Every finding on record at Barnert Subacute Rehabilitation Center, Llc

Complaint #: 2990897 Based on interviews, medical record reviews, and review of other pertinent facility documents on 08/04/2026, it was determined that the facility failed to consistently document in the medical record wound care provided to a resident with pressure ulcers (PUs) (injuries to skin and the tissue below due to pressure on the skin for a long time) to their and heels and lower back and a skin tear to their arm (Resident #1), and to a resident with PUs to their lower back and heels (Resident #2). This deficient practice was identified for 2 of 3 residents (Resident #1 and Resident #2) reviewed for wound care.This deficient practice was evidenced by the following:1. According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses including but not limited to: type two diabetes mellitus with hyperglycemia (chronic condition causing high blood sugar because the body cannot use insulin properly), muscle weakness (generalized), and need for assistance with personal care. A review of the Minimum Data Set (MDS) an assessment tool dated 03/10/2026, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #1 required a helper to provide more than half of the effort needed to roll left and right. A review of Resident #1's Care Plan (CP) initiated on 04/01/2026 revealed a Focus that the resident had impaired skin integrity related to a skin tear on their left arm, deep tissue injuries (DTIs) (pressure-related injury under intact skin that have the appearance of a deep bruise) on their left and right heels, and a stage three PU (injury that has broken through the top two layers of the skin into the fatty tissue below) on their sacrum (triangular bone at the base of the spine). The Goal related to this focus was for Resident #1's left arm skin tear to heal by 07/03/2026 and for the resident to maintain and develop clean, intact skin. Interventions related to the Focus and Goal included but were not limited to: Monitor/document location, size and treatment of skin injury. initiated on 04/01/2026 and revised on 04/13/2026 and Treatment to site as ordered initiated on 04/01/2026 and revised on 04/13/2026. A review of the Order Summary Report (OSR) for Resident #1 revealed the following physician orders (POs): Apply a Xeroform oil emulsion gauze external pad (sterile, fine mesh dressing) to the left forearm topically every day shift for wound care. Cleanse the area with normal saline (NS) (solution made of water and a small amount of salt, similar to the natural fluids in the human body), pat dry, apply Xeroform, cover with dry dressing daily and as needed. The order start date was 04/02/2026. Apply Medihoney (sterilized honey formulation designed for wound care) to the sacrum topically every day shift for wound care. Cleanse the area with NS, pat dry, apply Medihoney, cover with dry dressing daily and as needed. The order start date was 04/02/2026. A review of Resident #1's Treatment Administration Record (TAR) and Progress Notes (PNs) for the month of April 2026 revealed no documentation that the resident's wound care was provided or the resident refused treatment on the following dates and shifts: Apply a Xeroform oil emulsion gauze external pad to the left forearm topically every day shift for wound care on 04/05/2026. Apply Medihoney to the sacrum topically every day shift for wound care on 04/03/2026 and 04/05/2026. 2. A review of the AR for Resident #2 revealed no information related to the resident's admitting diagnoses. A review of the MDS dated [DATE], revealed that Resident #2 had severely impaired cognitive skills for daily decision making. The MDS revealed that Resident #2 was dependent on a helper to roll left and right. The MDS revealed that Resident #2 was frequently incontinent of urine and always incontinent of bowel. The MDS further revealed that Resident #2's active diagnoses included but were not limited to peripheral vascular disease (a slow and progressive circulation disorder caused by the narrowing, blocking, or spasm of blood vessels outside the heart) or peripheral arterial disease (narrowed arteries that reduce blood flow to the limbs), malnutrition or risk for malnutrition, muscle weakness (generalized), and need for assistance with personal care. A review of Resident #2's CP revealed a Focus initiated on 03/27/2026 that the resident had impaired skin integrity related to DTIs to the left and right heels and a sacral PU. The Goal related to this focus was for Resident #2 to maintain clean and intact skin. Interventions related to the Focus and Goal included but were not limited to Treatment to site as ordered. Initiated on 03/28/2026 and revised on 04/28/2026. A review of the OSR for Resident #2 revealed the following POs: Apply ammonium lactate solution (treatment for dry or scaly skin) to bilateral (both sides) heels topically every day shift for dry skin. Cleanse with NS, apply ammonium lactate to periwound (intact skin surrounding a wound), apply skin prep (allow to dry), leave open to air, daily and as needed. The order start date was 04/09/2026. Apply heel booties when in bed every shift for pressure offloading. The order start date was 04/08/2026. Apply heel protectors every shift for preventative care. The order start date was 03/28/2026. Apply skin barrier ointment topically to sacral and perineal (the diamond-shaped region of soft tissue located at the bottom of the pelvis between the thighs) area every shift for prevention of skin breakdown. The order start date was 03/27/2026. A review of Resident #2's TAR and PNs for the month of April 2026 revealed no documentation that skin integrity treatments were provided or the resident refused treatment on the following dates and shifts: Apply ammonium lactate solution to bilateral heels topically every day shift for dry skin on 04/14/2026. Apply heel booties when in bed every shift for pressure offloading on evening shift on 04/10/2026. Heel protectors every shift for preventative care evening shift on 04/10/2026. Apply skin barrier ointment topically to sacral and perineal area every shift for prevention of skin breakdown on day shift on 04/03/2026 and evening shift on 04/10/2026. During an interview on 08/04/2026 at 12:57 PM, the facility's wound nurse (RN #1) stated that wound care was documented on each resident's TAR. RN #1 further stated that the nurse who provides the wound care documents the care provided. During a follow up interview on 08/04/2026 at 4:23 PM, the Director of Nursing (DON) stated that the expectation was for staff to document the care they provide or document if residents refused care. Resident #1's TAR for April 2026 was reviewed with the DON. The DON stated that the blank spaces on the TAR meant that staff did not sign out (document) the resident's treatments. The DON further stated that not documenting the care provided did not follow the facility's documentation policy. A review of the facility policy Charting and Documentation with an effective date of 10/2018 and a reviewed date of 06/2026, revealed under Policy Interpretation and Implementation that 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. [ .] 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; [ .] e. Whether the resident refused the procedure/treatment [ .].A review of the facility policy Wound Care with a revised date of 6/2026, revealed under Documentation that The following information should be recorded in the resident's medical record [ .] 2. The date and time the wound care was given. [ .] 4. The name and title of the individual performing the wound care. [ .] 9. If the resident refused the treatment and the reason(s) why. [ .] NJAC 8:39-35.2 (f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice, by failing to ensure; a.) physicians' orders and approved plan of care were followed, b.) provider's (consultant) recommendation was followed through for 1 of 17 residents, (Resident #27), from March 2024 through April 2025, for a total of 13 months, and c.) routine Braden scale assessment was done for residents with history of facility acquired wounds, for 1 of 2 residents, (Resident #27), reviewed for pressure ulcer. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes 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 4/17/25 at 8:30 AM, the surveyor observed Resident #27 inside their room eating breakfast. The surveyor reviewed the resident's diet slip and revealed that orange juice (OJ) was not provided to the resident's meal tray. The resident's fluid restriction indicated in their diet slip was 1500 ml/day (milliliters/day) fluid restriction and the amount of 600 ml was below coffee. The surveyor observed the following fluids that were in the meal tray were 4 ounces (oz) regular milk and a cup of coffee. The resident confirmed that they supposed to have the OJ and stated, probably, they do not have it. On 4/17/25 at 8:33 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) about the breakfast tray of the resident and what was in the diet slip that the resident received. The LPN/CN confirmed the resident did not have an OJ in their meal tray as part of the diet slip. The LPN/CN stated that the diet slip did not have a breakdown of the amount of fluids resident received, except for the information that the total fluid restriction was 1500 ml/day and below the coffee 600 ml. She further stated that it should have been clarified. On 4/17/25 at 8:43 AM, the surveyor went to the kitchen and met with the Regional Food Service Director (RFSD) and the facility FSD. The surveyor asked the RFSD and FSD if the facility had OJ. The RFSD then asked the FSD if the facility had the pre-poured OJ, and the FSD stated they do not have it, but they have the fountain for OJ. On that same date and time, the surveyor notified the RFSD of the concern that the diet slip did not match what the resident supposed to get about OJ, and that the resident's fluid restriction was not clear for amount of each fluid for milk, OJ, and coffee. The surveyor asked the RFSD the oz and ml per cup of coffee, OJ, and milk the resident should receive, and the RFSD stated that she would get back to the surveyor. On 4/17/25 at 8:55 AM, the RFSD provided the fluid restriction information. After reviewing, the surveyor asked the RFSD, how do staff know in the information provided how much milk, juice, and coffee to give if they were not included in the diet slip, and the RFSD stated that she would get back to the surveyor. The RFSD further stated, as far as she knew, the facility had only one type of coffee container for meals, unsure of how many oz the coffee container, and it was 4 oz for juice and milk. A review of the provided Fluid Restriction information by the RFSD, revealed that the 1500 ml/24 hour fluid restriction included: -All liquids shift: 7 AM-3 PM (7:00 AM-3:00 PM) shift 1320 ml: Dietary Breakfast tray=600 ml, Dietary Lunch tray=420 ml, Nurse 7-3 shift 300 ml 3 PM-11 PM (3:00 PM-11:00 PM) shift 420 ml: Dietary Dinner tray=300 ml, Nurse 3-11 shift=120 ml 11 PM-7 AM (11:00 PM-7:00 AM) shift 60 ml: Nurse 11-7 shift=60 ml The surveyor reviewed the medical records of Resident #27, and revealed: A review of the Admission Record (an admission summary) reflected that Resident #27 was admitted to the facility with medical diagnoses which included but not limited to; unspecified systolic (congestive) heart failure, essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and anemia (deficiency of healthy red blood cells in blood. Red blood cells (RBCs) are essential to carry oxygen to all parts of the body). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 4/15/25, with a brief interview for mental status (BIMS) score of 14 out of 15, reflected that the resident's cognition was intact. A review of the current Resident #27's personalized care plan (CP) reflected a focus CP for altered cardiovascular status related to (r/t) diagnosis (dx) of HTN (hypertension), PVD (Peripheral vascular disease is a slow and progressive disorder of the blood vessels), and new dx of CHF (congestive heart failure occurs when the heart is unable to pump blood throughout the body efficiently) that was initiated on 8/12/24. The CP interventions included but were not limited to; cardio/vascular medications as ordered, fluid restriction of 1.5 L/day (liters/day) [1500 ml/day], and notify MD (medical doctor) of significant abnormalities. Further review of the CP reflected a focus for potential for impairment of skin integrity r/t history of DTI (deep tissue injury, refers to damage that occurs beneath the skin's surface, affecting muscles, bones, or connective tissues), impaired mobility, and bladder and bowel incontinence that was initiated on 7/30/22, and revised on 11/15/22. The CP interventions included but were not limited to, educate resident/family/caregivers of causative factors and measures to prevent skin injury and follow facility protocols for treatment of injury. A review of the Braden Scale (standardized, evidence-based tool to assess and document a patient's risk for developing pressure injuries) for Predicting Pressure Score Risk revealed that the most recent assessment was done 1/10/25, with a score of 13, which reflected that resident had moderate risk. A review of the Report of Consultation of Nephologist revealed: -3/21/24, recommendations: increase Furosemide (also known as Lasix, a diuretic (water pill) medication (med) that prevents body from absorbing too much salt, causing it to be passed in urine. Lasix treats fluid retention (edema) in people with congestive heart failure, liver disease, or kidney disorders such as nephrotic syndrome) to 40 mg (milligram) BID (twice a day). -9/19/24, recommendations: continue with Lasix 40 mg BID. There was a handwritten note from the LPN/CN that the recommendations were noted and carried out. -3/20/25, recommendations: increase Lasix 40 mg BID. A review of the March 2024 Progress Notes (PN) revealed that there was no documented evidence that the MD was notified of the recommendation to increase the Lasix BID, or documented evidence that the recommendation was declined or followed through. A review of the 6/21/24 Nurse Practitioner PN, revealed, the resident was seen and examined in their room, the bp (blood pressure) was controlled since nephrology increased furosemide to 40 mg BID, the case was discussed with the MD, and the plan was approved. A review of the 11/4/24 and 12/2/24 Physician Assistant PN revealed, the resident was seen and examined in their room, the bp was controlled since nephrology increased furosemide to 40 mg BID, the case was discussed with the MD, and the plan was approved. A review of the 3/20/25 PN of Licensed Practical Nurse #1 (LPN#1) revealed that Resident #27 had an appointment today with the Nephologist and returned from the appointment with recommendations of Lasix 40 mg BID, and orders carried out. A review of the Physician's Orders (PO) from March 21, 2024, through April 17, 2025, the recommendation and plan for Lasix 40 mg BID was not carried out and followed, and revealed: -order date 2/24/25, CHF: Fluid restriction 1500 ml/24 hour every day shift 1080 ml (Nursing=240 ml, Dietary Breakfast tray=600 ml & Dietary lunch tray=240 ml), Every evening shift 360 ml (Nursing=120 ml, Dietary Dinner tray=240 ml), and Every night shift 60 ml (Nursing) -order date 1/28/25, Lasix oral tablet (tab) 40 mg, give one tab by mouth once a day for CHF. On 4/22/25 at 8:21 AM, the surveyor asked the LPN/CN to go with the surveyor to resident's room and to check resident's breakfast. Inside the room, the resident informed the surveyor that they just about to start breakfast. Both the surveyor and the LPN/CN observed the breakfast tray with 4 oz of OJ, 8 oz of regular milk, 8 oz coffee, two pancakes, scrambled egg, and farina. The LPN/CN confirmed the fluid amount by ounces. Outside the resident's room, the LPN/CN confirmed that the resident should have received 8 oz of milk on 4/17/25, and 4 oz of OJ to total 600 ml for breakfast. In the nursing station, the surveyor asked the LPN/CN to review the resident's electronic medical records (EMR). The LPN/CN informed the surveyor that Resident # 27 was cognitively intact, non-compliant with fluid restriction which the family and physicians were aware, and with order for Lasix 40 mg once day. The LPN/CN also stated, I think resident used to be on Lasix 20 mg and it was increased to 40 mg. She further stated that the resident with order for ace wrap in lower extremities due to chronic legs edema, no SOB (shortness of breath), and being followed up by nephrologist. Upon opening the computer, the LPN/CN stated that with regard to Nephrologist consult on 3/21/24, the nurse should have a documentation, and notified the physician about the recommendation of the Nephrologist for Lasix 40 mg BID in the PN. The LPN/CN confirmed that the PN of the Nurse Practitioner on 6/21/24, was about that the primary physician agreed with the plan for Lasix 40 mg BID. The LPN/CN also stated that on 9/19/24, the Nephrologist consult that the Lasix should be on 40 mg BID, and she did not know what happened why it was not followed. She also confirmed that on 9/19/24 PN of the nurse documented that resident should be on Lasix 40 mg BID, and that the physician agreed should be followed. She further stated that the Physician Assistant documented on 11/5/24, that the primary physician agreed on Lasix 40 mg BID should have been followed, as well as the 3/20/25 PN of the nurse documented that the Lasix 40 mg BID physician notified and ordered. At that time, the LPN/CN acknowledged that the resident should have been on Lasix 40 mg BID from 3/21/24 through April 2025. On 4/22/25 at 8:48 AM, the surveyor asked the LPN/CN about Braden scale, and the LPN/CN responded that as per facility's process and policy, it was being done by nurses as scheduled quarterly, and usually within the period or date of quarterly MDS. The LPN/CN also stated that it should be in the assessment of the EMR, and it will show in red if needed to be done. She further stated that it was important to do the Braden assessment, specially for the resident with pressure ulcer or at risk for pressure ulcer, like history of pressure ulcer to determine plan of care and prevent wound. At that time, the surveyor notified the LPN/CN of the concern that the Braden assessment was in red in the EMR, and the last Braden was done on 1/10/25. The LPN/CN checked the EMR and stated that the Braden should have been done on 4/15/25. She acknowledged that it was red in the assessment which meant that it should have been done, and she stated that it was overdue. On 4/22/25 at 12:52 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON (RDON), and Chief Operating Officer (COO). The LNHA stated that we did the in service for fluid restriction and following order for each resident, and following proper meal tickets for choices. The RDON stated that I am still investigating the concern with Resident # 27's Nephrologist recommendation for Lasix 40 mg BID, and we are waiting for the return call of the physician. On that same date and time, the surveyor also notified of the concern regarding the Braden scale not done. The RDON confirmed that the policy that was provided today, for Pressure Ulcer Risk Assessment discussed about risk assessment, and it was the Braden assessment that was being identified in the policy. The following policies were provided by the RDON on 4/22/25 at 11:57 AM: -A review of the facility's Pressure Ulcer Risk Assessment Policy, with revised date of October 2010, revealed under Assessment: 1. Risk Assessment: a pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes . -A review of the facility's Nutritional Assessment Policy, with a reviewed date of 10/2024, did not include information about fluid restriction. -A review of the facility's Resident Hydration and Prevention of Dehydration Policy, with a revised date of December 2008, revealed under Policy Interpretation and Implementation . 8. Orders may be written for extra fluids to be encouraged between meals and/or with med passes. A specific minimum amount should be included in the order (e.g. 240 ml fluids BID with med pass) . On 4/22/25 at 2:24 PM, the RFSD provided a copy of the resident's diet slip that included the ounces in the fluids and she stated that the diet slip should have the amount in fluids for fluid restriction. On 4/23/25 at 11:59 AM, the survey team met with the LNHA, DON, and RDON. The RDON stated that there were three dates the resident went to the Nephrologist with recommendations to increase Lasix BID 40 mg, 2 of 3 nurses documented that orders were carried out. The RDON further stated that we did an investigation, it was the LPN/CN, LPN#1, and LPN#2 were the nurses involved. The RDON also stated that LPN#2 was not at the facility anymore, who never called the physician to notify the recommendation to increase the Lasix. She further stated that disciplinary action was provided to other nurses for this was considered a med error. At that same time, the RDON informed the surveyor that we called the current physician about the above concerns with Lasix. The RDON further stated that the physician told her that he would not increase this time the Lasix because the resident was stable. The RDON also stated that we called the cardiologist and did not recommend this time to increase the Lasix but added another blood pressure med and a PN was documented yesterday after surveyor's inquiry. She further stated that the Assistant DON did an assessment yesterday and no negative effect, the resident was not hospitalized , and we also audited all medical records yesterday to make sure that we did not miss anything from the consultant recommendations, we realized it could get out of hand, the good thing no negative outcome. Furthermore, the RDON stated another Braden scale was done yesterday. On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse, and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:39-3.2(a,b); 11.2(b); 27.1(a)

