Every finding on record at Avalon Rehab and Care Center

Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 154 of 159 residents who consume food prepared from the facility's kitchen.Findings include:An observation on 06/02/26 from 10:25 AM to 11:15 AM, with the Dietary Manager (DM), revealed the following: The main refrigerator contained 56 carrots in an open plastic bag with no date label.Two halves of lettuce heads in plastic wrap with no date label. An open cardboard box with ten limes with no date label. Two of the limes had visible white spots. Four opened pie shells with no date label. During an interview on 06/02/26 at 11:20 AM, the DM confirmed the above observations and stated that staff should date all refrigerated products once the food items are opened. The DM also stated that there was no schedule for checking all food for date labels or expired food. Review of the facility's policy titled, Pinnacle Dietary Global, which indicated in Section 4. Labeling and Dating: All opened, cut, peeled, or prepared vegetables must be .dated when prepared/opened. Also, in Section 8. Monitoring: The Food Service Director or designee shall . verify date labels. NJAC 8:39-17.2(g)

Based on record review, interviews, and facility policy review, the facility failed to inform and provide written information for 13 out of 19 residents (Residents (R ) 9 R10, R11, R15, R17, R19, R36, R92, R99, R117, R121, R140 and R142 concerning the right to accept or refuse medical or surgical treatment and, at the resident's or family's or legal representative's option, to formulate and advance directive. This failure had the potential to affect the residents' and their legal representatives' right to participate in and be informed of his or her treatment. Findings include:1.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed Resident (R) 10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), type II diabetes, and schizoaffective disorder. Review of R10's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/21, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated their cognitive function was intact. 2. Review of the admission Record located in the Profile tab of the EMR revealed R17 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, dementia, and peripheral vascular disease. Review of R17's admission MDS with an ARD of 02/09/25, located in the EMR under the MDS tab, revealed a BIMS score of nine out of 15, which indicated their cognitive function was moderately impaired. 3. Review of the admission Record located in the Profile tab of the EMR revealed R19 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, dementia with behavioral disturbance, and congestive heart failure. Review of R19's admission MDS with an ARD of 10/31/21, located in the EMR under the MDS tab, revealed a BIMS score of zero out of 15, which indicated their cognitive function was severely impaired. 4. Review of the admission Record located in the Profile tab of the EMR revealed R36 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, chronic obstructive pulmonary disease (COPD), and neoplasm of unspecified behavior of brain. Review of R36's admission MDS with an ARD of 01/29/20, located in the EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated their cognitive function was intact. 5. Review of the admission Record located in the Profile tab of the EMR revealed R92 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of the ankle and foot, type II diabetes, and peripheral vascular disease. Review of R92's admission MDS with an ARD of 03/02/20, located in the EMR under the MDS tab, revealed a BIMS score of 14 out of 15, which indicated their cognitive function was intact. 6. Review of the admission Record located in the Profile tab of the EMR revealed Resident (R) 99 was admitted to the facility on [DATE] with diagnoses of COPD, type II diabetes, and pneumonia. Review of R99's admission MDS with an ARD of 08/29/25 located in the EMR under the MDS tab, revealed a BIMS score of five out of 15, which indicated their cognitive function was severely impaired. 7. Review of the admission Record located in the Profile tab of the EMR revealed R117 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, manic episodes, and heart failure. Review of R117's admission MDS with an ARD of 11/18/19, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated their cognitive function was intact. 8. Review of the admission Record located in the Profile tab of the EMR revealed R121 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, cerebral infarction, and epilepsy. Review of R117's admission MDS) with an ARD of 04/29/26, located in the EMR under the MDS tab, revealed a BIMS score of 12 out of 15, which indicated their cognitive function was moderately impaired. Review of the EMR for R10, R17, R19, R36, R92, R99, R117, and R121 revealed no evidence of education or discussions in relation to advance directives were provided to the residents or their legal representatives. 9. Review of R140's admission Record, located in the EMR under the Profile tab, revealed R140 was admitted to the facility on [DATE] with diagnoses that included sepsis, unspecified COPD, and methicillin resistant Staphylococcus aureus (MRSA)Review of R140's admission MDS, with an ARD of 04/20/26 and located under the MDS tab of the EMR, revealed R140 had a BIMS score of 15 out of 15, which indicated R140 was cognitively intact. There was no documentation that information, education or offer of assistance to create an advance directive was offered. 10. Review of R142's admission Record, located in the EMR under the Profile tab, revealed R142 was admitted to the facility on [DATE] with diagnoses that included Diverticulitis, peritoneal abscess, and sepsis, Review of R142's admission MDS, with an ARD of 03/23/26 and located under the MDS tab of the EMR, revealed R142 had a BIMS score of 14 out of 15, which indicated R142 was cognitively intact. There was no documentation that information, education or offer of assistance to create an advance directive was offered. 11. Review of R9's admission Record, located in the EMR under the Profile tab, revealed R9 was admitted to the facility on [DATE] with diagnoses that included, unspecified dementia, depression unspecified, and unspecified atrial fibrillation.Review of R9's annual MDS, with an ARD of 03/30/26 and located under the MDS tab of the EMR, revealed R9 had a BIMS score of two out of 15, which indicated R9 was severely cognitively impaired. There was no documentation that information, education or offer of assistance to create an advance directive was offered. 12. Review of R11's admission Record, located in the EMR under the Profile tab, revealed R11 was admitted to the facility on [DATE] with diagnoses that included non-ST elevated myocardial infarction, hypertension, epilepsy unspecified.Review of R11's quarterly MDS, with an ARD of 05/28/26 and located under the MDS tab of the EMR, revealed R11 had a BIMS score of 15 out of 15, which indicated R11 was cognitively intact. There was no documentation that information, education or offer of assistance to create an advance directive was offered. 13. Review of R15's admission Record, located in the EMR under the Profile tab, revealed R15 was admitted to the facility on [DATE] with diagnoses that included pneumonia, sepsis and anxiety disorder.Review of R15's annual MDS, with an ARD of 05/15/26 and located under the MDS tab of the EMR, revealed R15 had a BIMS score of 15 out of 15, which indicated R15 was cognitively intact. There was no documentation that information, education or offer of assistance to create an advance directive was offered. During an interview on 06/03/26 at 3:44 PM, the Social Worker (SW) stated, .There are no advance directives, and they are used for educational purposes only, it's like a legal document that provides wishes, medical care and its normally meshed with a living will, in nursing homes, we only give the education part of the advance directive, the families normally provide it, when we are given POA or living will documentation, if they have it, we only give the education of it all, we don't provide it. If the family doesn't bring it in or doesn't have it, and a lot of times they will just use the POA documentation. During an interview on 06/03/26 at 4:08 PM, the Director of Nursing (DON) stated, .We do a 48–72-hour baseline care plan meeting- we formulate the Portable Medical Orders or Provider Orders for Life-Sustaining Treatment (POLST) and advance care planning. We have the power of attorney or the family in the meeting, and we discuss Advance care planning, meaning, palliative care, chronic disease care, and the goals of care. The advance directives are in the binder. We go by the power of attorney, or the living will if the resident has one. The advanced directives are in the binder. The binder was verified by two surveyors, that the contents of the said binder are the Practitioner Orders for Life-Sustaining Treatment (POLST) and not advance directives. During an interview on 06/03/26 at 4:57 PM, the Assistant Director of Nursing (ADON) stated, .In our initial meeting with the residents or families, we always ask the resident, or family if they have a POLST or advance directive, we do document the POLST but never the advance directive. The POLST is not good enough, the advance directive is the big umbrella. The problem is there is no documentation that we educated the residents on advanced directives. Yes, we read the regulation on advanced directives. Review of the facility's policy titled, Advance Directives dated 12/16, indicated that Advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. NJAC 8:39-9.6(e)

Based on record review and interviews the facility failed to ensure Pre-admission Screen and Resident Review (PASARR), an evaluation for serious mental illness and/or intellectual disability, Level I (preliminary assessment) was accurately completed to identify the resident's psychiatric diagnoses for two out of seven residents, (Resident (R) 5 and R19). The failure to accurately complete the assessment created the potential for R5 and R19 not to be assessed to receive specialized services as needed. Findings Include:1. Review of R5's admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R5 was initially admitted to the facility on [DATE] with diagnoses that included bipolar disorder. Review of R5's annual Minimum Data Set (MDS), located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 03/06/26, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact. The MDS revealed R5 had a diagnosis of bipolar disorder and did not have a Level II PASARR. Review of R5's Care Plan, found under the Care Plan tab in the EMR dated 03/16/22 revealed, .has a behavior problem impulsive behavior r/t [related to] bipolar disorder. Review of R5's PASARR Level I Assessment, provided by the facility and dated 05/12/26 revealed R5 did not have a diagnosis of serious mental illness. 2. Review of R19's admission Record, found in the EMR under the Profile tab, revealed R19 was initially admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type. Review of R19's annual MDS, found under the MDS tab of the EMR, with an ARD of 07/05/25, revealed R19 was severely impaired for daily decision making according to a staff assessment for decision making. The MDS revealed R19 had diagnosis of schizophrenia and did not have a Level II PASARR. Review of R19's Care Plan, found under the Care Plan tab in the EMR dated 11/14/22 revealed, .has a mood problem of shouting.Schizophrenia DX [diagnosis]. Review of R19's PASARR Level I Assessment, provided by the facility and dated 04/10/26 revealed R19 did not have a diagnosis of serious mental illness. During an interview on 06/04/26 at 3:03 PM, the Social Worker (SW) stated she had read the instructions wrong when completing the Level I screening assessments for R5 and R19 and confirmed the severe mental illness diagnoses should have been included in the assessment. During an interview on 06/05/26 at 10:37 AM, the Administrator confirmed the Level I screening assessments for R5 and R19 should have included the severe mental illness diagnoses. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, with a revision date of March 2019, provided by the facility, noted the following:.All residents will receive a Level I PASARR] screen.If level 1 screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process. NJAC 8:39-27.1(a)

Based on observation, interview, record review and policy review, the facility failed to provide assistance with activities of daily living (ADLs) for five residents (Resident (R) 6, 16, 9, 140, and R36) reviewed for activities of daily living (ADLs) out of a total sample of 33. This failure increased the potential for residents to have unmet hygiene needs. Findings include:1. Review of R140's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R140 was admitted to the facility on [DATE] with diagnoses that included sepsis, unspecified chronic obstructive disease (COPD), and methicillin resistant Staphylococcus aureus (MRSA). Review of R140's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/26 and located under the MDS tab of the EMR, revealed R140 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R140 was cognitively intact. It was recorded that R140 was dependent on staff for assistance with ADL's and had no documentation of refusing care. Review of R140's Care Plan, located under the Care Plan tab in the EMR, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative. Observation on 06/02/26 at 8:21 AM R140 had facial hair approximately 1/2 inches long. Observation on 06/03/26 at 10:00 AM R140 still had facial hair. Observation on 06/04/26 at 10:30 AM R140 still had facial hair. R140 stated they would send his/her son to get razors. 2. Review of R16's admission Record, located in the EMR under the Profile tab, revealed R16 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, unspecified chronic obstructive disease (COPD), and Type 2 Diabetes. Review of R16's annual MDS, with an ARD of 04/22/26 and located under the MDS tab of the EMR, revealed R16 had a BIMS score of three out of 15, which indicated R16 was severely cognitively impaired. It was recorded that R16 required substantial/maximum assistance for ADLs and had no documentation of refusing care. Review of R16's Care Plan, located under the Care Plan tab in the EMR, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative. Observation on 06/03/26 9:03 AM revealed R16 had facial hair greater than 1/2 inch on their chin. Observation on 06/04/26 at 8:30 AM revealed R16 had facial hair greater than 1/2 inch on their chin. 3. Review of R6's admission Record, located in the EMR under the Profile tab, revealed R16 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, hypertension, and Type 2 Diabetes. Review of R6's admission MDS, with an ARD of 04/26/26 and located under the MDS tab of the EMR, revealed R6 had a BIMS score of eight out of 15, which indicated R6 was moderately cognitively impaired. It was recorded that R6 was dependent on staff for ADLs with no documentation of refusing care. Review of R6's Care Plan, located under the Care Plan tab in the EMR, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative. Observation on 06/02/26 at 3:26 PM revealed R6 needed a shave and R6's fingernails were greater than 1/4 inch over fingertips with brown debris under their nails and around their nail beds. Observation on 06/04/26 at 10:20 AM revealed R6 needed a shave and R6's fingernails were greater than 1/4 inch over fingertips with brown debris under their nails and around their nail beds. Interview on 06/04/26 at 10:20 AM Certified Nurse Aide (CNA)3, while in R6's room, revealed CNA3 was about to change and bathe R6. CNA3 stated R6 fights them, so it takes two staff to do anything. CNA3 said she was afraid to cut R6's nails because she might cut him/her due to him/her fighting. 4. Review of R9's admission Record, located in the EMR under the Profile tab, revealed R9 was admitted to the facility on [DATE] with diagnoses that included, unspecified dementia, depression unspecified, and unspecified atrial fibrillation. Review of R9's annual MDS, with an ARD of 03/30/26 and located under the MDS tab of the EMR, revealed R9 had a BIMS score of two out of 15, which indicated R9 was severely cognitively impaired. It was recorded that R9 required partial/moderate assistance for ADLs and there was no documentation of refusing care. Review of R9's Care Plan, located under the Care Plan tab in the EMR, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative. Observation on 06/02/26 at 4:33 PM revealed R9 had facial hair noted greater than 1 inch in length and his/her blouse stained with food. Observation on 06/03/26 at 10:00 AM revealed R9 still had facial hair. Observation on 06/04/26 at 9:15 AM revealed R9 resting in bed. R9 still had facial hair. Interview on 06/04/26 at 10:25 AM with Unit Manager Licensed Practice Nurse (UMLPN)2 revealed the resident's nails should be cleaned and trimmed at each bath or shower and at that time facial hair should be removed if the resident wants. Interview on 06/04/26 at 1:55 PM with CNA4 revealed that I help clean the resident's face and change them; I never shave the resident. Interview on 06/04/26 at 2:05 PM with CNA6 revealed that I washed their (R140 and R9) face, I didn't shave their, I never do that. Interview on 06/04/26 at 2:10 PM with UMLPN1 revealed that our female residents should not have facial hair unless they refuse to be shaved, I will get that taken care of. 5. Review of the admission Record located in the Profile tab of the EMR revealed R36 was admitted to the facility on [DATE] with diagnoses of hydrocephalus, osteoarthritis, and chronic obstructive pulmonary disease (COPD). Review of R36's quarterly MDS with an ARD of 05/20/26, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated that R36's cognitive function was intact. The MDS indicated R36 required partial to moderate assistance for oral care and personal hygiene. Review of R36's Care Plan, focus initiated on 03/24/26 and located under the Care Plan tab of the EMR, revealed that R36 had the potential for functional ability performance deficit related to confusion, dementia, disease process, impaired balance, and limited mobility. Interventions in place indicated that the resident is totally dependent on one staff for personal hygiene and oral care. Review of the document titled, Documentation Survey Report v2 for the months of 05/26 and 06/26, located under the Reports tab of the EMR, revealed that R36 required partial to moderate assistance with oral hygiene and personal hygiene. Observations were conducted on 06/02/26 at 12:49 PM, 06/04/26 at 3:34 PM, and on 06/05/26 at 10:35 AM; R36 was observed with chin hair. During an interview on 06/02/26 at 12:56 PM, R36 stated, I didn't even know that I had this hair on my face. I would like it to be removed. During an interview on 06/05/26 at 10:53 AM, UMLPN2 stated, I do make my rounds on the unit, but the CNAs are the ones responsible for residents' grooming and personal hygiene because it is part of the Activities of Daily Living (ADL) task. The CNAs can find it in the plan of care. Review of the facility's undated policy titled, .Activities of Daily Living (ADL), Supporting, revealed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. NJAC 8:39-27.2(g)

