Every finding on record at Atlas Post Acute at Woodbury Country Club

Complaint 2616856Based on interview, record review, and policy review on 9/26/2025 and 9/29/2025, it was determined that the facility failed a. to ensure medications were administered to a resident according to standards of practice and b. to follow their own policy for medication administration. This deficient practice resulted in Resident #1 receiving a scheduled pain medication late, with the potential for unrelieved pain and discomfort.This deficient practice was identified for 1 of 8 sampled residents (Resident #1) and was evidenced by the following:According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: fracture of the nasal bones. A Review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 08/19/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident had a moderately impaired cognition.A Review of Resident #1's Care Plan (CP) revealed a focus of I have ( acute) pain r/t [related to] recent nasal bone fx's [fractures] and Arthritis initiated 08/14/2025 and an intervention of Administer analgesia as per orders.On 9/26/2025 a review of the Physicians Orders revealed Resident #1 had an order for Oxycodone 10 milligram (mg) give 1 tablet by mouth every 8 hours for severe pain, scheduled for 6:00 A.M., 2:00 P.M. and 10:00 P.M. beginning on 8/27/2025 and discontinued on 9/10/2025. A Review of the Medication Admin Audit Report (MAAR) for 9/08/2025 revealed the 2:00 P.M. dose was administered at 3:53 P.M. That is 1 hour and 53 minutes after the scheduled time. In an interview on 9/26/2025 at 12:45 P.M., with the Assistant Director of Nursing (ADON), the surveyor showed the MAAR for 9/8/2025 and the ADON said the medication was given late, the policy was not followed, and the physician should have been notified to clarify next steps for the medication. In an interview on 9/29/2025 at 11:32 P.M., with the Licensed Practical Nurse (LPN) the surveyor showed the MAAR for 9/8/2025 and the LPN explained the documentation showed the medication was given late. A review of the facility's policy titled Administering Medications with a revision date of April 2019 revealed under Policy Interpretation and Implementation that 4. Medications are administered in accordance with prescriber orders. and 7. Medications are administered within one (1) hour of their prescribed time.NJAC 8:39-11.2 (b), 29.2 (d)

Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/16/25 from 9:37 AM to 10:33AM, the surveyor observed the following in the presence of the Food Service Director (FSD #1): The Dry Storage Room 1. Plastic portion cup lids spilling out of the plastic bag, not covered. The FSD #1 stated that the lids should be covered and in the plastic bag. 2. A box of white plastic fork utensils spilling out of the plastic bag, not covered. FSD #1 stated that that the plastic forks should be covered and stored in the plastic bag. Reach in Refrigerator 1. A half empty blue sports drink bottle not dated or labeled. FSD #1 stated that the bottle could have belonged to a staff member or a resident and should not have been in the refrigerator. FSD #1 discarded the blue sports drink bottle. The kitchen floor by the stove and food prep area had black debris. The bottom shelf of the food prep area had debris and sticky substances. FSD #1 stated that the floors were cleaned every shift by the staff. On 4/22/25 at 10:49 AM, the surveyor observed the lunch meal tray line and observed the following: 1. Dietary Aide's (DA #1) hair not fully covered under the hair net with had a long strand of black hair outside the hair net. 2. DA #2's hair not fully covered under the hair net. On 4/22/25 at 11:25 AM, the surveyor interviewed FSD #2 who stated that hair nets should include all the hair on the head and should not have any hair out of the hair net. On 4/23/25 at 1:33 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON, the Assistant LNHA, Regional Director of Clinical Services (RDCS) and the survey team, the surveyor reviewed the above kitchen concerns. A review of the Sanitation policy, revised November 2022, included that all kitchens, kitchen area and dining area are kept clean, free form garbage and debris. A review of the Preventing Foodborne illness- Employees Hygiene and Sanitary policy, revised November 2022, included hair nets or caps and /or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. A review of the facility's Food Receiving and Storage policy, revised November 2022 included under 'Dry Food Storage' 1.)Non-refrigerated foods, disposable dishware and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 3.) Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to appropriately administer pain medications in accordance with physician orders. This deficient practice was identified for one (1) of five (5) residents (Resident #20) reviewed for unnecessary medications and was evidenced by the following: On 4/23/25 at 10:12 AM, the surveyor observed Resident #20 in bed with their eyes closed. On 4/23/25 at 10:19 AM, the surveyor reviewed the medical records for Resident #20. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, generalized anxiety disorder. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/17/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 6/12/2024, that the resident had chronic pain related to neuropathy (a nerve problem that can cause pain, numbness, tingling, swelling, or muscle weakness in various parts of the body). Interventions included: monitoring/documenting the probable cause of each pain episode and monitoring/recording pain characteristics on a pain scale of 1 to 10. A review of the Order Summary Report (OSR), dated as of 4/23/2025, included the following physician orders (PO): A PO, dated 11/17/2023, for oxycodone hydrochloride (hcl) 15 milligrams (MG) by mouth, every four (4) hours as needed for moderate/severe pain. A PO, dated 11/17/2023, for acetaminophen 650 mg by mouth every six (6) hours as needed for mild pain. A review of the February 2025 Medication Administration Record (MAR), revealed Resident #20 was administered Oxycodone hcl 15 mg on the following dates when the pain rating was not in accordance with the PO: On 2/3/25 at 12:24 AM, the pain level was documented as a three (3). On 2/5/25 at 12:59 PM, the pain level was documented as a 3. On 2/ 8/25 at 12:30 AM, the pain level was documented as a zero (0). On 2/8/25 at 8:22 AM, the pain level was documented as a 0. On 2/8/25 at 12:28 PM, the pain level was documented as a 0. On 2/12/25 at 12:19 AM, the pain level was documented as a 0. On 2/12/25 at 1:40 PM, the pain level was documented as a 3. On 2/13/25 at 12:55 PM, the pain level was documented as a 3. On 2/16/25 at 12:36 PM, the pain level was documented as a 3. On 2/17/25 at 12:52 PM, the pain level was documented as a 3. On 2/18/25 at 1:16 PM, the pain level was documented as a 3. On 2/22/25 at 8:26 AM, the pain level was documented as a 0. On 2/23/25 at 1:14 PM, the pain level was documented as a 3. A review of the March 2025 Medication Administration Record (MAR), revealed Resident #20 was administered Oxycodone hcl 15 milligrams on the following dates when the pain level was not in accordance with the PO: On 3/8/25 at 8:06 AM, the pain level was documented as a 0. On 3/9/25 at 8:32 AM, - the pain level was documented as a 0. On 3/19/25 at 10:06 AM, the pain level was documented as a 0. A review of the April 2025 Medication Administration Record (MAR), revealed Resident #20 was administered Oxycodone hcl 15 milligrams on the following dates when the pain level was not in accordance with the PO: On 4/4/25 at 11:15 PM, the pain level was documented as a 0. On 4/5/25 at 9:35 AM, the pain level was documented as a 0. On 4/5/25 at 2:53 PM, the pain level was documented as a 0. On 4/5/25 at 11:02 PM, the pain level was documented as a 0. On 4/6/25 at 3:05 AM, the pain level was documented as a 0. On 4/6/25 at 9:53 AM, the pain level was documented as a 0. On 4/6/25 at 2:50 PM, the pain level was documented as a 0. On 4/14/25 at 8:37 AM, the pain level was documented as a 0. On 4/16/25 at 11:32 PM, the pain level was documented as a 0. On 4/19/25 at 7:32 AM, the pain level was documented as a 0. On 4/19/25 at 11:37 AM, the pain level was documented as a 0. On 4/23/25 at 10:19 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #8, who stated that before administering as needed (PRN) pain medication, she would ask the resident their pain level, using the pain scale 0 to 10, 10 being the worst pain and then she would document it on the MAR. When asked what she would do if the resident stated that their pain level was a zero, she replied, I would still administer it to them since they are asking for it. LPN #8 further stated that the resident could say that she was withholding their medications, so she administered it to them as long as they could get it at the time they ask. LPN #8 stated that she followed the PO when administering medications and would follow any parameters included in the order. At that time, the surveyor showed LPN #8 the MAR for Resident #20, indicating the resident received oxycodone that morning. She confirmed that the resident stated they were not in pain that morning before administering the oxycodone. She further stated that she probably should not have given the medication this morning (4/23/2025), and she should have called the doctor. On 4/23/25 at 10:36 AM, the surveyor interviewed the Acting Licensed Practical Nurse/Unit Manager Nurse (LPN/UM) who stated, the pain scaled 1 to 3 was considered mild pain, 4 to 6 was moderate pain, and anything above 6 was severe pain. He further stated the PO should be followed, and if the resident did not have pain and was requesting pain medication, the doctor should be notified. On 4/23/25 at 11:57 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the PO should be followed according to any parameters. She further stated that when a resident asks for pain medication and was not in pain, he/she should be educated on the reason for the pain medication and the doctor should be notified. A review of the facility's undated Administering Medications policy revealed, 4. Medications are administered in accordance with the prescriber orders, including any required time frames. NJAC 8:39-27.1(a)

Complaint NJ #171463 Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to a.) administer medications in accordance to the physician's orders for Resident #177), b.) ensure that the declining controlled substance count was signed for two (2) residents (Resident #20 and #58) on one (1) of three (3) medication carts (cart #3) checked during the medication storage task, and c.) ensure that the narcotic shift to shift was not presigned on one (1) of three (3) medication carts checked during the Medication storage task. This deficient practice was evidenced by the following: 1.) On 4/23/25 at 2:00 PM, the surveyor reviewed the medical record for Resident #177. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, hypertension (high blood pressure), and tachycardia (fast heart rate). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/30/2024, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 1/24/2024, that the resident had hypertension. Interventions included: give anti-hypertensive medications as ordered. A review of the Order Summary Report (OSR), included a physician's order (PO), dated 1/23/2024, for carvedilol (used to treat various heart conditions, including high blood pressure and heart failure) tablet 6.25 milligrams (MG) two (2) times per day (9:00 AM and 5:00 PM) A review of January and February 2024 Medication Administration Audit Report (MAAR - a report that shows the time that the medication was documented as being administered) revealed that the 9:00 AM dose of carvedilol 6.25 MG was administered outside of the prescribed time on the following dates and times: On 1/24/24 at 10:33 AM On 1/26/24 at 11:43 AM On 1/28/24 at 12:20 PM On 1/31/24 at 11:01 AM On 2/1/24 at 10:13 AM On 2/3/24 at 11:09 AM On 2/4/24 at 1:26 PM On 2/8/24 at 2:48 PM On 2/12/24 at 10:40 AM A review of the OSR, included a PO, dated 1/23/2024, for carvedilol tablet 3.125 mg 2 times per day (9:00 AM and 5:00 PM), start date 2/20/2024. A review of the February, March and April 2024 MAAR revealed that the 9:00 AM dose of carvedilol 3.12 MG was administered outside of the prescribed time on the following dates and times: On 2/21/24 at 11:28 AM On 2/27/24 at 12:13 PM On 3/4/24 at 10:21 AM On 3/24/24 at 2:23 PM On 3/29/24 at 10:25 AM On 3/30/24 at 10:40 AM On 4/7/24 at 11:56 PM On 4/8/24 at 12:02 PM On 4/17/24 at 10:46 AM On 4/22/25 at 1:52 PM, the surveyor interviewed the Director of Nursing (DON), who stated medications should be administered as per the PO. She further stated that the medication could be administered one (1) hour before or one (1) hour after the scheduled time, and any time outside of that would require a PO to be administered at that time. At that time, the surveyor reviewed the MAAR with the DON, who confirmed that the carvedilol was not administered in accordance with the PO. A review of the facility's undated Administering Medications policy included, Medications are administered in accordance with the prescriber orders, including any required time frame. 2.) On 4/22/25 at 9:16 AM, a medication storage inspection was conducted in the presence of LPN #10, the following was observed on the 200 Unit cart #3: Upon reviewing the narcotic binder located on the medication cart, the surveyor observed that the Controlled Substance Count Shift Change Signature Log was presigned for the 4/22/2025, 3:00 PM outgoing slot. At that time, the surveyor interviewed LPN #10, who stated that this morning (4/22/25) she made a mistake and presigned the outgoing slot. She further stated that it should be signed when the narcotic count was being done together with the incoming 3 PM to 11 PM nurse. 3.) Further review of the narcotic book revealed that the Declining Controlled Substance Count log for Resident #58 indicated that there were eight (8) bottles of methadone 120 milligrams (mg). The surveyor observed there were only seven (7) bottles in the cart. At that time, the surveyor interviewed LPN #10, who stated that she gave Resident #58 one (1) bottle at 9:00 AM, but did not sign it out. She further stated that the declining inventory sheet should be signed immediately after the medication was administered. Further review of the narcotic book revealed that the Individual Patient Controlled Substance Administration Record for Resident #20 indicated that there were 28 tablets of xanax, 1 mg tablet left in the bingo card (small pockets that store medication). The surveyor observed there were only 27 tablets in the cart. At that time, the surveyor interviewed LPN #10, who stated that she did not sign it out when she administered it to Resident #20 today (4/22/2025) by mistake. On 4/22/25 at 2:36 PM, the surveyor interviewed the Acting Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that the narcotic count should be done together with the incoming and outgoing nurses. He further stated that, once the narcotic was out of the package, it was signed out on the declining sheet log. On 4/22/25 at 3:29 PM, the surveyor interviewed the DON, who stated the outgoing and incoming nurses count the narcotics together and then the shift to shift log should be signed at that time. She further stated that the narcotics should be signed off on the resident's declining inventory log at the time the medication was administered. A review of the facility's undated Controlled Substances policy revealed, The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. NJAC 8:39-27.1(a) NJAC 8:39-29.7(c)