Based on interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure accurate documentation of a residents' advance directives for 2 of 3 residents, (Resident #15, Resident #16) reviewed. This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #15, which revealed: A review of the Admission Record (AR) (an admission summary) revealed that the resident was admitted with diagnoses that included but were not limited to, urinary tract infection and hypertension (high blood pressure). A review of the most recent discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A review of the personalized Care Plan (CP), a document that outlines a patient's healthcare needs and the nursing interventions required to meet those needs, which did not reflect any documentation of the resident's advance directive (AD), code status or other resident wishes for life saving measures. A review of the Social Services Assessment (SSA) with an effective date of 2/13/25, reflected nothing on line six, for code status, reflected YES on line 6a. AD and reflected POLST (practitioner orders for life sustaining treatment) on record on line 6b. Comments/Notes. Further review of the SSA with an effective date of 11/4/24, also reflected nothing on line six, and reflected NO on line 6a and NO on line 6c. It also included If No AD, do you want the facility to initiate an AD? There was no further information provided on the assessment. The POLST form, located in the resident's paper chart, which was undated and not filled out, to indicate what AD, nor was it signed by the resident, attending physician or facility staff. There was no documentation in the medical records that indicated that the resident or Responsible Representative (RR) was educated on the AD process. A review of the resident's electronic medical record (eMR) did not indicate information that reflected AD status in the resident information area. 2. The surveyor reviewed the hybrid medical records of Resident #16, which revealed: A review of the AR that reflected that the resident was admitted with diagnoses that included but were not limited to spinal stenosis, lumbar region, (a condition characterized by the narrowing of the spinal canal in the lower back) and hypertension. A review of the comprehensive MDS, with an assessment reference date (ARD) of 3/30/25, reflected a BIMS score of 15 out of 15, which indicated resident's cognition was intact. A review of the personalized CP, reflected a focus on AD that was initiated on 4/4/24, revised on 12/30/24, with a target date for revision on 4/9/25. The CP interventions that was initiated on 4/4/24, reflected that the resident was a full code. A review of the SSA with an effective date of 1/15/24, reflected nothing on line six. Code Status reflected NO on line 6a. AD reflected NO on line 6c. The surveyor was unable to locate a POLST form in Resident #16's paper chart. There was no documentation in the medical records that indicated that the resident or RR was educated on the AD process. On 4/17/25 at 10:36 AM, the Licensed Nursing Home Administrator (LNHA) provided, after surveyor inquiry, signed POLST forms for Resident #15 dated 4/16/25, (time not legible), and Resident #16 dated 4/16/24 at 6:50 PM. The LNHA also provided a requested facility's Policy titled Advance Directives with revised date of 11/25. On 4/21/25 at 9:41 AM, the surveyor interviewed the Director of Social Services (DSS). The DSS stated that on admission, the resident or RR was asked if there was an AD or other statement of healthcare wishes currently in place. The DSS also stated that a packet of information about AD was provided to the resident or RR if required. The DSS further stated that the Social Worker will also explain any detail and ask what the wishes of the resident were. The DSS provided the surveyor with a copy of the packet. On that same date and time, the surveyor asked how the AD or POLST was communicated to the staff if there was an emergency. The DSS stated that they rely on the paper copy in the chart as a copy usually goes to the hospital with the resident if they were to go. The surveyor asked the DSS about the POLST that were missing from or not filled out in the paper charts. The DSS stated they could have been waiting for the physician to sign. The surveyor then asked the DSS would that be normal for several months if the physician comes in regularly, and the DSS stated no it should not be, but some residents change their mind or have not made a choice. At that same time, the surveyor notified the DSS that they could not find any documentation to support that. The surveyor asked the DSS about the SSA documents, the information and that line six was blank. The DSS stated that she does not fill in line six only 6a, 6b, or 6c which ask if the resident has an AD and/or if they would like one. Furthermore, the surveyor asked the DSS if the educational packet and forms were provided to resident and/or RR or were also put into the medical record. The DSS stated, no, just given to resident or RR depending on cognitive state. The DSS gave an example for Resident #16, who's RR was estranged and rarely comes as it upsets the resident. On 4/21/25 at 12:59 PM, the survey team met with the LNHA and Director of Nursing (DON) to discuss above concerns with AD documentation for Residents #15 and #16 for missing documentation in the paper chart for AD and no record of educational materials in the medical record. On 4/22/25 at 12:52 PM, the survey team met with the LNHA, DON, Chief Operating Officer (COO), and Regional DON (RDON). The DON stated that the AD material and other communications with the RR were sent through another electronic platform or tool the facility uses for outside communication. The surveyor asked if the communication tool was tied to the medical record, and the DON stated no it was not part of the medical record. A review of the facility's Advanced Directives Policy, with revised date of 11/25, reflected: Line 4. Information about whether or not the resident has executed an AD shall be displayed prominently in the medical record. Line 8. Changes or revocations of a directive must be submitted in writing to the Administrator, the Administrator may require new documents if the changes are extensive. The CP Team will be informed of such changes and/or revocations so that the appropriate changes can be made in the resident assessment (MDS) and CP. Line 9. The DON Services or designee will notify the attending physician of AD so that appropriate orders can be documented in the resident's medical record and plan of care. Line 10. The Nurse Supervisor will be required to inform emergency medical personnel of a resident's AD regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made. The facility did not provide any further pertinent documentation. N.J.A.C. 8:39-9.6(b)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified in dining room for 2 of 5 days observation, and was evidenced by the following: On 4/17/25 at 8:25 AM, the surveyor observed the dining room (and recreation area) with no residents inside the room. The surveyor observed the floor with accumulation of grayish and blackish substances, pieces of small plastic wrapper and paper, and the tv (television) with accumulation of grayish substances. There was a bed at the end of the dining area with no cover, with stack of different chairs, the windowsill with accumulation of grayish substances, and the vending machine near the window with plastic with papers, and with accumulation of grayish substances. Afterward, the surveyor was in the hallway between dining room and kitchen, and surveyor interviewed the Regional Food Service Director (RFSD), who informed the surveyor that the dining room was being used for lunch and dinner only, and once a month for breakfast for subacute residents. On 4/17/25 at 11:56 AM, the surveyor observed the dining room, there were six residents and three staff waiting for lunch to be served. The surveyor interviewed the Licensed Practical Nursing Supervisor (LPNS), who informed the surveyor that the kitchen staff were preparing the residents' meals, and it will be served shortly. Residents #6, #18, #27, #30, #31, and #37 were inside the dining room. On 4/17/25 at 12:10 PM, the surveyor observed in the dining room with the same six residents were served with soup. The surveyor observed the dining area on the end part by the window with stored bed with mattress with no cover with stained grayish color, stocks of regular chair with different colors, rollator, walker, folded long table which was visible to all residents and staff in the dining area, and where residents could go. The surveyor asked the LPNS about the equipment, bed, and chairs stocked in the area where the residents were using as the dining area, and the LPNS said that he would check why it was there. On that same date and time, the surveyor observed the vending machine had papers on top of it and the surveyor asked the LPNS what those papers were. The LPNS took the paper on top of the vending machine and showed it to the surveyor. The papers were emergency crash care checklist. The LPNS acknowledged that the accumulation of grayish substances on top of the vending machine were dust. On 4/21/25 at 11:15 AM, the surveyor observed the dining with staff and residents during recreational activity. The surveyor observed the floor with accumulation of grayish and blackish substance, pieces of small plastic wrapper and paper, the windowsill with accumulation of grayish substances, and the vending machine with accumulation of grayish substances. On 4/21/25 at 12:58 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The LNHA and DON acknowledged the surveyor's concerns about the dining room environment. Both the LNHA and DON confirmed that the dining room should not be used as storage and environment should be dust free and clean. On 4/22/25 at 12:52 PM, the survey team met with the LNHA, DON, Regional DON (RDON), and Chief Operating Officer (COO). The LNHA stated that education was provided to housekeeping department to maintain homelike environment and maintain free from dust and clutter. A review of the facility's Quality of Life-Homelike Environment Policy, with a revised date of October 2009, that was provided by the RDON, revealed, residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation: 2. The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse (IPN), and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:39-31.2(e), 31.4(a)(f)

