Every finding on record at AristaCare at Manchester LLC

Complaint: NJ183978Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice. This identified for 1 of 46 residents (Resident # 150) reviewed medical records and evidenced by the following:A review of the admission Record, an admission summary, revealed that Resident #150 had diagnoses which included, but were not limited to: metabolic encephalopathy and moderate protein-calorie malnutrition. A review of the resident's individual comprehensive care plan (ICCP) had the following a focus areas, dated 2/27/2025, that the resident had an alteration in gastro-intestinal status [related to] presence of colostomy. Interventions included, but not limited to, monitor colostomy site for [signs/symptoms] of infection every shift and provide colostomy care every shift; that the resident used antidepressant medication [related to] the management of depression. Interventions included, but not limited to, antidepressant medications as ordered by physician; that the resident has chronic pain [related to] quadriplegia, presence of wounds, and polyneuropathy. Interventions included, but not limited to, monitor/record/report to nurse my complaints of pain or requests for pain treatment; that the resident had a suprapubic catheter [related to diagnosis] of neurogenic bladder. Interventions included, but not limited to, empty drainage bag [every] 8 hours. Record output if necessary; render catheter care every shift.A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated as of 8/21/2025, included, but not limited to, the following physician orders (PO) and corresponding blank entries:A PO, dated 2/22/2025, for Duloxetine oral capsule delayed release particles 80 miligrams (mg) to give 1 capsule by mouth at bedtime related to depression. On 2/23/2025 a blank space was observed. A PO, dated 2/22/2025, for Fluoxetine HCL oral capsule 10mg to give 5 capsules by mouth at bedtime related to depression. On 2/23/2025 a blank space was observed. A PO, dated 2/22/2025, for Blaclofen oral tablet 10mg to give 1 tablet by mouth two times a day (2pm and 9pm) for muscle spasm *give with 20mg to equal 30mg). On 2/23/2025 a blank space was observed for the 9 PM entry.A PO, dated 2/22/2025, for Blaclofen oral tablet 200mg to give 1 tablet by mouth two times a day (2pm and 9pm) for muscle spasm *give with 10mg to equal 30mg). On 2/23/2025 a blank space was observed for the 9 PM entry.A PO, dated 2/22/2025, for Methenamine Hippurate oral tablet 1 gram (GM) to give 1 tablet by mouth every 12 hours for ESBL of urine. On 2/23/2025 a blank space was observed. A PO, dated 2/22/2025, for Gabapentin oral capsule 400mg to give 3 capsule by mouth three times (9am, 2pm, 9pm) a day for neuropathy. On 2/23/2025 a blank space was observed for the 9 PM entry.A PO, dated 2/22/2025, to monitor vital signs every shift for assessment. On 2/23/2025 (second shift) and 2/27/2025 (morning shift) did not have vital signs entered. On 2/23/2025 (day), 2/24/2025 (day), 2/27/2025 (day) blank spaces were observed. A PO, dated 2/22/2025, for Santyl External Ointment 150unit/GM to apply to sacrum and right heel topically every day and evening shift for wound care. A PO, dated 2/22/2025, to monitor colostomy stoma for [signs/symptoms] of infection every shift for infection. On 2/23/2025 (day) and 2/24/2025 (day) blank spaces were observed.A PO, dated 2/22/2025, to offload heels when in bed every shift for prevention. On 2/23/2025 (day) and 2/24/2025 (day) blank spaces were observed.A PO, dated 2/22/2025, for skin protectant to apply to buttock topically every shift for prevention. On 2/23/2025 (day) and 2/24/2025 (day) blank spaces were observed.A PO, dated 2/22/2025, to record supra pubic cather output every shift for monitoring. On 2/24/2025 (day) a blank space was observed.A PO, dated 2/22/2025, to render suprapubic catheter care every shift for prevention. On 2/24/2025 (day) a blank space was observed.On 8/26/2025 at 8:41 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that upon administered medication and/or treatments the MAR/TAR should be checked off to show that it was given or completed. When asked what a blank box could mean, LPN #1 stated that the medication was not given or the treatment was not completed. On 8/26/2025 at 8:57 AM, the surveyor interviewed the Licensed Nurse Practioner/Unit Manager (LPN/UM) who stated that physicians orders should be carried out as written and that there should never be blanks in the MAR/TAR. When asked what a blank could mean, the LPN/UM responded that it was not done. During an interview on 8/26/2025 at 1:48 AM with the surveyor the Director of Nursing, in the presence of the Licensed Nursing Home Administrator Regional Clinical Director acknowledged that the MAR/TAR should be completed in its entirety upon completion of the order and that if it was not filled in it could mean that the order was not done. A review the undated facility policy titled, Administering Medications revealed the following under Policy Interpretation and Implementation: [ .] 3. Medications must be administered in accordance with the orders, including any required time frame. [ .] 11. The individual administering the medication must document in [electronic records] after giving each medication by clicking the Y. [ .] 13. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall click the N on the EMAR and then document as prompted by PCC. A review the undated facility policy titled, Charting and Documentation revealed the following under Policy Interpretation and Implementation: 1. All observations, medications administered, services performed, etc, must be documented in the resident's clinical record. NJAC 8:39- 23.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) sanitize reusable medical equipment in between resident use during medication administration and b.) contain soiled laundry securely and transport to the designated holding area to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 2 unsampled residents (Resident #81 and Resident #155) observed during medication administration and was evidenced by the following:Reference: Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately. Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage. https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.htmlReference: Perform low-level disinfection for noncritical patient-care surfaces and equipment (e.g. blood pressure cuff) that touch intact skin. https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_9-4-7-noncritical-patient-care-equipment 1. On 8/25/2025 at 8:13 AM, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare to administer medications to Resident #155. LPN #1 sanitized their hands with alcohol-based sanitizer. LPN #1 proceeded to take the vital signs machine to the resident's bedside. The nurse applied the blood pressure (BP) cuff on the resident's right upper arm and the pulse oximeter (a device used to measure the percentage of oxygen in the blood) on the resident's left forefinger. The surveyor observed the nurse touched the resident's right temple area with the touch-less sensor thermometer. LPN #1 did not clean or sanitize the BP cuff, pulse oximeter, and thermometer prior to use and after using them.On 8/25/2025 at 9:57 AM, the surveyor observed LPN #1 prepare to administer medications to Resident #81. LPN #1 sanitized their hands with alcohol-based sanitizer. LPN #1 proceeded to take the vital signs machine to the resident's bedside. The nurse applied the blood pressure (BP) cuff on the resident's right upper arm and the pulse oximeter (a device used to measure the percentage of oxygen in the blood) on the resident's left forefinger. The surveyor observed the nurse touched the resident's left temple area with the touch-less sensor thermometer. LPN #1 did not clean or sanitize the BP cuff, pulse oximeter, and thermometer prior to use and after using them.On 8/26/2025 at 1:49 PM, during an interview with the survey team, the Director of Nursing (DON) stated that reusable medical equipment like the BP cuff, thermometer and pulse oximeter should be cleansed after each use in between residents. A review of the facility-provided undated policy titled Cleaning and Disinfection of Resident-Care Items and Equipment included under Policy Interpretation and Implementation, 1.) . c.2) Most non-critical reusable items can be decontaminated where they are used. 4.) Reusable resident care equipment will be decontaminated and/ or sterilized between residents according to manufacturer's instructions. 2.) On 8/26/2025 at 12:13 PM, the surveyor entered the nursing unit's shower room with Certified Nursing Assistant (CNA) #1. The surveyor observed a big pile of soiled linens, towels, and clothes in an opened plastic bag on the floor. One white wet towel was observed partly inside the plastic bag and partly on the floor. The surveyor asked CNA #1 if the soiled laundry should be sitting on the floor. CNA #1 stated that they should have been taken out to the dirty utility room because there are germs. CNA #1 also stated that nothing should be on the floor. CNA #1 was observed to put on gloves and transported the plastic bag of soiled laundry to the soiled utility room. On 8/26/2025 at 12:19 PM, Licensed Practical Nurse (LPN) #1 stated that dirty laundry should not sit on the floor. LPN #1 further stated that the dirty laundry should be bagged and put on the chute in the soiled utility room. On 8/26/2025 at 1:07 PM, the Infection Preventionist (IP) stated that soiled laundry should be put in a bag, tied, and thrown in the soiled utility room. On 8/26/2025 at 1:50 PM, during an interview with the survey team, the Director of Nursing (DON) stated that soiled laundry should go to a bag and to the linen chute immediately. The DON further stated that the soiled laundry should not sit on the floor in the shower room.A review of the facility-provided undated policy titled Departmental (Environmental Services) - Laundry and Linen included under General Guidelines, 3.) Consider all soiled linen to be potentially infectious. 5.) All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. N.J.A.C. 8:39 - 19.4 (a); 21.1 (a)

Based on observation, record review, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. Specifically, the facility failed to secure medication that was left at a resident's bedside. This deficient practice was identified for 1 of 1 resident (Resident #10) and was evidenced by the following: On 08/21/2025 at 11:21 PM, the surveyor observed Resident #10 in their bedroom, seated in a wheelchair with a bedside table in front of them. On the table was a box containing a 10-milliliter bottle of eye itch relief drops (used to relieve itching in the eyes). The resident stated that their daughter had brought the eye drops because their eyes sometimes feel dry.Review of the electronic medical record on 08/20/2025 at 10:00 AM, revealed the following: A review of the admission Record indicated that Resident # 10 was admitted to the facility with diagnoses that included but was not limited to, dementia (a condition that impairs mental abilities needed for everyday activities), and lack of coordination. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate care management dated 07/08/2025, included a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. A review of Resident #10's comprehensive care plan dated 05/06/2025, included a focus area which indicated that the resident had cognitive deficits. A review of the Medication Administration Record, dated as of 08/2025, included the following physician orders (PO): a PO, dated 01/06/2025, for ophthalmic eye solution 1.4-0.6%, to instill 1 drop in both eyes every 4 hours as needed for dry eyes; and a PO, dated 06/17/2025 for ophthalmic eye solution, to instill 1 unit in both eyes as needed for dry eyes.The surveyor conducted an interview on 08/21/2025 at 12:34 PM with the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that she was aware the resident had the eye drops at the bedside and that she would speak with the resident's family. She admitted that the resident should not have the eye drops at the bedside if she had not been assessed for safe self-medication administration. During an interview with the surveyor on 08/27/2025 at 11:40 AM, the Director of Nursing stated that Resident #10 should not have had eye drops at the bedside due to safety reasons. A review of the facility's undated policy, titled, Storage of Medication, revealed that, The nursing staff shall be responsible for maintaining medication storage. A review of the facility's undated policy, titled, Administering Medications, revealed that, Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. NJAC 8:39-29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that appropriate care and services were provided to prevent complications of enteral feeding (delivers nutrition directly into the digestive system through a tube), by failing to check for proper placement of the feeding tube before administering the enteral feeding.This deficient practice was identified for 1 of 1 resident (Resident #46) investigated for tube feeding and was evidenced by the following: On 8/21/25 at 9:15 AM, the surveyor reviewed the medical record for Resident #46.A review of the admission Record (admission summary) reflected that Resident #46 was admitted to the facility with diagnoses that included but not limited to; aphasia (disorder that affects communication), dysphagia (difficulty swallowing), adult failure to thrive (FTT), and pneumonitis (inflammation of the lungs) due to inhalation of food and vomit.A review of the admission Minimum Data Set (MDS), an assessment tool dated 5/31/25, reflected that Resident #46 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. Further review of Section K (Swallowing/Nutritional Status) revealed that Resident #46 had a feeding tube in place and received 51% or more total caloric intake through tube feeding.A review of the Order Summary Report of active orders as of 8/27/25 included a physician's order (PO) dated 3/17/25, for enteral feeding. The order directed staff to check the feeding tube for proper placement prior to each feeding, flush, or medication administration at every shift.A review of the August 2025 Medication Administration Record (MAR) for the physician's order dated 3/17/25, reflected that tube placement checks were documented as completed every shift, as ordered.A review of the Interdisciplinary Care Plan (IDCP) revealed a focus area, revised on 3/18/25, indicating that Resident #46 required tube feeding due to poor oral intake, dysphagia, and a diagnosis FTT. The IDCP included an intervention to check tube placement and assess gastric contents/residual volume in accordance with facility protocol and record.On 8/25/25 at 10:13 AM, the surveyor observed Resident #46 in his room lying in bed. On 8/25/25 at 10:15 AM, the surveyor observed a Registered Nurse (RN) attempting to flush Resident #46's feeding tube without first verifying tube placement, as required by facility policy. The surveyor interviewed the RN who acknowledged that tube placement should be checked prior to administering flushes and confirmed that this step had been missed.On 8/26/25 at 1:49 PM, in the presence of the survey team, the Director of Nursing (DON) confirmed that the RN should have checked the feeding tube placement prior to administering flushes. The DON stated that verifying tube placement was essential to ensure the feeding tube was properly positioned and prevent potential complications.A review of the facility's Bolus Nasogastric/Gastrostomy Tube-Feeding policy, dated February 1, 2021, and revised on March 10, 2023, indicated the purpose as to provide a means of feeding per tube to meet the nutritional requirements of residents who are unable or unwilling to take nutrients by mouth. NJAC 8:39-25.2(c)2,5

Based on interview, record review, and review of facility policy, the facility failed to ensure the SNF ABN (skilled nursing facility advanced beneficiary notice) was complete and accurate which placed the residents and/or representatives at risk of not being fully informed. This was identified for 1 of 3 residents (Resident # 98 ) reviewed for SNF Beneficiary Protection and was evidenced by:A review of Resident #98's admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Muscle Weakness, Dysphagia, and Malignant Neoplasm of the Colon.Review of Resident #98's SNF Beneficiary Notification Review, which was provided by the facility, indicated the resident no longer required skilled care effective 5/6/2025. Continued review of Resident #98's ABN revealed Medicare doesn't pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on 5/7/2025, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Resident# 98's ABN noticed also documented Therapy and the reason listed was Met Max Potential . The Estimated Cost was left blank. In addition, on the lower half of the page was an area with three boxes. The instructions read, Check one box. We can't choose a box for you. All three option boxes were left blank. During an interview on 8/26/2025 at 9:07 AM, the Social Worker (SW#1), in the presence of of SW #2, stated that no estimated cost was not required as the business office would take care of the estimated cost and that the resident or representative don't always check a box. During an interview on 8/26/2025 at 1:48 AM with the surveyor the Licensed Nursing Home Administrator, in the presence of the Regional Clinical Director (RCD) acknowledged that one of the three options and that an estimated cost should have been filled in. The facility did not provide a policy referencing SNF ABN. NJAC 8:39-5.1(a)

