Every finding on record at Autumn Lake Healthcare at Salem County

COMPLAINT# 3043799, 3045753 Based on interviews, review of medical records and other pertinent facility documentation on 6/22/26, it was determined that the facility failed to follow professional standards of practice when they: a) failed to implement Provider's verbal wound treatment order for Nystatin and b) transcribe the verbal order for Nystatin onto the resident's Treatment Administration Record (TAR). This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), and was evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record, Resident #1 was admitted with diagnoses that included, but were not limited to: encephalopathy (brain dysfunction), cachexia (a condition that causes significant weight loss and muscle loss), and hyperlipidemia. A review of Resident #1's comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 3/19/26, revealed a Brief Interview of Mental Status (BIMS) of 5 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #1' medical record revealed a document titled, AUTM Medical Visit 1.0 - V 3, dated 6/4/26 at 9:59 PM, which revealed that the resident was, .noted with fungal rash to sacrum and anus, will add nystatin cream and wound consult. The evaluation further revealed an order as follows: Nystatin cream to the sacrum and anus [twice daily] x7days and wound care consult. A review of Resident #1's Order Summary Report did not reveal the physician's or provider's order for Nystatin. A review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2026, did not include an order for Nystatin. A review of Resident #1's progress notes did not reveal nursing documentation related to the provider's evaluation of the resident's sacral fungal rash. An interview was conducted on 6/22/26 at 1:01 PM with the Nurse Practitioner (NP), who reviewed the evaluation referenced above in the presence of the surveyor. NP confirmed that she evaluated Resident #1 on 6/4/26. She stated she was contacted by the assigned nurse on the day shift, who asked her to assess the resident's bottom. NP further stated that she gave a verbal order to the nurse. NP could not recall any additional details regarding the notification. A review of the medical record revealed that Licensed Practical Nurse (LPN #1) was assigned to the resident on that shift. Surveyor attempted to reach LPN #1 during the survey but was not successful. An interview was conducted on 6/22/26 at 1:34 PM with the Director of Nursing (DON), who stated that she expected that nurses document and implement verbal orders given by a treating provider. In the presence of the surveyor, the DON reviewed the above NP's evaluation and stated that LPN #1 should have documented and implemented the verbal order. A review of the facility's Physician Orders policy, revised April 2024, revealed that nurses were to follow physician/practitioner orders. A review of the facility's Documentation in Medical Record policy, revised April 2026, revealed that the medical record should reflect an accurate representation of the resident's experience and that the documentation should be complete and accurate. N.J.A.C. 8:39-27.1(a)

Intake ID: 2636901Based on interviews, review of closed medical records and other facility documentation, it was determined that the facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission to the facility in accordance with the facility Skin Assessment Policy to prevent altered skin integrity.This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for pressure injury prevention and was evidenced by the following:On 10/23/25 at 10:28 AM, the surveyor reviewed the closed electronic medical record for Resident #1.A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnosis that included but were not limited to; aphasia (loss of ability to understand or express speech), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side, other abnormalities of gait (manner of walking) and mobility, type 2 (two) diabetes (the body does not use or produce insulin effectively to regulate blood sugar levels) without complications, and major depressive disorder, recurrent, unspecified.A review of the comprehensive Minimum Data Set (MDS), an assessment tool, revealed that the resident was discharged from the facility prior to the completion of the admission Assessment and the assessment was unable to be viewed.A review of the Admit/Readmit Screening Tool dated 9/23/25, revealed that the resident was oriented to person and situation only and was not oriented to place or time. Further review of the Admit/Readmit Screening Tool revealed that the resident required one-person physical assistance for transfers. Further review of the Admit/Readmit Screening Tool revealed that the resident's skin integrity was described as normal, warm, dry, with normal turgor (elasticity), and indicated that the resident's skin was intact.A review of the Baseline Care Plan dated 9/23/25, revealed that the resident required one-person physical assistance for personal hygiene, toilet use, dressing, bathing, and bed mobility, and used mobility devices which included a walker and wheelchair. A Further review of the Base Line Care Plan revealed that the resident was alert and was always incontinent of urine and was frequently incontinent of bowel. A Further review of the Base Line Care Plan revealed that the resident did not have any current skin integrity issues and had no history of skin integrity issues.A review of the resident's Order Summary Report revealed a physician's order dated 9/24/25, for Zinc Oxide External Cream 10% (Zinc Oxide (topical)) Apply to b/l (bilaterally, both sides) buttocks topically every shift for wound care.A review of the Treatment Administration Record (TAR) revealed an entry dated 9/24/25 at 5:00 PM, for a Skin Evaluation Weekly; Document under weekly skin evaluation in the evening every Wed (Wednesday) document using the following codes: 0-No Skin impairments, 1-Previous skin impairment present, 2-Newly identified skin impairment . Further review of the entry revealed that the entry was signed out as administered with a code of 1 (one), which indicated the resident had a previous skin impairment present.A Further review of the TAR revealed an order dated 9/24/25 at 10:21 AM, for Zinc Oxide External Cream 10% (Zinc Oxide (Topical)) Apply to b/l buttocks topically every shift for wound care that was administered during the evening shift on 9/24/25.The surveyor reviewed the resident's Progress Notes (PN) which failed to indicate that the facility had previously identified that the resident had a previous skin impairment present upon admission to the facility.On 10/23/25 at 11:44 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #1 who stated that if she noted that a resident's skin was red, she would put Zinc Oxide on it and tell the nurse.On 10/23/25 at 11:44 AM, the surveyor interviewed the License Practical Nurse (LPN) #1 who stated that if any skin issues were identified she would complete an incident report, document the findings in the electronic medical record (EMR), and get an order for a wound treatment. The LPN #1 stated that if a previous skin impairment were identified on the skin assessment then an incident report should have been initiated. The LPN #1 reviewed the resident's closed EMR and confirmed that the resident's skin assessment was coded to indicate that a previous skin impairment was present and that a risk management, or incident report was not completed on behalf of the resident.On 10/24/25 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that nursing was required to document what type of skin impairment was identified. The DON stated that she did not believe that an incident report was initiated for Resident #1 and whether the resident had a previous skin impairment.On 10/24/25 at 1:01 PM, in a later interview with the DON she presented the surveyor with a Body Check Form dated 9/24/25 at 10 AM, which indicated that the resident had edema to b/l Lower extremities and had excoriation (a superficial wound on the skin) to b/l buttocks. When the surveyor asked why the Body Check Form documentation completed on 9/24/25 differed from the Admit/Readmit Screening that was completed on 9/23/25 and indicated that the resident's skin was intact the DON stated, It must have been missed. The DON stated that we do the Body Check Form within 24 hours of admission so we can check to pick up on things that were missed upon admission. The DON further stated, Depending on the severity, it was possible to develop excoriation overnight.On 10/23/25 at 1:36 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that she completed the Body Check Form on 9/24/25 at 10 AM, and described the findings of: edema noted to b/l lower extremities. Excoriation to b/l buttocks. The LPN/UM #1 stated that this was our second day skin assessment because they usually do not catch everything on the first day skin admission assessment. The LPN/UM #1 stated that she did not know if the nurse who completed the admission screening skin assessment was short staffed or was assigned to the medication cart and missed it. The LPN/UM #1 stated that the excoriation to the bilateral buttocks indicated that the resident's buttocks was red and may have been caused by sheering (irritation from friction) and I initiated an order for Zinc Oxide right away to take away the redness. The LPN/UM #1 further stated that the resident was only here for less than 23 hours at that time when she identified the excoriation while she assisted the resident to the bathroom.On 10/23/25 at 1:53 PM, the DON provided the surveyor with an Approved Referral for Medical Care form dated 9/23/25, and she stated that the resident was admitted to the facility from home and was previously ordered Zinc Oxide previously for skin irritation while in the community. The DON acknowledged that the resident's admission assessment failed to identify that the resident had a previous skin impairment present upon admission to the facility and the resident's need for Zinc Oxide was not identified until the resident's skin was assessed by the LPN/UM #1 during care on 10/23/25, which resulted in a delay of Zinc Oxide administration for the resident as was indicated in the resident's medical referral to the facility.A review of the facility's Skin Assessment policy, undated, included:It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management A skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, PRN (as needed) and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified area.NJAC: 27.1(e)