Complaint: #NJ184884 #NJ 170485 Based on interview, record review, and review of facility documents, it was determined that the facility failed to: a.) maintain an accurate accountability for the management and administration of a Milrinone (a medication primarily used to treat life-threatening heart failure) intravenous infusion b.) ensure skin assessments were completed accurately upon admission, per physician's order, and according to the facility policy when a new skin condition was identified. This deficient practice was identified for 1 of 3 residents (Resident #179) reviewed for a change in condition and for 1of 5 residents (Resident # 178) reviewed for pressure ulcers and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/16/25 at 1:14 PM, the surveyor reviewed the electronic health record (EHR) for Resident #179. A review of the Admission Record , an admission summary, revealed the resident had diagnoses which included, but were not limited to, heart failure, unspecified, unspecified atrial fibrillation (an irregular heart rate), and essential (primary) hypertension (persistently high blood pressure with no identifiable cause). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/31/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received intravenous (IV) medications and had an IV access (unspecified). A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 1/27/25, that the resident had an altered cardiovascular status related to (r/t) congestive heart failure (CHF), hypertension (HTN), and hypokalemia (a decreased potassium level). Interventions included: Milrinone pump (a device used to administer an intravenous medication at a set rate and volume in accordance with physician's orders), Notify MD of significant abnormalities . A review of the Order Summary Report (OSR), dated as of 1/24/25, included the following physician orders (PO): A PO, dated 1/24/25, for Milrinone Lactate Solution use 45.75 micrograms (mcg)/hour (hr) intravenously every 24 hours for monitoring for 30 days. A PO, dated 1/27/25, for Milrinone Lactate Solution use 45.75 mcg/hr intravenously every shift for monitoring. A PO, dated 1/27/25, Milrinone Reservoir: amount in reservoir (a place where something is kept and stored) every 4 (four) hours for Milrinone infusion. A PO, dated 1/27/25, Milrinone Pump Battery: Change every day shift for protocol. A review of the Progress Notes (PN) included a Nurse's Note (NN), dated 2/8/25 at 11:50 PM, that was written by the Registered Nurse Unit Manager (RN/UM) #1 included: Resident observed with Peripherally Inserted Central Catheter (PICC - a long flexible catheter that is inserted into a large vein in the arm and threaded upwards toward the heart, stopping in the superior vena cava (a major vein near the heart, used for long-term medication administration) line dislodged from right upper arm. The PICC line was inspected, 42 centimeters (cm) no signs of breaks or tears. 24 gauge (G) [sic.] peripheral IV placed in right forearm and Milrinone infusion resumed. Resident has no distress. A review of a PN dated 2/9/25 at 9:09 AM, that was written by RN/UM #1 included: Family made aware of PICC line dislodgement and scheduled replacement. A review of a PN dated 2/9/25 at 9:30 AM, that was written by RN/UM #1 included: On call medical doctor (MD) was made aware. A review of a PN dated 2/9/25 at 3:29 PM, that was written by RN/UM #1 included: Tech arrived but stated PICC placement at bedside was contraindicated A call was placed .to schedule PICC placement for Monday, 2/10/25 but the department was closed and will not open until 2/10/25 at 8:00 AM. Milrinone currently infusing without any complications. A review of a PN dated 2/9/25 at 7:20 PM, that was written by RN/UM #1 included: Peripheral IV found to be infiltrated (the leakage of IV fluid or medication from a peripheral IV catheter into the surrounding tissues instead of the vein). Line removed and attempt to reinsert peripheral IV (PIV) unsuccessful. Order placed for PIV insertion, estimated time of arrival (ETA) 10:30 PM. A review of a PN dated 2/10/25 at 12:10 AM, that was written by Registered Nurse (RN) #1 included: awaiting transport to ER to place Mid line (a type of IV access) or PICC. A review of a PN dated 2/10/25 at 1:19 AM, that was written by RN #1 included: the resident was transported by emergency medical services (EMS) to the hospital at 12:45 AM for IV access placement. A review of a PN dated 2/10/25 at 6:33 AM, that was written by RN #1 included: was D/D's (not defined) to hospital with a diagnosis (dx) of PICC line not patent. On call M.D. notified. A review of a PN dated 2/10/25 at 9:20 AM, that was written by Licensed Practical Nurse (LPN) #3 included: This nurse received call from the hospital that the resident was being sent to another hospital ER to have his/her PICC line placement . A review of the January 2025 Medication Administration Record (MAR) revealed the following: Milrinone Reservoir: amount in reservoir every 4 (four) hours for Milrinone infusion: -On 1/27/25 at both 10:00 AM and 2:00 PM, LPN #3 documented NA in the space provided for the volume of Milrinone that remained in the reservoir. -On 1/27/25 at 6:00 PM, a volume of 200 milliliters (ml) was documented. -On 1/27/25 at 10:00 PM, a volume of 470 ml was documented. -On 1/28/25 at 2:00 AM, a volume of 464 ml was documented. -On 1/28/25 at 6:00 AM, a volume of 464 ml was documented. -On 1/28/25 at both 10:00 AM and 2:00 PM, LPN #3 documented NA in the space provided for the volume of Milrinone that remained in the reservoir. -On 1/28/25 at 6:00 PM, 150 ml was documented. -On 1/28/25 at 10:00 PM, 40 ml was documented. -On 1/29/25 at 2:00 AM, 434.8 ml was documented. -On 1/29/25 at 6:00 AM, 404.3 ml was documented. -On 1/29/25 at 10:00 AM, 19 hours (hr) was documented, instead of the volume of Milrinone that remained in the reservoir. -On 1/29/25 at 2:00 PM, 16 hr was documented, instead of the volume of Milrinone that remained in the reservoir. -On 1/29/25 at 6:00 PM, 14 hr was documented, instead of the volume of Milrinone that remained in the reservoir. -On 1/29/25 at 10:00 PM, 10 hr was documented, instead of the volume of Milrinone that remained in the reservoir. -On 1/30/25, at 2:00 AM, 116.2 ml was documented. -On 1/30/25 at 6:00 AM, 0 ml was documented. -On 1/30/25 at 10:00 AM, 27H3 was documented, instead of the volume of Milrinone that remained in the reservoir. -On 1/30/25 at 2:00 PM, NA was documented in the space provided for the volume of Milrinone that remained in the reservoir. -On 1/30/25 at 6:00 PM, 289.4 ml was documented. -On 1/30/25 at 10:00 PM, 289.4 ml was documented. A review of an eMAR (electronic Medication Administration Record) dated 1/30/25 at 6:38 AM, revealed, Supervisor will change Bag. There was no further documentation that indicated when the bag of Milrinone was changed. -On 1/31/25 at 2:00 AM, 96 ml was documented. -On 1/31/25 at 6:00 AM, 78 ml was documented. -On 1/31/25 at 10:00 AM, 78.6 ml was documented. -On 1/31/25 at 2:00 PM, 45.74 ml was documented. -On 1/31/25 at 6:00 PM, 38 ml was documented. -On 1/31/25 at 10:00 PM, 20 ml was documented. A review of the February 2025 Medication Administration Record (MAR) revealed the following: Milrinone Reservoir: amount in reservoir every 4 (four) hours for Milrinone infusion: -On 2/1/25 at 2:00 AM, 246 ml was documented. -On 2/1/25 at 6:00 AM, 155 ml was documented. -On 2/1/25 at 10:00 AM, 6 hours (H) 20 minutes (M) was documented. -On 2/1/25 at 2:00 PM, 6 H 20 M was documented. -On 2/1/25 at 6:00 PM, 30 H was documented. -On 2/1/25 at 10:00 PM, 420.2 ml was documented. -On 2/2/25 at 2:00 AM, 380 ml was documented. -On 2/2/25 at 6:00 AM, 302 ml was documented. -On 2/2/25 at 10:00 AM, 256 ml was documented. -On 2/2/25 at 2:00 PM, 300 ml was documented. -On 2/2/25 at 6:00 PM, 5 hr 50 M was documented. -On 2/2/25 at 10:00 PM, 2 H 30 M was documented. -On 2/3/25 at 2:00 AM, 2 H 30 M was documented. -On 2/3/25 at 6:00 AM, 24 H was documented. -On 2/3/25 at 10:00 AM, 24 H was documented. -On 2/3/25 at 2:00 PM, 24 H was documented. -On 2/3/25 at 6:00 PM, 20 H was documented. -On 2/3/25 at 10:00 PM, 9 H was documented. -On 2/4/25 at 2:00 AM, 2 H was documented. -On 2/4/25 at 6:00 AM, 30 H was documented. -On 2/4//25 at 10:00 AM, 30 H was documented. -On 2/4/25 at 2:00 PM, 30 H was documented. -On 2/4/25 at 6:00 PM, 329.8 ml was documented. -On 2/4/25 at at 10:00 PM, 329 ml was documented. -On 2/5/25 at 2:00 AM, 200 ml was documented. -On 2/5/25/25 at 6:00 AM, 200 ml was documented. -On 2/5/25 at 10:00 AM, 200 ml was documented. -On 2/5/25 at 2:00 PM, 500 ml was documented. -On 2/5/25 at 6:00 PM, 420 ml was documented. -On 2/5/25 at 10:00 PM, 400 ml was documented. -On 2/6/25 at 2:00 AM, 350 ml was documented. -On 2/6/25 at 6:00 AM, 300 ml was documented. -On 2/6/25 at 10:00 AM, 300 ml was documented. -On 2/6/25 at 2:00 PM, 300 ml was documented. -On 2/6/25 at 6:00 PM, 150 ml was documented. -On 2/6/25 at 10:00 PM, 500 ml was documented. -On 2/7/25 at 2:00 AM, 338.6 ml was documented. -On 2/7/25 at 6:00 AM, 338.6 ml was documented. -On 2/7/25 at 10:00 AM, 500 ml was documented. -On 2/7/25 at 2:00 PM, 500 ml was documented. -On 2/7/25 at 6:00 PM, 300 ml was documented. -On 2/7/25 at 10:00 PM 50 ml was documented. -On 2/8/25/25 at 2:00 AM, 36.6 ml was documented. -On 2/8/25 at 6:00 AM, 483.5 ml was documented. -On 2/8/25 at 10:00 AM, 483.5 ml was documented. -On 2/8/25 at 2:00 PM, 483.5 ml was documented. -On 2/8/25 at 6:00 PM,283.3 ml was documented. -On 2/8/25 at 10:00 PM, 283.3 ml was documented. On 2/9/25 at 2:00 AM, 480 ml was documented. On 2/9/25 at 6:00 AM, 283.3 ml was documented. On 2/9/25 at 10:00 AM, 283.3 ml was documented. On 2/9/25 at 2:00 PM 18 H was documented. On 2/9/25 at 6:00 PM, 201.4 ml was documented. On 2/9/25 at 10:00 PM, 201.4 ml was documented. On 2/10/25 at 02:00 AM, hospital (H) was documented. On 4/22/25 at 11:33 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) #2 who stated that nursing should document that Milrinone was infusing at the right dosage and rate. RN/UM #2 further stated that staff did not always document the volume of Milrinone that remained in the reservoir but they should have. RN/UM #2 reviewed the Progress Notes and stated that if nursing documented in a PN that the resident's IV line was not patent (functional), they may not have necessarily documented the volume of Milrinone that remained in the IV pump at that time. RN/UM #2 stated that if a PICC line were dislodged, then we were required to start a peripheral IV. RN/UM #2 further stated that if the peripheral IV were lost, then we notified the doctor and sent the resident out to the hospital. On 4/22/25 at 12:16 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 who stated that the facility LPNs were required to monitor and document the volume of Milrinone that remained in the reservoir and the RNs changed the bags. LPN #4 stated that if the amount of Milrinone that remained in the reservoir remained the same after a four hour period, it was not infusing and she would have reported it right away. On 4/22/25 at 2:04 PM, the surveyor interviewed LPN #5 who stated that she recalled Resident #179 and stated that the resident had a Milrinone pump which he/she carried in a pouch that resembled a pocket book. LPN #5 stated that she was responsible to document the volume that remained in the pump to ensure that there was enough medication. LPN #5 stated that the LPNs were not allowed to touch the pump and were required to get the RN if the pump beeped. LPN #5 stated that she checked the pump and it was always running. At that time, the surveyor asked LPN #5 why on 2/7/25 at 10:00 AM, and 4:00 PM, she documented that there was 500 ML of Milrinone remaining in the reservoir? LPN #5 stated that the pump would have beeped if it were not working, and it was a loud beep. LPN #5 stated that if it beeped, then she would alert the RN, as it meant that the pump was not working. LPN #5 stated that since the pump had not beeped, it meant that the resident received their medication. LPN #5 stated that she had not noted that the numbers that she recorded remained unchanged to reflect that the medication had infused. On 4/22/25 at 2:29 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident came to the facility with a PICC line and their own pump from the hospital and then we put them on our own pump with our own bag of Milrinone that was preset by the pharmacy. The DON stated that the assigned nurse documented the volume that remained in the pump to ensure that it had not run dry every shift. The DON stated that if the amount of Milrinone that was documented was repeated multiple times, then it meant that it was a documentation issue. The DON stated that pump would alarm to indicate malfunction if it had not infused properly. The DON stated that the nurses were taught to monitor the bag to ensure that it did not run dry. The DON stated that the LPNs were taught to never touch the bag of Milrinone, because it was an RN duty to change the bag. The DON stated, It was important that the pump ran constantly so that the resident did not go into complete heart failure. At that time, the DON stated that on 2/9/25 at 3:29 PM, RN/UM #1 documented that when the resident's PICC line became dislodged, he phoned the hospital to arrange for PICC line placement and inserted a peripheral IV and the Milrinone was infusing. The DON stated that on 2/9/25 at 7:20 PM, the line infiltrated, and RN/UM #1 documented that it was too late to have the company come out to reinsert an IV, so he sent the resident out on 2/10/25 at 12:45 AM. The DON confirmed that according to the documentation in the PN, it appeared that the resident had no IV access after 7:20 PM, until he/she was sent out to the hospital. The DON further stated that RN/UM #1's documentation had not indicated that he alerted the doctor or the Nurse Practitioner of the situation at that time. The DON stated that she was notified that the resident's IV was infiltrated and the staff were not able to get it back in, so they were instructed to send the resident out to the hospital. The DON stated that everybody knew that the resident could not be without the medication and had to go out. The DON stated, If it were not documented, it did not happen. On 4/23/25 at 12:41 PM, the surveyor interviewed he Licensed Nursing Home Administrator (LNHA) who stated that the RN or Unit Manager was responsible to oversee the documentation of Milrinone administration. The LNHA stated that it was important that all documentation was accurate for safe general patient care. On 4/23/25 at 12:50 PM, the surveyor interviewed RN/UM #1 via telephone who stated that he was the supervisor from 7 AM to 11 PM, and the resident had a PICC line which had come out. RN/UM #1 stated that he tried to place a peripheral IV line to keep the Milrinone going, but was unable to get it at first. RN/UM #1 stated that he stayed late and got an IV line in the resident, but it came out again and the resident was sent out to the hospital. RN/UM #1 stated that he believed that he told the nurse practitioner and the DON. RN/UM #1 stated that he may have not documented the successful insertion of the peripheral IV. RN/UM #1 stated that the resident was a little distraught because of the IV line and voiced that he/she wanted to go to the hospital to get IV access after he inserted the peripheral IV. On 4/24/25 at 9:54 AM, the surveyor interviewed the LNHA in the presence of the survey team who stated that the facility acknowledged RN/UM #1's lack of documentation, and indicated that though the documentation did not reflect it, the resident still had Milrinone infusing. The Regional Director of Clinical Services (RDCS) who was present at that time, stated that a peripheral IV was inserted at approximately 7:00 PM, and infused until 11:45 PM, and that was when the nurse called the doctor. The RDCS stated that it was important to document so that anyone who read the record could tell what was done. There was no documented evidence within the resident's EHR or MAR to indicate that the resident received Milrinone between 7:00 PM and 11:45 PM on 2/9/25 as indicated by the RDCS. On 4/23/25 at 1:16 PM, the surveyor interviewed the Medical Director (MD) who stated that if a PICC line came out, he would have expected the facility to insert an IV access until they could get a PICC line established. The MD stated that he would have expected for cardiology to have been notified, preferably, to see what they wanted done. The MD stated, everything should be documented accurately. 41072 2. The surveyor reviewed the medical record for Resident #178. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, fracture of the unspecified part of the neck of the left femur (thigh), nontraumatic subdural hemorrhage (bleeding near the brain), hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction affecting the left non dominant side, and muscle weakness. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/4/2023, included the Brief Interview for Mental Status (BIMS) was not assessed because the resident was barely or never understood. A staff assessment for Mental Status included that the resident had moderately impaired cognitive skills for daily decisions. Further review of the MDS revealed the resident was dependent for activities of daily living, bed mobility and was non-ambulatory. Section M Skin conditions revealed that the resident was at risk for developing pressure ulcers, was not admitted with any pressure ulcers, skin conditions or surgical wounds. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/7/23, that the resident was at risk of skin breakdown related to decreased mobility. Interventions included: to complete skin risk assessments as per facility policy A review of the Order Summary Report (OSR), dated 12/1/23 through 1/31/24, included the following physician orders (PO): A PO, dated 12/7/23, for admission second day skin evaluation: complete under the assessments tab (schedule this on day two of admission) every day shift for 1 day. A PO, dated 12/7/23, .for weekly skin check: complete .weekly skin check under the assessment tab (you must schedule this-see shower schedule and skin check days) every evening shift Tuesday and Friday for monitoring. A PO, dated 12/13/23, for a Peri Guard External Ointment, apply to entire buttocks topically every shift for Moisture Associated Skin Damage (MASD -a condition where skin inflammation and erosion occur due to prolonged exposure to moisture, such as urine, stool, perspiration, wound exudate or saliva) A PO, dated 12/13/23, for wound consult. A PO, dated 1/2/24, to remove staples from left hip. A review of the Nursing Admission/ Readmission Evaluation, dated 12/7/23 at 8:52 PM, revealed that the resident's skin was intact. The skin assessment did not include staples to the left hip. A review of the Weekly Skin check, dated 12/8/23 and 12/12/23, revealed that the resident's skin was intact. The skin assessments did not include staples to the left hip. A review of the History and Physical note (H&P), dated 12/8/23 at 2:33 PM, which included on 11/8/23 the resident underwent a left hip arthroplasty (left hip replacement). The resident was transferred to a rehabilitation facility then readmitted to the acute hospital from 11/29/23 to 12/7/23. Further review of the H&P revealed that the resident had a left hip incision with a dressing intact. The H&P did not indicate that the resident had staples to the left hip. Further review of the Progress Notes included a Physician note (PN) dated 12/13/23 at 10:13 AM, that the resident had a new wound to the left buttocks and the left hip incision with dressing was intact. A PN dated 12/23/23 and 12/29/23 revealed the resident had a left hip incision, a left buttock wound and no rash. A review of the Progress Notes, including the Nurses' Notes (NN), from 12/7/23 until 1/2/24, did not include documentation that the resident had staples to the left hip. Further review of the Progress Notes did not include a 12/13/23 NN of a new wound on the left buttock. A review of the electronic medical record (EMR) did not include a skin assessment from 12/13/23 after a new wound was observed or weekly skin assessments as ordered after the 12/12/23 skin assessment. A review of the Progress Notes included a NN, dated 1/2/24 at 9:16 AM, which included that 17 staples were removed from the left hip and 2 staples remained because the skin was growing around the staples. On 4/22/25 at 12:58 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated skin assessments were completed on admission, weekly and if a new skin condition was identified. If a resident was admitted with staples to an incision that should be documented on the admission skin assessment. The LPN further stated if a new skin condition was identified, a progress note and a skin assessment should be completed. An incident report would be completed if the skin was open, and not just red. The skin assessment should include the color, drainage location, size, and odor. On 4/22/25 at 1:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated skin assessments were completed on admission, the second day of admission, weekly and if a new skin condition was identified. The DON further stated that if a new skin condition was identified, the nurse would complete a skin assessment, an incident report, write a progress note, notify the doctor and the family. The DON further stated that if a resident was admitted with staples to an incision, it should be documented on the admission skin assessment. The DON stated the skin assessment should include the size, color, location, and if any drainage or odor. The DON stated it was important to complete skin assessments per policy so appropriate interventions could be put into place. On 4/23/25 at 1:33 PM, in the presence of the Licensed Nursing home Administrator (LNHA) the DON, the Assistant LNHA, Regional Director of Clinical Services (RDCS) and the survey team, the surveyor reviewed the above skin assessment concerns. On 04/24/25 at 9:45 AM, in the presence of the LNHA, the DON, the RDCS and the survey team, the DON provided the surveyor with an incident report, dated 12/13/23, for the MASD identified on the left buttock. The DON confirmed that the incident report was not part of the medical record and that a skin assessment should have been completed on 12/13/25. The DON further stated that the staples to the left hip should have been documented on the skin assessments and weekly skin assessment should have been documented in the EMR per policy. A review of the facility's Administration of Inotropic Agents policy, revised 3/28/18, included: .Procedure: .Documentation in the medical record includes, but is not limited to: .Rate, route and total dose administered, Patient assessment and response to therapy, Complications and interventions . A review of the facility's Charting and Documentation policy, revised July 2017, included, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. A review of the facility's Skin Assessment policy, revised 12/3/24, included that a full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/ readmission, daily for three days and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. NJAC 8:39-13.1(d), 27.1 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 5 residents (Resident #32) reviewed for pressure ulcers and was evidenced by the following: On 4/17/25 at 9:53 AM, the surveyor observed Resident #32 lying in bed awake on an air mattress. The air mattress pump was noted on the foot of the bed and it was set at 350 pounds (lbs). When interviewed, the resident stated that they weighed 260 lbs. The resident stated that they had a wound on their left heel that resulted prior to admission after two hip surgeries. The resident stated that he/she wore a boot on the right foot. On 4/22/25 at 12:32 PM, the surveyor observed Resident #32 lying in bed. The resident stated that he/she had a boot on their right foot. The resident then stated that the air mattress kept running out of air, and the staff had already changed it once. The surveyor noted that the weight setting was still set at 350 lbs. On 4/22/25 at 12:37 PM, the surveyor reviewed the medical record for Resident #32. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, passenger injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter, encounter for other orthopedic aftercare, fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, unspecified fracture of unspecified lumbar vertebra (bone at lower section of spine), subsequent encounter with routine healing, unspecified fracture of first thoracic vertebra (bone at middle section of spine), subsequent encounter with routine healing, and unspecified protein calorie malnutrition. A review of the resident's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 2/18/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the assessment revealed that the resident was admitted to the facility with one Stage 3 (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle was not exposed) and a foot (not specified) infection. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/11/25, I have actual skin breakdown (right heel). Interventions included: Low air mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown). A review of the Order Summary Report (OSR), dated as of 2/27/25, for a Low Air Loss Mattress: Check placement and function every shift. A review of the Treatment Administration Record (TAR) revealed an entry dated 2/27/25 for Low Air Loss Mattress: Check placement and function every shift. The entry was signed out as completed on day, evening and night shifts with the exception of both the evening and night shifts on 4/23/25. A review of the resident's Weekly Skin Check dated 4/22/25, indicated that the resident had no new skin alterations. Further review of the assessment indicated that the resident had a right heel wound and fungi in the groin. A review of the Weights and Vitals Summary revealed that the resident's weights as follows: On 4/10/2025, 268.0 Lbs Mechanical Lift (Manual) On 4/2/2025, 271.6 Lbs Mechanical Lift (Manual) On 3/10/2025, 275.1 Lbs Mechanical Lift (Manual) On 3/5/2025, 272.5 Lbs Mechanical Lift (Manual) On 2/28/2025, 271.0 Lbs Mechanical Lift (Manual) On 2/24/2025, 273.0 Lbs Mechanical Lift (Manual) On 2/12/2025, 310.0 Lbs Mechanical Lift .Mistaken Entry On 4/22/25 at 12:40 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #11 who stated that she had just completed the resident's right heel wound treatment. LPN #11 stated that the resident's wound had improved. LPN #11 further stated resident was admitted to the facility with the wound. On 4/23/25 at 10:55 AM, the resident was not in their room at time of observation. The setting on the low air mattress pump was set at 350 lbs. On 4/23/25 11:02 AM, the surveyor interviewed the acting Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who confirmed that the resident had an air mattress. LPN/UM #1 accompanied the surveyor into the resident's room and the low air loss mattress pump settings were reviewed. LPN/UM #1 stated that the pump should have been set to the resident's current weight, but instead it was set to 350 lbs. LPN/UM #1 stated that it was important that the pump was to set to the correct weight to ensure it was properly functioning. LPN/UM #1 stated that we checked the weight and verified that the settings were correct and documented the check on the TAR. LPN/UM #1 stated that stated if the resident's current weight was 268 lbs, it should be set at 260 lbs. LPN/UM #1 then proceeded to change the setting on the pump from 350 lbs to 260 lbs, and he then stated that it should soften. The mattress appeared very inflated. On 4/23/25 at 11:23 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the low air loss mattress setting was determined by the resident's weight. The ADON stated that nursing should go into the rooms routinely and check the settings because the pump could get bumped. The ADON stated that if the setting was too high, the resident could develop a pressure ulcer if the pump was not set at the correct weight. The ADON further stated that maintenance was to be notified if the bed was uncomfortable to determine if it needed to be replaced. On 4/23/25 at 12:09 PM, the surveyor interviewed the Director of Nursing (DON) who stated that an air mattress was ordered for resident's with known pressure ulcers and the pump was set according to the resident's weight. The DON stated that it was important not to go over the resident's weight because it was no longer an air mattress, and it may be too tight, and would not help pressure relief. The DON stated that the purpose of the pump being set at the correct setting was to prevent pressure ulcers. On 4/23/25 at 12:45 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that it was important to ensure the low air mattress pump was set to the resident's correct weight for pressure relieving purposes. On 4/24/25 at 10:06 AM, The surveyor interviewed the DON who stated that when staff signed the order for the low air mattress check, they confirmed that they checked to see that the air mattress was inflated and was set at the proper setting. The DON further stated, if staff signed it, they confirmed that the weight setting was correct. A review of the facility's Use of Support Surfaces policy, reviewed/revised 12/3/24, included: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing specialized support surfaces: .Size and weight (i.e., allows for turning without contact with side rails, enhanced features for residents with obesity) Support surfaces will be utilized in accordance with manufacturer recommendations (including considerations for contraindications). NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) label, date, and store respiratory equipment in a sanitary manner and b.) clarify a physician's order. This deficient practice was identified for 1 of 1 resident (Resident #88) reviewed for respiratory care and was evidenced by the following: On 4/16/2025 at 10:10 AM, the surveyor observed resident #88 resting in bed, alert and awake. The nasal cannula (N/C - a medical device used to deliver supplemental oxygen or air to a patient through the nostrils) was draped over the resident's nightstand, open to air, and unused. At that time, the resident stated that he/she last used the oxygen yesterday (4/14/2025) and the doctor was trying to wean them off the oxygen. As the surveyor exited Resident #88's room, a portable oxygen tank was noted on the resident's wheelchair (W/C) in the bathroom. The N/C tubing was draped over the W/C and the part of the tubing that would be applied under the resident's nostrils was touching the floor. A review of the Admission Record, an admission summary, revealed the resident had diagnoses that included, but were not limited to, acute respiratory failure with hypoxia, anemia, and morbid obesity. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/21/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed that the resident was on continuous and intermittent oxygen therapy. A review of the resident's individual comprehensive care plan (ICCP), dated 2/6/2025, included a focus area that the resident was on oxygen therapy as needed related to ineffective gas exchange. Interventions included: oxygen as ordered. A review of the Order Summary Report (OSR), dated as of 4/16/2025, included the following physician orders (PO): A PO, dated 2/6/2025, to keep tubing in a bag when not in use. A PO dated 2/6/2025, to change and date tubing every Monday on the night shift. A PO, dated 2/6/2025, for oxygen continuous via N/C at two (2) liters (L) per minute every shift continuous (14 hours or greater per day continuous). A PO, dated 3/24/2025, to wean the resident off oxygen as tolerated, every shift. On 4/17/2025 at 12:07 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #9, who stated that the N/C tubing should be labeled and dated and stored in a bag when not in use, for infection control purposes. On 4/17/2025 at 12:31 PM, the surveyor interviewed the Acting Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that the N/C tubing should be dated and initialed. He further stated that the N/C should be stored in a bag labeled with the resident's room number, their name, and the date, when it was not in use. On 4/17/2025 at 12:37 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated there was a bag that the N/C was stored in. She also stated the oxygen tubing should be dated, initialed and placed in the bag when it was not in use. On 4/17/2025 at 12:41 PM, the surveyor and the ADON entered the resident's room. Upon exiting the room, the ADON confirmed that the oxygen tubing on the residient's W/C was undated and was touching the bathroom floor. The ADON stated that she would replace the tubing. On 4/22/2025 at 3:54 PM, the surveyor interviewed the Director of Nursing (DON), who stated the N/C should be stored in a bag when not in use and the tubing should be labeled with the date and initials. She further stated that the PO to wean the resident off oxygen was not how the weaning is done, and the order should have been clarified to include titration. On 4/24/25 at 12:11 PM, the DON stated that the facility did not have a policy or a written protocol addressing weaning a resident off oxygen. A review of the facility's undated Oxygen Administration policy did not address dating and storing the oxygen tubing. NJAC 8:39-27.1(a)