Based on observation, record review, interview and review of pertinent facility documentation, it was determined that the facility failed to treat residents with respect and dignity. Specifically, by a.) staff failed to provide timely assistance to Resident #2, who was observed with drool and an orange liquid substance dripping from the mouth and beard and b.) staff failed to provide privacy for Resident #95 during hygienic care. This deficiency was identified in 2 of 2 residents (Resident #2 and Resident #95) reviewed for dignity and was evidenced by the following:1.) Review of the admission Record (AR), the Resident #2 was admitted to the facility with diagnoses including, but not limited to, Parkinson's Disease (a nervous system disorder that affects movement), dementia (a condition that impairs mental abilities needed for everyday activities), muscle weakness, and lack of coordination.A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 06/18/2025, included a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. Further review of the MDS revealed that Section GG- Functional Abilities: Self Care revealed that personal hygiene was coded as a 3, indicating the resident required partial/moderate assistance.On 08/20/2025 at 10:52 AM, the surveyor observed Resident #2 seated in a wheelchair on the second-floor hallway with a bedside table in front of them, coloring on a sheet of paper. The resident had a large amount of drool visibly dripping from their mouth. Two facility staff members walked by without offering assistance or making any attempt to clean the drool from the resident's mouth.On 08/21/2025 at 10:40 AM, the surveyor observed Resident #2 in the main dining room, seated in a wheelchair at a dining table, asleep while activity staff and other residents participated in an exercise activity. An orange liquid substance was observed dripping from the resident's mouth onto their beard. The surveyor continued observing the resident for five minutes, during which time multiple staff members entered and exited the dining area. At no point did any staff offer or attempt to assist the resident in cleaning their mouth or beard.2/) Review of the AR indicated that Resident #95 the was admitted to the facility with diagnoses which included but was not limited to muscle weakness, difficulty in walking, and lack of coordination. A review of the resident's admission MDS, an assessment tool used to facilitate care management, dated 06/17/2025, included a BIMS score of 13 out of 15, indicating intact cognition. Further review of the MDS revealed that Section GG- Functional Abilities: Self Care revealed that toileting hygiene was coded as a 2, indicating the resident required substantial/maximal assistance. On 08/21/2025 at 10:09 AM, the surveyor observed a certified nurse aide (CNA) providing incontinence care to Resident #95 in the bathroom of room [ROOM NUMBER]. The resident had a bowel movement, and the CNA was seen wiping the resident's buttocks with tissue. The bathroom door was left open during care, and Resident #95's abdomen, breasts, and buttocks were fully exposed and visible from the bathroom. The resident's roommate was present in the shared bedroom, seated in a wheelchair near the bathroom entrance, watching television.The resident's comprehensive care plan, dated 06/20/2025, included a focus area indicating that the resident has impaired mobility. The resident's comprehensive care plan, dated 06/19/2025, included a focus area indicating that the resident has impaired mobility. During an interview with the surveyor on 08/21/2025 at 12:34 PM, the Licensed Practical Nurse/Unit Manager stated that staff should have offered or assisted with helping Resident #2 clean their mouth and beard. During an interview with the surveyor on 08/27/2025 at 11:35 AM, the Director of Nursing (DON) stated that staff should have offered assistance or helped Resident #2 clean their mouth and beard. The DON acknowledged that Resident #95 should have been provided privacy during hygienic care and confirmed that both residents should have been treated in a manner that maintained their dignity.A review of a facility policy undated titled, Resident Rights, revealed that, The facility will treat you with dignity and respect in full recognition of your individuality. N.J.A.C. 8:39-4.1(a)(16)

Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure the Infection Preventionist actively performed responsibilities in accordance with her facility designated role. Specifically, by not administering an annual influenza vaccine to 1 of 5 residents reviewed for vaccinations (Resident #10). The deficient practice was evidenced by the following: On 08/25/2025 at 12:10 PM, the surveyor reviewed the electronic medical records of Resident #10, which revealed that the resident was admitted to the facility on [DATE], during the influenza season. Documentation showed that the resident signed an influenza immunization consent form on 11/01/2024, indicating agreement to receive the vaccine. However, the record also indicated that the last documented administration of the influenza vaccine was on 11/23/2023, prior to the resident's admission to the facility, with no evidence that the vaccine was administered during the 2024 influenza season. Review of the admission record indicated that Resident #10 was admitted to the facility with diagnoses including, but not limited to, dementia (a condition that impairs mental abilities needed for everyday activities), and lack of coordination. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate care management dated 07/08/2025, included a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. A review of Resident #10's comprehensive care plan, dated 05/06/2025, included a focus area indicating that the resident has cognitive deficits. During an interview with the surveyor on 08/25/2025 at 1:10 PM, Resident #10 stated that she could not remember the last time she received an influenza vaccination. On 08/27/2025 at 10:20 AM, the surveyor interviewed the Infection Preventionist who stated that Resident #10 received an influenza vaccine at a pharmacy on 11/17/2023, prior to admission, and was not due for another influenza vaccine until 07/2025.On 08/27/2025 at 11:45 AM, the surveyor interviewed the Director of Nursing who stated that Resident #10 should had received an influenza vaccination between 10/01/2024 to 03/31/2025, which was considered influenza season. She further stated that the facility did not administer influenza vaccines in 07/2025 because it was outside of the influenza season. A review of the facility's undated policy, titled, Influenza Vaccine, revealed that, Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. NJAC 8:39-19.1(b)