NJ#168277 Based on interview and review of facility documentation, the facility failed to provide and document sufficient preparation and orientation to resident to ensure safe and orderly transfer or discharge from the facility. This deficient practice was identified in 1 of 1 resident, (Resident #212), reviewed for discharge. The deficient practice was evidenced by the following: The surveyor reviewed the hybrid medical record (paper and electronic) for Resident #212. A review of Resident #212's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited vertebral disc displacement (when a disc in the spine shifts and may cause pain) and difficulty walking. A review of Resident #212's most recent discharge (d/c) Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #212 had no cognitive impairment. The MDS also reflected, under section GG Functional Abilities and Goals- Discharge, the ability to go up and down 4 steps, partial/moderate assistance, and the ability to go up and down 12 steps, not attempted. A review of Resident #212's Progress Notes, including but not limited to Social Services Notes (SSN), therapy notes, and Interdisciplinary Care Plan Team (IDCP Team) notes revealed the following: An IDCP Team Meeting Note dated 9/27/23, that reflected that the team met with Resident #212 on 9/26/23, regarding her plan of care and d/c plan. The note reflected that the resident was able to walk 10 feet with assistance of a walker device but requires a great deal of assistance to do stairs. The d/c plan included referral for home care as well as a home health aide, and that the resident must use four steps to enter the residence and 14 additional steps once inside. A review of the resident's Physical Therapy Evaluation and Plan of Treatment (PTEPT) notes revealed a goal for the resident to be able to go up or down four stairs safely with a target date of 9/26/23, and a goal to go up or down 14 stairs safely with supervision with a target date of 10/18/23. The PTEPT notes also reflected that the resident's home had four steps outside to navigate as well as 14 steps inside. A review of the resident's Physical Therapy Discharge Summary (PTDS) revealed that a short-term goal for the resident to safely go up or down four steps was met on 10/9/23, and a long-term goal of being able to go up or down 14 steps safely was discontinued on 10/9/23, with the resident being able to navigate eight steps. The PTDS also revealed a d/c recommendations that reflected the resident was given safety precautions, had medical equipment ordered, and required a Home Exercise Program (HEP) (a program designed to facilitate rehabilitation through exercises performed at home supervised by a therapist), for safe d/c to home. A review of the resident's Physical Therapy Progress Report (PTPR) revealed a Justification for Skilled Services that reflected a requirement for services to increase independence, mobility, functional activity tolerance to enhance quality of life by improving ability to safely return to private residence. An SSN dated 10/11/23, reflected on 10/9/23, the facility was notified by Resident #212's insurance that the last covered day would be 10/9/23, and the facility notified the resident and provided a phone number for an appeal if the resident wished to. The SSN also reflected that the resident was going to appeal since they could not navigate the steps at home. The SSN revealed that the resident was upset with the process and short notice. The SSN reflected that the resident d/c home on [DATE]. A SSN dated 10/10/23, reflected that the Director of Social Services (DSS) was informed that multiple home care services would not be able to accept Resident #212's case. The note also included that the resident was unable to safely manage their own stairs at the current time and outpatient rehabilitation services (resident goes to an outside center) was not an option. A review of additional SSN dated 10/11/23, reflected that a home health agency agreed to accept the resident's case, and there would be a delay in getting physical therapy started, information which, was provided to the resident. On 4/22/25 at 12:52 PM, the survey team met with The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional DON (RDON), and Chief Operating Officer (COO) to discuss concerns with Resident #212's d/c. On 4/23/25 at 11:32 AM, the survey team met with the LNHA and DSS. The DSS stated the resident chose to go home because they did not want to have to pay for services if they were denied appeal. The DSS and LNHA did not dispute that there were no other options offered to the resident to stay in facility. The DSS stated that she called several home care agencies and finally got one after a second call to take the resident's case but there would be a delay of about a week to get therapy services in home. The DSS continued to assert that the resident was very worried about being able to pay and elected to go home. Furthermore, the DSS provided to the surveyor a copy of an e-mail sent to the resident with the contact information for the home health service that was willing to take the case. The email also reflected that there was a delay in physical therapy services. The facility did not provide any further pertinent information. N.J.A.C. 8:39-4.1(a)30,32

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physician's order with regard to medication with parameters for 1 of 4 residents, (Resident #44) and b.) ensure that the emergency cart (e-cart) was routinely check and supplies were not expired for 1 of 3 e-cart inspected, according to the standard of clinical practice and facility policy. 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 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. 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. 1. On [DATE] at 10:02 AM, Surveyor #1 (S#1) observed Resident #44 in their room, lying in bed with the television on. The resident stated that they were in the facility for Physical Therapy because two months ago they had a left leg surgical amputation and will see the surgeon in June for possible prosthesis. A review of the medical records of Resident #44, an Admission Record (AR, an admission summary) revealed diagnosis that included but not limited to; hypertension (the pressure of blood circulating around the body is higher than normal), complete traumatic amputation at level between knee and ankle, left lower leg, subsequent encounter, and acquired absence of left leg below knee, gangrene, not elsewhere classified. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of (ARD) [DATE], revealed a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had intact cognition. A review of the resident's Order Summary Report reflected a physician's orders (PO): -start date [DATE], Metoprolol Tartrate Oral Tablet (tab) 50 mg (milligram), give 0.5 tab by mouth two times a day for hypertension (HTN). Hold if SBP (systolic blood pressure, is the first number, it is the pressure caused by your heart contracting and pushing out blood.) is less than 110 or HR (heart rate) less than 55. -start date [DATE] at 9:00 AM-d/c (discontinued) date [DATE] at 10:00 AM, Losartan Potassium Oral tab 50 mg, give 0.5 tab by mouth one time a day for HTN. Hold if SBP is less than 110 or HR less than 55. -start date [DATE] at 9:00 AM, Losartan Potassium Oral tab 50 mg, give 0.5 tab by mouth one time a day for HTN. Hold if SBP is less than 110 or HR less than 55. 0.5 tab = 25 mg. The above PO were transcribed to the electronic Medication Administration Record (eMAR) and revealed: Metoprolol Tartrate was found to have been given outside the SBP parameters on: [DATE] with a SBP of ,d+[DATE] at 8:00 AM (8 AM); [DATE] with a SBP of ,d+[DATE] at 5:00 PM, administered by License Practical Nurse (LPN) #1, [DATE] with SBP of ,d+[DATE] at 8 AM, [DATE] with SBP of ,d+[DATE] at 8 AM, administered by LPN #2, [DATE] with SBP of ,d+[DATE] at 8 AM, administered by LPN #2. Losartan Potassium Oral Tablet was found to have been given out of parameters on: [DATE] with a SBP of ,d+[DATE] at 9:00 AM (9 AM), administered by LPN #2, [DATE] with a SBP of ,d+[DATE] at 9 AM, administered by LPN #2. On [DATE] at 9:34 AM, S#1 interviewed LPN #2 regarding Metoprolol and Losartan medications (meds). The surveyor and LPN #2 reviewed the [DATE] eMAR, and LPN #2 stated, Instead of me clicking hold I pushed given but it was not given. It was an accident. LPN #2 further stated that the meds should have been held and follow the parameters when the blood pressure (BP) was below the parameters. LPN#2 also stated yes, I should have documented it, I should have double checked myself. On [DATE] at 1:13 PM, S#1 notified the License Nursing Home Administrator (LNHA), DON, Regional DON (RDON), and Chief Operating Officer (COO), regarding concerns with not following the PO for BP parameters for Metoprolol and Losartan. On [DATE] at 2:10 PM, the DON stated regarding meds with parameters, the nurses were expected to follow the PO for BP parameters and to document if it was outside the parameters. The DON further stated, I do weekly in-services, some were agency nurses, and yes the expectations are the same, they were in serviced too. On [DATE] at 2:15 PM, S#1 reviewed the in-services completed by the DON dated [DATE], for ensuring parameters were noted when administering BP meds, which revealed, both LPN#1 and LPN#2 signed the attendance sheet. A review of the facility's Administering Medications Using Electronic System Policy, dated ,d+[DATE], that was provided by the DON, revealed on the Policy Statement: Meds shall be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation #3, further revealed, meds must be administered in accordance with doctor's orders, including any required time frame and following medication cautionary . 