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure proper personal protective equipment (PPE), was donned (put on) by Licensed Practical Nurse (LPN) 1 prior to entering into one of six sample residents (Resident (R) 92's) room who was under enhanced barrier precaution. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.Findings include: Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R92 was admitted to the facility on [DATE] with diagnoses of osteomyelitis on ankle and foot, non-pressure chronic ulcer of left heel and midfoot with unspecified severity, and type II diabetes. Review of R92's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/03/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R92's cognitive function was intact. The MDS indicated R92 required partial to moderate assistance for bed mobility and transfers. Review of R92's Care Plan, found under the Care Plan tab of the EMR, had a focus area of Dialysis, and indicated an intervention dated 04/15/24 of Enhanced Barrier Precautions. Observation conducted on 06/02/26 at 12:35 PM, Licensed Practical Nurse (LPN) 1 was observed entering R92's room with gloves on, a glucometer, a glucometer strip, alcohol wipes, and glucometer lancet (puncture needle). LPN1 was observed at R92's bedside, with gloves on, completed the blood sugar testing with no concern, took off his/her gloves and exited R92's room. During an interview on 06/02/26 at 12:39 PM, LPN 1 stated, .I don't need to put the gown on because I just checked the blood sugar. While reading the enhanced barrier precaution signage posted by R92's room, LPN1 read the signage and stated, .See, I only need to put the personal protective equipment, the gown on when I am providing wound care because R92 has a wound. During an interview on 06/05/26 at 2:26 PM, the Infection Preventionist (IP) stated, .When a resident is on enhanced barrier precautions for a wound and has diabetes, the nurses do not need to wear gowns (PPE) when checking for blood sugar levels. The training that we were given is to only wear the gown when giving high-contact care and checking for blood sugar levels is not high-contact care. Review of the document titled Residents who require Enhanced Barrier Precautions dated 01/06/26, indicated, Enhanced Barrier Precautions (EBP) applies to residents with any of the following (for the duration of their stay, unless condition resolves): item #2. Chronic wounds (for example, pressure ulcers, diabetic ulcers, unhealed surgical wound, venous stasis ulcers). Procedure for EBP: 1. Donning PPE – perform hand hygiene, then don gown and gloves before entering the resident's room or beginning high-contact care. 2. During Care _ Keep gown and gloves on for the entire high-contact activity. 3. Doffing (taking off) PPE – Remove gloves and gown inside the resident's room (or immediately after), perform hand hygiene, and change PPE before caring for the next resident. 4. Face Protection – Use mask + eye protection if splash or spray is anticipated. 5. Shared Equipment – Clean and disinfect after use. Note: EBP does not require resident room restriction or dedicated equipment (unlike full Contact Precautions). NJAC 8:39-19.4(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure one of 42 sampled residents (Resident (R) 2) were treated with dignity and respect in a manner and environment that maintained their quality of life. This failure had the potential to negatively impact the quality of life and self-esteem for the affected residents. Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, left femur fracture, and peripheral vascular disease. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated that R2's cognitive function was moderately impaired. Review of R2's care plan focus initiated on 06/01/26, R2 had a functional ability performance deficit related to activity intolerance, aggressive behavior, confusion, dementia, disease process, impaired balance, limited mobility, limited range of motion, musculoskeletal impairment, and hip pain. In place were the interventions: to provide sponge bath when a full bath or shower cannot be tolerated, and the resident required max assistance by two staff to turn and reposition in bed every two hours and as necessary. During an observation on 06/02/26 at 9:36 AM, R2's door was open and R2 was found in bed undressed from the waist down without a sheet or blanket covering R2, and the privacy curtain was not in use while Certified Nurse Assistant (CNA) 5 was gathering additional supplies from the supplies closet, outside of R2's room, for R2's bed bath in progress. The resident remained exposed while asleep as the brief was opened exposing R2's private area. Social Worker (SW) was called to the room and observed with the surveyor that R2's private area was exposed and the privacy curtain was not pulled to provide privacy for R2. Upon CNA5's return to R2's room, she stated that she covered the resident with a sheet, but the resident took it off. SW reminded CNA5 to make sure to utilize the privacy curtains when providing care to residents. During an interview on 06/02/26 at 12:42 PM, SW stated, .Thank you for bringing that to our attention. We started to provide education on privacy and dignity. During an interview on 06/03/26 at 3:11 PM, CNA5 stated, they were giving R2 a bed bath, and after washing him/her, I put him/her shirt on first. CNA5 saw that she ran out of cream and went out to get the cream. When she came back, she saw the surveyor and the social worker in R2's room. CNA5 continued that she should have brought everything inside the room before starting R2's bath. CNA5 stated that she should have closed the door. CNA5 stated that she covered R2, but he/she took off the blanket. CNA5 stated she should have closed the curtain to protect R2's privacy and cover R2 with a banket. CNA5 stated the curtain doesn't close all the way. An observation on 06/03/26 at 3:18 PM with CNA5 in R2's room revealed that the privacy curtain was loose on the curtain rail, but it was still functioning for it to be pulled all the way around R2's foot of the bed and provide complete privacy. Review of the facility's policy titled, Confidentiality and Personal Privacy dated 10/17, indicated, Our facility will protect and safeguard resident confidentiality and personal privacy and on Item #2, sub-item d. The facility will strive to protect the resident's privacy regarding his or her personal care. NJAC 8:39-(a)16

Based on observation, interview and record review, it was determined that the facility failed to provide reasonable access to a telephone without being overheard. This deficient practice was identified for 1 of 3 residents reviewed, Resident#1, and as evidenced by the following:The surveyor reviewed the electronic medical record (EMR) for Resident #1. A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to, schizophrenia (a long-lasting brain disorder that affect how people think logically) and mild intellectual disabilities (below average cognitive functioning). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 8/20/25, had a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident has moderate cognitive impairment. A review of the resident's Comprehensive Care Plan (CCP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, dated 9/1/25, revised 10/17/25 revealed, under the behavior focus area, an entry reflecting the incident with interventions. The interventions section did not reflect an entry that the facility removed the telephone from the resident's room, or what substitute form of private communication the facility provided. On 10/22/25 at 11:15 AM, the surveyor observed Resident #1 was in low bed and did not verbalize care issues. At 1:10 PM, the survey team met and interviewed Employee #1 (E#1), who informed the surveyor that they were surprised of the allegation of Resident #1. E#1 further stated that the resident had history of calling 911 for non emergency situation and that the facility team had decided to remove the resident's phone in their room. At 1:20 PM the surveyor did not observe a phone in Resident #1's room. At 1:45 PM the surveyor interviewed the Unit Manager (UM) where Resident #1 resided. The UM stated that the Resident's Representative (RR) agreed to have the phone removed. The UM further stated that we let them use the phone at the nurse's station. The UM also confirmed that the care plan was not updated to reflect the plan for removing the phone in resident's room. At 1:47 PM, the surveyor interviewed a Licensed Practical Nurse (LPN), who stated that they (resident) could use the phone at the nurse's station. At 1:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Nurse for the above concerns. The DON stated that the RR of Resident #1 had agreed to remove the phone in room. The DON further stated that any resident can use the phone at the nurse's station. The facility management had no response when asked by the surveyor how the facility able to provide privacy and accommodation to the resident if resident would be using the phone in the nurse's station. On 10/22/25 at 2:10 PM, the surveyors met with the LNHA, DON, and Regional Nurse for an exit conference and there was no additional information provided by the LNHA. A review of the undated facility's Resident Rights Policy reflected, under 1f. Communicate with and access to people and services.outside the facility. 1x. Communicate with outside agencies.1ab. Access to a telephone. 1ac. Communicate in person and by mail, email and telephone with privacy. N.J.A.C. 8:39-4.1 (a)(20)

Based on record review, interview, and facility policy review, the facility failed to ensure residents and/or resident representatives were provided with a written bed hold notice for facility initiated emergent hospital transfer for four of four residents (Resident (R) 50, R110, R123, R57) reviewed for facility initiated emergent hospital transfers of 33 sample residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility. Findings include: 1.Review of Nursing Progress Note, located in the Progress Note tab of R123's electronic medical record (EMR) revealed she had a Nursing Note dated 10/15/24 and timed 6:40 PM stated she was sent to the hospital emergency room for increased confusion, lethargy, stumbling and getting physically and verbally aggressive. Review of the Nursing Progress Note, located in the Progress Note tab of R123's EMR, dated 10/15/24 and timed 3:03 AM, stated the hospital was called and the nurse was informed R123 was admitted to the hospital with delirium with dementia and acute kidney injury. Review of the Nursing Progress Note, located in the Progress Note tab of R123's EMR,dated 10/18/24 and timed 3:02 AM, stated she was readmitted to the facility. The EMR was reviewed in its entirety and was silent for a bed hold notice related to this transfer/discharge. 2. Review Nursing Progress Note, located in the Progress Note tab of R110's EMR revealed she was transferred/discharged to the hospital from [DATE] to 06/18/24, from 08/21/24 to 08/24/24, and from 11/06/24 to 11/10/24. A Nursing Progress Note, located in the EMR under the Progress Note tab, dated 06/05/24 and timed 12:58 PM, stated she was admitted to the hospital for respiratory failure. Review of a Nursing Progress Note, located in the EMR under the Progress Note tab, dated 08/21/24 and timed 8:39 AM, stated, at around 5:45 AM the resident was noted to have shortness of breath, was wheezing, and was using her accessory muscle to breath. According to the note she was transferred to and admitted to the hospital for congestive heart failure. Review of the Nursing Progress Note, located in the EMR under the Progress Note tab, dated 11/06/24 and timed 10:24 PM, stated the resident was sent out to the hospital at 9:45 PM. Review of the Nursing Progress Note, located in the EMR under the Progress Note tab, dated 11/07/24 and timed 1:50 AM, stated the hospital was called and stated she was admitted to the hospital with congestive heart failure and respiratory distress. The record was reviewed in its entirety and was silent for a bed hold notice being issued to the resident or the resident's responsible party at the time of each transfer/discharge. 3. Review of R50's nursing progress note located in the progress note tab of R50's EMR dated 11/05/24 and timed 9:25 AM stated R50 was sent to the emergency room because she had a low blood pressure, low oxygen saturation, low hemoglobin, elevated blood urea nitrogen and creatine. Review of a nursing note dated 11/11/24 and timed 4:12 pm revealed she remained in the hospital until 11/11/24 at 12:35 PM when she was readmitted to the facility. The record was reviewed in its entirety and was silent for a bed hold notice related to this transfer/discharge. 4. Review of R57's nursing progress note located in the progress note tab of R57's EMR dated 12/10/24 and timed 2:21 PM stated R57 was sent to the hospital emergency room because of abnormal blood work. A nursing progress note dated 12/11/24 and timed 1:09 AM stated he was admitted to the hospital for acute Renal failure. The record was reviewed in its entirety and was silent for a bed hold notice related to this transfer/discharge. On 12/19/24 at 9:54 AM each of the above discharges/transfers were reviewed with the Regional Nurse, and she verified the residents/residents' responsible parties were not given a bed hold notice at the time of each discharge/transfer to the hospital. Review of the facility's policy titled Bed-Holds and Returns with a revised date of 03/22 stated, All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding and reserving a resident's bed during periods of absence (hospitalization or therapeutic leave) at the time of transfer and it the transfer was an emergency within 24 hours. NJAC 8:39-5.3

Based on record review, interview, and facility policy review, the facility failed to ensure residents were provided with written transfer/discharge notice that contained the option to appeal the transfer/discharge for four of four residents (Resident (R) 50, R110, R123, and R57) reviewed for facility initiated emergent hospital transfer of 33 sample residents. This failure had the potential to affect the residents and their Resident Representative by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of a Nursing Progress Note, located in the Progress Note tab of R123's electronic medical record (EMR), dated 10/14/24 and timed 6:40 PM, stated R123 was sent to the hospital emergency room for increased confusion, lethargy, stumbling and getting physically and verbally aggressive. Review a Nursing Progress Note, located in the EMR under the Progress Note tab, dated 10/15/24 and timed 3:03 AM, stated the hospital was called and the nurse was informed R123 was admitted to the hospital with delirium with dementia and acute kidney injury. Review of a Nursing Progress Note, located in the EMR under the Progress Note tab, dated 10/18/24 and timed 3:02 AM, stated she was readmitted to the facility. Review of the issued document titled, Notice of Emergency Transfer dated 10/14/24 and provided by the facility, revealed the document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 2. A Nursing Progress Note, located in the Progress Note tab of R110's EMR revealed she was transferred/discharged to the hospital from [DATE] to 06/18/24, from 08/21/24 to 08/24/24, and from 11/06/24 to 11/10/24. A Nursing Progress Note, located in the EMR under the Progress Note tab, dated 06/05/24 and timed 12:58 PM, stated she was admitted to the hospital for respiratory failure. Review of the issued document titled, Notice of Emergency Transfer dated 06/05/24 and provided by the facility, revealed she was transferred to the hospital for shortness of breath. The document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Review of a Nursing Progress Note, located in the EMR under the Progress Note tab, dated 08/21/24 and timed 8:39 AM, stated at around 5:45 AM the resident was noted to have shortness of breath, was wheezing, and was using her accessory muscle to breath. According to the note she was transferred to and admitted to the hospital for congestive heart failure. Review of the issued document titled, Notice of Emergency Transfer dated 08/21/24 and provided by the facility, revealed she was transferred to the hospital for shortness of breath. The document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. Review of a the Nursing Progress Note, located in the EMR under the Progress Note tab, dated11/06/24 and timed 10:24 PM, stated the resident was sent out to the hospital at 9:45 PM. Review of the Nursing Progress Note, located in the EMR under the Progress Note tab, dated 11/07/24 and timed 1:50 AM, stated the hospital was called and stated she was admitted to the hospital with congestive heart failure and respiratory distress. Review of the issued document titled, Notice of Emergency Transfer dated 11/06/24 and provided by the facility, revealed she was transferred to the hospital for shortness of breath and was admitted for congestive heart failure and respiratory distress. The document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. Review of R50's Nursing Progress Note, located in the EMR under the Progress Note tab, dated 11/05/24 and timed 9:25 AM, stated R50 was sent to the emergency room because she had low blood pressure, low oxygen saturation, low hemoglobin, elevated blood urea nitrogen and creatine. Review of a Nursing note dated 11/11/24 and timed 4:12 PM revealed she remained in the hospital until 11/11/24 at 12:35 PM when she was readmitted to the facility. Review of the issued document titled, Notice of Emergency Transfer dated 11/05/24 and provided by the facility, revealed she was transferred to the hospital for decreased oxygen saturation and decreased vital signs. The document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 4. Review of R57's Nursing Progress Note, located in the Progress Note tab of R57's EMR dated 12/10/24 and timed 2:21 PM, stated R57 was sent to the hospital emergency room because of abnormal blood work. A Nursing Progress Note, dated 12/11/24 and timed 1:09 AM, stated he was admitted to the hospital for acute renal failure. Review of the issued document titled, Notice of Emergency Transfer dated 12/10/24 and provided by the facility, revealed she was transferred to the hospital for abnormal bloodwork. The document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. On 12/19/24 at 9:54 AM the notices were reviewed with the Regional Nurse and she verified the discharge notices did not include the explanation of the residents/responsible parties right to appeal and corresponding documentation. Review of the facility's policy titled, Transfer or Discharge Notice with a revised date of 03/2021 stated, The resident and his/her representative would be given a transfer/discharge notice as soon as practicable before a transfer or discharge. Five (5) d of the policy stated the notice would include an explanation of the resident's right to appeal the transfer or discharge to the state, including: the name, address, email, and telephone number of the entity which receives appeal hearing requests; information about how to obtain, complete, and submit an appeal; and how to get assistance completing the appeal process. NJAC 8:39-4.1(a)31