Complaint NJ #165621 Based on record review, interview, and review of pertinent documentation, it was determined that the facility failed to a.) adequately supervise a cognitively impaired resident (Resident # 535) with exit seeking behavior from eloping the facility. This posed the likelihood of serious injury, serious harm, serious impairment or death for 1 of 3 residents reviewed for wandering/elopement. A review of a closed record revealed a Progress Note (PN) dated 05/28/23, identified that staff were unable to locate Resident #535 in the facility for approximately one hour. Resident # 535 was found at a local restaurant located near the facility. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 05/28/23 and was identified on 04/17/24. The IJ template was given to the Licensed Nursing Home Administrator (LNHA) on 04/17/24 at 3:10 PM. An acceptable removal plan was received on 04/18/24 at 1:52 PM and was verified on-site on 04/18/24 at 2:00 PM. The removal plan indicated the facility took the following steps to prevent serious harm from occurring or recurring: 1. Resident 535 was discharged from the facility; 2. All 9 residents at risk for wandering or elopement had a wandering risk assessment completed and updated Care plans. Assessments reviewed by the Nursing administration, Administrator, Assistant Administrator, Nurse Practitioner (NP), Activities, and Social Work team. The nine (9) residents indicated were reviewed; and 3. Staff education via facility wide text message portal which consisted of where to find all residents at risk for elopement within the electronic medical record, the requirement to review the at-risk residents, and interventions at each shift. Department heads with departments that don't have access to the electronic medical record, educated their staff that the electronic medical record list will be printed and posted at the time clock and the pictures of the residents at risk will be kept at the reception desk. The lists will be updated with any changes through the weekly intervention meeting or as needed. F 689 remains a deficiency at a scope and severity of a D based on the following: The facility further failed to b.) maintain the safety of a resident who was identified as a fall risk by not following the plan of care for 1 of 32 residents (Resident #24) reviewed for falls. The evidence was as follows: Part A A review of the facility policy for Wandering, Unsafe Resident, undated, included but was not limited to: The facility will strive to prevent unsafe wandering . for residents who are at risk for elopement. 1. The staff will identify residents who are at risk . because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement . Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 5. When the resident returns the Director of Nursing or charge nurse shall: f. document relevant information in the resident's medical record. On 04/17/24, the surveyor reviewed Resident #535's electronic medical record. A review of the Admission Record dated 04/13/22, documented that Resident #535 had diagnoses which included but were not limited to: senile degeneration of the brain, dementia with behavioral disturbance, and delirium. A review of a Psychological Evaluation dated 04/19/22, included but was not limited to; resident was being referred for acting more confused . staff says he/she is wandering. A review of the current Comprehensive Care Plan on 04/20/22, revealed that the resident was an elopement risk related to dementia with goals to not leave the building unescorted, to ensure supervision while outside, and if unable to redirect resident from exit seeking, stay with resident. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 03/16/23, reflected the resident had a Brief Interview for Mental Status (BIMS) of 08 out of 15, indicating moderate cognitive impairment. Review of the PN dated 04/20/23, indicated that the resident tried to elope, redirected and wander guard was applied to the left ankle. Review of the PN dated 05/02/23, revealed that the resident removed his/her wander guard, and it was not reapplied. There were no new interventions added to the care plan to prevent further exit seeking. Review of the PN dated 05/03/23, reflected that the resident was found on the elevator. The resident stated, I want to go home . I'm like in a jail here. There were no new interventions added to the care plan to prevent further exit seeking. Review of the Interdisciplinary Team notes dated 05/04/23, revealed that the resident continued to remove the wander guard and the wander guard was discontinued. The document further revealed, Observation in place and resident not a wanderer as [he/she] has a plan to where he/she is going. There were no new interventions added to the care plan to prevent further exit seeking or that the resident's wander guard had been discontinued. The Wandering Risk Scale [an assessment tool] revealed a 9, which indicated at risk to wander. Review of the PN dated 05/22/23, revealed that the resident stated he/she was leaving, had a packed bag and was headed toward the elevator and was redirected. There were no further interventions added to the care plan. A review of the facility's Reportable Event Record/Report dated 05/28/23, identified that Resident #535 exited/eloped the facility undetected through the front door late morning. The resident was found by staff almost an hour later at a restaurant near the facility. On 05/28/23, Resident # 535 was transferred to another facility that had a locked unit. Review of the May 2023 Treatment Administration Record, included an order for OBSERVATION CHECKS every hour for OBSERVATION CHECKS-Start Date 05/18/2023 1200 [12:00 PM]. The correlating PN dated 05/19/23, documented resident is on observation monitoring r/t [related to] going in and out of other resident's rooms. On 04/17/24 at 10:46 AM, the surveyor interviewed the receptionist who stated she worked at the facility since 04/20/22, but she was not working on 5/28/2023. The receptionist stated residents who were an elopement risk or wander would wear a wander guard. She stated the wander guard and alarm would go off if a resident were close to the monitoring device. If a resident did not wear a wander guard, she could use a button to lock the front door. She stated there was a list and pictures at the front desk of residents who wander. On 04/17/2024, the Director of Nursing (DON) provided a statement dated 6/1/2023, from the receptionist who was working on 05/28/23, when the resident eloped which indicated, I was at the front desk the entire time and did not see resident leave. The receptionist who was working on 05/28/23, is no longer employed at the facility and could not be interviewed. On 04/17/24 at 10:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who worked on the unit the day Resident #535 eloped. She stated, I think I remember the primary care nurse told me that the resident was missing and that she thought the resident was found at a restaurant in the area. The LPN stated the normal process for a missing resident would be to search the unit, the building, announce the code, and all start searching. On 04/17/24 at 11:31 AM, the surveyor interviewed the Director of Nursing (DON) who stated she has been at the facility since 02/14/23. The DON stated the process for a resident who was an elopement risk would be to do an assessment, apply a wander guard depending on the assessment, and ensure there was a photo at the reception desk. When asked if the resident were to remove the wander guard, the DON stated it would be placed somewhere like the wheelchair or the walker if the resident used one. The DON further stated that interventions for an elopement risk or wanderer would include a wander guard, name, and photo at the reception desk, and to inform the staff. The DON explained the day Resident #535 eloped was a weekend and the staff called her. She instructed the staff to do a building sweep, open all doors, check all exits, check the stair wells, basement, inside and out. She stated the police, physician, Licensed Nursing Home Administrator (LNHA) and family were notified. She was unsure how long the resident was missing, where he/she was found, or how he/she was returned to the facility. On 04/17/24 at 1:02 PM, the surveyor interviewed the then LNHA, current Assistant LNHA, who stated she did not remember when she was made aware that Resident #535 was identified as an elopement risk. She stated the resident eloped, was found, and brought back to the facility by a staff member. The resident was transferred to a facility with a locked unit. On 04/17/24 at 1:11 PM, the then LNHA stated the front desk has a board and folder with pictures of wanderers/elopement risk residents and that the camera was working but the views did not show what we needed to see. She stated the resident had a wandering assessment on admission 04/13/22 and on 05/04/23, both with a score of 09 which indicated at risk for wandering. She stated she was not aware of any elopement seeking behaviors but would have to check. She stated the resident was never a wander risk inside the facility. The surveyor reviewed the 05/03/23 PN and asked if the documentation constituted an elopement behavior. The LNHA stated, I don't know if that constitutes an elopement behavior. On 04/22/24 at 10:39 AM, the surveyor in the presence of the survey team, interviewed the then LNHA who stated, I do not remember at that time if Resident #535 was an elopement risk. She stated there was conflicting documentation in the medical record and that when the resident would walk around, he/she had a goal so [he/she] was not a wanderer because [he/she] knew where [he/she] wanted to go. 33106 Part B According to the Admission Record, Resident #24 was admitted to the facility with the diagnoses which included but was not limited to hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left dominant side, hydrocephalus (fluid build-up in fluid-containing cavities of the brain) and dementia. The quarterly Minimum Data Set (MDS) an assessment tool that facilitates a resident's care dated 03/31/24, indicated that Resident #24 had severe cognitive deficits, had limited range of motion on one side of the body, required maximum assistance with activities of daily living (ADLs) and was dependent on staff for transfers. On 04/17/24 at 09:39 AM, the surveyor interviewed Resident #24 who stated that he/she recently fell in the shower when a male Certified Nursing Assistant (CNA) was transferring him/her. The resident could not provide the surveyor with specifics due to cognitive deficits. The resident did not appear to have any injury on the upper arms. On 04/17/24 at 09:43 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that he had been employed in the facility for approximately 3 (three) years. He described the resident as having confusion and was incontinent of bladder and bowel. CNA #1 stated that the resident required assistance of two staff members for transfers. He stated that the resident required total care with all aspects of activities of daily living (ADLs). He continued to explain that the resident was at risk for falls and required the use of a chair alarm and utilized walker for support with assistance of two staff member for transfers. CNA #1 revealed that the resident fell a couple weeks ago. He stated that the resident currently received therapy. CNA #1 then added that it took two staff members to assist Resident #24 with showers due to the resident's height and because the resident was a fall risk. CNA #1 stated that he applied an orthotic device to the resident's left leg and that it was indicated on CNA #1's assignment schedule. He revealed that a timeframe was not documented on the assignment as to when the brace was to be applied or removed, just that the resident was supposed to wear it. On 04/17/24 at 09:53 AM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that Resident #24 was on skilled physician therapy (PT), occupational therapy (OT) and speech therapy (ST). She stated that PT was working on standing tolerance and transfers. She stated that the resident required two-person assistance with transfers and had weakness on the left side. She stated that the resident had a history of a cranial shunt due to intracranial pressure (ICP). She continued to explain that the resident received OT therapy for range of motion (ROM), strengthen exercises for the left arm. She stated that the resident wore left Ankle foot orthosis (AFO): used to stabilize the ankle. She explained that it was a good idea to wear the AFO when standing to prevent accidents. On 04/17/24 at 10:05 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that she had been employed in the facility for 1 (one) year. The LPN explained that Resident #24 had confusion and required total care with all aspect of ADL's and required a two-person assistance with transfer. She stated that it was important that two staff members assisted the resident during transfers to help protect the resident and the staff from getting injured. The surveyor reviewed Resident #24's Care Plan (CP), which indicated that the resident had a brace to the left lower leg. The CP intervention dated 02/24/21, indicated that the resident required extensive assistance of two staff members for transfers. The CP also indicated that the resident fell on [DATE] while CNA was transferring the resident to the shower chair, the resident lost his/her balance and was lowered to the floor and developed a skin tear. The Progress note dated 3/13/2024 at 10:39 PM (22:39), indicated the following: Health Status Note Text: Post fall- notified by CNA that resident begin to lose balance and was lowered to the ground by the CNA while being transferred into chair after shower. On assessment resident noted to have skin tear to back of left arm which was treated with Bacitracin and a band aid. Resident alert and stable no complaints of pain. Will continue to monitor. The 7:00 AM-7:00 PM, CNA Assignment Sheet dated 03/13/24, indicated that the resident required a 2-person assistance with transfers and wore a brace to the left lower leg. On 04/17/24 at 10:23 AM, the surveyor interviewed the Licensed practical Nurse Unit Manager (LPN/UM) on the B Unit second floor for a couple year and employed in the facility for [AGE] years. The LPN/UM stated that Resident #24 was alert and oriented to person and required extensive assist with ADLs. She stated that the resident required 2-person transfer for over 5 months. She explained that Resident #24 had poor balance and was also very tall, so for his safety and staff safety, he/she required two-person assistance with all transfers. She stated that the resident fell in the shower room a month ago. She revealed that the CNA assigned to Resident #24 on 03/13/24 on the 3:00 PM-11:00 PM shift did not follow the resident's plan of care and transferred the resident by himself. She stated that the resident sustained a skin tear to the left elbow during the fall. She continued to explain that the resident had an AFO brace on the left leg. She stated that the brace was applied by the CNA during morning care. She explained that the AFO brace was importance to wear to stabilize the resident's left leg. She also stated that the orthotic device was documented on the resident's care plan. On 04/17/24 at 10:51 AM, the surveyor interviewed the CNA #2 who stated that he worked for the agency and worked 2-3 days a week at the facility. He stated that he was familiar with the residents in the facility. He stated that he worked on 03/13/24 on the 3:00 PM-11:00 PM shift and provided care to Resident #24. He stated that while he was providing a shower to Resident #24, he transferred the resident in the shower independently and resident lost his/her balance and was lowered to the floor. He stated that the resident sustained a skin tear on left elbow area. He admitted that he did not review the assignment sheet and did not know that the resident was a two-person transfer. He stated that he should have received a briefing from the other nurses prior to showering and received help with transferring of the resident. The surveyor asked CNA #2 if there were facility documents that he could have referred to regarding how to care for the residents and he indicated that there was a section on the CNA assignment that indicated how many people were supposed to assist a resident with transfers. He stated that the facility Administration educated CNA #2, and they also performed a shadowing with another CNA to observe him while he transferred a resident so that I didn't make that mistake again. CNA #2 added that the resident had bare feet during the transfer and was not wearing a AFO at the time of the fall. On 04/17/24 at 01:17 PM, the surveyor interviewed the DOR who stated resident had a AFO (ankle foot orthosis). The DOR stated that Resident #24 Res was to wear when standing and with transfers. She stated that the resident did not need to wear it at night in bed. The DOR provided the surveyor with a Physical Therapy Treatment Encounter dated 03/25/24, which indicated that Resident #24 required maximum assistance with two staff members with AFO on the left foot. The undated facility policy titled, Care Plans indicated that the comprehensive care plan was developed for each resident that identified the highest level of functioning the resident may be expected to attain and identify the professional services that are responsible for each element of care. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure that staff provided a resident with the appropriate physician ordered liquid consistency. This posed the likelihood of serious harm to the health and well-being of Resident #24. This resulted in an Immediate Jeopardy (IJ). This deficient practice occurred for 1 of 9 resident (Resident #24) reviewed for physician ordered pudding thick liquid consistency and was evidenced by the following: On 04/12/24 at 8:40 AM, the surveyor observed a Certified Nurse Aide (CNA) adding two thickener packets to Resident #24's coffee, instead of the required four, and then provided the coffee to the resident. Resident #24 was then observed drinking the coffee from the nine-ounce cup that was filled closely to the top, and Resident #24 then coughed. The meal ticket on Resident #24's tray at that time identified Resident #24's diet as Puree, Pudding Thick at the top and !!!Pudding Thick!!! at the bottom. The IJ was identified and began on 04/12/24. The IJ template was provided to the Licensed Nursing Home Administrator (LNHA) at 04/12/24 at 12:51 PM. An acceptable removal plan was received on 04/12/24 at 3:35 PM, and was verified on-site on 04/17/24 at 12:09 PM. An acceptable removal plan was received on 04/12/24 at 3:37 PM, indicating the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: 1. Resident #24 was immediately examined by the Nurse Practitioner. 2. The physician was called and made aware. 3. The Nurse Aide was immediately in-serviced which included return demonstration. All other staff who may serve Resident # 24 as well as any other staff who may serve other residents with thickened liquids have been in-serviced with return demonstration. The evidence was as follows: On 04/12/24 at 8:31 AM, during a surveyor interview with Resident #24 a Certified Nurse Aide (CNA) brought the resident's meal tray into the room and placed it on the bed-side table. The CNA informed the resident he was going to get the resident coffee and then exited the room. The CNA returned with a 9-ounce burgundy coffee cup that was filled close to the top of the mug with coffee. On 04/12/24 at 8:40 AM, the CNA removed two packages of thickener from a drawer next to the resident's bed, then emptied the contents of both thickener packets into the coffee, stirred the contents and placed the cup in front of the resident. The CNA told the resident, go ahead and eat. The resident then proceeded to pick up the coffee cup, put his/her head back and proceeded to drink the coffee from the mug. Resident #24 again was observed coughing. The CNA then opened a coffee creamer, picked up the coffee and stirred in the creamer and again placed the coffee cup next to the resident. At that time, the surveyor observed a meal ticket on Resident #24's tray and asked the CNA to show the surveyor the ticket. The ticket identified Resident #24's diet as Puree, Pudding Thick at the top and !!!Pudding Thick!!! at the bottom. The surveyor asked the CNA what type of liquids the resident was supposed to consume, and the CNA stated, it is supposed to be nectar. The surveyor asked the CNA if he looked at the ticket and the CNA stated, I looked at the ticket. On 04/12/24 at 8:45 AM, the surveyor exited the room to inform the Licensed Practical Nurse, Charge Nurse (LPN/CN) of the surveyor's observations and asked what type of liquids the resident was prescribed. The LPN/CN stated the resident was on pudding thick liquids and accompanied the surveyor to Resident #24's room. The LPN/CN looked at the coffee and proceeded to take a spoon and lift up the coffee and drop it back into the cup. The coffee was observed to freely flow back into the cup and was not pudding thick in appearance. The surveyor asked if the coffee was the appropriate consistency. The LPN/CN stated the coffee was not pudding thick consistency and was not appropriate for the resident. At that time, in Resident #24's room, affixed to the wall close to the bed, was an 8 1/2 X 11-inch sheet of paper with large black printed instructions which indicated: Pudding thick liquids -2 packets per 5 ounces. Diet: Pureed. A review of the Thickened Liquids, Fluid Restrictions and NPO [nothing by mouth] Policy dated 05/2023, included but was not limited to: Staff Responsibilities . 5. Nurse's aides are able to use prepared thickened liquid preparation from the dietary department . 6. Staff who were educated on the process are able to use thickening packet to prepare appropriate fluids. On 04/12/24 at 9:00 AM, the surveyor reviewed Resident #24's electronic medical record. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/30/23, reflected the resident had a brief interview for mental status (BIMS) score of 05 out of 15, indicating that the resident had a severely impaired cognition. Section K revealed the resident received a Mechanically Altered and Therapeutic Diet. Section GG was coded as 04 which indicated that the resident required supervision for eating. Review of the Admission Record dated 04/12/24, revealed that Resident #24 had diagnoses which included dysphagia (difficulty swallowing), oropharyngeal phase (middle part of throat), cerebral infarction, and hemiplegia and hemiparesis. Review of a Physician Order dated 02/16/24, revealed a Diet order for a Consistent Carbohydrate Diet, Puree Texture, Pudding consistency, No Straws, 2 packs of honey thickener to 5 ounces. Review of the Resident's current Comprehensive Care Plan documented a Focus area for the resident having a chewing and swallowing deficit which was initiated on 02/16/24. The Goal revealed the resident will chew and swallow the least restrictive diet without overt [signs and symptoms] of aspiration 95%-100% of the time given [minimum cues] which was initiated 02/16/24 with a target date of 06/29/24. The Intervention was to receive skilled [Speech Therapy] 12 sessions/30 days for [treatment] of oropharyngeal dysphagia, cognitive-linguistic deficits, [patient] caregiver training and [discharge] planning which was initiated 02/16/24. Review of the Key Information section of the electronic medical record revealed Precautions, Aspiration Precautions Puree/Pudding Thick. Review of a Speech Therapy Treatment Encounter Note signed by the Speech Therapist on 04/11/24 at 3:36 PM revealed Precautions: Aspirations precautions, Puree/pudding thick. The International Dysphagia Diet Standardization Initiative 2016: Oral Intake: Current Drinks/Liquids=Extremely Thick Drinks; Current Foods/Solids=Puree Foods; Functional Status as a Result of Skilled Interventions: Oral Intake: Current Liquids = Pudding thick liquids, Current Solids= Puree Consistencies. Review of a Nurse Practitioner Note dated 08/28/23, timed at 10:40 AM, revealed that the resident was post hospitalization for TIA [Transient Ischemic Attack ], LL PNA [Lower Lobe Pneumonia] from 8/8 to 8/13. The Plan included the following: Problem/Diagnosis Status Notes/Considerations Action Orders/Recommendations; At risk for poor prognosis, expect decline in cognitive/physical function, risk of pneumonia, swallowing difficulties, weight loss and falls; Diagnoses: Oropharyngeal dysphagia Stable Chronic Per medical records .Monitor for s/s of aspiration and if suspected stat [immediate] CXR [chest X-Ray], add steroids, duonebs [respiratory treatment], oxygen and antibiotics as warranted. Pneumonia, unspecified organism Stable Chronic Per hospitalization ,d+[DATE] to 8/13. Completed Augmentin monitor for recurrent symptoms. Monitor, Evaluate, Assess, Treat Monitor SPO2 and give supplemental O2 as needed to maintain SPO2 [blood oxygen level] > 92%. High risk for aspiration if suspected obtain stat imaging, steroids, duonebs and antibiotics as warranted. Review of a Registered Dietitian Quarterly Note, dated 03/26/24, revealed Puree diet with pudding thick liquids. On 04/12/24 at 9:50 AM, the surveyor interviewed the Speech Therapist (ST) who stated she worked at the facility for two and half years and was responsible for prescribing resident diet consistencies, working with residents on swallowing exercises and education for staff and residents. The surveyor asked the ST if she had been made aware of the observed concerns with Resident #24's liquid consistency. The ST stated she had been informed by the nurse that the liquids were not properly thickened and did not observe the resident after the incident. The ST confirmed that Resident #24's diet order was for puree food and pudding thick liquids and staff was to use 2 thickener packs for 5 ounces of liquids, and 4 packets for 8 ounces of liquid. The surveyor asked what would happen if Resident #24 did not receive the proper liquid consistency. The ST stated there was a potential for aspiration as the physician ordered aspiration precautions. On 04/12/24 at 8:53 AM, the surveyor interviewed the Registered Dietitian (RD) regarding Resident #24's physician ordered diet. The RD stated the resident had recently declined and the diet consistency had been downgraded. The surveyor asked the RD if it was important for Resident #24 to be on a thickened liquid diet and the RD stated, if the resident had pudding thick liquid on the tray ticket, absolutely, they should receive it. The surveyor asked if pudding thick liquids could be drunk from a cup and the RD stated, no, it should be by a spoon. On 04/12/24 at 9:17 AM, the surveyor interviewed the Food Service Director (FSD) regarding who was responsible for thickening liquids. The FSD stated the nursing department was responsible to thicken liquids. One packet of thickener would be used for 4 ounces of liquid to thicken to nectar thick, spoon like would require 2 packets for 4 ounces and pudding thick would require 3 packets for 4 ounces. The surveyor reviewed the thickener packet provided by the FSD which revealed: Add 1 packet to four ounces of liquid, stir with a spoon or fork for approximately 15 seconds or until thickener is dissolved. Allow 1 to 4 minutes for product to reach desired thickness. Products may thicken slightly over time. The amount of thickener may be adjusted to meet your individual needs. Results may vary depending on source of water, type, and temperature of beverages of foods. For spoon-like consistency: Add two packets to 4 ounces of liquid. On 04/12/24 at 10:28 AM, the surveyor, in the presence of four other surveyors, interviewed the Director of Nursing (DON). The surveyor asked the DON to explain the process that was in place for staff to provide thickened liquids to a resident. The DON stated the resident's meal tray would be delivered from the kitchen; a nurse would read the ticket to determine if the resident had a modified diet; if the resident had a thickened liquid diet nursing was responsible to thicken the liquids as there were no pre-thickened liquids for the past few months and the packets of thickener were available on the resident units. We thicken it to the appropriate texture and then take it to the resident, and we pour the coffee as it doesn't come up on the tray. The DON further stated, we are supposed to be completing competencies for thickening liquids. The surveyor then asked if all staff had been trained on thickening liquids for the residents and the DON stated, I don't want to say competencies, and then stated, in services. The DON stated, they should be doing thickened liquid competencies and the nurses know the consistency of the diets and liquids and should be monitoring that. The surveyor asked the DON if the nurses should be checking the consistency of the liquids and she stated, I would hope so. The surveyor asked if Resident #24's liquids should have 2 packets of thickener added to 8 ounces to make it pudding consistency, and the DON stated, no. The surveyor asked if that was a concern and the DON stated, yes. On 04/19/24 at 11:19 AM, the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA) and Corporate Clinical Officer (CCO) presented additional information to the survey team. The LNHA stated, I agree, they didn't follow the doctor order, and confirmed by the AA. NJAC 8:39-17.4 (a)1-2; 27.1(a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to complete and maintain an ongoing communication record between the facility and the dialysis center for 1 of 2 residents (Resident #19) reviewed for dialysis. The deficient practice was evidenced by the following: A review of the facility policy Hemodialysis Communication undated, included but was not limited to: to have effective communication . between facility and dialysis center . Steps . ensure the resident has their communication binder with them and filled out completely to include pre and post dialysis weights, vitals, and any medications provided . According to the Admission Record, Resident #19 was admitted with diagnoses which included but were not limited to acute kidney failure, psychosis, Dementia, and dependence on renal dialysis. The resident-centered comprehensive Care Plan (CP) included a focus area . attend dialysis Tuesday, Thursdays, and Saturdays. Interventions included to ensure the resident has the dialysis communication book when going to treatments. The Quarterly Minimum Data Set (MDS) a tool used to facilitate care dated 01/17/24, documented a Brief Interview for Mental Status (BIMS) as resident is rarely/never understood and was not conducted. On 04/12/24 at 7:05 AM, the surveyor observed Resident #19 sleeping in bed. At that time, the surveyor reviewed the resident's dialysis communication binder which started January 2024 and documented the following: January 2024: Included ten forms. Nine of ten were missing the resident's name; four of ten had incomplete pre-dialysis information from the facility; and two of ten had incomplete post-dialysis information required from the dialysis facility. Two of the twelve dialysis treatment forms were missing. February 2024: Included 10 forms. Nine of ten were missing the resident's name; two of ten had incomplete pre-dialysis information; and one of ten had incomplete post-dialysis information. Two of the twelve dialysis treatment forms were missing. March 2024: Included four forms. Four of four were missing the resident's name; Two of four had incomplete pre-dialysis information; and eight of twelve dialysis treatment forms were missing. April 2024, through 04/12/24: Included five forms. Five of five were missing the resident's name. On 04/16/24 at 9:22 AM, the surveyor interviewed the direct care Licensed Practical Nurse (LPN) who stated Resident #19 would be sent with the dialysis communication book to treatment. She stated that it was the nurse's responsibility to document the vitals and that the dialysis nurse would document the vitals when the resident was finished with the treatment. She further stated that the vitals should be completely filled out so we can communicate with dialysis and provide the proper care needed. On 04/17/24 at 8:38 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility filled out the pre-dialysis information and the dialysis center filled out the post-dialysis information. The DON stated that if that was not completely filled out, that it indicated that the post-dialysis information was incomplete, and the nurse must call the dialysis center to obtain all of the missing information. She stated the facility pre-dialysis portion should be completed and that there should be a communication sheet for every dialysis visit. The surveyor asked to review the communication book for Resident #19 with the DON. The DON confirmed that there was no name on the pages and that it was important to have the resident name on all the pages in case a page was separated from the binder. The DON acknowledged there were many blank pages and stated it was the Unit Managers (UM) responsibility to check the dialysis communication sheets to ensure completeness. On 04/17/24 at 8:45 AM, the surveyor interviewed the LPN UM who stated she was responsible to check the dialysis communication sheets to ensure they were complete and if there were orders or recommendations from the dialysis center. At that time, the surveyor reviewed the facility policy with the DON and the LPN UM. Both confirmed the facility policy was not being followed. On 04/19/24 at 11:49 AM, the surveyor informed the facility Administration of the concern and was afforded the opportunity to provide additional information. On 04/22/24, the facility Administration had no additional information to provide. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 3 of 3 forms provided: This deficient practice was evidenced by the following: On 4/17/24 at 10:45 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed on three of the three provided forms Part 5, had not been completed upon receipt of the medications from the Provider Pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 231659497; 231659498; 23165949. On 4/17/24 at 10:50 AM, the surveyor and DON reviewed the provided DEA 222 forms. The DON acknowledged she should have completed in Part 5 as instructed on the reverse of the DEA 222 form as required. A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item . NJAC 8:39- 29.2(d), 29.7(c)

