE] with diagnoses that included major depressive disorder, altered mental status, catatonic disorder, generalized anxiety disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of R4's Care Plan, dated 01/10/25 and located under the Care Plan tab in the EMR, revealed a focus of alteration in neurological status related to tardive dyskinesia (TD). Interventions included administering medications as ordered, monitoring and documenting for side effects and adverse reactions, and reporting findings to physicians or designees as clinically indicated. Review of R4's Physician Order, dated 03/13/25 and located under the Orders tab in the EMR, revealed R4 was to receive Latuda (Lurasidone HCL, an atypical antipsychotic) oral tablet 40 milligrams (mg), give one tablet mouth one time a day for bipolar disorder. Review of R4's Quarterly Evaluation, dated 07/08/25 and 10/08/25 and located under the Evaluations tab in the EMR, revealed no documented evidence R4 was monitored for tardive dyskinesia (a possible and well-known adverse reaction to the use of Latuda). Both evaluations were marked that the resident did not receive an antipsychotic medication and the AIMS section of both forms was left blank. Review of R4's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an ARD of 10/17/25, revealed R4 had a BIMS score of 11 out of 15, which indicated R4 was cognitively moderately impaired. The MDS recorded R4 received an antipsychotic medication daily. During an interview on 11/25/25 at 10:49 AM, the Assistant Director of Nursing (ADON) confirmed the AIMS evaluations should be completed for residents receiving antipsychotic medications, and those evaluations should be documented on the Quarterly Evaluation form. The ADON confirmed the AIMS evaluation had not been completed for R4 and should have been done since the resident was on Latuda. Review of an undated facility policy titled, Abnormal Involuntary Movement Scale (AIMS) revealed, .Residents using antipsychotic medications will be monitored for side effects and adverse consequences. The Abnormal Involuntary Movement Scale (AIMS) examination procedure may be used as an adjunct to periodically evaluate patients for signs of tardive dyskinesia (TD), to evaluate the effectiveness of treatment for TD, and to follow the severity of TD over time. NJAC 8:39-4.1(a)6

Based on interview, record review, and review of facility policy, the facility failed to ensure the admission PASARR (Pre-Admssion Screening and Resident Review-a mandatory review prior to admission to screen for mental illness and intellectual disabilities) was accurate for one resident (Resident (R)10) of two residents reviewed for PASARR in a total sample of 29 residents. This failure placed residents at risk of not receiving the appropriate mental health services.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, activity levels, ranging from manic highs to depressive lows), major depressive disorder, and anxiety disorder. Review of the 04/22/25 Level I PASARR located in the Miscellaneous tab of the EMR and completed by the hospital social worker, revealed that in Section II Mental Illness Screen stated, Does the individual have a diagnosis or evidence of a major illness limited to the following disorders.mood (bipolar and major depressive type). the section was marked No.Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/01/25 revealed, R10 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R10 was cognitively intact, had rejection of care for four to six days out of seven days, and was administered an antipsychotic medication, anti-anxiety medication and anti-depressant medications during the seven-day observation period. During an interview on 11/23/25 at 12:57 PM, R10 stated, I have bipolar disorder and have been in and out of psychiatric hospitals multiple times, but it's been more than two years since I was last admitted . During an interview on 11/24/25 at 4:00 PM, Licensed Social Worker (LSW) was asked if she reviews new admission PASARR's for complete documentation. The LSW stated, Yes, I typically do that. The LSW further stated, Her previous PASARR was correct by this most recent PASARR, now that I am looking at it, it is inaccurate. The psychiatric diagnoses are not documented on the page and R10's psychiatric treatment was not included, and she just had a significant change assessment, though it was not related to her mental illness. The LSW confirmed that a new PASARR should have been done as the one from the hospital was incorrect. Review of the facility policy titled, admission Criteria dated 2001, revealed, .All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. NJAC 8:39-5.1(a)

Based on observations, interviews, record review, and review of facility policy, the facility failed to utilize the physician ordered hand splints or a hand roll for two of two residents (Residents (R) 5 and R81) reviewed for contractures in a total sample of 29. This failure placed the residents at risk of further decreased range of motion (ROM) and worsening contractures (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints.)Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with a diagnosis that included a non-traumatic brain injury. Review of the Order Summary located in the Orders tab of the EMR revealed an order dated 08/27/25 to Apply bilateral hand splints for 4 hours twice daily. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/29/25 revealed, R5 had a staff assessed Brief Interview of Mental Status (BIMS) of three out of 15 which indicated R5 was severely impaired in cognition. During an observation on 11/23/25 at 11:43 AM, R5 was lying in bed with her arms bent at the elbow and her hands were lying on her chest. There were no hand rolls or hand splints observed. Her right hand was observed to be more contracted than her left. Hand splints were observed on the dresser to the left of R5's bed. During an interview on 11/23/25 at 2:07 PM, Family Member (FM)1, who asked to remain anonymous, stated They do not put any washcloths (hand rolls) in her contracted hands. She has splints but I'm not sure if they are putting them on or not. During an observation and interview on 11/24/25 at 11:48 AM, Licensed Practical Nurse (LPN)2 confirmed that R5 did not have hand rolls or hand splints on. During an observation on 11/25/25 at 7:44 AM, R5 was observed to have a hand roll lying on her chest instead of her hands and the hand splints were on the dresser to the left of R5's bed. 2. Review of the admission Record located in the Profile tab of the EMR revealed R81 was admitted to the facility on [DATE] with a diagnosis of a stroke with right side paralysis. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 09/24/25 revealed, R81 had a BIMS score of 12 out of 15 which indicated R81 was moderately impaired in cognition and had range of motion (ROM) impairment on one side. Review of the 04/28/24 Comprehensive Care Plan dated 06/14/24 revealed, I have hemiplegia [paralysis on one side of the body] or hemiparesis [muscular weakness] related to: CVA [cerebral vascular accident-stroke]. Interventions included Right arm trough on the wheelchair. There were no interventions for R81's right hand. During an interview and observation on 11/23/25 at 1:42 PM, R81 was lying in bed with her right arm bent at the elbow and her hand close to her face. There was no hand roll or splint. R81 stated, This is from my stroke. R81 was asked if staff provided her with a hand roll. R81 stated, No. Review of the current Order Summary located in the Orders tab of the EMR revealed no order for hand rolls, hand splints, or therapy for the right-hand contracture. During an observation on 11/24/25 at 8:49 AM, R81 was observed in bed. Her right hand did not contain a hand roll or splint. This observation was verified by Certified Nursing Assistant (CNA)1. During an interview on 11/25/25 at 12:45 PM, the DON was told about the lack of splinting and hand rolls for R5 and R18. The DON stated, We need to follow up with this. Review of the facility policy titled, Resident Mobility and Range of Motion dated July 2017 revealed, .Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility policy, the facility failed to provide timely repositioning for one (Resident (R)5) of two residents reviewed for positioning in a total sample of 29 residents. This failure placed the resident at risk of skin breakdown.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain injury, aphasia (language disorder caused by damage to the parts of the brain that control language, speech and understanding language), and respiratory failure. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/29/25 revealed R5 had a Brief Interview of Mental Status (BIMS) score of three out of 15 which indicated R5 was severely impaired in cognition, had no pressure ulcers, and was always incontinent of bowel and bladder. Review of the 02/14/25 ADL [activities of daily living] Self-Care Performance Deficit Care Plan revealed, I have an ADL Self Care Performance Deficit related to impaired mobility. During an interview on 11/23/25 at 2:29 PM, Family Member (FM) 1 was asked if staff were repositioning R5 regularly. FM1, who asked to remain anonymous, stated . I do not believe they are repositioning her every 2-3 hours. During an observation on 11/24/25 at 8:52 AM, R5 was lying on her back with her eyes closed. On 11/24/25 at 9:57 AM, Certified Nursing Assistant (CNA) 3 entered R5's room with supplies to provide morning cares. CNA 3 left the room after providing care and R5 was not repositioned off her back until 10:29 AM when two flat pillows, one on each side, were placed under her upper back however, R5 remained on her back. CNA3 was asked at on 11/24/25 at 10:33 AM why wasn't R5 placed on her side since she was on her back prior to cares. CNA3 stated that there were two pillows one on each side of her prior to starting cares and when she works with her, that is how she is repositioned by just placing pillows behind her. During an interview on 11/24/25 at 11:41 AM, CNA1 entered the room. The two flat pillows were next to R5's right hip, however, R5 was flat on the bed. CNA1 confirmed that R5 had not been repositioned and it should be done every 2 hours. CNA1 repositioned R5 onto her left side with pillows to support her. During an observation on 11/24/25 at 2:50 PM, R5 was observed on her left side, in the same position she was placed in earlier. During an interview on 11/25/25 at 8:44 AM, the Director of Nursing (DON) stated, She is to be repositioned and was aware the survey team had spoken to CNA1 and CNA3 regarding the repositioning needs for R5. The DON further stated, There is no excuse for it. Review of the facility policy titled, Repositioning dated May 2013, revealed, .The purpose of this procedure is to provide guidelines for the evaluation of resident positioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relied for residents . NJAC 8:39-27.1(a) NJAC 8:39-27.2(b)