Based on observation, interview, and policy review, the facility failed to ensure the kitchen was clean and staff performed handwashing between glove use and task changes. These failures had the potential to affect 103 residents who consumed food prepared by the facility's kitchen.Findings include: During observation of the kitchen on 08/04/25 at 10:02 AM, dust was noticed on the potholder above the steam table where meals were served and on the ceiling around the vent areas above the sink and shelving. During observation on 08/06/25 at 11:56 AM, lunch was served from the steam table that sat directly beneath the potholder that had dust on it. And staff were observed to use tongs that had been hanging on the potholder. Also, the trays and plates were set up under the vent area where dust was hanging from the ceiling. During the meal service on 08/06/25, the following was observed: At 11;:6 AM, Cook1 was observed to take off gloves and went over to the stove and touched the knob on the front of the stove. Cook1 went to the sink and started grabbing utensils that hung above the sink and moving them over to the steamtable for serving. At 11:58 AM, Cook1 was observed to put gloves on and took dirty dishes to the dish area and returned to the main kitchen wearing the same gloves and went to the sink and began wiping it down. At 12:01 PM, Cook1 was observed to take off gloves and wash hands. There were no paper towels in the dispenser, and she left the kitchen area and went to the storeroom with wet hands and grabbed some napkins. She returned with the napkins and placed them at the sink area. At 12:03 PM, Cook1 was observed to pick up a paper towel off the floor and put it in the trash. Cook1 went over to the stove and adjusted knobs and then reached into a box of gloves and pulled out a pair. During an interview on 08/06/25 at 12:51 PM, Cook1 was asked about the different observations made during the meal service. Cook1 agreed with the observations and admitted her hands should have been washed after taking off gloves and before putting on new gloves. Cook1 stated she should have washed hands after picking up the paper towel and placing it in the trash. Cook1 also confirmed the dust on the ceiling and potholder above the food service area. Cook1 was asked who should be cleaning the ceiling. Cook1 stated she did not know. During an interview on 08/06/25 at 12:55 PM, the Dietary Manager (DM) was shown the ceiling. The DM confirmed the dust and grease was over the food service area. The DM was asked who should clean it and she stated it was maintenance that should clean the ceilings. The DM was also asked about the hand washing observations for Cook1. The DM stated hands should be washed when gloves are removed and before putting on another pair. The DM also stated hand washing should have occurred after picking up the paper towel off the floor. During an interview on 08/07/25 at 12:22 PM, the Maintenance Director (MD) was asked who should clean the ceilings in the kitchen and he stated it was maintenances responsibility. Review of the facility policy titled, Routine Cleaning and Disinfection dated August 2025 revealed, Policy Statement: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Policy Explanation and Compliance Guidelines. 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to. o. Ceiling vents, tiles and ceiling surfaces should be inspected and cleaned when visibly soiled or as part of scheduled deep- cleaning protocols to minimize dust and microbial buildup. 13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Ceiling tiles and air vents should be dusted and cleaned as needed or as part of scheduled preventive maintenance. Review of the facility policy titled, Hand Hygiene dated April 2023 revealed, Policy Statement: All staff perform proper hand hygiene procedures to prevent the spread of infection to the other personnel residents, and visitors. This applies to all staff working in allocations within the facility. Policy Explanation of Compliance Guidelines. immediately before putting on gloves and after glove removal. NJAC 8:39-17.2(g)

Based on observation, interview, and policy review, the facility failed to ensure the dumpsters' lids were closed, the plugs were in place, and used gloves and debris was picked up off the ground. This failed practice had the potential to allow trash and animals to enter and leave the dumpster and cause sanitary issues.Findings include: Observation of the dumpster on 08/04/25 at 10:10 AM, revealed two dumpsters for refuse. Both dumpsters' lids were open and when the dietary Director (DM) shut the lids a liquid substance splashed on the DM. There were gloves and other debris lying on the ground around the dumpsters. Neither dumpster had plugs in the holes at the bottom of the container. During an interview on 08/04/25 at 10:10 AM, The DM was asked whose responsibility it was to clean up the area and maintain the dumpsters. The DM stated the maintenance department. During an interview on 08/07/25 at 12:22 PM, the Maintenance Director (MD) stated it was maintenance responsibility. Review of the facility policy titled, Preventive Maintenance Program dated 12/28/22 revealed, Policy: A preventive Maintenance Program shall be developed and implemented to ensure the provision of safe, functional, sanitary, and comfortable environment for residents, staff, and the public. NJAC 8:39-19.7

Based on observation, record review, interview, and policy review, the facility failed to assess one resident (Resident (R) 7) of 33 sampled residents to self-administer medications prior to leaving medications at the bedside. This had the potential for the resident not to receive their ordered medications.Findings include: During an observation on 08/04/25 at 11:26 AM, an inhaler and a bottle of nose spray were sitting on the bedside table. The resident was asked why they were there. R7 stated, I need to use them. Review of R7's undated admission Record found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and shortness of breath. Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the R7's EMR under the Orders tab revealed physician orders on 03/04/24 for Breo Elipta 200-25 micrograms (MCG)/inhalation aerosol powder, breath activated one puff inhale orally one time a day for COPD. And on 07/03/24 Fluticasone Propionate Nasal Suspension 50 mcg, two sprays in both nostrils one time a day for rhinitis and congestion. Review of R7's comprehensive Care Plan located in the EMR under the Care Plan tab was reviewed and indicated no Care Plan related to the resident administering his own medication. During an interview on 08/07/25 at 1:24 PM, Licensed Practical Nurse (LPN)7 was shown the medication at the bedside. LPN7 stated, These medications should not be there. During an interview on 08/07/24 at 2:34 PM, the Unit Manager (UM)2 was asked if the resident should have medications at the bedside. The UM2 stated residents should be assessed and verified that R7 had not been assessed. During an interview on 08/07/25 2:56 PM, the Director of Nursing (DON) was asked about residents having medication at the bedside. The DON stated, Not without an assessment. Review of the undated facility policy titled, Self-Administration of Medications revealed, Policy Statement: Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation: As part of their overall evaluation, the staff and practitioner (Interdisciplinary team) will assess resident's mental and physical abilities, to determine whether a resident is capable of self-administering medication. NJAC 8:39-29.2(c)6

Based on observation, interview, and review of policy, the facility failed to ensure a resident's dignity was maintained when he laid in bed with his backside exposed to anyone walking in the hallway outside of his room for one resident (Resident (R) 102) out of a total sample of 33 residents. This failure had the potential to cause distress to the resident and other residents and visitors who might witness the exposure.Findings include:Review of R102's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy.Review of Evaluations tab of the EMR revealed R102 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) dated 07/25/25, which indicated moderate cognitive impairment.During an observation on 08/05/25 at 8:30 AM, R102's room door was fully open with R102 lying in the far bed on his side facing away from the door. R102 wore a gown, tied at the neck and open in the back with his back and upper buttocks exposed. He wore an incontinent brief which was also observed and covered the lower half of his buttocks but not the upper buttocks. The top of his blanket covered a strip of his mid-back and the lower part of the blanket covered his legs. No privacy curtain was pulled around the bed.During constant observation of R102's hallway on 08/05/25 from 8:30 AM to 9:30 AM, four staff were observed walking past the door and three residents passed the doorway. None appeared to look into the room.During an interview and observation on 08/05/25 at 9:30 AM, Licensed Practical Nurse (LPN) 2 was asked by this surveyor to look at R102. LPN2 stated his privacy curtain needed to be pulled to provide dignity, as R102 was currently exposed to anyone who might look into his room. LPN2 pulled the privacy curtain around the bed, stated she would get a certified nursing assistant (CNA), and asked the resident if he wanted to get up. R102 responded with a groan-like noise but did not verbally talk.During an interview and observation on 08/07/25 at 3:10 PM, R102 laid in bed facing away from the door. The door was partially closed, which made it difficult to see R102 from the hallway. The resident was observed from the doorway; the privacy curtain was not pulled around his bed. R102 was dressed in a shirt and pants with his pants pulled down exposing most of his buttocks from the doorway. When asked if he wanted others to see his bottom, R102 shook his head no but did not answer further questions.During an interview on 08/06/25 at 4:11 PM, the Director of Nursing stated she expected staff to maintain residents' dignity and to close doors or pull privacy curtains as needed.Review of the facility's Dignity and Respect policy, updated January 2025, revealed that, Residents shall be treated with dignity and respect at all times. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. NJAC 8:39-4.1(a)