Complaint NJ #'s: 171463, 176079, and 182553 Based on interview, record review, and review of pertinent facility documentation, it was determined the facility failed to ensure sufficient nursing staff and call bells were answered timely without waiting a long period of time for 1 of 3 residents (Residents #182) reviewed for sufficient nurse staffing. This deficient practice was evidenced by the following: The surveyor reviewed the Call bell Audit Report for Resident #182 from 7/5/24 to 8/11/24. The section under Response reflected the following dates and response times greater than (>)15 minutes): On 7/8/24 at 10:32 AM, response time was 16 minutes (mins) and 38 seconds (secs) On 7/8/24 at 1:39 PM, response time was 15 mins and 58 secs On 7/16/24 at 1:28 AM, response time was 15 mins and 25 secs On 7/21/24 at 7:18 AM, response time was 15 mins and 42 secs On 7/24/24 at 7:29 PM, response time was 17 mins and 13 secs On 7/26/24 at 12:34 PM, response time was 17 mins and 38 secs On 8/8/24 at 12:41 AM, response time was 17 mins and 39 secs A review of Resident #182's electronic medical records (EMR) revealed the following: A review of Admission Record, an admission summary, revealed the resident had diagnosis which included, intraspinal abscess and granuloma (collection of pus within the spinal canal, while a granuloma is a localized collection of inflammatory cells), type 2 diabetes mellitus, muscle weakness, abnormalities of gait and mobility. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/12/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was dependent for lower body dressing, bathing, toileting and was dependent for transfers and was non ambulatory. On 4/22/25 at 12:53 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that call bells should be answered within five (5) minutes. On 4/22/25 at 12:58 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the call bells should be answered as soon as someone sees the call bell ringing. On 4/22/25 at 1:24 PM, the surveyor interviewed the Director of Nursing (DON) who stated that her expectation would be that the call bells should be answered within a 15-minute period. The DON stated that the staff could be busy with other residents and felt that the call bell being answered within 15 minutes was appropriate time. The DON further stated that it was important to answer a residents' call bell timely because you never know what the resident may need or how much of an emergency it could be. On 4/23/24 at 1:33 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, the Assistant LNHA and the Regional Director of Clinical Services (RDCS) and reviewed the above concerns and findings about call bell response time as mentioned above. The LNHA stated that her expectation on call bell response time would be less than 15 minutes. Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two-week period beginning 7/14/24 and ending 7/27/24 revealed the facility was not in compliance with the State of New Jersey minimum staffing requirements for residents on 3 of 14 day shifts as follows: -07/14/24 had 11 CNAs for 93 residents on the day shift, required at least 12 CNAs. -07/20/24 had 11 CNAs for 93 residents on the day shift, required at least 12 CNAs. -07/21/24 had 11 CNAs for 93 residents on the day shift, required at least 12 CNAs. A review of the facility's Answering the Call Light policy, revised September 2022, included the purpose of this procedure is to ensure timely responses to the residents' request and needs. The policy also included to answer the residents call system immediately. NJAC 8:39-25.2(a,b)

Complaint NJ #171463 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were accurately implemented for 1 of 1 resident (Resident #20) reviewed for dining and was evidenced by the following: On 4/22/25 at 8:50 AM, the surveyor observed Resident #20 sitting upright in their bed with a breakfast tray on the overbed table. The resident's diet slip indicated a Western omelette, home-fried potatoes, margarine, two cold cereals, yogurt, coffee with cream and sugar. Instead of an omelet, the resident's breakfast tray included scrambled eggs, one cold cereal, and no yogurt. At that time, the surveyor interviewed the resident, who stated that occasionally the facility ran out of yogurt, and would not receive any. On 4/22/25 at 12:00 PM, the surveyor reviewed the medical record for Resident #20. A review of the Admission Record, an admission summary, revealed that the Resident #20 had a diagnosis that included, diabetes mellitus and generalized anxiety disorder. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/17/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 11/1/2023, that the resident had a nutritional problem or potential nutritional problem related to obesity. Interventions included: providing and serving a diet as ordered. A review of the Order Summary Report (OSR), dated as of 4/23/2025, included a diet consisting of no added salt (NAS), no concentrated sweets (NCS), regular texture and regular liquids. On 4/22/25 at 1:06 PM, the surveyor interviewed the Registered Dietician (RD), who stated that the food trays should be accurate as shown on the ticket. On 4/22/25 at 2:30 PM, the surveyor interviewed the Acting Licensed Practical/Unit Manager (LPN/UM), who stated that the physician's order excludes yogurt or extra cereal. He stated those items would be included on the diet slip, which informed the staff what should be on each resident's meal tray. He further stated the tray would then be checked for accuracy. On 4/23/25 at 11:47 AM, the surveyor interviewed the Director of Nursing (DON), who stated that staff distributed the meal trays and were expected to check the contents to ensure residents were receiving an accurate diet and everything that was ordered. A review of the facility's undated Resident Food Preferences policy included: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will be ordered with the resident's or representative's consent. NJAC 8:39-17.4(e)

Complaint # NJ176079, #NJ182553 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a resident was provided a shower as scheduled. This deficient practice was identified for 1of 5 residents (Resident #122) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following: On 4/17/25 at 10:00 AM, a resident council meeting was conducted with six (6) alert and oriented residents (Residents #19, #33, #39, #52 and #122), Resident # 122 stated that he/she was supposed to receive a shower the day before (4/16/25) and was not offered a shower. Resident #122 further stated that their shower days were Wednesdays and Saturdays and stated, My hair gets greasy. On 4/17/25 at 11:33 AM, the surveyor observed Resident #122 awake and alert sitting in their room, hair appeared slick. Resident #122 stated that he/she did not get their shower as scheduled the night before (4/16/25). The resident further stated, Can't you see by my greasy hair? The resident stated he/she did not have to ask for a shower on scheduled shower days, but that staff usually would come and get him/her on their scheduled shower day. The surveyor reviewed the medical record for Resident #122. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, primary osteoarthritis of the left knee, muscle wasting and atrophy, and patellofemoral disorders left knee. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/6/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident needed partial/moderate assistance with shower/bathing and dependent for a shower transfer. A review of the resident's individual comprehensive care plan (ICCP) included a focus are, dated 3/31/25, that the resident had a deficit in ADL self-care performance related to decreased mobility. Interventions included: the resident required one staff to participate in bathing. A review of the Order Summary Report, dated as of 4/22/25, included the following physician orders (PO): A PO, dated 3/30/25, for bath/shower/nail care twice a week. Document refusals (Wednesday/Saturday) every evening shift every Wednesday, Saturday for hygiene. A review of the Certified Nursing Assistant (CNA) Documentation Report included documentation by a CNA that the resident had received a bath/shower on 4/16/25 at 7:55 PM. A review of the April 2025 Treatment Administration Record (TAR) did not indicate that the resident refused their scheduled shower on 4/16/25. On 4/17/25 at 11:40 AM, the surveyor interviewed CNA #2 who stated the residents should not have to ask for a shower on their scheduled shower days, but the aide should automatically tell the resident it's their shower day and then give the resident a shower. If the resident refused the shower, the CNA would tell the nurse. On 4/17/25 at 11:43AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated that the residents should automatically be given their shower on their scheduled shower day and as needed or requested. The LPN further stated that if a resident refused the shower, the nurse would document it in the electronic medical record (EMR). It is important that residents get a shower as scheduled because this is their home. On 4/17/25 at 1:27 PM, the surveyor interviewed the Director of Nursing (DON) who stated that residents were scheduled for a shower twice a week and that the residents should not have to ask for the shower on their scheduled shower day The DON further stated that the CNA's would know the residents' shower schedule because it was in the shower book and in the tasks section of the EMR. The DON stated her expectation was that the residents received their showers as scheduled. On 4/23/25 at 1:33 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON, the Assistant LNHA, the Regional Director of Clinical Services (RDCS) and the survey team, the surveyor reviewed the above shower concern. On 4/24/25 at 9:45 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, the RDCS, and the survey team, acknowledged that Resident #122's shower was missed on 4/16/25. A review of the facility's Bath, Shower/Tub policy, revised February 2018, included that the purpose of this procedure was to promote cleanliness, provide comfort to the residents and to observe the condition of the resident's skin. Documentation includes the date and time of the shower was performed and to notify the supervisor if the resident refused a shower/tub bath. N.J.A.C. 8:39-27.2 (g)(h)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to prevent the spread of infection. This deficient practice was identified for 2 of 2 Licensed Practical Nurses (LPN #6, and #7) observed during the medication observation task and was evidenced by the following: On 4/17/2025 at 8:49 AM, the surveyor observed Licensed Practical Nurse (LPN #6) administer the medication to Resident #112. After administering the medication and performing hand hygiene, she went into an unsampled resident's room to assist the resident. She touched the resident's mattress, then proceeded to wash her hands. After washing her hands, she turned off the faucet with her bare hand. At that time, the surveyor interviewed LPN #6, who stated that she should have turned the faucet off with a dry paper towel. On 4/17/2025 at 9:49 AM, the surveyor observed LPN #7 administer medication to Resident #226, immediately following the administration, LPN #7 washed her hands then turned the faucet off with her bare hands. At that time, the surveyor interviewed the LPN, who stated that she should have turned the faucet off with a paper towel instead of her bare hands. On 4/17/2025 at 12:25 PM, the surveyor observed LPN #7 administer eye drops to Resident #41. Immediately after administering the eye drops, LPN #7 washed her hands, grabbed a paper towel, and took one small stroke to dry her hands. She then used the same damp towel to turn the faucet off. After turning the faucet off, she grabbed a couple more paper towels to dry her hands. On 4/22/2025 at 3:46 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the proper way to perform hand hygiene was to wet the hands, obtain soap, rub hands together for 20 seconds, then rinse with fingertips pointing downward, dry the hands with a paper towel, and then grab a new paper towel to turn the faucet off. On 4/23/25 at 10:00 AM, the surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) who stated, when performing hand hygiene, the staff should turn on the faucet, wet their hands, get soap, lather hands, scrub hands thoroughly for at least 30 seconds outside the stream of water, rinse hands one at a time under the water, grab a paper towel to dry hands and throw it away, grab a new paper towel to turn off the faucet and throw it away. She further stated that the process prevents the hands from being contaminated. A review of the facility's undated Handwashing/Hand Hygiene policy revealed, Washing Hands 1. Wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands.3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet. NJAC 8:39- 19.4(n)

Complaint NJ#: 171460 Based on observation, interview, and review of facility documents, it was determined that the facility failed to store medications properly. This deficient practice was identified on one (1) of two (2) units (200 Unit) and evidenced as follows: On 4/16/25 at 11:05 AM, during the initial tour, the surveyor entered Resident #10's room and observed a fluticasone-salmeterol 500 - 50 microgram/actuation (mcg/act) inhaler (used to treat chronic obstructive pulmonary disease, a progressive lung disease that makes it difficult to breathe) on the resident's overbed table. At 11:11 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #7, who stated that medications were stored in the medication cart and should never be left in the resident's room at the bedside. At that time, LPN #7 was informed that the fluticasone-salmeterol was in the resident's room. LPN #7 stated that she would follow up and was observed going into the resident's room. On 4/16/25 at 1:44 PM, the surveyor conducted a follow-up interview with LPN #7. LPN #7 stated that the inhaler was removed from the resident's bedside and discarded because it was empty. She further stated that she did not know how the resident obtained the inhaler. At that time, the surveyor looked in the medication cart (cart #3) and did not see the fluticasone- salmeterol inhaler. LPN #7 stated she used the last dose this morning (4/16/25) and discarded the empty container. On 4/22/2025 at 9:23 AM, the surveyor made a follow-up visit to Resident #10's room and observed a tube of diclofenac sodium 1% gel (used to treat arthritis pain and inflammation) in a bag that was hung on the resident's side rail. On 4/22/25 at 3:29 PM, the surveyor interviewed the Director of Nursing (DON) who stated that medications should be stored in the medication cart and never left at the resident's bedside. She stated that empty medication containers should also never be left at the bedside. She further stated that a resident could be assessed to self-medicate, which would require a physician's order. The DON then stated even then, the resident would be given a key to lock the medication up appropriately. She stated that all staff must inform the Licensed Nursing Home Administrator (LNHA) or DON if any medicines were observed at the bedside. The DON confirmed that Resident #10 was not assessed to self-medicate. At that time, the surveyor showed the DON a picture of the diclofenac sodium 1% gel observed at the bedside. The DON stated that at 9:39 AM, staff informed her that it was there and removed it. She also stated that before the morning meeting at 9:00 AM, everyone was assigned to a resident room and report anything found. She stated that education was provided upon hire that medication was not to be left at the bedside. A review of the facility's undated Medication Labeling and Storage policy included, Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. NJAC 8:39-29.4(h)

Complaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy, it was determined that the facility failed to ensure residents code status was documented in the medical records, the Physician's Order for Life-Sustaining Treatment (POLST) reflected the residents' end of life wishes and the proper documentation was completed so that those end of life wishes were honored in the facility and/or during transport. The facility also failed to follow its policies titled Residents' Rights Regarding Treatment and Advance Directives and the Social Services Director Job Description for 8 of 28 residents (Resident (R)2, R10, R13, R17, R24, R25, R26, and R28) reviewed for code status. R17 was admitted to the facility from the hospital with documented evidence that he/she had chosen a Do Not Resuscitate (DNR) code status; however, the facility ordered a Full Code despite no documented evidence the facility verified with the resident and/or family that R17 wishes were not to be a DNR. On [DATE], this failure resulted in Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) being initiated when the resident became unresponsive. Additionally, R2, who had a DNR code status, was transferred to the hospital via ambulance; however, the facility failed to ensure the proper documentation was completed and provided to the ambulance transport company for the resident's code status of DNR to be honored. This failure resulted in psychosocial harm to R2 when the ambulance personnel informed the resident that CPR would be required if he/she became unresponsive during transport. Also, during R2's readmission to the facility on [DATE], a physician's order was obtained for a full code from [DATE] until [DATE] without verification if R2 had changed his/her end-of-life wishes from DNR to full code. These failures placed R2, R10, R13, R17, R24, R25, R26, R28, and all other residents who were admitted and/or readmitted to the facility in an Immediate Jeopardy (IJ) situation that the likelihood that their end-of-life code status would not be honored. An Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at §483.10 F578: Request/Refuse/Discontinue; Formulate Advance Directives. The Administrator was notified on [DATE] at 7:06 PM of the Immediate Jeopardy. . The IJ ran from [DATE] through [DATE] at 4:30 PM, when the facility submitted an acceptable removal plan. On [DATE], the Surveyors conducted a revisit to verify that the Removal Plan was implemented. The facility implemented the Removal Plan. So, the noncompliance remained on [DATE] as a level E for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented the removal plan, which included the following: The Regional Director of Clinical Services educated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON)on the procedure, ensuring when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON and the ADON or Regional Nurse began re-educating, ensuring when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON or designee initiates audits of transfers to the hospital to ensure that when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/code status. Findings include: 1. Review of R17's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed that R17 was admitted to the facility on [DATE] from the hospital with diagnoses of osteomyelitis (bone infection), diabetes mellitus with foot ulcer, and heart failure. Review of R17's hospital History and Physical Report, electronically signed by a provider on [DATE], and uploaded on [DATE] into the Misc tab of R17's electronic medical record (EMR), revealed that R17 had a code status of DNR. Review of R17's New Jersey Universal Transfer Form, dated [DATE] and located in the paper chart, revealed that R17 came from the hospital to the facility with a DNR code status. Review of R17's Order Summary Report, located in the Orders tab of the EMR, revealed orders dated [DATE] and [DATE] for Full Code. The Medical Director signed both orders on [DATE] at 11:56 AM. Review of an Admission/readmission Note, dated [DATE] at 1:23 AM and located in the Prog Note tab of the EMR, revealed, Code Status: FULL CODE. Review of the note showed no documentation that R17 was asked what his/her wishes were regarding code status or to verify a change from a DNR to a Full Code. Review of R17's electronic and hard copy closed medical records revealed no documented evidence that the facility spoke with the resident or his/her family to verify his/her code status and end-of-life wishes after they were admitted to the facility. Review of a Progress Note, dated [DATE] at 8:30 AM, and located in the Prog Note tab of R17's EMR, revealed, At approx [approximately] [7:45 AM] resident was observed unresponsive to verbal and tactile stimuli. CPR was initiated. 911 called. CPR continued. The patient [resident] was transported to [the hospital]. Review of the facility-provided, CPR/Code Blue Documentation, dated [DATE], revealed CPR was initiated on R17 at 7:45 AM. At 7:53 AM, R17 was suctioned. EMS arrived at 8:00 AM, took over CPR, and intubated [tube inserted into the windpipe to provide oxygen via a ventilator] R17 at 8:02 AM. Review of R17's Progress Note, dated [DATE] at 5:02 PM, and located in the Prog Note tab of the EMR, documented a follow up call to the hospital revealed R17 had expired. During an interview on [DATE] at 3:43 PM, R17's Family Member (FM17) revealed that the resident was a DNR in the hospital and wore a DNR wristband from the hospital during his/her stay at the facility. FM17 stated that if the facility had asked R17 what his/her end-of-life wishes were, R17 would have been verified and chosen to be a DNR. During an interview on [DATE] at 1:38 PM, Licensed Practical Nurse (LPN) 1 stated that the facility received code status orders from the provider when a resident was admitted . According to LPN1, the nursing staff verbally spoke to residents about their wishes and relayed them to the provider. Nurses were not allowed to have the resident sign a POLST (Practitioners Orders for Life Sustaining Treatment). LPN1 stated, Someone else did that. However, LPN1 was uncertain about who ensured the POLST forms were signed. During an interview on [DATE] at 2:10 PM, Unit Manager (UM)1 stated the Nurses reviewed the admitting resident's hospital papers to determine what their code status was in the hospital. UM1 stated that nurses did not ask the residents what their wishes were regarding code status. Instead, they relayed the resident's code status in the hospital to the physician and obtained the same orders. During a concurrent interview with the DON and Administrator on [DATE] at 2:48 PM, they stated the following facility's process: if the hospital records clearly indicate DNR or full code, these were the orders the Nurses asked for from the physician when residents were admitted to the facility. On admission or the day after, nursing asked residents if they wanted a consultation with the palliative nurse practitioner to discuss code status. When asked what the expectation was regarding the discussion of code status, the DON and Administrator stated the expectation was that residents were asked what their wishes were regarding code status. It was expected that a nurse practitioner or physician had a conversation with residents regarding code status and that the nurses followed the physician's orders. If residents did not want a discussion about code status, then their code status was whatever the doctor confirmed based on hospital records. In the same interview, the DON stated she expected a conversation to be documented in EMR for code status changes. The Administrator stated if code status changed from the hospital to the facility, she expected documentation of that either in a nurse's assessment, a progress note, or verification with the physician's order. When asked for documentation that R17 had changed her code status from DNR to Full Code, a social service progress note was provided as documentation. Review of the social service progress note, Social Services Assessment and Documentation, dated [DATE], revealed no documentation that code status was discussed with R17 or that R17 had changed her code status from DNR to Full Code. During an interview on [DATE] at 8:20 PM, the Certified Social Worker/Social Services Director (SSD) stated social services did not ask residents what their wishes for code status were when they were admitted . According to the SSD, within 72 hours of the resident's admission, social services asked residents if they had any advanced directive or living will and provided information regarding filling out an advanced directive or POLST if they wished. If a resident expressed interest in filling out a POLST, the SSD assisted but did not otherwise ask residents what their wishes were. During an interview on [DATE] at 6:44 PM, LPN2, the nurse who entered R17's admission orders for a Full Code into the EMR, stated she was agency staff and worked the night shift. LPN2 stated that she had not been trained concerning the facility's code status policy. LPN2 stated that other nurses instructed her to review the hospital records and request orders from the physician for the code status the resident had in the hospital. If the records were unclear or did not mention the code status, full code orders were requested and entered into the EMR. LPN2 stated she was told by other nursing staff that the facility did not want the nurses asking residents for their code status, so she did not ask about their end-of-life wishes. During an interview on [DATE] at 12:26 PM, the Medical Director stated he expected the admitting nurse to attempt to talk to the resident or family about their code status wishes before calling the provider for orders. If unable to obtain their input, the Universal Transfer Form could be used for code status until current wishes were verified. The Medical Director stated there were many opportunities to discuss code status with the resident by the admitting provider, the palliative nurse practitioner, nursing, or a social worker. In addition, the Medical Director further stated, We [the facility] need to make sure we close the loop. The Medical Director further stated he expected code status to be clarified within 48 to 72 hours after admission to the facility but was uncertain who ensured this was done. 2. Review of R2's undated admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. The undated admission Record also documented under the Advance Directive section, R2 was DNR-DO NOT RESUSCITATE/DNI-DO NOT INTUBATE [insertion of a tube into the windpipe to provide oxygen through a ventilator]. A review of R2's untitled hospital record dated [DATE] and located in the resident's EMR under the Misc [Miscellaneous] tab revealed on the second-page order of DNR/DNI. The order documented, .I am attending, or I conferred with the attending physician prior to placing this order .Discussed with Patient . The print date of the document was [DATE] at 4:40 PM. Review of R2's physician Order Summary Report (POS), dated [DATE] through [DATE] and provided by the facility, revealed an order dated [DATE] of DNR/DNI. The order summary report did not have any physician signatures, nor did it have what provider gave the order. Review of R2's admission Agreement, dated [DATE] (four days after the resident was admitted to the facility), revealed . Facility Representative Documentation on Advance Directives: Resident has executed a Living Will [marked 'Yes'] . Resident has executed a Medical Order for Life Sustaining Treatment [nothing marked] .Resident has executed a Do Not Resuscitate (DNR) [nothing marked] . Review of R2's nursing Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab., revealed .at 1700 [5:00 PM], patient's son and his/her daughter .requested that [the] patient [be] transferred out to the hospital. 1810 [6:10 PM] Patient transferred to hospital via stretcher by [name of ambulance transport company] . Review of R2's New Jersey Universal Transfer Form, dated [DATE] and provided by the facility, revealed .CODE STATUS: DNR [marked], DNI [marked] .19. Attached Documents: .Code Status [marked] . The New Jersey Universal Transfer Form, dated [DATE], was completed by Licensed Practical Nurse (LPN) 3. No documents were attached to the facility provided New Jersey Universal Transfer Form, dated [DATE]. R2 was readmitted to the facility on [DATE] and even though the facility was aware the resident was a DNR, R2 was ordered a Full Code status until the next day. Review of the admission Record for R2 readmission with a print date of [DATE], provided by LPN1 and located in the resident's Paper Medical Record adjacent to the 200 nurses' station, revealed that R2 was readmitted to the facility on [DATE] and under the Advance Directive section it was documented Full Code. Review of R2's nursing Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab, revealed an admission/readmission note of [R2's Name] arrived at the facility on 11/15/ [at] 6:15 PM from a hospital via stretcher .Code Status: FULL CODE . Review of R2's Order Recap Report, revealed an order dated [DATE] of Full Code. The order for the resident to have a Full Code status ended on [DATE] when the order was changed to DNR Do Not Resuscitate. A review of R2's physician's Progress Note, dated [DATE] as a late entry and located in the resident's EMR under the Progress Notes tab, revealed .plan of care discussion had with family and patient's CODE STATUS was changed to DNR/DNI . During an interview on [DATE] at 6:13 PM, R2 stated that during the transfer to the hospital on [DATE], prior to leaving the facility, the ambulance transport staff informed him/her that the facility could not find the correct paperwork for them to take with them to verify that he/she was a DNR. The resident stated he/she, and the nurse told the ambulance staff he/she was a DNR code status. The resident stated that he/she had been a DNR since admission to the facility. According to the resident, the ambulance staff told him/her that if he/she was to code during transfer to the hospital, they would be required to perform CPR. The resident stated this made him/her very upset. During an interview on [DATE] at 9:23 AM, LPN3 stated on [DATE] that he was the nurse who had completed R2's transfer to the hospital. When asked if there were any concerns with R2's transfer to the hospital, LPN3 stated he could not locate R2's Practitioner Orders for Life-Sustaining Treatment (POLST) form. LPN3 stated the POLST had R2's code status on it and was supposed to go with the resident to the hospital. LPN3 revealed that because he could not locate R2's POLST, the ambulance transport company told him and the resident they would have to make her a Full Code while being transported. LPN3 also stated he and R2 both verbally told the ambulance personnel that R2 was a DNR; however, the ambulance personnel stated they needed either a copy of the POLST form or a copy of a signed physician's order for the DNR. LPN3 further stated he completed the New Jersey Universal Transfer Form, dated [DATE], and indicated the resident was a DNR on the form. In addition, LPN3 stated he sent a copy of R2's Order Summary Report, which indicated the resident had a physician's order for a DNR code status. When asked if R2's Order Summary Report had either a physician's signature or a physician's electronic signature on the report, LPN3 stated it did not. During a record review on [DATE] at 2:00 PM, LPN1 reviewed R2's Paper Medical Record, located adjacent to the nurses' station, and verified the resident's medical record did not contain a signed physician's order for a DNR status or a POLST form. During an interview on [DATE] at 2:55 PM with the DON and the Administrator, the DON stated when a resident was transferred to the hospital from the facility, the facility sends, at a minimum, the resident's order summary report and verbal report of the resident's code status is given to the ambulance company. The Administrator stated a POLST form was not required to be completed; they (the facility) just recommended that it be completed to ensure the residents' wishes are honored. The DON stated it was her expectation for residents to be offered a POLST form, and if the resident declined to complete a POLST form, the declination should be documented in the record. During a subsequent interview on [DATE] at 11:54 AM, R2 was further asked about his/her transfer to the hospital on [DATE]. R2 stated when the ambulance staff told him/her since the facility did not have the required document (completed POLST or signed physician's order) for his/her DNR status and if he/she coded on the way to the hospital, they would be required to do CPR, he/she became very upset and started crying. R2 stated all he/she could think about was the conversation his/her granddaughter had with him/her related to not being a full code at his/her age. The resident stated he/she pictured in his/her mind the tears coming down his/her granddaughter's face when he/she was having this conversation with him/her. R2 stated he/she did not want to be a vegetable and feared that it would happen if he/she coded on the way to the hospital. R2 stated even though his/her transfer to the hospital was not an emergency; the ambulance driver knew he/she was upset and transported him/her with the lights and siren on like it was an emergency to get there quicker. R2 was teary while relaying the incident to the surveyor. During an interview on [DATE] at 4:36 PM, when asked if there were documents that were required to be attached to the New Jersey Universal Transfer Form, the DON stated the Medication Administration Record/Treatment Administration Record (MAR/TAR), physician order summary (POS), face sheet, labs, and if the resident had a POLST. The continued interview revealed that when the POS (order summary report) was printed out for a transfer, the orders had been approved by the physician, whether verbal or signed. The DON verified that the POS did not have a physician's signature/electronic signature (which was required by the EMS to be a valid order). 3. Review of R10's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R10's EMR and paper medical record revealed no documented evidence that the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 4. Review of R13's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R13's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 5. Review of R24's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R24's EMR and Paper Medical Record revealed no documented evidence that the resident's record included a POLST form to document the code status of DNR/DNI, so that the resident's end of life wishes would be honored by the ambulance staff during transport. During a record review and interview on [DATE] at 2:00 PM, LPN4 verified that R24's medical records did not contain a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 6. Review of R25's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R25's EMR and Paper Medical Record revealed no documented evidence that the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 7. Review of R26's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R26's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 8. Review of R28's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R28's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. During a record review and interview on [DATE] at 2:08 PM, Unit Manager (UM) 1 stated a POLST form should be completed and placed in the residents' chart. UM1 verified that R10, R13, R24, R25, R26, and R28's Paper Medical Record and EMR did not include a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. Review of the facility's Social Services Director Job Description, updated [DATE], revealed, The Social Services Director will oversee the process of Advance Care Planning for each resident upon admission, and make sure that any Advance Directives are reviewed with the resident/resident representative on a regular basis. The Director will ensure that staff members are made aware of the resident's code status and end-of-life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised [DATE] revealed Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive .Policy Explanation and Compliance Guidelines: .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . A review of the NEW JERSEY PRACTITIONER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST), form dated [DATE] revealed DIRECTIONS FOR HEALTHCARE PROFESSIONAL .POLST orders are actual orders that transfer with the person and are valid in all settings in New Jersey. It is recommended that POLST be reviewed periodically, especially when: The person is transferred from one care setting or care level to another .Any incomplete section of POLST implies full treatment for that section .Section D. Make a selection for the person's preferences regarding CPR . Review of Section D revealed a selection of Attempt CPR or Do not attempt resuscitation/DNAR Allow Natural Death . Continued review of the POLST revealed on the front page at the bottom is a signature line for the resident/representative to sign confirming I have discussed this information with my physician/APN/PA [advanced practice nurse/physician assistant]. The POLST also had a signature line for the physician/APN/PA to sign, making the POLST document an order. NJAC: 8:39-9.6

Complaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, it was determined that the facility failed to ensure the physician's orders matched the resident's documented end-of-life wishes, which resulted in cardiopulmonary resuscitation (CPR) being done on a resident (Resident (R) 17) reviewed for code status out of a total sample of 22 residents. While in the hospital, R17 chose to be a do-not-resuscitate (DNR). However, the facility was unable to provide evidence that they implemented their policy for R17 for Advance Directives upon R17 admission to the facility. On [DATE], when R17 was found unresponsive, the facility performed approximately five rounds of chest compressions on the resident before the emergency medical services (EMS) arrived. EMS intubated [inserted a tube into the windpipe to provide oxygen via ventilator] R17 when they arrived on site and continued CPR via an automatic machine as they departed the facility for the hospital. R17 expired after leaving the facility. This failure resulted in an Immediate Jeopardy identified on [DATE] and was determined to exist on [DATE] at F678: Cardio-Pulmonary Resuscitation (CPR) at a Scope and Severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:54 PM. The facility submitted an acceptable removal plan on [DATE]. On [DATE], the Surveyors conducted a revisit to verify that the Removal Plan was implemented. The facility implemented the Removal Plan. So, the noncompliance remained on [DATE] as a level D for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented the removal plan, which included the following: The Regional Director of Clinical Services educated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on the procedure: ensuring the resident's wishes regarding code status are reflected in the resident's chart, communicating the correct code status to the physician, and interviewing the resident or responsible party regarding completing a POLST form upon admission to the facility. The DON and the ADON or Regional Nurse began re-educating, all nursing and social services staff on ensuring residents wishes regarding code status are reflected in the resident's chart communicating the correct code status to the physician, and interviewing the resident or responsible party regarding completing a POLST form upon admission to the facility. to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON or designee initiates audits of new admission and readmission to ensure the nurse(s) completing the admission have reviewed: residents hospital records are reviewed, if they exist the resident's advanced directives is reviewed, the resident's POLST is reviewed, the resident's Living Will is reviewed, and the wishes regarding code status are reviewed with the resident or responsible party and are reflected accurately in the chart and communicated to the physician and that a POLST was offered if one wasn't already in place. Findings include: Review of R17's hospital History and Physical Report, electronically signed by a provider on [DATE], and uploaded on [DATE] into the Misc tab of R17's electronic medical record (EMR), revealed that R17 had a code status of DNR. Review of R17's New Jersey Universal Transfer Form, from the hospital to the facility dated [DATE], and located in the resident's paper chart, revealed R17 came from the hospital to the facility with a DNR code status. Review of R17's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R17 was admitted to the facility on [DATE] from the hospital with diagnoses of Osteomyelitis (bone infection), diabetes mellitus with foot ulcer, and heart failure. Review of an Admission/readmission Note, dated [DATE] at 1:23 AM, and located in the Prog Note tab of the EMR, revealed, Code Status: FULL CODE. Further review of the note revealed no documentation that R17 was asked what his/her wishes were regarding code status or to verify whether R17 had changed his/her code status to a Full Code. Review of R17's Order Summary Report, located in the Orders tab of the EMR, revealed orders dated [DATE] and [DATE] for Full Code. The Medical Director signed both orders on [DATE] at 11:56 AM. Review of the R17's electronic and hard copy closed medical records revealed no documented evidence that the resident or his/her family changed R17's code status from DNR to a Full Code status after he/she was admitted to the facility. Review of a Progress Note, dated [DATE] at 8:30 AM, and located in the Prog Note tab of R17's EMR, revealed, At approx [approximately] [7:45 AM] resident was observed unresponsive to verbal and tactile stimuli. CPR was initiated. 911 called. CPR continued. Patient was transported to [hospital]. Review of the facility-provided, CPR/Code Blue Documentation, dated [DATE], revealed CPR was initiated on R17 at 7:45 AM. At 7:53 AM, R17 was suctioned (fluid removed from the oral cavity via vacuum suction). EMS arrived at 8:00 AM, took over CPR, and intubated R17 at 8:02 AM. Review of R17's Progress Note, dated [DATE] at 5:02 PM, and located in the Prog Note tab of the EMR, documented a follow up call to the hospital revealed R17 had expired. During an interview on [DATE] at 3:43 PM, Family Member (FM)17 revealed that R17 was a DNR in the hospital and wore a DNR wristband from the hospital during his/her stay at the facility. FM17 stated if the facility had asked R17 what his/her end-of-life wishes were, R17 he/she would have chosen to continue to be a DNR. During an interview on [DATE] at 1:22 PM, the Director of Nursing (DON) stated that when a resident was admitted to the facility, the admitting nurse relayed the code status the resident had at the hospital to the Doctor to obtain an order. If there was a discrepancy in the hospital records, the Doctor was likely to order a full code. During a concurrent interview with the DON and Administrator on [DATE] at 2:48 PM, they stated if the hospital records clearly indicated DNR or full code, these were the orders the nurses asked for from the physician when residents were admitted to the facility. During an interview on [DATE] at 6:44 PM, LPN2, the nurse who entered R17's admission orders of a Full Code into the EMR, stated she was agency staff and worked the night shift. LPN2 stated she was not provided with the facility's code status policy. She further stated that other nurses she had worked with instructed her to review the hospital records and request orders from the physician for the code status of the resident in the hospital. LPN2 no longer worked at the facility and could not remember why she entered Full Code as R17's code status. During an interview on [DATE] at 12:26 PM, the Medical Director stated he expected the admitting nurse to attempt to talk to the resident or family about their wishes regarding code status prior to calling the provider for orders. If unable to obtain their input, the Universal Transfer Form could be used for code status until current wishes were verified within 48 to 72 hours after admission to the facility. When asked if he verified what code status R17 wanted before signing the orders, the Medical Director stated he could not remember R17 but that physicians and Nurse Practitioners had an area in the progress notes to document any discussions with the resident or family about code status. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives reviewed/revised [DATE], included the following: Under Policy: revealed It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Under Definitions: showed Advance directive is a a written instruction, such as a living will or a durable power of attorney for health care . Under: Policy Explanation and Compliance Guidelines: included 1. On, admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, . 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. NJAC: 8:39-4.1(a)2 NJAC: 8;39-9.6 (b)

C#'s: NJ00177015 and NJ00180017. Based on interviews, record review, and review of the facility's policy, the facility failed to ensure documentation of controlled substance medications accurately reflected disposition and administration times in 3 of 28 residents (Resident (R)4, R23, and R24). The facility's failure placed residents who were ordered and administered controlled medications at risk of their controlled medications being misappropriated/diverted. This provided inaccurate documented evidence during the investigation of misappropriation/diversion events and/or allegations. Findings include: 1. Review of R4's undated admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. Review of R4's physician Orders, located in the resident's EMR under the Orders tab revealed the resident was ordered alprazolam (a benzodiazepine used to treat anxiety and is a schedule 4 controlled medication) 2 MG [milligram] twice a day. Review of R4's untitled and undated document provided by the facility revealed R4 was administered alprazolam 2 MG on 12/08/24 at 12:53 PM. The medication was scheduled to be administered at 12:00 PM. Review of R4's Individual Patient Controlled Substance Administration Record-30 dose, for alprazolam, with a received date of 11/27/24 revealed it was documented on 12/08/24 under the Time column, that the alprazolam was removed from the narcotic lock box at 1200 (53 minutes before the medication was administered to the resident). 2. Review of R23's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE]. Review of R23's physician Order Summary Report, provided by the facility revealed the resident was ordered pregabalin (Lyrica) 75 MG for pain on 09/12/24. Review of R23's untitled and undated document provided by the facility revealed that R23 was administered Lyrica 75 MG capsule on 12/10/24 at 8:04 AM. The medication was scheduled to be administered at 9:00 AM. Review of R23's Individual Patient Controlled Substance Administration Record-30 dose, for Lyrica, with a received date of 11/30/24 revealed it was documented on 12/10/24 under the Time column, that the Lyrica was removed from the narcotic lock box at 0900 [9:00 AM] (56 minutes after the medication was administered to the resident). 3. Review of R24's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R24's physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab, revealed the resident was ordered Lyrica (schedule 5 controlled medication used to treat nerve and muscle pain) on 11/01/24. Review of R24's untitled and undated document provided by the facility revealed R24 was administered a Lyrica 25 milligram (MG) capsule on 12/10/24 at 8:31 AM. The medication was scheduled to be administered at 9:00 AM. Review of R24's Individual Patient Controlled Substance Administration Record-30 dose, for Lyrica, with a received date of 12/05/24 revealed on 12/10/24 under the Time column, that the Lyrica was removed from the narcotic lock box at 0900 [9:00 AM] (31 minutes after the medication had been administered to the resident). During record reviews and interview on 12/12/24 at 9:28 AM, the Director of Nursing (DON) reviewed the Individual Patient Controlled Substance Administration Records (controlled drug records) and medication administration records (MAR) for R4, R23, and R24. The DON stated the nurses were documenting the scheduled administration time for the controlled medications because they (nurses) knew it would be time-stamped on the MAR when the medication was administered. When asked about the Individual Patient Controlled Substance Administration Records for the residents having documentation of the scheduled administration times for the controlled medications and not reflecting the time the nurse retrieved the controlled medication from the narcotic lock box, the DON stated it was her expectation the nurse would document the scheduled medication administration time on the residents' Individual Patient Controlled Substance Administration Record. The DON stated the facility's current practice of completing the Individual Patient Controlled Substance Administration Records was acceptable since the MAR documents the actual time of administration. During an interview on 12/12/24 at 11:13 AM, when asked about how residents' Individual Patient Controlled Substance Administration Records should be completed, the Regional Director of Operations stated as a nurse, she would document the Individual Patient Controlled Substance Administration Record the times she pulled the controlled medication from the controlled medication lock box. During an interview on 12/12/24 at 4:45 PM, Licensed Practical Nurse (LPN) 6 stated when she administered a controlled medication to a resident, she recorded the time she administered the medication on the Individual Patient Controlled Substance Administration Record. During an interview on 12/12/24 at 4:48 PM, Registered Nurse (RN)2 stated he documented the time the controlled medication was scheduled to be administered to the resident and not the time he punched the controlled medication out. During an interview on 12/12/24 at 5:54 PM, when asked what the expected procedure was for signing out controlled medications, the facility's Consultant Pharmacist (CP) stated the facility used declining inventory sheets (Individual Patient Controlled Substance Administration Record). The CP also stated as soon as the nurse pops the medication out from the mediation card, they sign the declining inventory sheet. The CP further stated that if the controlled medication was routinely scheduled, the nurses were to document the medication administration time. When asked, was she indicating the declining inventory sheet was not a reflection of when the scheduled controlled medications were punched (removed from the lockbox/medication card) but a reflection of when the controlled medications were scheduled, the CP stated, Yes, that's correct. Review of the facility's policy titled Controlled Substances, revised November 2022, revealed The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Scheduled II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) .4 .an individual resident controlled substance record is made for each resident who will be receiving a controlled substance .This record contains: .a. name of resident; b. name and strength of the medication; c. quantity received; d. number on hand; e. name of the prescriber .h. date and time received; i. time of administration .Storing Controlled Substances. 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following: a. records of personnel access and usage; b. Medication administration records . NJAC: 8:39-29.3 NJAC: 8:39-29.4