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/13/24 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: Upon entering the kitchen the surveyor observed the FSD and Dietary Aide #1 (DA#1) both wearing earrings that hung more than one inch (in) from their earlobes. The FSD acknowledged both she/he and DA#1 were wearing jewelry that was prohibited in the kitchen area. On 6/17/24 at 9:04 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a kitchen policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, with a revised date of November 2022. Under the policy interpretation and implementation section it states, Fingernails/Jewelry, 17. Jewelry will be kept to a minimum. Hand jewelry and wrist jeweler are covered with gloves during food handling. On 6/17/24 at 12:46 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional Director of Nursing (RDON) and Administrator in Training (AIT) to discuss the above findings and concerns. There were no comments from facility staff. On 6/18/24 at 9:46 AM, the LHNA and DON met with survey team to provide explanations for previous concerns. The LNHA provided a copy of an in-service for the dietary staff for jewelry and hygiene. No further comments provided. NJAC 8:39-17.2(g)

Based on interviews and record review, it was determined that the facility failed to provide the resident or resident representative appropriate written notification of the facility's bed hold and reserve payment policy upon transfer to the hospital for two (2) of two (2) residents (Resident #69 and #85) reviewed for hospitalization s. The deficient practice was evidenced by the following: 1. A review of Resident #69's hybrid (combination of paper and electronic) medical record revealed the following: Resident #69's two discharge assessment-return anticipated Minimum Data Set's (DRAMDS), an assessment tool used to facilitate the management of care, reflected that the resident was transferred to the hospital. A review of Resident's hybrid medical record did not include a written notification of the facility's bed hold policy to the resident or resident representative (RR) prior to the transfer to the hospital. On 6/14/24 at 10:24 AM, the surveyor interviewed the Business Office Manager (BOM) regarding the facility's written notification of the bed hold policy process. The BOM stated that she would leave a message and mail a letter. She showed the surveyor a copy of the facility's bedhold policy and stated that she mailed out a copy of the policy. She then showed the surveyor a binder and stated that she kept a list of the residents that she mailed the policy to. On that same date and time, the surveyor asked if any additional information was provided each transfer to the hospital. The BOM stated that no additional information was given and that all residents were given the daily rate of the bed within 24-48 hours of their initial admission. The surveyor reviewed the document titled Bed Hold & Emergency Transfer Policy. The document included Date, Resident, To and Payor. The first three sections were filled out and the fourth section labeled Payor was blank. On 6/17/24 at 12:46 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations/Registered Nurse (RDoO/RN) and Administrator in Training (AIT), the concern that the facility did not provide Resident #69 written notification of the bed hold policy which included the reserve bed payment and other information. On 6/18/24 at 9:50 AM, in the presence of the survey team and the DON, the LNHA stated that she inserviced the BOM to include the rate on the information given to the resident and to include it on her log. The facility did not provide any additional information. 46049 2. On 6/14/24 at 11:50 AM, the surveyor reviewed the hybrid medical records for Resident #85 which revealed the following: According to the Admission Record (an admission summary), Resident #85 had diagnoses that included but were not limited to, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), hyperlipidemia (high levels of fat particles in the blood), and hypertension (high blood pressure). A New Jersey Universal Transfer Form and nurse progress notes documented Resident #85 was transferred to an acute care hospital on 3/21/24. A physician's order dated 3/21/24 read: Transfer to ER (emergency room ) for eval (evaluation). On 6/14/24 at 12:12 PM, the surveyor interviewed the Social Worker (SW) who stated the business office provided bed hold policy notifications to residents and/or RR. On 6/14/24 at 12:57 PM, the surveyor interviewed the BOM who confirmed she mailed the facility's bed hold policy and would also call RR. The BOM provided a list of residents in which bed hold policy notification was provided. Resident #85 was on the list. The BOM confirmed the facility's Bed-Holds and Returns bed policy was what was sent to all the residents or RR upon a resident's transfer. A review of the undated facility provided policy titled, Bed-Holds and Returns, included the following: 1. Residents may return to and resume resident in the facility after hospitalization or therapeutic leave as outlined in this policy. 2. The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid resident in the facility. 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid residents); c. the facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. the details of the transfer (per the notice of transfer). 4. Medicaid residents who exceed the state's bed hold limit and/or non-Medicaid residents who request a bed-hold are responsible for the facility's basic per diem rate while his or her bed is held N.J.A.C. 8:39-5.1 (a); 5.2 (a)

Based on observation, interview, and record review 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 three (3) of twenty four (24) residents, Resident #69, Resident #105 and Resident #306 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 6/13/24 at 10:31 AM, Surveyor #1 (S#1) observed Resident #69 seated in a wheelchair calling for the nurse. The Licensed Practical Nurse (LPN) stated to the surveyor that Resident #69 had just returned from dialysis. On 6/13/24 at 01:00 PM, S#1 reviewed Resident #69's medical record. A review of Resident #69's Admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (dependence on renal dialysis) and anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). The Discharge assessment-return anticipated Minimum Data Set (DRAMDS), dated [DATE], did not indicate Resident #69 received dialysis treatment. On 6/13/24 at 01:42 PM, S#1 requested the MDS Coordinator (MDSC) to print Resident #69's DRAMDS dated [DATE] section O which indicated if a resident received dialysis treatments. The printed copy did not indicate the resident received dialysis treatment. On 6/14/24 at 10:09 AM, S#1 interviewed the MDSC regarding Resident #69's DRAMDS. The MDSC stated that she had modified the DRAMDS after surveyor inquiry. She added that the DRAMDS should have been coded to indicate Resident #69 received dialysis treatment. She added that she followed the RAI (Resident Assessment Instrument) manual. On 6/17/24 at 12:46 PM, in the presence of the survey team, S#1 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations/Registered Nurse (RDoO/RN) and Administrator in Training (AIT), the concern that the Resident #69's MDS was coded incorrectly. On 6/18/24 at 10:09 AM, in the presence of the survey team and DON, the LNHA confirmed that the MDS not coded correctly and that the MDSC was inserviced and modified the MDS. 38327 2. On 6/13/24 at 01:41 PM, S#2 reviewed the closed medical records for Resident #105 and revealed the following: The quarterly MDS and the modified MDS with an assessment reference date of 4/07/24 did not identify the resident as a hospice resident, and the flu vaccine was offered and declined. The immunization record showed that Resident #105 received the flu vaccine on 12/06/23. The Universal Transfer Form dated 3/13/24 revealed that the resident had flu vaccine on 12/06/23. A review of the physician's order showed an order for hospice on 3/22/24. On 6/14/24 at 02:13 PM, S#2 in the presence of two other surveyors interviewed the MDSC and the Regional Case Manager/Registered Nurse (RCM/RN). The MDSC stated that the facility followed the RAI Manual for MDS and there was no separate policy for MDS. The surveyor notified the facility management of the above findings and concerns regarding the accuracy of coding the MDS for hospice and vaccination. Both facility management stated that they would get back to the surveyor. On 6/17/24 at 10:49 AM, Surveyor #3 interviewed the MDSC and the RCM/RN. The MDSC stated that it was missed to check off and indicated that the resident was under hospice care. 39399 3. On 6/17/24 at 11:53 AM, S#3 reviewed the discharge medical records for Resident #306 and revealed the following: The DRAMDS for Resident #306 dated 02/02/24 which revealed that the resident was discharged to an acute hospital. The Interdisciplinary Progress Notes dated 02/02/24 which documented that Resident #306 was discharged to home. On 6/17/24 at 12:56 PM, the survey team met with the facility's LNHA, DON, RDoO/RN, and AiT. S#3 discussed the above concern. A review of the facility provided policy titled, Discharge Assessments dated October 2023, included the following: 1. A discharge assessment is completed when: a. a resident is admitted to an acute care hospital; b. a resident has a hospital observation stay greater than 24 hours; . A review of the facility provided policy titled, Electronic Transmission of the MDS with a revised date of November 2019, included the following: 1. All staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual 4. The MDSC is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes. On 6/18/24 at 9:46 AM, the facility's LNHA stated that the MDS was coded in incorrectly and acknowledged that Resident #306 was discharged to home. No further information was provided. NJAC 8:39-11.1, 11.2(e)(1)

