Every finding on record at Arbor Ridge Rehabilitation and Healthcare Center

Complaint Intake ID #408686Based on interviews, record reviews and reviews of pertinent facility documents, it was determined that the facility failed to ensure care and treatment were provided timely to Resident #121, to prevent further change in condition. This failure delayed care for Resident #121 who was admitted to the intensive care unit at an acute care hospital with a diagnosis of septic shock (the most severe, life-threatening stage of sepsis [body's extreme response to an infection], which is a critical medical emergency requiring immediate hospitalization.) This deficient practice was identified for 1 of 3 residents (Resident #121) reviewed for hospitalization.On 12/28/24 at 8:00 PM, Resident #121 had a change in condition with rapid, shallow breathing and difficulty breathing at rest, noisy breathing, restlessness, and cold lower extremities. The physician was notified and ordered to send the resident to the hospital. The nurse called a transport company instead of 911 to transport Resident #121. On 12/28/24 at 11:00 PM, Resident #121's oxygen saturation was 72% on 10 liters of oxygen via non-rebreather mask. Pulse was 43 and respirations were 31. The resident's family was at the bedside and demanded that the nurse call 911. Resident #121 was transported to the hospital on [DATE] at 12:30 AM, four and a half hours later. The resident was admitted to the Intensive Care Unit (ICU) with septic shock. Interviews with the Director of Nursing (DON) confirmed that the nurse should have called 911 instead of the transport company.The facility's failure to ensure Resident #121's change in condition was addressed timely without a delay in treatment placed Resident #121 as well as other residents with a change in condition at risk for a delay in treatment. This posed the likelihood for serious harm, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 12/28/24, when Resident #121 had a change in condition. The facility's Administration was notified of the IJ on 6/5/26 at 2:50 PM. The facility submitted an acceptable Removal Plan (RP) on 6/5/26 at 6:25 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/5/26, and determined the immediacy was removed as of 6/5/26 at 9:00 PM.The evidence is as follows: A review of the facility policy revised March 2018, titled Acute Condition Changes – Clinical Protocol revealed, Assessment and Recognition . 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example . someone with unstable vital signs . Treatment/Management . 3. lf it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, Emergency Room, or another appropriate setting . A review of Resident #121's admission Record revealed Resident #121 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness, or organ failure rather than a direct physical injury), pneumonitis (inflammation of the lung tissue), and stage three chronic kidney disease. Resident #121's admission orders included an order for Full code, indicating Resident #121 was to receive all interventions to sustain life. A review of Resident #121's Progress Notes (PN) dated 12/28/24 at 10:12 PM, revealed a note written by the Registered Nurse (RN #2) . at around 7pm [7:00 PM], the BP [blood pressure] was noted to be low 91/62, midodrine [medication that increases blood pressure] was given via G-Tube [gastrostomy tube – a tube in the stomach] that brought the BP to 114/75 but within an Hour the BP went down again, MD [medical doctor] was notified with the order of CXR [chest x-ray] and IV [intravenous] Rocephin [antibiotic] 1g [gram] daily x [times] 2 [two] days, Resident was transferred back to bed at around 8pm [8:00 PM], Resident was noted with change in health conditions, more reapid [sic] and shallow breathing, difficulty breathing even at rest, noisy breathing, restlessness and cold lower extremities. [MD's name] was made aware of the change in conditions, new order received to send the Resident to the hospital, [family member name and relationship] was made aware, She/he consented to send [Resident #121] to the hospital [name of general transport company] made aware, they will pick [Resident #121] up. The PNs did not reveal documentation to support RN #2 calling 911, but called the transportation services instead. A review of a PN written by the Licensed Practical Nurse (LPN #4) dated 12/29/26 at 12:56 AM, revealed 11pm [11:00 PM] received report from the supervisor [RN #2] that resident had low bp for he/she [sic] was treated, suctioned for chest congestion. Was reported ambulance will arrive soon after waiting x3 [three] hours. Upon this writer assessment bp unable to register [sic], but pulse 43, o2sat [oxygen saturation – the amount of oxygen in the blood] 74 [percent] with o2 [oxygen] via n/c [nasal canula – a tube at the nostrils] @ [at] 2L/min [liters per minute], respiration 31. Resident usually is aphasic [unable to speak]. Non rebirthing [sic - rebreathing] mask initiated with O2 @ 10L/min. 10min later 02 [oxygen saturation] went to 93% then going down @ 73, 72 [percent oxygen saturation]. T [temperature] 98.6- continued with non-rebirthing [sic] mask. Unable to restore resident. family at bedside demanded to call 911 after ambulance did not show up. 911 called and transferred resident to [name of hospital] Hospital @ 12:30 PM [sic – AM]. Further review of Resident #121's PN dated 12/29/24 at 6:57 AM revealed, admitted with septic shock – resident in ICU [intensive care unit]. During an interview with RN #2 on 06/04/26 at 4:59 PM, RN #2 confirmed the physician gave him/her an order to send Resident #121 to the hospital on [DATE], at around 8:00 PM. RN #2 stated, We called 911 and 911 said to call the local transport company because they were busy and it would be a while and after they didn't come within 15 minutes, we called 911 again and they came. RN #2 reviewed his/her documentation on 12/28/24 and did not address the discrepancy between his/her interview and his/her documentation. During an interview on 06/04/26 at 5:52 PM, with the RN Unit Manager (RNUM #1) and the Director of Nursing (DON), they both stated RN #2 should have called 911 and not the transport company when Resident #121 had a change in condition at around 8:00 PM on 12/28/24. RNUM #1 stated he/she thinks RN #2 called a transportation company at around 8:00 PM and 911 wasn't called until around 12:00 AM by LPN #4 (three to four hours after the physician's order to send Resident #121 to the hospital). During an interview with RN #2 on 06/04/26 at 7:07 PM, he/she stated he/she reviewed Resident #121's record, including his/her nursing note in the PNs dated 12/28/24 at 10:12 PM. RN #2 confirmed Resident #121 had a decline in condition with decreased blood pressure and respiratory distress at around 8:00 PM and he/she called a transportation company, not 911. RN #2 stated, I should have sent him/her 911. During an interview with the Medical Doctor (MD #1) on 06/05/26 at 9:51 AM, he/she stated on 12/28/24, Resident #121's condition deteriorated and he/she gave RN #2 an order to send him/her to the hospital. MD #1 stated, I didn't know it was going to take three hours. MD #1 stated, I'm not gonna lie, and confirmed 911 should have been called rather than a transportation company. MD #1 confirmed he told RN #2 to send Resident #121 to the hospital because he/she needed urgent care. [Resident #121] was delicate. During an interview with LPN #4 on 06/05/26 at 10:25 AM, he/she stated after he/she received report on 12/28/24 at 11:00 PM from RN #1, that Resident #121 had a change of condition . immediately I went to see the patient. I was thinking I needed to call 911. I reassessed the patient and I noticed it was needed to call 911, because of the blood pressure and change in condition. LPN #4 stated if 911 didn't come within 15 minutes, I would call the police if 911 doesn't come. I need rapid 911. During an interview on 06/05/26 at 11:06 AM with the previous DON (DON #2), he/she confirmed he/she was the DON at the facility on 12/28/24. DON #2 stated on 12/28/24, RN #2 notified him/her Resident #121 had a change in condition. DON #2 confirmed 911 should have been called rather than a transportation company at around 8:00 PM on 12/28/24. DON #2 stated, If 911 didn't come within 30 minutes, they would have to call again . second time called 911, you would call the police. DON #2 stated, If progression is going down and down, it's not a [name of transport company], it's an ambulance. An acceptable Removal Plan (RP) was received on 06/05/26 at 6:25 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the immediacy including; All licensed nurses and nursing supervisors were immediately re-educated on the current Acute Condition Changes – Clinical Protocol policy and Change in Condition and Transfer process by Assistant Director of Nursing. Handouts included the Change in Condition and Transfer Process for nursing, which was also posted on all nursing units, and included the following content: Timely activation of EMS/911 for emergent conditions. Escalation procedures when transportation delays occur. Required ongoing nursing assessments and monitoring while awaiting transfer. Physician notification requirements. Documentation requirements related to emergency transfers. DON/Nursing Supervisor oversight responsibilities. The survey team verified the implementation of the Removal Plan on-site and determined the immediacy was removed on 06/05/26 at 9:56 PM. N.J.A.C. 8:39-27.1(a)

Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that one resident (Resident (R) 95) out of 15 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner. Findings include: Review of the Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.20.1, dated 10/25 revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS.RAI OBRA-required assessment summary for Entry tracking record.MDS completion date (Z0400) no later than entry date + 7 calendar days.Transmission date no later than entry date + 14 calendar days. Review of R95's Face Sheet, located under the Census tab in the electronic medical record (EMR), indicated R95 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and diabetes. Review of the entry tracking record MDS, assessment with an Assessment Reference Date (ARD) of 11/19/25, located under the MDS tab in the EMR revealed, MDS completed on 11/26/25 and submitted on 12/10/25. Review of the Assessment History, located under the MDS tab in the EMR, revealed Entry tracking record batched and accepted on 12/10/25. During an interview with the MDS Coordinator and Regional Case Manager on 06/04/26 at 3:22 PM, both confirmed that the assessment was transmitted late and should have been transmitted seven days after completion. NJAC 8:39-11.2(e)3

Based on interviews, record reviews, and review of facility policy, the facility failed to ensure a baseline care plan was given to the residents or their representatives for two Residents (R's), R150 and R121) of 25 sampled residents. These failures had the potential to cause the residents and/or their representatives not to be informed of or are included in the development of the plan of care. Findings include: 1.On 06/01/26 at 1:17 PM, R150 was observed sitting in a wheelchair in his/her room. During a concurrent interview, the resident was unable to state how long he/she had been in the facility and if the facility had provided him/her with a written baseline care plan. On 06/02/26 at 10:45 AM, an interview was conducted with R150's representative. The representative stated he/she was not informed of the plan of care for R150 and did not receive a written plan of care after R150 was admitted . On 06/02/26 at 11:00 AM, review of R150's record revealed he/she was admitted to the facility on [DATE] (six days prior to the start of the survey) with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness, or organ failure rather than a direct physical injury) and acute kidney failure. In an interview with the Director of Nurses (DON) on 06/03/26 at 3:00 PM, he/she reviewed R150's record in the Electronic Medical Record (EMR). He/she confirmed a written baseline care plan was supposed to be given to R150 or his/her representative but there was no documentation to show that occurred. In an interview with Unit Manager Registered Nurse (UMRN) 1 on 06/04/26 at 10:25 AM, he/she stated he/she created the plans of care after residents were admitted and gave them to the residents or their family members usually around 72 hours after admission. He/she reviewed the EMR and confirmed a baseline care plan had not been given to R150 or his/her representative. 2.Review of R121's record on 06/02/26 at 5:25 PM revealed R121 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy and acute respiratory failure. Review of the annual MDS under the MDS tab in the EMR, dated 12/12/24 revealed R121's Brief Interview for Mental Status (BIMS) was 6 (indicating severe cognitive impairment.) Review of the care plan under the Care Plan tab and the attachments under the Misc tab in the EMR revealed there was no documentation indicating a baseline care plan was given to R121's representative after the resident's admission on [DATE]. In an interview with the Assistant Director of Nurses (ADON) on 06/05/26 at 9:42 PM, he/she confirmed a baseline care plan had not been given to R121's representative. Review of the facility policy revised March 2022, titled, Care Plans – Baseline revealed, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . 4. The resident and or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: a. The stated goals and objectives of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary. 5. Provision of the summary to the resident and/or resident representative is documented in the medical record. NJAC 8:39-13.2(a)