38327 2. On [DATE] at 12:10 PM, Surveyor #2 (S#2) observed in the dining room six residents during lunch. S#2 also observed the vending machine had papers on top of it and the surveyor asked the Licensed Practical Nurse Supervisor (LPNS) what those papers were. The LPNS took the paper on top of the vending machine and showed it to S#2. The papers were emergency crash care checklist. On that same date and time, S#2 asked why the emergency crash care checklist last date was for [DATE] ([DATE], last day it was filled out and signed), and the LPNS checked the other papers, and it were all for 2021 and 2020. There were no papers for 2022, 2023, 2024, and 2025. At that same time, S#2 observed a sign for AED (stands for automated external defibrillator, a device that can help those experiencing sudden cardiac arrest) in the dining room. S#2 asked the LPNS where the AED was located and the e-cart, and LPNS did not have a response. Then, the Regional Food Service Director (RFSD) came and helped the LPNS and surveyor to find the AED and the e-cart. Afterward, S#2, the LPNS, and the RFSD found the AED and e-cart in the next room next to the dining area. S#2, in the presence of the LPNS and RFSD observed the following expired supplies in the e-cart and inside the AED box: -ambu bag (also known as a manual resuscitator or bag valve mask, is a device used to provide respiratory support to patients in emergency and non-emergency situations. It consists of a self-inflating bag, a mask or mouthpiece, and a valve to control the flow of air) with a use by date of 211110. According to the FSD, the ambu bag was expired because the date 211110 meant [DATE], for use by date. - suction tubing non-conductive sterile, use by date [DATE] that was attached to the suction machine the tip and the tubing inside a bag. According to the RFSD, the suction tubing was expired. - prefilled humidifier 340 ml (milliliters) sterile water date [DATE]. The RFSD acknowledged that the prefilled humidifier sterile water was also expired and should not be in the e-cart. -the unopened AED pad, use before date of [DATE] and the opened AED with a use before date of [DATE]. The RFSD stated and confirmed that AED pads were all expired and would be replaced. At that same time, S#2, LPNS, and the RFSD did not see a cardiac board and oxygen (O2) tank as indicated in the checklist. The LPNS and RFSD had no response when asked by S#2 why there was no O2 tank and cardiac board in the e-cart. S#2 also asked the LPNS and RFSD who was responsible for checking the e-cart, the AED, and filling out the emergency crash care checklist, and both LPNS and RFSD did not respond. On [DATE] at 12:58 PM, the survey team met with the LNHA and DON. The LNHA and DON acknowledged S#2's concerns about the expired supplies for e-cart and AED pads. A review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation (CPR) Policy, with a reviewed date of ,d+[DATE], that was provided by the DON, revealed under Emergency Procedure-CPR . 7. When the AED arrives, assess for need and follow AED protocol as indicated. a. Check AED machine for function daily, including battery test, extra AED pads available for use . On [DATE] at 12:40 PM, the survey team met with the LNHA, DON, RDON, Infection Preventionist Nurse, and COO for an exit conference. The LNHA did not provide additional information. NJAC 8:,d+[DATE].2(b), 29.2(d)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 1 of 5 days during the annual re-certification survey. This deficient practice was evidenced by the following: On 4/16/25 at 9:00 AM, the survey team entered the facility. The surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the receptionist. The NHRCSR posted was dated 4/16/25 with a census of 60, for the [7:00 AM to 3:00 PM] day shift. On 4/16/25 at 9:30 AM, in the presence of the survey team, the Admission Director, stated that the census (total number of residents) was 61. On 4/16/25 at 9:40 AM, the surveyor interviewed the License Practical Nurse/Unit Manage (LPN/UM) for both Units, who stated that census was 60. On 4/16/25 at 12:40 PM, the surveyor showed a copy of the NHRCSR posted on 4/16/25 from the receptionist desk and the census given by the LPN/UM as 60, to the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and the DON both confirmed the Census was 61. The LNHA stated, There was an admission before midnight last night, so the correct census is 61. On 4/17/25 at 9:00 AM, the surveyor interviewed the Receptionist. The surveyor asked the Receptionist what the process was of posting the NHRCSR, and she stated, I am responsible for posting and updating the form. The admission person will update the system for census and that is how I get my information. In the weekend, we will leave the forms on Friday for the weekend receptionist to post and update it. She further stated that she made a mistake yesterday with the census, I did not know there was an admission the night before, but I fixed it and posted the correct one. On 4/17/25 at 9:30 AM, the surveyor asked the LNHA regarding the incorrect posting of the NHRCSR census yesterday, 4/16/25, it was posted as a census of 60 and the census was 61. The LNHA confirmed that, The form needed to be corrected when admission staff comes in and put it in the system. On 4/21/25 at 9:50 AM, the LNHA stated that there was no policy for posting the staffing. On 4/21/25 at 12:59 PM, the survey team met with the LNHA and the DON to notify them of the above concern with posting. The surveyor asked what the expectation was for posting, and the LNHA responded that the expectation was after the admission person gets in and goes through the census line and updates the staffing, the posting will be done. The LNHA further stated they had an admission, and they did not clear the census line yet when the day the surveyors came in. The LNHA also stated that the admission staff gets in around 9:30 AM. At that same time, the LNHA confirmed, The visiting hours are 8:00 AM-8:00 PM. The expectation is for visitors to see the accurate posting when they come in the morning. On 4/22/25 at 9:32 AM, the LNHA responded regarding staffing posting/census updates, Moving forward, in the event the receptionist and/or admissions director is not in the facility, the nursing supervisor will be responsible to update the staffing posting at the front desk. Education has been initiated. NJAC 8:39-41.2(a,b,c,d)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #33). The deficient practice was evidenced by the following: The surveyor reviewed Resident #33's electronic medical record (EMR) which revealed the following: A review of Resident #33's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia, (a reduced number of red blood cells) and major depressive disorder (persistent depressed mood). A review of Resident #33's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/20/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #33 had no cognitive impairment. A review of Resident #33's Order Summary Report (OSR), a listing of the resident's active physician's orders, revealed the following active as needed (PRN) medication (med) orders: Acetaminophen tablet (tab) (a pain reliever) 325 mg (milligram), give 2 tab by mouth every 4 hours PRN for pain- Mild Scale=1-3. Percocet Oral tab 5-325 mg Oxycodone w/Acetaminophen (a narcotic pain reliever), give 1 tab by mouth every 12 hours PRN for pain- Moderate Scale 4-7, Pain-Severe Scale=8-10. Percocet Oral tab 5-325 mg Oxycodone w/Acetaminophen, give 1 tab by mouth every 12 hours PRN for pain-Severe Scale=8-10. Tramadol HCL Oral tab 50 mg (a prescription pain reliever), give 1 tab by mouth every 12 hours PRN for pain- Moderate Scale=4-7. A review of the resident's electronic Medication Administration Record (eMAR) reflected the same orders that were found on the OSR. A review of the resident's Pain Assessment/Evaluation dated 2/21/25, reflected that the resident reported occasional generalized pain over the past five days daily with a scale of five or moderate. A review of the resident's Comprehensive Care Plan dated 2/27/25, reflects a Focus, Goals, and Intervention put in place for pain treatment. On 4/21/25 at 11:08 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN). The surveyor asked if and how the resident expresses or verbalizes pain. The LPN/CN stated that Resident #33 verbalized their needs and any pain well. The LPN/CN further stated that mostly generalized pain, usually upon waking, with some muscle spasms. The surveyor asked the LPN/CN about Resident #33's PRN medications (meds) used for pain. At that same time, the surveyor asked how the nursing staff differentiates which med or how much to give as there were multiple orders. The LPN/CN stated yes that it could be confusing for which order to use as it looks [NAME] there was a duplicate and that one tab of Percocet for moderate pain and the same dose for severe pain was confusing as well. The surveyor asked the LPN/CN about the resident's Tramadol order. The LPN/CN stated that they would call the resident's primary physician (MD) to clarify the PRN orders and find out which Percocet order to keep and what to do with the Tramadol. On 4/21/25 at 11:33 AM the surveyor interviewed Resident #33 in their room. The resident stated they were doing okay, and that the pain med makes the pain tolerable. The resident stated the staff do come to give pain meds when they ask. On 4/21/25 at 11:50 AM, the Director of Nursing (DON) stated that Resident #33's MD will be called to clarify the PRN pain orders as they could be confusing. On 4/21/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss concerns for duplicate Percocet and pain orders for Resident #33. A review of the facility's Administering Medications Using Electronic System Policy, dated as updated 11/2024, reflected, under item 4. If a dosage is believed to be inappropriate .the person preparing or administering the med shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The LNHA did not provide any further pertinent information. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 5 residents. There were 26 opportunities for error, 2 errors were observed which calculated to a med administration error rate of 7.69%. This deficient practice was identified for 1 of 5 residents, (Resident #3), that was administered meds by 1 of 3 nurses that were observed. The 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 4/17/25 at 8:23 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare meds for Resident #3. The meds included an active physician's orders (PO) for the following: Docusate Sodium 100 mg (milligram) capsules (cap) give 1 cap by mouth two times a day for constipation. (a med that softens the stool). Albuterol Sulfate HFA Inhalation Aerosol 108 mcg (microgram) 1 puff inhale orally two times a day for asthma. (a med that opens the lung airways). Trelegy Elipta Inhalation Powder Breath Activated 100-62.5-25 mcg 1 puff inhale orally every 12 hours for asthma. (a combination of 3 long-acting powder meds, that reduce lung inflammation and relax airway muscles). The surveyor observed the LPN prepare and administer Resident #3's meds which included one (1) Docusate Sodium 100 mg tablet. The surveyor then observed the LPN administer the inhaled meds to the resident. The LPN first administered the Albuterol, had the resident rinse their mouth, then immediately after, administer the Trelegy and have the resident rinse their mouth. The surveyor asked the LPN to show him the stock bottle that they took the Docusate from and compare it to what was indicated on the electronic Medication Administration Record (eMAR) that reflected the PO. The LPN showed the surveyor the bottle that she took the Docusate from and stated it reflected tablets. The LPN compared it to the eMAR and stated that the order reflected capsules. The LPN then located another Docusate bottle in the med cart (med-cart) that reflected capsules. The LPN stated she should have used those. The surveyor asked the LPN if there was a procedure that was followed when a resident was administered two or more inhaled meds, specifically if there was any waiting