Based on observation, interviews, and record review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for one (1) of one (1) resident (Resident #3) reviewed for PASRR. This deficient practice was evidenced by the following: On 6/13/24 at 10:20 AM, the surveyor observed Resident #3 lying in bed in their room. The resident was alert and oriented. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #3 which revealed the following: According to the Admission Record (AR, an admission summary), Resident #3 had diagnoses that included but were not limited to, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety disorder, major depressive disorder, and paranoid schizophrenia (a type of delusion that usually involves persecution). Further review of the AR revealed the diagnosis of paranoid schizophrenia had an onset date of 01/18/23 during the stay of the resident at the facility. A quarterly Minimum Data Set (qMDS) assessment, a tool used to facilitate the management of care, dated 3/19/24, indicated the facility assessed the resident's cognition using a Brief Interview for Mental Status (BIMS) test. Resident #3 scored a score of 14 out of 15 which indicated the resident was cognitively intact. The qMDS in Section I, Active Diagnosis for Resident #3 included depression, anxiety disorder, and schizophrenia. There was no documentation found in the hybrid medical records of a PASRR (is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level I screen being completed for Resident #3 during their time at the facility. On 6/14/24 at 12:12 PM, the surveyor interviewed the Social Worker (SW) in the presence of the Licensed Nursing Home Administrator (LNHA) about PASRR processes. The SW stated a PASRR level I screen was completed for residents prior to admission to screen for mental disorders (MD), or intellectual disabilities to ensure a resident received appropriate care and services. On that same date and time, the SW further stated that if a Level I screen indicated a resident may meet the criteria, they would be referred for a PASRR Level II evaluation screening to determine if specialized services were needed. The SW stated a resident who had a new onset of a possibly serious mental disorder during their stay at the facility, a PASRR screen should be completed. The SW confirmed schizophrenia would be considered a serious mental disorder. At that time, the surveyor notified the SW that there was no PASRR found for Resident #3. The SW stated she would review and provide the surveyor with further information. On 6/14/24 at 01:44 PM, the Director of Social Services (DSS) provided the surveyor with a PASRR Level I for Resident #3. The DSS stated the PASRR provided was done today after surveyor inquiry and the resident did not trigger for requiring a PASRR Level II. She further stated that any prior PASRR for Resident #3 could not be found in their medical record or in the facility records. The DSS stated Resident #3 when admitted to the facility in 2021 had a diagnosis of schizophrenia and the PASRR should have been completed previously. On 6/17/24 at 10:45 AM, the surveyor interviewed the MDS Coordinator (MDSC) and the Regional MDSC about the resident's medical diagnoses. The MDSC and Regional MDSC stated the resident was admitted with unspecified schizophrenia and on 01/18/23 the diagnosis was updated to specify the resident's schizophrenia diagnosis to paranoid schizophrenia. Both the facility management acknowledged a PASSR should have been completed for the resident at the time of their admission. On 6/17/24 at 12:45 PM, the surveyor informed the Director of Nursing (DON), the LNHA, the Administrator in Training, and the Regional Director of Operations of the above concerns. The surveyor reviewed the facility provided policy titled Behavioral Assessment, Intervention and Monitoring, with a revised date of 3/2019. Under Policy Interpretation and Implementation, Assessment, it read: .a. All residents will receive a Level I PASRR screen prior to admission .b. If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASRR representative for the Level II (evaluation and determination) screening process . The surveyor reviewed the facility provided policy titled Admission Criteria, with a revised date of 3/2019. Under Policy Interpretation and Implementation, it read: .8. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process .a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD . On 6/18/24 at 10:10 AM, the DON and LNHA met with the survey team. There was no additional information provided by the facility. NJAC 8:39-11.2(i), 27.1(a)

Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to accurately: a) documenting medication administration for one (1) of 24 residents, Resident #18, reviewed for insulin medications, b) complete dialysis post assessment forms for one (1) of one (1) resident, Resident #69, reviewed for dialysis, and c) complete behavior monitoring sheets for one (1) of five (5) residents, Resident #50, reviewed for unnecessary medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 6/13/24 at 01:40 PM, the surveyor observed Resident #18 sitting in a wheelchair (w/c) in their room. The Resident was alert, oriented, and verbally responsive. Resident #18 stated they were diabetic and had no concerns with their care. The Surveyor reviewed the electronic health record (EHR) of Resident #18 which revealed the following: According to the Admission Record (AR, an admission summary), Resident #18 had diagnoses that included but were not limited to, type 2 diabetes mellitus, urinary tract infection, depression, and hypotension (low blood pressure). A quarterly Minimum Data Set (qMDS) assessment, a tool used to facilitate management of care, dated 4/29/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #18 scored a 15 out of 15, which indicated the resident was cognitively intact. Resident #18 had a care plan with a focus that read I have Diabetes Mellitus, initiated on 11/09/23. An intervention of the care plan read Diabetes medication as ordered by doctor. Monitor and document side effects and effectiveness. A physician's order (PO) dated 3/16/24 read: Insulin Lispro Injection Solution (Insulin Lispro) Inject 15 unit subcutaneously before meals for DM [Diabetes Mellitus]. A PO dated 3/25/24 read: blood sugar checks AC/HS [before meals and at bedtime], document in [EHR], no SS[sliding scale] coverage AC and at HS for DM2 [Diabetes Mellitus Type 2]. A PO dated 3/19/24 read: [brand name] Autocover Pen Needle Miscellaneous 30 G X 8 MM (Insulin Pen Needle) Inject 1 pen needle subcutaneously AC and at HS for DM A review of the April 2024 Medication Administration Record (MAR) revealed Insulin Lispro Injection entries were not signed by the nurses and left blank on 4/24/24 at 1600 [4 PM] and 4/27/24 at 1600. A review of the April 2024 MAR revealed blood sugar check entries were not signed by the nurses and left blank on: 4/24/24 at 1600, 4/24/24 at 2100 [9 PM], 4/27/24 at 1600, 4/27/24 at 2100, and 4/29/24 at 2100. A review of the April 2024 MAR revealed Insulin Pen Needle entries were not signed by the nurses and left blank on 4/24/24 at 1600, 4/24/24 at 2100, 4/27/24 at 1600, 4/27/24 at 2100, and 4/29/24 at 2100. Further review of the April 2024 MAR revealed the following medication (med) entries had no nurse signature and were left blank: - Ezetimibe Tablet 10 MG (milligram) Give 1 tablet by mouth at HS for cholesterol control, on 4/24/24 at 2100. - Lidocaine External Patch 4 % (Lidocaine) Apply to right knee topically one time a day for pain management remove at HS and remove per schedule, which was scheduled for removal on 4/27/24 at 2100. - Lidocaine External Patch 4 % (Lidocaine) Apply to right upper arm topically one time a day for strain remove at HS and remove per schedule, which was scheduled for removal on 4/27/24 at 2100. - Calcium Carbonate Oral Tablet (Calcium Carbonate) Give 1250 mg by mouth two times a day for supplement, on 4/24/24 and 4/27/24 at 1600. - Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, on 4/24/24 and 4/27/24 at 1700 [5 PM]. - Famotidine Tablet 20 MG Give 1 tablet by mouth two times a day for acid indigestion, on 4/24/24 at 1700. - Active Liquid Protein two times a day for 30 ml po [oral] supplement, on 4/24/24 and 4/27/24 at 1700. A review of the May 2024 MAR revealed Insulin Lispro Injection entries were not signed by the nurses and left blank on 5/11/24 at 1100 [11 AM], 5/12/24 at 1100, and 5/12/24 at 1600. A review of the May 2024 MAR revealed blood sugar check entries were not signed by the nurses and left blank on 5/11/24 at 1100, 5/12/24 at 1100, 5/12/24 at 1600, 5/12/24 at 2100, and 5/26/24 at 2100. A review of the May 2024 MAR revealed Insulin Pen Needle entries were not signed by the nurses and left blank on 5/11/24 at 1100, 5/12/24 at 1100, 5/12/24 at 1600, 5/12/24 at 2100, and 5/26/24 at 2100. Further review of the May 2024 MAR revealed the following med entries had no nurse signature and were left blank: - Ezetimibe Tablet 10 MG Give 1 tablet by mouth at HS for cholesterol control, which was scheduled for 5/12/24 and 5/26/24 at 2100. - Lidocaine External Patch 4 % (Lidocaine) Apply to right knee topically one time a day for pain management remove at HS and remove per schedule, which was scheduled for application on 5/11/24 at 0900 and 5/12/24 at 0900; and scheduled for removal on 5/26/24 at 2100. - Lidocaine External Patch 4 % (Lidocaine) Apply to right upper arm topically one time a day for strain remove at HS and remove per schedule, which was scheduled for application on 5/11/24 at 0900 and 5/12/24 at 0900; and scheduled for removal on 5/26/24 at 2100. - Calcium Carbonate Oral Tablet (Calcium Carbonate) Give 1250 mg by mouth two times a day for supplement, on 5/12/24 at 1600. - Docusate Sodium Capsule 100 MG Give 1 capsule by mouth two times a day for constipation, on 5/12/24 at 1700. - Famotidine Tablet 20 MG Give 1 tablet by mouth two times a day for acid indigestion, which was scheduled for 5/12/24 at 1700. - Active Liquid Protein two times a day for 30 ml po [oral] supplement, which was scheduled for 5/12/24 and 5/29/24 at 1700. A review of the June 2024 MAR revealed an Insulin Lispro Injection entry was not signed by the nurse and left blank on 6/9/24 at 1100. A review of the June 2024 MAR revealed a blood sugar check entry was not signed by the nurse and left blank on 6/9/24 at 1100. A review of the June 2024 MAR revealed an Insulin Pen Needle entry was not signed by the nurses and left blank on 6/9/24 at 1100. Further review of the June 2024 MAR revealed the following med entries had no nurse signature and were left blank: - Lidocaine External Patch 4 % (Lidocaine) Apply to right knee topically one time a day for pain management remove at HS and remove per schedule, which was scheduled for application on 6/9/24 at 0900. - Lidocaine External Patch 4 % (Lidocaine) Apply to right upper arm topically one time a day for strain remove at HS and remove per schedule, which was scheduled for application on 6/3/24 at 0900. On 6/14/24 at 11:16 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 about documentation of med administration. LPN #1 stated the MAR should be signed by the nurses at the time of med administration. LPN #1 further explained entries should not be left blank, nurses were to document when a med was administered and to document the reason why a med was not administered to a resident. On 6/14/24 at 11:20 AM, the surveyor informed the Director of Nursing (DON) of the concerns for missing signatures of nurses on the April 2024, May 2024, and June 2024 MARs. The DON stated she would review and provide further information. On 6/17/24 at 11:25 AM, the DON met with the surveyor. The DON acknowledged there were unsigned entries on the MARs of Resident #18. The DON could not respond to why there were blank entries and was following up with the nurses to determine what happened. The DON stated it was expected for the nurses to complete their MAR documentation at the time medications (meds) were administered and there should be no unsigned entries. The DON further explained if meds were administered or not, nurses had to sign the MAR and document the reason why a med was not administered. On 6/17/24 at 12:45 PM, the surveyor informed the DON, Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDoO/RN), and Administrator in Training (AIT), about the concerns of the missing nurse signature for the April 2024, May 2024, and June 2024 MARs of Resident #18. The surveyor reviewed the facility provided policy titled Administering Med, with a revised date of 04/2019. Under Policy, it read: Meds are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, it read: .4. Meds are administered in accordance with prescriber orders, including any required time frame .22. The individual administering the med initials the resident's MAR on the appropriate line after giving each med and before administering the next ones . On 6/18/24 at 9:47 AM, the DON and LNHA met with the survey team. The DON stated she was following up with nurses regarding the unsigned MAR entries and was providing education to nursing staff. There was no additional information provided by the facility. 