C#'s: NJ00177015 and NJ00180017. Based on observations, interviews, and record review, it was determined that the facility failed to utilize the proper personal protective equipment (PPE) for residents on special droplet/contact precautions for 4 of 22 residents (Residents (R) 10, R11, R12, and R13) reviewed for COVID-19 out of a sample of 22 residents. The facility also failed to follow its COVID-19 Prevention, Response, and Reporting policy. This created the potential for the transmission of infection to staff and other residents. Findings include: 1. Review of R10's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with a diagnosis of urinary tract infection. On 12/07/24, COVID-19 was added as a diagnosis. Review of R10's Prog Note tab revealed a Skilled Note, dated 12/07/24 at 10:34 PM, During the first shift, resident tested positive for covid. All isolation precautions put in place . A review of R10's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, I am COVID-19+ and exhibiting symptoms consistent with COVID-19, initiated 12/07/24. Interventions included contact/droplet isolation precautions and instruct staff to wear PPE when entering the room. In addition, the Care Plan revealed a focus area, I require droplet isolation precautions R/T [related to] Covid-19, initiated 12/07/24. Under: Interventions included Place protective equipment/isolation station at the entrance of the room. During an observation on 12/08/24 at 6:21 PM, Certified Nurse Aide (CNA) 1 walked into R10's room wearing a surgical mask over an N95 mask, gown, and gloves. No eye protection was worn. The Special Droplet/ Contact Precautions sign on R10's door staged to wear gloves, gown, a mask, fit tested N95 if doing aerosolizing procedures, and eye protection. A three-drawer cart with PPE was in the hall outside the room. During an interview on 12/08/24 at 6:23 PM, when CNA1 exited R10's room and was asked about wearing eye protection, she opened the PPE cart, pointed to a face shield, and asked if it was the eye protection being referred to. CNA1 then walked down the hall to speak to another staff member. 2. Review of R11's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with a diagnosis of wedge compression fracture of first lumbar vertebra. On 12/07/24, COVID-19 was added as a diagnosis. Review of R11's Prog Note tab revealed a Nurses Note, dated 12/07/24 at 4:02 PM, Rapid Covid-19 test completed on a patient [resident] with positive results. [Provider] made aware and notified. Patient symptomatic stated cough . Review of R11's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, I am COVID-19+ and exhibiting symptoms consistent with COVID-19, initiated 12/07/24. Under: Interventions included contact/droplet isolation precautions and instruct staff to wear PPE when entering the room. In addition, the Care Plan revealed a focus area, I require droplet isolation precautions R/T [related to] Covid-19, initiated 12/07/24. Interventions included Place protective equipment/isolation station at the entrance of the room. During an observation on 12/08/24 at 6:18 PM, the Licensed Practical Nurse (LPN)5 was observed in F11's room with the door open. LPN5 wore a gown, N95 mask, and gloves but had no eye protection other than her glasses. The Special Droplet/ Contact Precautions sign on R11's door staged to wear gloves, gown, a mask, fit tested N95 if doing aerosolizing procedures, and eye protection. A three-drawer cart with PPE was in the hall outside the room. During an interview on 12/08/24 at 6:24 PM, LPN5 stated the facility had face shields, but she did not wear them unless the resident was having symptoms such as cough or diarrhea. She stated that R11 had no symptoms. LPN5 reported nurses and CNAs care for both COVID-positive and COVID-negative residents in the hall during their shifts. 3. Review of R12's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with a diagnosis of diabetes. On 12/07/24, COVID-19 was added as a diagnosis. Review of R12's Prog Note tab revealed a Nurses Note, dated 12/07/24 at 4:21 PM, Rapid Covid-19 test completed on patient with positive results. [Practitioner] made aware and notified. Patient symptomatic stated cough and flu-like symptoms at this time . Review of R12's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, I am COVID-19+ and exhibiting symptoms consistent with COVID-19, initiated 12/07/24. Under: Interventions included contact/droplet isolation precautions and instruct staff to wear PPE when entering the room. In addition, the Care Plan revealed a focus area, I require droplet isolation precautions R/T [related to] Covid-19, initiated 12/05/24. Interventions included Place protective equipment/isolation station at the entrance of the room. During an observation on 12/08/24 at 6:15 PM, CNA2 entered R12's room after donning a gown, gloves, and a surgical mask over the surgical mask already worn. She wore glasses but no additional eye protection. The Special Droplet/ Contact Precautions sign on R12's door staged to wear gloves, gown, a mask, fit tested N95 if doing aerosolizing procedures, and eye protection. A three-drawer cart with PPE was in the hall outside the room. During an interview on 12/08/24 at 7:15 PM, CNA2 stated the caddy did not have an N95 mask, so she put on two surgical masks. It also had no eye protection, so she used her glasses. 4. Review of R13's admission Record in the Profile tab of the EMR revealed she was re-admitted to the facility on [DATE] with a diagnosis of urinary tract infection. On 12/07/24, COVID-19 was added as a diagnosis. Review of R13's Prog Note tab revealed a Skilled Note, dated 12/07/24 at 2:20 PM, Earlier during this shift, resident was seen lying quietly in bed c/o [complaining of] not feeling so well . Resident tested positive for covid and was immediately put on isolation precautions . Review of R13's Care Plan, located in the Care Plan tab of the EMR, revealed a focus area, I am COVID-19+, initiated 12/06/24. Under: Interventions included contact/droplet isolation precautions and instruct staff to wear PPE when entering the room. In addition, the Care Plan revealed a focus area, I require droplet isolation precautions R/T [related to] Covid-19, initiated 12/06/24. Interventions included Place protective equipment/isolation station at the entrance of the room. During an observation on 12/08/24 at 6:45 PM, Registered Nurse (RN) 1 went into R13's room after donning a gown, gloves, and N95 mask but no eye protection. The Special Droplet/ Contact Precautions sign on R13's door staged to wear gloves, gown, a mask, fit tested N95 if doing aerosolizing procedures, and eye protection. A three-drawer cart with PPE was in the hall outside the room. During an interview on 12/08/24 at 7:15 PM, RN1 verified he had not worn eye protection. RN1 stated the expectation was to wear eye protection, but R13 did not have the correct PPE set up. During an interview on 12/09/24 at 4:22 PM, the Infection Preventionist (IP) stated she expected staff to wear a gown, goggles or face shield, gloves, and an N95 mask when entering a room of a resident who has COVID-19. Failure to wear the correct PPE could spread COVID-19 to the staff or others in the facility. During an interview on 12/09/24 at 4:25 PM, the Director of Nursing (DON) stated she expected staff to wear a gown, goggles or face shield, gloves, and an N95 mask when entering a room of a resident who has COVID-19. Review of the facility's COVID-19 Prevention, Response, and Reporting policy, dated 05/29/24, revealed, HCP [health care personnel] who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. NJAC: 8:39-19.4(a)

Complaints: NJ00158123, NJ00158489, NJ00158677, NJ00159247, NJ00159800, NJ00167295, NJ00168400, NJ00168603, NJ00169368, NJ00169776 Based on observations, interviews, record reviews, and review of the facility's policies, the facility systemically failed to provide and maintain pharmaceutical services to acquire, receive, dispense, administer, and reconcile medications for 10 residents reviewed for medications (Resident R 60, R14, R33, R64, R31, R32, R63, R13, R11, and R9) out of a total sample of 65 residents. This systemic failure affected and/or had the likelihood to affect all residents of the facility, and any future admissions to the facility. The facility's systemic failure to ensure pharmaceutical services were provided to meet the needs of each resident had caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the area of S483.45 Pharmacy Services F755 at a scope and severity (S/S) of L. The Administrator was notified of the Immediate Jeopardy on [DATE] at 7:46 PM. The facility was notified that an acceptable plan of removal had been accepted on [DATE]. On [DATE], the surveyors conducted a revisit and verified that the Removal Plan was fully implemented. The noncompliance remained on [DATE] at a Level F for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Review of R60's undated Admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] at 11:30 PM post back surgery. Review of R60's hospital discharge summary dated [DATE] at 5:40 PM, located in the resident's electronic medical record (EMR) under the Misc (Miscellaneous) tab, revealed the resident was recipient of a kidney transplant on [DATE]. Continued review of R60's hospital discharge documentation revealed the resident's discharge medications included tacrolimus (a medication used to prevent the body from rejecting a transplanted organ) 0.50 mg [milligram] oral capsule, every 12 hours. Review of R60's hospital medication administration record (MAR) revealed the last dose of tacrolimus 0.5 mg administered at the hospital was at 2:16 PM on [DATE]. Review of R60's Physician's Orders, dated [DATE] at 1:36 Am located in the resident's EMR revealed the resident was ordered tacrolimus 0.5 mg capsule every 12 hours for prophylactic. During an interview on [DATE] at 9:38 AM, Registered Nurse (RN) 3 stated R60's transplant medication had not been received from the pharmacy and she was unable to administer the medication to R60. RN3 also stated R60 was admitted to the facility on [DATE] at approximately 10:00 PM. Review of R60's order audit report for the medication of Tacrolimus revealed the facility ordered the medication from the pharmacy on [DATE] at 1:36 AM. Review of R60's nursing Progress Note, dated [DATE] at 9:40 AM, completed by Regional Nurse (RGN) 1 and located in the resident's EMR under the Progress Notes tab revealed, [Medical Director's name] made aware that [R60's Name] Tacrolimus due at 9am today has not arrived. The pharmacy was contacted and confirmed that the Tacrolimus is being delivered on the first pharmacy delivery today. [Medical Director's Name] was also made aware of this. He ordered toplace [sic] a one-time order when the medication arrives and to hold this mornings dose. The progress note, notification, and order to hold the resident's medication doses were all made after R60's physician ordered scheduled administration time for the transplant medication. A subsequent interview with RN3 on [DATE] at 11:00 AM revealed she called the pharmacy, and the medication would be leaving the pharmacy at 2:00 PM. RN3 stated it should be at the facility by 3:00 PM. Review of R60's nursing Progress Note, dated [DATE] at 3:25 PM, completed by the Director of Nursing (DON) and located in the resident's EMR under the Progress Notes tab, revealed [Medical Director's Name] called made aware of arrival time of Tacrolimus and received orders to give now and administer next dose as ordered at 9pm. Review of R60's Medication Administration Record (MAR), dated [DATE] and located in the resident's EMR under the Orders tab, revealed Tacrolimus Oral Capsule 0.50 MG .Give 1 capsule by mouth every 12 hours for prophylactic. Start Date [DATE] 0900 [9:00 AM]. Hold Date from [DATE] 0946 [9:46 AM] to [DATE] 2100 [9:00 PM]. For the scheduled administration date and time of [DATE] at 9:00 AM, the administration block was blank, which indicated the medication was not administered. For the administration date and time [DATE] at 9:00 PM, the administration block was documented with H indicating the medication was held. Continued review of the MAR revealed on [DATE] at 3:36 PM, it was documented R60 was administered his tacrolimus transplant medication. It had been over 25 hours since R60 received his post-transplant medication that was ordered to be administered every 12 hours. Further review of the MAR revealed that the 9:00 PM dose ordered by the physician on [DATE] was not administered. During an interview with the Consultant Pharmacist (CP) on [DATE] at 11:27 AM revealed post-transplant medication was very important, and the resident should be receiving the medication twice a day and they never want a resident to miss a dose of transplant medication. The CP stated if the resident received his last dose at 2:00 PM on [DATE], it would be optimum he received his next dose within 12 hours. During an interview on [DATE] at 3:10 PM, the Medical Director stated R60 was admitted after 10:00 PM on [DATE], so there was no way to get the resident's medications to the facility for him to be administered his morning medications. The Medical Director stated the transplant medication was a specialty medication. The Medical Director stated that other than the family bringing in the medication from home, there was no way of getting the medication to the facility any sooner. 2. Review of R14's undated Admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, post laminectomy syndrome, seizures, and generalized anxiety disorder. Review of the National Library of Medicine [Department of Health and Human Services, National Institutes of Health] updated on [DATE] revealed .Clonazepam tablet .Boxed Warning [the strongest warning that the Food and Drug Administration (FDA) requires, signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects] . The continued use of benzodiazepines, including clonazepam tablets, may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily dose. Abrupt discontinuation or rapid dosage reduction of clonazepam tablets after continued use may precipitate acute withdrawal reactions, which can be life-threatening . Acute Withdrawal Signs and Symptoms. Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements .anxiety .fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, insomnia, muscle pain and stiffness, restlessness, tachycardia, and tremor .Medication Guide . Physical dependence and withdrawal reactions. Clonazepam tablets can cause physical dependence and withdrawal reactions. Do not suddenly stop taking clonazepam tablets. Stopping Clonazepam tablets suddenly can cause serious and life-threatening side effects, including, unusual movements, responses, or expressions, seizures, sudden and severe mental or nervous system changes, depression, seeing or hearing things that others do not see or hear, an extreme increase in activity or talking, losing touch with reality, and suicidal thoughts or actions. Call your healthcare provider or go to the nearest hospital emergency room right away if you get any of these symptoms . https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ebc11109-e7bf-452d-b,d+[DATE]b3236d54164 Review of R14's Physician Orders, located in the resident's EMR under the Orders tab, revealed R14 was originally ordered clonazepam (a benzodiazepine medication used to treat anxiety) 2 mg, two times a day on [DATE] and discontinued on [DATE]. The orders also revealed on [DATE], R14 was ordered clonazepam tablet 1 mg two times a day. The physician orders also indicated on [DATE] R14's clonazepam was reduced to 0.5 mg every 12 hours as needed. On [DATE] the resident was ordered clonazepam tablet 1 mg two times a day for anxiety. The resident had continuously received the medication at varying dosages since he was admitted which would be considered long term use of the Clonazepam. Review of R14's MAR dated [DATE], located in the resident's EMR under the orders tab, revealed the resident was scheduled to be administered Clonazepam 1 mg by mouth at 5:00 PM and 10:00 PM every day. Continued review of the MAR revealed R14's routine Clonazepam was not documented as administered for [DATE]- both doses, [DATE]-both doses, [DATE]-both doses, [DATE]-both doses, and [DATE]-both doses. The administration dates and times were documented with a 9 which indicated Other. Review of R14's nursing Progress Notes, dated [DATE] at 6:11 PM and [DATE] at 10:08 PM, located in the resident's EMR under the Progress Notes tab revealed Administration Note. Note Text: awaiting pharmacy. Review of R14's nursing Progress Notes, dated [DATE] at 6:35 PM and [DATE] at 9:33 PM, located in the resident's EMR under the Progress Notes tab revealed Administration Note. Note Text: on order. Review of R14's nursing Progress Notes, dated [DATE] at 4:36 PM, located in the resident's EMR under the Progress Notes tab revealed Administration Note. Note Text: med [medication] not available at this time. Continued review of the progress notes dated [DATE] revealed a note completed at 9:00 PM revealed Administration Note. Note Text: on order. Review of R14's nursing Progress Note, dated [DATE] at 4:39 PM, located in the resident's EMR under Progress Notes tab revealed Administration Note. Note Text: Medication on order, awaiting from pharmacy. Review of R14's nursing Progress Note, dated [DATE] at 9:28 PM, located in the resident's EMR under the Progress Notes, tab revealed Administration Note. Note Text: On order, awaiting from pharmacy. Review of R14's Individual Patient Controlled Substance Administration Record-30 dose for clonazepam 1mg tablet revealed on [DATE] at 10:00 PM, the resident's last dose of clonazepam was signed out for administration. Review of the facility's untitled emergency medication backup (cubex) transaction reports dated [DATE], [DATE], [DATE], [DATE], and [DATE], provided by the facility, revealed no documented evidence clonazepam was retrieved to be administered to R14. During an interview on [DATE] at 1:00 PM, R14 stated at the end of [DATE], his regular nurse went on vacation and that was the last time he received his clonazepam until she returned from vacation. R14 stated the nurses would tell him every day that the pharmacy said it would be on the night delivery. R14 stated he reported to the nurses he had nausea and vomiting, uncontrollable shaking inside his body and on the outside of his body, headache, sweating and stomach pain. R14 stated he had never had this feeling before. Review of R14's EMR revealed no documented evidence that the nursing staff documented any withdrawal symptoms other than the resident complaining of a headache on [DATE]. During an interview on [DATE] at 11:27 AM, the CP stated if the facility was out of R14's clonazepam for multiple days, that was a problem. The CP stated nursing should have notified the physician to see if they could have ordered a different medication that was the same class of drug that was in stock in the cubex. The CP also stated R14 could experience withdrawal due to going without the medication. Review of an untitled and undated facility document, provided by the facility on [DATE] revealed .the center [facility] had an adequate supply of Klonopin [Clonazepam] in the cubex on these dates [[DATE], [DATE], [DATE], [DATE], and [DATE]]. So, while his medication administration record [MAR] documents that the medication wasn't administered on the dates in question, the medication was in the center . The medication being available at the facility but not administered further indicated the facility's systemic failure to provide pharmaceutical services which included accurate acquiring, receiving, dispensing, and administering of all drugs. 3. Review of R33's undated Admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included bacteremia (bacterial infection in the blood). Review of R33's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R33's hospital Summary of Care, dated [DATE], located in the resident's EMR under the Misc tab, revealed Follow-Up After Discharge .Additional instructions: IV cefazolin [antibiotic] 2 grams every 8 hours until [DATE]th or as otherwise directed by infectious disease . Continued review revealed the last time R33 was administered cefazolin at the hospital prior to discharging was on [DATE] at 5:56 AM. Review of R33's admission Progress Note, located in the resident's EMR under the Progress Notes tab, revealed the resident was admitted to the facility on [DATE] at 4:03 PM. Review of R33's Physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated [DATE] for cefazolin sodium solution reconstituted 2 GM [grams]. Review of R33's Order Audit Report, located in the resident's EMR under the Orders tab, revealed for the medication of Cefazolin intravenously every 8 hours for bacteremia, the medication was ordered on [DATE] at 4:05 PM. Review of R33's nursing Progress Note, dated [DATE] at 12:51 AM, located in the resident's EMR under the Progress Notes tab, revealed This nurse called [Pharmacy's Name] to make sure that the patients IV ABT [antibiotic] would be delivered in the am. The pharmacy stated that the IV pharmacy won't open until 8 am and will be processed then . Review of R33's nursing Progress Note, dated [DATE] at 10:31 AM, located in the resident's EMR under the Progress Notes tab revealed Orders-Administration Note. Note Text: cefazolin sodium solution reconstituted 2 GM. Use 2 gram intravenously every 8 hours for bacteremia. Awaiting medication from pharmacy. Review of R33's MAR, dated [DATE], located in the resident's closed EMR under the Reports tab, revealed ceFAZolin Sodium Solution Reconstituted 2 GM .Use 2 gram intravenously every 8 hours for bacteremia with a start date of [DATE]. Continued review of the MAR revealed for the date of [DATE], 9 was documented for the 12:00 AM and 8:00 AM administration times. The MAR showed the antibiotic medication was administered on [DATE] at the 4:00 PM, 33 hours and 56 minutes after the last dose was administered in the hospital prior to admission to the facility. There was no documented evidence provided when the medication was delivered or that the medication was retrieved from the facility's cubex. During an interview on [DATE] at 1:43 PM, R33 stated he missed a total of five doses of the antibiotic medication. R33 stated he was admitted to the facility on [DATE] around 4:00 PM and was told by the nurse that the facility did not have his antibiotic medications yet. The resident stated he expected to get an infusion as soon as he was admitted to the facility; however, the facility was not prepared nor equipped to receive him as an admission. R33 stated he refused to take the rest of his medications the first day hoping that would expedite the facility getting his antibiotic. Continued interview revealed the nurses kept telling him that they called the pharmacy, and the medication would be on its way. R33 also stated the antibiotic was for a blood infection that about killed him, so he was afraid the infection was going to come back and that he would die if it did return. During an interview on [DATE] at 11:27 AM, the CP stated it was important R33 would have received his antibiotic infusions as ordered. The CP stated the nurses should have notified the physician if the antibiotic was not at the facility. The CP also stated with resident not getting the continued antibiotic infusion as ordered after leaving the hospital placed the resident at risk for the infection not clearing up completely and the resident could have built up a resistance to the antibiotic. There was no documented evidence that the resident's physician was notified of the missed administration of the antibiotic after the [DATE] notification. Review of an untitled and undated facility document, provided by the facility on [DATE] revealed .the center [facility] had an adequate supply of Cefazolin in the IV Antibiotic box on these dates [[DATE] and [DATE]]. So, while the medication administration record [MAR] documents that the medication wasn't administered on the dates in question, the medication was in the center . The medication being available at the facility but not administered further indicated the facility's failure to provide pharmaceutical services which included accurate acquiring, receiving, dispensing, and administering of all drugs. 4. Review of R64's undated Admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm (cancer) of lung, malignant neoplasm of brain, and malignant neoplasm of bone. Review of R64's Admission Note, dated [DATE] at 11:23 PM, located in the resident's EMR under the Progress Notes tab, revealed the resident was admitted to the facility on [DATE] at 4:00 PM. Review of R64's Physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated [DATE] at 9:00 PM for Lyrica Capsule 75 MG give one capsule by mouth twice a day. During an interview on [DATE] at 5:35 PM, Licensed Practical Nurse (LPN) 2 stated the facility had not received R64's Lyrica (used to treat pain caused by nerve damage) from the pharmacy 24 hours after the resident was admitted and the resident was in pain. LPN2 stated he was not assigned to the resident during the interview. During an observation and interview on [DATE] at 5:40 PM, LPN9 revealed the medication cart lacked R64's Lyrica medication. LPN9 confirmed the resident's medication had not arrived from the pharmacy yet. When asked if the medication could be retrieved from the facility's backup medications in the cubex, LPN9 stated she was an agency nurse and agency nurses did not have access to the cubex. During an observation and interview on [DATE] at 6:11 PM, R64 was tearful and stated she arrived at the facility on [DATE] and her pain was not fully controlled. The resident stated she was experiencing back pain, and her pain level was eight out of 10. Review of R64's Pain Level Summary, dated [DATE] at 6:24 PM, located in the resident's EMR under the Vitals tab revealed the resident's pain was assessed by LPN9 and the resident rated the pain an eight out of 10. Review of R64's MAR dated [DATE], located in the resident's EMR under the Orders tab, revealed it was documented the Lyrica medication was administered to R64 on [DATE] at 9:00 PM, on [DATE] at 9:00 AM, and on [DATE] at 9:00 PM, even though the pharmacy had not delivered the resident's medication to the facility. Review of R64's pharmacy Packing Slip Proof of Delivery, dated [DATE], provided by the facility revealed the resident's pregabalin (Lyrica) was not delivered to the facility until [DATE] at 6:47 AM. Review of the facility's cubex Transactions By Patient, C14, with the date range of [DATE]-[DATE], provided by the facility revealed the medication of Lyrica was not dispensed from the cubex for R64. During an interview on [DATE] at 11:27 AM, the CP stated Lyrica was a pain medication that worked differently for pain than other pain medications, so the facility may have fewer options to replace the medication with a medication from the cubex. The CP stated the nurse should have notified the resident's physician if the medication was not at the facility when it was scheduled to be administered to ensure the resident's pain was being managed. During an interview on [DATE] at 2:13 PM, the Director of Nursing (DON) stated per R64's MAR, the facility's nurses administered the resident's Lyrica to her on [DATE] at 9:00 PM, on [DATE] at 9:00 AM, and on [DATE] at 9:00 PM. The DON confirmed for these administration times and dates, R64's medication had not been delivered to the facility yet and she also confirmed the medication had not been dispensed from the facility's cubex. When asked how the nurses would have administered the medication if the medication were not in the facility and if the MAR was inaccurate, the DON stated she was not sure where the nurses would have obtained the medication from, but the MAR documented that Lyrica was administered. 5. Review of R31's undated Admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R31's Medical Diagnoses located in the resident's EMR under the Med Diag tab, revealed the resident was admitted to the facility with diagnoses which included dementia, pulmonary embolism (blood clot in the lung), urinary tract infection, and depression. Review of R31's nursing Admission/Readmission Note, located in the resident's EMR under the Progress Notes tab, revealed the resident was admitted to the facility on [DATE] at 10:00 PM. Review of R31's Physician Orders, located in the resident's EMR under the Orders tab revealed the resident was ordered the following medications on [DATE], the day after the resident was admitted : Rivaroxaban Oral Tablet (an anticoagulant medication used to help prevent blood clots) 20 MG give 1 tablet by mouth in the evening for prophylactic, Ambien (hypnotic medication used for insomnia) 5 MG tablet give 1 tablet every 24 hours as needed for insomnia, prednisone Oral Tablet (a corticosteroid used to reduce inflammation) 1 MG give 1 tablet three times a day for pain, Rivaroxaban 15 MG give 1 tablet by mouth two times a day for prophylactic, and Dexamethasone Oral Tablet (a corticosteroid used to reduce inflammation) 6 MG Give 1 tablet my by mouth one time a day for pain . Review of R31's Order Audit Report, located in the resident's EMR under the Orders tab, revealed the resident's Rivaroxaban 15 MG and 20 MG tablets were ordered from the pharmacy on [DATE] at 12:15 PM which indicated the medication was ordered 14 hours after the resident was admitted to the facility, Ambien 5 MG tablets were ordered from the pharmacy on [DATE] at 2:29 PM which indicated the medication was ordered 16 hours after the resident was admitted to the facility, prednisone 1 MG tablets were ordered from the pharmacy on [DATE] at 12:15 PM which indicated the medication was ordered 14 hours after the resident was admitted to the facility, and dexamethasone 6 MG tablets was ordered on [DATE] at 12:15 PM which indicated there medication was ordered 14 hours after the resident was admitted to the facility. Review of R31's MAR, dated February 2023, located in the resident's EMR under the Orders tab revealed the resident was not administered any medications during her brief admission to the facility. Review of R31's nursing Progress Notes, dated [DATE], located in the resident's EMR under the Progress Notes tab, revealed a note at 9:51 PM of .21:40 [9:40 PM] pt left AMA [against medical advice] with Daughters. Refused to sign AMA paperwork. Family very upset, felt staff was not attentive to their mother's needs. Continued review revealed a note at 10:18 PM of .Pt's family unhappy with care client receiving at facility. Family spoke with nursing supervisor regarding concerns and family adamant about taking client home. During an interview on [DATE] at 1:52 PM, Family Member (F) 31 stated R31 was admitted to the facility from the hospital at approximately 11:00 PM on [DATE]. F31 stated came back to the facility the next morning on [DATE] to visit R31. Continued interview with F31 revealed R31 had not received her medications since being admitted to the facility so she found R31's nurse who informed her that R31's medications had not been ordered yet. F31 stated the whole day had passed and the facility never obtained medications to administer to R31. F31 also stated at approximately 9:00 PM on [DATE], she decided it was not safe for her mother to stay at the facility and she took the resident home. F31 stated it was important for her mother to receive medications to prevent blood clotting as her mother was admitted to the facility from the hospital after sustaining a pulmonary embolism. 6. Review of R32's undated Admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Revive of R32's Medical Diagnoses, located in the resident's EMR under the Med Diag tab, revealed the resident was admitted with diagnoses which included acute cholecystitis (inflammation of the gallbladder), chronic kidney disease stage 4, and encounter for surgical aftercare following surgery on the digestive system. Review of R32's nursing Admission/Readmission Note, dated [DATE] at 12:30 AM, located in the resident's EMR under the Progress Notes tab, revealed [Resident's name] arrived at the facility on [DATE] [at] 3:02 PM . Review of R32's New Jersey Universal Transfer Form, dated [DATE], located in the resident's EMR under the Misc tab, revealed the resident was being transferred from the hospital to the facility for reasons of IV Antibiotics and Ambulatory [walking] dysfunction. Review of R32's hospital discharge instructions titled, My Discharge Instructions, dated [DATE] revealed .Other Instructions: You came to the hospital because your gallbladder was infected. You had your gallbladder removed on [DATE]. You were experiencing fevers as well as an increased white blood cell count. Infectious disease was consulted. You were started on antibiotics .Your white blood cell count was still going up. Interventional radiology was consulted as CT abdomen and pelvis showed a small fluid collection. Interventional radiology felt this collection was not something that could be drained. They felt it would be better managed with antibiotics per infectious disease. Infectious disease switched your antibiotic to meropenem. Your white blood cell count started to decrease. Infectious disease wants you to complete a 2-week total course of IV meropenem. Unfortunately, meropenem is only able to be given with IV so you had a midline placed to be able to receive your antibiotics at rehab. You are able to be discharged to rehab. You are to finish 9 more days of antibiotics, including today. Today, you received 1 dose so far. You will have 2 more doses of meropenem today, Afterwards, you will have meropenem every 8 hours for 8 more days. You will receive you last dose of antibiotics on [DATE] . Continued review of the discharge instructions revealed R32 received her last dose of Meropenem IV antibiotics at the hospital on [DATE] at 12:13 PM. Review of R32's Order Audit Report, located in the resident's EMR under the Orders tab, revealed the resident's meropenem intravenous solution reconstituted 500 MG was ordered from the pharmacy on [DATE] at 9:15 PM which indicated the medication was ordered six hours after the resident was admitted to the facility. Continued review of R32's order audit report revealed on [DATE] at 12:19 AM, the resident's meropenem was again ordered from the pharmacy as Meropenem Intravenous Solution Reconstituted 1 GM .Use 1 gram intravenously one time only for Elevated [NAME] blood count post gallbladder removal until [DATE] . Review of R32's nursing Alert Note, dated [DATE] at 12:22 AM, located in the resident's EMR under the Progress Notes tab, revealed Note Text: Resident med [medication] no delivery on time. MD [medical doctor] call and new order given 1 time dose Meropenem 1g IV for elevated white blood count. Order will be resume upon pharmacy delivery tomorrow . Review of R32's MAR, dated [DATE], located in the resident's EMR under the Orders tab, revealed for Meropenem intravenous solution for elevated white blood count post gallbladder removal, it was documented the medication was administered on [DATE] at 1:41 AM which indicated it had been over 13 hours since the resident received her last dose at the hospital on [DATE] at 12:13 PM for an IV antibiotic that was physician ordered every 8 hours. 7. Review of R63's undated Admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R63's Medical Diagnoses, located in the resident's EMR under the Med Diag tab revealed the resident was admitted to the facility with diagnoses which included abscess of liver. Review of R63's Physician Orders, located in the resident's EMR under the Orders tab revealed an ordered dated [DATE] of Ertapenem Sodium [an IV antibiotic] Injection Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for hepatic [liver] lesion . Review of R63's pharmacy Packing Slip Proof of Delivery, dated [DATE], provided by the facility revealed the facility received seven doses of Ertapenem 1GM . from the pharmacy. Review of the facility's pharmacy Packing Slip, dated [DATE], provided by the facility revealed R63 had seven doses of Ertapenem 1GM . delivered to the facility. During an interview on [DATE] at 3:34 PM, the DON confirmed the facility had received two deliveries of R63's antibiotic medication of Ertapenem, of seven doses each delivery which totaled 14 doses. Review of R63's MAR, dated [DATE], located in the resident's EMR under the Orders tab revealed it was documented the resident had been administered one dose of the IV antibiotic ertapenem. Review of R63's MAR, dated [DATE], located in the resident's EMR under the Orders tab revealed it was documented the resident had been administered eight doses of the IV antibiotic ertapenem. Review of the MARs revealed the resident had been administered at total of nine doses of the resident's 14 doses received from the pharmacy by the facility. During the continued interview on [DATE] at 3:34 PM, the DON stated she counted the number of R63's ertapenem doses the facility had on hand as of [DATE], and the resident only had four doses left when she should have had five doses left which indicated a deficit of one dose. When asked if she could explain why there was one dose of the resident's antibiotic missing, the DON stated she did not know as there was nothing documented in the resident's EMR to account for the missing dose. When asked if the missing dose of the resident's IV antibiotic should be reported as misappropriation and if the facility should investigate what happened to the resident's medication, the DON state[TRUNCATED]