Based on interviews, record reviews and review of facility policy, the facility failed to develop a comprehensive care plan for one resident, Resident (R) 121, when he/she was readmitted to the facility. This failure had the potential to cause R121 to receive a less effective plan of care which could affect the quality of care and services provided.Findings include: Review of R121's record revealed R121 was readmitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by chemical imbalances, systemic illness or organ failure other than direct physical injury), pneumonitis (inflammation of the lungs), chronic kidney disease stage three, catatonia (a complex neuropsychiatric syndrome characterized by profound abnormalities in movement, speech, and responsiveness), acute respiratory failure with hypoxia (low oxygen levels) and a history of traumatic brain injury. Review of the admission Minimum Data Set (MDS) dated [DATE], under the MDS tab in the Electronic Medical Record (EMR), revealed R121 had a Brief Interview for Mental Status (BIMS) of 6 (severe cognitive impairment). Review of the orders under the Orders tab in the EMR, revealed an order dated 12/20/24 indicating, Please change PureWick [external urinary collection device] catheter q [every] shift and prn [as needed] if soiled with feces . AND every shift for incontinence care. Review of the care plan under the Care Plan tab in the EMR revealed multiple problems and interventions on the care plan that were dated 03/03/23, including a problem titled, [R121's name] enjoys painting especially watercolor painting. He/she wants to teach others how to paint watercolor. Date Initiated: 03/04/2023; And I have potential for skin breakdown r/t [related to] dx [diagnosis] of CVA [cerebrovascular accident] with hemiparesis [paralysis on one side of the body], decline in mobility . admitted : bilateral buttock and sacral redness. Date Initiated: 03/07/2023. Review of the progress notes under the Progress Notes tab in the EMR revealed the admission nurse's note dated 12/05/24 at 10:49 PM read, New admission . sacral wound dressing pad observed on mid sacrum, no wounds observed, place [sic] for protection from pressure sores, as per [family members relationship] statement . In an interview with the Maintenance Director on 06/03/26 at 10:15 AM, he/she was unable to confirm if R121 had a low air loss mattress (LALM). On 06/03/26 at 11:35 AM, the Maintenance Director provided an untitled document dated 12/11/24 with R121's name and room number, and a document titled, Work Order . created on Dec. 11, 2024, indicating needs air mattress requested by Unit Manager Registered Nurse (UMRN)1 on 12/11/24 at 3:13 PM and completed on 12/12/24 at 11:11 AM. Review of R121's record was conducted with the Director of Nurses (DON), Assistant DON (ADON), and UMRN1 on 06/04/26 at 5:52 PM. They all reviewed R121's record and confirmed the PureWick catheter and LALM were not included in the plan of care for R121. UMRN1 and the DON reviewed the record and stated R121 did not have any redness to his/her coccyx or skin breakdown during his/her stay. UMRN1 and the DON confirmed the care plan indicated R121 was admitted with redness to his/her sacrum, which was in 2023, not on 12/05/24. UMRN1 and the DON stated the care plan was not accurate because it was from 2023. They stated when R121 was discharged in March of 2023, the care plan was supposed to be closed but it wasn't, so when he/she was readmitted on [DATE] (almost two years after being discharged ) the old care plan was in the EMR, and a new care plan was not initiated and developed. NJAC 8:39-11.2(e)1

Based on observations, interviews, record reviews and review of facility policy, the facility failed to ensure devices to prevent hand contractures were applied as ordered and/or according to the plan of care for three of five residents, Resident (R) 34, R93, and R108, reviewed for positioning. These failures had the potential to cause worsened hand contractures.Findings include: 1.On 06/01/26 at 11:10 AM, R34 was observed sitting in a high back wheelchair in his/her room with a splint on his/her left hand, but no splint on his/her right hand which was contracted. On 06/01/26 at 3:35 PM, R34 was observed in his/her room sitting in a high back wheelchair. No splints were on his/her hands. On 06/02/26 at 10:05 AM, R34 was observed sitting in a high back wheelchair in his/her room. No splints were on his/her hands. On 06/02/26 at 2:26 PM, Review of R34's record revealed R34 was originally admitted to the facility on [DATE] with a primary diagnosis of cerebral palsy. R34 was diagnosed with a right elbow contracture and a left hand contracture on 04/01/20. Review of the Minimum Data Set (MDS) under the MDS tab in the electronic medical record (EMR), revealed the quarterly MDSs dated 08/29/25 and 02/25/26, indicated R34's Brief Interview for Mental Status (BIMS) was 9 (moderate cognitive impairment) and he/she was dependent for all activities of daily living (ADL's) except set-up was required for eating and moderate assist was required for oral hygiene. The MDSs indicated he/she had bilateral upper and lower limb impairments. Review of the care plan under the Care Plan tab in the EMR revealed, I will not experience contracture progression as evidenced by continued ability to wear splints comfortably and without complication . Date Initiated: 02/15/2022 . Functional Maintenance Program: FMP L [left] hand C bar splint 5 hrs [hours] during AM [morning]. R [right] hand cock up splint 5 hrs during AM . Date Initiated: 02/22/2025. Review of the tasks under the Tasks tab in the EMR and review of the progress notes under the Progress Notes in the EMR revealed no documented evidence R34's left hand C-bar splint and right hand cock up splint were applied as indicated in the care plan. In an interview with the Director of Rehabilitation (DOR) on 06/03/26 at 2:10 PM, he/she reviewed R34's record and stated he/she was supposed to have a C-bar on his/her left hand and a cock-up bar splint on his/her right hand. The DOR stated the CNA's were responsible for application and removal of the hand splints. The DOR reviewed the resident's record and confirmed there was no documented evidence of the application and removal of the C-bar and hand splint for R34. In an interview with certified nursing assistant (CNA) 2 on 06/04/26 at 2:46 PM, he/she stated the CNAs were supposed to document when they put the hand splints on and took them off and they were supposed to report to the nurse if the patient refused. In an interview with CNA4 on 06/04/26 at 2:48 PM, he/she stated the CNAs were supposed to document when they put on and took off the hand splints and they were supposed to notify the nurse if the patient refused. In an interview with the Director of Nurses (DON) on 06/05/26 at 2:15 PM, he/she reviewed the resident's record and confirmed there was no documentation of the application and removal of hand splints for R34. 2. On 06/01/26 at 11:11 AM, R93 was observed in his/her room in a Geri-chair. R93 had contractures to both hands and no hand rolls were in his/her hands. Review of R93's record on 06/02/26 at 4:40 PM revealed he/she was originally admitted to the facility on [DATE] with diagnoses of intellectual disabilities and multiple sclerosis (MS – an autoimmune disease affecting the central nervous system) on 10/01/25. Review of the MDS under the MDS tab in the EMR revealed the quarterly MDS dated [DATE] and the annual MDS dated [DATE] indicated R93's BIMS was 0 (severe cognitive impairment), he/she was dependent for all activities of daily living, and he/she had impairment of both upper and lower extremities. Review of the care plan under the Care Plan tab in the EMR revealed, I have an ADL Self Care Performance Deficit r/t (related to) MS, immobility, contractures. Date Initiated: 12/27/2019 . Apply hand rolls to both hands. May remove during care and skin check. Review of the orders under the Orders tab of the EMR revealed an order dated 1/17/25, indicating, Apply hand rolls to both hands. May remove during care and skin check. Every shift. Review of the tasks under the Tasks tab in the EMR and review of the progress notes under the Progress Notes tab in the EMR revealed no documented evidence the hand rolls were applied as ordered. In an interview with the DOR on 06/03/26 at 2:28 PM, he/she reviewed R93's record and stated bilateral hand rolls were supposed to be worn all of the time except for when care was provided. The DOR stated the CNAs were responsible for application and removal of the hand rolls. The DOR reviewed the resident's record and confirmed there was no documented evidence of the application and removal of the bilateral hand rolls for R93. 3. On 06/01/26 at 12:00 PM, R108 was observed lying supine in his/her bed. R108's right hand was contracted and there was no device on. On 06/01/26 at 3:36 PM, R108 was observed lying supine in bed and there was no device on his/her right hand. On 06/01/26 at 4:31 PM, R108 was observed lying supine in bed and there was no device on his/her right hand. In an interview with the DOR on 06/03/26 at 2:10 PM, he/she reviewed R108's record and stated R108 was supposed to wear a right hand finger spreader and palm protector for five hours a day. The DOR stated the CNAs were responsible for application and removal of the finger spreader/palm protector. The DOR reviewed the resident's record and confirmed there was no documented evidence of the application and removal of the right hand finger spreader and palm protector for R108. Review of R108's record on 06/05/26 at 4:14 PM revealed he/she was originally admitted to the facility on [DATE] with a nontraumatic intracerebral hemorrhage (bleeding in the brain) and a cerebrovascular accident (stroke). R108 was diagnosed with right hand contracture on 8/23/22. Review of the orders under the Orders tab in the EMR revealed there was an order dated 06/25/24 which indicated, R (right) hand finger spreader and palm protector 5 hrs everyday shift. On 06/05/26 at 4:20 PM, review of the care plan under the Care Plan tab in the EMR revealed, FMP tolerate R hand finger spreader and palm protector 5 hrs without any ill effect . 06/14/24. In an interview with the DON on 06/04/26 at 2:15 PM, he/she reviewed R108's record and confirmed there was not any documentation indicating the finger spreader/hand splint was applied to R108's right hand as ordered. Review of the facility policy revised July 2017, titled, Resident Mobility and Range of Motion revealed, 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion . Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts . The care plan will include the type, frequency, and duration of interventions . NJAC 8:39-11.2(b)

Based on observations, interviews, and review of facility policy, the facility failed to ensure staff used personal protective equipment (PPE) when providing care to two residents on enhanced barrier precautions (EBP's), Resident (R) 93, and R128 out of a sample of 25. These failures had the potential to cause the spread of infection.Findings include: 1. Observation of wound care provided to R93 on 06/03/26 at 11:41 AM, by Licensed Practical Nurse (LPN) 6 with assistance in positioning by Certified Nursing Assistant (CNA) 1 was conducted. R93 had a sign on the door titled, Enhanced Barrier Precautions. R93 was in a Geri-chair in his/her room. CNA1 stood against the side of the Geri-chair and held R93's left leg. LPN6 removed the dressing from R93's left posterior knee, cleaned the wound, and applied a new dressing. Neither CNA1 nor LPN6 wore gowns during the procedure. Immediately after the wound care, in an interview with LPN6, he/she stated only gloves were required for the wound care for R93. LPN6 stated gowns are only required when we're doing something with the PEG (percutaneous endoscopic gastrostomy tube – a tube placed through the skin into the stomach) tube. In an interview with Unit Manager Registered Nurse (UMRN) 1 on 06/03/26 at 11:45 AM, he/she stated, gowns are required for wound care for residents on EBPs. He/she further stated, staff were supposed to wear gowns when providing personal care and bed baths to residents on EBP. 2. On 06/04/26 at 10:35 AM, CNA5 was observed in R128's room. There was a sign on the door indicating, Enhanced Barrier Precautions. CNA5 was leaning against R128's bed and pushing a pile of clothes into a plastic bag on the bed. CNA5 did not have a gown on and R128's clothes were touching CNA5's clothing. R128 was sitting in a chair at the side of the bed. Immediately after CNA5 exited R128's room, an interview was conducted. CNA5 stated he/she was providing AM [morning] care to R128. He/she stated the family liked him/her to wear clothes rather than a hospital gown, so he/she was bagging his/her clothes which were dirty, for the family. CNA5 stated he/she should have been wearing a gown. During an interview with the Infection Preventionist (IP) on 06/05/26 at 6:09 PM, he/she stated if residents are on EBPs and staff are bagging dirty clothes, providing morning care, providing wound care, or assisting to position a resident, they were supposed to wear gowns. Review of the facility policy revised April 2025, titled, Enhanced Barrier Precautions revealed, Enhanced barrier precautions EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug resistant organisms (MDROs) during high contact resident care activities . 2. Enhanced barrier precautions apply when . b. a resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained . EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gowns are applied prior to performing the high contact resident care activity . 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged high contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g. in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing). NJAC 8:39-19.4(a)

Based on interview, record review and review of facility policy, the facility failed to provide the SNF ABN (skilled nursing facility advance beneficiary notice) for two (Residents (R) 91 and R109) of three residents reviewed for beneficiary notices. This failure placed the residents at risk of not knowing the costs or appeals process when they remained at the facility. Findings included. Review of the facility policy titled, Medicare Advanced Beneficiary and Medicare Non-Coverage Notices, dated September 2022 revealed, .The requirement to notify and explain via the SNFABN that the individual is no longer receiving Medicare Part A services based on the SNF's belief that Medicare Part A will not pay for the resident's stay separate and unrelated to the admission and discharge requirement under 42 CFR 483.15, which outlines the notification and requirements under which an individual may be discharged from the facility or when the transfer or discharge is not initiated by the resident .Termination-In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects the Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care the SNF ABN is issues to the beneficiary before such extended care items or services are terminated. The resident or representative is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility . 1. Review of the SNF Beneficiary Notification Review for Residents who received Medicare Part A Services form, provided by the Administrator, revealed R91 had a Medicare A start date of 02/07/24 and a last covered Medicare Part A Day of 04/30/24. There was no documentation provided that R91 had received the SNF ABN form. 2. Review of the SNF Beneficiary Notification Review for Residents who received Medicare Part A Services form, provided by the Administrator, revealed R109 had a Medicare A start date of 04/12/24 and a last covered Medicare Part A Day of 04/30/24. There was no documentation provided that R109 had received the SNF ABN form. During an interview on 10/16/24 at 10:05 AM, the Administrator stated, In April, we had a social worker that either lost or threw them away. We had a Medicare audit and that is when we identified there was a problem. He left in July but we just can't find the notices. NJAC 8:39- 5.4(b)(c)

Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one of four residents (Resident(R) 39) reviewed for abuse out of 27 sample residents when R32, who had no cognitive impairment, kissed R39's hand, who lacked any capacity to give consent. This had the potential to affect all the residents on the 2nd floor of the facility who were at risk of abuse. Findings include: 1.Review of R39's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R39 admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, obsessive compulsive disorder, anxiety disorder, major depressive disorder and mood disorder. Review of R39's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/09/24 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R39 was severely cognitively impaired. 2. Review of R32's ''Admission Record'' located in the ''Profile'' tab of the EMR, revealed R32 admitted to the facility on [DATE] with diagnoses including major depressive disorder, and anxiety. Review of R32's quarterly MDS'' with an ARD of 06/21/24 revealed a BIMS score of 15 out of 15 which indicated no impairment. Review of R32's care plan, located under the ''Care Plan'' tab of the EMR and dated 01/24/20, revealed The resident had a psychosocial wellbeing problem related to ineffective coping skills. Review of ''Nurse's Notes'' located in the EMR under the ''Notes'' tab, revealed no documentation related to the incident that occurred on 10/06/24 between R32 and R39. Review of Investigation Summary and Conclusion provided by the facility, dated 10/16/24, revealed R32 admitted to kissing R39 on the hand but the facility found that abuse did not occur. During an interview on 10/16/24 at 10:27 AM Family Member (FM)1 said he was at the facility on Sunday 10/06/24 sitting and talking in the dining room. He said his mom told him to look over at another table where R32 was touching on R39. He said he looked over and saw R32 kissing R39's hand and he reported it to Recreation Aide (RA)1. She went over to the table and told R32 to stop, and he wheeled himself out of the dining room. During an interview on 10/16/24 at 10:58 AM, RA1 said on 10/06/24 she was in the dining room from about 3:30 PM to 4:00 PM getting ready to take the residents back to their rooms after their church service activity. Another resident and their family were sitting close by, and the resident told her That guy is touching that person over there and when she looked she saw R32 sitting next to R39 but his hands were on the table and she did not see anything. She said R39 was chewing on her clothing, but she went over and told R32 that he had to leave the room, and he did. She did not report the incident to a supervisor because she did not see a supervisor around. During an interview on 10/16/24 at 1:18 PM the Assistant Director of Nursing (ADON) said she became aware od the incident on 10/09/24 after FM1 came to her and reported it. She said he told her on Sunday while he was in the dining room with his mom, along with an activity aide. He said his mom told his look at a resident that was messing with a female resident. When he looked over he said R32 kissing R39's hand. He told her he reported it to RA1 but by the time the aide looked R32 was not touching R39 anymore. He was asked to write a statement but to her knowledge he did not. She spoke with RA1 who told her she did not witness anything but asked R32 to leave. But she did not report it to anyone since she didn't witness anything. During an interview on 10/16/24 at 2:28 PM the Administrator stated he interviewed R32 who admitted to kissing R32's hand and told him it was the 1st time that he had done that, but he did not ask R32 why he decided to do it that day? He stated R32 meant it in a friendly gesture and there was no sexual intention. And that was why they concluded it was not abuse. He stated even though R32 was unable to tell anyone how it affected her he would still agree it was not abuse. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a valid physician order for a narcotic was obtained for one (Resident (R)25) of six sampled residents reviewed during medication pass. The facility failed to obtain a documented physician order for narcotic medication and failed to ensure there was documentation of symptoms for the use of narcotics. This failure placed the resident at risk of receiving medication Findings included. Review of an undated facility policy titled, Administering Medications, revealed, .Medications are administered in a safe and timely manner and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frames . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R25 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/03/24 revealed R25 had a Brief Interview of Mental Status (BIMS) score of zero out of 15 which indicated she was severely impaired in cognition, had not been administered an antianxiety medication during the observation period and was on hospice. On 10/16/24 at 8:44 AM, the narcotic book on medication cart two-north, cart two was reviewed with Licensed Practical Nurse (LPN) 5. During the observation, the October 2024 Narcotic Sheet revealed missing initials on 10/14/24 for the 3:00 PM to 11:00 PM shift. In addition, there were initials signed out for the 10/16/24 3:00 PM to 11:00 PM, even though that shift had not started yet. On 10/16/24 at 9:04 AM, a full narcotic count was conducted with LPN5 and the Director of Nursing (DON). During the narcotic count, the last page in the narcotic book revealed a sign-out sheet for R25's Lorazepam Oral Concentrate (an anti-anxiety medication) 2 MG/ML (milligrams/milliliter) Give 0.25 ml by mouth every 2 hours as needed for Anxiety for 14 days. Start Date: 07/22/24 and End Date: 08/05/24 The narcotic sign-out sheet revealed that R25 had received two doses of Lorazepam signed out by LPN 3. One for 09/22/24 at 3:30 PM and the other one for 09/22/24 at 6:00 PM (48 days past the discontinued date). There was no documentation the facility notified the doctor of the resident's and obtained an order for the administration of the discontinued medication. On 10/16/24 at 9:17 AM, Unit Manager (UM) 2 confirmed the medication had been signed-out in September despite the medication having been discontinued on 08/05/24. During an interview on 10/16/24 at 9:21 AM, the DON stated, If a medication has been discontinued, then it should not have been administered. During an interview on 10/16/24 at 3:28 PM, with the DON and LPN 3, LPN 3 was asked if she was aware that the Lorazepam order for R25 had been discontinued in August. LPN 3 stated, Yes. LPN 5 was asked to share what happened that evening. LPN 3 stated, I signed it out, she (R25) was like exhausted, like yelling out. I called the doctor because she didn't have an order, so I called R25's physician and she gave me an order for 24 hours and that's what I gave to her. LPN 3 was asked why she did not write the physician's order, knowing that she did not have an order to administer the medication, after speaking with the physician or write a Nursing Progress Note to indicate R25's behavior and if the medication was effective. LPN 5 stated, It was a busy day. I might have forgotten, sorry. During the interview, the DON stated that it was her expectation that a physician order should have been entered into the EMR and a Nursing Progress Note written as to R25's behaviors and effectiveness of the medication. In addition, the discontinued medication should have been removed from the refrigerator and destroyed. NJAC 8:39-29.2(d)

Based on record review, interview, and policy review, the facility failed to an report an allegation of sexual abuse by a resident for one of four residents (Resident (R) 39) reviewed for abuse out of 27 sample residents when R32 kissed R39 hands who lacked the ability to give consent, this had the potential to affect all the residents on the 2nd floor of the facility who were at risk of abuse. Findings include: 1.Review of R39's ''Admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R39 admitted to the facility on [DATE] with diagnoses including dementia, schizophrenia, obsessive compulsive disorder, anxiety disorder, major depressive disorder and mood disorder. Review of R39's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/09/24 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R39 was severely cognitively impaired. 2. Review of R32's ''Admission Record'' located in the ''Profile'' tab of the EMR, revealed R32 admitted to the facility on [DATE] with diagnoses including major depressive disorder, and anxiety. Review of R32's quarterly ''MDS'' with an ARD of 06/21/24 revealed a BIMS score of 15 out of 15 which indicated no impairment. Review of Investigation Summary and Conclusion provided by the facility, dated 10/16/24, revealed R32 admitted to kissing R39 on the hand but the facility found that abuse did not occur Further review revealed the incident was not report to the state until 10/09/24 after a family member reported it to the facility. During an interview on 10/16/24 at 10:27 AM Family Member (FM)1 said he was at the facility on Sunday 10/06/24 sitting and talking in the dining room. He said his mom told him to look over at another table where R32 was touching R39. He said he looked over and saw R32 kissing R39's hand and he reported it to Recreation Aide (RA)1 at the time of the incident. During an interview on 10/16/24 at 10:58 AM RA1 said on 10/06/24 she was in the dining room from about 3:30 PM to 4:00 PM when another resident and their family were sitting close by, and the resident told her That guy [R39] is touching that person over there and when she looked she saw R32 sitting next to R39 but his hands were on the table and she did not see anything. She did not report the incident to a supervisor because she did not see a supervisor around. During an interview on 10/16/24 at 1:18 PM the Assistant Director of Nursing (ADON) said she became aware of the incident on 10/09/24 after FM1 came to her and reported it. She saidFM1 told her on Sunday while he was in the dining room with his mom, along with an activity aide his mom told him to look at a resident that was messing with a female resident. When he looked over he said R32 kissing R39's hand. He told her he reported it to RA1 but by the time the aide looked R32 was not touching R39 anymore. She spoke with RA1 who told her she did not witness anything but asked R32 to leave. But she did not report it to anyone since she didn't witness anything. During an interview on 10/16/24 at 2:28 PM the Administrator confirmed the allegation was not reported timely. During an interview on 10/17/24 at 1:36 PM the Director of Nursing (DON) said she expected staff to report any allegations immediately NJAC 8:39-9.4(f)

Based on record review, interview and policy review, the facility failed to ensure that MDS assessment was completed timely for one residents R32. This had to affect all the residents with MDS assessments. Findings include: Review of R32's ''Admission Record'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R32 admitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety. Review on 10/14/24 of R32's Annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 09/20/24 was listed as Pending. Further review revealed the ARD date for completion was 10/15/24. During an interview on 10/17/24 at 10:00 AM with the MDS Coordinator (MDSC) who stated she has asked for additional help to assist with completing the assessments timely. She knew the 09/20/24 assessment was not completed within the times frames, and it should have been within 14 days. During an interview on 10/17/24 at 1:36 PM the Director of Nursing (DON) said she expected that assessments were completed in a timely manner and completed within the timeframes. NJAC 8:39-11.1

Based on record review, interview and review of the Resident Assessment Instrument Manual, the facility failed to ensure that a significant change Minimum Data Set (MDS) assessment was completed timely for one residents R27 out of 27 residents reviewed in the sample. This had the potential to affect all residents with a significant change. Findings Include: Review of R27's Admission Record, located in the Profile tab of the electronic medical record (EMR) revealed readmission to the facility on [DATE]. Review on 10/14/24 of R27's Significant change MDS under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/30/24. Further review revealed the ARD date for completion was 08/04/24. Review of Physician Orders under the Orders tab of the EMR, dated 07/17/24, revealed an order for hospice. During an interview on 10/17/24 at 10:09 AM with the MDS Coordinator (MDSC) and Regional MDS coordinator (RMDS) the MDSC stated she was on vacation at the time the significant change assessment should have been completed. The RMDS have had problems with hospice notifying them after a resident goes on hospice and has told the nurses to let them know when they make an order for hospice. She stated there are per-diem staff that help when the MDSC is out, and she would periodically check to ensure assessments were being completed timely. She said this one was missed but that she caught it on the 30th and initiated it but she said it was not completed timely within the 14 days and it should have been. During an interview on 10/17/24 at 1:36 PM the Director of Nursing (DON) said she expected that assessments were completed in a timely manner and completed within the timeframes. Review of the Minimum Data Set Resident Assessment Instrument (RAI) revealed, Guidelines for Determining the Need for an SCSA For Residents With Terminal Conditions. The key in determining if an SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration, an SCSA assessment is required. Similarly, if the resident enrolls in a hospice (Medicare Hospice program or other structured hospice program), but remains a resident at the facility, an SCSA should be performed if the terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration. The facility is responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. NJAC 8:39-11.2(i)

Based on interview, record review, and review of facility policy, the facility failed to ensure a psychotropic medication contained a 14-day stop date, as required for one (Resident (R)106) of five residents reviewed for unnecessary medications. This failure placed the residents at risk of being administered a medication unnecessarily. Findings included. Review of the facility policy titled, Psychotropic Medication Use, dated July 2022 revealed, .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record .PRN orders for psychotropic medications are limited to 14 days . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R106 was admitted to the facility on [DATE] with a diagnosis of cancer and pneumonia. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 09/19/24 revealed R106 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated he was cognitively intact and had been administered an antianxiety medication during the observation period. Review of the current Physician Orders located in the Orders tab of the EMR revealed a 10/01/24 Order for Alprazolam (an antianxiety medication) 0.25 mg give one table every 12 hours as needed for Anxiety. There was no stop date on the Order. During an interview on 10/16/24 at 1:15 PM the Director of Nursing (DON) stated, R106 should have been reassessed to see if the medication needed to be continued. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the label on an insulin pen matched the physician order for one (Resident (R) 87) of six residents reviewed during medication pass observation. This failure placed the resident at risk of receiving the wrong dose of medication. Findings included. Review of the facility policy titled, Medication Labeling and Storage, dated 2001 revealed, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items .Only the dispensing pharmacy may label or alter the label on a medication container or package . During a medication storage observation on 10/16/24 at 7:35 AM, Licensed Practical Nurse (LPN) 5 obtained an insulin pen from the top drawer of the medication cart. He stated that he would be administering the insulin to R87. LPN5 asked how much insulin he would be administering to R87. LPN 5 stated, 15 units. Review of the label on the insulin pen revealed, Glargine insulin (long-acting insulin) 36 units every day. Review of the Medication Administration Record (MAR) for October 2024 revealed the insulin order had changed to 15 units on 10/08/24. During the observation LPN5 was asked what the process was when an order changed to an existing medication. LPN5 stated, Pharmacy will send us a new pen with the correct order. LPN 5 was asked why this had not been done since 10/08/24 when the order changed. LPN 5 stated, I don't know. During an interview on 10/16/24 at 8:41 AM, the Director of Nursing (DON) was asked what her expectation was regarding labeling of medications when the order changed. The DON stated, Staff are to call and verify the order with the physician, if the order is different, and then notify the pharmacy who will send us the corrected label. The DON further stated that we have change stickers to use until the new label arrives. NJAC 8:39-29.4(a)(h)(d)