39885 2. On 6/13/24 at 10:31 AM, the surveyor observed Resident #69 seated in a w/c calling for the nurse. The Licensed Practical Nurse (LPN #2) stated to the surveyor that Resident #69 had just returned from dialysis. On 6/13/24 at 01:10 PM, the surveyor asked the Unit Manager North Unit (UM/NU) to view Resident #69's Dialysis Communication Binder (DCB), which is a binder that contains documents that was filled out in three sections; by the facility prior to going to dialysis facility, by the dialysis facility post treatment and lastly by the facility when the resident returned to the facility. On 6/13/24 at 01:12 PM, the LPN #2 provided the binder to the surveyor and stated that she had not filled out the document post return yet but that she had assessed the resident and taken vital signs. On 6/13/24 at 01:20 PM, the surveyor reviewed Resident #69's DCB which included the following: Hemodialysis Communication Record (HCR) dated 6/11/24 Section 3. Completed by facility upon return from dialysis was blank. HCR dated 6/6/24 Section 3 was blank. HCR dated 5/21/24 Section 3 was blank. HCR dated 5/16/24 Section 3 was blank. There was a handwritten note dated 3/11/24 in the front of the HCB which included the following: Section 3-Completed by facility (Facility nurse) upon return. On 6/13/24 at 01:22 PM, the surveyor showed the LPN #2 Resident #69's HCRs that were blank. LPN #2 confirmed that Section 3 was blank and that they should have been filled out. On 6/13/24 at 01:30 PM, the surveyor interviewed the UM/NU regarding Resident #69's HCRs. The UM/NU stated that the HCR should be filled out by the nurse and that it was an assessment that was done by the nurse when the resident returned from dialysis treatment. She added that she usually checked the HCRs to make sure they were filled out before she moved them to a larger binder. On 6/13/24 at 01:40 PM, the surveyor reviewed Resident #69's medical record. Resident #69's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (dependence on renal dialysis) and anemia (condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). On 6/17/24 at 12:46 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, RDoO/RN and AIT, the concern that the Resident #69's dialysis communication record post dialysis assessment upon return to the facility was not completed. On 6/18/24 at 9:58 AM, in the presence of the survey team and LNHA, the DON stated that the resident's communication log appeared to be incomplete. She added that she educated the nurses on completing communication log in its entirety. The facility did not provide any additional information. A review of the facility provided policy titled, Dialysis Communication with an adopted date of June 2021, included the following: Policy Statement The facility and dialysis center will establish a communication and reporting mechanism to promote situational awareness between both facilities. The policy did not contain information on the facility's HCR document. 3. On 6/13/24 at 10:52 AM, the surveyor observed Resident #50 seated in a w/c in his/her room. On 6/14/24 at 12:39 PM, the surveyor reviewed Resident #50's medical record. Resident #50's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease ( group of lung diseases that block airflow and make it difficult to breathe), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression (common and serious medical illness that negatively affects how you feel, the way you think and how you act). Resident #50's June 2024 MAR/Treatment Administration Record (TAR)/Behavior Monitoring included the following orders: [BEHAVIORS/INTERVENTION] Monitor for (difficulty falling asleep) .every evening and night shift; 3 of 15 evening shifts were blank. BEHAVIORS/INTERVENTION] Monitor for (being nervous) .every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. [BEHAVIORS/INTERVENTION] Monitor for (excessive fear about everyday situation) .every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. [BEHAVIORS/INTERVENTION] Monitor for (persistent worrisome) .every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. [BEHAVIORS/INTERVENTION] Monitor for (Sudden feelings of intense anxiety) .every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. [SIDE EFFECTS] Monitor for Side Effects of Anti-Anxiety Meds every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. [SIDE EFFECTS] Monitor for Side Effects of Hypnotic Meds every shift; 9 of 15 day shifts were blank; 3 of 15 evening shifts were blank. On 6/17/24 at 11:46 AM, the surveyor interviewed LPN #2 regarding behavior monitoring and side effect monitoring. LPN #2 stated that there was a PO for monitoring in the computer. She added that each shift would document a yes or no if there was behaviors or side effects. The surveyor showed LPN #2 Resident #50's blanks for behavior monitoring and side effect monitoring. LPN #2 stated that there should not be blanks. The surveyor asked what the importance of behavior monitoring was. LPN #2 stated that it was to know if a med was necessary or if it needed to be changed. On 6/17/24 at 12:02 PM, the surveyor interviewed the UM/NU regarding behavior monitoring and side effect monitoring. The UM/NU stated that every shift should have documentation and should not see blanks. She added that if the resident was not in the building the nurse should document a code to indicate that. On 6/17/24 at 12:09 PM, the surveyor interviewed the DON regarding Resident #50's blank behavior monitoring and side effect monitoring. The DON stated that it should not be blank. On 6/17/24 at 12:48 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, RDoO/RN and AIT, the concern that the Resident #50 had multiple blanks on the June 2024 MAR/TAR for multiple PO for behavior monitoring and side effect monitoring. On 6/18/24 at 10:07 AM, in the presence of the survey team and LNHA, the DON stated that there was missing behavior monitoring. The facility did not provide any additional information. A review of the facility provided policy titled, Behavioral Assessment, Intervention and Monitoring with a revised date of March 2019, included the following: Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT (Interdisciplinary Team) will seek and document any improvements or worsening in the individual's behavior, mood, and function. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interviews, record review, and review of facility policies, it was determined that the facility failed to identify and accurately address an Enteral Feeding (EF) order discrepancy. This deficient practice was identified for one (1) of two (2) residents reviewed for EF (Resident #27). The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take eat by mouth and receives a tube feeding (TF, an EF, is a way of delivering nutrition directly to stomach or small intestine). On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: Resident #27's Admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia (difficulty swallowing) following cerebral infarction, encounter for attention to gastrostomy and unspecified severe protein-calorie malnutrition. The Minimum Data Set (MDS), an assessment tool used for the management of care dated 4/05/24, documented the resident had a Brief Interview for Mental Status (BIMS) and scored a 12 out of 15, indicating that Resident #27 had moderately impaired cognition. The MDS also showed that Resident #24 was receiving >51% of total calories from a TF. A review of the June 2024 Physician Orders (PO) included a PO dated 4/10/24, Enteral Feed, five times a day Jevity 1.5 Cal 237 ml (milliliters) 6 times per day via gravity bolus. The Medication Administration Record (MAR) revealed from 4/10/24 through 6/14/24, Resident was receiving bolus feeding (Bolus tube feeding is a method of delivering formula through a feeding tube. It is used for people who can tolerate a normal amount of food at one time. The formula is given every 4 to 6 hours) of Jevity 1.5, 237 ml five times daily. On 6/14/24 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1), who regularly oversees Resident #27's care. LPN #1 stated, Resident #27 receives a bolus feeding five times daily which was confirmed when LPN #1 checked the MAR. On that same date and time, the Surveyor asked LPN #1 to review the PO for the bolus feeding. LPN #1 acknowledged that the order for bolus feeding should had been clarified because the order states five and six times daily bolus feeding. LPN #1 further stated they have not previously observed the error and would contact the Registered Dietitian (RD) for correction. On 6/14/24 at 11:59 AM, the surveyor interviewed the RD, who stated the bolus feeding order should have been for six times daily but could not state why the error occurred and was not caught by themselves or facility staff. No further comments provided. On 6/17/24 at 9:04 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Enteral Feeding with a revised date of November 2018. Under the policy interpretation and implementation, it states, 4. Enteral nutrition is ordered by the provider based on recommendations of the dietitian. 8. The dietitian monitors residents who are receiving enteral nutrition and make appropriate recommendations to enhance tolerance and nutritional adequacy of enteral feeding. 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include: a. the enteral nutrition product; d. administration method (continuous, bolus); e. volume and rate of administration. On 6/17/24 at 12:46 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional Director of Nursing (RDON), Administrator in Training (AIT). The Surveyor notified the facility management of the above findings and concerns. The facility management did not provide any comments at that time. On 6/18/24 at 9:46 AM, the LHNA and DON met with the survey team with responses to the survey teams concerns. The DON stated, we were not compliant, the resident had been receiving five bolus feedings a day when they should have been receiving six. The resident's doctor and family were notified, the resident did not have any weight loss. The RD completed an audit on all residents who were NPO (nothing by mouth), and the completed an assessment on the resident and the TF order was corrected. An audit was completed on all tube feeding residents. NJAC 8:39-11.2(e), 17.1(c), 27.1(a)