time. The LPN stated yes, I think you should wait a minute, maybe two between inhalers. The surveyor completed the med pass observation with the LPN. The surveyor reviewed the electronic medical record (EMR) for Resident #3 including, but not limited to, the Order Summary Report (OSR), a listing of the resident's active PO, and eMAR. Both the OSR and eMAR reflected orders for: Docusate Sodium 100 mg cap give 1 cap by mouth two times a day for constipation to be given at 9:00 AM and 5:00 PM. Albuterol Sulfate HFA Inhalation Aerosol 108 mcg 1 puff inhale orally two times a day for asthma to be given at 9:00 AM and 5:00 PM. Trelegy Elipta Inhalation Powder Breath Activated 100-62.5-25 mcg 1 puff inhale orally every 12 hours for asthma to be given at 9:00 AM and 9:00 PM. On 4/17/25 at 12:01 PM, the surveyor interviewed the facility's Consultant Pharmacist (CP) by telephone. The surveyor asked the CP if they did any education on medication pass (medpass), specifically using inhalers and following physician orders. The CP stated yes, education was done, the staff gets a copy of the in-service, and it includes topics on checking the medication against the eMAR and separating different inhalers by 1 to 2 minutes. On 4/21/25 at 12:59 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss concerns with medpass. A review of the reference material [name] Drug Guide for Nursing Students, 14th Edition, reflected, administer bronchodilators first and wait several minutes before administering inhaled corticosteroids to allow optimal penetration . A review of the facility's Administering Medications Using Electronic System Policy, dated updated 11/2024, reflected under item 3. Meds must be administered in accordance with doctor's orders, . and under item 6. The individual administering the med must check the label three times to verify the right med, . The LNHA did not provide any further pertinent information. N.J.A.C 8:39-29.2 (d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring, a.) that the Infection Preventionist Nurse (IPN) was aware in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread and b.) the water management plan was implemented. This deficient practice was identified for 1 of 2 positive water testing results reviewed. This deficient practice was evidenced by the following: According to Centers for Disease Control & Prevention (CDC), Water Management in Healthcare Facilities, March 15, 2024, Key points: CDC recommends that healthcare facilities develop and implement comprehensive water management programs. They can help reduce the risk for Legionella growth and transmission. They can also help control other waterborne pathogens. On 4/21/25 at 9:04 AM, the surveyor interviewed the Director of Maintenance (DoM), who informed the surveyor that he was responsible for water management in the building, and it was facility's process to do annual test of water for Legionella. The surveyor asked for the policy and procedure for water management and water testing results, and the DoM said he would get back to the surveyor. On 4/21/25 at 9:16 AM, the DoM provided Water Management binder that included water testing results and Water Management Plan. The surveyor asked the DoM for the monitoring and accountability log that the plan was implemented, and the DoM said he would get back to the surveyor and will ask the Regional Maintenance Director (RMD). A review of the provided Laboratory Certificate of Results dated 3/6/24, revealed, room [ROOM NUMBER] bath sink with comment PR. The comment table for PR indicated that any numerical result is a cause for concern. Further review of the provided Laboratory Certificate of Results, revealed, dated 3/26/24, for a sample date of 3/25/24, reflected that room [ROOM NUMBER] bath sink comment not detected. A review of the provided documentation for Water Management Plan and binder, revealed, the following Control Measures to follow for the following but not limited to risk factors: -Eyewash Station. Plumbed units are to be activated weekly to flush the line and verify operation; at least a 3-minute flush is recommended. -Ice Machine. Clean and disinfect ice machine based on equipment manufacturer's instructions. Change filter and clean, if installed. -Medical Device. Clean and sterilize medical devices according to the manufacturers' instructions in their prescribed manner and procedure; or as required or necessary as determined by the Program Team. -[NAME] Filter/Point of Use Filter. Replace as directed according to the manufacturers' instructions; or as required or necessary as determined by the Program Team. -Expansion Tank. Check for leaks, calcifications and corrosion around attachment fittings. Frequency: annually. -Water Heater. Check flow and return temperatures (temp) at hot water heater. Monitoring: Supply temp should be checked at the outlet of the hot water heater and should not be lower than 140 degrees Fahrenheit (F). The return temp should also be checked monthly and should not be lower than 122 degrees F. -Backflow Preventer/Check Valve. Identify and test the integrity of all backflow preventers and check valves to ensure protection of domestic water from cross-contamination with processed water through a building code-approved method. Frequency: Biannually or as required by state or local authorities. -Cooling Tower. Check the appearance of the recirculation water, check if clean and clear without sediment or foaming. Frequency: weekly. -Electronic and Manual Faucets. Ensure typical daily use of the faucet occurs. The water flow decreases the possibility of bacterial colonization. -Infrequently Used Fixtures. Flush infrequently used fixtures. Flush for several minutes, until temp stabilizes and is comparable to supply water. Frequency: twice weekly where users are at high risk, weekly in all other buildings. -Showerhead, Hose, and Sink. Replace or dismantle, disinfect, and eliminate all deposits of scale from all shower heads, hoses, sinks, aerators or flow restrictors. Frequency: quarterly or as necessary. Further review of the reports, documents, and binder provided by the DoM, revealed that there was no accountability log on the above risk factors and followed the control measures for Water Management. On 4/21/25 at 10:18 AM, the RMD was unable to provide documentation and accountability log for the above water management monitoring, and what was done to correct the detected Legionella on 3/6/24. The RMD stated that whatever was provided to the surveyor would be the process the facility followed. The RMD also stated that the 3/6/24 detected or positive results for Legionella testing was corrected after following the water management plan, and that was why the 3/25/24 report came out not detected when another test was done. The RMD further stated that he was unsure what was missing in the report and documents provided but he would get back to the surveyor. On 4/21/25 at 9:35 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the above concerns with Legionella and that surveyor asked the Regional Director of Nursing (RDON) for the documents regarding the Legionella positive test on 3/6/24. The LNHA stated that she was aware and that they were putting all the documents together to be given to the surveyor. On 4/22/25 at 1:45 PM, the surveyor asked the LNHA for the monitoring and accountability log done in accordance with the Water Management Plan of the facility that was previously asked by the surveyor, and the LNHA stated that she would get back to the surveyor. On 4/23/25 at 8:29 AM, the surveyor met with the DoM for a follow up interview about the water management implementation, and the DoM stated that they have the plan that was in the binder. The surveyor asked the DoM what the facility should do with their plan, and he did not respond. The surveyor asked how the facility monitor and follow the water management plan, and he responded that he checks water temperature (temp) routinely. The surveyor asked to provide documentation, and he said he would get back to the surveyor. On 4/23/25 at 8:38 AM, the surveyor and the Regional Food Service Director (RFSD) went to the eye wash station near the reception area. Both the surveyor and the RFSD observed the eye wash was covered with brownish hard substances. The surveyor asked the RFSD what the brown substances was, and the RFSD stated that it looks like chocolate. The RFSD stated that it should have been cleaned. On 4/23/25 at 8:43 AM, the surveyor interviewed the LNHA, DON, and the Infection Preventionist Nurse (IPN) regarding the water management. The IPN informed the surveyor that it was the DoM who was responsible for water management and as an IPN she should be aware of the results of the water testing and if there would be a positive test that could affect the resident. The surveyor asked the IPN if she was made aware that the February 2025 test had an issue with one tube broken and the last year report was positive, and the IPN responded that she was unaware of the February 2025 issue and that she was not at the facility yet at the time on March 2024. The IPN stated that I know they must check the temp and any issue or concern I need to be aware. On that same date and time, the DON stated that there should be a report to local health department if there was a positive result. The surveyor notified the LNHA, DON, and IPN of the above concerns that for the last four days since the entrance conference meeting, the surveyor asked for documentation and an accountability log for the water management plan implementation, and the facility was unable to provide documentation. The surveyor also notified the LNHA, DON, and IPN about the concern with the eye wash area, and the IPN stated that it should have been cleaned. On 4/23/25 at 9:06 AM, the surveyor in the presence of the LNHA and IPN went to the DoM's office. Inside the office was also the RMD. The surveyor asked and followed up with the DoM the monitoring and accountability log that the surveyor asked, and the RMD stated that he did not know what else the surveyor was asking for if the facility had provided the water management plan. The DoM was unable to provide documentation and accountability log except for the water temp log. On 4/23/25 at 9:12 AM, the surveyor, LNHA, and the IPN went to the Spectrum Unit shower room. The surveyor, LNHA, and IPN observed the shower head with whitish substances. The surveyor asked the LNHA and the IPN what was the white substances, and the LNHA stated it was the calcium deposit, while the IPN stated it was the soap residue. Both acknowledged that it should have been cleaned and if the water flushing was being done according to the water management plan, that should have been checked and corrected. On 4/23/25 at 9:22 AM, the DoM, in the presence of the survey team informed the surveyor that to be honest, I was unable to follow the Water Management Plan with