Based on record review, interview, and policy review, the facility failed to ensure residents were free from resident-to-resident abuse for two residents of three residents (Resident (R8 and R55) reviewed for abuse out of a sample of 33 residents. Findings include: 1. Review of R8's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R8 admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and other schizophrenia. Review of R8's annual ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/21/25 revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. 2. Review of R55's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R55 admitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety disorder. Review of R55's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 05/02/25 revealed he scored three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 4, dated 05/31/25, revealed nurse reported R8 scratched R55 in face and an incident report was needed. Upon investigation, residents were in dining room in activities and when R8 got in reach of R55, R8 scratched R55's face. When asked why R8 stated I don't know. Residents separated immediately. Review of the Self-Report Form provided by the facility, dated 06/01/25 at 8:04 AM revealed the incident occurred on 05/31/25 at 11:40 AM. Further review revealed the incident did occur and R8 did intentionally scratch R55 in the face. During an interview on 08/06/2025 at 11:29 AM with Unit Manager (UM)1 revealed she spoke with R8 after the incident occurred and he stated that he scratched R55 in the face because he did not like the way he (R55) spoke to a female, and he thought R55 was being disrespectful. During an interview on 08/06/25 at 12:07 PM, LPN4 said on 05/31/25 staff came and told her there was an issue. She saw R55's face, and it was scratched. She said she got statements from the staff and spoke with R8 who stated he did not know why he did it. During an interview on 08/07/25 at 12:43 PM, the Activities Aide (AA)1 said on 05/31/25 R8 and R55 were sitting together in the dining room, while she was reading the daily chronicle to the residents. R8 went to get a lollipop and on his way back he reached across and scratched R55 in the face. AA1 stated she immediately took R55 to the nursing supervisor and then went back and took R8 to his room. During an interview on 08/07/25 at 5:09 PM, the Administrator stated the investigation concluded that the incident did occur. He said they were able to see the incident occur on the security cameras. He said R8 scratched R55 because he felt R55 said something suggestive to a female staff member, and he believed he was defending her. NJAC 8:39-4.1(a)NJAC 8:39-9.4(f)

Based on interviews, record reviews, and policy review, the facility failed to monitor target behaviors for the use of Risperdal (an antipsychotic medication) for one of five residents (Resident (R)5) reviewed for unnecessary medications out of a total sample of 33. This had the potential for R5 to receive medication without being assessed if behaviors had improved or declined. Findings include: Review of R5's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia. Review of R5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/25 and located in the EMR indicated a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated R5 was severely cognitively impaired. The assessment indicated the resident was not exhibiting any behavioral symptoms during the assessment period but was taking an antipsychotic medication. Review of R5's Physician Order Report, dated 08/14/24 and found in the EMR under the Orders Tab, indicated R5 was to receive Risperdal 1 milligrams (mg), one tablet by mouth twice daily for psychotic disorder. Review of R5's Medication Administration Record (MAR), dated June, July and August 2025 and found in the EMR under the Orders tab, revealed no documented evidence to show which specific behaviors were associated with the administration of the resident's antipsychotic medications and required routine monitoring. Review of R5's ''Nurse's Notes'' located in the EMR under the ''Notes'' tab for June, July and August 2025 revealed no documented behaviors related to the diagnosis of psychotic disorder. During an interview on 08/06/25 at 11:29 AM, Unit Manager (UM)1 was asked if specific target behaviors were listed on the resident's monthly psych evaluation. She said if the resident were having any behavior during a shift it would be documented under progress notes, which she counts all behaviors each month and those behaviors are discussed during their weekly meetings. She stated the side effects were listed on the medication administration review to track but not specific behaviors. She was unable to state how any nurse would know what specific behaviors were tracked for a resident if they were only listed on the monthly psych evaluations. During an interview on 08/07/25 at 3:07 PM, the Director of Nursing (DON) stated she expected staff to be monitoring specific target behaviors for residents with psychotropic medications. NJAC 8:39-4.1(a)NJAC 27.1(a)

Based on record review, interview, and policy review, the facility failed to report an allegation of resident-to-resident abuse for two of three residents (Resident (R) 8 and R55) reviewed for abuse out of 33 sampled residents. This failure had the potential to allow for continued abuse. Findings include: 1. Review of R8's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R8 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder and other schizophrenia. Review of R8's annual ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/21/25 revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. 2. Review of R55's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R55 admitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety disorder. Review of R55's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 05/02/25 revealed he scored three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of a ''Nurse's Notes'' located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 4 dated 05/31/25 revealed nurse reported R8 scratched R55 in face and an incident report was needed. Upon investigation, residents were in dining room in activities and when R8 got in reach of R55, R8 scratched R55's face. When asked why R8 stated I don't know. Residents separated immediately. Review of the Self-Report Form provided by the facility, dated 06/01/25 at 8:04 AM revealed the incident occurred on 05/31/25 at 11:40 AM. During an interview on 08/06/25 at 12:07 PM, LPN4 said immediately after the incident occurred on 05/31/25 she reported it to the corporate nurse and the Administrator. During an interview on 08/07/25 at 5:09 PM, the Administrator stated they did not report the incident within two hours of becoming aware of it because the facility had to complete their investigation first. Review of the facility's policy titled Abuse, Neglect and Exploitation undated revealed, the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-9.4(f)

Based on record review, interviews, and policy review, the facility failed to ensure written notice of the transfer to the hospital and the bed hold policy were provided to the resident and the resident's representative upon transfer for three (Resident (R)25, R88, and R4) of four residents reviewed for hospitalization out of a sample of 33 residents. This failure had the potential to cause confusion or distress upon transfer and a lack of understanding of appeal rights or bed hold should the resident not be permitted to return or disagree with the reason for transfer.Findings include: 1. Review of R25's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses including stroke and prostate cancer. Family Member (F) 1 was listed as his only emergency contact. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/06/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition. Review of General Nurses Notes dated 06/28/25 and 06/29/25 and located in the EMR under the Progress Notes tab revealed R25 was sent to the emergency department (ED) on 06/28/25 due to a non-responsive episode. F1 was informed by nursing of the transfer to the ED. He was admitted to the hospital on [DATE]. Review of a copy of R25's Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave dated 06/28/25 and provided by the facility revealed it was directed to R25. The transfer form was addressed: To: ______ with Residents Name under the line where R25's name was handwritten. The transfer form documented the location of the transfer, reason for the transfer, appeal rights, and contact information for appeals and the facility Ombudsman. There was no evidence that this written notice was provided to F1. Review of a copy of R25's Notice A Bed Hold Form dated 06/28/25 and provided by the facility revealed it included the facility's policy on holding a bed and the cost. The form documented: Sent to the hospital with the residents transfer documentation on 6/25/25 by [nursing]. There was no evidence that the form was provided to F1. During an interview on 08/05/2025 at 11:17 AM, F1 reported the facility called him when R25 was sent to the hospital. No verbal information was given regarding the bed hold policy, and no written notice of transfer or bed hold policy were provided to him. 2. Review of R88's admission Record in the EMR under the Profile tab revealed R88 was admitted to the facility on [DATE] with diagnoses including stroke and diabetes. Review of General Nurses Notes dated 11/27/24 and located in the EMR under the Progress Notes tab revealed R88 was taken from an appointment to the hospital where she was admitted for pneumonia. Review of R88's quarterly MDS with an ARD of 07/20/25 and located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated intact cognition. The facility was unable to locate a Notice A Bed Hold Form or Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave for R88's 11/27/24 discharge to the hospital. During an interview on 08/04/25 at 11:30 AM, R88 reported she had been hospitalized for pneumonia. She did not recall receiving any written notice of transfer or the bed hold policy. During an interview on 08/06/25 at 12:37 PM, Licensed Practical Nurse (LPN) 1 reported that the facility had a packet of items which went to the hospital with the resident when they were sent to the ED. The packet included the Notice A Bed Hold Form and the Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave both of which were triplicate forms. The white copy went with the resident, and the pink and yellow copies were kept by the facility. During an interview on 08/06/25 at 12:50 PM, the Social Services Director (SSD) reported she received the pink copies of the Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave and Notice A Bed Hold Form and kept them to use for notifying the Ombudsman of the discharges. During an interview on 08/06/25 at 12:53 PM, the Admissions Coordinator stated it was the facility's policy to let the family know of the transfers to the hospital with a phone call. The Admissions Coordinator was not aware of any paper trail regarding the transfer or bed hold policy. During an interview on 08/06/25 at 2:20 PM, LPN3 reported nursing called residents' responsible parties to let them know when a resident was sent to the hospital. She let the responsible party know where the resident went and why. The facility had a packet of items which went to the hospital with the resident. LPN3 said the original of the Notice of Emergency Transfer to a Hospital and/or Therapeutic Leave and Notice A Bed Hold Form was sent with the resident, and she thought the two copies went to the Director of Nursing (DON) and to the Admissions Coordinator, who notified the family. During an interview on 08/06/25 at 4:02 PM, the SSD provided the pink copies of the two forms for R25 but reported she was unable to locate them for R88. To the knowledge of the SSD, no one in the facility followed up with the responsible party and provided the written forms to them. R25's responsible party was F1. R25 was unable to make decisions on his own. There were no forms for R88 because she went directly from an appointment to the hospital, so the facility did not send them with her. During an interview on 08/07/25 at 2:50 PM, the DON stated that nurses filled out the triplicate sheets for the emergency transfer to the hospital and for the bed hold policy. They sent one to the hospital with the resident, gave one to her, and one went to the SSD to notify family. 3. Review of R4's undated admission Record found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy and multiple sclerosis. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/25 located in the EMR under the MDS tab revealed the facility assessed R4 to have a Brief Interview for Mental Status (BIMS) score of one out of 15 indicating severe cognitive abilities. Review of R4's Progress Notes dated 03/31/25 in the EMR under the Progress Notes tab revealed R4 was transferred to the hospital due to increased oral secretions with respiratory distress. R4 was transferred to the hospital. During an interview on 08/07/25 at 1:43 PM, Licensed Practical Nurse (LPN)7 was asked about the Bed Hold. LPN7 stated, The Bed Hold is in triplicate one copy goes to the hospital with the resident. Second goes to the to the Social Worker (SW) and the third goes to the Director of the Nurses (DON). All we do is call the family member and notify of the hospital. During an interview on 08/07/25 at 2:19 PM, Unit Manager (UM)2 stated the packet is put together and a copy of the Bed Hold is sent with resident, the SW and the DON. UM2 stated the SW will mail the Bed Hold to the family. During an interview on 08/07/25 at 2:44 PM, the SW stated she was not aware of the family receiving the Bed Hold or transfer. Review of the facility's undated Bed Hold Prior to Transfer policy revealed: The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalization or therapeutic leave. The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences. The facility will provide this written information to all facility residents, regardless of their payment source. Review of the facility's undated Transfer or Discharge, Emergency policy revealed: Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: . Prepare a transfer form to send with the resident; Notify the representative or other family member . The policy failed to contain information regarding the notification to the representative or other family member needed to be in writing. NJAC 8:39-4.1(a)NJAC 8:39-5.1(a)NJAC 8:39-5.3(b)

Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one resident (Resident (R)8) out of 33 sampled residents. This failure increased the risk for the resident not receiving specialized services as determined by a Level II prompted by a Level I that indicated mental illness.Findings include:Review of R8's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed R8 admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, post-traumatic stress disorder and other schizophrenia. Review of R8's annual ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 07/21/25 revealed a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Review of the Facility Reportable Investigation dated 06/01/25 revealed he was physically aggressive towards another resident and was sent out for a psych crisis evaluation. Review of R8's PASARR I, located under the Resident Documents tab in the EMR dated 06/25/25 revealed it did not indicate the resident's diagnosis of bipolar disorder, post-traumatic stress disorder or schizophrenia. Further review revealed it did not indicate R8 was sent out for psychiatric crisis evaluation on 06/01/25. During an interview on 08/07/25 at 11:52 AM, the Social Services Director (SSD) revealed R8's PASARR level I was not completed correctly and based on his diagnosis and crisis intervention R8 should have been referred for a level II PASARR. NJAC 8:39-5.1(a)

Based on interview, record review, and policy review, the facility failed to ensure the medical staff documented the correct indication for the use of an antipsychotic medication and instead documented a diagnosis of Schizophrenia in the medical record for one resident (Resident (R) 6) out of five residents reviewed for unnecessary medications out of a total sample of 33 residents. This failure had the potential to cause psychological distress and impact treatment.Findings include:Review of R6's admission Record located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD).Review of the Care Plan tab revealed a focus area, [R6] uses psychotropic medications r/t [related to] mood disorder dated 04/02/25. The Care Plan did not reflect a diagnosis of schizophrenia.Review of a General Nurses Note dated 04/07/25 and located in the EMR under the Progress Notes tab revealed R6 was sent to a hospital for a procedure.Review of an admission Note dated 05/02/25 and located in the EMR under the Progress Notes tab revealed R6 returned to the facility but medications were unable to be verified because he returned without a medication list. The facility was waiting for a fax.Review of a hospital Discharge summary dated [DATE], faxed to the facility on [DATE], and located under the Misc tab of the EMR revealed: continue quetiapine [Seroquel] under the heading of PTSD/mood. The hospital records did not document a diagnosis of schizophrenia.Review of an Order Audit Report for Seroquel (an antipsychotic medication) ordered 05/03/25, located under the Orders tab, revealed the medication order was entered by Licensed Practical Nurse (LPN) 4 and was indicated for schizophrenia. The order was signed by a nurse practitioner on 05/07/25.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS indicated R6 had schizophrenia.Review of the Med Diag [Medical Diagnoses] tab of the EMR revealed a diagnosis of schizophrenia was created on 06/06/25 with an effective date of 05/02/25.During an interview on 08/04/25 at 3:43 PM, R6 reported he had PTSD but denied having schizophrenia.During an interview on 08/05/25 at 3:18 PM, the MDS Coordinator (MDSC) stated she entered the diagnosis of schizophrenia into the EMR while she completed the 05/31/25 quarterly MDS assessment. She clicked the Verify button as directed after completing the MDS to review coding inconsistencies for quality measures. An alert showed up: QM [quality measures] Alert: Resident is receiving antipsychotic [medication] without a diagnosis of schizophrenia, Tourette's Syndrome or Hungtington's disease. This QM is included in the Five Star calculation. The MDSC stated she saw that R6 had an order for Seroquel for schizophrenia and so used that diagnosis for the MDS and entered the diagnosis in the EMR under the Med Diag tab.During an interview on 08/05/25 at 3:50 PM, the Director of Nursing (DON) reported the nurse practitioner who signed the Seroquel order was on emergency medical leave and unavailable for interview.During an interview on 08/06/25 at 9:25 AM, the Regional Nurse stated the schizophrenia diagnosis was an error on admission. During an interview on 08/06/25 at 4:16 PM, the DON stated she looked over R6's documentation and verified he should not have had a schizophrenia diagnosis. During an interview on 08/07/25 at 3:15 PM, LPN4 reported she knew that Seroquel was tricky to receive from pharmacy without a correct diagnosis. When asked if she saw a schizophrenia diagnosis in his hospital documentation, LPN4 stated she was unable to say she saw it, but she had glanced through R6's records and saw that he had behavioral episodes. LPN4 said she went with her clinical judgment to be able to get the Seroquel from the pharmacy.Review of the facility's Medication and Treatment Orders policy, dated July 2024, revealed: Orders for medications must include: . clinical condition or symptoms for which the medication is prescribed . NJAC 8:39-27.1(a)

Based on observation, interview, and record review, the facility failed to provide wound treatments as ordered by the physician for one (Resident (R) 80) of 33 sampled residentsFindings include: Review of R80's admission Record located in the electronic medical record (EMR) under the Admission tab revealed R80 was admitted to the facility on [DATE] with diagnoses including cellulitis of other sites and type 2 diabetes mellitus with other circulatory complications. During an observation and interview on 08/04/25 at 11:15 AM, revealed R80 had an ace bandage on his lower right leg. R80 stated the bandage had not been changed since 08/01/25 and it was supposed to be changed daily. During an observation and interview on 08/04/25 at 11:23 AM, Licensed Practical Nurse (LPN1) revealed R80 had a white bandage under an ace bandage dated 08/01 with LPN1's initials. LPN1 also stated she did wound care on R80's lower right leg on 08/01/25. She further stated R80's wound care was supposed to be done daily. Review of the physician order dated 07/28/25 and located in the EMR Orders tab revealed : Cleanse right lower extremity with normal sterile saline apply absorbent dressing followed by cling wrap with ace bandage every day shift for weeping. Record review of the Treatment Administration Record (TAR) located in R80's EMR under the Orders tab revealed the following: Cleanse right lower extremity with normal sterile saline apply absorbent dressing followed by cling wrap with ace bandage everyday shift for weeping. Order date 07/28/25, discharge date [DATE]. During an interview on 08/07/25 at 2:03 PM, the Administrator stated if the resident's bandage was ordered to be changed every day, his expectation was the bandage to be changed every day. During an interview on 08/07/25 at 2:19 PM, the Director of Nurses (DON) stated the resident's bandage should have been changed every day until the order was discharged according to the physician's order Review of the facility's policy and procedure titled Wound Care, undated, revealed the following: It is the policy of this facility center to provide wound care as directed by physician order to promote healing. NJAC 8:39-3.2(a)