Complaint # NJ 169435 Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure the development of an individualized resident-centered care plan for a resident with documented behaviors toward residents and staff. This deficient practice was identified for 1 of 29 residents reviewed for the development of individualized care plans (Resident # 234). The evidence was as follows: On 04/16/24 at 10:00 AM, the surveyor reviewed the medical record for Resident #234. A review of the Admission face sheet record (an admission summary), reflected that the resident was admitted to the facility with diagnoses which included schizo-affective disorder, depression, and dementia with behavioral disturbance. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], an assessment tool used to facilitate the management of care, reflected that the resident had severe cognitive impairment for daily decision making and had difficulty communicating with others. A review of the progress notes dated 09/14/23, reflected that Resident #234 had episodes of resisting care and increased frustration, restlessness. According to an entry dated 09/30/23, Resident #234 was sent out for psychiatric evaluation due to aggressive behavior toward another resident, threatening staff and agitation. A Note Text dated 09/30/23 and timed at 9:45 AM, revealed that staff heard a resident yelling in the hallway and observed Resident #234 standing in the doorway of another resident's room with his/her arms raised in the air and was yelling at the other resident. Staff slowly approached the resident to redirect him/her away from the other resident. Resident #234 balled the fists up and lunged at the staff. Resident #234 was sent out to the hospital. Review of the psychiatric assessment/evaluation form dated 09/30/23, reflected the following: Per staff on 9/30/23, pt [patient] was agitated, yelling, verbally aggressive towards others, labile, & impulsive . history of harm to others. Pt sent out for Evaluation on 9/30/23. Resident was sent to a Behavioral health facility (name redacted). Olanzapine (an antipsychotic) 2.5 mg (milligram) x 3 daily and Ativan 0.5 mg Q [every] 6 hours as needed was started at the Behavioral Health. Another entry dated 10/03/23, revealed that Resident #234 was sent out to be evaluated due to increased agitation. Resident #234 was admitted for worsening dementia and returned to the facility on [DATE]. According to an entry in the clinical record dated 10/02/23, the resident was last seen by the psychiatrist on 10/02/23 with a new order to increase Depakote (a mood stabilizer) 375 mg at bedtime, Depakote sprinkles 250 mg in the morning and at 2:00 PM and to obtain the Depakote [blood] level on 10/09/23. Another psychiatric assessment dated [DATE], revealed the following: Seen for f/u [follow up] as per staff request due to recent incident. On 01/29/23 patient was agitated and grabbed another resident by the right arm, currently 1:1 [one to one observation]. Pt was sent out on 11/29/23 for an evaluation and returned to the facility on [DATE]. A review of the resident's individualized care plan dated 08/06/23, failed to address Resident #234's aggressive behavior toward staff and other residents prior to 11/30/23. The facility indicated that Resident #234 was placed on 1:1 observation. Review of the 1:1 observation log provided by the facility revealed that Resident #234 was on 1:1 observation prior to 11/30/23. However, the 1:1 observation log did not document the behavior exhibited. On 11/29/23, Resident #234 assaulted another resident around 8:30 PM causing pain to the right arm. X-Ray results revealed soft tissue injury to the right arm. The other resident had to be medicated for pain with Tylenol (a pain releiving medication). The behavior was not documented on the 1:1 observation log. The facility did not provide documentation to indicate how Resident #234 was able to make contact with the other resident while on a 1:1 observation. Further review of the resident's care plan revealed a focus area dated 11/17/23, for a mood problem related to anxiety, depression dementia and psychosis. The interventions included to provide the resident with a program of activities that is meaningful and of interest talking about diving was initiated on 11/30/23. On 04/18/24 at 10:15 AM, the surveyor interviewed a Certified Nursing Assistant (CNA) who cared for the resident prior to being discharged . The CNA revealed that the resident was very aggressive with staff and others. The CNA stated, you must know how to approach the resident. On 04/18/24 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the unit who confirmed that Resident #234 had increased agitation and did exhibit behaviors of aggression towards staff and other residents. The LPN and the surveyor together reviewed the resident's care plan. The LPN confirmed there was no behavioral care plan developed to address the resident's behavior. The LPN stated the nurses document his/her behavior and interventions in the nurses notes. On 04/18/24 at 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who initiated the care plan on 11/30/23. The DON revealed that she could not recall if the resident had behaviors of being aggressive toward other residents or staff prior to 11/29/23. The DON stated that a care plan for the behavior should have been in place if the resident exhibited the behavior prior to 11/29/23 the date of the incident. The surveyor asked the DON what specific interventions were implemented to prevent the resident from being aggressive toward other residents. The DON stated, I could not recall, I will have to review the record. On 04/19/24 at 12:30 PM, the surveyor discussed the findings with the facility administration. On 04/22/24 at 10:35 AM, the DON stated the interventions added after the 09/30/23 incident were medication reviews, room changed, and referral to crisis center. The DON further stated that upon the resident's return to the facility, the resident was placed on 1:1 observation. The surveyor reviewed the 1:1 observation logs with the DON as there was no documentation on the log to reflect the behavior exhibited. The DON stated in the presence of the survey team that the 1:1 observation log was to verify that the resident was on 1:1 observation and was not a visual observation. The DON stated Resient #234's behavior was documented in the Progress Notes. There was no care plan implemented with specific interventions to address Resident #234's documented behaviors. The care plan created by the Director of Nursing on 11/30/23, failed to provide the interventions for staff to utilize for addressing the specific documented behaviors. A review of a facility provided untitled instructions on 1:1 observation last revised 07/12/23, indicated the following: Policy: A structured process will be established to identify high risk behaviors and implemented 1:1 interventions when necessary to ensure the safety of residents and staff. The decision to implement 1:1 observation will be based on the resident's assessed risk level. Any resident presenting a direct and aggressive threat to themselves or others will be placed on 1: 1 observation. This intervention requires continuous visual supervision within arm's length of the resident. Staff will document on the designated observation form that the 1:1 occurred. NJAC 8:39-11.2(e).

Based on observation, interview, and record review, it was determined that the facility failed to adhere to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 2 of 2 residents reviewed (Resident #40 and #241). The deficient practice was evidenced by the following: 1. On 04/11/22 at 10:30 AM during the initial tour, the surveyor toured the subacute Unit and observed Resident #241 in bed, the head of the bed was elevated and the resident was resting with their eyes closed. The resident was receiving oxygen via a nasal cannula (tube inserted to the nose for oxygen delivery). The surveyor observed the Nebulizer mask (used for breathing treatments) directly placed on top of the night stand, touching the Nebulizer machine and in closed proximity of the resident's phone and toiletries items. The Nebulizer tubing was labeled and dated 04/11/24. On 04/12/24 at 9:45 AM, the surveyor returned to the room and observed that the Nebulizer mask was on the night stand as observed the day before. On 04/16/24 at 9:30 AM, the surveyor returned to the room and observed the Nebulizer mask directly placed on the night stand next to the Nebulizer machine. The surveyor observed the resident resting in bed. The surveyor attempted to interview the resident but the resident could not proceed with the interview. The surveyor returned to the room after the resident had been assisted with care and received morning medication and observed the Nebulizer mask on the night stand face down and not protected. The mask was dated 04/11/24. On 04/16/24 at 10:20 AM, the surveyor observed the Nebulizer mask still on the night stand, not protected and exposed to the environment. The surveyor accompanied the Infection Control Nurse Preventionist (IP) to the room where we both observed the Nebulizer Mask on the night stand and not protected. Upon inquiry, the IP informed the surveyor that the Nebulizer mask should have been placed inside a plastic bag when not in use to prevent infection. On 04/16/24 at 11:30 AM, review of the medical record reflected that Resident #241 was admitted to the facility with diagnoses which included, but were not limited to; acute respiratory failure with hypoxia, pneumonia unspecified organism. On 04/16/24 at 12:30 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the unit. She stated that after being used the Nebulizer mask should be stored in a plastic bag to prevent infection. A review of the Order Summary Report for April 2024, revealed the following orders for Resident #241: Ipratropium-Albuterol inhalation Solution 0.5-2.5(3)MG (milligrams)/ML (milliliter) Ipratropium-Albuterol 3 ml inhale orally 6 hours as needed for wheezing and shortness of breath. 2. On 04/11/24 at 10:35 AM, the surveyor entered Resident #40's room. The resident was not in the room. The surveyor observed the oxygen tubing and the nasal cannula on the bed. The oxygen tubing was not protected. Another nasal cannula was also noted on the night stand not protected. The nasal cannula on the night stand was not labeled/dated. On the same day at 12:11 PM, the surveyor returned to the room and observed a staff from physical therapy assisting the resident to the room. The staff assisted the resident to switch from the portable oxygen tank to the concentrator which was located behind the curtain next to the bed. The humidifier bottle was labeled and dated 04/11/24. The staff applied the nasal cannula that was noted on the bed. The staff used the nasal cannula that was left on the bed and not protected. On 04/12/24 at 8:30 AM, the surveyor returned to the room and observed the nasal cannula on the night stand as it was the day before, exposed to the environment. On 04/17/24 at 9:42 AM, the surveyor interviewed the LPN assigned to provide care to the resident. The LPN stated that all respiratory equipment including Nebulizer masks and oxygen tubing should be disinfected after use and placed in a bag to prevent infection. On 04/17/24 at 11:30 AM, the surveyor reviewed Resident #40's clinical record which reflected that Resident #40 had diagnoses which included but were not limited to; acute respiratory failure with hypoxia, pneumonia, emphysema and adult failure to thrive. The Order Summary Report dated April 2024, reflected an order for continuous oxygen at 2 liters per minute via nasal cannula with an original date of 03/27/24. The Order Summary Report also included an order to change and date oxygen tubing and humidification bottle (if in use) every night shift every on Wednesday for infection prevention. The order had an original date of 03/27/24 timed 23:00 [11:00 PM]. On 04/16/24 at 1:15 PM, the facility was informed of the above concerns and the surveyor requested the policy for oxygenation therapy. On 04/17/24 at 8:08 AM the facility provided an undated policy, titled, Respiratory Therapy Equipment Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. Steps 4 and 4 of the procedure indicated the following: 4. Change the oxygen cannula and tubing weekly and/or as needed. 5. Keep the oxygen cannula and tubing used PRN[as needed] in a plastic bag when not in use. Under Infection Control Considerations related to Medication Nebulizers/ Continuous aerosols the following were noted: After completion of therapy: Remove the Nebulizer container Rinse the container with fresh tap water; and Dry on a clean paper towel or gauze sponge. Reconnect to the administration set-up when air dried. Wipe the mouth piece with damp paper towel or gauze sponge. Store in plastic bag. The policy was not being followed. NJAC 8:39-19.4 (a)1,2