Complaints: NJ00157215, NJ00161186, NJ00161762, NJ00162457, NJ00162827, NJ00167295, NJ00168400, NJ00168545, NJ00168603, NJ00169368 Based on observation, interview, record review, and facility policy review, the facility failed to protect one resident's (Resident (R) 38) right to be free from physical abuse by staff and failed to protect two residents' (R37 and R57) right to be free from neglect out of a total sample of 65 residents. An allegation was reported that R38 was found with adhesive paste inside his ileostomy stoma. It was reported the stoma adhesive paste was in an amount sufficient to obstruct R38's stoma. The facility failed to identify the alleged incident as an allegation of abuse, failed to report the allegation to the state agency, failed to conduct a thorough investigation, and failed to protect residents during the investigation. R37 received Eliquis, an anticoagulant medication, suffered an unwitnessed fall, and the facility neglected to monitor for changes in level of consciousness. R37 was sent to the hospital, and it was recorded that she had a traumatic brain injury. R57 had diagnoses including congestive heart failure (CHF) and exhibited signs and symptoms of an exacerbation of CHF. The facility neglected to obtain a cardiologist appointment as requested by the resident, neglected to monitor daily weights, neglected to notify the physician when R57 had shortness of breath, and neglected to intervene when providers did not provide care and services necessary for a resident having an exacerbation of CHF. R57 was admitted to the hospital and had 45 pounds (lbs) of fluid drained from his body. The failures to identify allegations of abuse, monitor for changes in level consciousness, and provide care and services for a resident having an exacerbation of CHF resulted in an Immediate Jeopardy (IJ) at F600-L; Freedom from Abuse, Neglect, and Exploitation due to the increased likelihood of serious harm or impairment, up to and including death. The facility provided an acceptable removal plan on 01/9/24. The removal plan included assessments of all residents with stomas and educating all nursing staff, including agency nurses, on ostomy management. The removal plan included reviewing all residents receiving anticoagulants and any falls to determine if monitoring and educating nursing staff, including agency nurses, on monitoring residents on anticoagulants who fall, monitoring residents for changes in condition, timely physician notification, accurate documentation, and sending residents to outside providers per physician orders. The removal plan included assessing all residents with a diagnosis of heart failure and educating nursing staff, including agency nurses, of signs and symptoms of CHF and evaluating residents with CHF. On 1/17/2024, the surveyors conducted a revisit and verified that the Removal Plan was fully implemented. The noncompliance remained on 1/17/2024 at a Level F for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Review of R38's Admission Record, provided by the facility, revealed R38 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, ileostomy (surgical opening and attachment of the small intestine to the abdomen where waste is collected in a bag attached to the outside of the abdomen) status, and other intestinal obstruction. Review of R38's Physician Orders, dated 12/06/23 and located under the Orders tab of the electronic medical record (EMR), revealed R38's ostomy wafer and ostomy bag were to be changed daily on the 11-7 shift. Review of R38's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/12/23, revealed R38 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R38 was cognitively intact. Review of R38's undated Care Plan, provided by the facility, documented a focus problem related to R38's ileostomy. It was recorded to change the wafer as ordered and when indicated, to change/empty the ostomy bag after each bowel episode or when full, and to place a proper-fitting wafer around the ostomy site. Review of R38's Progress Notes, dated 01/01/24 through 01/04/24, revealed no documentation of any concerns related to R38's ileostomy. On 01/04/24 at 6:00 PM, R38's family member (F) 6 stated that on the morning of 01/02/24, F7 had started to change R38's ostomy bag, and when F7 removed the bag, F7 found stoma adhesive paste inside of R38's stoma. F6 showed the surveyor a photo of what appeared to be a stoma with a yellow-colored substance occluding the opening of the stoma. F6 reported that the Director of Patient Relations and two nurses had been informed of the incident. F6 stated she believed the photo had been forwarded to staff members. On 01/04/24 at 6:25 PM, the Administrator and Director of Nursing (DON) were asked if they were aware of the alleged incident. The Administrator stated she had been informed on 01/03/24, and she had opened a grievance regarding the allegation. The Administrator confirmed a state reportable incident report had not been sent to the state survey agency. The Administrator stated she had seen the photo but had not enlarged it for closer inspection. The DON stated she had not seen the photo. The Administrator identified two staff members, Registered Nurse (RN) 4 and RN2, as working with R38 on the 11-7 shift from 11:00 PM on 01/01/24 through 7:00 AM on 01/02/24. The Administrator stated RN2 had been suspended because she would not return their call and that RN4 was coming to provide a statement before his shift on 01/04/24. The Administrator did not identify any nurse aides that had worked with R38 on the shift in question. The Administrator confirmed she had not identified the allegation as an allegation of abuse and had not started an investigation of the alleged incident. On 01/04/24 at 6:58 PM, the Administrator provided documentation concerning the allegation. Included in the documentation were R38's Admission Record, Order Summary Report, and a Grievance/Concern Form, where it was recorded, . 1/3/23 [sic] [F6] stated that that [sic] whomever on the 11-7 shift did not change bag/care for colostomy properly . It was documented that the Director of Public Relations filled out the form. There was no documentation of the allegation that stoma adhesive paste was found in R38's stoma. On 01/05/24 at 7:53 AM, the Administrator provided documentation of her investigation of the alleged incident with R38. The documentation included an untitled document, dated 01/04/24, that recorded, . The resident was interviewed by the DON and he stated that there was stoma paste on his stoma. The investigation documentation included a statement from RN4 where it was noted RN4 did not provide care for R38 on 01/02/24, a statement from Licensed Practical Nurse Supervisor (LPNS), and a statement from Licensed Practical Nurse (LPN) 5. It was recorded LPN5 was asked what care he provided to R38 on 01/02/24. It was recorded LPN5 stated he did not change the ostomy bag and did not note any concerns with the ostomy bag. There was no documentation LPN5 was asked any questions specific to the allegation of stoma adhesive paste being inside R38's stoma. On 01/05/24 at 6:55 PM, the Regional Clinician (RC) stated she had been informed a family member had found stoma adhesive paste inside R38's stoma and she had reported it immediately. The RC stated she had seen the photo and F6 had told staff that the substance was stoma adhesive paste. The RC stated R38 had a high output ileostomy, and the facility was using different processes to determine what was the best method for changing and maintaining R38's ileostomy bag. The RC stated staff and family members had been changing R38's ileostomy system two to three times per shift because of leakage. The RC reported that RN2 had tested positive for COVID-19, and that was why she had not been answering the facility's calls. On 01/05/24 at 2:00 PM, F7, who was the family member that allegedly found the stoma adhesive paste in R38's stoma, reported that on 01/02/24 when he arrived at the facility, R38's ostomy bag was clean. F7 stated he found that unusual and began to change R38's ostomy bag. F7 stated when he removed the bag, he found what looked to be stoma adhesive paste inside the stoma. F7 stated, It looked like someone squirted it [adhesive paste] in there. F7 reported he inserted a Q-tip into the stoma three quarters to one inch and pulled out approximately one to one and a half inches of adhesive. F7 reported he began to clean around the stoma, and the pressure caused three additional pieces of adhesive to come from the stoma. F7 reported that after the last piece of adhesive came out, bowel movement began coming out. On 01/06/24 at 10:00 AM, the surveyor observed ostomy supplies, including two tubes of Adapt ostomy adhesive paste, were noted on R38's bedside table. The ostomy adhesive paste was noted to be yellow in color. On 01/06/24 at 10:36 AM, the Unit Manager (UM) stated nurses changed and emptied ostomy bags and aides emptied the ostomy bags. On 01/06/24 at 11:35 AM, the Administrator provided an update to her investigation of the alleged incident with R38. Included a document dated 01/02/24 which recorded Certified Nurse Aide (CNA) 4 had been assigned to R38 on 01/02/24. There was no documentation of an interview with CNA4 included in the documents provided to the surveyor. A statement from CNA3, who was the other CNA assigned to R38's unit, was included in the documentation. The Administrator stated RN4 and RN2 had been interviewed and neither worked with R38 on the shift in question. The Administrator reported that LPN5 had been assigned to R38 on the shift in question and that he had been interviewed and denied any concerns. The Administrator provided documentation of interviews with three other residents where the residents were asked How would you describe your overall care and Do you have any concerns at all that you want to express. There was no documentation the residents were asked questions specific to abuse. There was no documentation a statement had been obtained from F7. The Administrator stated the investigation was ongoing and confirmed the incident did occur. The Administrator was asked if all the aides assigned to R38 on that shift had been interviewed. She stated, No. The Administrator was asked how the facility was protecting residents during the investigation. The Administrator stated residents were being protected with general rounds and observing and monitoring R38's stoma. The Administrator reported she did not know if there were any other residents with stomas in the facility. No further documentation was provided to the surveyor by the end of the survey on 01/09/24 at 12:30 PM. 2. Review of R37's hospital Active Meds sort by Name, located under the Misc (Miscellaneous) tab of the EMR, revealed R37 received 5 milligrams (mg) of apixaban (Eliquis, an anticoagulant) at the hospital on 06/14/23 at 9:00 AM. Review of R37's Admission Record, provided by the facility, revealed R37 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat). Review of R37's Physician Orders, located under the Orders tab of the EMR, revealed R37 was to receive Eliquis 5mg twice daily for atrial fibrillation. Review of R37's Fall Risk Evaluation, dated 06/15/23 at 3:11 AM, revealed documentation R37 was assessed to have behaviors of an altered level of consciousness continuously. The evaluation did not indicate what behaviors R37 exhibited. It was also recorded R37 was ambulatory and incontinent, walking did not occur, and R37's vision was adequate. The Licensed Practical Nurse Supervisor (LPNS) electronically signed the form. Review of R37's Nurses Notes, dated 06/15/23 at 3:22 AM and located under the Progress Notes tab of the EMR, revealed, . @ 0300 [3:00 AM] [R37] was overheard calling out. Upon entering her room, she was noted lying on the floor with only a diaper on (diaper was dry) and was on her left side. Full body assessment revealed no bruised [sic], marks, or contusions. She was assisted back intobed [sic] and [family member] and primary physician were notified, and neurochecks [sic] were initiated . Review of R37's Progress Notes, dated 06/15/23 and located under the Progress Notes tab of the EMR, revealed no documentation to show R37's level of consciousness was monitored from 3:00 AM through 7:00 AM. Review of R37's Nurses Notes, dated 06/15/23 at 8:30 AM and located under the Progress Notes tab of the EMR, revealed, . after reporting on my shift the night nurse said they received a patient [R37] who at the moment was sedated. Patient did not respond at all for entire shift. She had moments of confusion about 3.00am [sic] while they were going round the staff found patient on the floor. they [sic] assessed her and picked her up. They started neuro status. around [sic] 8.30 am [sic] i [sic] walked to the room i tried to call the patient but could respond with mubling [sic]. on the sheet was yellow vomit as if the patient had thrown up. i took her vital signs bp [blood pressure], 159/81, p [pulse]: 161, oxygen 93%, Temp [temperature]: 97.8, and BS [blood sugar]: 251, patient could not obey the command and while i was there patient threw up again. Informed the supervisor, NP [nurse practitioner] and Doctor informed, they decided to evaluate her for few hrs [hours] and then send her out . This was five and one-half hours after R37's fall. Review of R37's Medication Administration Records (MARS), dated 06/15/23 and located under the Orders tab of the EMR, revealed no documentation R37 had been administered a sedative or any medication known to cause sedation. It was documented R37 had received Eliquis, 5 mg at 9:00 AM on 06/15/23. Review of R37's Assessments, Progress Notes, and Misc tabs of the EMR revealed no documentation of neuro checks or monitoring for R37 after her fall. Review of R37's Nurses Notes, dated 06/15/23 at 1:28 PM and located under the Progress Notes tab of the EMR, revealed, . patient was sent out for evaluation due to change of mental status, vomiting, and previous history of fall . Review of R37's Physician/Practitioner Progress Note, dated 06/15/23 at 1:59 PM, revealed, . Nursing states patient had a fall last night. Nursing states patient had 3 episodes of vomiting this morning and is lethargic. Patient seen in bed with eyes closed with minimal response to sternal rub. Due to mental status change, new onset of vomiting, and unwitnessed fall on Eliquis sending patient out for CT to r/o [rule out] bleed . Review of R37's Nurses Notes, dated 06/15/23 at 6:53 PM and located under the Progress Notes tab of the EMR, revealed, . [Hospital name withheld] nurse called at 18:30 [6:30 PM] to ask when was the last time [R37] had Eliquis. Eliquis was las [sic] given at 09:00 [9:00 AM], Diagnosis traumatic brain injury . During an interview on 01/04/24 at 2:35 PM, Registered Nurse (RN) 1 stated neuro checks were supposed to be documented on paper and then placed in the resident's hard chart. RN1 stated she did not remember anything about R37. During an interview on 01/04/24 at 4:41 PM, the Administrator and DON provided a copy of R37's incident report for the fall on 06/15/23. Review of the incident report, dated 06/15/23 and prepared by LPNS, revealed, . heard resident call out for help. Staff entered room and observed her lying on her r [right] side on the floor near the bath [unable to read the rest of this sentence] . was last seen in bed. Resident ambulated without asking for assistance and lost balance . It was recorded R37 was alert and oriented to person and situation. The Administrator and DON were asked if the incident report recorded any neuro checks for R37. They stated no. During an interview on 01/05/24 at 7:58 AM, RN4, who was the nurse responsible for R37 on 06/15/23, stated when R37 was found in the floor, the house supervisor was notified, an assessment was completed, and neuro checks were started. RN4 stated the physician was notified via the on-call system and no call back from the physician was requested. RN4 stated he did not request a return call because R37 did not have any injuries. RN4 stated he did review R37's medications but did not inform the physician that R37 was receiving Eliquis. RN4 stated his call to the physician was just a notification of a fall. RN4 stated he documented the neuro checks, including vital signs, on a neuro check log sheet. RN4 stated after neuro checks were completed, the log sheet was given to the Unit Manager (UM). RN4 stated he did not note any changes in R37's neurological status or vital signs. RN4 stated he believed he did notify the physician R37 was receiving Eliquis. RN4 was reminded he had previously stated he did not notify the physician of this. RN4 then stated, I believe I did. On 01/05/24 at 8:57 AM, the facility provided an investigative summary of R37's fall. The investigative summary included a neuro check sheet and statements from RN4, LPNS, and RN1. Review of the investigative summary revealed: a. Review of R37's Neurological Check Flowsheet, dated 06/15/23, revealed no documentation that R37's level of consciousness had been monitored by RN4 from 06/15/23 at 3:00 AM through 06/15/23 at 7:00 AM. It was documented by RN1 that R37 was alert from 7:00 AM until 11:00 AM on 06/15/23. It was documented R37's BP was 152/70 and pulse rate was 78 at 8:30 AM. This was inconsistent with the documentation included in the Nurses Note dated 06/15/23 at 8:30 AM where RN1 had documented R37's BP was 159/81 and her pulse rate was 161. b. Review of RN4's Accident/Incident Investigation Statement Report, dated 06/15/23, revealed, . I overheard [R37] yelling [and] went into room. I called [LPNS] into the room [and] we assessed her body [and] did neuro checks. The assessment showed no injuries, marks, or contusions. I offered Tylenol for pain [and] [patient] refused. Neuro checks continued to show no change from base line to the last one, between 0630 [6:30 AM] [and] 0645 [6:45 AM]. Pt left in bed in low position [and] encouraged her to stay in bed [and] she stated she understood . c. Review of LPNS's Accident/Incident Investigation Statement Report, dated 06/15/23, revealed, . Around 3 am assigned nurse and myself heard a noise from pt's room so we went in to check on her, upon entering room we found pt laying [sic] on the floor. Pt was assessed and helped back to bed. VS [vital signs] was [sic] stable no visible sign swelling around the head and no injury noted at the time. Pt was talking and was alert, denies any pain. Mentation was within normal limits. Monitored throughout night with no change. Before 8am pt was in bed sleeping and no s/s [signs and symptoms] of distress noted . This was inconsistent with R37's Fall Risk Evaluation, dated 06/15/23 at 3:11 AM, where it was recorded R37 had an altered level of consciousness present continuously. d. Review of RN1's typed statement from the facility provided fall investigative summary revealed, . 6/15/2023 I arrived for my 7am shift on 6/15/2023. I received report about [R37] having a fall overnight and that there were no apparent injuries. The nurse gave me the neuro-check sheet. I rounded on all my residents. [R37] was in bed sleeping. Her bed was low. Her call bell was in reach. Her neuro-checks were within normal limits. I rounded around 8:30am and observed her in bed with a small amount of yellow fluid on her sheet. She was alert but confused and mumbling. I took her vital signs and called the provider. Her vital signs were 159/81, p:61, oxygen 93%, Temp: 97.8 and BS: 251. The provider said to continue monitoring her. We continued to monitor her. Around 11am, the Director of Nursing spoke with the nurse practitioner and received an order to send her to the hospital for an evaluation due to a change in mental status . The form contained RN1's signature. The information in the statement was inconsistent with the Nurses Note, dated 06/15/23 at 8:30 AM, where it was documented R37 was sedated and had not responded at all on the previous shift. The statement did not address R37 vomiting while RN1 was completing her assessment or R37 being unable to obey commands as was documented in the progress note on 06/15/23 at 8:30 AM. On 01/05/24 at 8:59 AM, the surveyor attempted to contact RN1 by telephone. A voice message was left, but no return phone call was received by the end of the survey. During an interview on 01/05/24 at 9:06 AM, Nurse Practitioner (NP) 2 stated she was notified of R37's fall on 06/15/23 at approximately 9:30 AM when she arrived at the facility for her morning rounds. NP2 stated she was not notified when R37 fell . NP2 stated she assessed R37 after being told she had suffered a fall, found the resident unresponsive, and immediately sent her to the hospital. NP2 reviewed R37's EMR and stated she would look at her call reports. NP2 stated she was not at the facility at 3:00 AM and did not receive a call from the facility. NP2 opened a Word document on her computer. The document was headed, Wednesday 6/14/2023. Five nursing homes, including Spring Hills [NAME], were listed on the document. Under each nursing home was a line list containing resident names and specific communication for each resident listed. Under Spring Hills [NAME], R37's name was listed. The specific communication for R37 was recorded as new admit. Continuing with the interview on 01/05/24 at 9:11 AM, NP2 stated she assessed R37 at approximately 9:30 AM. This was six and one-half hours after R37's fall. NP2 stated R37 was unresponsive, had vomited three times, and was on Eliquis, so she had R37 sent to the hospital. NP2 was asked if R37 was sent to the hospital on 06/15/23 at 1:59 PM, the time of her documentation in the progress notes. NP2 stated no. NP2 reviewed documentation in her NP electronic medical records system and stated she had the time of her note detailing R37's assessment and her actions as 10:06 AM. NP2 stated she had recorded the event in the facility's EMR on 06/15/23 at 1:59 PM. Continuing with the interview on 01/05/24 at 9:11 AM, NP2 stated if she had been notified of R37's fall and the fact R37 was receiving Eliquis, she would have probably sent her to the hospital, especially since R37 was vomiting and was unresponsive. NP2 stated again that she was not notified of R37's fall. NP2 was asked what her expectation of staff was if a resident was receiving an anticoagulant and suffered an unwitnessed fall. NP2 stated, Who did they call if I was on call? NP2 stated she should have been notified when the fall occurred and should have been notified at 8:30 AM when the resident was found with vomit on her sheet, vomited again, and was only mumbling. NP2 stated, They should have initiated a 911. During an interview on 01/05/24 at 11:09 AM, the former DON confirmed the facility's policy was to complete an assessment, do neuro checks, notify the physician, and monitor a resident for three days following a fall. The former DON confirmed that monitoring consisted of writing notes on your shift and checking the resident. The DON confirmed levels of consciousness should be monitored with neuro checks. The former DON confirmed the physician should be notified at least within an hour following a fall. The DON confirmed neuro check sheets were part of the clinical documentation and stated at the facility, neuro check sheets were pulled and kept with any statements obtained. The former DON confirmed that information in any statements obtained should be consistent with the information in the clinical record. The former DON confirmed the progress notes at 3:30 AM and 8:30 AM recorded the physician was notified and that staff had been ordered at 8:30 AM to continue evaluation of R37 for a few hours. The former DON stated the progress note at 8:30 AM was detailing what RN4 had allegedly told RN1, and she did not know where RN1 had received that information. The former DON stated the facility did not always send a resident out if they were receiving Eliquis and had an unwitnessed fall; that it would depend on what the doctor said. Continuing with the interview on 01/05/24 at 11:09 AM, the former DON stated information on the neuro check sheets and progress notes should be consistent. The DON confirmed the vital signs listed on the 8:30 AM progress note, RN1's statement, and the neuro check sheet were inconsistent. The DON stated the nurse could have taken multiple sets of vital signs at that time. Continuing with the interview on 01/05/24 at 11:09 AM, the former DON was asked where the documentation was of RN1 monitoring R37's level of consciousness from 3:00 AM through 7:00 AM, following the unwitnessed fall. The former DON stated, He wrote it in his statement that he checked. Review of the facility's policy titled, Head Injury, reviewed October 2023, revealed, . It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury . Assess resident following a known, suspect, or verbalized head injury. The assessment shall include . Neurological evaluation for changes in . Level of consciousness . 36898 3. Review of R57's undated Admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R57's Medical Diagnoses, located in the resident's EMR under the Med Diag tab, revealed the resident was admitted to the facility with diagnoses which included chronic respiratory failure and obstructive sleep apnea. On 11/01/23 the diagnosis of acute on chronic congestive heart failure was added. Review of R57's quarterly Minimum Data Set (MDS), with an ARD of 11/17/23, located in the resident's EMR under the MDS tab, revealed the facility assessed R57 to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. During an interview on 01/04/24 at 9:40 AM, R57 stated back in October 2023, he started having swelling with water. R57 stated he requested an appointment with a cardiologist because of the swelling; however, the facility did not take him seriously. R57 also stated the swelling was so bad, he touched his right leg and the skin split open. R57 stated he finally got an appointment with the cardiologist who sent him directly to the hospital where he had about 60 pounds of fluids drained from him. Review of R57's Physician Note, dated 02/06/23, located in the resident's EMR under the Progress Notes tab, revealed .Chief Complaints chf [congestive heart failure], right knee pain, cardiomegaly .58 yo [year old] male .pt [patient] evaluated today for monitoring of his sob [shortness of breath] .pt completed his ct [CT scan] of his chest .PLAN heart failure seen on ct [.] fu [follow up] with [Cardiologist Name] not available until august [.] will monitor pt currently on diuretics .pt counseled on his high risk of death due to his morbid obesity . Review of R57's Progress Note, dated 10/02/23, revealed Pt complained of r [right] sided swelling. MD [Medical Doctor] notified will be evaluated tomorrow. The nursing progress notes lacked assessment information related to R57's edema (swelling). Review of R57's Physician/Practitioner Progress Note, dated 10/04/23, revealed Note Text: MEDICAL PROGRESS NOTE .chief complaints .chf [congestive heart failure], cardiomegaly .pt is resting, in bed, noted to have ongoing Left side swelling and pain, pt being treated with increased dose of diuretic [fluid pill] .CT chest ordered STAT .Care plan reviewed with pt and nursing [.] vitals reviewed will cont. [continued] to monitor. The note was completed by Nurse Practitioner (NP) 1. NP1's note did not document the extent of the edema or what signs or symptoms nursing was to monitor for the CHF and edema Review R57's Radiology Note, dated 10/04/23, located in the resident's EMR under the Progress Notes tab, revealed Procedure: .Findings: There is moderate congestive heart failure. There is moderate interstitial edema [fluid in the interstitial spaces of the lung], cardiomegaly, and pulmonary vascularredistribution [sic] . Review of a nursing progress note, dated 10/11/23, revealed PT [patient] c/o having trouble breathing. SPO2 [oxygen level]=95%. Will continue to monitor. There was no documented evidence that the resident's physician was notified. Review of R57's Progress Note, dated 10/21/23 revealed small open area to RLE [right lower extremity] weeping measuring about 1.7x2 medi honey applied and covered with CDD [clean dry dressing] NP made aware follow up with podiatry on Monday morning. There was no documented evidence of any intervention to address the CHF and edema that caused the resident to sustain an open area. Review of R57's Progress Note, dated 10/21/23 revealed .Pt complained of shortness of breath O2 @ 94%. I sat resident up and placed O2 @ 2 liters throughout the evening until replaced by C-PAP for sleep. Review of the Progress Notes, dated 10/04/23 through 10/23/23 and located in the EMR Progress Notes tab, revealed no documentation of monitoring for signs and symptoms of CHF for R57. Review of R57's Progress Note, dated 10/23/23 revealed [resident name] left unit with medical transport Mon [DATE]:30 for a Cardiology. Review of R57's Progress Note, dated 10/23/23 revealed Patient confirmed to have been sent from Cardio appt w. [Dr. Name] to [hospital name] and admitted with Dx. CHF. This was 21 days after R57 first complained of swelling and 19 days after an x-ray revealed CHF with no consistent monitoring by nursing and no other treatment than an oral diuretic. During an interview on 01/04/24 at 2:32 PM, LPN 6 was asked if she remembered back in October 2023 when R57 had some swelling. LPN6 started to cry and stated she remembered the resident had so much swelling she called and told NP1 that it looked like he was going to bust open all over his body. LPN6 stated NP1 came into the facility, assessed the resident, and wanted to send the resident to the hospital for IV diuretics; however, the prior Director of Nursing (PDON) told the NP no because of the facility's census numbers. LPN6 stated the NP increased the resident's Lasix medication; however, it continued to worsen. LPN6 further stated his swelling got so bad, the resident's right leg busted open from so much swelling. LPN6 with tears in her eyes stated she thought the resident was going to die. During an interview on 01/05/24 at 10:33 AM, NP1 stated when she assessed R57, she recommended the resident to be sent out to the hospital; however, the facility wanted to treat the resident in house. NP1 stated she ordered a CT scan and increased the resident's diuretic; however, the CT was not able to be completed due to the resident's weight and they had to find a place for him to be able to have the CT completed which caused a delay in treatment. NP1 stated prior to sending out a resident to the hospital, the former DON would have to approve. NP1 stated she wanted to send R57 out to the emergency room because he was already on a high dose diuretic by mouth, so she wanted to send him for IV diuretics. NP1 stated R57 having 45 pounds of fluid drained off was a lot and it was concerning the DON not wanting the resident sent out. NP1 stated a possible negative outcome would have been respiratory failure. During an interview on 01/05/24 at 11:11 AM, the prior Director of Nursing (PDON) stated she did not remember NP1 wanting to send R57 to the hospital due to excess edema. The PDON confirmed the facility's practice was that she would be notified prior to sending any resident to hospital; however, she stated sh[TRUNCATED]