Based on observation, record review, interviews, and policy review, the facility failed to ensure a resident utilizing supplemental oxygen (Resident (R) 65) had orders and a plan of care for its use and a resident (R31) had clean oxygen concentrator filters out of two residents reviewed for oxygen use out of a total sample of 33 residents. This failure had the potential to cause impaired respiratory function.Findings include: 1.Review of R65's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low oxygen levels), acute pulmonary edema (fluid in the lungs), pleural effusion (fluid between the lung and chest wall), and heart failure. Review of the hospital Discharge summary dated [DATE] and located under the Misc tab of the EMR revealed: Patient received incentive spirometry, . and we weaned O2 [oxygen] as tolerated. Patient has been weaned from 4L [liters] to 1L, baseline is room air. Will discharge with oxygen. It also stated to wean O2 as tolerated. If O2 requirements increase, can consider transfer for pulm [pulmonary] eval [evaluation]. Review of R65's Baseline Care Plan dated 07/21/25 and located under the Evaluations tab of the EMR revealed the box for oxygen therapy was not checked. It included no information regarding supplemental oxygen use. Review of R65's Brief Interview for Mental Status (BIMS) dated 07/22/25 and located under the Evaluations tab of the EMR revealed she scored a seven out of 15, which indicated severely impaired cognition. Review of Medical Visits dated 07/22/25 and 07/23/25 and located under the Evaluations tab of the EMR revealed R65 was: Seen at bedside today. continues with supplemental O2 at 1L via NC [nasal cannula]. Review of the Order Recap Report dated 07/21/25 to 08/04/25 and located under the Orders tab of the EMR revealed an order dated 07/23/25 to consult pulmonology for acute hypoxemia requiring supplemental O2. There were no orders regarding supplemental oxygen use to include the amount of oxygen required or the checking of oxygen saturation levels. Review of a Medical Visit dated 07/24/25 and located under the Evaluations tab of the EMR revealed directions to: Wean FiO2 [supplemental oxygen] to keep O2 sat [greater than] 90%.If pulse OX [oxygen saturation levels] remains above 90 percent, patient may not need long term O2. Review of the unfinished Care Plan on 08/04/25 revealed no documentation of R65's use of supplemental oxygen. Review of the O2 Sats [saturations] Summary dated 08/05/25 revealed five documented oxygen saturation levels from 07/21/25 to 08/01/25 and none after 08/01/25. Review of the Progress Notes tab of the EMR revealed no documentation regarding R65's use of oxygen. During an observation on 08/04/25 at 12:23 PM, R65 had a nasal cannula in her nostrils, connected to oxygen tubing, with the end of the tubing lying on the floor and not connected to any oxygen concentrator or tank. The oxygen concentrator in her room was turned on and set at 1L. R65 did not appear in respiratory distress. During an observation on 08/04/25 at 1:08 PM, R65 held the oxygen tubing in her hand with it not connected to her oxygen concentrator or tank. During an interview on 08/04/25 at 2:14 PM, Licensed Practical Nurse (LPN) 1 stated she recalled R65 needed oxygen when she was first admitted to the facility. She felt R65 had orders on admission to wean off the oxygen and to consult pulmonology if she continued to need oxygen. LPN1 reviewed the EMR Orders tab and located the pulmonology order but no orders indicating the use of oxygen. She then went into R65's room and noted her oxygen tubing was connected to the oxygen tank on the back of her wheelchair, which was set at 1L. LPN1 said sometimes when R65 was in bed she did not use oxygen, and her saturation levels were fine. LPN1 felt R65 used the oxygen more with therapy. During an interview on 08/06/25 at 3:44 PM, the Director of Rehab (DOR) reported R65 needed oxygen during therapy. The therapists checked her saturation levels before and during therapy to determine her needs. R65's oxygen saturations sometimes dropped below 90% during activity while utilizing oxygen. During an interview on 08/06/25 at 4:06 PM, the Director of Nursing (DON) voiced the expectation that if a resident used oxygen there were orders for it in the EMR to include the rate and to check a pulse ox (oxygen saturation level) every shift. If there was no order, the nurses were expected to call the provider to obtain one. The nurses were to document oxygen use in the Baseline Care Plan evaluation. Review of the facility's undated Oxygen Administration policy revealed: Oxygen is administered under orders of a physician, except in the case of an emergency. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, . 2.Review of R31's admission Record, located under the Resident tab of the electronic medical record (EMR), revealed R31 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia and acute respiratory failure with hypoxia. Review of R31's quarterly Minimum Data Set (MDS), located in the EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 07/13/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating R31 had severe cognitive impairment. Review of R31's Physician Order Sheet, located in the EMR under the Resident tab, revealed the following order dated 07/10/25: Oxygen Inhalation (via nasal cannula @ 2 lpm) every shift check every shift. During observations on 08/04/25 at 10:59 AM, R31's oxygen concentrator had two dust filled filters located on each side of the concentrator. During an interview on 08/05/25 at 3:48 PM, Registered Nurse Supervisor (RN SUP) stated an RN or Licensed Practical Nurse (LPN) were responsible for cleaning oxygen concentrator filters. During an interview and observation on 08/05/25 at 3:50 PM, LPN1 went into R31's room and brought out the filters and showed them to this surveyor on the 100 hall. LPN1 stated both filters were dusty and dirty. LPN1 further stated maintenance were responsible for cleaning oxygen filters. During an interview on 08/05/25 at 3:57 PM, the Maintenance Director (MD) stated the Certified Nurse Aides (CNA) were responsible for cleaning oxygen concentrator filters. During an interview on 08/05/25 at 3:57 PM, the Director of Nurses (DON) stated the nurses were responsible for cleaning the oxygen concentrator filters. She further stated the filters should be cleaned weekly. During an interview on 08/07/25 at 2:03 PM, the Administrator stated his expectation was for the filters to be cleaned weekly. Review of the facility's policy and procedure titled Departmental (Respiratory Therapy Equipment) - (Prevention of Infection), undated, revealed the following: 9. Wash filters from oxygen concentrators as needed with soap and water. Rinse and squeeze dry. NJAC 8:39-27.1(a)

Based on record review, interview, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms were used between the facility and the dialysis center for one of one resident reviewed for dialysis (Resident (R) 2) out of 33 sampled residents. This had the potential to affect the health of residents receiving dialysis.Findings include:Review of R2's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis.Review of the Care Plan tab revealed a focus area, [R2] needs hemodialysis renal failure dated 03/04/24 with interventions including to check the thrill and bruit (dialysis access site) per protocol, observe/document/report any peripheral edema, any signs of infection to the access site, and any bleeding. Review of the Order Summary Report revealed orders to check vital signs every day shift order date 07/04/24, monitor fistula on left upper extremity every shift dated 05/03/24, remove pressure dressing from dialysis fistula every dialysis day dated 06/03/24, and Dialysis: Dialysis center phone number is: xxx-xxx-xxxx Dialysis days: Monday, Wednesday, Friday. Time for pick up: 4:45 AM, return time 10:30 AM. Transport to: [dialysis center] via wheelchair. with order date 05/03/24.Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS indicated R2 received dialysis.Review of R2's Evaluations tab of the EMR revealed no pre- and post- dialysis evaluations.Review of R2's Medication Administration Record (MAR) dated 07/01/25 - 07/31/25 and located under the Orders tab of the EMR revealed vital signs were recorded daily by day shift but not by night shift when she went out to dialysis.Review of R2's Weights/Vitals and Progress Notes tabs of the EMR revealed inconsistent documentation of pre- and post- dialysis assessments, to include vital signs.Review of R2's Misc tab of the EMR revealed no scanned communication forms between dialysis and the facility.Review of R2's paper chart, located at the nursing desk, revealed Nursing Home Communication Sheets from dialysis to the facility with recorded pre- and post- dialysis weight, blood pressure, and heart rate by dialysis. There were forms for dates: 03/17/25, 03/10/25, 03/21/25, 03/24/25, 03/26/25, 03/28/25, 04/02/25, 05/02/25, and 05/09/25. In addition, the facility was able to provide communication sheets from 07/25/25, 08/01/25, and 08/06/25. There were no communication forms between 04/02/25 to 05/02/25 and between 05/09/25 to 07/25/25. During an interview on 08/05/25 at 8:46 AM, R2 reported she went to dialysis via transport from the facility around 4:00 AM on Mondays, Wednesdays, and Fridays. R2 was unable to recall if the facility staff checked her vital signs, to include her blood pressure, before and after dialysis. She knew they were checked at the dialysis center. R2's dressing over her dialysis access site on her left arm remained intact from her dialysis the day prior. R2 removed the dressing during the conversation and stated, Sometimes when I take it off, I bleed so I put it back.During an interview on 08/06/25 at 2:20 PM, Licensed Practical Nurse (LPN) 3 reported R2 left for dialysis on night shift. When R2 returned on day shift, LPN3 got a paper sent from dialysis with her blood pressure and pre- and post- weights recorded on it. LPN3 stated she put a note in the EMR about what was recorded on the paper from dialysis, and the paper went into R2's paper chart. There were no orders for an assessment upon R2's return from dialysis. During an interview on 08/06/25 at 4:02 PM, the Unit Manager (UM) 1 reported that nursing checked residents' vital signs before they left for dialysis. If there was anything abnormal or anything changed with the residents, nursing called the dialysis center. Dialysis sent a paper communication form back with R2. They were in the paper chart at the desk. In addition, UM1 located three more communication forms from dialysis at the desk that were not in the chart.During an interview on 08/06/25 at 4:05 PM, the Director of Nursing (DON) reported she was used to facilities using communication sheets that went out with residents to dialysis with pertinent information from the facility about the resident's status prior to dialysis as well as the communication from the dialysis center, but she did not think the facility did that. A review of R2's paper chart was completed with the addition of the three dialysis papers provided by UM1, and the DON acknowledged many days were not accounted for. Review of the facility's undated Dialysis policy located in the facility's Survey Binder revealed the facility will send a Dialysis Communication book with communication sheets to be completed and returned.Review of the facility's End Stage Renal Disease, Care of a Resident with policy, updated June 2024, revealed: Staff caring for residents with ESRD [End Stage Renal Disease], including residents receiving dialysis care outside of the facility shall be trained in the care and special needs of these residents. Initiate communication sheets which will be sent and received from the dialysis unit to have routine communication. The communication sheet will be kept on unit and/or in resident medical record. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. NJAC 8:39-27.1(a)