Based on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect all 107 residents who resided in the facility and who received dietary services. There were five residents receiving tube feedings, but they also received food from the kitchen. The facility had a census of 107 residents. Findings include: Review of the facility's policy titled, Sanitization, dated 11/2022 (sic), revealed, Policy Statement: The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination . During an observation and interview on 10/14/24 at 9:22 AM, the Food Service Director (FSD) confirmed five pans, 12 inches by 6 inches by 8 inches deep that had been cleaned and stacked for use were still wet and had food particles on them when they were unstacked. The pans were found to have been stacked wet and not allowed to air dry. The FSD stated, they should be dry before they are put away, my normal dishwasher is on vacation and the person washing everything didn't let them dry before stacking them. They need to be rewashed. During an observation and interview on 10/14/24 at 9:33 AM, the FSD confirmed six pans, 10 inches by 12 inches by 6 inches deep; eight pans 10 inches by 6 inches by 6 inches deep: fifteen pans 12 inches by 24 inches by 4 inches deep that had been cleaned and stacked for use were still wet when they were unstacked. The pans were found to have been stacked wet and not allowed to air dry. The FSD stated, they should be dry before they are put away, we're just going to rewash everything. NJAC 8:39-17.2(g)

Based on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for two residents (Residents (R) 210 and R 90) in a total sample of 30. The facility failed to ensure daily, weekly, and monthly weights were in the medical record to ensure continuity of care. This failure placed the residents at risk of unmet care needs. Findings included. Review of the facility policy titled, Charting and Documentation, dated 2001 revealed, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R210 was admitted to the facility on [DATE] with a diagnosis of heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/26/24 revealed R210 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R210 was cognitively intact for daily decision-making and was administered a diuretic medication during the observation period. Review of the Physician Orders located in the Orders tab of the EMR revealed an 09/24/24 Order for Daily weights at 8 am weight (sic) pt [patient] before breakfast. Notify MD [Medical Doctor] if weight is greater than or equal to 3-pound increase in one day or if increase is greater than or equal to 5 lbs. in one week. Review of the daily weights located in the Weights and Vitals tab of the EMR revealed the following: 09/19/24: 126.0 lbs. 09/21/24: 126.1 lbs. There were no daily weights from 09/25/24 to 10/02/24 in the medical record. 10/02/24: 132.8 lbs. No weight documented for 10/03/24. 10/04/24: 134.4 lbs. 10/05/24: 135.8 lbs. No weight documented for 10/06/24. 10/07/24: 133.3 lbs. There were no further weights documented in the medical record. During an interview on 10/15/24 at 1:15 PM, Licensed Practical Nurse (LPN) 2 stated, R210 gets up early and we weigh him when they are getting him ready. We give the aides a list of the weights that are needed on a sheet of paper and the names of who are daily weights. Once they are done, we pass them along to the Unit Manager (UM) for review. During an interview on 10/15/24 at 1:22 PM, UM1 stated, I collect the paper from the nurse and then put all the weights into an excel spreadsheet. The Director of Nursing (DON) then takes it for review. During an interview on 10/15/24 at 1:23 PM, the DON stated, I put the list of daily weights in a binder for the aides, then the aides put the weight in for the day, the nurse compares them for weight changes. UM1 does the tracking (of the weights). The only weights we allow in the PCC (point click care-electronic medical record) are those entered by the dietician. During a follow-up interview on 10/15/24 at 1:51 PM, the DON stated, We have been putting the weights in a binder for safekeeping. The Registered Dietician (RD) and the Physician can review them anytime. 2. Review of the undated Admission Record located under the electronic medical record (EMR) under the Profile tab, revealed R90 was admitted to the facility on [DATE] with a diagnosis which included muscle wasting and atrophy, malignant neoplasm and pancreas. Review of R90'S Progress Notes, found under the Progress Notes tab of the EMR a Nutrition Note, dated 08/20/24 indicated, This RD[Registered Dietician] was notified by nursing that R90 is not tolerating bolus feeds . R90 continues with poor appetite.Recommendations . 5. Weekly weights. Review of Resident (R) 90's electronic medical record (EMR) on 10/15/24 at 12:25 PM, under the Vitals tab, weights revealed only three entries: 08/14/24 - 154lbs. 09/04/24 - 131.4 lbs. 10/02/24 - 132 lbs. A request as made for R90'S weekly weights was made on 10/16/24. Further review of R90's EMR on 10/16/24 at 3:06 PM, under the Vitals tab, weights revealed eight entries dated: 08/22/24 - 132 lbs. 08/29/24 - 131.9 lbs. 09/04/24 - 131.4 lbs. 09/11/24 - 132.5 lbs. 09/18/24 - 131.9 lbs. 09/25/24 - 132.2 lbs. 10/02/24 - 132 lbs. 10/09/24 - 131.7 lbs. The additional weight entries were located in a binder at the nurse's station on the second floor and had not been entered into R90's medical record. During an interview on 10/16/24 at 11:05 AM the Registered Dietitian stated, The weights were on a sheet in a notebook and not in the EMR. 32513 NJAC 8:39-35.2(c)(d)(6)(g)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure a quarterly assessment was coded accurately for one (Resident (R)83) in a total sample of 30. The facility failed to accurately code hospice for R83. This failure placed the residents at risk of unmet care needs. Findings included. Review of the October 2024 RAI, manual, page 1-5 revealed, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS [minimum data set] items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R83 was admitted to the facility on [DATE] with a diagnosis of a brain tumor. Review of the Physician Orders located in the Orders tab of the EMR revealed R83 was admitted to hospice services on 03/27/24. Review of the quarterly MDS located in the MDS tab of the EMR with and Assessment Reference Date of 06/28/24, Section O revealed R83 was not coded for hospice care. During an interview on 10/15/24 at 11:47 AM, the MDS Coordinator (MDSC) stated, I missed the quarterly assessment indicating hospice. It was an error. NJAC 8:39-33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure that a.) an expired narcotic medication was removed from active inventory that resulted in repeated administration of an expired medication to Resident #93 for three months and b.) discontinued biologicals were removed from active inventory for 3 of 3 unsampled residents (Resident #6, #32, and #34). This deficient practice was identified during 1 of 1 medication rooms inspected (First-floor) and evidenced by the following: 1. On 11/16/22 at 10:23 AM, the surveyor inspected the First-floor medication room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed an expired, opened bottle of lorazepam concentrate 2 milligram (mg)/1 milliliter (ml; a narcotic medication used for anxiety) labeled with Resident #93's name. The LPN/UM confirmed the seal was broken on the bottle. At that time, the surveyor and the LPN/UM reviewed the manufacturer's package that reflected Discard opened bottle after 90 days. The resident's label revealed a pharmacy dispense date of 6/9/22. A review of Resident #93's Controlled Drug Record (a narcotic inventory log) revealed lorazepam was signed received on 6/10/22, and the first dose was deducted from the inventory on 6/10/22. At that time, the LPN/UM confirmed the medication should have been discarded on 9/10/22. A further review of Resident #93's Controlled Drug Record for lorazepam revealed doses on 9/30/22, 10/01/22, and 11/15/22 were deducted from inventory after the expiration date. A review of the Resident #93's corresponding electronic Medication Administration Record for September 2022, October 2022, and November 2022 revealed lorazepam was administered on 9/30/22, 10/1/22, and 11/15/22. On 11/16/22 at 10:52 AM, the surveyor interviewed the LPN/UM who stated it was important for expired medication to be discarded since the potency of the medication may be affected and the medication may not be as effective. On 11/16/22 at 11:21 AM, the surveyor interviewed the Regional Clinical Nurse who confirmed expired medications should have been removed from active inventory. On 11/23/22 at 10:19 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations, Regional Clinical Nurse, and survey team confirmed the expired lorazepam should have been removed from the active inventory. 2. On 11/16/22 at 10:23 AM, the surveyor inspected the First-floor medication room in the presence of the LPN/UM and observed the following: Unsampled Resident #6's sealed Basaglar (insulin glargine) with a dispense date of 6/23/22. Unsampled Resident #32's sealed Novolog (insulin aspart) with a dispense date of 4/27/22. Unsampled Resident #34's sealed Humalog (insulin lispro) with a dispense date of 5/2/22. On 11/16/22 at 11:55 AM, the LPN/UM reviewed the electronic Medical Record and confirmed the insulin found for unsampled Residents #6, #32 and #34 were discontinued. A review of Resident #6's Order Recap Report (ORR) dated 5/1/22 to 11/30/22, reflected that Basaglar was discontinued 8/2/22 A review of Resident #32's ORR dated 3/1/22 to 11/30/22, reflected that Novolog was discontinued on 5/16/22. A review of Resident #34's ORR dated 4/1/22 to 11/30/22, reflected that Humalog was discontinued on 5/16/22. On 11/16/22 at 11:21 AM, the surveyor interviewed the Regional Clinical Nurse who confirmed discontinued medications should have been removed from active inventory. On 11/23/22 at 10:19 AM, the DON in the presence of the LNHA, Regional Director of Operations, Regional Clinical Nurse, and survey team confirmed the discontinued insulin should have been removed from the active inventory. A review of the undated facility provided Storage of Medications policy included .Policy Interpretation and Implementation .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . NJAC 8:39- 29.2(d); 29.4(g)

Based on interview, record review, and record review of facility documents, it was determined that the facility failed to ensure the Consultant Pharmacist identified and/or reported a medication interaction during the monthly medication regimen review from August to November 2022. This deficient practice was identified for 1 of 4 residents (Resident #26) reviewed for medication administration via tube feeding and was evidenced by the following: A review of the manufacturer's specifications for Levothyroxine under section 7.0 titled, Drug Interactions, Table 2. Drugs That May Decrease T4 Absorption (Hypothyroidism) included .Potential impact: Concurrent use may reduce the efficacy of levothyroxine sodium by binding and delaying or preventing absorption, potentially resulting in hypothyroidism. Phosphate Binders (e.g., calcium carbonate, ferrous sulfate, sevelamer, lanthanum) Phosphate Binders may bind to levothyroxine. Administer levothyroxine sodium tablets at least 4 hours part from these agents. On 11/14/22 at 10:35 AM, during the initial tour, the surveyor observed Resident #26 sleeping, covered with a flat sheet. The bed was positioned at the lowest height and the resident was positioned at approximately a 30-degree incline with a fall mat next to the bed. The surveyor reviewed the medical record for Resident #26. A review of the Admission Record face sheet (an admission summary) reflected the resident was originally admitted to the facility in December 2020 with diagnoses which included Parkinson's Disease, dysphagia, heart failure, dementia, hematuria (blood in the urine) and hypothyroidism. A review of the Order Summary Report (OSR) from admission included an initial physician's order (po) dated 7/6/21 for levothyroxine 25 microgram (mcg); give one tablet by mouth one time a day for hypothyroidism, and a po dated 8/27/22 for ferrous sulfate tablet 325 milligram (mg; medication for anemia); give 1 tablet via a feeding tube one time a day for anemia. A review of the corresponding August 2022, September 2022, October 2022, and November 2022 electronic Medication Administration Record (eMAR) revealed levothyroxine and ferrous sulfate were scheduled to be administered both at 9:00 AM daily from 8/28/22 to present. This was not in accordance with manufacturer's recommendations to separate the levothyroxine and ferrous sulfate by at least four hours. A review of the Consultant Pharmacist's Recommendations report from 9/10/22 through 11/15/22 did not reflect a recommendation to separate the administration of levothyroxine and ferrous sulfate by at least four hours apart as indicated on the manufacturer's specifications. On 11/18/22 at 10:42 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated she was not the regular CP for the facility and that all recommendations made by the CP were documented. The CP continued she was unsure if the recommendation to administer levothyroxine and ferrous sulfate at least four hours apart was made. The CP added that if Resident #26's laboratory values were stable, and the resident had been taking the medications at the same time for some time, then the physician may not have agreed to separate both medications. The CP stated she would look into what occurred and inform the surveyor if a recommendation was made. On 11/23/22 at 9:05 AM, during an interview via telephone, the surveyor asked the resident's Physician/Medical Director if levothyroxine and ferrous sulfate could be administered at the same time. The Physician/Medical Director responded that he relied on the pharmacy for drug interaction recommendations and usually followed them. The Physician/Medical Director could not speak to Resident #26's levothyroxine being administered at the same time as the ferrous sulfate. On 11/23/22 at 10:28 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Clinical Operations Nurse, Regional Director of Operations, and the survey team confirmed a recommendation was not made by the CP to separate levothyroxine and ferrous sulfate. Review of the facility's undated Medication Regimen Reviews policy included .Policy Interpretation and Implementation: 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 5. The MRR [medication regimen review] involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities .9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services . NJAC 8:39-29.3(a)(1)(6)