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records. This deficient practice was identified for 1 of 29 residents (Resident #183) medical records reviewed and was evidenced by the following: The surveyor reviewed the medical record for Resident #183. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included, lack of coordination, type 2 diabetes mellitus (high blood glucose), and abnormalities of gait (pattern a person walks) and mobility. A review of the Incident Report revealed that a staff member (Certified Nursing Assistant - CNA) bumped into the resident with a meal cart resulting in the resident sustaining a skin tear on their right third toe on 2/24/23 at 8:45 AM. A review of the Full QA [Quality Assurance] Report revealed investigative statements from the nurse, the resident, and the witnessed CNA were obtained. It further indicated the CNA immediately informed the nurse, the resident was assessed, a treatment was ordered, and the physician and family was notified. A review of the Progress Notes (PN) from February 2023, revealed there was no progress note in the electronic medical record (EMR) on 2/24/23 during the 7 AM to 3 PM regarding the incident not until 2/25/23 at 02:37 (2:37 AM), which indicated the resident had redness noted to the third right toe and the physician ordered an X-ray with a bacitracin (topical antibiotic ointment) treatment. On 04/17/24 at 09:30 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that they completed an accident/incident report and wrote a progress note in the electronic medical record (EMR) for any incident that occurred. She stated that it was important to document a progress note in the EMR because it was a communication tool from shift to shift, so everyone was aware of what happened with the resident. On 04/17/24 at 09:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated the process for any incident would be to call the nurse and to stay with the resident. The CNA stated that she would then write a statement for the incident report and describe what she saw if it was witnessed. She further stated that if it was unwitnessed and the resident was her resident then she would describe what the resident was doing prior to the incident. On 04/17/24 at 11:03 AM, the surveyor interviewed LPN #2 who stated the process for any incidents was to assess the resident. She then stated that she would call the supervisor to complete a full head to toe assessment. LPN #2 stated that the nurses would get statements from staff regarding the incident, notify the family and the physician. She stated they would then complete an incident report and write a progress note in the EMR. When asked should there be a progress note of the incident. LPN #2 stated that a progress note should be done with the incident report. She explained it was important to also document a progress note in the EMR, so the oncoming shift knew what was happening. She further explained it was our way of communicating and this way all staff that has access to it is aware of what occurred. LPN #2 concluded they documented for three (3) days after any incident in the EMR. On 04/17/24 at 11:04 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the protocol for any incident at this facility was to get a full assessment of the resident, the nurses would complete the incident report and collect statements, and document a progress note in the EMR. The LPN/UM stated that there should be a progress note in the EMR because the progress note informs the facility and all staff of what occurred with the resident, so they are aware. She further stated that the progress notes are a communication tool for the staff and physicians as well as the resident and the power of attorney (POA) so the communication could be successful. She then stated that the nurses also document on the 24-hour report daily, so all the nurses were aware of what happened in those 24 hours. The LPN/UM stated that if a resident was bumped by a cart and received a skin tear then an incident report would be completed. She further stated that they would obtain statements from the resident if alert, from staff that was around, and from other staff to see what the resident was doing prior to the incident. When asked would there also be a progress note in the EMR? The LPN/UM emphasized absolutely there should be a progress note because it was an incident, and we need to know what happened. She stated that the resident assessment, and physician and family should be notified. On 04/18/24 at 09:31 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the process for any incidents was that staff would notify the supervisor, the physician, and the family. The nurses would assess the resident and an incident report was completed. She stated that the staff then wrote statements which were collected from anyone that witnessed the incident. She clarified if the incident was unwitnessed then the nurse would collect the statements from the staff that seen the resident prior to the incident. The DON stated that the nurses would write a progress note of the incident, or they would just write their note in the incident report. She then stated that if the nurses completed an incident report, then they did not have write a progress note in the EMR. She explained that they did not have a write a progress note, if they wrote in the incident report because the incident report could be printed out. When asked how would staff be aware of the incident? The DON stated that staff were aware of the incident from the 24-hour report. When asked when should a progress note be written? The DON stated it should be written for any change because it was communication tool for the staff to be informed about the resident. She stated that a progress note was considered a part of the medical record. On 04/19/24 at 11:12 AM, the Assistant Licensed Nursing Home Administrator (LNHA) stated in the presence of the survey team, the LNHA and the Corporate Clinical Officer (CCO) that it was correct the progress note was missing and should have been in the EMR. A review of the facility's undated Charting and Documentation policy, included, All services provide to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. 3. All incidents, accidents, or changes in the resident's condition will be recorded as soon as physically as close to the occurrence as possible. 5. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: c. The assessment data. f. Notification of family, physician, or other staff, if indicated. NJAC 8:39-35.2 (d)

Based on observation, interview, review of medical records, and other pertinent facility documentation it was determined that the facility failed to obtain physician orders consistent with professional standards of clinical practice for an orthotic device (used to treat various conditions of the foot and ankle) and for the treatment of a skin tear. This deficient practice was identified for 1 of 28 residents reviewed (Residents #24) and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the Admission Record, Resident #24 was admitted to the facility with the diagnoses which included but was not limited to hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left dominant side, hydrocephalus (fluid build-up in fluid-containing cavities of the brain) and dementia. The quarterly Minimum Data Set (MDS) an assessment tool that facilitates a resident's care dated 03/31/24, indicated that Resident #24 had severe cognitive deficits, had limited range of motion on one side of the body, required maximum assistance with activities of daily living (ADLs) and was dependent on staff for transfers. On 04/17/24 at 9:39 AM, the surveyor interviewed Resident #24 who stated that he/she recently fell in the shower when a male Certified Nursing Assistant (CNA) was transferring him/her. The resident could not provide the surveyor with specifics related to the event of the fall. On 04/17/24 at 9:43 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that he had been employed in the facility for approximately three years. He described the resident as having confusion and was incontinent of bladder and bowel. The CNA stated that the resident required assistance of two staff members for transfers. He stated that the resident required total care with all aspects of activities of daily living (ADLs). CNA #1 indicated that the resident was at risk for falls and required the use of a chair alarm and utilized walker for support and the assistance of two staff member for transfers. The CNA revealed that the resident fell a couple weeks ago but had been receiving therapy. The CNA then added that it took two staff members to assist Resident #24 with showers due to the resident's height and because the resident was a fall risk. CNA #1 stated that he applied an orthotic device to the resident's left leg as it was documented on the CNA assignment schedule. He stated that a timeframe was not documented on the assignment as to when the brace was to be applied or removed, just that the resident was supposed to wear it. On 04/17/24 at 09:53 AM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that Resident #24 was on skilled physician therapy (PT), occupational therapy (OT) and speech therapy (ST). She stated that PT was working on standing tolerance and transfers. She stated that Resident #24 required two-person assistance with transfers and had weakness on the left side. She stated that the resident had a history of a cranial shunt due to intracranial pressure (ICP). She continued to explain that the resident received OT therapy for range of motion (ROM), strengthen exercises for the left arm. She stated that the resident wore left ankle foot orthosis (AFO): used to stabilize the ankle. She explained that it was a good idea to wear the AFO when standing to prevent accidents. On 04/17/24 at 10:05 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that she had been employed in the facility for 1 (one) year. The LPN explained that Resident #24 had confusion and required total care with all aspect of ADL's and required a two-person assistance with transfer. She stated that it was important that two staff members assisted the resident during transfers to help protect the resident and the staff from getting injured. The LPN went into the resident's room to see what the resident was wearing on the left lower extremity and then confirmed that the resident was wearing a AFO on the left lower extremity. The LPN stated that Resident #24 fell two weeks ago but that she could not recall the details. She stated that the resident had a left elbow skin tear, but it had healed. She stated that she was not sure how developed. The surveyor reviewed the Treatment Administration Record (TAR) for April 2023 and there was no physician's order for an AFO to the left foot. There was also no documentation on who was to apply the brace, when the brace was to be applied or removed. The surveyor reviewed the TAR for March 2024, and there was no documentation for a physician's order that the staff performed treatments to skin tear of the back of the left arm that was sustained when the resident fell on [DATE]. The surveyor reviewed the facility incident and accident report and investigation dated 03/13/24 at 3:30 PM, which indicated that after Resident #24 had a shower, the resident was transferred to the wheelchair, lost his/her balance and was lowered to the ground. In the process the resident sustained a skin tear to the left elbow which was treated with bacitracin (antibiotic ointment) and a band aid. The report also indicated that the residents Responsible Party (RP) was notified and the Physician was notified. There was no documentation that indicated a treatment order was obtained from the physician. The surveyor reviewed Resident #24's Care Plan (CP), which indicated that the resident had a brace to the left lower leg. The CP also indicated that the resident's skin should be checked under the brace every shift. The CP also indicated that the resident fell on [DATE]. The CP reflected that while transferring the resident to the shower chair the resident lost his/her balance and was lowered to the floor and developed a skin tear. The Progress note dated 3/13/2024 at 10:39 PM (22:39) indicated the following: Health Status Note Text: Post fall- notified by CNA that resident begin to lose balance and was lowered to the ground by the CAN while being transferred into chair after shower. On assessment resident noted to have skin tear to back of left arm which was treated with bacitracin and a band aid. Resident alert and stable no complaints of pain. Will continue to monitor. The 7:00 AM-7:00 PM, CNA Assignment Sheet dated 03/13/24, indicated that the resident required a 2-person assistance with transfers and worn a brace to the left lower extremity. On 04/17/24 at 10:23 AM, the surveyor interviewed the Licensed practical Nurse Unit Manager (LPN/UM) on the B Unit second floor who had been employed in the facility for [AGE] years. The LPN/UM stated that Resident #24 was alert and oriented to person and required extensive assist with ADLs. She stated that the resident required 2-person transfer for over 5 months. She explained that Resident #24 had poor balance and was also very tall, so for his safety and staff safety, he/she required two-person assistance with all transfers. She stated that the resident fell in the shower room a month ago. The LPN/UM revealed that the CNA assigned to Resident #24 on 03/13/24 on the 3:00 PM-11:00 PM shift did not follow the resident's plan of care and transferred the resident by himself. She stated that the resident sustained a skin tear to the left elbow during the fall. She continued to explain that the resident had an AFO brace on the left leg. She stated that the brace was applied by the CNA during morning care. She explained that the AFO brace was importance to wear to stabilize the resident's left leg. The LPN/UM stated there should be a physician's order for orthotic device. She stated that the order should contain information on when the AFO should be applied, removed and who was to apply it. The LPN/UM reviewed the physician's orders in the presence of the surveyor and confirmed that there were no physicians order for the AFO. She also stated that the orthotic device was documented on the resident's care plan. She stated that physicians order for the AFO wound have been important to have so the staff knew when to apply and when to remove the AFO. She stated that the AFO should have been documented on the TAR (Treatment Administration Record) and the TAR should have contained an order for application, removal and to check skin every shift. She stated that the nurse should sign out on the TAR that the AFO was being applied, removed and that the nurses were checking the resident's skin under the AFO. The LPN/UM then stated that stated she would correct the error immediately and would obtain and physician's order for the AFO and would implement the order on the TAR. On 04/17/24 at 10:51 AM, the surveyor interviewed the CNA who stated that he worked for the agency and worked 2-3 days a week at the facility. He stated that he was familiar with the residents in the facility. He stated that he worked on 03/13/24 on the 3:00 PM-11:00 PM shift and provided care to Resident #24. He stated that while he was providing a shower to Resident #24, he transferred the resident in the shower independently and the resident lost his/her balance and was lowered to the floor. He stated that the resident sustained a skin tear on left elbow area. He admitted that he did not review the assignment sheet and did not know that the resident was a two-person transfer. He stated that he should have received a briefing from the other nurses prior to showering the resident and received help with transferring of the resident. The surveyor asked the CNA if there were facility documents that he could have referred to regarding how to care for the residents and he indicated that there was a section on the CNA assignment that indicated how many people were supposed to assist a resident with transfers. He stated that the facility Administration educated the CNA, and they also performed a shadowing with another CNA to observe him while he transferred a resident so that I didn't make that mistake again. The CNA then added that the resident had bare feet during the transfer and was not wearing a AFO at the time of the fall. On 04/17/24 at 12:44 PM, the surveyor interviewed the LPN/UM. The LPN/UM reviewed the March TAR in the presence of the surveyor and confirmed that there was no treatment order documented on the TAR for the skin tear that was sustained during the fall on 03/13/24. On 04/17/24 at 1:17 PM, the surveyor interviewed the DOR who stated resident had a AFO (ankle foot orthosis). The DOR stated that Resident #24 was to wear when standing and with transfers. She stated that the resident did not need to wear it at night in bed. On 04/17/24 at 1:27 PM, the surveyor interviewed the DOR who stated that the Resident #24 has had the AFO since had been here for about 2 years. She stated that the AFO should have had a physician's order. She stated that when therapy recommended a splint or brace, they would let the nurse know and the nurses will put the physicians order in the electronic medical record. On 04/18/24 at 10:03 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed that a physician's order was required for the treatment of a skin tear or the use of an orthotic device. The undated policy titled, Equipment-Use for all Residents indicated that splints are individualized per patient and that request or the need for special equipment should be referred to the rehabilitation Department. The undated policy titled, Charting and Documentation indicated that all observations, medications administered, services performed, etc. must be documented in the clinical record. Documentation of treatments and procedures shall include care-specific details and shall include at minimum: -The date and time the procedure and treatment were provided. -The name and the title of the individual who provided the care. -The assessment data and/or any unusual findings obtained during the treatment/procedure. -How the resident tolerated the procedure/treatment. -Whether the resident refused the treatment/procedure. -Notification of the family, physician and or other staff if indicated. -The signature and title of the individual documenting. The undated facility policy titled, Accident and Incidents indicated that the injured persons physician was to be notified and his or her instructions. NJAC 8:39-27.1 (a) (d) (1-3)