Based on interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails and that assessments were completed for the risk of entrapment for one of four residents (Resident (R)59) reviewed for side rails out of 33 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.Findings include: Review of R59's admission Record located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and cognitive communication deficit. Review of R59's annual Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/09/25, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment. Review of R59's Care Plan, located under the Care Plan tab of the EMR and dated 06/25/24, revealed no intervention related to side rail use. Review of R59's Physician Orders, located under the Orders tab in the EMR and dated 06/27/24, revealed, .may have two half side rails while in bed for repositioning. Review of R59's Resident Evaluation/Bedrail Assist Device, located under the Observations tab in the EMR and dated 06/25/25, revealed no evidence of alternatives explored and no assessment for risk for entrapment. During an interview on 08/06/25 at 11:29 AM, Unit Manager (UM)1 revealed that on admission staff determine if residents need side rails for repositioning, and if so, they get a consent form signed. She said side rails were considered a restraint unless they were used for repositioning and bed mobility. They got a physician order and care planned it and residents were reevaluated quarterly. She said they offer residents alternatives on admission but most of the time they do not want the alternatives, so they are offered the bedrails. UM1 said they do not explore alternates prior to bed rails being used for residents. She said risk for entrapment was done with the consent form, but she did not want to say there was a process to assess for risk of entrapment. She said nursing and nursing assistant staff do a visual observation of the bed and bedrail.During an interview on 08/07/25 at 11:24 AM, the Maintenance Director stated there was not a process to assess for risk of entrapment for bedrail use.During an interview on 08/07/25 at 3:07 PM, the Director of Nursing (DON) said sometimes the family would request bedrails and/or therapy would say if there was a need for bedrails. She said it would be on the care plan, and they got informed consent. She said she was unsure if they are accessing for risk of entrapment or exploring alternatives prior to use.Review of the facility policy titled Siderails undated revealed, each resident has the right to be free from restraints imposed for purposes of convenience or discipline. Siderails will beapplied and monitored within the context of individualized care planning after alternative methods for treating the resident's medical symptoms have been found to be ineffective. On admission all residents will be evaluated for side rail use. Maintenance will do side rail entrapment assessment of the bed and equipment. NJAC 8:39-27.1(a)

Based on interview, record review, and policy review, the facility failed to ensure a medication was ordered upon admission from the hospital for one resident (Resident (R) 113) out of a total sample of 33 residents. This failure increased the risk that the resident would have unrelieved pain.Findings include:Review of R113's admission Record located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses including spondylosis (degenerative changes of the spine) and encounter for other orthopedic aftercare (surgery).Review of R113's hospital Discharge Documentation dated 10/17/24 and provided by the facility from the resident's paper chart revealed she underwent fusion of the spine (back surgery) on 10/08/24 and 10/14/24. R113 had an unplanned cage migration (movement of hardware used during the surgeries, which can cause pain) on 10/15/24. Discharge medications included acetaminophen 1000mg every six hours as needed (PRN) for mild pain and oxycodone 5mg every four hours as needed for moderate pain (pain scale four to seven) for up to five days.Review of R113's Order Recap Report for her admission located under the Orders tab of the EMR revealed orders on admission [DATE]) for pain management included acetaminophen 1000mg every six hours PRN for mild pain as well as for acetaminophen 650mg every four hours PRN for mild pain. The oxycodone 5mg every four hours for moderate to severe pain ordered on the hospital's discharge medication list was not ordered by the facility staff.Review of R113's Medication Administration Record (MAR) dated 10/01/24 - 10/31/24 and located under the Orders tab of the EMR revealed she received acetaminophen 1000mg on 10/17/24 at 10:20 PM for pain rated as 5 on a zero to ten pain scale, which indicated moderate pain, for which oxycodone was ordered per the hospital Discharge Documentation. Review of the MAR revealed the Tylenol was effective with a pain scale rating of zero.Review of NP1's General Note dated 10/18/24 and located under the Progress Notes tab of the EMR revealed R113 appears in obvious pain and restlessness. States she has only had Tylenol for pain and was taking oxycodone 10mg in the hospital.Review of R113's Order Recap Report located under the Orders tab of the EMR revealed that on 10/18/24 at 11:35 AM, NP1 ordered oxycodone 10mg every six hours PRN.Review of R113's discharge Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/26/24 revealed a score on the Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated intact cognition.During a telephone interview on 08/05/25 at 2:20 PM, R113 stated she had major surgery on her back a week prior to her admission to the facility. She stated she had to wait for her oxycodone because the pharmacy closed at a certain time the day she arrived. R113 reported she was in pain and unable to sleep or eat for three days. The oxycodone finally arrived, and the Tylenol (acetaminophen) helped a little bit.During an interview on 08/05/25 at 12:37 PM, Licensed Practical Nurse (LPN)1 reported the process for ordering medications was that nurses entered the admission orders into the EMR off of the hospital's discharge summary after confirming all medications with the nurse practitioner. If medications were awaiting delivery by the pharmacy, there were back up boxes of medications in the medication room. If a medication was not available in the back-up supply, nurses were to call the doctor or nurse practitioner about changing the medication to one the facility had access to.During an interview on 08/06/25 at 2:20 PM, LPN3 also reported that the facility was able to get medications from the back-up box in the medication room. If a medication was not in the back-up supply, nurses called to see if a different medication was available.During an interview on 08/07/25 at 2:55 PM, the Director of Nursing (DON) reported nurses called and reviewed medication orders with the provider for all new admissions. Then nurses entered the medication orders into the EMR. The DON said she was unsure why the oxycodone order from the hospital was not transcribed into the EMR. The nurse who entered the order was no longer employed by the facility, and NP1 was unavailable due to emergency medical leave.During an observation on 08/07/25 at 3:30 PM, the medication room had a locked cupboard of back-up medications. A list of available medications included in the back-up supply included both oxycodone 5mg and oxycodone 10mg.During an interview on 08/07/25 at 5:55 PM, the Medical Director stated that when a resident was admitted to the facility, the nursing staff called the nurse practitioner to confirm the medications. The nurse practitioner conferred with the Medical Director. Nursing staff entered the orders into the EMR for the nurse practitioner to sign. The Medical Director stated he expected that a resident who had a fusion of the vertebrae from lumbar five to sacral one with a biomedical cage/bone graft nine days prior to admission, who received oxycodone in the hospital, and who had it ordered on discharge from the hospital, to have oxycodone ordered by the facility.Review of the facility's Medication and Treatment Orders policy, dated July 2024, revealed, Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Review of the facility's undated Pharmacy Services Overview policy revealed that pharmaceutical services consisted of: The processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, . Pharmacy services are available to residents 24 hours a day, seven days a week. Residents have sufficient supply of their prescribed medications and receive medications [routine, emergency or as needed] in a timely manner. NJAC 8:39-27.1(a)