Based on interviews, record review, and review of facility policy, the facility failed to ensure a care plan was revised quarterly for one of 36 residents (Resident (R) 103) reviewed for care plan revision. Specifically, the facility failed to schedule quarterly care conferences or invite R103 to the scheduled care conferences. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team, revealed, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. During an interview on 12/16/24 at 3:48 PM, R103 said she did not know about any care conferences and had never been invited. She said she would like to participate in the care conferences. Review of R103's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included type 2 diabetes, depression, and muscle weakness. Review of R103's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an assessment reference date (ARD) of 09/06/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R103 had no cognitive impairment. The MDS revealed R103 was dependent on all activities of daily living (ADL) except eating and oral hygiene. Review of the IDCP (Inter-Disciplinary Care Plan) Meeting dated 10/12/23 revealed a care conference was held and R103 attended. Review of the IDCP Meeting dated 01/16/24 revealed a care conference was held and R103 attended. There was no additional documentation of R103 attending the care conference after January 2025 During an interview on 12/18/24 at 3:30 PM, the Director of Social Services (DSS) said normally he would get a list from the MDS Coordinator (MDSC) and schedule the care conferences based on that list. He said he would invite the resident and if they were unable to attend their family would be contacted. He said he would document whether the resident was invited and whether they attended the meeting. He said it was important for the resident to attend the meeting. The DSS said he had started working at the facility in July 2024. During an interview on 12/19/24 at 9:37 AM, the MDSC said she and the other MDS nurse would complete care conferences when there was not a social worker available. The MDSC said they would schedule quarterly care conferences by following the MDS schedule. The Director of Nursing (DON) said it was very important to have the care conference, so residents were updated on their medical status. NJAC 8:39-11.2(e),(f),(h)

C#NJ 148344 Based on observation interview, and facility policy review, the facility failed to ensure the meal menu was followed. This failure had the potential to result in weight loss and/or continued hunger for 40 of 119 residents. Findings include: Observation and interview on 05/14/24 at 11:45 AM in the kitchen revealed Dietary Employee (DE) 1 placed the scoops/serving utensils in the food items located on the steam table. He placed a #10 scoop (3.2-ounce scoop) in the sausage paella. He was observed to serve the residents on the first three carts the 3.2 ounce serving when the menu stated a 6-ounce portion should have been given. At 11:45 AM DE1 verified he used the #10 scoop to serve the sausage paella. At 11:54 AM the scoop size was again verified with DE1 and the Dietary Manager (DM). The DE used the 3.2-ounce scoop to serve the trays on the first and second carts to the first floor, and to the residents on the first cart to the second floor. During an interview on 05/16/24 at 9:12 AM the menu for the lunch meal on 05/14/24 meal was reviewed with the DM and the Regional Corporate Manager. Review of the menu revealed the regular and chopped diets were supposed to receive six ounces of the sausage paella. The DM verified DE1 should have used a six-ounce scoop for the sausage paella. Review of the list of residents on the carts with there diets was requested. On 05/16/24 at 10:30 AM the list was provided. Review of the list revealed 26 residents on regular diets were on the first two carts to the first floor and 14 resident trays for residents on regular diets was sent to the second floor. Review of the facility's policy titled Menu Accuracy Policy dated 12/10/23 stated the Facility kitchen staff will follow menu in place as provided, as approved by the dietitian to meet nutritional requirements and regulations .menu items and portion sizes listed on the menu must be served. NJAC 8:39-17.4 (a)3

C#NJ 148344 C#NJ 148677 Based on observation, interview, and facility policy review, the facility failed to ensure window screens were in good repair, open windows had screens; and failed to ensure walls and floors in resident rooms were maintained in clean condition for 10 of 53 rooms. This failure created a non-homelike environment. Findings include: Observation on 05/14/24 at 3:38 PM of resident room [ROOM NUMBER] revealed the window screen in the window had a hole that extended the entire width of the window. Observation on 05/15/24 at 10:58 AM of resident room [ROOM NUMBER] revealed the window screen was torn all the way across the window. Observation on 05/15/25 at 2:41 PM of resident room [ROOM NUMBER] revealed the window screen was torn all the way across the window. Observation on 05/15/24 at 11:47 AM of resident rooms [ROOM NUMBER] revealed the window screens were torn and had several holes. Observation on 05/15/24 at 2:14 PM of resident room [ROOM NUMBER] revealed the window screen 232 was torn all the way across the window. Observation on 05/14/24 at 11:06 AM of resident room [ROOM NUMBER] revealed the window did not contain a window screen. Continued observation revealed the window was opened approximately two inches. The window did not have a screen to prevent the entrance of insects. Observation on 05/15/24 at 3:39 PM of the window in the resident activity room on unit B3 was open approximately two inches. Continued observation revealed there was no screen in place to prevent the entrance of insects. Observation on 05/15/24 at 11:05 AM of resident room [ROOM NUMBER] revealed the wall by the door and under the window was soiled with dried, yellow-colored drips. The floor had brown dirt built up along the walls all the way around the room. Observation on 05/15/24 at 11:17 AM of resident room [ROOM NUMBER] revealed what appeared to be dirt build up on the floor along the wall in room. During an observation and interview on 05/15/24 at 2:41 PM, the Director of Maintenance (DOM) and the Administrator verified the walls and floor were both soiled. The DOM stated it appeared as if someone waxed over the dirt on the floor along the walls. Continued observation of the above identified rooms revealed both the DOM and the Administrator verified the concerns. Review of the facility's policy titled Environment Care revised 05/01/23, stated the Maintenance Department would maintain the building in good repair. Review of the facility's policy titled, Housekeeping revised 09/01/23. The policy indicated the facility would have enough equipment and supplies required to meet the needs of the housekeeping services. NJAC 8:39-4.1(a)11, 31.4(a)

Based on observation, interview and review of the facility's policy, the facility failed to ensure medications were locked in a secure storage area and only authorized personnel had access to the medications. Observation revealed medications delivered by the pharmacy was left at a nurses' station where residents, visitors, and unauthorized employees had access to the medications. This had the potential to cause injury to residents who would ingest them or to residents who need them in the event they are stolen due to not being supervised. This had the potential to affect the 93 residents residing on the second floor with a census of 119. Findings include: Observation on 05/16/23 at 6:05 AM of the second floor nurses' station revealed four brown paper bags of medications sitting on the nursing station within plain view and within reach of anyone standing at the nursing station. Continued observation revealed no staff around were in the line of sight of the bags of medications and Resident (R) 24 was sitting in a chair across from the nursing station. During the continuous observation on 05/16/23, at 6:10 AM Certified Nurse Aide (CNA) 9 came behind the nursing station and sat down and began working on the computer next to the bags of medications. At 6:12 AM Licensed Practical Nurse (LPN) 6 arrived at the nurses' station. LPN6 stated the medications had arrived from the pharmacy that morning and they should have been locked up. She verified CNA9 was sitting in the nursing station and R24 was sitting in the hall directly across from the nurses' station where the medications were sitting. Three of the bags were open with easy access to any of the medications and one of the bags was stapled shut. Observation on 05/16/24 of the bags of medications with LPN6 revealed the bags contained the following medications: Humalog insulin, a card containing 24 tablets of pantoprazole, Finasteride (one card of 24 tablets)a urinary retention medication; Amlodipine (two cards of 24 pills) a high blood pressure medication, Gabapentin (three cards of 24 tablets) an anticonvulsant, Midodrine (three cards of 24 tablets) a blood pressure medication, Torsemide (one card) a diuretic, Paliperidone (one card) a antipsychotic, singular (one card)a leukotriene receptor antagonists, escitalopram (one card) antidepressant, [NAME] (one card) a anticholinergic, Lipitor (three cards) a statin, amantadine (one card) Parkinson's medication, Prevacid (two cards) a stomach acid reducer, entacapone (three cards) a Parkinson's medication, Catapres (two cards) a high blood pressure medication, ibuprofen (one card) a pain reducer, Pepcid (one card) an acid reducer for reflux, Vitamin D (one card), Depakote (one card) an anticonvulsant, and (Keflex one card) an antibiotic. R24's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/08/24 located in the MDS tab of the electronic medical record (EMR) revealed the facility assessed the resident to have a Brief Interview for Mental Status score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated the resident was independent with ambulating/walking. Review of the facility's Census sheet dated 05/13/24 and provided by the facility revealed 93 residents resided on the second floor. Review of the facility's policy titled Storage of Medications revised date of 2020 stated, .Drugs and biologicals used in the facility are stored in locked compartments .only persons authorized to prepare and administer the medications have access to the locked medications. NJAC 8:39-29.4(h)