regard to monitoring what supposed to monitor except for the water temp routinely. He further stated that he checked the eyewash monthly, but he did not have an accountability log to show the surveyor. On 4/23/25 at 9:34 AM, the survey team met with the LNHA to discuss the above concerns with water management that the plan was not all implemented, and that the DoM had no accountability log for the monitoring of risk factors except for the water temp log. The LNHA stated that she was not the administrator in March 2024, she knew that when the result was positive for legionella testing, it should have been communicated to the local health department and test resident if applicable. On that same date and time, the LNHA confirmed that according to the provided documents to the surveyor the facility followed the recommendation of the vendor with regard to flushing, unable to provide documentation, it was tested back again and came out negative. She further stated that it was an expectation to follow the water management plan and there should be an accountability for monitoring on what was on the plan. She also stated that she just found out after surveyor's inquiry that it was not being done accordingly. She acknowledged also what the RMD had stated to the surveyor earlier that he was unsure what was the surveyor was asking for, but it should have been done. On 4/23/25 at 9:41 AM, the DoM came back and stated to the survey team that he wanted to correct himself that he was checking the eye wash station weekly, and not monthly, and that he did not have an accountability to show the surveyor. A review of the facility's Legionella Water Management Program Policy, with a revised date of July 2017, that was provided by the LNHA, revealed under Policy Interpretation and Implementation . 5. The water management program includes the following elements . f. The control limits or parameters that are acceptable and that are monitored . j. Documentation of the program. A review of the facility's Infection Preventionist Job Description that was provided by the LNHA, revealed under Position Responsibilities and Qualifications, in this key position, essential job duties and responsibilities include: -Partners with the Medical Directors and medial personnel to implement and evaluate infection prevention goals and action plan . -Oversees the operations of the infection prevention, epidemiology, industrial hygiene, and relevant safety programs, -Accountable for surveillance of healthcare acquired and community acquired infections . On 4/23/25 at 12:40 PM, the survey team met with the LNHA, DON, Regional DON, IPN, and Chief Operating Officer for an exit conference. The LNHA did not provide additional information. NJAC 8:39-19.1, 19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to notify the resident's representative in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #60 reviewed for hospitalization . The deficient practice was evidenced by the following: On 2/21/23 at 11:50 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #60. The nurse progress notes revealed that the resident was transferred to the hospital on 1/25/23 at 2:45PM. According to the Discharge Minimum Data Set, an assessment tool used to facilitate the management of care dated 1/25/23, reflected that Resident #60 was discharged to the hospital with a return not anticipated to the facility. On 2/22/23 at 12:07 PM, the surveyor interviewed the facility's Social Services Director who provided a documentation indicating that the Long-Term Care Ombudsman was notified. However, the resident's responsible party was not provided with a written notification of the reason for an emergency transfer. A review of the facility's policy titled, Making an Emergency Transfer or Discharge with a review date on 6/2022. 1.) Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedure . e. Notify the representative (sponsor) or other family member. On 2/22/23 at 12:45 PM, the survey team met with the facility's Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse and Infection Preventionist. The above concern was discussed. There was no further information provided. NJAC 8:39-5.3; 5.4

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice to hold a medication used to treat high blood pressure in accordance with the physician's order (PO) for 2 of 2 residents reviewed, Resident #50 and Resident #59. The deficient practice is evidenced by the following: Reference: New Jersey Statuses 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 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 otherwised 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On [DATE] at 11:35 AM, the surveyor observed Resident #50 in bed in his/her room. The surveyor reviewed Resident #50's hybrid medical records that revealed the following: The Admission Record (an admission summary) revealed that Resident #50 was admitted to the facility with a diagnosis that included but not limited to Hypertensive Heart Disease with Heart Failure. The Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. The January and February 2023 electronic Medication Administration Record (eMAR) included a physician's order for Amlodipine Besylate 5 mg tablet- Give 1 tablet by mouth two times a day for Hypertension with a start date of [DATE]. The medication had instructions to obtain blood pressure (BP) and to hold the medication if the Systolic Blood Pressure (SBP) (top number of a blood pressure reading) was less than 110 and Heart Rate (HR) less than 55. A review of the documentation on the eMAR revealed that the medication Amlodipine Besylate was administered once in [DATE] and 4 times in February 2023 when the medication should have been held due to SBP below 110. On [DATE] at 11:13 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) and discussed the above concern. LPN #1 acknowledged that the BP medication was administered and should have been held due to SBP below 110. LPN #1 stated, the nurses should ensure that they check three times prior to administering the blood pressure medication and to make sure the blood pressure and heart rate are not outside the parameters. 39399 2. On [DATE] at 9:53AM, the surveyor reviewed the hybrid medical records for Resident #59. The resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. A review of the electronic Order Summary Report for [DATE] reflected a PO dated [DATE] for a medication, Hydrochlorothiazide tablet. The PO specified to give 1 tablet (25mg) by mouth one time a day for Hypertension and to hold the medication for SBP less than 110. Further review of the electronic PO reflected an order dated [DATE] for a medication, Metoprolol Tartrate tablet. The PO specified to give 1 tablet (25mg) by mouth two times a day for Hypertension and to hold the medication for a SBP less than 110 and HR less than 55. A review of the eMAR for [DATE] through [DATE] reflected that the medication Hydrochlorothiazide was to be administered at 0900 (9AM). The eMAR reflected that the Hydorchlorothiazide was signed as given when the resident's SBP was less than 110. Further review of the documentation on the eMAR revealed that the medication was administered 2 times in [DATE] times in [DATE], and 7 times in [DATE]. A review of the eMAR for [DATE] through [DATE] reflected that the medication Metoprolol Tartrate was to be administered at 0830 (8:30AM and 1630 (4:30PM). The eMAR reflected that the Metoprolol Tartrate was signed as given when the resident's SBP was less than 110 and heart rate was less than 55. Further review of the documentation in the eMAR revealed that the medication was administered 3 times in [DATE] times in [DATE], and 9 times in [DATE]. A review of the facility policy titled, Administering Medications Using Electronic System (PCC), with a revised date of [DATE] under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed. A further review of the policy under Policy Interpretation and Implementation indicated, 3. Medications must be administered in accordance with doctor's orders, including any required time frame and following medication cautionary. 7. The following information must be check/verified for each resident prior to administering medication: .b. Vital signs, if necessary. On [DATE] at 12:49 PM, the team met with the Licensed Nursing Home Administrator (LNHA), Regional Nurse, Director of Nursing (DON), and Infection Preventionist (IP). The surveyor discussed the above concern. The DON acknowledged that the blood pressure medications should have been held as indicated in the PO. NJAC 8:39- 29.2 (d)

Based on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was observed and evidenced by the following: On 2/15/23 at 10:00 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: At 10:20 AM, in the presence of the FSD, the surveyor observed the following in the walk-in refrigerator: 1. One fan covered with a heavy build up of a gray fuzzy substance. The FSD identified the substance as dust build up and acknowledged that the substance could dislodge from air blowing and go onto the food. 2. On all the wire racks in the refrigerator (five racks with four shelves each), the surveyor observed a sticky brown and black debris (which could be wiped off with a paper towel). The FSD was unable to identify the substances. The surveyor further observed the following during the kitchen tour in the presence of the FSD: 3. The dual stack standing oven had a white chalk-like substance on the side of the top oven doors and a gray dust like substance on the top on the oven. The substance was able to be wiped off with a paper towel. The FSD was unable to identify the substance. 4. A small shelf connected to the back of the six-range stove top had a heavy buildup of a sticky green colored substance. The FSD described it as grease. The substance was able to be partially wiped off with a paper towel. 5. The top of the steamer was observed with a heavy build-up of a brown and black-colored caked on substance. The substance was not able to be wiped off with a paper towel. The FSD was unable to identify the substance. On 2/15/23 at 10:50 AM, the FSD stated, the walk-in refrigerator should be cleaned weekly and all the other equipments should be cleaned daily at the end of the evening shift. The FSD provided the surveyor with a copy of the daily cleaning schedule which revealed that from 2/1/23 through 2/15/23 the kitchen shelves were being checked off as cleaned. The FSD could not speak to the accountability of cleaning the walk-in refrigerator and other kitchen equipment. A review of the facility policy titled, Cleaning and Sanitation of Equipment with a revised dated of 9/13/2022 revealed under Policy, Cleaning and sanitation of equipment is to remove food debris that bacteria need to grow, and to kill those bacteria that are present. It is important that the cleaned and sanitized equipment are stored dry so as to prevent bacteria growth. A further review of the policy under Procedure indicated Cleaning and Sanitation: 1. Refrigerator - Walk-In. Shelving. Frequency: Weekly. a. Remove all food shelves b. Scrub shelves with sanitizing solution and clean cloth. DO NOT USE ABRASIVES. c. Wash walls with sanitizing solution and clean cloth. d. Allow air dry. e. Return food to shelves. 