Complaint #: 2569972Based on interviews, medical record review, and review of other pertinent facility documents on 7/28/2025, it was determined that the facility failed to notify a resident's physician of a low blood sugar result, and to follow facility policy titled Notification of Changes. This deficient practice was identified for (Resident #7), 1 of 3 residents reviewed and was evidenced by the following:A review of the closed Electronic Medical Record (EMR) was as follows:According to the admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes, Hypertension, and Chronic Pain Syndrome. The resident was discharged from the facility on 12/30/2024. According to the Minimum Data Set (MDS), an assessment tool dated 12/30/2024, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. A review of Resident #7's Order Summary Report (OSR) included the following physician orders (Pos):Insulin Aspart Flex Pen Subcutaneous Solution Pen Injector 100 Unit/ml. Inject as per sliding scale: If blood sugar is 0-150=0 Units, 151-200=2 Units, 201-250= 4 Units, 251-300= 6 Units, 301-350= 8 Units, 351-400= 10 Units subcutaneously before meals for Diabetes. Call the Medical Doctor if blood sugar is below 70 or above 350. A review of Resident #7's Medication Administration Record (MAR) dated December 2024 revealed that; on 12/27/2024 at 4:30 PM, the resident's blood sugar was 52. A review of Resident #7's Progress Notes (PNs) for December 2024 did not show any documented evidence that the resident's physician was notified of the resident's blood sugar of 52 on 12/27/2024 at 4:30 PM.A review of the facility's incident report dated 12/28/2024, revealed that the Licensed Practical Nurse (LPN#1) who cared for Resident #7 failed to notify the physician of resident 's low blood sugar result. The surveyor attempted to interview (LPN#1) during the survey but the nurse was not available for an interview and did not return the surveyor's phone call. On 7/28/2025 at 12:05 PM, the surveyor interviewed a unit nurse (LPN #2) who stated that if the resident's blood sugar was less than the parameters listed in the physician's orders, she would notify the doctor. LPN #2 further stated that she would document in a progress note once the doctor was notified. LPN #2 indicated that it was important to call the doctor about a resident's low blood sugar to make them aware so they can determine the next course of action for the resident. On 7/28/2025 at 1:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the doctor should have been notified of the resident's blood sugar result of 52. The DON further stated that the nurse was responsible for notifying the doctor and writing a progress note. The DON indicated that the resident's blood sugar result should have been called to the doctor on the same day. The DON stated it was important to notify the doctor because the resident's medical condition could require immediate treatment. A review of the facility's undated policy titled Notification of Changes under Policy Statement, revealed that The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. NJAC 8:39-13.1(d)

Based on interviews, medical record reviews, and review of other pertinent facility documentation on 7/28/2025, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents. Also, the facility failed to follow its policy titled ADL Documentation Policy. This deficient practice was identified for 3 of 4 residents reviewed for ADL documentation. This deficient practice was evidenced by the following:1.According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Quadriplegia (paralysis of all four limbs), Acute Respiratory Failure, and Dysphagia (difficulty swallowing).According to the Minimum Data Set (MDS), an assessment tool dated 5/15/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident's cognition was intact. A review of Resident #3's DSR (an Activity of Daily Living Record) and progress notes revealed lack of documentation to indicate the resident's ADL care was provided and/or that the resident refused care on the following dates and shifts:Toilet Use:7:00 AM-3:00 PM shift on 7/3/2025, 7/11/2025, 7/16/2025, and 7/24/2025.3:00 PM-11:00 PM shift on 7/27/2025.11:00 PM-7:00 AM shift on 7/5/2025, 7/12/2025, 7/20/2025 and 7/21/2025.2. According to the AR, Resident #4 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Bipolar Disorder, Dementia, and Hyperlipidemia (high levels of fat). According to the MDS, an assessment tool dated 6/14/2025, Resident #4 had a BIMS score of 00 which indicated the resident's cognition was severely impaired. A review of Resident #4's DSR and progress notes revealed lack of documentation to indicate the resident's ADL care was provided and/or the resident refused care on the following dates and shifts:Toilet Use:3:00 PM-11:00PM shift on 7/3/2025.11:00 PM-7:00 AM shift on 7/15/2025.3. According to the AR, Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Diabetes, Hypertension, and Chronic Pain Syndrome. The resident was discharged from the facility on 12/30/2024. According to the MDS, an assessment tool dated 12/30/2024, Resident #7 had a BIMS score of 15 out of 15, indicating the resident's cognition was intact. A review of Resident #7's DSR and progress notes revealed lack of documentation to indicate the resident's ADL care was provided and/or the resident refused care on the following dates and shifts:Toilet Use:7:00 AM-3:00 PM shift on 12/26/2024.11:00 PM-7:00 AM shift on 12/25/2024 and 12/27/2024.On 7/28/2025 at 12:00 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the CNAs were responsible for documenting the resident's ADLs in the computer. The CNA further stated that the ADLs should generally be documented by the end of the shift. The CNA indicated that if the ADL documentation was blank, it does not always mean that care was not given. The CNA stated that the ADL documentation should not be blank, and it was important to document the resident's ADLs to show the type of care the resident received and if there was a decline or improvement in the resident's ADLs. On 7/28/2025 at 1:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the CNAs use the Point of Care (POC), a mobile enable app that runs on wall mounted kiosks that enable care staff to document ADLs. The DON further indicated that the ADL documentation should be completed before the staff clock out for their shift. The DON stated that the Unit Manager (UM) was responsible for checking the ADL documentation to ensure it was completed. The DON stated that a blank space does not necessarily mean that the staff did not provide care. On 7/28/2025 at 1:36 PM, the surveyor interviewed the Unit Manager (UM) who stated I usually try my best to ensure that the POCs are completed. There are times, I can't check by 2 o'clock because I have meetings or get busy. The UM further indicated that she will usually follow up with the regular staff at some point to complete the documentation. The UM further indicated that if there was a blank space that it didn't necessarily mean the care was not provided but that the ADL documentation should have been completed. A review of the facility's undated policy titled ADL Documentation Policy revealed under Policy Statement, The purpose of this policy is to establish guidelines for the documentation of Activities of Daily Living (ADLs) in order to ensure accurate, timely, and comprehensive records that reflect the care provided to residents in our long-term care facility. Under Policy Interpretation and Implementation, 3. Responsibility: All nursing staff and caregivers are responsible for documenting ADLs as part of their daily care routines. Supervisors and management will regularly review documentation for compliance and accuracy.NJAC 8:39-35.2(d) (9)

Complaint #: NJ00179130 Based on interviews, medical record review, and review of other pertinent facility documents on 11/07/2024 and 11/08/2024, it was determined that the facility failed to develop a Care Plan (CP) for a resident that had a diagnosis of Diabetes (high blood sugar levels) and was admitted to the facility with elongated(long) toenails. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was identified for 1 of 7 residents (Resident #2) reviewed for care plans. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Diabetes, Major Depressive Disorder, and Unspecified Dementia (general decline in cognitive abilities that affects a person's ability to perform everyday activities). A review of Resident #2's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 10/27/2024 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition was severely impaired. Revealed under Section I that resident had an active diagnosis of Diabetes. A review of Resident #2's medical record document titled [NAME] (AUTM) Admit/Readmit Screener 1.0-V7 with an effective date of 01/18/2024 and signed date of 01/18/24 revealed under Comments, elongated toenails. A review of Resident #2's CPs did not reveal a focus that addressed Resident #2's diabetes and elongated toenails. During an interview with the surveyors on 11/08/2024 at 10:50 AM, Licensed Practical Nurse (LPN#1) stated that the Unit Manager (UM) was responsible for developing and updating a resident's care plan. LPN#1 further stated the care plan was important for a resident's safety and prevention. LPN #1 stated if a care plan needed to have interventions added she would notify the UM. During an interview with the surveyors on 11/08/2024 at 11:15 AM, the UM stated that she typically updated a resident's CP every quarter and as needed. The UM stated if a resident was a new admission, she would implement the baseline CP and the MDS coordinator would do the comprehensive CP. The UM further stated The baseline CP was a check off sheet. This is where I would check off if a resident was diabetic. The UM further stated that the information she would check off on the baseline care plan would then be transferred to the comprehensive CP. The UM stated that she was responsible for updating the nursing portion of a resident's CP. The UM stated, I do not recall doing a CP for Resident #2's toenails. The UM further stated that if a resident had diabetes there should be a CP in place that addressed the diabetes. The UM stated that it was important that the CP was updated so that the correct interventions were in place to care for the resident's needs. During an interview with the surveyors on 11/08/2024 at 1:21 PM, the Director of Nursing (DON) stated that the nurse, UM, or MDS Coordinator should have caught if a care plan was not initiated for a resident. The DON confirmed that Resident #2 did not have a care plan that addressed diabetes or elongated toenails. The DON further stated Yes, there should have been a care plan that addressed the resident's diabetes and elongated toenails. The DON confirmed that the facility's care plan policy was not followed. Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 07/2024 revealed under Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Revealed under Policy Interpretation and Implementation, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. NJAC 8:39-11.2 (a)