Based on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication (med) reviews for one (1) of six (6) Residents, Resident #27. The deficient practice was evidenced by the following: On 6/13/24 at 10:24 AM, the surveyor interviewed Resident #27 in the resident's room. The resident stated he/she does not take any medications (meds) by mouth. On 6/14/24 at 9:04 AM, the surveyor reviewed Resident #27's hybrid (paper and electronic) medical record which revealed the following: Resident #27's Admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: dysphagia (difficulty swallowing) following cerebral infarction, encounter for attention to gastrostomy and unspecified severe protein-calorie malnutrition. The Minimum Data Set (MDS), an assessment tool used for the management of care dated 4/05/24, documented the resident had a Brief Interview for Mental Status (BIMS) and scored a 12 out of 15, indicating that Resident #27 had moderately impaired cognition. A review of the June 2024 Physician Orders (PO) included a PO dated 3/15/24 that read, Nothing by Mouth (NPO) diet, NPO texture, NPO consistency. Tube feeding. And an addition PO dated 4/15/24, Ascorbic Acid Tablet 500 MG (milligram), Give 1 tablet by mouth two times a day for Facilitate iron absorption Give with Ferrous Sulfate. A review of the CP medication review for April and May 2024 read, the following is a list of residents which were reviewed during the CP's visits but did not require any recommendations. The list included Resident #27 for both April and May 2024. On 6/17/24 at 10:36 AM, the surveyor conducted a phone interview with the CP, who stated, they missed the Ascorbic Acid med written as by mouth not via PEG tube (a percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. Feeding tubes, or PEG tubes, allow you to receive nutrition and/or med through the stomach). No further explanation provided. On 6/17/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy title, CP with a revised date of August 2021. Under the policy interpretation and implementation section of the policy it states, 1. The facility will arrange for the provision of a CP who shall direct pharmaceutical services and provide consultation as needed. 3. The pharmacist shall assist the facility with: d. Reviewing med administration records (MAR) on a quarterly basis documenting any concerns, proposing solutions to identified concerns. On 6/17/24 at 12:46 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional Director of Nursing (RDON), Administrator in Training (AIT). The Surveyor notified the facility management of the above findings and concerns. The facility management did not provide any comments at that time. On 6/18/24 at 9:46 AM, the LHNA and DON met with the survey team with responses to the survey teams concerns. The DON stated, we were not compliant with the meds, an audit was completed on all residents who were NPO, and the CP will be developing a Quality Assurance and Performance Improvement (QAPI) to assure this does not happen again. No further comments made. NJAC 8:39- 29.3 (a)

Based on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for one (1) of one (1) employee reviewed for IP. This deficient practice was evidenced by the following: On 6/14/24 at 12:10 PM, the surveyor reviewed the facility provided signed job description for the IP which listed the date of hire as 6/10/21. The IP's job description included the following Educational and Certification Requirements: The IP's job description included the following acknowledgement that was signed by the IP and dated 6/10/21: I have read this job description and fully understand that the requirements set forth therein have been determined to be essential to this position (unless otherwise noted in Column 2). I hereby accept the position of Infection Preventionist and agree to perform the tasks outlined in this job description in a safe manner and in accordance with the Center's established procedures. At that same time, the surveyor reviewed the facility provided IP's specialized training certificates for which were dated from. The surveyor then reviewed the facility provided specialized training certificates for 15 modules that had different completion dates from 8/07/21 to 8/23/24. The IP did not have the specialized training prior to assumption of the IP role. On 6/17/24 at 10:49 AM, in the presence of the Director of Nursing (DON), the surveyor interviewed the IP. The IP confirmed that her date of hire as the facility's IP was 6/10/21. The IP confirmed that the specialized training certificates were done in August 2021. She added that she had done some [name redacted] training but had not finished the certification. The IP did not provide documentation of any additional training. On 6/17/24 at 12:47 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Director of Operations/Registered Nurse (RDoO/RN) and Administrator in Training (AIT), the concern that the IP did not have specialized training prior to assuming the role of IP. On 6/18/24 at 9:55 AM, in the presence of the survey team and DON, the LNHA stated that the IP started as the IP after the date of hire that was on the job description. She added that when the facility was acquired by a new company the staff had new job descriptions done. The surveyor asked the LNHA that if the 6/10/21 IP job description dated 6/10/21 was not for function of IP then should the job description signed indicate a different job description. The LNHA added that she was not the LNHA at that time. On 6/18/24 at 12:32 PM, the surveyor reviewed a timeline for IP that the facility provided. The timeline did not reflect the same information that the signed IP job description dated 6/10/21 by the current IP that the facility provided prior to the timeline. A review of the facility provided policy titled Infection Preventionist with a revised date of September 2022, included the following: Specialized Training 1. The infection preventionist has obtained specialized IPC training beyond initial professional training or education prior to assuming the role 2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. N.J.A.C. 8:39-19.1(b)

COMPLAINT # NJ171657 Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This deficient practice was identified for one (1) of two (2) residents reviewed, Resident # 157. This deficient practice was evidenced by the following: On 6/17/24 at 12:10 PM, the surveyor in the company of another surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations/Registered Nurse (RDoO/RN) who explained that the investigation involves a look back of 48 hours, including statements from staff who cared for the resident. The surveyor reviewed the medical records of Resident #157 and revealed the following: The Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to essential (primary) hypertension (elevated blood pressure), unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (serious illnesses that affect the mind), mood disturbance, and anxiety. A review of the Significant change in status Minimum Data Set, an assessment tool used to facilitate the management of care, dated 01/12/24, reflected that Resident #157 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated that Resident #157 had severe cognitive impairment. The facility reportable event (FRE) documenting an injury of unknown origin to Resident #157 on 02/20/24. The FRE described that Resident #157 was identified by a family member as having a swollen discolored left thumb. The family member informed a facility staff member (nurse) of the resident's injury. The surveyor reviewed the Employee Statement (ES), provided by RDoO/RN, which was an incident investigative form used to document 48 hours of staff interviews prior to any incident. The Employee Statement form included interviews from 02/18/24 shift 3-11 to 02/20/24 7-3 shift when the injury was identified. Further review of the above provided ES, there were two blank interview spaces marked for 02/19/24 11-7 Nurse and 02/19/24 11-7 CNA (Certified Nursing Assistant) (the shift prior to the identified injury) missing any documented statements. On 6/18/24 at 12:09 PM, the surveyor interviewed the Director of Nursing (DON) and RDoO/RN who acknowledged that they could not find any interviews from the shift prior to the incident being identified for 02/19/24 11-7 shift. The RDoO/RN stated that staff interviews were important factors to completing an investigation of unknown origin. The RDoO/RN acknowledged that the facility should have interviewed and gotten a written statement from the 02/19/24 11-7 CNA and nurse, who had cared for Resident #157 prior to the shift in which the injury was identified. A review of the facility's undated policy titled Investigating Resident Injuries included: 7. If the nursing and medical assessment determines an injury of unknown source, interviews/ statements from staff over the prior 48 hours will be obtained and the investigation will follow the protocols set forth in our facility's established abuse reporting and investigation guidelines. A review of the facility policy titled Accidents and Incidents- Investigating and Reporting was revised on 7/2017, under Policy Statement included: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating was revised on 9/2022, under Policy Statement included: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Section Investigating Allegations of Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating included: 7e.) interviews any witnesses to the incidents; h.) interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incidents; i.) interviews the resident's roommate, family members, and visitors. 8d.) Witness statements are obtained in writing, signed, and dated. The witness may write his/her statement, or the investigator may obtain a statement. On 6/18/24 at 01:09 PM, the surveyor interviewed the RDoO/RN who acknowledged that the investigation of Resident #157's injury of unknown origin was incomplete and should have included the staff interviews missing from the 11-7 shift on 02/19/24. No further information was provided. NJAC 8:39-5.1(a)