Based on observation, interview, and record review, it was determined that the facility failed to provide a.) a chair and b.) a clean comfortable mattress to a resident. This deficient practice was identified for 1 of 2 residents reviewed for hospice and end of life care (Resident #1) and was evidenced by the following: On 11/14/22 at 11:05 AM, during the initial tour, the surveyor observed Resident #1 sitting on their bed. Resident #1 informed the surveyor that the bed was not comfortable and that they had previously discussed his/her discomfort with the Licensed Practical Nurse (LPN) and the previous Unit Manager (UM #1). Resident #1 also stated that he/she wanted to sit somewhere else other than their bed but was unable to since he/she has not had a chair for about three weeks. At that time, the surveyor did not observe a chair in the resident's side of the room or the hallway. The surveyor reviewed the medical record for Resident #1. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in January of 2018 with diagnoses which included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lung), chronic embolism and thrombosis (blood clots), diabetes mellitus, major depressive disorder, and paranoid schizophrenia. A review of the most recent significant change Minimum Data Set (MDS; an assessment tool) dated 10/13/22, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. A review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 9/29/22, reflected the resident was discharged from hospice on 10/1/22. 1. On 11/15/22 at 11:05 AM, the surveyor observed Resident #1 was transferred from the bed to a chair. On 11/15/22 at 11:14 AM, the surveyor asked Resident #1 where the chair they were in came from, and the Certified Nursing Assistant (CNA) who was present at the time, stated the chair that the resident was in came from the Physical Therapy (PT)/Occupational Therapy (OT) department that day. On 11/15/22 at 11:18 AM, during an interview with the surveyor, the LPN stated the resident was discontinued from hospice and that hospice had taken her chair and the facility had to relinquish hospice provided items once their services ended. On 11/15/22 at 11:37 AM, during an interview with the surveyor, the LPN/UM #2 confirmed that the chair was given by the PT/OT department on that day. On 11/15/22 at 11:40 AM, during an interview with the surveyor, the Director of Nursing (DON) could not recall the date when the chair was ordered. On 11/15/22 at 12:05 PM, during an interview with the surveyor, the CNA stated she transferred the resident out of bed every other day and Resident #1 has not had a chair for about two and a half weeks, since hospice took their recliner back. The CNA continued that she had reported to the previous UM #1 and the DON. The CNA informed the surveyor that when therapy provided a chair, she (CNA) was then able to get the resident out of bed. She also stated that she had to hunt for a chair to get Resident #1 out of bed. On 11/22/22 at 12:57 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Regional Director of Operations (RDO), Regional Clinical Nurse, and survey team, stated that Resident #1 was being trialed for a chair by the PT/OT department. The LNHA acknowledged Resident #1 should have had an alternate chair while being trialed by the PT/OT department. The LNHA confirmed that there was breakdown in the communication process and stated this was not their normal practice or process. 2. On 11/15/22 at 11:14 AM, the surveyor in the presence of another surveyor observed Resident #1's mattress had a white stain, a darkened area above the white stain and was sunken in the middle. On 11/15/22 at 11:18 AM, the surveyor interviewed the LPN who indicated that the mattress belonged to hospice but was not relinquished because they had nowhere to move the resident to and at that time Resident #1 did not have a chair. At that time, the LPN assessed the mattress and described the mattress as hard, concaved, and stained. The LPN informed the surveyor that the Maintenance department was aware of the resident's bed. She stated that the process for requesting a new mattress would be the nurse opened an electronic work order in the [name redacted] system for the Maintenance department to check the mattress. On 11/15/22 at 11:55 AM, the surveyor met with the Regional Director of Plant Operations (RDPO) regarding the resident's mattress. The RDPO stated there was not a previous work order in the electronic system for the resident's mattress prior to surveyor inquiry. On 11/15/22 at 11:57 AM, during a follow up interview with the surveyor, the LPN acknowledged the mattress should not have been soiled and was aware of the conversation Resident #1 had with the previous UM #1 and CNA about the uncomfortable bed. The LPN also stated that she reminded the previous UM #1 about the need for a new mattress. On 11/15/22 at 12:09 PM, the surveyor interviewed the CNA who confirmed the resident was complaining about their bed hurting their behind and she (CNA) reported to the previous UM #1. The CNA informed the surveyor that during morning care the cream went onto the bed and that the resident had blood in his/her hands from scratching. The CNA called Housekeeping who cleaned the mattress, but the white stain could not be removed. On 11/15/22 at 12:39 PM, the surveyor interviewed the DON who confirmed the bed should not have been discolored. She informed the surveyor that it was their policy for the CNAs to report items in disrepair and the staff should have reported to the UM. On 11/22/22 at 2:12 PM, the Regional Clinical Nurse informed the survey team the resident's mattress was discarded. On 11/23/22 at 10:19 AM, the LNHA in the presence of the RDO, Clinical Nurse, and survey team confirmed that the facility was aware of the resident's concerns regarding their mattress as of 10/17/22. The LNHA confirmed the resident's mattress had been discarded in the trash. A review of a Staff Statement from the CNA dated 11/15/22, provided by the LNHA, indicated that the CNA was made aware on 10/17/22 during morning care, Resident #1 complained to them about their mattress, and she informed the Supervisor. A review of the facility provided undated Work Orders, Maintenance policy included policy statement: maintenance work orders shall be completed to establish priority of maintenance service. Policy Interpretation and Implementation 1. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director. This may be achieved electronically via the use of [name redacted electronic work order program]. A review of the undated facility provided Assistive Device and Equipment policy included policy statement: our facility maintains and supervises the use of assistive devices and equipment for residents .Policy Interpretation and Implementation .6 .c. Device condition - devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. NJAC 8:39-31.8(c)(1)(10); 31.8(f)(3)