C#: NJ164217 Based on interviews, medical record review, and review of other pertinent facility documents on 5/25/2023, 5/31/2023, and 6/1/23, it was determined that the facility failed to reevaluate the effectiveness of the Care Plan and revise its interventions to prevent physical harm for a resident (Resident #2) with a known history of Major Depressive Disorder and Anxiety who had changes in behavior and committed suicide. The facility also failed to follow its policy, Care Planning - Interdisciplinary Team. This deficient practice was identified for 1 of 4 residents (resident #2) and was evidenced by the following: A review of the Electronic Medical Records (EMRs) was as follows: According to the Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Major Depressive Disorder (MDD), anxiety disorder, chronic pain syndrome, and legal blindness. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 5/5/23, Resident #2 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicated the resident was cognitively intact. Resident #2 had a mood score of 6, which indicated mild depression. Resident #2 had a pain intensity score of 8, indicating severe chronic pain. The MDS also showed Resident #2 was independent, needed one-person assistance with Activities of Daily Living (ADLs), and had severely impaired vision. A review of the medical records for the Licensed Clinical Social Worker (LCSW) clinical visit notes revealed the following: On 4/21/23 at 12:40 PM to 1:15 PM, Resident #2 reported that he/she has high Anxiety a deep depression over his/her medical conditions. Resident #2 currently endorses anhedonia (inability to experience pleasure from activities usually found enjoyable), disturbed sleep and appetite, low self-esteem, difficulty concentrating, difficulty making a decision, anxiety, worry, tension, and difficulty relaxing. Under Ongoing symptoms, Symptoms that needed treatment and monitoring, sadness, anger outburst, high anxiety, restlessness, poor sleep, and family conflicts. On 5/12/23 at 12:37 PM to 1:15 PM, Resident #2 reported the following symptoms, Anxiety over his/her upcoming appointment regarding his/her eyesight. He/she is trying to stay positive. He/she is frustrated over his/her situation and feels the need to increase Xanax medication. She informed him/her to speak to the nurses and Psychiatrist. Resident #2 feels depressed over the situation with his/her spouse and wants to live with the spouse in ALF [Assisted Living Facility]. Review of the Psychiatric Notes from the Psychiatrist revealed the following: On 4/13/23, Resident #2 reported increased Anxiety and frustration at nighttime. Has been upset related to pain. On 4/26/23, Resident #2 was described as having a Chief Complaint of Agitation and Anxiety. Initially calm, cooperative, and pleasant, later becomes tearful [and] reports continued Anxiety and frustration at night. Reports frame of panic when laying in bed at night, anxious about eye exam and blindness. On 5/3/23, Resident #2 reported being tortured by Post Traumatic Stress Disorder (PTSD) symptoms. The Psychiatrist noted, Today patient states that he/she is miserable, and states he/she was hoping to be accepted at Assisted Living Facility (ALF) but was recently denied. The Care Plan dated 11/9/21 and revised on 7/16/22 indicated under Resident #2 Focus I am at risk for psychosocial well-being related to a diagnosis of depression/Anxiety. Under Interventions to 'Encourage me to express feelings of depression that I may be experiencing, offer support and offer 1:1 as needed; and Monitor for any change in mood, behavior, routine, negativity, isolation, withdrawal, hopelessness, decreased participation in the treatment plan; and at risk for pain related to chronic pain syndrome, with interventions to provide me with my medication as indicated by my doctor. The Special Instructions listed, monitor target behaviors (Alprazolam - nervousness), Zoloft sadness, and Buspar anxiety voiced by the resident. The Goals listed included but were not limited to I will verbalize/communicating any feelings of depression or diagnosis-related symptoms while in the facility. In addition, Resident #2's CP included under Focus Resident I am independent with daily routine and decisions re: daily routine, with interventions to Encourage me to express feelings and any frustrations I may be experiencing; Monitor for any change in my mood, behavior, routine, negativity, isolation withdrawal, hopelessness, decreased participation in the treatment plan; and Provide me with support, encourage, motivate, remind me of my progress and capabilities, reassure as needed. However, there was no documentation to address Resident #2's new symptoms of increased Anxiety and depression after a psychiatrist visit on 5/3/23 or after the clinical visits with the LCSW. During an interview on 5/25/23 at 10:57 AM, the LPN/Unit Manager (UM) stated if the resident had a major depressive disorder, it would be on the CP with interventions, and the UM would update the care plans. The CP would be updated right away if there was a change in the resident's condition. If the resident required supervision or monitoring, it would be on the CP too. During an interview on 6/1/23 at 12:45 PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), stated, The whole Interdisciplinary Team (IDT) updates the CP. The CP is updated as needed and quarterly. The CP would note refer to psych as needed as an intervention. A review of the facility policy, Care Planning - Interdisciplinary Team, under Policy Statement: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. REF: F600 NJAC-8:39-11.2(e)(2)(i) NJAC-8:39-27.1(a)

C#: NJ164217 Based on interviews, medical record (MR) review, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to provide services necessary to prevent physical harm when a Resident (Resident #2) with a known history and diagnosis of Major Depressive Disorder and Anxiety, had changes in behavior, which included an increase in anger and anxiousness and had expressed concerns about changes in sleep and appetite. The facility also failed to follow its policy titled Abuse and Neglect - Clinical Protocol. This deficient practice was identified for 1 of 4 residents (Resident #2) and was evidenced by the following: On [DATE], the facility submitted a Facility's Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents to NJDOH. The FRE had an event date of [DATE] and a time of event of 6:05 AM and revealed the following: According to the Timeline of Events (TLE) indicated on [DATE] at approximately 6:05 AM, the Certified Nursing Assistant (CNA) went into Resident #2's room to provide care to the Resident's roommate. The CNA headed to the bathroom with care supplies, and when she went to open the door, she felt weight against the door. Resident #2 fell backward from the bathroom as the CNA opened the door. The CNA attempted to lower the Resident to the floor, but the Resident landed on the CNA's shoes as he/she fell to the ground. The CNA immediately called for the Licensed Practice Nurse (LPN) and Registered Nurse (RN) Supervisor on duty. The TLE also indicated the RN Supervisor and LPN #1 assessed Resident #2 at that time; the Resident had no pulse and was seen with his/her bathrobe tied around his/her neck. The RN supervisor and LPN #1 did not resuscitate the Resident due to the DNR (Do Not Resuscitate) status but immediately called 911. Resident #2 was noted as deceased . The Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Medical Examiner (ME), and the local police department were notified. A review of the Individual Statement Form (ISF) dated [DATE], written by the CNA, revealed at 4:15 AM, Resident #2 was sitting on his/her bed facing the wall; the Resident was usually up at night. The CNA further noted in her statement, During my last round of the shift, I came into the room to change A bed resident. I came in [and] spoke to A bed resident, letting [the Resident] know I was going to change him/her. I grabbed my washcloths and headed to the bathroom. I went to open the door, and it felt like something was against the door. I went to open the bathroom door, and Resident #2 came falling out. I attempted to catch him/her but failed. [The Resident's] head fell on to my shoes as he/she fell towards the ground. I screamed for the nurse. A review of the ISF dated [DATE], written by LPN #1, revealed that Resident #2 was in bed sleeping during the night. The last time Resident #2 was checked by staff was 4:00 AM. The LPN further noted in his statement, At around 6:15 AM, I'm on the 1st floor with the supervisor; staff called this writer and reported that the Resident (Resident #2) is on the toilet floor. Upon arrival in the Resident's toilet room, I found the Resident in a supine position, wearing a bathrobe. Immediately called the supervisor, this writer checked the Portable Medical Orders (POLST) with code status: Do not resuscitate (DNR), Do not intubate (put a breathing tube in the throat) (DNI), Do not hospitalize (DNH). The supervisor arrived on the scene, and we both noticed the robe ring tied tight on Resident #2's neck, and both untied the ring immediately. Resident unresponsive and warm, no pulse and no vitals. A review of the Employee Statement form dated [DATE] at 7:16 AM, written by the RN, noted, Around 6:10 AM, this writer was paged to the 3rd floor. Upon arriving at the unit, I was met by the floor nurse (LPN #1). He was explaining the current situation on the unit for Resident #2's bathroom. While he was talking, we walked to the room. At approximately 6:12 AM, [Resident #2] was lying on the floor on the left side/back position as if he/she had dropped out of the bathroom once the door opened. According to the statement, Resident #2's tongue was discolored and protruding from the mouth; unable to obtain a pulse or note respirations, this writer observed the bathrobe belt wrapped around [the Resident's] neck and knotted. I quickly removed the belt from [Resident #2's] throat. Multiple knots were undone (3) and unwrapped twice from around [the Resident's] throat. This writer opened the Resident's mouth to allow air around his/her tongue. Air escaped, but no breaths were taken in. The floor nurse notified this writer of the Resident's code status of DNR/DNI. No Cardiopulmonary Resuscitation (CPR) started. Called 911 to report the alleged suicide with a police response. Call also place to DON, the LNHA, and the 3rd-floor unit manager. All paperwork prepared for 911 and awaited police. A review of the Electronic Medical Records (EMRs) was as follows: According to the Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Major Depressive Disorder (MDD), anxiety disorder, chronic pain syndrome, and legal blindness. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], Resident #2 has a Brief Interview for Mental Status (BIMS) score of ,d+[DATE], which indicated the Resident was cognitively intact. Resident #2 had a mood score of 6, which indicated mild depression. Also, in the MDS under Section D D0200 Resident Mood Interview (PHQ-9), a depression screen revealed Resident #2 showed little interest and pleasure in doing things and had episodes of feeling down, depressed, or hopeless. The depression screen indicated that Resident #2 had a total of 6 episodes of feeling down, depressed or hopeless, and had trouble falling asleep or sleeping too much, being present at least once for several days, and feeling tired or having little energy nearly every day. The MDS also showed Resident #2 was independent, needed one-person assistance with Activities of Daily Living (ADLs), and had severely impaired vision. Review of the Care Plan (CP) dated [DATE] and revised on [DATE] revealed under Focus, Resident #2 was at risk for psychosocial well-being related to a diagnosis of Depression/Anxiety. Under Interventions, Encourage me to express [my] feelings of depression that I may be experiencing, offer support and offer 1:1 as needed; and Monitor for any change in mood, behavior, routine, negativity, isolation, withdrawal, hopelessness, decreased participation in [the] treatment plan. Further review of Resident #2's CP revealed under Focus, Special Instructions listed, Monitor target behaviors (Alprazolam - nervousness), Zoloft sadness, and Buspar anxiety voiced by the Resident. Under Goals, included but were not limited to I will verbalize/communicate any feelings of depression or diagnosis-related symptoms while in the facility. Also noted on Resident #2's CP was independent with daily routine and decisions re: daily routine, with interventions to Encourage me to express feelings and any frustrations I may be experiencing; Monitor for any change in my mood, behavior, routine, negativity, isolation withdrawal, hopelessness, decreased participation in the treatment plan; and Provide me with support, encourage, motivation, remind me of my progress and capabilities, reassure PRN. A review of the Physician's Orders (PO) dated [DATE] revealed the following: Psychiatry Evaluation and Treatment, Psychiatry Evaluation with NYNJ (NewYork, New Jersey) Psych, Psychotherapy evaluation and treatment as indicated. Sertraline Oral Capsule 200 milligrams (mg). Give 1 capsule by mouth one time a day related to Major Depressive Disorder (MDD). Buspirone HCL tablet 10mg, Give 1 tablet by mouth three times a day for Anxiety. Xanax Oral Tablet 0.25mg, Give 1 tablet by mouth one time a day related to Anxiety. Xanax Oral Tablet 1mg, Give 1 tablet by mouth at bedtime related to Anxiety Disorders. Review of the Progress Note (PN) dated ,d+[DATE] included the following: On [DATE] at 8:57 PM, the Registered Nurse (RN) marked YES for Resident #2 had a behavior that was observed. The RN was not specific in her progress note of the Resident's behavior and what interventions were implemented. However, the RN was unavailable for an interview at the time of the survey. On [DATE] at 5:33 PM, the Medical Doctor's (MD) progress note revealed Resident #2 said he/she was getting anxious about the outcome of his/her follow-up with the eye specialist to see if anything could be done about his/her vision. On [DATE] at 8:49 PM, the Licensed Practical Nurse (LPN) noted increased anger as soon as scheduled medication administration for Resident #2. The Resident was upset because the LPN touched his left arm to get his attention prior to giving the Resident his/her medications. On [DATE] at 2:39 PM, Resident #2 expressed to the Advanced Practice Nurse (APN), I haven't been feeling well; I couldn't sleep all night. According to the PN, Resident #2 went on to report that the Resident will find out if he/she is permanently blind in the next few days. Additionally, Resident #2 reported that he/she had a poor appetite and some nausea. Resident #2 stated, I just don't feel right. I think I need my medications increased. The APN noted the Resident was referring to his pain and psychiatric medications. However, the APN did not further question Resident #2 about his/her mental health or notify the physician regarding the Resident's concerns. On [DATE] at 9:41 PM, the LPN marked YES for Resident #2 that behavior was observed. The progress note was struck out on [DATE] at 3:56 PM, signed by the LPN after Resident #2 was deceased , indicating the documentation was an error. Further review of the PN showed the facility no evidence that the staff addressed Resident #2's aforementioned concerns. A review of the medical records for the Licensed Clinical Social Worker (LCSW) clinical visit notes revealed the following: On [DATE] at 12:40 PM to 1:15 PM, Resident #2 reported that he/she has high Anxiety a deep depression over his/her medical conditions. Resident #2 currently endorses anhedonia (inability to experience pleasure from activities usually found enjoyable), disturbed sleep and appetite, low self-esteem, difficulty concentrating, difficulty making a decision, anxiety, worry, tension, and difficulty relaxing. Under Ongoing symptoms, Symptoms that needed treatment and monitoring, sadness, anger outburst, high anxiety, restlessness, poor sleep, and family conflicts. On [DATE] at 12:37 PM to 1:15 PM, Resident #2 reported the following symptoms, Anxiety over his/her upcoming appointment regarding his/her eyesight. He/she is trying to stay positive. He/she is frustrated over his/her situation and feels the need to increase Xanax medication. She informed t/her to speak to the nurses and Psychiatrist. Resident #2 feels depressed over the situation with his/her spouse and wants to live with a spouse in ALF [Assisted Living Facility]. Review of the Psychiatric Notes from the Psychiatrist revealed the following: On [DATE], Resident #2 reported increased Anxiety and frustration at nighttime. Has been upset related to pain. On [DATE], Resident #2 was described as having a Chief Complaint of Agitation and Anxiety. Initially calm, cooperative, and pleasant, later becomes tearful [and] reports continued Anxiety and frustration at night. Reports frame of panic when laying in bed at night, anxious about eye exam and blindness. On [DATE], Resident #2 reported being tortured by Post Traumatic Stress Disorder (PTSD) symptoms. The Psychiatrist noted, Today patient states that he/she is miserable, and states he/she was hoping to be accepted at Assisted Living Facility (ALF) but was recently denied. The EMR for Resident #2 showed no evidence that the Psychiatrist was notified of the Resident's voiced concern to the LCSW on [DATE] or the APN on [DATE]. During a telephone interview on [DATE] at 11:23 AM, LPN #1 stated Resident #2 slept all night until about 5:00 AM. LPN #1 stated around 6:00 AM, while on the 1st floor, the CNA called the LPN and stated Resident #2 was on the floor. The bathroom door was open when he got to the room, while Resident #2 was flat on the floor. The LPN stated he looked at Resident #2 and asked the Resident if he/she was ok. The LPN then checked Resident #2's code status, saw he/she was a DNR/DNI/DNH, and immediately called the nurse supervisor. When the nursing supervisor came to the floor, we both noticed the bathrobe tie was around the lower part of the Resident's neck, which was tight around the neck. LPN #1 further stated, Initially, it was hard to see due to the resident's neck position. The LPN and the Nursing Supervisor immediately removed the bathrobe tie. The LPN explained the bathrobe tie was hard to remove because it was tight. They checked for a pulse and vital signs since the Resident was still warm when we found him/her. Resident #2 had no pulse and no vital signs. The nursing supervisor called the DON, LNHA, and the police to inform them of what happened. He continued he last saw Resident #2 at 11:00 PM after the report when he went to check on the Resident, and he/she was in bed asleep, which was the Resident's usual routine. The LPN added Resident #2 was legally blind and depressed because he/she couldn't see. During an interview on [DATE] at 1:50 PM, LPN #2 stated if a resident was suicidal, she would call the doctor immediately for safety precautions and to issue physician's orders. She would provide close supervision, and if necessary, the physician would determine if a resident needs to get sent out for evaluation. When asked by the Surveyor if the Resident had behaviors such as being depressed or anxious, she would document it in the Resident's chart under behaviors. On [DATE] at 9:30 AM, LPN #2 stated she would make a behavior note when it was out of the Resident's baseline. She further stated even though she marked YES for the [DATE] PN at 9:30 AM, which indicated Resident #2 as having a behavior that she described as being anxious. She considered it Resident #2's baseline. When asked by the Surveyor if this was considered a change in behavior for Resident #2, LPN #2 replied, It would be a behavior to me. When asked why the behavior note for Resident #2 was struck out on [DATE] at 3:56 PM, after the Resident had passed, LPN #2 stated, I don't remember why I struck out the entry. Whatever I struck out, I struck out on my shift on [DATE] since I didn't work on [DATE]. During an interview on [DATE] at 3:28 PM, the Advanced Practice Nurse (APN) stated she saw the Resident for a medical issue on [DATE] at 1:39 PM. Resident #2 reported, I haven't been feeling well; I couldn't sleep all night; and I don't feel right; I think I need my medications increased. The APN told the Resident that the facility psychiatrist had been following the Resident. Resident #2 stated, I missed her last week because I went outside to smoke. When the Surveyor asked the APN what she would do if a resident with MDD stated they didn't feel right, the APN replied, If someone said they don't feel right, she would ask about symptoms and do a head-to-toe physical assessment. The APN stated the Resident had complaints he/she wasn't feeling well, not sleeping well, and that he/she may be permanently blind, but no complaints of being upset or depressed. The APN indicated she made no further inquiry into the Resident's concerns or what Resident #2 meant when he/she made the statement, I don't feel right; I think I need my medications increased. When asked by the Surveyor why she did not inquire further about Resident #2's concerns or notify the Psychiatrist, she did not respond. During a telephone interview on [DATE] at 2:00 PM, the Psychiatrist stated that if a resident voiced concerns about not feeling right, she would ask the Resident what he/she meant by not feeling right. The Psychiatrist further stated whenever there is a problem, they (the nurses) could call my office. She stated that her office had a schedule about who she saw in a week, when at the facility, and if the number of residents is more than she could see in one day; she would talk to facility staff about who was stable and others who are a higher priority. After she sees residents, she leaves a list with all the Nurse Managers (NM) on the floor, with changes/ recommendations, and she will write notes and her office send them to the facility. She further stated The last time she saw Resident #2 was [DATE]. The Psychiatrist stated, [Resident #2] was supposed to be seen on [DATE] and was on her schedule, but [the Resident] wasn't seen because he/she was off the unit. During an interview on [DATE] at 12:19 PM, the Licensed Clinical Social Worker (LCSW) stated she last saw Resident #2 on [DATE], and he/she wanted Xanax increased for Anxiety about his/her upcoming medical appointment for his/her eyes. She wrote in her notes, Speak with the nurse and psychiatrist about his medications. The Surveyor asked the LCSW if she followed up with the nurse after the session, and the LCSW stated, No, I did not. The LCSW stated Resident #2's biggest frustration was being in the facility because he/she wanted to go home with his/her spouse. The CNA assigned to Resident #2 at the time of the incident was unavailable for an interview at the time of the survey. Review of the facility policy titled Abuse and Neglect - Clinical Protocol revealed the following under Assessment and Recognition, 2. The nurse will report the findings to the physician. As needed, the physician will assess the Resident to verify or clarify such findings, especially if the cause or source of the problem is unclear; under 4. The physician and staff will address causes of problematic Resident behavior where possible, such as mania, psychosis, and medication side effects. N.J.A.C:8:,d+[DATE].2 (b) N.J.A.C:8:,d+[DATE].1(a)(5)