NJ#162614 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report as required to the New Jersey Department of Health (NJDOH) within two hours an allegation of abuse for one (1) of two (2) residents (Resident #156) reviewed for abuse. This deficient practice was evidenced by the following: On 6/13/24 at 11:20 AM, the surveyor reviewed a Reportable Event Record (RER) for a resident to resident abuse that indicated the RER was submitted to the NJDOH by the facility's Administrator at that time, on 3/20/23. A review of the RER included the following: Today's Date: 3/20/23 Date of Event: 3/18/23 Time of Event: 11:00 PM The section that the facility can document if the incident was a significant event and if the event was called in was blank. Further review of the RER indicated that Resident #156 was hit by an unsampled resident on 3/18/23. On 6/13/24 at 12:30 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the facility's complete documentation of the RER for Resident #156. On 6/14/24 at 9:39 AM, the surveyor reviewed the facility provided Full QA (Quality Assurance) Report (facility's incident report) for Resident #156 which included the following: Incident Date/Time: Saturday March 18, 2023 11:00 PM Conclusion: Resident #156 AAO x 3 (awake, alert and oriented to time, place and person) .Resident woke up, while getting hit by roommate, unsampled resident, who was a confused resident and has occasional aggressive behaviors to caregivers. No injury noted. Resident #156 verbalized, I am okay, I am not pressing charges. Patient transferred to another room immediately. Notifications: Administrator 3/18/23 11:00 PM (phone) Director of Nursing 3/18/23 11:00 PM (phone) Ombudsman 3/20/23 3:00 PM (phone) NJDOH 3/20/23 3:00 PM (phone) Further review of the above information, the facility did not report the allegation of abuse within two hours. Resident #156 and the unsampled resident no longer resided at the facility. On 6/17/24 at 11:03 AM, the surveyor interviewed the Director of Nursing (DON) regarding an allegation of abuse. The DON stated that any allegation of abuse should be reported within two hours whether the abuse was substantiated or not. The surveyor then asked the DON about the incident between Resident #156 and the unsampled resident and when it should have been reported. The DON stated that she had been at the facility for only three weeks. She added that the incident should have been reported within two hours. On 6/17/24 at 12:47 PM, in the presence of the survey team, the surveyor notified the LNHA, DON, Regional Director of Operations/Registered Nurse (RDoO/RN) and Administrator in Training (AIT), the concern that the facility did not report an allegation of abuse within two hours of the incident. On 6/18/24 at 10:00 AM, in the presence of the survey team and LNHA, the DON stated that the incident should have been immediately, within two hours reported and that she inserviced everyone in the facility about abuse reporting. The facility did not provide any additional information. A review of the facility provided policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022, included the following: Policy Statement All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. N.J.A.C. 8:39-5.1(a)

Complaint Intake #NJ154287 and #NJ156112 Based on record review, interviews, and facility policy review, it was determined that the facility failed to ensure quality care and treatment were provided for 3 (Residents #3, #4, and #1) of 13 sampled residents. Specifically, the facility failed to ensure all admission medications were implemented for Resident #3 and Resident #4 and failed to ensure accurate laboratory tests were obtained for Resident #1. Findings included: 1. The facility's undated policy, titled, Admission Criteria, indicated, Prior to or at the time of admission, the resident's attending physician provides the facility with information needed for the immediate care of the resident, including orders covering at least medication orders, including (as necessary) a medical condition or problem associated with each medication. A review of Resident #3's Admission record revealed the facility admitted the resident on 05/30/2022 with a diagnosis that included type 2 diabetes mellitus. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. A review of the Discharge Form from the hospital, dated 05/30/2022, revealed an order for blood sugar checks four times a day before meals and at bedtime with lispro insulin (a short-acting manmade version of human insulin) coverage. A review of Resident #3's Order Summary Report indicated the order for the lispro insulin was not entered and started until 06/08/2022, nine days after the resident was admitted to the facility on [DATE]. According to the order, Resident #3 was to receive sliding scale insulin coverage based on the resident's blood sugar before meals and at bedtime. A review of an IDT [Interdisciplinary Team] Care Plan Meeting Review, dated 06/02/2022, indicated the resident was checking their blood sugars at home but was not on insulin at home. A review of Resident #3's June 2022 Medication Administration Record (MAR) revealed the lispro insulin was started on 06/08/2022 at 4:00 PM. During an interview on 01/31/2023 at 1:20 PM, Unit Manager (UM) #3 stated the facility received a list of discharge medications when a resident was admitted from the hospital. She stated they would go over these orders with the physician and clarify any orders if needed. She stated the night nurse did a medical record check every night to double check the orders to ensure they were correct. UM #3 reviewed Resident #3's record and stated she was not sure why the blood sugar checks and insulin were not ordered when the resident was admitted . During an interview on 01/31/2023 at 1:30 PM, Registered Nurse (RN) #4 stated she was a nursing supervisor for the whole building. She stated that when a resident was admitted or readmitted to the facility, they received the admission orders from the hospital. She stated she would go over the medications one by one with the physician to verify. She stated the supervisor or Director of Nursing (DON) was responsible for double checking the orders. She stated she did not remember Resident #3. During an interview on 01/31/2023 at 2:03 PM, Licensed Practical Nurse (LPN) #5 stated when a resident was admitted to the facility, their admission orders would come in a packet from the last place they were at, whether it was a hospital or another nursing facility. She stated those orders were reviewed with the physician. LPN #5 stated the nursing supervisors usually put the orders in and then the other nurse reviewed them. She stated usually one nurse would do the assessment and the other would do the orders. During an interview on 01/31/2023 at 2:54 PM, LPN #11 stated that when a resident was admitted or readmitted to the facility, they came with a packet from the hospital with orders for medications. He stated they would call the physician and go over each medication and make changes if needed. He stated the supervisor double checked the orders. During an interview on 01/31/2023 at 4:05 PM, LPN #9 stated when a resident was admitted to the facility, they received the orders for the medications that were on the hospital discharge form. She stated they would call the physician and go over the orders with them. She stated the supervisor would go over everything afterwards. During an interview on 02/01/2023 at 1:58 PM, the DON stated they received orders for a resident that was admitting or readmitting from the outgoing facility, usually in a packet that showed all the medications. She stated those were verified with the physician and double checked with another nurse. She stated the DON, ADON, and all supervisors should help with admissions. She stated she was not aware the orders for Resident #3's blood sugars had been missed from the admission orders. During an interview on 02/01/2023 at 4:22 PM, the Administrator stated he had only been at the facility since October 2022 and was not familiar with Resident #3. The Administrator stated residents came to the facility with physician orders, and those were clarified with the oncoming physician and verified. He stated he was not familiar with how the nurses double checked the orders. 2. The facility's policy, titled, Medication and Treatment Orders, undated, indicated, Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date the time of the order. A review of Resident #4's Admission Record revealed the facility admitted the resident with diagnosis that included type 2 diabetes mellitus. A review of the five-day Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The resident required supervision with their activities of daily living (ADLs). The MDS indicated the resident received insulin injections two out of the last seven days of the assessment period. A review of Resident #4's care plan, initiated 02/05/2022, indicated the resident had diabetes mellitus. Interventions included to administer diabetes medication as ordered by the doctor and monitor and document for side effects and effectiveness. A review of a document titled Discharge Disposition from the hospital record, dated 10/04/2022, indicated Resident #4 had orders for Insulin-glargine (Lantus) 100 units per milliliter (mL) solution, inject 15 units subcutaneously one time daily. A review of Resident #4's Order Summary Report for active orders as of 10/04/2022 revealed no order for the insulin glargine. A review of Resident #4's physician orders revealed an order for insulin glargine solution 100 unit/mL, inject 15 units subcutaneously at bedtime for diabetes with a start date of 10/06/2022. A review of Resident #4's October 2022 Medication Administration Record (MAR) indicated the resident did not receive Insulin glargine on 10/04/2022 or 10/05/2022. A review of a Health Status Note, dated 10/07/2022 at 3:19 PM, indicated Resident #4 had concerns regarding their insulin and did not think they had received their long-acting insulin. During an interview on 01/31/2023 at 1:20 PM, Unit Manager (UM) #3 stated the facility received a list of discharge medications when a resident was admitted from the hospital. She stated they would go over those orders with the physician and clarify any orders if needed. She stated the night nurse did a medical record check every night to double check the orders to ensure they were correct. UM #3 reviewed Resident #4's record and stated she was not sure why the insulin was not ordered. During an interview on 01/31/2023 at 1:30 PM, Registered Nurse (RN) #4 stated she was a nursing supervisor for the whole building. She stated when a resident was admitted or readmitted to the facility, they received the admission orders from the hospital. She stated she would go over the medications one by one with the physician to verify. She stated the supervisor or Director of Nursing (DON) was responsible for double checking the orders. During an interview on 01/31/2023 at 2:03 PM, Licensed Practical Nurse (LPN) #5 stated when a resident was admitted to the facility, their admission orders would come in a packet from the last place they were at, whether it was a hospital or another nursing facility. She stated those orders were reviewed with the physician. LPN #5 stated the nursing supervisors usually put the orders in and then the other nurse reviewed them. She stated usually one nurse would do the assessment and the other would do the orders. During an interview on 01/31/2023 at 2:54 PM, LPN #11 stated that when a resident was admitted or readmitted to the facility, they came with a packet from the hospital with orders for medications. He stated they would call the physician and go over each medication and make changes if needed. He stated the supervisor double checked the orders. During an interview on 01/31/2023 at 4:05 PM, LPN #9 stated when a resident was admitted to the facility, they received the orders for the medications that were on the hospital discharge form. She stated they would call the physician and go over the orders with them. She stated the supervisor would go over everything afterwards. During an interview on 02/01/2023 at 1:58 PM, the DON stated they received orders for a resident that was admitting or readmitting from the outgoing facility, usually in a packet that showed all the medications. She stated those were verified with the physician and double checked with another nurse. She stated the DON, ADON, and all supervisors should help with admissions. She stated she was not aware the orders for Resident #4's insulin had been missed from the admission orders. During an interview on 02/01/2023 at 4:22 PM, the Administrator stated he had only been at the facility since October 2022. The Administrator stated residents came to the facility with physician orders and those were clarified with the oncoming physician and verified. He stated he was not familiar with how the nurses double checked the orders. 