C#NJ 172626 Based on observation, record review, interview, and review of the facility's policy, the facility failed to ensure an Injury of Unknown origin was immediately reported to the State Survey Agency in accordance with the required timeframes for one of five residents (Resident (R) 20) reviewed for injuries of unknown origin out of a total sample of 24. R20 was found with redness and swelling to the right foot on 03/26/24 which resulted in a fracture of the fifth metatarsal bone. The facility did not report the injury of unknown origin until 03/29/24, which was four days later. This failure placed the resident at risk of possible abuse when. Findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised April 2021, indicated, All reports of resident abuse (including injuries of unknown origin) .are reported to local, state and federal agencies (as required by current regulations) .Reporting Allegations to the Administrator and Authorities- 1. If resident .injury of unknown source is suspected, the suspicious must be reported immediately to the administrator and to the other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility, b. The local/state ombudsman .3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. During an observation and interview on 05/14/24 at 9:55 AM, R20 was observed in her room sitting in a wheelchair. Further observation revealed R20's right foot had a white bandage on it. R20 was asked what happened and stated, I was trying to get in bed, or out. I don't remember. I yelled out for help. I must have hit my toes because I broke two toes. This was awhile back. Review of R20's undated Face Sheet located in the resident's electronic medical record (EMR) under the Resident tab indicated R20 was admitted to the facility on [DATE]. Review of R20's medical diagnoses located in the resident's EMR under the Med Diag [Diagnoses] tab indicated diagnoses to include muscle weakness, nondisplaced fracture of the shaft of right clavicle, abnormalities of gait, osteoarthritis, Parkinsons disease, unspecified dementia, repeated falls, and aftercare following joint replacement surgery. Review of R20's significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/30/24 and located in the resident's EMR under the MDS tab revealed the facility assessed R20 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. The MDS further indicated R20 had an impairment on one side to the upper extremity and on one side of the lower extremity. The MDS further indicated R20 required Partial/Moderate assistance for transfers. Review of R20's Reportable Event Record/Report provided by the Administrator indicated Date of Event 03/26/24 at 2:00 PM. Today's date: 03/29/24. Was this a significant event? Yes. Was Significant event called in? Yes. Date: 03/29/24 at 1:55 PM. Person reporting: [name of former Administrator]. Location of Incident: Resident room. Type of Incident: Injury. Narrative: Describe the event: Resident noted with redness and swelling to right foot on 03/26/24. When resident was asked what happened to her foot, she stated that she must have bumped it during a fall she had on 03/14/24. What interventions were implemented after the incident/event? X-ray was ordered to the right foot with impression of fracture of the fifth metatarsal. Further review of the incident report revealed this incident was not reported until 03/29/24 (four days after it was identified). Review of R20's X-ray Results dated 03/28/24 and located in the resident's EMR under the Misc [Miscellaneous] tab revealed an x-ray was not conducted until 03/28/24 (three days after finding the resident with redness and swelling to the right foot) which revealed, Findings: Marked osteopenia is noted. There is a deformity of the fifth metatarsal bone with fracture suspected. Impression: Fracture of the 5th metatarsal. Review of the facility's Investigation Summary dated 03/29/24 and provided by the facility indicated, Resident [R20] with swelling and redness to the right foot on 03/26/24, x-ray done to right foot with impression Fracture of 5th metatarsal. During an interview on 05/14/24 at 1:49 PM, the Director of Nursing (DON) stated, This was reported on 03/29/24. Initially she [referring to R20] had swelling to the foot on 03/26/24. We did an x-ray and sent her to the hospital on [DATE]. She returned the same day with splinting and [the facility] reported [it] the next day. When the DON was asked why the delay in reporting, she stated, We were gathering all the information and as soon as we completed it, we reported it to the state. Most of the time reportables or any types of injuries of unknown origin, we complete an incident report and report within 24-48 hours. NJAC 8:39-9.4(f)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to perform handwashing appropriately for two of five staff (agency Certified Nursing Aide (aCNA) and Supply Clerk/CNA) observed during incontinence care in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for infection control and facility policy. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines, Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, page last reviewed 01/18/2021 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. Immediately after glove removal. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. On 12/05/22 at 6:27 AM, the surveyor observed an aCNA in front of room [ROOM NUMBER] with a supply cart of linens, towels, and incontinence pads. The aCNA informed the surveyor that she was an agency nursing aide that had been working in the facility for two weeks now, worked the 11 PM-7 AM night shift last night, and was about to perform morning care for the two residents in the room. Upon entry inside the resident's room, the aCNA immediately went inside the bathroom and washed both hands with water. The aCNA did not apply soap and proceeded to wash her hands for five seconds and then dried both hands with the use of clean paper towels. Then, the aCNA took a new pair of gloves. At that time, the surveyor asked the aCNA if she was done with hand hygiene and the aCNA stated yes, I did wash my hands when I came out of the other room but my hands were sticky that is why I just washed them now with water. Why? You want me to see me wash my hands again? At that same time, the aCNA then turned on the faucet, without wetting both hands with water. The aCNA lathered her hands with soap, then washed off the soap under the stream of running water, and dried hands with clean paper towels. During an interview of the surveyor with the aCNA regarding hand washing, the aCNA stated that no hand hygiene education and competency was provided to her by the facility since she started two weeks ago. She further stated that she knew how to wash her hands from her other job. The surveyor then asked the aCNA why she did not wet her hands prior to applying soap and the aCNA responded: this is how we do handwashing in my other job, we do not need to wet our hands first. On 12/05/22 at 6:40 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN) immediately of the above concern. The IPN informed the surveyor that she worked last night during the 11 PM-7 AM nigh shift as the Nursing Supervisor because she was on-call. The IPN stated that as per facility protocol, she believed that the aCNA should have been educated and provided a competency for hand hygiene and PPE (personal protective equipment) use. The surveyor then asked the IPN why the aCNA had not received education or a competency on hand hygiene, the IPN replied, I have to find out. On that same date and time, the IPN stated that the aCNA should have wet her hands first before applying soap and performed handwashing with soap and water before applying gloves or PPE. Immediately, the IPN went to room [ROOM NUMBER] and spoke to the aCNA. On 12/05/22 at 6:55 AM, the surveyor observed the Supply Clerk/CNA (SC/CNA) enter a resident's room and donned (applied) a new pair of gloves without performing hand hygiene. On that same date and time, the surveyor asked the SC/CNA for an interview and he immediately removed gloves and performed handwashing inside the resident's bathroom. The surveyor observed the SC/CNA perform handwashing under the stream of running water for 10 seconds, applied soap to both hands which immediately washed off the soap, dried both hands with clean paper towels, and left the resident's room. During an interview with the surveyor, the SC/CNA stated that the Assistant Director of Nursing (ADON) provided him an education and competency with regard to hand hygiene. He further stated that it was appropriate for him to lather his hands with soap under the stream of running water at the same time and to apply soap immediately rinse under water. Furthermore, he stated that he should wash his hands before applying a new pair of gloves. At that time, the Registered Nurse (RN) in the nursing station informed the supply clerk that he should lather his hands with soap outside the stream of running water. On 12/05/22 at 7:13 AM, the surveyor interviewed the IPN in the presence of another surveyor. The surveyor discussed the findings of the hand hygiene breaches with the IPN. The IPN stated that after speaking with the aCNA about the above concerns, the aCNA acknowledged that she did not wet her hands before applying soap because she was following the hand hygiene procedure from another job. At this time, the surveyor notified the IPN that both the aCNA and the SP/CNA did not use ABHR (alcohol base hand rub) during hand hygiene observations. On 12/05/22 at 9:06 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and were made aware of the above findings. On 12/07/22 at 11:37 AM, the LNHA provided the surveyor a copy of the Competency Validation for PPE, Competency Skills Checklist signed/dated on 11/23/22 (this did not correspond with the aCNA's interview on 12/05/22 in which the aCNA told the surveyor she had not had a competency). The surveyor inquired with the LNHA regarding that discrepancy. The LNHA replied that the competency date should have been dated 12/05/22, and not 11/23/22. She acknowledged that there was no education and competencies done to aCNA by the facility until the surveyor's inquiry. On 12/08/22 at 01:41 PM, the survey team met with the Regional LNHA (RLNHA), LNHA, and DON. The RLNHA acknowledged that the aCNA should have followed the appropriate hand hygiene guidelines to wet hands first before applying soap. The facility management acknowledged that the hand hygiene breaches included performing hand hygiene for less than the minimum of 20 seconds according to their facility policy, lathering hands under the stream of running water, and hand hygiene not done after removal of PPE. A review of the facility's Handwashing/Hand Hygiene Policy that was provided by the LNHA with the last update date of May 2021 included Policy Interpretation and Implementation: .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .Procedure: Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature .2. Rinse hands thoroughly under running water.Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves On 12/12/22 at 02:44 PM, the survey team met with the LNHA, RLNHA, and the DON and no further documentation was provided to the survey team to refute these findings. NJAC 8:39-19.4 (a)(1)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to routinely and accurately post the nurse staffing information on four of 10 days during the survey period in a place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 11/28/22 at 8:48 AM, upon entry into the facility, the surveyor observed that the Nursing Home Staffing Report Form (NHSRF) that was posted in the reception area of the lobby showed a staffing report dated 11/28/22 with the census of 115 for Day Shift 7 AM - 3 PM. On that same date and time, the Licensed Nursing Home Administrator (LNHA) provided a copy of the facility's census in the presence of the Regional LNHA (RLNHA) and the Regional Director of Nursing (RDON). The provided copy of the facility's census showed 118 with one bed hold. The surveyor asked the facility management why the posted NHSRF in the reception area and the provided census copy did not match. The LNHA stated that she will get back to the surveyor. On 11/28/22 at 10:00 AM, during the Entrance Conference of the surveyor with the LNHA, DON, RDON, and RLNHA, the LNHA confirmed that the facility census was 117 with two bed hold. On Monday, 12/05/22 at 8:12 AM, the surveyor observed the NHSRF that was posted in the reception area of the facility lobby dated 12/02/22, three days prior on Friday, 12/02/22 with a census of 118 for the Day Shift 7 AM-3 PM, Evening Shift 3 PM-11 PM, and Night Shift 11 PM-7 AM. The 12/05/22 NHSRF was not posted for the day shift. On 12/05/22 at 8:13 AM, the surveyor interviewed the Receptionist regarding the posted NHSRF. The Receptionist informed the surveyor that she was not responsible for posting the NHSRF. She further stated that it was the Staffing Coordinator's responsibility to post the updated NHSRF during weekdays and the Nursing Supervisor's responsibility to post it during the weekends in the facility lobby. On 12/07/22 at 10:58 AM, the surveyor copied and reviewed the posted 12/07/22 NHSRF in the reception area and showed that on the Day Shift the total number of patients (census) was 120. The surveyor reviewed the facility-provided schedule, revealed a conflicting resident census of 122 for 12/07/22 for the Day Shift. On 12/07/22 at 11:05 AM, the surveyor interviewed the Staffing Coordinator (SC) who informed the surveyor that she was also a Certified Nursing Aide (CNA). The SC stated that her job responsibilities included creating the schedule of nurses and CNAs, entering information into the NHSRF, and posting the NHSRF in the facility lobby. On that same date and time, the surveyor asked the SC why the census that was posted on 11/28/22 and 12/07/22 NHSRF did not match the actual census report for those days. In addition, the surveyor asked why on Monday, 12/05/22 there was still the Friday 12/02/22 staffing posted? The SC stated that it was probably my mistake, I'm sorry. The SC further stated that on the days that she was not working, it will be the Nursing Supervisor's responsibility to post the correct and updated NHSRF. At that time, the SC stated that she receives the census daily via email from admission, then she entered the information to the NHSRF, and post it in the lobby area. Furthermore, the surveyor asked the SC who was responsible for posting the updated and correct NHSRF this weekend, on 12/03/22 and 12/04/22. The SC stated that she worked on 12/03/22 and 12/04/22, then the surveyor asked the SC why the updated and correct NHSRF was not posted. The SC responded, I cannot remember why. On 12/07/22 at 12:57 PM, the survey team met with the DON, LNHA, and RLNHA who were made aware of the above findings. A review of the facility's Posting of Nurse Staffing Information Policy and Procedure dated 11/22/22 that was provided by the LNHA showed that it was the facility's policy to post the nurse staffing information on a daily basis, to make nurse staffing information readily available in a readable format to residents and visitors at any given time. The procedure included that the SC will post the notice of nurse staffing daily, placed at the first-floor receptionist desk (lobby), and the notice will include the following information: facility name, current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses, Certified nurse aide, current resident census. On 12/12/22 at 02:44 PM, the survey team met with the LNHA, DON, and Regional LNHA. The facility management acknowledged the above findings and there was no further documentation was provided to the survey team to refute these findings. NJAC 8:39-41.2 (a)(b)(c)(1)

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for blood pressure (BP) parameters according to standards of clinical practice for one of 24 residents reviewed (Resident #18). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as 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. On 12/06/22 at 9:45 AM, the surveyor observed Resident #18 in bed watching television. The surveyor reviewed the medical records of Resident #18. Resident #18's Admission Record (Face sheet; an admission summary) revealed that the resident was admitted to the facility with diagnoses that included: dependence on renal dialysis, end stage renal disease (a condition in which a person's kidney ceases to function), and malignant neoplasm of the kidney (cancer of the kidney). The Annual Comprehensive Minimum Data Set, an assessment tool used to facilitate the management of care, dated 12/02/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the resident's cognition was intact. The December 2022 Order Summary Report (OSR) revealed an original physician order dated 11/17/22 and was updated on 11/29/22 for Midodrine (a medication used to treat low blood pressure) 10 mg (milligrams) to give one tablet (tab) by mouth three times daily every Tuesday, Thursday, Saturday, and Sunday for hypotension to be given for Systolic Blood Pressure (SBP) (top number on a blood pressure reading) less than 100. The December 2022 OSR also showed a physician order dated 11/29/22 for Midodrine 10 mg give one tab by mouth two times a day on Monday, Wednesday, and Friday for hypotension for SBP less than 100. The above orders for Midodrine were transcribed to the November and December 2022 electronic Medication Administration Record (eMAR) and signed by the nurses as administered. The November and December 2022 eMAR revealed that the Midodrine was administered when the medication should have been held on: 11/18/22 at 9 AM the SBP was documented as 156 11/21/22 at 9 PM the SBP was documented as 111 12/01/22 at 1 PM the SBP was documented as 116 12/04/22 at 9 AM the SBP was documented as 103 12/04/22 at 5 PM the SBP was documented as 109 A review of the eMAR revealed that this deficient practice was first noticed on 11/18/22. The medical records showed that there were three nurses administered the medications when the medication should have been held. On 12/07/22 at 9:15 AM, the surveyor was unable to interview Licensed Practical Nurse#1 (LPN#1) because she called out sick. On 12/07/22 at 11:00 AM, the surveyor left a message with LPN #2 who did not return the surveyor call. On 12/07/22 at 12:00 PM, the surveyor interviewed a LPN #3 who stated that when the resident's SBP is above 100 the nurse must hold the Midodrine. The LPN reviewed the November and December 2022 eMARs with the surveyor and acknowledge that on five occasions in November and December 2022 that Midodrine was administered when it should have been held for Resident #18. Furthermore, LPN#3 acknowledged that administering Resident #18's Midodrine when the resident's SBP was above 100 could have elevated the resident's SBP. LPN#3 further stated that there was no negative effect to the resident. A review of the facility's policy for Administering Medications that was dated 5/31/21 and was provided by the DON indicated the following: 3. Medications must be administered in accordance with the orders, including any required time frame 8. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vitals signs, if necessary. On 12/08/22 at 01:40 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON). The surveyor presented his findings to the administration. The DON acknowledged that administering Midodrine when Resident #18's SBP was above 100 could have potentially elevated the resident's SBP. The DON stated that there was no negative effect to the resident. No further documentation was provided to the survey team to refute theses findings. NJAC 8:39-11.2(b)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and apply for a change in ownership upon 30 days of their sale in April 2022 in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. On 11/28/22 at 8:48 AM, upon arrival of the surveyors to the facility, the surveyor observed a stone mantel facility entrance sign that had a name that did not correspond with the CMS approved name and provider registered name. Covering that sign was a banner with another facility name indicating Springhills Post Acute Wayneview written on top of it indicating Under New Management. The facility name indicating on the banner and was listed as Avalon Rehabilitation Care Center did not correspond with a CMS approved name change. On 11/28/22 at 10:00 AM, during the Entrance Conference with the Licensed Nursing Home Administration (LNHA), Director of Nursing (DON), and the Regional LNHA (RLNHA), the surveyor asked the facility management why the signs outside the facility in the entrance of the parking lot showed two different facility names Springhills Post Acute Wayneview with a banner over that with a new name of Avalon Rehab & Care Center both of which do not match with the CMS approved name of Atrium Post Acute Care of Wayneview. On that same date and time, the surveyor asked the facility management about the website which reflects that the CMS approved name of Atrium Post Acute Care of Wayneview reflects it was permanently closed. At that same time, the RLNHA stated that the facility transitioned to a new facility name and new management of Avalon Rehabilitation & Care Center since 4/25/22 and that the facility had been using the new company's name and logo. She further stated that the other name Springhills Post Acute Wayneview was changed from the current license name for unspecified number of years, and then under the new management of Avalon Rehabilitation & Care Center. On 12/07/22 at 12:57 PM, the survey team met with the DON, LNHA, and RLNHA and were made aware of the above findings. On 12/08/22 at 01:16 PM, the surveyor reviewed documents and the facility's policies that were provided by the LNHA and showed that the facility name and logo that were used were not according to the facility's licensed name and CMS approved name/change of ownership approval. On 12/12/22 at 8:46 AM, the surveyor notified the LNHA that the team was requesting any and all communication with CMS, including the CMS-855 form (application for change of ownership) submitted to the CMS for a change of ownership. The LNHA stated that she will get back to the surveyor. On 12/12/22 at 01:34 PM, the RLNHA and the LNHA both stated to the surveyor that they will follow up again with the corporate office about communications with the CMS Medicare Administrative Contractor (MAC). On 12/12/22 at 01:52 PM, the RLNHA informed the surveyor that the application for a change in ownership was not submitted according to their Corporate Representative (CR) who was responsible for applying for the change of name and other facility's licensing because the CR thought form 855 was only to be submitted once closing happened and the facility did not receive the final approval from NJDOH (New Jersey Department of Health). A review of the facility license that was issued by the New Jersey Department of Health Division of Certificate of Need and Licensing with an issue date of 3/4/22 and an expiration date of 2/28/23. The NJDOH issued the license for the facility name of Atrium Post Acute Care of Wayneview, not Springhills or Avalon Rehab & Care Center. On 12/12/22 at 02:44 PM, the survey team met with the LNHA, RLNHA, and the DON and no further documentation was provided to the survey team to refute these findings. NJAC 8:39-5.1 (a)