Based on interviews, record review, and review of the facility Administrator's Job Description, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This failure had the likelihood to affect all 115 residents of the facility. 1. The facility's administration failed to ensure residents remained free from neglect and abuse when R37 and R57 sustained actual harm from being deprived of treatment; and R38's family reported that ostomy paste adhesive was found directly in the center of R38's stoma, obstructing the waste from emptying into his ileostomy bag. Even after being informed of the potential abuse, the Administrator failed to identify the event as an allegation of abuse, report the event as an allegation of abuse to the state survey agency, and failed to complete a thorough investigation. Cross Reference: F600-L 2. The facility's administration failed to ensure pharmaceutical services were maintained to meet residents' needs. During the abbreviated survey, the facility consistently had issues with the procurement of residents' admission medications and re-ordering of medications dating back to 06/04/22. The facility's administration stated they were not aware of any concerns related to procurement of medications even though residents' medical records verified a longstanding and ongoing issue. Cross Reference: F755-L Immediate Jeopardy at F600-L Freedom from Abuse, Neglect, and Exploitation was identified and the Administrator was notified on 01/06/24 at 7:46 PM and was determined to start on 06/15/23. Immediate Jeopardy at F755-L Pharmacy Services was identified and the Administrator was notified on 01/06/24 at 7:47 PM and was determined to start on 06/04/22. Acceptable Immediate Jeopardy Removal Plans were received on 01/09/24, which alleged removal of the Immediate Jeopardies at F600 and F755. 3. In addition, Substandard Quality of Care (SCQ) was identified at S483.12 Freedom from Abuse, Neglect, and Exploitation F600. During the survey, actual harm of a resident was identified at F684 Quality of Care. 4. Additionally, the facility's administration failed to ensure through a position description or contract with the Medical Director, how the Medical Director would fulfill their responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility; the facility failed to ensure residents received care from competent nursing staff; the facility failed to ensure residents' clinical medical records were complete and accurate; and failed to have an effective Quality Assurance/Performance Improvement (QAPI) program. Cross References: F726 Competent Nursing Staff; F841 Responsibilities of Medical Director; F842 Resident Records; and F867 Quality Assurance and Performance Improvement. These failures resulted in an Immediate Jeopardy at F835-L being identified and the Administrator notified on 01/08/24 at 6:13 PM. The facility provided an acceptable Removal Plan on 01/9/2024. On 1/17/2024, the surveyors conducted a revisit and verified that the Removal Plan was fully implemented. The noncompliance remained on 1/17/2024 at a Level F for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Review of the Administrator's Job Description, signed and dated 12/06/23, revealed .Position Purpose .Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents .Major Duties and Responsibilities .Plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities, in accordance with current state and federal laws and regulations .Identifies, in conjunction with the Director of Nursing and selected department heads, the facility's key performance indicators. Establishes an ongoing system to monitor these key indicators such as the Quality Assurance and Performance Improvement process throughout the facility .Leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solutions with facility leaders such as census, collections, clinical health, survey readiness, customer service satisfaction .Ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover .optimal resident functioning-physically and psychosocially. Identifies and collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify opportunities for enhanced services to the residents and/or resolve issues .Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight .Makes written and oral reports/recommendations to the governing board concerning the operation of the facility .Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement .Additional Tasks .Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of resident to appropriate regulatory entities. Protects residents from abuse, and cooperates with all investigations . The Director of Nursing's (DON's) job description was requested but not provided prior to exit. During an interview on 01/08/24 at 4:00 PM, the Regional Director of Operations (RDO) stated the facility's administration should have been aware of the pharmacy services issues identified by the survey team. Review of an email from the Administrator to the surveyor dated 01/08/24 revealed the facility did not have a position description for the Medical Director. Review of a statement on the facility's letterhead, signed by the Administrator on 01/07/24 revealed the facility did not have a contract with the Medical Director. NJAC 8:39-9.2 (a) NJAC 8:39-9.3 (a) NJAC 8:39-29.2 (d) NJAC 8:39-29.3 (a) 5, 6 NJAC 8:39-27.1 (a)