3. The facility's policy, titled, Medication and Treatment Orders, undated, indicated, Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the prescriber's last name, credentials, the date the time of the order. A review of Resident #1's Admission Record revealed the facility admitted the resident with diagnoses that included protein-calorie malnutrition, gastrostomy status, and cerebral infarction (stroke) with right sided weakness. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. The MDS indicated the resident required extensive assistance with all activities of daily living (ADLs). The MDS indicated Resident #1 had a feeding tube and received 51% or more of their total calories and 501 cubic centimeters (cc) of fluid through the feeding tube daily. A review of Resident #1's care plan, initiated on 02/23/2022, indicated the resident required tube feedings related to dysphagia and was on continuous tube feeding. A review of a Health Status Note, dated 04/28/2022 at 12:30 AM, indicated a call was received from the physician with orders to do hourly vital signs on the resident, obtain a complete blood count (CBC) and urine analysis (UA) with culture and sensitivity (C & S), and stool for Clostridium difficile (c-diff), WBC (white blood count), Ova (egg) and parasite in the morning. A review of Resident #1's physician orders revealed on order dated 04/28/2022 for a stool sample for C-diff, WBC, ova, and parasites. A review of Resident #1's medical record revealed there were no results for the C-diff, WBC, ova, or parasite from the stool sample that was collected on 04/28/2022. According to the Lab Results Report, the stool sample was checked for occult blood and was negative. A copy of the lab results was requested from the Director of Nursing (DON) on 01/30/2023 and was not provided by the end of the survey. During an interview on 01/30/2023 at 2:47 PM, the DON stated the facility had done education and write-ups with the nurses in April 2022 due to labs not being reported to the physician and not being followed up on. The DON stated they also educated the nurses about taking verbal orders from the physician and making sure they read back the order for clarification. She said she did this after they had identified that lab orders were not being transcribed correctly. She stated she did not think the nurse took down the right order when she wrote the order for c-diff, ova, and parasites for Resident #1 to be obtained because the physician had not mentioned it in their progress note. She stated the nurse was written up for that. During an interview on 01/31/2023 at 3:45 PM, Licensed Practical Nurse (LPN) #12 stated she would not document the physician ordered something if he did not actually order it, and she always repeated back the order to the physician for verification. She stated she did not know why the tests on Resident #1's stool were not done as ordered by the physician. During an interview on 02/01/2023 at 4:22 PM, the Administrator stated he had only been at the facility since October 2022 and was not involved in the clinical aspect of the resident's care and deferred to the DON. New Jersey Administrative Code S 8:39-27.1(a)

Complaint Intake #NJ154287 Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide appropriate care and services to prevent complications of tube feeding for 3 (Residents #7, #9, and #1) of 3 residents reviewed for the use of feeding tubes. Specifically, the facility failed to ensure medications were administered through a feeding tube according to physician orders for the three residents. Findings included: Review of an undated facility policy titled, Administering Medications through an Enteral Tube indicated, Administer each medication separately and flush between medications. Dilute crushed (powdered) medication with at least 30 ml [milliliters] of purified water (or prescribed amount). Administer each medication separately. If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount). 1. A review of Resident #7's Admission Record revealed the facility admitted the resident with diagnoses that included dysphagia (difficulty swallowing) and a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. The resident required extensive assistance with all activities of daily living (ADLs). The MDS indicated Resident #1 had a feeding tube and received 51% or more of their total calories and 501 cubic centimeters (cc) of fluid through the feeding tube daily. A review of Resident #7's care plan, initiated 01/07/2023, indicated the resident required an enteral tube feeding related to dysphagia. Interventions included to administer tube feeding as ordered; auscultate for proper position before administering medications or feedings; check residual as ordered or clinically indicated. Notify the physician or designee if above acceptable volume; consult dietitian as needed; consult speech therapy as needed. A review of Resident #7's Order Summary Report indicated orders related to the feeding tube included: - Jevity 1.2 Cal liquid (nutritional supplement) via feeding tube with the feeding pump set at 60 milliliters (mL) per hour (hr.) for 22 hours, for a total volume of 1,320 mL. Up at 4:00 PM and down at 2:00 PM, ordered 01/25/2023. - Flush feeding tube with 5 mL of water in between each medication administered through the feeding tube every shift, ordered 01/07/2023. - Free water flushes of 150 mL every six hours, ordered 01/07/2023. - Keep head of bed (HOB) elevated 30-45 degrees every shift while feeding is being administered and for one hour after feeding has been stopped, ordered 01/07/2023. - May crush all medication according to guidelines and mix each medication separately in 5 mL of water, ordered 01/07/2023. A medication pass observation was conducted on 01/30/2023 at 8:49 AM with Licensed Practical Nurse (LPN) #1 for Resident #7. The medications LPN #1 prepped for Resident #7 included: - Liquid protein 30 mL, which LPN #1 measured in a medication cup but then poured into a water cup without ensuring all the medication was removed out of the medication cup. - Divalproex Sprinkles (used for seizures) 125 mg, two capsules, which LPN opened and poured into a medication cup. - Potassium chloride 10% 7.5 ml, which LPN #1 measured in a medication cup and then poured into a water cup. - Amiodarone (medication to treat an irregular heartbeat) 100 mg, one tablet. - Eliquis (a blood thinner) 2.5 mg, one tablet. - Magnesium oxide (a supplement) 400 mg, one tablet. - Multivitamin, one tablet. - Vitamin C 500 mg, one tablet. LPN #1 crushed all of the tablets together and poured the powder into a water cup. LPN #1 questioned to herself aloud at that time whether the medications should have been crushed separately or together. LPN #1 then took all three water cups and the medication cup into Resident #7's room. LPN #1 stopped Resident #7's feeding of Jevity 1.2 and capped the tubing. LPN #1 then attempted to auscultate by listening through a stethoscope for the position of the tube by pushing air into the tube but met resistance and had to force air into the tube. She then attempted to flush the tube with approximately 30 mL of water but it would not go down by gravity, so she put the plunger in the syringe and forced the water into the tube. She then flushed the tube with 30 mL of water again that went down the tube by gravity. LPN #1 mixed water into the liquid protein, filling the cup approximately 2/3 full, and poured it into the syringe to go into the tube by gravity. She mixed water into the cup of liquid potassium approximately 2/3 full and poured it into the syringe to go into the tube by gravity. She poured the medication cup of divalproex into the water cup with the other crushed medications and filled the cup approximately 2/3 full with water and mixed it together and poured it into the syringe. LPN #1 had to keep adding water to the cup to get the medication residue off the sides of the cup and syringe. 2. A review of Resident #9's Admission Record revealed the facility admitted the resident with diagnoses that included dysphagia (difficulty swallowing) and a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident was severely cognitively impaired. The MDS indicated the resident required extensive assistance with all activities of daily living (ADLs). The MDS indicated Resident #1 had a feeding tube and received 51% or more of their total calories and 501 cubic centimeters (cc) of fluid through the feeding tube daily. A review of Resident #9's care plan, initiated 01/07/2023, indicated the resident required enteral tube feeding related to dysphagia. Interventions included to administer tube feeding as ordered; auscultate for proper position before administering medications or feedings; check residual as ordered or clinically indicated. Notify the physician or designee if above acceptable volume; consult dietitian as needed; consult speech therapy as needed. A review of the Order Summary Report indicated orders for the feeding tube included: - Jevity 1.2 Cal liquid via feeding tube every shift with feeding pump set at 45 milliliters (mL) per hour (hr.) for 20 hours for a total volume of 900 mL. Up at 2:00 PM and down at 10:00 AM, ordered 01/17/2023. - Free water flushes of 100 mL every six hours four times a day, ordered 01/01/2023. - May crush all medications according to guidelines and mix each medication separately in 5 mL of water every shift, ordered 01/07/2023. A medication pass observation was conducted on 01/30/2023 at 9:15 AM with Licensed Practical Nurse (LPN) #1 for Resident #9. The medications LPN #1 prepared for Resident #9 included: - Liquid protein 30 mL, which LPN #1 measured in a medication cup but then poured into a water cup without ensuring all the medication was removed out of the medication cup. - Multivitamin, one tablet. - Eliquis 5 mg, one tablet. - Metoprolol (a blood pressure medication) 25 mg, one tablet. - Tylenol 325 mg, two tablets. LPN #1 crushed all the tablets together and put them in a water cup and took the cup into the resident's room. LPN #1 checked the placement of the tube by pushing air into the tube with a piston syringe and listening with her stethoscope. She then flushed the tube