Based on observation and interview and review of pertinent facility documentation, it was determined that the facility failed to a.) label and date Glucometer strips when opened in 2 of 5 medication carts inspected, b.) remove antibiotic medications from the medication cart that had no label in 1 of 5 medication carts inspected, and c.) replace the second floor emergency kit #2 (E-kit) when expired for 1 of 2 E-kits inspected. The deficient practice was evidenced by the following observed during the unit inspections: 1. On [DATE] 9:30 AM, the surveyor inspected the middle cart on the unit 2 B with Licensed Practical Nurse #1 (LPN#1) and observed a Glucometer strip container that was opened but not dated. LPN #1 stated she wasn't aware when the Glucometer strips container was opened and that the Glucometer strips would expire in three months once opened. In addition, the surveyor observed inside the top drawer of the medication cart five [MEDICATION NAME] (an antibiotic) 500 mg capsules in a blister pack with no resident's name. LPN #1 stated she floats the different units and did not know where the medication came from. 2. On [DATE] 9:40 AM, the surveyor inspected the top medication cart on unit 2 B with the Registered Nurse (RN). The surveyor observed the Glucometer strip container opened and not dated. The RN stated she had only been back to work approximately two weeks prior to the survey and did not know when the Glucometer strip container was opened. The manufacturer specifications for the Glucometer strips indicated to use the Glucometer strips within three months of opening. On [DATE] at 2:25 PM, the surveyor asked the Administrator (LNHA) and Director of Nursing (DON) who was doing the unit inspections since the Consultant Pharmacist was unable to come into the facility to perform this function. The LNHA stated that the nurse managers were performing the unit inspections daily and monthly. On [DATE] at 9 AM, the LNHA provided the audit tool used by the nurse managers for the unit inspections from [DATE]-[DATE] and the policy for Storage of Medications. According to the audit tool for [DATE], the nurse managers documented that the unit inspections were performed every shift from [DATE] to [DATE]. Included in the audit tool instructions under #1 and #3 the following: 1. Check all open vials/flex pens for date of expiration, and IV solutions and antibiotics for expiration. 3. Check E-kit for expiration and proper lock and replacement. The facility policy titled Storage of Medications with a revision date of [DATE], indicated under Policy Interpretation and Implementation #3 the following: Drug containers that have been missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Medications that are stored in more than one layer of packaging will have both the medication containers as well as the outer medication box/wrapper labeled with appropriate date opened on a II layers of storage. 3. The surveyor inspected the B 3 medication storage room in the presence of the unit LPN #2 on [DATE] at 10:02 AM. The E-kit #2 located in the B 3 storage room was noted to have expired on [DATE]. LPN #2 confirmed the expiration date. The surveyor interviewed the Unit Manager LPN (UMLPN) on [DATE] at 12:02 PM. The UMLPN stated she had identified the expired E-kit prior to the surveyor identifying that the kit had expired on [DATE]. The UMLPN stated she called the pharmacy for a replacement and the new kit had been delivered to the facility. The surveyor interviewed the LNHA on [DATE] at 1:00 PM regarding the expired E-kit #2. The LNHA stated there was always a 'swing kit' available in the facility to replace an expired or incomplete E-kit. The LNHA stated nurse managers were responsible for inspecting unit medication storage rooms during the time that Consultant Pharmacists were not permitted to enter the facility due to the COVID 19 pandemic. The LNHA provided the surveyor with the undated Provider Pharmacy policy regarding Emergency Pharmacy Service and Emergency Kits on [DATE] at 11:52 AM. The policy indicated the following: kits are monitored/inventoried by the consultant pharmacist at least every thirty days for completeness and expiration dating of the contents. the opened emergency kit is exchanged for the unopened 'swing kit' in the nursing office and the pharmacy is notified that a replacement kit is needed. NJAC 8:,[DATE].3 and 29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to: a.) provide oxygen therapy in accordance with the physician's order and b.) date oxygen equipment weekly when changed. This deficient practice was identified for 1 of 3 residents (Resident # 21) reviewed for respiratory therapy and was evidenced by the following: On 9/23/20 at 11:15 AM, the surveyor observed Resident #21 in bed. The resident had a [MEDICAL CONDITION] (a surgical opening in the windpipe). There was a [MEDICAL CONDITION] mask over the [MEDICAL CONDITION] that was attached to ribbed tubing which was connected to a humidification compressor (a machine that humidifies oxygen) which was attached to oxygen tubing and connected to the oxygen concentrator (a machine that delivers oxygen). The oxygen concentrator was set to deliver 5 liters of oxygen per minute (lpm). The humidification compressor was set at 35%. There was no date written on the cannister of sterile water and no date on the tubing to indicate when they were changed last. The the resident's eyes were open but the resident did not make eye contact and did not answer when spoken to, On 9/28/20 at 9:16 AM, the surveyor entered the resident's room with the Licensed Practical Nurse (LPN) who was assigned to the resident. The surveyor observed the [MEDICAL CONDITION] tubing dated 9/28, the oxygen tubing dated 9/28, the sterile water bottle dated 9/27, the oxygen was set at 5 lpm, the humidification compressor was set at 35%. The LPN confirmed the settings. The surveyor asked the LPN how often the tubing was to be changed. She stated weekly on Sunday by the 11 PM to 7 AM shift. The surveyor asked if they usually dated the oxygen tubing and sterile water bottles and she replied yes. The surveyor reviewed Resident #21's medical record which revealed the following: According to the face sheet Resident # 21 was admitted to the facility with [DIAGNOSES REDACTED]. The current physician's order sheet (POS) had an order which read; Change O2 tubing one time a day every 7 days. The order had a start date of 2/1/20. There was also an order which read; Oxygen 5 lpm [MEDICAL CONDITION] with humidifier 40% every shift. The September 2020 Electronic Treatment Administration Record was initialed every day from 9/1/20 to 9/27/20 to indicate the setting for the humidifier was at 40%. The care plan, which had an initiation date of 6/5/19 and a revision date of 2/5/20 revealed the following: The Focus was; TRACH: Resident is oxygen dependent [MEDICAL CONDITION] [REDACTED]. The second intervention on that care plan read; Administer oxygen [MEDICAL CONDITION]@ 5 L/min continuous with humidifier 40%. On 9/29/20 at 9:40 AM, the surveyor reviewed the facility's policy and procedure titled Oxygen Administration which read; 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. There was no mention in the policy and procedure of labeling or dating the oxygen tubing or sterile water bottle. On 9/28/20 at 10:00 AM, the surveyor asked the Assistant Director of Nursing (ADON) about the order on the POS for the Humidifier to be set at 40% and added that when the surveyor observed the resident with the LPN earlier that day and on 9/23/20 it was set at 35%. The LPN overheard the conversation and stated I fixed it. After you asked me to verify the setting I checked the order and I changed it to 40%. On 9/28/20 at 1:30 PM, the survey team met with the Administrator, the Director of Nursing, the ADON, and the Regional Nurse to discuss the concern with the oxygen humidification set incorrectly and the oxygen tubing not having been dated when changed. The Administrator said the dating of the oxygen tubing and bottles of sterile water was not in their policy but it was their protocol. NJAC 8:38-27.1 (a)