COMPLAINT #NJ Based on interviews and review of the medical records and other facility documentation, it was determined that the facility failed to notify the Physician and obtain a Physician order for [REDACTED].#2). On 1/6/16 Resident #2 was advanced to a Dysphagia Altered Diet from a Dysphagia Pureed Diet by the facility Speech Therapist. Resident #2 was provided the lunch meal with the new upgraded diet on 1/6/16. At 5 PM on 1/6/16, Resident #2 vomited digested food, prior to receiving the dinner meal. The deficiency is considered past non compliance because the facility identified the immediate jeopardy on 1/8/16 and corrected it the same day by the implementation of an acceptable plan of correction. The surveyor reviewed the medical record of Resident #2 on 1/14/16 at 10:40 AM. The Resident #2's Admission Record revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 12/9/15 indicated a Brief Interview for Mental Status (BIMS) score of 9 indicating that Resident #2's cognition was moderately impaired. According to the MDS, Resident #2 required extensive staff assist for Activities of Daily Living (ADL's). The surveyor reviewed the following approved diets in use at the facility: Dysphagia Pureed Diet - This diet follows the National Dysphagia Level 1 Diet. Foods are thick and smooth and have a moist pudding like consistency without pulp or small food particles. Sticky foods or foods that require a bolus formation or controlled manipulation of the mouth are omitted. Dysphagia Altered Diet - This diet follows the National Dysphagia Level 2 Mechanically Altered Diet. Foods are moist, soft and simple to chew. Moistened ground meats (pieces should not exceed ¼ inch cube,) vegetables cooked to a soft mashable texture are served. Certain fibrous vegetables are omitted along with regular consistency breads. A review of the Physician Order Sheet (POS), indicated the following entry in the POS as entered by the Speech Therapist (ST): 1/6/16 ST clarification order: Recommend diet upgrade to Dysphagia Altered with Nectar thick liquids. Continue all other orders as written. Aspiration Precautions: Liquids via straw only, small bites/sips, alternate solid - liquid frequently, pt. (Patient) must be upright during meals. On 1/6/16 at 6:20 PM, CXR (Chest X-Ray) tonight R/O (Rule Out) Aspiration Pneumonia. Monitor respiratory status. Monitor O2 sat (oxygen saturation), maintain at (greater than) 95%. Monitor every shift x (for) 4 days. On 1/6/16 at 7 PM, Calorie count x 2 days. OT (Occupational Therapy) eval (evaluation) for use of adaptive eating equipment. On 1/7/16, CBC (Complete Blood Count) with diff (differential), CMP (Comprehensive Metabolic Panel) & UA (Urinalysis). O2 PRN (as needed) if (O2) sat is (less than) 95%. On 1/7/16, D/C (Discontinue) Dysphagia advanced puree diet. On 1/7/16, Consult with (Pulmonologist). 1/7/16 Continue nectar thick liquids. 1/7/16 CX-Ray today. The surveyor interviewed the Speech Therapist (ST) on 1/14/16 at 1:20 PM. According to the ST, The previous ST provided training to me. We used to write the recommendations in the POS (Physician Order Sheet), verbalized it to the nurse and flagged the order sheet in the chart. We now write our recommendation on a form, then I and the nurse review what I wrote, and this way I know that the message was relayed. Also now, I speak with the doctor, with the nurse present. Then the nurse signs off on the same form and dates and writes who the MD was (that we spoke to). This form is then placed into the chart and flagged. Resident (#2) was NPO (Nothing by Mouth) when I started working here. Then he/she was on Dysphagia pureed with nectar thick liquids. I tried to see if other consistencies could be tried. I was very cautious with Resident #2, because of his/her history. I tried different consistencies very slowly. Every time he/she tried the chopped - mechanical soft, like pancakes, there were no issues. After a couple of weeks of trials, he/she was able to take Dysphagia altered diet, which is also pureed consistency with ground meat on the side. The vegetables and fruits are pureed. The ground meat, (i.e. Chicken), is very finely chopped. Resident (#2) was able to tolerate this diet for several weeks with me, so I wrote in the POS my recommendation and flagged in the chart and verbalized such, to the nurse. That is the process that we did. The next day the nurse told me the Resident (#2) vomited digested material from the lunch tray. But Resident (#2) vomited at 5 PM. The resident is not aware of how full he/she is when he/she eats so it may be a contributing factor. Now Resident (#2) is back to puree diet and nectar thick liquids. The surveyor interviewed the Director of Nursing (DON) on 1/14/16 at 11:25 AM. According to the DON, It has been our history that the recommendations from ST (Speech Therapist), PT (Physical Therapist) and OT (Occupational Therapist) were written in the POS. The DT (Dietician) has a separate form. The process was that ST, PT & OT would flag the POS and verbally told the nurse of the recommendations. The nurse then called the MD to obtain the T/O (Telephone Order). The nurse then sent a slip to the kitchen with the change in diet. This information was put into the 24 hour report. All shifts (nurses) must sign the T/O. It is our protocol for all 3 shifts to sign the POS to check if order was carried out. We now instituted a change. As of 1/11/16 we now have a form. We no longer have ST, PT & OT write in the POS. They write their recommendation on the form, place it into chart flagged and inform the nurse. The MD is called. The ST must be with the nurse when the MD is called. Unfortunately, the nurse forgot to call him (Physician) about the ST recommendation in the POS. The order was clarified; the diet was changed without the MD (Medical Doctor) being called. The diet change was in the AM, the Resident (#2) got the lunch tray in the afternoon with the new diet change. At 5 PM the Resident (#2) vomited digested food. This was before dinner. The Resident (#2) did not get a dinner tray at that time yet. A chest X-ray was done, then a Pulmonologist came and we did a second Chest X-ray to make sure no negative outcome. The X-ray was negative for aspiration pneumonia. The nurse (LPN #3) spoke with the MD and took the responsibility for her error (of not calling him about the ST recommendation on 1/6/16). The nurse (LPN#3) was suspended pending investigation outcome and was reinstated after teaching. LPN (#3) was in-serviced before the suspension. The LPN is under constant monitoring, done on a weekly basis by the DON (Director of Nursing). Re-inservices to be completed by the DON on the new policy by tomorrow. Technically there was no order for the Mechanical altered diet, but the resident was given it x 1 (one time) meal for lunch and vomited at 5 PM. The Pulmonologist evaluated the resident (#2) and ordered a second x-ray, secondary to, aspiration risk. As per the Pulmonologist, if there is ever any aspiration it would show up the next day. The surveyor interviewed the Pulmonologist on 1/19/16 at 4 PM. According to the Pulmonologist, The ST wrote an order without consulting with him (MD). ST should have not written the order. The Resident has a history of aspiration pneumonia in the past. X-ray #1 showed no pneumonia was there. The Radiologist was over reading the results. Aspiration pneumonia does not show up for 12 - 24 hours. The second X-ray did not show aspiration pneumonia. The resident (#2) [MEDICAL CONDITION](Gastro Esophgeal Reflux Disease) which led to a prolonged state of digestion, but this was not a reflux. Resident (#2) was in [MEDICAL CONDITION] stable status and did not exhibit any [MEDICAL CONDITION] issues. The O2 Sats were good. The surveyor observed that the documented O2 Sat on 1/6/16 during the 11-7 shift was 93%. MD ordered to monitor O2 sat and maintain at greater than 95 %. The surveyor interviewed the Primary Medical Doctor (MD) on 2/2/16 at 10:30 AM. According to the MD, the Resident (#2) started with aspiration pneumonia sometime in early 2015. We tried to upgrade her diet several times which were unsuccessful. She is 75% PO (by mouth) and 25% GT (Gastric Tube) fed. They changed the consistency of her diet without notifying me. The old Speech Therapist knew that the Resident (#2) would not get an advanced diet. This new Speech Therapist should have notified me and didn't. The evening nurse (RN #1 on 1/6/16) did not say that the resident had a diet change and vomited. He/she said the resident vomited and he/she wanted a chest X-ray order. I called the day nurse the next day (1/7/16) to check on my patient and that is when the nurse (LPN #3) told me the diet was changed. In the past they may have done it, placed the recommendations on the POS, but not for this patient (Resident #2). It was a lapse on my part in the past and yes I should have stopped it then, but on a change of diet order, they should have notified me. I am very accessible. Everyone has my cell phone number. They should have called me, especially on a resident who has had aspiration pneumonia in the past. The Administrator said this was just an accident and nothing happened. The Resident (#2) vomited and they did not have an MD order for the diet change. The surveyor reviewed the nurse's (LPN #3) statement as obtained by the facility. According to the statement, On January 6th 2016 I received a recommendation from ST that was for an upgrade in diet for Resident (#2). I took the recommendation and faxed it to the pharmacy, placed it on 24 hour report, sent a slip to kitchen, and documented the upgrade in nurses note. However, I did not notify MD (Medical Doctor). On January 7th 2016, I worked 7-3 shift. The Resident (#2) was my patient. There were new orders to monitor for respiratory status, oxygen level, and diagnostic testing. No coughing, no emesis, no distress, no sob (shortness of breath) and no temperature was noted on my shift. SPO2 was 93% on room air and 97% on oxygen as ordered PRN (as needed). MD had called in the morning to see how his patient was doing, and report was given to him. I then notified doctor of ST's upgrade and asked if he wanted to continue that (ST's recommendation) or place patient back on pureed diet. He wanted the upgrade discontinued and wanted patient (Resident #2) to be put back on puree. He was very mad and demanded to speak with the ADON (Assistant Director of Nursing), yelling into the phone. The DON needed to talk to me and was told I was suspended for two days. I am sorry for not notifying the doctor of the ST's recommendation. It truly was an honest mistake. The surveyor reviewed the statement of the Registered Nurse (RN #1) who worked on 1/6/16 during the 3-11 shift. According to the statement, On January 6th at 5 PM, Resident (#2) vomited a large amount of digested and undigested food particles mixed with mucus shreds. I assisted CNA (Certified Nursing Assistant) to place Resident (#2) in bed. Resident (#2) was cleaned and HOB (head of bed) elevated. He/she had positive bowel sounds and vitals were WNL (within normal limits). Resident's (#2) throat was congested and voice raspy. I auscultated the Resident's (#2) lungs and all fields sounded clear. The nurse practitioner (NP) was on the unit and I asked the NP if we can do a chest x-ray to R/O (rule out) Aspiration since the Resident's (#2) throat was congested and voice remained raspy. The NP said 'yes, but notify the MD (Medical Doctor).' I notified the MD about the situation, told MD that the NP was here and MD responded yes to the chest x-ray and to monitor Resident (#2's) respiratory status. I informed the NP and the NP wrote the order accordingly. The surveyor observed the following order written in the POS by the NP on 1/6/16 at 6:30 PM: CXR (chest x-ray) tonight R/O (rule out) Aspiration Pneumonia. Monitor respiratory status. Monitor O2 sat, maintain at greater than 95%. Monitor q (every) shift x (times) 4 days. The surveyor reviewed the facility investigation and conclusion of outcome. According to the investigation, Employee was suspended on 1/8/16 and 1/11/16 pending investigation for failure to notify MD of the new order. On 1/6/16, ST wrote a recommendation for Resident (#2) in the POS for a diet upgrade from Dysphagia Puree with Nectar Thick liquids to Dysphagia Altered with Nectar Thick liquid. The LPN (#3) faxed the order to the pharmacy and the diet slip was sent to dietary at approximately 11 am. Upon notification of the kitchen, Dietary Director changed the resident profile in the Meal Tracker System and a new Tray Ticket was printed reflecting the new diet. Lunch tray was sent up reflecting the new diet. On 3-11 shift at 5 pm, the RN (#1) documented that Resident (#2) vomited large amount of digested food particles with mucous shreds. According to the RN (#1), she did not have dinner yet. Resident (#2) was assessed; The NP (Nurse Practitioner) was in the unit and RN asked (NP) for a chest x-ray to R/O Aspiration. NP said yes but to notify MD (Medical Doctor). RN (#1) notified MD about the situation, told MD that the NP was in the unit and MD responded 'yes' to the chest x-ray and to monitor respiratory status. NP was informed and wrote the order. There were no further episodes of vomiting or signs of distress. On 1/6/16 11-7 shift, there was no vomiting, HOB elevated, T-97.8 with SPO2 of 93%. MD d/c'd (discontinued) dysphagia altered (diet) and change back to puree. MD ordered a consult with (Pulmonologist). The (Pulmonologist) came and recommended a repeat CXR (Chest X-Ray). CXR was negative for pneumonia. There was no negative outcome. Resident remained stable. As of 1/11/16, a statement was submitted by LPN (#3) and she acknowledged that she did not notify the attending physician of the new order. Employee record (LPN #3) was reviewed and LPN (#3) does not have any disciplinary action in file for 12 months. Recommendations: 2 day suspension will remain unpaid. Employee will be reinstated to full duty on 1/12/16. Plan: In-service employee on calling attending physician prior to carrying out order. In-service on new protocol re: Recommendation from Consultants. Employee's performance will be monitored for 60 days. Weekly audit of consultants/therapy recommendations in LPN (#3's) unit. The surveyor interviewed LPN #1 on 1/14/16 at 11 AM. According to the LPN #1, ST makes recommendations which are written on a sheet and then given to nursing. We call the MD and get the order. ST or DT (Dietician) never write in the POS now. They use a separate sheet only and give that sheet to nursing. Nursing has responsibility to obtain order from MD. The surveyor interviewed LPN #2 on 1/14/16 at 11:10 AM. According to the LPN #2, ST and DT recommend and we call MD to get the order. We got in-serviced on the protocol. The last in-service on this protocol, was last week. Now ST and DT have a separate sheet (form) and we get that sheet and inform the MD to obtain an order. Before the ST may have written in the chart and flagged it. The nurses write the T/O order and send a slip to the kitchen informing of diet changes. The nurse will put in 24 hour report. The feeding is entered in the MAR and we tell the CNA's as well. All 3 shift nurses must sign the order. The surveyor reviewed the inservice information dated 1/11/16, that was provided to the facility staff regarding the new protocol for placement of Rehabilitation (Rehab) Department recommendations. The following information was observed: Attention all nurses. Effective immediately, Rehab Department will complete the Request for Orders form, every time they have a recommendation to Nursing. The form must be flagged in the chart and the nurse must call the attending physician for approval before writing the order. Pls.(please) disregard previous in-service. The surveyor observed an In-service Sign-in Sheet dated 1/11/16 with the following description of the presentation: Rehab Dept (Department) to fill out request for orders, Nursing to notify MD with PT (Physical Therapist), OT (Occupational Therapist), ST (Speech Therapist) request and verify. Nursing to transcribe order or T/O (Telephone Order), verify order and approval by MD. The In-service-Sign-in Sheet indicated signatures were obtained from Nursing and Rehabilitation Department. The In-service Sign-in Sheets indicated that the Nurses, Dietary and Rehabilitation staff received the above mentioned information. A review of the Facility Policy entitled, Change in a Resident's Condition or Status (Revised April 2011) indicated the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: A significant change in the resident's physical/emotional/mental condition. Instructions to notify the physician of changes in the resident's condition. A review of the Telephone Orders policy (Revised April 2008) indicated the following: Verbal telephone orders may be accepted from each resident's Attending Physician. 1. Verbal telephone orders may only be received by licensed personnel. 2. The entry must contain the instructions from the physician, date, time and the signature and title of the person transcribing the information. 3. Telephone orders must be countersigned by the Physician during his or her next visit. Audits of recommendations by consultants or therapists began on 1/8/16 and are ongoing and results of the audits to be submitted to the QA Committee for review and further plan of action. As of 1/8/16, the DON began conducting weekly QA (Quality Assurance) Audits to ensure that recommendations made by Consultants/Therapists are approved or denied by the Physician before they are written as an order in the POS (Physician Order Sheet). These weekly audits will continue for 3 months and then will be conducted monthly for 3 months. Audit findings are submitted to the QA Committee monthly for performance improvement and any recommendation for further action. NJAC 8:39 - 11.2 (b)