Complaint: NJ00157215, NJ00157739, NJ00157827, NJ00158677, NJ00161186, NJ00161524, NJ00162977, NJ00167295, NJ00168545 Based on interview and record review, the facility failed to 1. implement physician orders for post-surgical care when staff did not obtain a high air loss mattress, provide dressing changes twice daily, and ensure the head of the bed was kept lower than 30 degrees for one of one resident (Resident (R) 8) reviewed for post-surgical care; 2. consistently administer wound care as ordered by the physician for resident (R5); and 3. flush gastrostomy tube and provide oral nutrition supplements as ordered for resident (R16) out of a total sample of 65 residents. These failures caused harm when R8's flap reconstruction sutures ripped and an additional surgery was required for repair. Findings include: 1. Review of R8's hospital records, dated 02/17/23 and located under the Misc (Miscellaneous) tab of the electronic medication record (EMR), revealed R8 had a stage 4 (open area exposing muscles, tendons, and bone) sacral (lower back) pressure ulcer with osteomyelitis (infection in the bone) that required surgical intervention consisting of a flap reconstruction (use of healthy tissue from one site of the body to close a wound) for healing. Review of R8's Admission Record, provided by the facility, revealed R8 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Review of R8's hospital discharge orders, dated 02/17/23 and provided by the facility, revealed orders for medications and .Continue local wound and special bed per Plastics [surgeon] . There were no orders from the surgeon attached to or included in the discharge orders. Review of R8's Physician's Orders, dated 02/17/23, revealed an order to cleanse R8's sacral flap closure with soap and water and cover with a dry dressing daily and to maintain head of bed at 30 degrees elevation. There were no orders related to a specialty bed. Review of R8's Care Plan, provided by the facility and dated 02/17/23, revealed a focus problem related to the risk of skin breakdown related to paraplegia and a history of wounds. Interventions included the use of a low air loss mattress. Another focus problem was recorded as actual skin breakdown related to a recent surgery. Interventions included the use of a low air loss mattress which is a type of specialty bed. Review of R8's Admission Summary, dated 02/17/23 at 9:32 PM and located under the Progress Notes tab of the EMR, revealed, . Resident is paraplegic but able to move his [bilateral] lower extremities but claims unable to feel pain, warmth, or cold. Per hospital report, resident maintained to be on bed rest and maintain on 30 degrees HOB [Head of Bed] elevation . Review of R8's Nurses Notes, dated 02/20/23 at 3:26 PM and located under the Progress Notes tab of the EMR, revealed, . patient has a flap incision at the back, patient wound is healing well. No signs of infection . Review of R8's Progress Notes and Assessments tabs of the EMR revealed no further documentation in regard to the sacral flap incision until 02/23/23 at 8:47 AM. Review of R8's Weekly Wound Evaluation, dated 02/23/23 at 8:47 AM and located under the Assessments tab of the EMR, revealed . sacral closure dehisced [opened up]. Deep sutures broken. Base clean. Drain removed. On OR [operating] schedule to reclose Monday . PATIENT SHOULD BE ON HIGH AIR LOSS MATTRESS LIKE CLINITRON, CURRENTLY ON LOW AIR LOSS BED, NURSING AWARE to wash/pack q8 [every eight hours] . The form was electronically signed by the Assistant Director of Nursing (ADON) on 03/17/23. Review of R8's Physician Note, dated 02/24/23 at 9:23 AM and located under the Progress Notes tab of the EMR, revealed, . suture malfunction . pt notes frustration over his sutures popping, pt states now he must go back on Monday to have his sutures redone. new air mattress ordered . Review of R8's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 02/24/23, revealed R8 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R8 was cognitively intact. It was recorded R8 required extensive assistance of two or more people for bed mobility and had a surgical wound. Review of R8's Nurses Notes, dated 02/27/23 at 12:35 PM and located under the Progress Notes tab of the EMR, revealed R8 returned to the facility following a surgical procedure. It was recorded to not slide or pull up on R8. Review of R8's Physician Orders, dated 03/01/23 and located under the Orders tab of the EMR, revealed an order for a Clinitron (a high air loss pressure bed filled with silicone coated glass beds and flushed with warm air which provides a dry fluid-like floatation) bed. On 01/04/24 at 10:39 AM, a call was placed to R8. R8 declined to be interviewed. During an interview on 01/05/24 at 12:31 PM, R8's plastic surgeon stated R8 had a stage 4 pressure ulcer with osteomyelitis that had required surgical intervention for healing. The surgeon stated the intervention involved two surgeries, and after the second surgery, R38 was sent to the facility for care. The surgeon stated his specific discharge orders should have been included with the hospital discharge order, and additionally, he had instructed his office to send his orders to the facility prior to R8's arrival to ensure the facility received them and R8 received the proper care and equipment required. The surgeon stated he had ordered a high pressure bed and for the head of the bed not to be over 30 degrees. The surgeon stated he came to the facility and noted R8 was not on the correct bed. He stated the nurse on duty argued with him, stating the bed was correct, and he had to show her it was not correct. The surgeon stated during his visit, he instructed the nurse to ensure the head of the bed was not elevated over 30 degrees. The surgeon stated that while he was in the room with R8, a staff member came into the room and elevated the head of the bed to 90 degrees. The surgeon stated he instructed the staff member to immediately lower the head of the bed, but the staff member stated, Well, he's got to eat. The surgeon stated during his visit, R8 was rolled to his side, and that is when he identified R8's sutures had been ripped open. On 01/05/24 at 1:18 PM, the surgeon provided a copy of a fax transmission, dated 02/16/23, that recorded, . Attention: . [ADON's name] Admissions . Instructions for New Admission. Pt: [R8] . High Air Loss Mattress [,] No Trapeze [,] Head of bed less than 30 degrees [,] Lift patient off of stretcher with multiple people. Do not use Hoyer. Log roll only with multiple people. Do not flex hips or pull on buttocks . Wash incision with soap and water q [every] 12 hours and dress with dry gauze . Attached was a Transmission Verification Report, dated 02/16/23 at 3:10 PM, that detailed two pages had been successfully sent to a fax number of [PHONE NUMBER]. During an interview on 01/06/24 at 2:36 PM, the Administrator confirmed the facility's fax number was [PHONE NUMBER]. On 01/05/24 at 2:00 PM, the Administrator was asked to provide all clinical documentation for R8, including any hard chart documentation and hospital discharge orders. During an interview on 01/06/24 at 3:58 PM, the Administrator reported she had electronically provided all clinical documentation for R8. The Administrator stated she had securely emailed everything in R8's clinical record to the surveyor. Review of the clinical documentation revealed no admission orders dated 02/17/23 from the surgeon were included. On 01/07/24 at 12:19 PM, the Administrator provided an email order request, dated 02/17/23 at 4:45 PM, which recorded, . We need to order an alternating pressure low air loss mattress for a new patient coming tonight - [R8] . The response was, . Just want to confirm you are ordering our standard size [NAME] APM LAL air mattress (no bed frame)? . The next response was, . Yes, that is correct . confirming that the facility ordered the wrong type of specialty bed for R8. During an interview on 01/07/24 at 10:10 AM, the ADON stated she had looked through the clinical record and did not find any orders or communication from the surgeon prior to R8's arrival at the facility. The ADON confirmed a high air loss mattress was different from a low air loss mattress and confirmed a Clinitron bed was a high air loss bed. The ADON confirmed she would expect staff to reach out to a physician for order clarification if there was something they did not understand and would expect staff to implement any orders received from the physician. The ADON confirmed the clinical record contained no information related to R8's suture malfunction and stated the expectation was for staff to document any incident occurring with the resident. The ADON confirmed the order for the Clinitron bed was dated 03/01/23 after R8 was readmitted to the facility after surgical repair of the flap. The ADON confirmed the care plan should not call for a low air loss mattress. The ADON confirmed the faxed orders were for dressing changes to be completed twice daily, but the orders in the EMR were for once daily dressing changes. The ADON confirmed the dressing changes were only completed once daily. The ADON confirmed the orders were for R8's HOB to be maintained at 30 degrees. On 01/07/24 at 10:50 AM, the Administrator stated it was her expectation for faxes to either be put into the recipient's mailbox or to be delivered to the person the fax was addressed to. The Administrator stated it was her expectation for staff to follow physician's orders, reach out with any questions, and document as appropriate in the clinical record. The Administrator stated she would have expected documentation and physician notification if a resident's sutures ripped or malfunctioned. On 01/08/24 at 2:28 PM, the surgeon was asked if the failure to use the correct specialty bed, not cleaning the incision twice daily as ordered, and elevating R8's HOB above 30 degrees caused the failure of R8's sutures. The surgeon stated, Yes. 29015 2. Review of R5's undated Admission Record located in R5's EMR, under the Profile tab, indicated R5 was admitted on [DATE] and discharged on [DATE] with diagnoses including displaced avulsion fracture of right ischium and peripheral vascular disease. Review of R5's admission Minimum Data Set (MDS), located in the EMR under MDS tab, with an Assessment Reference Date (ARD) of 08/18/22, revealed R5's Brief interview of Mental Status (BIMS) score was 15 out of 15, indicating R5 was cognitively intact. R5 required limited assistance of one person for all functional capabilities. Review of R5's care plan, located in the EMR under the Care Plan tab, dated 10/24/22 (cancellation date), documented R5 had actual skin breakdown left foot open wound, instructing staff to administer pain medication as ordered, and monitor lab results as ordered. There were no documented wound care interventions. Review of the Physician Orders located in the EMR under the Orders tab revealed, Mupirocin Ointment 2%, apply to left foot open wound topically every dayshift for wound care, cleanse left foot open wound with NSS [normal saline] pat to dry, apply Bactroban then cover with dry dressing daily. The order was dated 08/12/22 through 10/03/22. Review of the Treatment Administration Record (TAR), located under the EMR Orders tab, for August 2022 - October 2022, revealed the above treatment order for the left foot was not documented as completed on the following dates: 08/12/22, 08/31/22, 09/01/22, 09/03/22, 09/14/22, 09/18/22, 09/19/22, 09/22/22, 09/24/22, 09/29/22, and 10/03/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Mupirocin Ointment 2%, apply to lesions on chest, arms topically every 12 hours for skin lesions for 21 days. The order was dated 08/13/22. Review of the TAR, located under the EMR Orders tab for August 2022 and September 2022, revealed the above treatment order for lesions had not been documented as completed on the following dates: 08/24/22, 08/26/22, 08/31/22, and 09/01/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Betadine swab sticks swab - apply to right lateral dorsal foot topically every dayshift for right foot wound for 10 days, paint wound on top of right foot with betadine and cover with bordered gauze (not foam) dressing daily. The order was dated 08/23/22 through 09/01/22. Review of the TAR, located under the EMR Orders tab for August 2022 and September 2022, revealed the above treatment order to the right lateral dorsal foot was not documented as completed on the following dates: 08/31/22 and 09/01/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Medi honey wound/burn dressing paste (wound dressing). Apply to right lateral foot topically one time a day for wound care. Apply to right foot wound topically every day for non-healing diabetic foot wound. Cleanse wound at dorsal right lateral foot with NSS. Apply Medi honey, dated 08/24/22 through 09/01/22. Review of the TAR, located under the EMR Orders tab for August 2022 and September 2022, revealed the above treatment to the right lateral foot had not been documented as completed on the following dates: 08/31/22 and 09/01/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Betadine Swab sticks Swab 10%- apply to right lateral dorsal foot topically every shift for right foot wound for 10 days, paint wound on top of right foot with betadine and leave open to air, dated 09/02/22. Review of the TAR, located under the EMR Orders tab for September 2022, revealed the above treatment to the right lateral dorsal foot had not been documented as completed on 09/04/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Triple antibiotic + Pain Relief Ointment [TAO] 1% (Neomy-Bacti-Polymyx-Pramoxine). Apply to left ear topically every 12 hours for left ear wound for 14 days cleanse wound with NSS, apply TAO and cover with thickened gauze for protection, dated 09/01/22 through 09/14/22. Review of the TAR, located under the EMR Orders tab for September 2022, revealed the above treatment to the left ear had not been documented as completed on the following dates: 09/01/22, 09/03/22, 09/04/22, and 09/10/22. Review of the Physician Orders located in the EMR under the Orders tab revealed, Betadine Solution 10% - apply to bottom of left foot topically every day and evening shift for wound care twice daily paint areas on planter aspect with betadine, leave OTA (open to air), dated 10/11/22 through 10/14/22. Review of the TAR, located under the EMR Orders tab for October 2022, revealed the above treatment to the bottom of the left foot had not been documented as completed on the following dates: 10/11/22 and 10/14/22. During a telephone interview on 01/04/24 at 12:30PM, R5 stated her wound care was not consistently done while in the facility and her husband has had to assist. During an interview on 01/05/24 at 4:30PM, the Assistant Director of Nursing (ADON) stated the blanks on R5's TAR either meant it was not completed, or not documented as completed. 15406 3. Review of the undated Admission Record provided by the facility revealed R16 was admitted to the facility on [DATE] with diagnoses including cancer of the tongue, protein calorie malnutrition, tracheostomy (incision into the windpipe opening a direct airway) status, and gastrostomy (artificial opening into the stomach for nutritional support) status. R16 was discharged on [DATE]; his closed record was reviewed. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/18/23 provided by the facility revealed R16's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R16 was 71 inches tall (5'11) and weighed 130 pounds. a. Review of the Order Summary Report from 08/11/23 through 09/25/23, provided by the facility revealed R16 had an order for dated 08/11/23 for, Flush G [gastrostomy] tube with 30 ml [milliliters or one ounce] of water every 8 hr [hours], every shift. The order remained in effect until R16 was discharged on [DATE]. During an interview on 01/04/24 at 9:40 AM, R16 stated the nurses did not flush his G-tube every shift like they were supposed to and at times he went a couple of days without it being flushed. Review of the Care Plan with a cancellation date of 09/25/23 and provided by the facility revealed a focus area of, I require a tube feeding r/t [related to] swallowing problem. Intervention in pertinent part included, I require tube feeding and water flushes. See MD [medical doctor] orders for current feeding orders. The Care Plan did not document a problem of R16 refusing care and treatment. Review of the Medication Administration Record (MAR) for August 2023 in the EMR under the Orders tab revealed two instances, on 08/13/23 day shift and on 08/31/23 day shift, when the G-tube flush was not documented. There were blanks on the MAR on these shifts. Review of the nursing Progress Notes for August 2023 in the EMR under the Progress Notes tab revealed no entries related to these missed G-tube flushes. Review of the Medication Administration Record (MAR) for September 2023 in the EMR under the Orders tab revealed 11 instances: 09/02/23 - 09/08/23 day shift; on 09/08/23 and 09/16/23 afternoon shift; and on 9/13/23 and 9/18/23 night shift, when the G-tube flush was not documented. There were blanks on the MAR on these shifts. Review of the nursing Progress Notes for August 2023 in the EMR under the Progress Notes tab revealed no entries related to these missed G-tube flushes. During an interview on 01/06/24 at 3:31 PM, Registered Nurse (RN) 3 stated R16 was not always cooperative with nursing care. RN3 stated sometimes R16 reported to her he had flushed the G-tube himself. RN3 stated there should be a code entered into the MAR for the G-tube flushes and there should not be blanks on the MAR. RN3 stated there were codes nurses could enter for refusals, being out of the facility etc. During an interview on 01/05/24 at 2:50 PM, the Prior Director of Nursing (DON), who continued to be employed by the company and was in place during R16's stay, stated she remembered R16 and talked with him a lot during his stay. The Prior DON stated she was not aware of concerns related to R16's G-tube not getting flushed. The Prior DON stated if there were blanks on the MAR, she could not say that the G-tube was flushed and if it were not documented, it would not count as being done. During an interview on 01/08/23 at 12:02 PM, the DON stated it was important to flush the G-tube because sometimes it could back up and flushing kept the G-tube patent. The DON stated she could not say what a blank on the MAR meant, such as whether something was done or not done. b. Review of a Physician's Note Late Entry for 08/12/23 in the EMR under the Progress Notes tab revealed, Previously seen outpatient due to significant weight loss, and malnourishment . poor appetite and intake with a 3 months difficulties swallowing . it was determined that PT [patient] had squamous carcinoma [cancer] at left base of tongue . During an interview on 01/04/24 at 9:40 AM, R16 stated although he had a G-tube, during his stay at the facility he did not receive nutrition via the feeding tube and instead took nutrition orally. R16 stated he was supposed to get Ensure (concentrated liquid nutritional supplement) due to not being able to eat much related to cancer (of his tongue). R16 stated he subsisted on Ensure and should have gotten it three times a day. R16 stated he did not get Ensure as often as he should have and some days did not get it at all even though he asked the nurses for it. Review of Orders from 08/11/23 through 09/25/23 in the EMR under the Orders tab revealed R16 had an order dated 08/15/23 for, Ensure Plus three times a day for risk for malnutrition. The order was discontinued on 09/25/23 when the resident was discharged . Review of R16 Care Plan for .risk for malnutrition. with a cancellation date of 09/25/23, provided by the facility, lacked documentation of Ensure Plus or supplement use. Review of the Medication Administration Record (MAR) for September 2023 in the EMR under the Orders tab revealed 13 instances in which the Ensure was not administered: on 09/02/23 - 09/05/23 and 09/07/23 - 09/08/23 at 9:00 AM; 09/02/23 - 09/08/23 at 1:00 PM; and on 09/16/24 at 5:00 PM. There were blanks on the MAR on these shifts. Review of the nursing Progress Notes for August 2023 in the EMR under the Progress Notes tab revealed no entries related to Ensure on these dates/times. During an interview on 01/06/24 at 3:31 PM, Registered Nurse (RN) 3 stated she remembered R16 having Ensure in his room and that he drank when he wanted it. RN3 reviewed the Physician's Orders in the EMR and verified Ensure Plus was to be administered three times a day and that there were numerous blanks on the MAR. She stated there were codes nurses could enter for refusals, being out of the facility etc. During an interview on 01/05/24 at 2:50 PM, the prior Director of Nursing (DON) stated she was not aware of concerns related to R16 not being administered Ensure Plus. The prior DON stated if there were blanks on the MAR, she could not say the Ensure Plus was administered and if it was not documented, it would not count as being done. During an interview on 01/07/24 at 11:16 AM, the Assistant DON (ADON) stated she did not remember an issue with R16 getting his Ensure Plus. The ADON stated R16 should have gotten something else if the Ensure Plus was not available; however, Ensure Plus was typically available on the medication cart. The ADON stated if the facility was out of a supplement, the provider should be updated. Review of the Admission Orders policy dated 11/28/23 and provided by the facility revealed, A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. The licensed nurse will follow such orders. NJAC 8:39-27.1 (a)

Complaint Intake #NJ 4 Based on interviews, record reviews, and review of a facility policy, it was determined the facility failed to implement a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/21/2021, the podiatrist initiated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of not implementing the podiatrist's order, over the course of several weeks, Resident #3's feet became discolored, the left foot developed an open ulcer, and finally the deep tissue injury became covered with dry eschar (a scab like covering). The facility reported ten residents in the facility had pressure ulcers. Findings included: 1. The facility admitted Resident #3 from an acute hospital for rehabilitation after experiencing a fall at home and sustaining a fractured vertebra. The resident also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance with activities of daily living (ADLs) including bed mobility, transfers, locomotion on the unit, dressing, and toileting. The resident had no pressure, arterial, or venous ulcers on admission. A care plan, initiated 09/12/2021, indicated Resident #3 was at risk for impairment of skin integrity and included interventions of providing treatments as ordered and floating or elevating the resident's heels. The order for the Prevalon boots were on the resident's treatment administration record (TAR). A podiatrist's progress note, dated 09/14/2021, indicated Resident #3's heels were intact. A podiatrist's progress note, dated 09/21/2021, indicated Resident #3 had deep tissue injury (DTI) to the left heel. (According to the National Pressure Injury Advisory Panel, a deep tissue injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.) A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A podiatrist's progress note, dated 09/28/2021 at 10:18 AM, indicated Resident #3 did not have a bootie and was complaining of pain to the left heel. The note indicated both feet pulses were diminished, hair growth on the feet was absent, and the feet were discolored purple and tender. The note indicated skin prep (a barrier film) was to be applied to the heel. The note indicated a Prevalon boot was recommended due to deep tissue injury on the left heel. A podiatrist's progress note, dated 10/04/2021 at 9:59 AM, indicated Resident #3 did not have a heel bootie and was complaining of pain to the left heel. The note indicated both feet pulses were diminished, hair growth on the feet was absent, and the feet were discolored with an open superficial ulceration that was macerated (softened by soaking in liquid). An addendum to the podiatrist's progress note, dated 10/04/2021 at 10:00 AM, indicated Resident #3, must have heel bootie. The note indicated skin prep was to be discontinued and [MEDICATION(S)] (an antiseptic), gauze, and Kling (a stretch conforming bandage) were to be applied daily to the left heel. A nurse practitioner's progress note, dated 10/08/2021 at 10:56 AM, indicated Resident #3 had a macerated, small left heel deep tissue injury. The note indicated the podiatrist was following the resident and had ordered [MEDICATION(S)] treatment. The note indicated, Offload [to distribute the weight load to other areas which are not susceptible to pressure areas] with Prevalon boot. A podiatrist's progress note, dated 10/11/2021 at 9:50 AM, indicated the physician found the resident's heels under a pillow. The note indicated the left heel was, dry with eschar. The note indicated, Recommend Prevalon boot due to DTI [deep tissue injury] on the left. The note indicated a recommendation for a pillow to offload the heels while in bed due to the resident's multiple risk factors for [CONDITION(S)], including diabetes mellitus. A treatment administration record (TAR), dated October 2021, indicated a solution of [MEDICATION(S)] was to be applied to the left posterior heel topically every day-shift for a macerated deep tissue injury. The TAR indicated, Prevalon heel bootie needed for left heel. A review of the TARs, dated September and October 2021, indicated the order for the heel protective boots had not been scheduled and did not appear on the TAR. When interviewed on 12/05/2021 at 11:00 AM, the podiatrist stated they came once a week to see residents. The podiatrist stated Resident #3 was very prone to developing pressure ulcers. The podiatrist stated they first saw Resident #3 on 09/14/2021 and trimmed their nails. The podiatrist stated that, based on the resident's risk factors and pulse, they recommended using a pillow to offload pressure to the heels. The podiatrist stated that on 09/21/2021, the resident was complaining of heel pain, and while there was no ulcer, the area was discolored and tender. The podiatrist stated they recommended skin prep treatment and the use of a boot. The podiatrist stated they saw the resident on 10/04/2021, and the wound was progressing. The podiatrist stated the wound was wet and had broken open superficially. The podiatrist stated they were mad, as the resident still did not have a boot. The podiatrist stated they ordered [MEDICATION(S)] for the heel and indicated in their notes, must have bootie. The podiatrist stated they did not know why the resident never got their boot. The podiatrist stated the resident's heel wound was most likely from lying in bed with pressure on the heels. When interviewed on 12/07/2021 at 2:16 PM, Regional Nurse #21, who was the Director of Nursing (DON), during the resident's stay described the process for entering orders and stated when an order was entered, it must be scheduled and confirmed by a nurse to become an active order. Regional Nurse #21 stated a medication must have been scheduled to show up on the medication or treatment administration record (MAR) or TAR. Regional Nurse #21 stated the Prevalon boots, though entered, were not scheduled, or confirmed. Regional Nurse #21 stated the practitioner entered the order themselves but mistakenly did not schedule the order. When asked, Regional Nurse #21 had no explanation as to why the order and recommendations in the progress notes had not been followed up on. When interviewed on 12/07/2021 at 4:44 PM, the Administrator (ADM) stated that every morning a 24-hour report from the electronic record was reviewed in the team meeting. The ADM did not know why these recommendations for a boot were not followed up. When interviewed on 12/07/2021 at 4:44 PM, Regional Nurse #21 stated it was a nursing responsibility to follow up on the 24-hour reports. Regional Nurse #21 stated they did not know why the recommendations were not followed up on. When interviewed on 12/07/2021 at 4:56 PM, Registered Nurse (RN) #24, who was the unit manager during the resident's stay, stated the podiatrist usually correctly entered their own orders. RN #24 stated the 24-hour progress reports were generated daily and were about 35 pages long. RN #24 stated they tried to read the entire 24-hour report, but it was a lot. An undated facility policy titled, Prevention of Pressure Ulcer/Injury, stated, Use foot cradle as necessary and record treatment as ordered. New Jersey Administrative Code § 8:39-27.1(e)