Complaint # NJ 7 Based on observation, interview, review of medical records (MR) and other facility documentation, it was determined that the facility failed to protect the safety of the residents by ensuring the correct diet and/or consistency was provided for 3 of 3 residents (Resident #1, #2 and #4) who were on mechanically altered/modified diets. Resident #2 had a physician ordered (PO) ground diet. During day one of the survey on 2/12/2018 at 12:10 p.m., the surveyor observed meal service in the main dining area. At approximately 12:22 p.m., Resident #2 was observed feeding him/herself chicken. The resident was chewing, spitting out skin and chicken that appeared dry/hardened and swallowed pieces of chicken. The following was observed on Resident #2's plate; a full piece chicken on the bone with skin, green beans and mashed sweet potatoes. The surveyor checked the resident's ticket which indicated the resident was on a ground diet. At 12:23 p.m., the surveyor called over Registered Nurse (RN) #1 who was in the dining room (DR), to check the resident's food and the diet slip. When RN #1 was asked if that was ground diet, RN #1 stated It's supposed to be ground. The surveyor asked RN #1 if that was ground and RN #1 replied, Let me go find out and left the resident with the plate in front of him/her. Approximately a minute later at 12:24 p.m., RN #1 came back and took the resident's plate away and the plate was replaced by ground chicken at 12:25 p.m. The facility's failure to ensure the correct diet and/or consistency was provided to Resident #2 according to physicians orders resulted in an Immediate Jeopardy (IJ) to the resident's health and well being and had the potential to affect all residents who were on a mechanically altered/modified diet. The IJ began on day one of the survey on 2/12/2018 at 12:22 p.m. when Resident #2 was served a regular consistency diet instead of a ground diet. The IJ was identified by the surveyors and relayed to the Administrator and Director of Nursing (DON) on 2/12/2018 at 2:06 p.m. The immediacy was corrected/lifted on 2/12/2018 at 2:47 p.m. when in-services were initiated for facility staff on tray accuracy. A plan of correction was accepted on 2/14/2018. The deficient practice for Resident #1 and #4 continues at a scope and severity of D. See Example #2 and #3. Resident #1 had a PO for honey thickened liquids diet. On 1/13/2017, Resident #1's family member (FM) reported to the certified nurses aide (CNA #4) that the resident received nectar thick liquids instead of honey thick on his/her food tray. CNA #4 left the room, reported it to licensed practical nurse (LPN #2) who then removed the incorrect liquid from the resident's tray. Resident #4 had a PO for Regular diet, Pureed texture, Nectar thickened liquid consistency, PLEASURE FOOD. During a meal observation by the surveyor on 2/12/2018 at 12:10 p.m., a plate was in front of the resident which consisted of a full meal of pureed poultry, pureed beans, pureed sweet potato. The surveyor observed the meal ticket on the residents table which revealed a diet of pureed, pleasure foods and NTL. The bottom of the meal ticket included INSTRUCTIONS: PLEASE DO NOT GIVE MEAL. The meal was removed after the surveyor questioned the registered dietician (RD) about the diet. These deficient practices are evidenced by the following; 1. According to the facility Admission Record, Resident #2 was admitted in 8/20/2015 and has [DIAGNOSES REDACTED]. Review of a Minimum Data Set, (MDS) dated , 1/1/2018, indicated the resident had a Brief Interview of Mental Status (BIMS) of 6/10 which indicated the resident had severe cognitive impairment. The MDS also revealed the resident required supervision and set up with eating. Review of the physician's orders [REDACTED]. Review of the resident's Care Plan (CP), initiated on 7/12/2017 and revised on 10/4/2017, included a focus that the resident was a nutritional risk related to (r/t) [DIAGNOSES REDACTED]. Interventions included but were not limited to; eat in fine DR or B2 DR (initiated 12/29/2017), and provide ground diet (initiated 10/4/2017). The CP also indicated a focus, initiated on 12.29/2017, that the resident had severely impaired cognition r/t short term memory impairment and medical [DIAGNOSES REDACTED]. On 2/12/2018 at 12:10 p.m., the surveyor observed meal service in the main dining area. Staff included a RN (RN) #1, activity aide, unit secretary and a dietary supervisor (DS). Meal tickets were observed placed on a top shelf above the steam table. The meal tickets had the diet written on top of the ticket and also the consistency on the bottom right hand corner. The DS was observed reading the ticket, plating the food and handing to the staff who delivered the food with the ticket to the resident. During the meal observation in the main DR at approximately 12:22 p.m., Resident #2 was observed feeding him/herself chicken. The resident was chewing, swallowing pieces of chicken and spitting out skin, and pieces of chicken that appeared dry/hardened. The following was observed on Resident #2's plate; a full piece chicken on the bone with skin, green beans, and mashed sweet potatoes. The surveyor checked the resident's ticket which indicated the resident was on a ground diet. At 12:23 p.m., the surveyor called over RN #1 who was in the DR, to check the resident's food and the diet slip. When RN #1 was asked by the surveyor if that was a ground diet, RN #1 stated It's supposed to be ground. The surveyor asked RN #1 if Resident #2's food was ground and RN #1 replied, Let me go found out and left the resident with the plate in front of him/her. Approximately a minute later at 12:24 p.m., RN #1 came back and took the resident's plate away and the plate was replaced with ground chicken at 12:25 p.m. At 12:26 p.m., the surveyor asked the DS if he/she checked the ticket prior to plating the food, and the dietary supervisor stated, I thought I did check it, I'm sorry. The surveyor notified the DON at 12:30 p.m. During an interview with the surveyor on 2/12/2018 at 1:42 p.m., the Food Service Director (FSD), stated in the main dining room (MDR), the dietary supervisor checks the diet slips, plates the food, and is responsible for ensuring the diet slip matches the food. The FSD stated the DS did not have his glasses on during the observed meal service, so he/she did not see the word ground on the diet slip. Review of Resident #2's Progress Note (PN), dated 2/12/2018, at 2:23 p.m., revealed Resident was in dinning (sic) room and received wrong diet consistency resident took small bite of chicken chewed and swallowed. Once verified resident on chopped diet tray removed and correct diet consistency given. Resident observed with no coughing or chocking episode noted. After lunch resident retuned (sic) to (resident) unit where (resident) was assessed. Review of a Speech Therapy Plan of Care, dated 2/12/2018, included but was not limited to; Therapy necessary for dysphagia. Without therapy patient at risk for choking, aspiration and/or weight loss, Patient is a long term care resident with a h/o dysphagia .Edentulous upper .Pt (Resident} presented with oral motor weakness. Recommend continue ground/thin diet. During an interview with the surveyor on day two of the survey, 2/16/18, at 9:52 a.m., the Speech Therapist (ST) stated Resident #2 was on a ground diet because the resident had difficulty chewing due to a lot of missing teeth, and he/she didn't want the resident to choke because regular consistency was harder to swallow. Review of a facility policy titled, Tray Identification revealed, Appropriate identification/coding shall be used to identify various diets. 1. To assist in setting up and serving the correct food trays/diets to residents, the Dietary Services will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets. 2. The Food Service Director/Shift Supervisors will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing service staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the Charge Nurse will notify the Dietary Services immediately by phone so that the appropriate food tray can be served. The IJ began on day one of the survey on 2/12/2018 at 12:22 p.m. when Resident #2 was served a regular consistency diet instead of a ground diet. The IJ was identified by the surveyors and relayed to the Administrator and Director of Nursing (DON) on 2/12/2018 at 2:06 p.m. The immediacy was corrected/lifted on 2/12/2018 at 2:47 p.m. when in-services were initiated for facility staff on tray accuracy. An acceptable plan of correction was put into place as follows; 1. Resident #2 was assessed by RN and there were no untoward effects of the tray initially delivered, the tray was removed, and replaced with a mechanically altered diet tray. MD and RP notified, Speech-Language evaluated the resident on 2.12.18. 2. All residents receiving mechanically altered diets are potentially at risk. 3. The Assistant Director of Nursing or designee will in-service dietary, activities and nursing staff on tray accuracy prior to serving resident meals on 2.12.18. A new tray ticket verification system has been implemented for steam table meal service. The person plating the food and serving the food will provide a double check system for accuracy. The Assistant Director of Nursing or designee re-in-serviced all staff regarding thicken liquid consistencies and dot system. The person plating the food and serving the food will provide a double check for tray accuracy. 4. The Food Service Director or designee will audit steam table for tray card accuracy daily for four weeks, then weekly for four weeks, then monthly. The Director of Nursing or designee will audit plate distribution from steam table to resident for accuracy daily for four weeks, then weekly for four weeks, then monthly. Department head/ambassador round audits were implemented for accuracy of thickened liquids and reported out during daily wrap up meeting times 4 weeks. Results of these audits will be forwarded to the center QAPI Committee. The Committee will determine the need for further audits and/or action plans. This deficiency continues at a scope and severity of a D for Residents #1 and #4 as evidenced by the following; 2. According to the facility Admission Record, Resident #1 was admitted in 11/2017 and had [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], indicated the resident had short and long term memory impairments and required extensive assistance with eating. Review of a CP included a focus dated, 1/8/18, that the resident had dysphagia (difficulty swallowing) and required pureed consistency diet with honey thickened liquids with interventions that included but were not limited to; provide honey thickened liquids as ordered. Review of the POS [REDACTED]. Review of a Nutritional Assessment/Screening form, dated 1/9/2018, indicated the resident was recommended a pureed, honey thickened liquid diet and a ST evaluation was pending. Review of the ST PN, dated 1/9/2018, revealed a bedside evaluation was completed and the resident was on a puree diet with honey thickened liquids which was recommended in the hospital. Review of a PN, dated 1/13/2018 at 10:26 p.m. by LPN #2 read, .Patient is on honey liquids which facility will order on Monday. Thickener at the bedside but (residents family member) called upset that (resident) didn't get honey consistency liquids . Review of a Social Services Care Conference Note, dated 1/17/2018 at 2:31 a.m., indicated the interdisciplinary team met with Resident #1's family to address (family members) concerns made to social worker regarding resident's diet consistency. Family alleged that incorrect diet consistency could be the reason for resident recent hospital admission and was [DIAGNOSES REDACTED].Administrator also informed family of new measures that are put into place for the resident's food tray to be checked at meal time by designated person to ensure accuracy. During an interview with the surveyor on 2/16/2018 at 10:13 a.m., CNA #4 stated he/she was assigned to Resident #1 on 1/13/2018 during the 3 p.m. to 11 p.m. shift . CNA #4 stated, normally a nurse checks the food tray but LPN #2 was busy so CNA #4 checked the tray instead and thought nothing was wrong with it and delivered it to the resident. CNA #4 stated the resident's family member (FM) told CNA #4 that the wrong consistency liquid was on the tray. CNA #4 left the room to notify LPN #2. CNA #4 stated, it wasn't the right thing, was nectar not honey and didn't notice the wrong liquids because he/she is from an agency and doesn't work with the same residents all of the time. CNA #4 stated after the resident received the wrong consistency item, he/she was in-serviced about thickened liquids and reading the diet slips to make sure proper meals are being served. Review of an undated facility Investigational Summary completed by the DON for Resident #1 indicated that on 1/13/2018 during dinner, Resident #1 received nectar thick liquids instead of honey thick and CNA #4 was informed of the wrong liquids by the resident's FM. CNA #4 notified LPN #2 who removed the unopened nectar liquid, and then notified the nursing supervisor to locate thickener powder. At 8:00 p.m., LPN #2 located the thickened powder and offered honey thick beverage to the resident. Attached to the summary was a statement dated 1/18/2018, from LPN #2, included but was not limited to; Patient's (family member) was at the bedside around dinner time. When the tray was passed out to the patient, family member noticed that the patient had Nectar Thick Liquids instead of Honey consistency .The dietary order was clarified to be as family member stated. Nectar thickened liquids were removed from the tray and taken back to the kitchen where Honey consistency liquids were requested. The kitchen staff had reported that no Honey consistency was available and was to be ordered on Monday .Thickener was requested from kitchen but they also reported they were out of thickener .Afterwards, family member was notified that thickener was still not found but undersigned would still continue searching for it. In the meanwhile, patient did not show signs or symptoms of dehydration or aspiration .Thickener was eventually found by a fell ow nurse. Aspiration and safety precautions were maintained with patient entire shift . LPN #2 was unable to be interviewed. Review of the Conclusion of the investigation included but was not limited to; The appropriate diet was ordered from original admission and readmission, speech therapy evaluation was performed for both admissions .The staff are fully aware not to give inappropriate items to the resident, and the resident did not receive the incorrect diet consistency on the day of the allegation. The conclusion did not address what time the resident had the correct consistency of honey thickened liquids available to drink on 1/13/2018. 3. According to the facility Admission Record, Resident #4 was admitted to the facility in 12/2015. [DIAGNOSES REDACTED]. An MDS, dated [DATE], revealed the resident had severe cognitive impairment, was on a mechanically altered and therapeutic diet and had a feeding tube (FT). The MDS included that the resident was totally dependent on staff for all ADLs and needed the assistance of one staff member to eat. A 2/2018 POS, revealed a diet order, initiated on 1/30/2018 for; Regular diet, Pureed texture, Nectar thickened liquid consistency, PLEASURE FOOD. Additionally, the resident had physician orders [REDACTED]. Review of Resident #4's CP, initiated 1/25/2018, included that Resident #4 required tube feedings (TF) due to dysphagia and aspiration, failure to thrive and significant weight loss. Interventions included but were not limited to; resident is dependent with TF and water flushes and was receiving PO (by mouth) Pleasure Puree with nectar thick liquid. Review of a ST Plan of Care revealed the resident was seen on 1/25/2018 for an evaluation to determine the oral and pharyngeal phase of the swallow while reducing the risk of aspiration and the resident was seen 3 times weekly for therapy through 2/8/2018. On 2/8/2018, the ST documented in the ST DAILY TREATMENT NOTE; .Pleasure feeds of puree with nectar thick liquids remains as tolerated. Peg (tube feed) remains as primary means of nutrition. RN (registered nurse) reported no problems with current po (by mouth) diet and our plan is to upgrade to 3 meals daily as tolerated. We will follow for diet upgrade and aspiration precautions. Updates to Treatment Approach- tsp (teaspoon) size portions, puree with nectar pleasure feeds, decrease rate of po (by mouth) Goal is to upgrade (resident) to 3 meals daily as tolerated . Review of a NN, dated 1/26/2018 at 12:36 P.M. revealed the resident was evaluated by ST with recommendation to give pleasure feeding/puree with NTL. On 2/7/2018 a Nursing plan of care note revealed the resident is .on Pleasure Puree with nectar thick liquid. (Resident #4) is fed by staff . During a meal observation by the surveyor on 2/12/2018 at 12:10 p.m. Resident #4 was observed sitting in a geri chair in the dining room. A plate was in front of the resident which consisted of a full meal of pureed poultry, pureed beans, pureed sweet potato. Additionally there was a small cup of vanilla pudding on the table. The resident was not able to feed him/herself. The surveyor observed the meal ticket on the residents table which revealed a diet of pureed, pleasure foods and NTL. The bottom of the meal ticket included INSTRUCTIONS: PLEASE DO NOT GIVE MEAL. During an interview with the RD at 12:15 p.m., the surveyor asked why the resident was served a full meal and the RD stated the resident probably should not have had the full meal if that what it (meal ticket) says but the RD stated she thought the resident's diet had been upgraded. The meal plate was removed prior to any staff attempting to feed the resident. During an interview with the surveyor on 2/12/2018 at approximetely 12:30 p.m., the Unit RN stated she was aware that the resident was to have pleasure foods only and should only have been served the pudding, NTL but not a meal. During an interview with the surveyor on 2/16/2018 at 10:20 a.m., the ST confirmed that the resident was last seen on 2/8/2018 and was on pleasure foods only. The ST stated that the resident had a FT placed previously due to a poor intake and the resident's oral control was being evaluated. The ST stated that the reason for pleasure foods only, and not full meals, was to evaluate gradual intake to ensure the resident could tolerate it and she did not want a full meal given because of the risk for aspiration. During an interview with the surveyor on 2/12/2018 at 1:12 p.m. the RD stated that if pleasure foods are ordered, one or two, 4 ounce serving, are served, not a full meal. During an interview with the surveyor on 2/12/2018 at 1:42 p.m., the FSD stated that Resident #4 should not have received a full meal, only a small amount of a pudding or applesauce. The FSD was not sure why or how the resident received a full meal plate and confirmed that the meal should have been checked to ensure it matched the diet slip prior to serving. The facility was unable to provide a written policy on what was to be served if a resident was ordered pleasure foods, however, during interviews with the RD, ST and the FSD, all confirmed that a full meal is not served but one or two items in small portions was to be served. Review of facility documentation indicated in-services were done for staff on 1/18/2018 on Use of thickener for residents and Tray Accuracy. Attached to the in-services included different diet types and which foods were allowed and not allowed for each diet. Review of the Ground Diet indicated that meat, poultry or fish should be ground and not whole or chopped. Review of a facility policy titled, Tray Identification revealed, Appropriate identification/coding shall be used to identify various diets. 1. To assist in setting up and serving the correct food trays/diets to residents, the Dietary Services will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets. 2. The Food Service Director/Shift Supervisors will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing service staff shall check each food tray for the correct diet before serving the residents. 4. If there is an error, the Charge Nurse will notify the Dietary Services immediately by phone so that the appropriate food tray can be served. NJAC 8:39-17.4(a)(1)