Complaint #: NJ PART A Based on interviews and review of medical records (MRs) and other facility documentation, it was determined that the facility failed to follow a physician's orders [REDACTED].#2) which was not in accordance with nursing standards of practice. Although Resident #2 had a change in condition, on 3/9/2015 and the physician ordered a transfer to the hospital at 10:30 AM, the ADON wanted to treat Resident #2 in the facility. The physician was called several times for new orders, but he didn't return the calls, until approximately 4 PM and the physician at that time refused to discontinue the order to transfer Resident #2 to the hospital. Resident #2 was transferred to the hospital at approximately 5:45 PM on 3/9/2015, 7 1/4 hours after the initial telephone voice order (TVO) and was subsequently admitted to the hospital for 6 days. The delay in following the physician's orders [REDACTED].#2. The facility Administrator and DON were notified of the Immediate Jeopardy on 3/20/2015 at 1:15 p.m. The IJ began on 3/9/2015 and was lifted on 3/20/2015 at 3:50 p.m., the first day of survey, when an acceptable Plan of Correction (POC) was implemented. This deficient practice is evidenced by the following; Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states; "The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as 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: "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." "Observes, records, and reports nursing facts. Subfunctions: Recognition of signs and symptoms indicative of changes in the general physical and mental condition of the patient. Examples: Observes and reports: Vital Signs, Alterations of skin. Alterations of body emission. Restlessness and listlessness." 1. Resident #2 was admitted to the facility in 12/2010 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 2/14/2015, indicated Resident #2 had impaired cognition and needed assistance with all activities of daily living (ADLs). A facility Care Plan (CP), initiated 8/14/2014 indicated a focus on communication due to (d/t) a [DIAGNOSES REDACTED]. A "Health Status" Nursing Note (HS NN), dated 3/9/2015 at 3 p.m. by the 7-3 shift Licensed Practical Nurse (LPN #1) revealed; "...received in room. Alert and responsive. Nonverbal..fed by staff. Noted coughing with congestion T (temperature) 99.6 BP (Blood Pressure) 138/62. Gargling noted in back of throat. patient (Resident #2) not in distress. Call out to MD (physician) at 10am, awaiting call back. Call back from MD (physician) at 10:30 am, MD (physician) notified of patients condition, ordered to send patient to (hospital). I (LPN #1) then asked ADON (Assistant Director of Nursing) for second opinion. ADON suggested I (LPN #1) call MD (physician) back to ask if we could do xrays, breathing treatment, ABT (antibiotic therapy) before sending patient out because (Resident #2) is not in distress. Unit Manager was made aware of situation, Unit Manager went in to do a second assessment on patient (Resident #2). MD (physician's) office called back at 11 am and message was left at desk. Two more call outs were placed to MD (physician) between 11:15 and 12 pm, receptionist was made aware of multiple calls back. am care rendered by CNA (certified nurses aide)...still no call back from MD (physician) by 1 pm. T 97.9, BP within normal limits. No distress noted. appeared comfortable in bed. Endorsed to next shift to follow up call with MD (physician) Left in stable condition." Review of the NN/MRs (nurses note/medical record) showed no documentation of any further assessment by nursing staff during the 7-3 shift until a HS NN, dated 3/9/2015 at 11:56 p.m. by the 3-11 shift LPN # 2, which revealed; "received resident in bed awake, non verbal, occasional non productive cough BP (Blood Pressure)150/68, P (pulse) 102, R (respirations) 20, Temp (temperature) 97.9 F (Fahrenheit). Was sent to hospital as per MD (physician orders). Resident (#2) admitted with dx (diagnosis) of lactic acidosis. Additionally, an "SBAR" (Situation Background Assessment Recommendation), dated 3/9/2015 at 5:59 p.m. included that Resident #2 had new symptoms of cough congestion, trouble swallowing and gurgling which began on 3/9/3015 and "stayed the same." Vital Signs (VS) documented were BP 138/62, T 99.6 and Pulse Oximetry (POx) of 96 percent (%). Review of 3/2015 Physician order [REDACTED].#2 to the hospital at 10:30 a.m., however, a POS, dated 3/9/2015 at 5 p.m., included a TVO order to; "send to (hospital) ER (emergency room ) for eval. (evaluation)." A Universal Transfer Form, dated 3/9/2015 but untimed, signed by the 3-11 shift LPN #2, included that Resident #2 was transferred to the hospital d/t "coughing at times" and a T of "99.8 F in the am." During the entrance meeting at 9:15 a.m. the Director of Nursing (DON) stated that sometime in the last couple of weeks a physician was upset because he said the facility "held his orders" for transfer to the hospital after a change in condition for Resident #2. During an interview with the surveyor on 3/20/2015 at 10:55 a.m. and 1 p.m., the Administrator stated she had conducted an investigation related to (r/t) the delay in transfer to the hospital for Resident #2 and provided statements from staff which included the following; A statement, dated 3/9/3015 from the 7-3 shift LPN #1 included; After giving Resident #2 morning medications, LPN #1 noted the resident was congested and coughing with T-99.6 F and BP 138/62. "I put out a call to (physician) at 10 a.m. (Physician) called back around 10:30 a.m. and gave me an order to send to (hospital). As I (LPN #1) was at the nurses station, pulling (Resident #2's) chart, (the) ADON passed and was made (aware) of the situation. ADON (Assistant Director of Nursing) then suggested to call (physician) and ask if we could do STAT (immediate) xray, ABT (antibiotic therapy) or breathing tx's (treatments) here (at facility) before we send (Resident #2) out because resident (#2) was not in distress. Unit Manager (UM RN #1) then came up on the floor and re-assessed patient..." The physician's office was called 3 more times between 11 a.m. and 12 p.m. and the receptionist was made aware of multiple calls and said she would let the physician "know right away." "I (LPN #1) tried to call (physician) back several times but our telephone lines were down. At 3 p.m. I (LPN #1) endorsed to 3-11 shift and told to f/u (follow-up) with (physician) call." During an interview with the surveyor on 3/20/2015 at 10:20 a.m. and in a post survey telephone call (TC) on 3/27/2015 at 10:30 a.m., LPN #1 confirmed her statement and added that at approximately 9:30 a.m. she noted Resident #2 was diaphoretic, sounded congested and was coughing, took his T, which was 99.6 and called the physician. LPN #1 stated the physician said "send him out" and she then asked the physician if he was sure, and he said "yes - send him." LPN #1 stated she checked on Resident #2 every half hour during her shift, monitored the POx every hour, which was about 92, however, did not document any of the half hour checks or VS in the NN because they were within normal limits. Additionally, LPN #1 stated that in the past (prior to 3/9/2015) she was able to notify the physician without consulting anyone if a resident had a change in condition, however, the new facility procedure was to call the UM, Supervisor, ADON/DON if there is a change in condition. "Even if it is an emergency we call the same people except for someone 'coding', then we would call 911. If a resident is in respiratory distress and still breathing we call the DON/ADON first." The surveyor asked LPN #1 why she did not send the resident to the hospital according to the PO on 3/9/2015 and she confirmed that the ADON told her not to send the resident out but to contact the physician again for inhouse treatments. During an interview with the surveyor at 10:30 a.m., an additional 7-3 staff member, LPN #3 stated she had recently, within the last week or two, received inservices r/t a resident's change in condition, which included to call (911) immediately for a "code" but to call the DON/ADON prior to calling the physician for anything else r/t a change in condition prior to calling the physician. A statement, dated 3/9/2015 from UM RN #1 included; that at approximately 11 a.m. (on 3/9/2015), the UM RN #1 returned to the unit and LPN #1 informed her that Resident #2 had a low grade temperature, congestion and a cough. "(LPN #1) stated that (the physician) wanted (Resident #2) to go to (hospital) for (an) evaluation." RN UM #1 was made aware of the ADON's request to call the physician and request treatments at the facility. UM RN #1 documented in the statement that Resident #2 was in "no distress, no shortness of breath or wheezing noted" and she was aware that several calls had been placed to the physician. During an interview with the surveyor on 3/20/2015 (the first day of survey) at 10 a.m., UM RN #1 confirmed her statement and added that she was aware of the PO to send Resident #2 out, however, the ADON had instructed LPN #1 to follow up with the physician since the resident was in no distress. UM RN #1 stated she assessed Resident #2 at 11 a.m. and "was not congested" however, she did not document her assessment in the MR. UM RN #1 added that LPN #1 had kept her informed of the residents condition throughout the day and the call out to the physician was endorsed to the next shift. UM RN #1 stated she did speak with Resident #2's physician at approximately 4 p.m. who stated to her that he "did not want anyone second guessing sending a (resident) out." Additionally, UM RN #1 stated that LPNs can call a physician but "we are now emphasizing" for the LPNs and RNs to call the UM, Supervisor, ADON/DON prior to calling the physician. "The DON/ADON wants to be notified by LPNs and RNs before the doctor is called for anything." During an interview with the surveyor on 3/26/2015 (second day of survey) at approximately 12 p.m., the second day of survey, UM RN #1 confirmed that she received inservices r/t the new facility policy of not having to notify the ADON/DON prior to calling a physician for a residents change in condition. Additionally, the UM RN #1 stated that although the facility had a problem with the phone system on 3/9/2015 it did not affect any residents as inhouse calls were able to be made and cell phones were used. A statement, dated 3/9/2015 from the ADON included that she was notified at approximately 11 a.m. by LPN #1 that LPN #1 was sending Resident #2 to the emergency room (ER) "as ordered by the (physician)" because the resident had a temp of 99.6 F and a cough. "I asked the nurse (LPN #1) if the resident (#2) is having difficulty breathing or in distress and she said no and vitals (vital signs) were ok. I (Assistant Director of Nursing) was uncertain about the order given by the (physician) since the resident is not in any distress and wanted to clarify (if) (physician) really understood what was going on. So I suggested that she (LPN #1) call the doctor again and ask him if we could do some interventions here first before sending him to the ER (emergency room ) such as stat CXR (immediate chest xray), labs (laboratory tests) maybe a breathing treatment or maybe stat ABT (immediate antibiotic therapy) here (at the facility) instead of sending the resident to the ER (emergency room ) right away." The ADON's statement further indicated; "We held off on sending the resident (#2) to the hospital for the sake and welfare of the resident because we know that unnecessarily discharging a resident to the hospital can be worse for the resident than treating in-house. We wanted to be sure the doctor understood it was only a low grade fever and a cough and that the resident was in no distress at all. We hoped for an order for [REDACTED]. Everybody was concerned that the residents no (not) undergo an unnecessary discharge and he (Resident #2) was in no distress." "The nurse (LPN #1) said she was going to call the Doctor again as recommended." The ADON documented that she spoke with UM RN #1 and made her aware of the ADON's recommendations and that the physician had not yet returned the facility's call..."I endorsed to next shift to follow up with (physician)." During an interview with the surveyor on 3/20/2015 at 12:47 p.m., the ADON confirmed her statement and added that she requested a call back to the physician for clarification as maybe the physician would have wanted to start a treatment in the facility or maybe he had not been given the complete information on the resident. "It was just a cough." The ADON added that the staff checked on the resident during the day and Resident #2 not in distress, however, the ADON stated she did not observe/assess the resident on the 7-3 shift on 3/9/2015. The ADON confirmed that the Medical Director was not contacted when the facility was unable to reach Resident #2's physician. A statement, dated 3/9/2015 and signed by the DON included; at 4:40 p.m. she was asked to speak with the Administrator and with Resident #2's physician on the phone. Before the DON went to the Administrators office she asked the 3-11 shift, LPN #2 if there's "anything I need to know why (physician) is calling." "He (LPN #2) handed me the chart of (Resident #2) and UM RN #1 said that the resident is stable, not congestion (congested) and latest temp (temperature) is 97.9..." During an interview with the surveyor on 3/20/2015 at 9:15 a.m. the DON confirmed her statement and added that she was out of the facility until the afternoon on 3/9/2015 and was not apprised of the delay until asked to speak with the physician. The DON confirmed that she was aware of the protocol to have the staff LPNs and RNs notify the ADON and DON prior to calling the physician. The DON stated that since the incident with Resident #2, they wanted to make sure that the staff members are "making recommendations to the physician first before getting an order to send out to the hospital, as we can start Intravenous fluids here too...of course in an emergency we call 911 right away." The DON confirmed that the Medical Director was not contacted on 3/9/2015 when the staff were not able to contact Resident #2's physician. Additionally, the DON confirmed that the staff should have documented in the MR, all assessments, observations and VS for Resident #2. During an interview with the surveyor on 3/20/2015 at approximately 12:50 p.m., the DON gave the surveyor a copy of a "Meeting/Training Record"/Inservice, dated 3/15/2015, with the topic; "Acute Discharges-Call UM/Supervisor to reassess pt. (resident) noted with change in condition, then call the ADON/DON before calling the Attending physician." An undated attachment to the form with the facility name on it included; "to prevent unavoidable transfers to the hospital the facility will be utilizing the Stop and watch/SBAR forms..." The CNA was to fill out a "stop and watch" form and report to the nurse. The nurse will assess the patient using the SBAR and the physician is to be notified of the findings with suggestions made to the doctor to initiate inhouse treatment if appropriate. "Please inform supervisor of the change and DNS (director of Nursing Services)/ ADNS (Assistant Director of Nursing Services) before calling MD (physician) unless it's a 911 call." Additionally, a handwritten note at the top of the Inservice Record, dated 3/16/2015, showed; "Not for (Resident #2's physician's) pt. (patients/residents)". At the bottom of the Inservice Record a note was documented; "posted for the 11-7 shift and was seen by (Resident #2's physician) and "he wrote" Not for Dr. (Resdient #2's physician) patient." A statement, dated 3/9/2015 and signed by the 3-11 shift LPN #2, included that he was told during the change of shift nursing report that Resident #2 was congested with a low grade fever, the physician was called and ordered that the resident be sent to the hospital but the previous shift nurse was told to call the physician back to see if treatment could be done at the facility. RN #2 documented that he called the physician at 4 p.m. and spoke with the physician at 4:30 p.m.. The physician "was upset because (the) resident (#2) was still here and why are we calling him back..." During a telephone interview with the surveyor on 3/26/2015 at 12:04 p.m., the second day of survey, LPN #2 confirmed his statement and added that at 4 p.m. the physician again ordered the resident to be sent out. LPN #2 stated the resident did not have any shortness of breath. In addition, LPN #2 stated that the usual practice for residents with a change in condition was to notify the supervisor and call the physician, however, he was aware of the new protocol that was implemented for the supervisor to call the ADON/DON before a physician was called. During the interview, LPN #2 stated that he was inserviced in the past few days that staff were to call the physician without notifying the ADON/DON. During a telephone interview with the surveyor on 3/25/2015 at 10:30 a.m., Resident #2's physician stated that he remembered being notified by the nursing staff of a change in condition for Resident #2 which included a cough, increased T and shortness of breath and he gave a TVO to send the resident to the hospital for an evaluation as this was not the resident's "normal." The physician stated that he did not receive any emergency messages from the facility r/t a call back. He stated he returned the facility's calls in the afternoon and was upset to hear that his order had "not been carried out" as of yet. During a post survey telephone interview with the surveyor on 3/27/2015 at 9 a.m. the facility Medical Director stated he had discussed with the Administrator the policy of notifying the ADON/DON prior to calling the physician, however, he thought they would be called at the same time as the physician. The Medical Director stated he was made aware of the delay in sending Resident #2 to the hospital, confirmed that he was not contacted by the facility on 3/9/2015 and now the facility had implemented the protocol to notify the physician first without a delay. Review of a facility policy titled; "Acute Condition Changes-Clinical Protocol", dated/revised 12/2012, included but was not limited to; Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician, for example history of present illness and previous and recent test results for comparison...The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less)...The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriated response... The Physician will help identify and authorize appropriate treatments. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting." Review of a facility policy titled; "Change in a Resident's Condition or Status", dated/revised 4/2011, included but was not limited to; "Our facility shall promptly notify the resident, his or her Attending Physician, and representative...or changes in the resident's medical/mental condition and/or status..." Review of a facility policy titled; "Physician Services", dated/revised 8/2006 included but was not limited to; "The medical care of each resident is under the supervision of a Licensed Physician...The resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospital...to ensure that the resident receives quality care and medical treatments." The immediate Jeopardy which began on 3/9/2015, was identified on 3/20/2015 the first day of survey and lifted on 3/20/2015 when the facility implemented an acceptable plan of correction as evidenced by the following; 1. Resident #2 was transferred to the hospital on [DATE] at approximately 5:30 p.m. 2. All residents have the potential to be affected by this practice. 3. Effective immediately and ongoing, licensed nursing staff will be inserviced on ensuring that physician orders [REDACTED]. Nurses will also be inserviced on proper completion of transfer documents. 4. When residents present with a change in condition, the licensed nurse will contact the physician for orders. When a physician orders [REDACTED]. 5. All hospital discharges will be audited by the DON to determine that the physician orders [REDACTED]. 6. The DON will report to the facility Executive Director/ Nursing Home Administrator and the Quality Assurance committee monthly on the results of this program. This deficiency continues at a scope and severity of D as evidenced by the following; PART B Based on interviews and review of the MRs and other facility documentation, it was determined that the facility staff failed to transcribe a physician order [REDACTED].#1). This deficient practice is evidenced by the following; 1. According to the Admission Record, Resident #1 was admitted to the facility in 5/2012 with [DIAGNOSES REDACTED]. An MDS, dated [DATE], indicated Resident #1 had severe cognitive impairment and needed assistance with all ADLs. HS NNs on 2/28/2015 indicated that at 11:15 p.m. on 2/27/2015 Resident #1 had a Temperature (T) of 100.5, the physician was notified and an Antibiotic Therapy (ABT) was started. On 2/28/2015 at 3 a.m. T-100 F and 6 a.m. T- 99.5 and 6:45 a.m. T-99.8 A HS NN, dated 2/28/2015 at 10:02 a.m. by 7-3 shift, LPN #3 revealed; "...Face flushed and warm to touch. T (Temperature) -98.6 F (Fahrenheit). No s/s (signs/symptoms) of distress or discomfort...Awaiting CXR (chest xray)...Spoke with (physician), MD (Medical Doctor/physician) to be notified if temperature goes back up..." Review of Resident #1's POS for 2/28/2015 showed no Telephone Verbal Order (TVO)for the physician to be notified if Resident #1's T increased. A HS NN, dated 2/28/2015 at 2:24 p.m. by LPN #2, revealed that the chest x-ray had been competed and indicated no cardiopulmonary disease, T was 98.2, a urine test was pending and the Nurse Practitioner (NP) was aware of laboratory results. Review of a 24 hour Nursing Report, dated 2/28/2015 for the 3-11 shift confirmed the instruction from the physician; "Spoke (with) MD (Medical Doctor/physician)-Call if fever goes back up," however, there was no further indication on the 24 hour Nursing Report for 3/1/2015 r/t the PO. A HS NN, dated 3/1/2015 at 7:01 a.m. by LPN #4, revealed Resident #2's T was 98.8, ABT was in progress, CXR and Urinalysis were negative with a urine culture pending. At 9:42 a.m., a HS NN by the 7-3 shift, LPN #3 revealed; "...face flushed, warm to touch T-100.9 F, Tylenol given prn (as needed) for comfort... 9am- Temp 99.0 F. Resting comfortably." There was no indication and/or documentation in the MR that Resident #2's physician was notified of the increase in temperature. A HS NN on 3/2/2015 at 2:29 p.m. revealed a T of 99.0 F and at 3:30 p.m. T was 100.5 F. Resident #2 was subsequently transferred to the hospital on [DATE] at 8 p.m., per physician orders, due to abnormal laboratory results. During an interview with the surveyor on 3/26/2015 at approximately 12 p.m., LPN #3 stated that she did not transcribe the physician's verbal order on the POS because she felt it was "not really specific." LPN #3 stated that usually a physician would be more specific by indicating the exact T or how many days the staff were to observe for an increased T and she confirmed she did not clarify the order with the physician. The surveyor asked why she did not call the physician when she noted the increase in temperature on 3/1/2015 at 9:42 a.m., and LPN #3 stated that she only thought the physician wanted to know about it on the day he told her, 2/28/2015. During an interview with the surveyor on 3/26/2015 at approximately 12:30 p.m., the RN UM #1 stated that if a physician wants to be notified of something r/t to a resident it should be documented on the POS as a physician order. During an interview with the surveyor on 3/26/2015 at approximately 1 p.m., the DON reviewed the MR of Resident #1 with the surveyor and stated that LPN #3 should have documented the instruction given by the physician as a verbal order on the POS. NJAC: 8:39-27.1