Based on observation, interview and record review, it was determined that the facility failed to: 1) provide pressure relieving devices for a resident at high risk for skin breakdown. Subsequently, Resident #10 developed facility acquired pressure sores; and 2) consistently utilize all pressure relieving devices as identified in the care plan to protect Resident #7 from developing skin breakdown. This deficient practice was identified in Residents #7 and #10, 2 of 3 residents reviewed for pressure sores and was evidenced by the following: 1. During a tour of the facility on 2/23/11 at 9:45 a.m., the surveyor observed Resident #10 lying on his back but slightly turned to the left in bed. The nurse providing the tour information said the resident had [MEDICAL CONDITION]'s Disease as one of his diagnoses, this disease causes degeneration in the brain and is characterized by abnormal, involuntary movements. The nurse further informed the surveyor that this resident had history of pressure sores which were now healed. At 12:15 p.m. on 2/23/11, the surveyor observed the resident who was lying in the same position as seen at 9:45 a.m. this day. At this time, the television against the wall on the left side of the bed was on but the resident did not appear to be looking at it. The resident's eyes were open and the resident appeared to be looking at the surveyor. When the surveyor spoke to the resident, there was no response. At 2:30 p.m., the resident was observed and, again, was lying in the same position as previously observed. Review of the medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was staff dependent and received all nourishment via a gastrostomy tube. A body diagram included with the Admission Nursing Assessment form indicated a "healed decub" on the right hip and a "purple area" on the right great toe. The initial 2/10/11 Resident Assessment Instrument indicated Resident #10 had 1 stage 2 pressure sore on admission and was at risk for developing pressure sores. Documentation on 2/8/11 indicated that the resident was receiving intravenous antibiotics for pseudomonas pneumonia and needed to be sent to the hospital to have the intravenous catheter reinserted after it had become dislodged. The resident was readmitted to the facility on [DATE] and another body diagram was done. The 2/10/11 diagram indicated bilateral lower extremity contractures with skin breakdown. This breakdown was documented as a reddened area (stage 1 pressure sore ) on the left ankle, a stage 2 pressure sore on the left buttock, a healed "4 cm decub(pressure sore)" on the right outer buttock, a reddened scrotum and a "blood blister" on the right great toe. On 2/24/11 at 8:40 a.m., the surveyor observed Resident #10 lying in bed in the same position as observed on 2/23/11. Later on 2/24/11 at 11:30 a.m., the surveyor observed the resident lying on his back in a recliner in the hallway. The resident remained in the hallway until taken to the day room at 1:15 p.m. At 2:30 p.m., the surveyor observed the resident who was in the recliner in the day room. A seat cushion was under the resident's buttocks; there were no pressure relieving devices observed on the lower part of the recliner under the resident's lower extremities. During all surveyor observations throughout the survey Resident #10 was in the same position, on his left back in bed or in the recliner with the resident's legs in the same position: both knees bent with the outer side of the left foot and the inner side of the right foot lying directly against the mattress/chair. On 2/25/11 at 9:50 a.m., the surveyor observed Resident #10 lying in bed in the same left-side-of-back position as had been observed on the previous 2 days. At 11:30 a.m., the surveyor observed the resident was propped with a pillow behind his back and was facing the doorway. At 1:15 p.m., the resident was in the same position facing the doorway. At 1:30 p.m., 2 Certified Nursing Assistants (CNAs) entered the resident's room with a mechanical lift. While preparing to get the resident out of bed, the surveyor observed that both the resident's knees were bent, and did not straighten out when being moved by the CNAs. There were no pressure relieving devices on the resident's lower extremities. The surveyor observed reddish/purplish areas of skin impairment on the left outer ankle bone, the left outer foot and the right "bunion" area. The resident was then placed in a recliner; a cushion was under the buttocks but no pressure relieving devices were under the lower extremities. After this observation, the surveyor reviewed the 2/11 Treatment Administration Record (TAR). The 2/11 TAR included a treatment of [REDACTED]. On 2/28/11 at 9 a.m., the surveyor again observed Resident #10 lying in bed in the same left-side-of-back position. At 10 a.m., the nurse went into the room to provide treatments. The treatments were not started as the resident was exhibiting a change in status. The resident was sent to the hospital for evaluation and did return later the same day. On 3/1/11 at 12:45 p.m., the surveyor observed the resident lying in bed on the left-side-of-back position. Both lower extremities were pulled up and the treatment nurse said the knees were unable to straighten. The resident's skin condition and treatments were observed as follows: a. a 0.7 cm x 0.5 cm stage 2 area on the right 5th toe. b. a 2 cm x 1.5 unstageable area on the right medial heel. c. a 2.6 cm x 2.8 cm stage 1 on the right bunion. d. a 2 cm x 2 cm stage 1 area on the left outer ankle. e. a 3 cm x 2.5 cm stage 1 on the left lateral foot. (A "weekly decubitus report" for the left lateral foot noted a measurement of 2 cm x 1 cm on 2/23/11, thus showing an increase in size.) f. a 2.5 cm x 3.5 cm stage 1 on the left bunion. g. a 1 x 0.5 stage 1 on the left outer foot below the small toe. On 3/1/11 at 1:10 p.m., the surveyor interviewed the treatment nurse who said an air mattress had been ordered "today". The nurse also said she had spoken to the doctor regarding new areas of skin breakdown that had been identified "today". The nurse said treatment orders were obtained as well as a consult for the podiatrist who would be in "tomorrow". At 1:30 p.m., the treatment nurse told the surveyor that an open area on the right hip had been identified "yesterday" and there was a treatment order for this. The surveyor then observed the right hip which was identified as a stage 2 open area measuring 1.5 cm x 1.0 cm x 0.2 cm (depth). The entire affected area of [DIAGNOSES REDACTED] (redness) measured 5 cm x 5 cm. Surveyor observation of the treatment on 3/1/11, review of the 2/11 TAR, documentation in the medical record, the nurse's statement and the surveyor's observations 4 days earlier on 2/25/11, indicated the resident's skin integrity had deteriorated. 2. Resident #7 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The most recent comprehensive assessment by the facility was done on 1/31/11 and documented that the resident was staff dependent for all activities of daily living. The surveyor observed the resident throughout the survey from 2/23/11 to 3/1/11 either lying in bed or lying in a geri-recliner. There was an air mattress on resident #7's bed. The surveyor review of the medical record revealed a 2/16/11 nurse's note which documented the resident developed a right lateral foot pressure sore measuring 2.2 cm x 2.4 cm which was closed and unstageable but appeared to be black in color under the skin surface. On 2/18/11 the doctor wrote an order for [REDACTED]. When interviewed on 2/25/11 at 9:50 a.m., the Unit Manager (UM) told the surveyor that Resident #7 was always pulling her feet up on the mattress which was causing pressure and friction. The UM stated that he was going to have the Occupational Therapist review the resident's positioning. According to the resident's care plan, initiated on 9/6/10, the resident had several interventions which included a pillow between the knees, on the recliner and a pillow to keep the heels off the bed. Although noted as an intervention on the care plan, the UM said Resident #7 did not need a pillow to keep her heels off the bed because the resident was on an air mattress. When the surveyor observed the resident on 2/23/11 at 12:20 p.m., the resident was in a recliner with no pillow under her knees. When the surveyor interviewed the UM at that time, the unit manager informed the surveyor that the CNA forgot to put the pillow on the recliner. During surveyor observations on 2/23/11, 2/24/11, 2/25/11 and 2/28/11, the resident had no antipressure devices or padding to the feet or ankle areas. The surveyor observed Resident #7 wore only socks on her feet and did not have a pillow between her knees as specified in the care plan. When observed on 3/1/11, a pillow was in place. NJAC 8:39 - 27.1 (a)