C# NJ Based on observation, interviews, medical record (MR) review, and review of other pertinent facility documentation on 3/17/17 and 3/21/2017, it was determined that the facility failed to ensure the safety of the residents and the resident's environment when a small weapon owned by a resident, was found inside the facility. The weapon was moved and handled by the facility staff which caused the weapon to discharge/fire. This deficient practice potentially placed all residents in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Administrator, Director of Nursing (DON), and Clinical Nurse Consultant (CNC) on 3/21/2017 at 2:28 p.m. The IJ was identified as Past Non-Compliance for 12/3/16 into 12/4/16, when the Police were notified. The facility provided evidence of an implemented acceptable Plan of Correction (POC) on 3/21/17 at 2:28 p.m. This deficient practice was evidenced by the following: On 3/17/17 at 9:35 a.m., the Administrator showed the surveyor the location of where the weapon discharged . The Surveyor observed a round mark on the surface of the wall below the nurse's station counter (approximately 12 inches from the floor). An interview with the Administrator was conducted by the Surveyor on 3/17/17 at 9:29 a.m. The Administrator stated that on 12/3/16, a Certified Nursing Assistant (CNA #1) discovered a weapon in a Resident's bag while looking for a TV remote control. The Administrator stated that CNA #1 reported it to the 3-11 Nursing Supervisor, and the Licensed Practical Nurse (LPN #1). The Administrator explained that LPN #1 with CNA #2 went to the Resident's room and found the weapon in a bag. The Administrator further explained that CNA #2 removed the weapon from the bag, brought it to the Nurse's Station (NS) and handed it to LPN #2. The Administrator stated that according to LPN #2, the weapon accidentally fired when LPN #2 tried to remove a clip (a device that is used to store multiple rounds of ammunition together as a unit) from the weapon to make sure it was safe. The Administrator explained that there were no residents present at that time and that when the weapon fired, it hit the front wall of the Nurse's Station Counter. When asked by the surveyor on how the facility should have acted after the weapon was found and after it fired, the Administrator stated that the facility should have called the Police right away. When the surveyor asked the Administrator if he/she gave instructions to the facility staff to call the Police on 12/3/16, the Administrator stated No. The Administrator stated that the Police were called on 12/4/17, and that the Police interviewed the resident and searched the resident's room. On further interview, the Administrator stated that he/she did not inform the Local Police Department or the New Jersey Department of Health (NJDOH) that the weapon had fired. The Administrator did not offer any explanation why this information was withheld. The Administrator stated that if he/she could go back to the time of the incident, he/she would have approached it differently. An interview with LPN #1 was conducted by the surveyor on 3/17/17 at 10:05 a.m. LPN #1 stated that on 12/3/16, right before the end of 3:00 p.m. - 11:00 p.m. (3-11) shift, CNA #1 reported to him/her that they saw a weapon in a resident's bag when they were looking for the resident's TV remote control. LPN #1 stated that he/she went the resident's room with CNA #1 and CNA#2, and that CNA #2 removed the bag from the resident's room, put the bag down the floor outside of the resident's room, and removed the weapon from the bag. LPN #1 explained that the weapon was in a holster when removed from the bag by CNA #2, and taken to the NS,where CNA #2 handed it to LPN #2. LPN #1 stated that he/she did not see the weapon fired because he/she was already on the telephone with the DON. LPN #1 further explained that she did hear a loud noise and saw LPN #2 holding the weapon, in two pieces, out of the holster. LPN #1 stated that LPN #2 explained that he/she thought it would be safer if the clip was removed from the weapon. LPN #1 stated that there were no residents present when the weapon fired. When asked by the surveyor what should have been done after the gun was found and after it fired, LPN #1 stated that they should have called 911. LPN #1 explained that he/she, LPN #2, and CNA #2 wanted to call the Police, but the DON told him/her that the Administration would be called first and that the DON would call back. LPN #1 stated that the DON called back and instructed him/her not to call the Police and to secure the weapon in the Administrator's office. LPN #1 stated that LPN #2 brought and secured the weapon in a locked drawer in the Administrator's office per the DON's instruction. When LPN #1 was asked why the firing of the gun was not reported to the state agency (NJDOH), LPN #1 stated that he/she was instructed by the DON not to. LPN #1 further stated that before he/she went home on 12/3/16, he/she checked the resident's room for any other dangerous objects, found none, and left all the residents in a safe environment. LPN #1 stated that the facility gave an in-service after the incident; on what to do when a dangerous weapon was found, on what to do when there's an active shooter, and proper inventory of residents' personal effects. An interview with the DON was conducted by the surveyor on 3/17/17 at 11:45 a.m. The DON stated that the weapon accidentally fired when LPN #2 handled it. When asked by the surveyor how the DON knew that the weapon fired, the DON stated that he/she was on the phone with LPN #1 when the weapon accidentally fired. The DON explained that on the first telephone conversation with LPN #1, he/she instructed LPN #1 to secure the weapon and make sure that all the residents were safe. The DON stated that he/she did not instruct LPN #1 to call the Police, and that the Administrator did not give instructions to call the Police. When asked by the surveyor what should have been done after the weapon was found and after it fired, the DON stated that the facility had to make sure that all residents were safe. The DON stated that she did not think of calling the Police and that his/her first thought was to make sure that all the residents were safe and call the Administrator. The DON stated that the facility did not report the weapon had fired when the Police were called on 12/4/16, and when it was reported to the NJ Department of Health (NJDOH) on 2/17/17. When asked why the firing of the weapon was omitted in the reports, the DON stated that the Administrator handled all the reporting and provided no further explanation. On 3/21/2017 at 10:40 a.m., on further interview with the DON by the surveyor, the DON stated that the Local Police Department removed the weapon from the facility on 12/4/16, and a facility wide in-service was conducted on 12/4/16; on what to do when dangerous objects were found, and what to do when there is an active shooter. At 12:05 p.m., the DON further explained that a facility wide audit of all residents' personal effects for any dangerous objects was conducted on 12/5/16. The DON went on to state that no dangerous objects were found and that the resident's Care Plan was updated. A telephone interview with LPN #2 was conducted by the surveyor on 3/17/17 at 12:20 p.m. LPN #2 stated that CNA #2 handed him/her a weapon inside a holster. LPN #2 stated he/she removed the weapon from the holster and tried to remove the clip when the weapon fired. LPN #2 further explained that the weapon was pointed to the floor when it accidentally fired and hit the bottom front wall of the counter by the NS. LPN #2 stated that there were no residents at the NS when the weapon fired and that no resident asked or was aware of the incident. LPN #2 stated that he/she had no experience with weapons and that he/she thought it was safer to remove the clip. LPN #2 stated that he/she, CNA #2 and LPN #1 wanted to call the Police but LPN #1 was instructed not to by the DON. LPN #2 further stated that he/she was instructed not to inform the state agency or anyone, that the weapon fired. When asked by the surveyor what was done after the incident to ensure the safety of all the residents, LPN #2 stated that he/she locked the weapon in the drawer inside the Administrator's office and that he/she was suspended for carelessness. An interview with CNA #2 was conducted by the surveyor on 3/17/17 at 3:30 p.m. CNA #2 stated that he/she removed the bag that contained the weapon from Resident #5's room and put it down the floor in the hallway and removed the holster with the weapon in it. CNA #2 explained that he/she brought it to the NS and handed it to LPN #2. CNA #2 stated that the weapon accidentally fired when LPN #2 tried to remove the clip from the weapon. CNA #2 explained to the surveyor that the clip holds the bullets. CNA #2 further explained that he/she suggested they call 911, but LPN #1 was instructed not to. CNA #2 stated that he/she did not inform the state agency to protect the facility staff from getting into trouble. An interview with CNA #1 was conducted by the surveyor on 3/21/17 at 10:45 a.m. CNA #1 stated that he/she saw a weapon in a resident's bag while he/she was looking for a TV remote control. CNA #1 stated he/she reported it to LPN #1 immediately and went back to the resident's room with LPN #1 and CNA #2. CNA #1 stated that CNA #2 removed the bag with the weapon in it. CNA #1 stated that he/she continued to quickly check another resident who was at the end of the hallway and went home. CNA #1 further stated he/she did not see or hear that the weapon had fired, and explained that he/she did not work the next day and did not hear of any incident related to the accidental firing of the weapon when he/she came back to work. A review of the facility's Investigational Summary dated 12/3/16, under Description of Event revealed the following: on 12/3/16 at approximately 10:45 p.m., CNA #1 discovered a small weapon in a resident's bag. CNA #1 brought it to LPN #1's attention who instructed CNA #2 to verify that it was a weapon, and that CNA #2 brought the weapon to the NS where LPN #2 took possession of the weapon and secured it in the Administrator's office. The summary also revealed that the resident's room was immediately searched for any dangerous/harmful items and there were no items found. The summary, under Investigation Findings, also revealed the following: The Resident was interviewed and stated that he/she was not aware of the weapon being in the bag and that he/she had no reason to have it in his/her possession nor did he/she have any issues with it being locked up. The Resident was informed that the facility could not have any weapons or dangerous/harmful items in the residents' rooms or on the premises. Further review of the facility's Investigational Summary, under Conclusions, revealed the following but was not limited to: The weapon was immediately removed from the resident's room and secured in the Administrator's office. The Local Police Department was notified on 12/4/16, by the Administrator, and the weapon was removed from the facility by the Police on 12/4/16. The Local Police searched the resident's room to ensure there were no other weapons or dangerous objects present. The summary concluded that it was an isolated case and was being investigated by the Local Police Department. A review of the Incident Report (IR) from the Local Police Department dated 12/4/16 at 11:43 a.m., revealed that the Police were called and dispatched to the facility on [DATE] at 11:43 a.m. The IR revealed that the facility reported to the Police Headquarters that the Administrator had recovered a weapon from one of the residents. The IR recorded that the Administrator explained that on that date (12/4/16), the facility found a small silver weapon in a duffle bag while looking for the resident's remote control. The IR revealed that the Police found the slide was maneuvered and a spent cartridge shell casing was removed from the internal section of the weapon. The IR revealed that the Resident was identified as the registered owner of the weapon and that the resident's room was searched and no other firearms, ammunitions, or dangerous items were found. The IR showed that the Resident was interviewed by the Police and confirmed the Administrator's version of the events. The IR revealed that there were no injuries or property damage reported and that the weapon was secured and recovered for safekeeping by the Local Police Department on 12/4/16. A review of the Facility's Reportable Event Record (FRE) dated 2/17/17, revealed that on 12/3/16 at approximately 10:45 p.m., CNA #1 discovered a small weapon in a Resident's bag. CNA #1 brought it to LPN #1's attention who instructed CNA #2 to verify that it was a weapon, and that CNA #2 brought the weapon to the NS where LPN #2 took possession of the weapon and locked it in the Administrator's office. Further review of the FRE revealed the following interventions implemented after the event: The resident's room was immediately searched for any other dangerous/harmful items and there were no items found, the Local Police was called and the resident's room would be inspected weekly for 2 months and monthly thereafter. A review of the Facility's Employee In-service record revealed that a facility-wide in-service titled Discovering of Dangerous Harmful Items was held on 12/4, 12/5, and 12/7/16. The In-service Summary included identification of dangerous/harmful items, steps to follow if found, and inventory of resident's possession upon admission and as needed. A review of the Facility's Employee In-Service record revealed that a facility-wide in-service titled Active Shooter - How to Respond was held on 1/10/17 and 1/11/17. A review of LPN #2's Disciplinary Action dated 12/4/16, revealed that LPN #2 was suspended when he/she put staff and residents in harms way when a harmful/dangerous object was presented to him/her on 12/3/16. A review of LPN #2's Employee In-Service Record revealed that he/she was given an in-service titled Discovering of Dangerous Harmful Items on 12/5/16. A review of the December 2016-February 2017 document titled Inventory of Personal Effects for the Resident revealed that there were no harmful or dangerous items listed among the resident's belongings. A review of a document titled Inventory of Personal Effects for all residents revealed that there were no harmful or dangerous items found among any of the residents' belongings on 12/5/16. A review of a document included in the resident Admission Agreement titled Notice of Prohibition of Dangerous Items revealed that no person, which included residents or family members, could possess or carry, whether openly or concealed, any guns, rifles, pistols, or firearms of any type, or any type of potentially harmful/dangerous weapon on the premises of the facility. It indicated that violation of the policy would be deemed a violation of the applicable rental agreement or admission agreement and would constitute grounds for discharge. A review of the Facility's Policy titled Safety and Supervision of Residents, dated 12/4/16, revealed that our facility strives to make the environment as free from accident hazards as possible and that Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The Policy also revealed that upon discovering of any dangerous or suspicious items, the resident's safety was paramount and that the resident should be removed and the Police should be notified as warranted. The Immediate Jeopardy was identified as Past Non-Compliance for 12/3/16 through 12/4/16, and was corrected on 3/21/17 at 2:28 p.m., when an acceptable Plan of Correction (POC) was implemented. The POC included: I. 1. The affected resident was assessed and interviewed by Nurse and found to be safe on 12/3/16. I. 2. The weapon was immediately removed from the Resident's room and secured in the Administrator's office on 12/3/16. I. 3. The weapon was removed by the Local Police Department from the facility on 12/4/16. I. 4. The Resident's room was searched by the staff and no other dangerous items were found on 12/3/16. I. 5. The Resident's care plan was updated on 2/22/17. I. 6. The Resident's visitors were notified and reminded not to bring in any weapons or dangerous items. II. 1. All residents in the facility have the potential to be affected. II. 2. All resident's rooms were searched on 12/4/16, by staff for dangerous items and no dangerous items were found. III. 1. The Facility's Policy on Safety and Supervision of Residents was revised on 12/4/16, which included that upon discovering of any dangerous or suspicious items the resident's safety was paramount and that the resident should be removed and the Police should be notified as warranted. III. 2. All Staff have been in-serviced on the revised Policy regarding actions to take if a dangerous weapon or substance is identified in the facility or on the grounds; on 12/4,12/5, and 12/7/16. III. 2. The Nurse that handled the dangerous weapon was immediately suspended and was educated on proper procedure if dangerous weapons/substances were found on 12/5/16. III. 3. The Resident's room would be inspected weekly for 2 months and monthly thereafter for any further items, any bags brought in for the Resident from family and friends would be inspected and inventoried by staff upon entering the center. III. 4. Routine room inspections would be conducted by the Administrator or designee to observe for any dangerous items. III. 5. A Notice of Prohibition of Dangerous Items had been added to the admission process. IV. 1. The Administrator or designee would conduct routine rounds to observe for presence of dangerous items. If any item was identified, the Police would be notified for safe immediate intervention and any other agencies would be notified as required. IV. 2. The Admissions Coordinator or designee would report to QAPI Committee each month regarding provision of Notice of Prohibition of Dangerous Items for newly admitted residents. IV. 3. The result of these rounds would be forwarded to the facility's QAPI Committee. The Committee would determine the need for further audits or action plans. NJAC 8:39-27.1(a)