with 30 mL of water. LPN #1 mixed the liquid protein with water and put it in the syringe to go into the tube via gravity. LPN #1 then mixed all the crushed medications with water and put it in the syringe to go in by gravity. She flushed the tube with another 30-60 mL of water and capped off the tube. 3. A review of Resident #1's Admission Record revealed the facility admitted the resident with diagnoses that included protein-calorie malnutrition, gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and cerebral infarction (stroke) with right sided weakness. The admission record indicated the resident was discharged from the facility on 05/06/2022. A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. The resident required extensive assistance with all activities of daily living (ADLs). The MDS indicated Resident #1 had a feeding tube and received 51% or more of their total calories and 501 cubic centimeters (cc) of fluid through the feeding tube daily. A review of Resident #1's care plan, initiated on 02/23/2022, indicated the resident required tube feedings related to dysphagia and was on continuous tube feeding. Interventions included: - Check for tube placement and gastric contents/residual volume per physician's orders and record. Hold feeding if greater than 70 cc aspirate. - Received water flushes of 100 milliliters (mL) every eight hours. - Dependent on tube feeding and water flushes ordered. - Needs assistance/supervision/cueing with tube feeding and water flushes ordered. See physician orders for current feeding orders. - Needs the head of the bed (HOB) elevated 30-45 degrees during and thirty minutes after tube feeding. - Listen to lung sounds per orders. - Monitor/document/report to the physician as needed for aspiration, tube dislodgement, infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. - Registered dietitian (RD) to evaluate quarterly and as needed (PRN). Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. A review of a Health Status Note, dated 04/15/2022 at 5:39 PM, indicated the nurse was unable to flush Resident #1's feeding tube and start their feeding, and the resident complained of discomfort to the insertion site. The note indicated the resident was sent to the emergency room . A review of an Emergency Department Note, dated 04/15/2022, indicated Resident #1 presented to the emergency department due to a blocked feeding tube. The note indicated the tube was unclogged with irrigation in the emergency room and was working properly. A review of Resident #1's April 2022 Medication Administration Record revealed LPN #1 had administered Resident #1's medications prior to the tube being blocked. Following the medication pass observations with LPN #1 of Resident #7 and Resident #9, LPN #1 was unavailable for an interview. During an interview on 01/31/2023 at 1:30 PM, Registered Nurse (RN) #4 stated medications could be crushed and administered at the same time to a resident with a feeding tube if the physician ordered it that way. She stated feeding tubes should be flushed per the physician's orders. During an interview on 01/31/2023 at 2:03 PM, Licensed Practical Nurse (LPN) #5 stated medications given through a feeding tube should be crushed individually and mixed with a small amount of water, and then the tube should be flushed in between each medication with 15 mL of water. She stated the tube should be flushed before and after giving medications. During an interview on 01/31/2023 at 2:54 PM, LPN #11 stated medications given through a feeding tube should be crushed and given separately with 15 mL of water between each medication. During an interview on 02/01/2023 at 1:58 PM, the Director of Nursing (DON) stated medications, whether given orally or through a feeding tube, should be given according to the physician's orders. She stated the medications could be crushed and given together if that was what the physician's order said. The DON stated LPN #1 should have administered the medications per the physician's orders. During an interview on 02/01/2023 at 4:22 PM, the Administrator stated LPN #1 should have followed the facility's policy when administering the medications through the feeding tube like she was trained and obtained clarification from a nursing supervisor if she had questions on how to do the procedure correctly. New Jersey Administrative Code S 8:39-29.2(d)

Based on observation, interview and review of the medical record it was determined that the facility failed to follow the recommendations of the consulting physician and apply a brace to a resident's leg before initiating ambulation. Subsequently, the resident sustained [REDACTED]. This deficient practice was identified for Resident #23, 1 of 20 residents reviewed during the survey and was evidenced by the following: During the initial tour of the North Unit on 6/15/11 at 11:30 a.m., the licensed nurse told the surveyor that Resident #23 had a left [MEDICAL CONDITION], was being treated for [REDACTED]. The resident had a prosthesis for the left leg. During an interview on 6/20/11 at 1:00 p.m., Resident #23 told the surveyor he/she had the right hip replaced in December 2009 and then fell and fractured the femur in April 2010. The resident stated there were several other nursing facility admissions prior to being admitted to this facility in June 2010. The resident stated he/she was currently being treated for [REDACTED]. During the interview of the resident, the surveyor observed the resident's right foot to be externally rotated (bent to the right) and when the resident was asked about it, the resident stated that the right leg started turning to the right about three weeks prior. When the surveyor asked the resident the condition of the foot prior to this incident, the resident stated the foot was straight. The resident also stated that the right ankle was swollen when it started to rotate outward and the resident was placed on bedrest because of the swelling. Review of the Physical Therapy Notes (PT) dated from 1/28/11 until 5/20/11 revealed the resident was transferred from bed to wheelchair and from wheelchair to bed using a sliding board with contact guard. A 5/5/11 PT note indicated that as of this visit the resident was non-weight bearing, and was not allowed to walk. The PT note of 5/12 reflected that the resident was walking 20 feet X2 and the assistance of 1 to 2 people. The Physical Therapy note on 5/27/11 indicated that the resident ambulated up to 60 feet x 2 with a R/W (rolling walker) and with the minimal assistance of 1 person. Ambulation of the resident was continued until a 6/9/11 note indicated the resident was unable to attend PT due to swelling of the right ankle. There is no documentation that the resident was wearing a brace at any therapy visit. Review of the Consultant reports indicated the resident was being seen for wound care of the right leg wound and on 3/31/11 the consultant physican wrote, "until a custom brace is constructed we will not allow wt (weight) bearing." The consultant physcian's note of 4/26/11 included documentation that after wearing compression stocking for 1 week, the resident could begin ambulating with a walker no more than 20 feet. Resident #23 was seen again by the consultant physician on 6/9/11 and that report indicated the resident was seen in the office due to the "swelling of the right ankle and deformity secondary to physical therapy standing... Patient says happened about 1 week ago". The "exam shows resident has Charcot type deformity of ankle". The physician continued to document that "patient has been standing without brace and may now have ankle dislocation. Please follow instructions. These are orders, not suggestions." Review of the Nurse's Notes of 5/27/11 (no time was indicated) revealed the resident was observed to have swelling of the right lower leg, but denied pain. The attending physician was notifed and ordered [MEDICATION NAME], a diuretic medication, to decrease the swelling. The Nurse's Note of 6/911 at 8:00 a.m. indicated the resident had a large amount of swelling to the right medial ankle and the nurse notified the wound consultant who asked to have the resident come to the office that day. The resident left the facility at 10:00 a.m. and returned back at 12:00 noon. The Nurse's Note at 4:00 p.m. indicated that the therapy department was notified to have a consult to obtain a fitted brace for Resident #23. A CT Scan of the right ankle was also ordered. There was no documentation noted in the medical record to verify if a brace was ever fitted or ordered for the resident. At 6:38 p.m. the note indicated the resident returned from a CT Scan. Review of the Consultant reports indicated the resident was being seen for wound care of the right leg wound and on 3/31/11 the consultant physican wrote, "until a custom brace is constructed we will not allow wt (weight) bearing." Resident #23 was seen again by the consultant physician on 6/9/11 and that report indicated the resident was seen in the office due to the "swelling of the right ankle and deformity secondary to physical therapy standing... Patient says happened about 1 week ago". The "exam shows resident has Charcot type deformity of ankle". The physician continued to document that "patient has been standing without brace and may now have ankle dislocation. Please follow instructions. These are orders, not suggestions." The review of the CT Scan report performed on 6/9/11 indicated that the resident had "severe Charcot arthopathy associated with multiple fractures." Charcot arthopathy is a disease process in which the person has impaired pain perception and fragile bones and therefore injuries and fractures may not be perceived as painful by the person. On 6/21/11 at 9:45 a.m., the surveyor interviewed the Physician in charge of the Rehab Department. This interview revealed that the therapy department was only seeing the resident for wound care to the right lower leg and the physician explained he personally placed the resident in the whirlpool on several occasions and there was no deformity of the right leg/foot at that time. At 10:00 a.m. the surveyor, the Physician, and the Administrator went to see the resident who was lying in bed with a blue bootie to the right foot. The Physician stated that he never saw the resident's foot like that and was upset to see the external rotation. On 6/21/11 at 10:20 a.m., the surveyor interviewed the licensed nurse who revealed she noticed the external rotation about a week ago, but failed to document the condition or notify the Physician. On 6/21/11 at 11:45 a.m., the surveyor reviewed the quarterly Minimum Data Set (MDS) of 3/7/11 and the annual MDS of 6/6/11, which revealed the resident was coded on the Brief Interview of Mental Status (BIMS) as a 15 which indicated the resident was alert and oriented. The MDS was also coded as 0-1 for ambulation on the annual assessment of 6/6/11 which indicated that the resident was independent in walking. Interview of the attending physician by the surveyor at 11:25 a.m. revealed he was not aware of the 6/9/11 CT Scan results. NJAC 8:39-27.1(a)