COMPLAINT # NJ Based on observation, interviews and a review of medical records and other facility documentation, it was determined that the facility failed to consistently implement identified safety interventions (Bed/Chair Alarms) and/or documented that these interventions were implemented for 3 of 3 sampled residents (Residents #1, #2 and #3). In addition, Resident #1 fell and sustained a pelvic fracture which required hospitalization , medical intervention and pain management. This deficient practice is evidenced by the following: The surveyor conducted interviews and reviewed medical records on 9/22/10 unless otherwise indicated. 1. The Resident Admission Record for Resident #1 showed that the original admission to the facility was in 10/09. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 7/29/10, indicated the resident had some cognitive deficits and required assistance with transfer. The Fall Risk assessment total score was 20, which indicated the resident was a high risk for falls. A review of the physician's orders [REDACTED]. An Interdisciplinary Plan of Care, dated 4/19/10, identified the resident at high risk for falls related to syncope, confusion, unsteady gait, non compliance with walker at times, needs limited assist during ambulation and a history of falls. Interventions included bed and chair alarms and checking for placement of alarm every shift. A review of the Nursing Assistant's Plan of Care, dated 7/10, revealed that, under the heading "Protective Equipment," the bed alarm was not checked off. The Facility Reportable Event, faxed to the Department of Health and Senior Services on 9/13/10, reflected that Resident #1 was found on the floor in her room on 9/12/10. She had self ambulated to the bathroom immediately after receiving AM care. The "Bed Alarm was in place and did alarm." She was admitted to the hospital. Review of hospital records, dated 9/12/10, revealed that Resident #1 sustained a fracture of the pelvis. While hospitalized , Resident #1 was medicated for pain with 325 mg of Percocet 12 times and also received a Lidoderm Patch on 9/18/10. The resident returned to the facility on [DATE]. The readmit POS, dated 9/18/10, indicated that a Lidoderm Patch, 12 hours on left hip and 12 hours off, was ordered for pain. On 9/19/10, one dose of Percocet 5/325mg tablet was to be given "now" for pain and then every 6 hours as needed for severe pain. The resident received Percocet at least 4 times. Prior to 9/12/10, the resident only had Tylenol 325 mg, 2 tablets, as needed for mild pain ordered. The Accident/Incident Report, dated 9/12/10, indicated that the bed alarm was sounding when the resident was found on the floor. A review of the Treatment Administration Records (TAR) for September 2010 revealed that the bed/chair alarm was initialed as checked for function and placement on 9/12/10 during the day shift. The Supervising Registered Nurse's (RN) statement, dated 9/12/10, reflected that the resident's call bell was in place and the alarm was functioning and turned on. However, two other statements, from a Certified Nurse's Aide (CNA) and a Primary RN, did not indicate that the bed alarm was sounding when the resident was discovered on the floor. On 9/22/10 at 11:25 AM, in the presence of the Charge Nurse, the CNA who was responsible for the resident's care on 9/12/10, stated that there was no bed alarm on Resident #1 on 9/12/10, the day of the fall. During another interview at 2:00 PM, in the presence of the Director of Nursing (DON), the CNA stated that she was a floater and not the resident's regular CNA, therefore, she was not familiar with the care Resident #1 required. Although she had received report from the nurse that the resident was a fall risk, she was not told that Resident #1 required a bed alarm. She had performed AM care just before the fall and verified there was no bed alarm on Resident #1 prior to the fall. She acknowledged she did not look at the Nursing Assistant's Plan of Care prior to providing care to the resident. During a telephone interview on 9/22/10 at 1:45 PM, the Supervising RN stated she heard a bed alarm ringing while she was at the nurse's station. She went into Resident #1's room and there was no alarm sounding. She then stated that the Primary RN who was already in the room had turned it off. The Primary RN's statement, dated 9/12/10, revealed she was called to Resident #1's room by "another resident." Resident #1 was observed laying on the floor and she complained of pain to her left hip area. Tylenol was administered for the pain. The RN's statement did not indicate an alarm was sounding. During a telephone interview on 9/22/10 at 2:40 PM, the Primary RN stated that she "doesn't remember hearing a bed alarm." In an interview on 9/22/10 at 11:50 AM, another CNA, who was present on the day Resident #1 fell , stated she did not hear a call bell or bed alarm. During a tour of the Unit at 11:25 AM by the surveyor, accompanied by the Charge Nurse, Resident #1 was observed in her room lying in bed with no bed alarm in place. During a post survey telephone interview on 9/23/10 at 11:00 AM with the DON, she stated that when she asked the CNA why the bed alarm was not on, the CNA said she forgot to put it on. Review of the August and September 2010 TARs reflected the nurse was to check the bed/chair alarm for function and placement every shift and initial the TAR to confirm it was done. During August 2010, the TAR was not initialed 3 times on the night shift (11 PM-7 AM), 13 times on the day shift (7 AM- 3 PM) and 11 times on the evening shift (3 PM - 11 PM). From September 1 to 12, 2010, the TAR was not initialed 6 times on the day shift and 1 time on the evening shift. 2. According to the facility Resident Admission Record, Resident #2 was admitted to the facility in 8/10 with [DIAGNOSES REDACTED]. The MDS, dated [DATE], showed the resident had cognitive deficits and needed assistance with transfers. The Fall Risk assessment total score was 12, indicating the resident was at high risk for falls. Review of the POS, dated 9/5/10, revealed an order for [REDACTED]. An Interdisciplinary Plan of Care, dated 8/23/10, identified the resident as a high risk for falls due to Dementia. The Interventions on the Interdisciplinary Plan of Care did not include bed and wheel chair alarms or checking for placement of alarm every shift, as ordered by the physician. A review of the undated Nursing Assistant's Plan of Care revealed that, under the heading "Protective Equipment," the bed alarm was checked off. During a tour of the Unit at 11:15 AM on 9/22/10 by the surveyor, accompanied by the Charge Nurse, Resident #2 was observed in her wheel chair without a chair alarm in place. During a post survey interview on 9/23/10 at 11:00 AM with the DON, she stated that when she asked the CNA why the chair alarm was not on, the CNA said she forgot to put it on. Review of the August and September 2010 TARs reflected the nurse was to check the bed/chair alarm for function and placement every shift and initial the TAR to confirm that the check was completed. During August 2010, the TAR was not initialed 2 times each on the night and day shifts and 3 times on the evening shift. From September 1 to 21, 2010, the TAR was not initialed 9 times on the day shift and 1 time on the evening shift. 3. According to the Resident Admission Record, Resident #3 was admitted to the facility in August 2010 with [DIAGNOSES REDACTED]. The MDS showed the resident had cognitive deficits and needed assistance with transfers. The Fall Risk assessment total score was 19, indicating the resident was at high risk for falls. A review of the POS, dated 9/1/10, revealed an order for [REDACTED]. An Interdisciplinary Plan of Care identified the resident as high risk for falls related due to dementia. Interventions included on the Interdisciplinary Plan of Care included bed and chair alarms and check for placement and functioning of alarm every shift. A review of the undated Nursing Assistant's Plan of Care revealed that, under the heading "Protective Equipment," the bed alarm was checked off. Review of the August and September 2010 TARs reflected that the nurse was to check the bed/chair alarm for function and placement every shift and initial the TAR to confirm that the check was completed. From September 1 to 21, 2010, the TAR was not initialed 5 times on the day shift and 2 times on the evening shift. During a tour of the Unit at 11:05 AM by the surveyor, accompanied by the Charge Nurse, Resident #3 was observed in his bed with a bed alarm in place. During an interview with a Licensed Practical Nurse on 9/22/10 at 12:00 PM, she stated that Fall Risk residents are identified by the yellow dots which are on their doors. During an interview with the Nurse Educator on 9/22/10 at 12:15 PM, she stated that residents are identified as a Fall Risk by the leaf on the side of their door by the name tag. In addition, they are identified as a Fall Risk on the resident's Interdisciplinary Plan of Care and Nursing Assistant's Plan of Care. Yellow dots do not indicate Fall Risk, but rather, Dysphasia. She also stated that CNAs have to make sure that when the resident is in bed, the bed alarm is in place and, when the resident is in a chair, the CNA has to make sure that the chair alarm is in place. Review of the policy titled "Falls Management System" updated in 10/08 included "Residents with Fall Risk Evaluation score of 10 or above will have an individualized care plan developed"....."Residents who sustain a fall will have a care plan developed or the existing care plan updated (directly after such an incident occurs) to include date of the fall" and "Documentation of implementation will be in accordance with accepted standards ... " NJAC 8:39-27.1(a)