C # NJ Based on interviews and record review, as well as review of pertinent facility documents on 3/17/17 and 3/21/17, it was determined that the facility failed to ensure a safe and appropriate discharge for 1 of 4 sampled residents (Resident #3) reviewed for discharge (D/C). The facility staff failed to provide education and/or trainings and to ensure that the Resident's family/caregivers were competently trained on how to handle the Resident's medical devices (oxygen, gastrostomy tubes, foley catheter and [MEDICAL CONDITION]), medication administration, and wound care. In addition, the facility failed to coordinate, obtain verification, and to follow-up with the Home Health Service (HHS) to ensure Resident #3 was accepted as a patient by the HHS prior to discharge. Furthermore, the facility failed to follow their Policy titled, Discharge Summary and Plan. This deficient practice placed Resident #3 in an Immediate Jeopardy situation for Unsafe Discharge, as well as all other residents at risk for an Immediate Jeopardy (IJ) situation for the potential of an unsafe discharge. This IJ was identified on 3/21/17 at 2:28 p.m., when Administration was alerted. The IJ was lifted on 3/21/17 at 4:30 p.m., when the facility provided an acceptable plan of correction (POC). This deficient practice is evidence by the following: 1. According to the Admission Record, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 12/28/16, showed that the Resident was cognitively impaired. The MDS also indicated that the Resident was totally dependent on staff for Activities Of Daily Living (ADLs). A review of the Progress Notes, dated 12/21/16 at 10:37 p.m., under Nursing Note indicated that the Resident was non-verbal, on continuous oxygen at 2 LPM (liters per minute) via n/c (nasal cannula), with f/c (foley catheter), [MEDICAL CONDITION] and peg tube (gastrostomy feeding tube). The PN also showed multiple wounds including; Skin tear to right elbow, right bunion stage 3, right lower leg (near ankle), stage 3 with slough, right 5th digit DTI (deep tissue injury), right heel stage 4, right foot malleolus stage 3, unstageable to right foot, anterior abrasion to back of right knee, left arm/deltoid with bruising and swelling, left malleolus stage 3, left heel DTI, left lateral heel DTI, left hip stage 4, stage 4 to sacral area with undermining . Further review of the PN dated 12/22/16 at 2:42 p.m. on 3/17/17, under Nursing Note revealed: Patient noted with 13 wounds . According to Resident #3's Care Plan (CP), initiated on 12/22/16, The Resident wishes to discharge .to the community post subacute care. The CP included interventions not limited to: -Educate family on administering peg tube feeding, educate family on administration of wound care. -Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress. -Make arrangements with required community resources to support independence post-discharge (home care, PT-Physical Therapy, Wound Nurse). -Train family on [MEDICAL CONDITION] care management and ensure safe return demonstration of the training. Further review of the CP indicated that the aforementioned interventions were initiated on 12/22/16, however, there was no documentation in the medical record that education/trainings with return demonstrations were provided to the Resident's family/caregivers during Resident #3's stay at the facility. A review of the form titled Traditional Medicare Billing Form, for Resident #3 indicated an admitted on 12/21/16, and the Short Term section was marked, indicating that the resident was a planned Short Term stay. The form under the section Comments/additional information, specified that the Resident's 20th day (last day of Medicare coverage) was on 1/9/17. On 3/17/17 and 3/21/17, the surveyor further reviewed the PNs dated from 12/21/16 to 1/5/17, there was no documentation that indicated that education and/or trainings with return demonstrations were provided to the family/caregivers of Resident #3. During subsequent review on 3/17/17, the PNs showed the following: -On 1/6/17 at 2:39 p.m., under the section of Social Services Care Conference Note, indicated that the IDCP (Interdisciplinary Care Plan) team met with Resident #3's family members to discuss the plan of care. The note also indicated that the Resident's family members wished to have home health services set-up at home and therefore, the HHS was notified. There was no documentation on 1/6/17 at 2:39 p.m., to indicate that any education/trainings were provided to Resident #3's family. - On 1/6/17 at 2:56 p.m., under the section of Nursing Note, written by the LPN, showed: .resident son visited, as per social worker (SW) resident will be discharge home with hospice call placed to MD (medical doctor) office . There was no documentation that any education/trainings were provided to the Resident's family member during the visit on 1/6/17 at 2:56 p.m. - On 1/6/17 at 3:08 p.m., under the Social Services Note, written by the SW showed: D/C (discharge) plan was arranged with sons during IDCP meeting. Family made aware that the HHS will provide the in-home hospice care and D/C date was set up for 1/9/17. Resident was known to the HHS prior to admission to facility. As per the HHS nurse he/she got all the information needed and SW just needed to confirm date of D/C once in agreement with family. SW arranged transportation for pick-up for 1/9/17. There was no documentation about education/trainings provided to Resident #3's family on 1/6/17 at 3:08 p.m. - On 1/9/17 at 9:55 p.m., documented under the section NN, the nurse documented: Resident was scheduled for discharge today at 5 p.m., to be sent on and placed on hospice services with HHS .At this time received a call from resident's family member that he is unsure of discharge plans despite having meeting last week to discuss planning. As per the family member, he does not feel comfortable to have Resident #3 come home today because it is late, cold and dark .Family member remained apprehensive about the discharge. DON (Director of Nursing) and Admin (Administrator) of the facility aware and new D/C date of 1/10/17, per family's request with a pick-up time scheduled at 1 p.m. Family expressed concerns regarding resident's devices; [DEVICE] (gastrostomy tube), F/C (foley catheter), and [MEDICAL CONDITION]. As per UM (unit manager), hospice will discuss any trainings with family when pt (patient) arrived home. Offered the family member and any other family that wishes to have teaching provided to come to facility tomorrow prior to discharge to receive any teaching desired. Per the family member, he has to work tomorrow and his brother would also be unable to come. Also offered family members to come tonight and he stated that he didn't want to because he was too tired. Family member agreeable and aware of discharge tomorrow. The nurse documented that they spoke to the HHS staff and made HHS aware of situation. Endorsed to follow up with HHS in am. - On 1/10/17 at 2:48 p.m., under the NN: .all discharge instructions and paperwork given to (name of ambulance) driver to give to resident family . On 3/17/17 at 10:26 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN #1). The LPN stated that all teachings and trainings provided to the resident and their family were documented in the PN under the section of Nursing Notes. During an interview with the Unit Manager (UM) on 3/17/17 at 10:32 a.m., the UM explained that education provided to the resident and their family concerning their care needs begins on the day of admission. The UM revealed that the facility staff would initiate education/trainings with the resident and the family and not the HHS. The UM went on to say that all education/trainings provided to the resident and/or family were documented in the PN. However, the UM could not explain why there was no documentation of education and trainings provided to Resident #3's family from admission throughout Resident #3's stay, and prior to discharge. During subsequent interview with the UM on 3/17/17 at 11:12 a.m., the UM stated that Resident #3 was new to the facility; admitted in the sub-acute unit for rehabilitation, with multiple wounds, new gastrostomy tube, new [MEDICAL CONDITION], foley catheter, and on continuous oxygen. The UM explained that the facility knew that the Resident required long term care for this reason, and education/trainings were not initiated with the family. The surveyor asked when the facility was made aware of the family wishes to have Resident #3 discharged to home on 1/6/17, why was the family not provided with education/trainings followed with return demonstration concerning [DEVICE], [MEDICAL CONDITION], f/c, oxygen, and wound care on 1/6/17, and thereafter. The UM stated I don't know why there was no documentation about teaching/trainings to the family on [DEVICE], [MEDICAL CONDITION], f/c, and oxygen. All teachings should be documented in the PN. The UM went on to state It was offered to them on 1/9/17, the night prior to D/C, but they can't come. During a telephone interview with the HHS Intake Person (IP) on 3/17/17 at 11:36 a.m., the IP stated that Resident #3 was known to them since 6/2016. The IP indicated that they provided home services to Resident #3 for wound care from 6/2016 to 12/2016, prior to her hospitalization . The IP further explained that the Resident had 6 wounds, but did not have a pe[DEVICE], [MEDICAL CONDITION], foley catheter, or oxygen. The surveyor interviewed the HHS Supervisor (HHSS) on 3/17/17 at 11:50 a.m., the HHSS stated that their office received a referral from the facility for Resident #3 for Hospice at home to start on 1/9/17, after D/C from the facility. HHSS stated that on 1/9/17, the on-call nurse called the Resident's home twice and the family stated that the Resident was not home. The on-call nurse then called the facility. The HHSS went on to say that the facility staff told the on-call nurse that the Resident's family refused to take the Resident home because they were uncomfortable with the Resident's medical devices. During a subsequent interview with the HHSS on 3/17/17 at 12:15 p.m., he/she stated that on 1/10/17, at approximately 10:45 a.m., that the HHS Associate Director (HHSAD) told the facility's SW that HHS would not accept the Resident as a patient because the family had not received trainings on peg tube care as well as [MEDICAL CONDITION] care. The HHSS revealed that the facility's SW assured him/her that the D/C would be put on hold. The HHSS then stated that they had received a call from the Resident's family at approximately 2:30 p.m., and were told that Resident #3 was home, in pain, and that the family member was unsure of how to manage the Resident and expected someone from HHS to come to the home. The HHSS further revealed that they called the facility and spoke to the facility's SW and asked why the Resident was D/C'd home; the SW responded with silence and had no answer why the Resident was sent home. The HHSS went on to say; Not only did the facility discharge the Resident home without educating the family, the facility did not tell the family we did not accept the Resident under our services. The surveyor interviewed the facility Admission Director on 3/17/17 at 12:19 p.m. The Admission Director (AD) stated that Resident #3 came in from the hospital with the form titled: EARC-PAS (Enhanced At Risk Criteria Screening Tool) dated and completed by the EARC-PAS Assessor at the hospital on [DATE]. The AD stated that any resident who came in with an EARC-PAS form does not guarantee Long term care at the facility. In an interview with the Director of Nursing (DON) on 3/17/17 at 12:41 p.m., the DON stated that Resident #3 came in medically compromised, with multiple wounds, peg tube, [MEDICAL CONDITION], foley catheter, and on continuous oxygen. The DON indicated that the facility discussed with the family long term care placement, but the family wanted to take the Resident home. The surveyor asked the DON for the documentation about the discussion with Resident #3's family concerning long term care. The DON could not provide the documentation. The surveyor mentioned to the DON about the CP dated 12/22/16, and the IDCP meeting on 1/6/17, which indicated the Resident's desire to return to the community. The surveyor asked the DON to provide the documentation about education/trainings with return demonstration provided to the family prior to D/C on 1/10/16. Although the DON stated: I have to look if we have any, no documentation was provided to the surveyor. In an interview with the Administrator on 3/17/17 at 1:18 p.m., the Administrator stated that Resident #3's family felt that they wanted the Resident to die at home. The Administrator revealed that on the day of D/C on 1/10/17, we called Adult Protective Services (APS). The surveyor asked why APS was called, and the Administrator explained Because of non-compliance and the home situation. The Administrator also stated: Non-compliance with teachings and we have concerns about D/C. The surveyor questioned why the discharge occurred when the facility had concerns, and the Administrator stated that the family wanted the Resident home, and further stated We attempted teachings with them but they refused. The surveyor asked the Administrator where was it documented and care planned about the family's refusal and non-compliance with teachings/trainings. The Administrator stated I have to check. However, no documentation was provided to the surveyor. During a subsequent interview with the Administrator on 3/17/17 at 3:11 p.m., the Administrator stated that on 1/9/17 at 6:30 p.m., he/she received a call from a very angry family member that refused Resident #3 to be discharged to home. The Administrator indicated that they offered for the Resident to stay for additional days but the family member stated that they wanted the Resident to be home. The surveyor asked the Administrator who would provide care to the Resident and the Administrator stated that there were other siblings to help out. The surveyor asked if the other siblings were taught how to provide care to the Resident; and the Administrator stated I don't know if the other siblings were taught/trained; I instructed our SW to call APS. We felt that the family wouldn't be able to take care of the Resident at home. The surveyor again asked the Administrator why Resident #3 was discharged and the Administrator stated that the family wanted the Resident home, and we cannot force Resident #3 to stay here. On 3/21/17 at 10:30 a.m., the surveyor reviewed the form titled, HHS Company Patient Note (PN) that documented the following: -On 1/9/17 at 6:00 p.m., written by the HHS Staff Nurse (SN#1): TC (telephone call) to the facility and nurse informed me that son refused to bring patient home stated that it was too late and he would not be able to learn how to properly take care of patient if ( Resident #3) was to leave facility at that time. -On 1/9/17 at 9:15 p.m., indicated that SN#1 called the facility and found out that Resident's family refused to accept the Resident at home because they were not trained on the care of the [MEDICAL CONDITION] and peg tube. Further written: Reinforced with the facility staff, the 24/7 number for the HHS to update on patients discharge plan and this author emailed referral department and supervisor on discharge status. - On 1/10/17 at 10:00 a.m., written by HHS Staff Nurse (SN#2), showed that the HHS received a call from the SW from the facility stating that the family refused to accept the Resident home because they had not been instructed on how to take care of the Resident. SN #2 explained to the SW that if the Resident was discharged and the family was willing to accept responsibility for the Resident, the nurse would make the visit and admit once the Resident was home. The note further documented: SW #1 insisted that the nurse must meet with the patient and family at home when the patient gets there. This clinician explained that hospice or home care does not work that way. That once the patient is discharged and home, the HHS would make the visit to the home to assess the patient, admit them to services and reinforce instruction of family . - On 1/10/17 at 10:30 a.m., written by HHS SN #3, showed that he/she was informed by the on-call nurse that Resident #3's family refused to accept the Resident at home and that the facility D/C was put on hold and the Hospice admission was unable to be completed. SN #3 further wrote: I spoke to SW #2 and explained that HHS was available to assist with this D/C, but we will step back until the Resident's family is ready to take the Resident home .I was informed that the family did not feel they received enough training to care for the Resident's new [MEDICAL CONDITION] and peg/tube feedings. I explained to SW #2, we understand this is a complicated patient and the family has to feel comfortable before they can care for her at home. I explained if the family felt this was too large responsibility, a new D/C may need to put in place .SW #2 told me that Resident #3 would be staying at the facility for few more days before being D/C'd (discharged ) .SW #2 was comfortable with this and said he/she would keep SN #3 informed on whatever DC (discharge) plan is agreed upon. - On 1/10/2017 at 10:45 a.m., written by HHSAD, indicated that SW #1 was made aware that the HHS cannot accept the Resident #3 as the Resident did not have a safe discharge plan. Further written SW#1 reports that D/C could be held. Offered HHS Hospice to make visit to the facility with family .to discuss hospice services, needed training for safe discharge and plan for client to be transferred home. Facility to contact HHS with plan going forward. - On 1/10/17 at 2:30 p.m., written by HHSAD, showed that HHS made a referral to APS regarding concerns that patient had been transported home with no safe plan in place. Further written Patient requires care in regards to peg tube and feedings, [MEDICAL CONDITION] care, medication management, and basic self care needs. Calls have been received at HHS from multiple family members that client is home, in pain, and that they are unsure how to manage the Resident and expect someone to come to the home . APS made aware at this time HHS has not accepted this case as it appears patient is unsafe to be home at present time. -On 1/10/17 at 2:33 p.m.,written by SN #2, indicated that: TC (telephone call) to SW #1 who reports that the patient was discharged home today at 1 p.m. Informed HHSAD of patient's discharge. During an interview with the DON and the Administrator on 3/21/17 at 11:05 a.m., the surveyor asked for the documentation provided to the family of Resident #3 regarding education/trainings with return demonstration, on the Resident's medical devices ([MEDICAL CONDITION], pe[DEVICE], etc.), medication administration, and wound care. The DON stated We have no other documentation. During an interview with LPN #1 on 3/21/17 at 11:14 a.m., LPN #1 stated that Resident #3's family verbalized from day 1 of admission that they wanted to take the Resident home. The LPN also stated that during his/her encounter with the family, he/she did not provide any education/trainings to the family concerning the Resident's medical devices. LPN #1 revealed that he/she did not hear that the family had refused education/trainings concerning the gastrostomy tube ([DEVICE]), [MEDICAL CONDITION], and other related care areas. LPN #1 also indicated that on 1/9/17, the family called multiple times and the last call was transferred to the Administrator. During an interview with the Rehabilitation Director (RD) on 3/21/17 at 11:46 a.m., the RD stated that any education/trainings in areas such as wounds, [DEVICE], [MEDICAL CONDITION], and foley catheter, are provided by the Nursing Department to the resident/family, not the Rehabilitation department. During a telephone interview with the SW #1 on 3/21/17 at 12:10 p.m., SW #1 stated that Resident #3's family made it clear that they wanted the Resident home with hospice care. SW #1 indicated that in-patient hospice was offered but the family refused. SW #1 also stated that long term care placement was never discussed with the Resident's family. SW #1 further stated, I think the day before discharge, the nurse offered teachings but the family refused. SW #1 went on to state that he/she did not know if education/trainings were provided to the Resident's family before 1/9/17. SW #1 revealed that he/she did not reach out to the family to verify if they received education/teachings involving the Resident's medical devices; and stated We had a problem, they had a difficult time reaching out with the family. The surveyor asked SW #1 if the family was made aware that the facility was having difficulty reaching them. SW #1 stated Not sure. The surveyor asked if the SW #2 told him/her that the HHS refused the Resident as a patient due to unsafe D/C. The SW #1 stated No, he/she didn't tell me. Furthermore, when the SW #1 was asked if he/she called the HHS to confirm that Resident #3 was accepted and will be seen at home prior to discharge on 1/10/17. The SW #1 made no comment and stated They know this Resident. The surveyor asked if the Administrator instructed him/her to call APS involving Resident #3. The SW #1 stated No, I made calls to APS but not for Resident #3. The surveyor attempted to call SW #2 on 3/21/17 at 12:30 p.m., but SW #2 was not available for interview. In an interview with the LPN #2 on 3/21/17 at 12:42 p.m., LPN #2 indicated that he/she met with the family on several occasions and the family verbalized that they wanted to take the Resident home. LPN #2 went on to say that he/she did not initiate or provided any follow-up education with the Resident's family. LPN #2 also stated that he/she did not hear that the family had refused education/trainings. A review of the facility's policy titled, Discharge Summary and Plan, dated 12/18/15, revealed under Policy Interpretation and Implementation-section #3: The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will contain, as a minimum: e. A description of how the resident and family need to prepare for the discharge. A review of the HHA policy titled, Patient Admission Criteria, dated 2009, revealed under Procedure #5: Care will be available to all patients who can benefit regardless of race, color, religion, national origin, sex, sexual preference, disability, age, socioeconomic level, marital status,source of payment or diagnostic status. Information to be gathered to determine eligibility includes: - Attitudes of the patient and family toward care are appropriate. - Care can be provided safely and effectively in the patient's home. - Family or caregiver is available, able and willing to participate in the patient's care when condition warrant. On 3/21/17 at 2:28 p.m., the Administrator, the DON and the Regional Director were notified that an IJ for Resident #3 had occurred on 1/10/17, when Resident #3 was discharged home without pre-education/trainings to the family, to ensure that the family were capable of providing care inclusive of: Resident's medical devices ([DEVICE], [MEDICAL CONDITION], f/c and oxygen), medications management and basic care. The facility staff discharged Resident #3 on 1/10/17, knowing how the family felt so uncomfortable having the Resident at home because of lack of trainings/teachings. The facility staff failed to coordinate and follow-up with the HHS to ensure that Resident #3 was accepted and will be seen as a patient prior to discharge. The IJ was corrected on 3/21/17 at 4:30 p.m., when the facility implemented an acceptable Plan of Correction (POC) that included staff education. The acceptable POC included the following: 1. All residents will have discharge planning start upon admission. Resident #3 was discharged . 2. The Director of Social Work or designee will audit current residents for discharge planning documentation and obtained community services to evaluate completion prior to discharge. All residents have the potential to be affected by this deficient practice. Therefore, this POC applies to all residents, current and future. 3. The interdisciplinary care team and licensed nurses will be in service on Discharge planning, family/resident teaching and documentation as well ensure appropriate community services are in place and necessary teaching completed. Licensed nurses and social workers will be in serviced on discharged documentation and assessment of residents identified as and preparation for anticipated discharge will begin as of 3/21/17. Monthly in services will be completed on all staff involved in discharged for 3 months and then quarterly for one year. 4. The Director of Social Work or designee will audit discharge planning documentation and community services obtained prior to discharge to meet the needs of the resident with each discharge weekly. Any issues found during audits will be corrected immediately. Results of these audits will be discussed at the quarterly QAPI meeting, the Committee will determine the need for further action. This will be a part of the centers ongoing Quality Assurance Performance Improvement committee meetings. 5. Completion date: 3/21/17. NJAC 8:39-5.4 (b)