C#: NJ164217 Based on interviews, medical record review, and review of other pertinent facility documents on 5/25/2023, 5/31/2023, and 6/1/23, it was determined that the facility failed to administer medications according to the Physician's Orders and standards of clinical practice for 1 of 4 residents (Resident #2) reviewed for medications. The facility also failed to follow its policies titled Administering Medications and Physician Medication Orders. This deficient practice was evidenced by the following: A review of the Electronic Medical Records (EMRs) was as follows: According to the Face Sheet, Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Major Depressive Disorder (MDD), anxiety disorder, chronic pain syndrome, and legal blindness. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 5/5/23, Resident #2 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicated the resident was cognitively intact. Resident #2 had a mood score of 6, which indicated mild depression. Resident #2 had a pain intensity score of 8, indicating severe chronic pain. The MDS also showed Resident #2 was independent, needed one-person assistance with Activities of Daily Living (ADLs), and had severely impaired vision. A review of the Physician's Orders (PO) dated 5/1/2023 revealed the following: Sertraline Oral Capsule 200 milligrams (mg). Give 1 capsule by mouth one time a day related to Major Depressive Disorder (MDD). Morphine Sulfate Extended Release (ER) tablet 15 mg. Give 1 tablet by mouth every 12 hours related to chronic pain syndrome. A review of the Medical Administration Record (MAR) dated 5/1/23-5/31/23 revealed Resident #2 did not receive his/ her medications as ordered by the Physician as follows: Morphine Sulfate ER 15 mg tablet. Give 1 tablet by mouth every 12 hours on 5/13/23, 5/14/23, and 5/15/23 at 9:00 AM and 5/14/23 and 5/15/23 at 9:00 PM. Sertraline Oral Capsule 200 mg. Give 1 tablet by mouth one time a day on 5/15/23 at 9:00 AM. The spaces on the MAR were coded with 9 - Other/See Progress Notes, which indicated from the 5/15/23 nursing progress notes the medications weren't available in the facility for administration to Resident #2. A review of Resident #2's Progress Notes (PNs) revealed the following: On 5/14/23 at 8:07 AM, Morphine Sulfate ER 15 mg was awaiting delivery. On 5/15/23 at 10:23 PM, Morphine Sulfate ER 15 mg, missed dose waiting on pending delivery confirmation to be delivered. On 5/15/23 at 1:41 PM, Sertraline 200 mg, This writer placed a call to [the Pharmacy] regarding the following missing medications. These medications are back ordered related to insurance coverage. He will be supplied 3 days' supply that is expected to arrive on the next delivery today; then the Pharmacy will send the information to the facility for clearance. During an interview on 6/1/23 at 12:45 PM, the DON stated Resident #2 didn't have his medication, Sertraline Oral Capsule 200 mg, on 5/15/23. Resident #2 was also out of Morphine Sulfate ER 15mg on 5/13/23, 5/14/23, 5/15/23 at 9:00 AM, and 5/14/23, 5/15/23 at 9:00 PM. The surveyor asked the DON when the medication would be refilled after it was depleted. The DON stated, There is no set rule of when to order a medication. No policy states to refill a medication when there are 7 pills left. When the medication gets low, the nurses would typically pull the bingo card (a specific card with each resident's medication). The DON stated her expectation for the nurses would be to pull the bingo card before it is totally empty because medications, when ordered, do not come on the same day. The DON stated, A reasonable expectation would be when they are on the last line of the bingo card. I believe there are 8 pills on the last line of the bingo card. The DON reviewed the MAR in the presence of the surveyors. The DON did not know why Resident #2 did not have Morphine Sulfate ER 15mg available on those days. During an interview on 5/31/23 at 12:50 PM, the Quality Assurance Pharmacist (QAP) gave the surveyors the delivery dates of Resident #2's Morphine Sulfate ER 15 mg and Sertraline Oral Capsule 200mg. The QAP stated that 14 capsules of Sertraline Oral Capsules were delivered on 4/15/23, and that was the most recent delivery. The QAP further stated the facility requested a refill on 5/15/23 via a phone call from the LPN, but it was not dispensed and would not have arrived at 7:41 PM on that date. The QAP stated that for the Morphine Sulfate ER 15 mg tablets, he had a record of 5/15/23, 10 tablets dispensed, 5/9/23, only four tablets left on the prescription, and they were also dispensed. At that time, a new prescription was given for Morphine Sulfate ER 15mg, given 1 tablet every 12 hours, and on 4/12/23, three tablets, 4/14/23, 22 tablets, and 4/25/23, 28 tablets were all dispensed to the facility. During an interview on 6/1/23 at 10:05 AM, LPN #1 didn't know why the resident was out of Morphine Sulfate ER 15 mg on 5/14/23 at 9:00 AM but indicated there was a note awaiting delivery. LPN #1 further stated, The doctor should have been notified when the medication wasn't available. During an interview on 6/1/23 at 1:19 PM, the surveyor asked LPN #2 how the resident received Morphine Sulfate ER 15 mg on 5/13/23 at 9:00 PM, but it wasn't available on 5/13/23, 5/14/23 and 5/15/23 at 9:00 AM and 5/14/23 and 5/15/23 at 9:00 PM. LPN #2 stated he didn't remember, but he most likely substituted with liquid or got it from the backup stock. LPN #2 further stated, If a medication wasn't available, I would notify the doctor to get a prescription and fax it to the Pharmacy. Sometimes it takes a while before it comes because the doctor is so busy. It would note awaiting delivery or waiting for the Physician to give a prescription. A review of the policy titled Administering Medications under Policy Statement, medications shall be administered in a safe and timely manner, and as prescribed; and under Policy Interpretation and Implementation. 3. Medications must be administered in accordance with the orders, including any required time frame. 8. Medications must be administered within one (1) hour of their prescribed time unless otherwise specified (for example, before and after meal orders), and 14. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall click N on the EMAR and then document as prompted on Point Click Care (PCC). A review of the facility policy titled Physician Medication Orders, dated 4/2023, under 4. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include the date and time of the order. 8. Drugs and biologicals that are required to be refilled must be reordered from the issuing Pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. N.J.A.C.: 8.39-27.1 (a)

COMPLAINT #: NJ 2 Based on interviews, review of the Medical Records, and review of other pertinent facility documents on 10/5/2022 and 10/6/2022, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an accident/incident which, resulted in serious bodily injury of a resident. The facility also failed to follow their policy titled Unusual Occurrence Reporting, for 1 of 5 Residents (Resident #2) sampled for accidents/incidents resulting in injury. This deficient practice was evidenced by the following: According to the Medical Record, Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) an assessment tool dated 6/21/2022, Resident #2 had a Brief Interview for Mental Status Score (BIMS) of 15/15, which, indicated the resident was cognitively intact. The MDS also revealed the resident required supervision with Activities of Daily Living (ADLs). A review of Resident #2's Smoking-Safety Screening, dated 4/28/2022, verified that Resident #2 was assessed and found to be safe to smoke cigarettes without supervision. A review of the Care Plan (CP) also verified that Resident #2 was Care Planned to be safe smoking independently. During an interview on 10/5/2022 and 10/6/2022, the Director of Nursing reported, in mid-July at approximately 10:30 p.m., the Nursing Supervisor (NS) called her at home to report an incident. Resident #2 was smoking outside in the designated smoking area and burned himself while smoking. The supervisor called 911 and was sending him out to the hospital. The DON stated, she did not report the incident to the NJDOH. During an interview on 10/5/2022, the Administrator reported that on 7/15/2022, between 11:00 and 11:30 p.m., she was called at home by the NS, who reported that Resident #2 was outside smoking in the smoking area and burned himself with a cigarette. The NS called 911 and she was sending him out to the hospital. The Administrator verified that she did not report the incident to NJDOH because the incident did not meet the criteria. A review of the Accident Incident Investigative Report received from the Administrator on 10/6/2022, revealed the incident occurred to Resident #2 on July 15, at 10:39 p.m. Type of incident: Skin Issue Location: Patio, Activity: Smoking, Witnesses: no. Resident sent to the hospital. Skin Issue type: Burn with redness to multiple areas, serous drainage, and Eschar. A review of the facility policy titled Unusual Occurrence Reporting, revealed the following under Policy Statement: As required by federal or state regulation, Aristacare at Manchester reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. Under Policy Interpretation and Implementation: d. Death of a resident, employee or visitor because of unnatural causes (e.g., suicide, homicide, accidents, etc.) A review of the Reportable Event List provided to the surveyor by the Administrator on 10/6/2022, revealed the following: The facility shall notify the Department of Health immediately by phone, followed by written confirmation within 72 hours for the following: 3. Fires, disaster, or accidents that result in injury or death of patients, residents, or employees . N.J.A.C. 8:39-13.4(c)2(iv)

Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) was removed in accordance with nationally accepted guidelines for infection prevention and control. This deficient practice was identified for 2 of 3 staff members (2 Housekeepers) exiting rooms that were identified as Persons Under Investigation for COVID-19. The evidence was as follows: According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Protecting Healthcare Personnel reviewed 10/13/22 included, resources for the use of Personal Protective Equipment (PPE), specifically the Sequence for Donning and Doffing ,(Removing Personal Protective Equipment). The guidelines included, Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. Further revealed, section for Doffing PPE included, PPE is doffed in the designated PPE removal area in the healthcare facility. As with all PPE doffing, meticulous care should be taken to avoid self-contamination. Place all PPE waste in a leak-proof infectious waste container. A review of Sub-Acute-1st floor PUI [Persons Under Investigation]/COVID-19 list provided by the facility's regional Director of Population Health reflected Resident #2, #4, #6 were on Transmission-Based Precautions (use of PPE including gowns and gloves to prevent the spread of COVID-19). On 10/3/2022 at 10:44 AM, the surveyor interviewed the Housekeeping Director (HKD). He stated, I have been at the facility for five years and I am a contracted employee. The surveyor asked if his employees were contracted staff as well, and he replied, They are all facility staff. The Housekeeping Director stated that there are four total housekeepers, one on each floor and one in the 'T' hall. On 10/3/2022 at 11:14 AM, the surveyor observed two housekeeping staff (HK-1 and HK-2) working together on the Sub-Acute unit on the first floor. The surveyor observed both Housekeepers wearing blue disposable gowns and gloves as they exited room of Resident #2 and Resident #6 in room [ROOM NUMBER]. The surveyor then observed HK-1 doff (remove) her gloves and gown in the hallway and placed the gloves and gown into the housekeeping trash container on the housekeeping cart. The housekeeper HK-1 was training HK-2 and instructed him to remove his PPE while they stood in the hallway. The surveyor watched HK-2 doff his PPE in the hallway and disposed of the gloves and gown in the housekeeping cart trash. Outside of the room was a PPE storage bin hanging over the door, which indicated that the residents were on Transmission Based Precautions. On 10/3/2022 at 11:49 AM, the surveyor observed the same two housekeepers exit room [ROOM NUMBER], which housed Resident #4. Both were wearing PPE, blue disposable gown, and gloves in the hallway. They both doffed their gloves and gowns in the hallway and placed the gloves and gown into the housekeeping trash bin on the housekeeping cart. Outside the room was a PPE storage bin hanging over the door, indicating that the resident in the room was on Transmission Based Precautions. On 10/3/2022 at 11:55 AM, the surveyor interviewed HK-1. The HK-1 stated, I have to use PPE in the rooms that have yellow PPE bins on the door or a cohort sign. The survey then asked about doffing PPE in the hallway. The HK-1 replied that yes she would doff [the PPE] in the hallway and place my PPE in the trash of the housekeeping cart and then I wash my hands with sanitizer. The surveyor then asked why she chose to doff in the hallway instead of inside the resident's room and discarding the PPE in a waste receptacle inside the room? She replied, I didn't know I had too. The HK-1 stated that she had been in-serviced in the past on COVID-19 protocols. On 10/3/2022 at 11:59 AM, the surveyor interviewed HK-2. He stated, I just started a few weeks ago, I am new to the facility, and I am employed by the housekeeping agency. The surveyor asked him if he was in-serviced on the expectations during a COVID-19 outbreak? He responded, Yes, I was given a packet by my agency. On 10/3/2022 at 12:05 PM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM). When asked about the yellow PPE storage bin hanging on the door? She stated, They are yellow isolation door kits, which hold the PPE prior to entering any isolation room. When the surveyor asked what was the expectation for doffing PPE? She stated that PPE was removed inside the resident's room prior to exiting and disposed of in the trash can provided in the room. Then the staff should wash their hands and clean their goggles. On 10/3/2022 at 2:00 PM, the survey team met with the Administrator, Director of Nursing, the Infection Preventionist, and the facility's regional Director of Population Health (DPH) to discuss the surveyor's findings. On 10/4/2022 at 9:59 AM, the HKD stated, The housekeepers were re-educated regarding doffing of PPE. The DON, DPH, and the HKD acknowledged that the housekeepers did not discard their PPE (blue disposable gown and gloves) in accordance with infection prevention and control standards. On 10/4/2022 at 12:22 PM, the surveyor interviewed the LPN/UM regarding Residents #2, #4, and #6. The LPN/UM stated that Residents #2 and #6 were roommates and are on a Cohort 3. She stated that the residents received their initial two dose series of vaccines but did not have a booster vaccine. The LPN/UM confirmed that both residents had tested negative for COVID-19 and both are vaccinated times 2 doses without boosters. Resident # 4 was alone in their room on cohort 2, they are negative for COVID-19 and tested 4 times weekly due to going to the [CONDITION(S)] center several times a week and has been vaccinated with two doses but has not received the booster the LPN/UM added, Per my facility outbreak plan they are placed on PUI starting with day of admission as day 0, and isolation continues for 7 days for a total of 8 days. A review of the Electronic Medical Records (eMR) for Resident #2, who resided in room [ROOM NUMBER], reflected an admitted [DATE]. The progress note (PN) dated 9/29/2022 revealed, COVID-19 testing results were negative, asymptomatic. Per facility COVID-19 Outbreak Plan, revised 9/21/2022, on admission this resident was placed in Cohort 3 on PUI. A review of the resident's vaccination record revealed the resident was vaccinated with a two dose vaccine series and was eligible for a booster, but had not yet received it. A review of the eMR for Resident #6, who resided in room [ROOM NUMBER], eMR, reflected an admitted [DATE]. The PN dated 9/29/2022, revealed COVID-19 testing results were negative, asymptomatic. According to the COVID-19 Outbreak Plan, revised 9/21/2022, on admission this resident was placed in Cohort 3 on PUI because he/she was negative, and his/her immunization status was vaccinated with a two dose vaccine series and was eligible for a booster, but had not yet received it. A review of the eMR for Resident #4, who resided in room [ROOM NUMBER], revealed an admitted [DATE]. The PN dated 9/26/2022 revealed, COVID-19 results were negative, and patient was asymptomatic. Further review of PN dated 9/28/2022 resident was still COVID-19 negative and asymptomatic. According to the the facility's cohorting grid that was provided by the administration on entrance on 10/3/22, Resident #4 was placed originally on cohort 3 due to their vaccine status but his/her roommate tested positive and he was downgraded to cohort 2. The resident was negative for COVID-19. A review of the facility's revised 05/2020 COVID-19 Isolation Room Cleaning Housekeeping In-service, provided by HKD, in section after finishing room it read, Remove PPE, place in isolation bag, dispose in appropriate receptacle. A review of the COVID-19 Outbreak Plan, revised 9/21/2022, provided by the DON, defines cohort sections as follows: *Cohort 1 (red zone): positive for infectious disease outbreak. Consistent of both symptomatic and asymptomatic residents who test positive for COVID-19, regardless of vaccination status. *Cohort 2 (orange zone): symptomatic with suspected [CONDITION(S)] CoV-2 infection. Consistent of all symptomatic residents and test negative but could be incubating to test positive later. *Cohort 3 (yellow zone): asymptomatic residents who are not up to date with all the recommended COVID-19 vaccine doses, have a [CONDITION(S)] test that is negative and have had close contact with someone with [CONDITION(S)]-CoV-2 *Cohort 4 (green zone): asymptomatic residents who are up to date with all recommended COVID-19 vaccine doses and have had a [CONDITION(S)] test that is negative. A review of the COVID-19 Outbreak Plan, revised 9/21/2022, provided by the DON, included donning and doffing sequence for putting on and removal of PPE from Center Disease Control, (CDC). NJAC 8:39-5.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that planned interventions to prevent injury were followed. As a result, a resident sustained [REDACTED]. This deficient practice was identified for Resident #20, 1 of 3 residents reviewed for fractures and was evidenced by the following: During the initial tour on 11/26/12 at 10 a.m., the Unit Manager said that Resident #20 had End Stage Multiple Sclerosis (a debilitating auto-immune disease that affects the brain and spinal cord), had limited range of motion of both arms and legs, and received Hospice services from an outside agency. On 11/28/12 at 11 a.m., the surveyor observed the resident propel a motorized wheelchair with the right hand, using a joystick located on the right armrest. The resident's left arm was supported by a sling which was visible underneath the resident's shirt. The Resident Assessment Instrument (RAI), dated 11/2/12, identified that Resident #20 was alert and oriented, had multiple diagnoses, including Multiple Sclerosis (MS) with quadriplegia (a partial or total loss of use of all limbs and torso) and was dependent on staff for care. The care plan, initiated 7/31/12, identified that the resident was at risk for falls and/or injury related to the MS. Care plan interventions included assisting the resident in and out of bed with 2 person assistance using a mechanical (Hoyer) lift. According to a Team Note dated 11/6/12 at 11:30 a.m., the resident was being transferred from the bed to a motorized wheelchair by 2 Certified Nursing Assistants (CNAs), one of which was employed by the Hospice agency. The nurse documented that the resident refused to be lifted via the mechanical lift. The note indicated that, as the CNAs were transferring the resident, they turned the wrong way, causing the wheelchair control (or joystick) to be hit. The motorized wheelchair moved forward, pinning the Hospice CNA against the bed. The remaining CNA pulled the resident over the wheelchair armrest and into the wheelchair to complete the transfer. The nurse documented that the resident was crying and subsequently returned to bed where, upon assessment, swelling was observed at the top of the left shoulder. The nurse notified the physician and obtained an order for [REDACTED]. A review of the Xray results confirmed that the resident had sustained a fracture of the left humeral neck (the large bone located between the elbow and shoulder). A Change In Condition Review & Communication Form identified that on 11/7/12 at 7:40 a.m., the resident was transferred to the emergency room for further evaluation. The corresponding facility investigation corroborated the events contained in the Team Note dated 11/6/12 and contained additional documentation by the involved CNAs regarding the occurrence. In an Individual Statement Form dated 11/6/12, the Hospice CNA wrote that the other CNA involved in the transfer on 11/6/12 that resulted in the resident sustaining a fracture, was also employed by an outside agency. The Hospice CNA documented that upon the resident's refusal to use the lift, both CNAs had used a "2 man lift assist, arm and leg" method of transfer. The Hospice CNA wrote that while the transfer was in progress, the agency CNA started turning the wrong way, resulting in the resident's leg hitting the motorized wheelchair which had been left turned on. The wheelchair propelled itself, running over the legs of the Hospice CNA and hitting the Hospice CNA in the stomach. The agency CNA then "pulled" the resident into the wheelchair "hurting her arm." In another Individual Statement Form, dated 11/6/12, the agency CNA documented that when the motorized wheelchair propelled itself into the Hospice CNA, the resident voiced hearing and feeling the shoulder "pop" and added "When I care for (the resident) I always use (the) Hoyer lift." In a meeting with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) on 11/28/12 at 2:20 p.m., the DON said that when the resident had refused to use the mechanical lift on 11/6/12, the agency CNAs should have notified the nurse of the refusal and not proceed with the manual transfer unless authorized by the nurse. The LNHA added that, if the involved agency CNAs had used the mechanical lift as specified in the care plan, the resident's fracture "probably would not have happened." In an interview on 11/29/12 at 10 a.m., the Unit Manager said that resident specific care instructions were communicated to all Hospice CNAs and agency CNAs both verbally and in written form, and that all CNAs were encouraged to talk to the nurse on duty if they had questions. Upon review, both the Hospice Aide Care Plan and CNA daily assignment sheet identified that the resident was to be transferred using a mechanical lift. In a follow up interview on 11/29/12 at 10:45 a.m., the Unit Manager said that Resident #20 had refused to use the mechanical lift on previous occasions and that these refusals had been reported to the nurse. The nurse then educated the resident on the need for safety during transfers, after which the resident complied. The Unit Manager went on to say that CNA staff should always notify the nurse when the resident refuses to use a mechanical lift to transfer. This would give the nurse the opportunity to intervene and/or revise the plan of care so that staff could transfer the resident safely. N.J.A.C. 8:39-27.1(a) N.J.A.C. 8:39-11.2(b)

Based on observation, interview and record review, it was determined that the facility failed to follow an established plan of care to prevent injury. As a result, a resident sustained [REDACTED]. This deficient practice was identified in Resident #20, 1 of 3 residents reviewed for fracture and was evidenced by the following: On 11/28/12 at 11 a.m., the surveyor observed Resident #20 sitting in a motorized wheelchair. The resident's left arm was supported by a sling visible underneath of the resident's shirt. A review of the medical record identified that on 11/6/12, the resident had sustained a fractured left humerus (the large bone located between the elbow and shoulder.) The surveyor reviewed the care plan that was initated on 7/31/12 and noted the following: Two staff members were to assist the resident in getting out of bed using a mechanical lift. Upon review of a Team note dated 11/6/12, Resident Incident And Accident Report dated 11/6/12, and the corresponding facility investigation, this had not been done. According to the documentation, Resident #20 had refused to be transferred out of bed using the mechanical lift on 11/6/12. The 2 caregivers in attendance, a Hospice Certified Nursing Assistant (CNA) and a CNA from an outside agency, attempted to manually transfer the resident into the motorized wheelchair without prior authorization by the nurse and without first confirming that the motorized wheelchair was in the "off" position. During the unauthorized manual transfer, the functional motorized wheelchair was impacted, causing it to propel itself, strike a CNA, and halt the transfer. The remaining CNA attempted to complete the manual transfer alone, by lifting the resident over the wheelchair's armrest. At that time, the resident voiced hearing a "pop" and feeling pain in the left arm. An Xray report dated 11/6/12 identified that the resident had sustained a fractured left humerus. In an interview on 11/28/12 at 220 p.m., the Director of Nursing said that when the resident had refused to use the mechanical lift on 11/6/12, the CNAs should have notified the nurse on duty and not proceed with a manual transfer. In addition, on 11/29/12 at 10 a.m., the Unit Manager said that resident-specific care instructions were communicated to all Hospice CNAs and agency CNAs both verbally and in written form. Upon review, both the Hospice Aide Care Plan and CNA daily assignment sheet identified that Resident #20 was to be transferred using a mechanical lift. (Refer to F-323) N.J.A.C. 8:39-11.2(b)