2. Oven - Convection - Frequency: Immediate. a. Remove spills, spillovers, and burned food deposits. Frequency: Daily a. Wipe cool over exterior and interior with wet cloth. b. Remove and scrape drip pans, send through dishwasher cycle, and allow air dry. Frequency: Weekly a. Wipe and clean oven exterior. Use damp cloth. On 2/17/23 at 12:45 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing and discussed the above concerns during the initial kitchen tour. The LNHA acknowleged with the findings above. No further information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident #24. This deficient practice was evidenced by the following: On 3/8/21 at 10:38 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) perform a wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the March 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ strength Dakin's Solution, pat dry, apply Santyl, [MEDICATION(S)], Calcium Alginate Wound Dressing, and cover with a dry dressing daily. The PO was noted on the March 2021 Electronic Treatment Administration Record. The surveyor observed LPN #1 wash his hands, put on gloves, and disinfect the over-bed table with Super Sani-Cloth Germicidal Disposable Wipes, which have a recommended 2 minute dwell time (the amount of time it takes for the product to disinfect the surface properly.) LPN #1 immediately covered the over-bed table with a plastic barrier without waiting the 2 minute dwell time. LPN #1 then disinfected scissors with a Sani-Cloth Wipe, opened the treatment cart outside of the room, gathered all the supplies, and opened the supplies wearing the same contaminated gloves. The surveyor then observed LPN #1 remove the previously contaminated gloves, wash his hands, put on a new set of gloves. LPN #1 removed the Sterile Calcium Alginate Wound Dressing from its sterile package and placed it directly onto the plastic barrier. LPN #1 also placed a plastic trash bag on top of the resident's bed to discard all contaminated supplies. The surveyor observed LPN #1 wash his hands, change to a clean set of gloves, remove the heel boot, remove the soiled dressing, tossed the contaminated dressing into the plastic garbage bag located on the resident's bed. LPN #1 then approached his treatment cart located in the hallway, still wearing the contaminated gloves, and obtained a paper measuring ruler. The surveyor observed LPN #1 continued to do the treatment; He washed his hands, changed to a clean set of gloves, measured the wound, cleansed the wound with Dakin's solution, applied the Santyl, and [MEDICATION(S)] Ointments. The surveyor stopped LPN#1 just before applying the Sterile Calcium Alginate Wound Dressing and asked LPN #1 to step outside of the room. The surveyor asked LPN #1 why he completely removed the Sterile Calcium Alginate Wound Dressing from its packaging and placed it directly on the barrier pad, contaminating the pad. LPN #1 replied that he should have left the Sterile Calcium Alginate Wound Dressing in its Sterile package. On 3/8/21 at 11:53 AM, the surveyor interviewed LPN #1 and discussed the breaks in Infection Control technique. LPN #1 acknowledged that he should have removed his gloves and sanitized his hands after cleaning the table and scissors before exiting the Resident's room and obtaining supplies from the treatment cart. He further stated that he hadn't been aware that the Sani-Wipes had a 2 minute dwell time. LPN #1 also recognized that he should not have completely removed the Calcium Alginate Wound Dressing from its packaging and placed it onto the barrier pad but should have left the dressing in its original packaging. The surveyor reviewed the Admission Minimum Data Set (MDS), an assessment tool dated 11/22/20 with a Brief Interview for Mental Status score of 12, which reflected the resident had a moderately impaired cognition. The surveyor reviewed the Admission/Readmission Screening Skin Evaluation, which indicated that Resident #24 was admitted from the hospital with a stage 4 wound to the right heel, which measured 10 cm x 7 cm with eschar, slough, and biofilm (a thin film of bacteria that adheres to a surface.) The surveyor reviewed the wound evaluation & management summary dated 12/18/20, which reflected the wound measured 8 x 6 cm. The surveyor reviewed the wound evaluation & management summary dated 3/5/21, which reflected the wound measured 2 x 2.8 x 0.1 cm with 90% granulation tissue. The wound was healing and was noticeably smaller in size. The surveyor reviewed the facility's Handwashing/Hand Hygiene policy dated as revised November 2020. The policy's statement reflected, This facility considers hand hygiene the primary means to prevent the spread of infection. Further review reflected that use of an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap and water should be used : a. before handling clean or soiled dressings b. after contact with a resident's intact skin c. after handling soiled dressings d. after removing gloves. On 3/8/21 at 1:39 PM, the survey team met with the LNHA and DON; The facility provided no further information. NJAC 8-39-19.4 (a)

C#: NJ 8 Based on interview, record review, and review of pertinent facility documents on 6/5/19, it was determined that the facility failed to consistently document on the Activities of Daily Living Tracking Form (ADLTF) to indicate that the task for turning side to side was provided and to follow the facility's policy on Charting and Documentation for 1 of 3 residents (Resident #2), reviewed for care. This deficient practice is evidenced by the following: 1. According to Admission Record, Resident #2 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 8/31/18 revealed Resident #2 had a Brief Mental Status (BIMS) score of 0/15, which indicated severe cognitive impairment. The Interdisciplinary Plan of Care (IDPC) dated 8/24/18, showed that the Resident had skin integrity impairment as evidenced by stage 2 wound on the sacral area. Measurements were documented as 2 centimeters (cm) x (by) 0.7 cm. Interventions included but were not limited to: turn and reposition every two hours, render treatment as ordered, weekly wound rounds, and nutritional supplements as ordered. The IDPC dated 8/24/18, showed under Bed Mobility that the Resident would require extensive assistance of one (1) from staff. The ADLTF for the month of (MONTH) (YEAR), under Bed Mobility showed the following but was not limited to: How the Resident turns side to side. The ADLTF revealed that the Resident would require extensive assistance of one (1) staff to turn side to side. However, the ADLTF revealed the following: On 9/5/18, 9/14/18, 9/15/18, 9/19/18, and 9/24/18, there was no documentation to indicate that the Resident was turned side to side on the 7:00 a.m.-3:00 p.m. shift. On 9/4/18, 9/8/18, and 9/21/18, there was no documentation to indicate that the Resident was turned side to side on the 3:00 p.m.-11:00 p.m. shift. Furthermore, the ADLTF for the month of (MONTH) (YEAR), under Bed Mobility revealed the following: On 10/9/18 and 10/12/18 there was no documentation to indicate that the Resident was turned side to side on the 7:00 a.m.-3:00 p.m. shift. On 10/5/18, 10/9/18, and 10/11/18 there was no documentation to indicate that the Resident was turned side to side on the 3:00 p.m.-11:00 p.m. shift. In addition, there was no documentation anywhere in the medical record as to the reason turning side to side was not provided. The surveyor conducted an interview with Licensed Practical Nurse (LPN #1) on 6/5/19 at 12:54 p.m., who was one of the nurses assigned to Resident #2. LPN #1 was unable to explain why he did not document on the the ADLTF on the days he was scheduled to work for the month of 9/2018 and 10/2018. However, he stated that residents who were at risk for skin breakdown must be turned and repositioned every two (2) hours. He also stated turning and repositioning, including refusal, must be documented in the nurse's notes and/or ADLTF. The facility's policy titled Charting and Documentation, was revised on (MONTH) (YEAR), showed under Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The same policy under Policy Interpretation and Implementation: #1. Documentation in the medical record may be electronic, manual or a combination. #2. The following information is to be documented in the resident medical record: .c. Treatment or services performed; .#7. Documentation of procedures and treatments will include care-specific details, including: .e. Whether the resident refused the procedure/treatment . NJAC 8:39-27.1(a)(e)

Based on interview and review of pertinent facility documents it was determined that the facility failed to ensure 3 of 5 Certified Nursing Aides (CNA) (CNA #1, #2 and #3) had their annual performance reviews. This deficient practice was evidenced by the following: On 5/23/19 at 10:00 AM, the surveyor reviewed the education files for 5 Certified Nursing Aides. The surveyor reviewed the following: CNA #1 had a hire date of 2/19/15; CNA #2 had a hire date of 7/10/16; CNA #3 had a hire date of 1/09/17. The education files did not include evidence of their annual performance reviews based on their corresponding hire dates. On 5/23/19 at 11:08 AM, the surveyor interviewed the Chief Nursing Officer (CNO) who was responsible for providing the surveyor the education files and performance review information. The CNO acknowledged there were no annual performance reviews for the CNA's in question, and stated, I don't know if I have performance reviews. The CNO stated that the facility had started a new electronic education tracking system in (MONTH) 2019, and she would need to ask the Director of Nursing (DON) if she had them. On 5/23/19 at 11:52 AM, the surveyor interviewed the DON who stated that she started as the DON in (MONTH) (YEAR) and added that she took over for the other DON and did not have the performance reviews. She also acknowledged she could not find any performance reviews for the three CNA's from the previous DON. She added that she believed the previous Assistant Director of Nursing (ADON) was doing it, but that the ADON left employment at the facility three weeks ago. The DON stated that she did see that some were missing and I will have him make sure that everyone is caught up. NJAC 8:39-13.4; 25.4 (b);43.17

Based on observation, interview and record review, it was determined that the facility failed to ensure: a.) the accurate accountability of the inventory for a controlled drug ([MEDICATION NAME]) from the facility's controlled drug back-up supply, b.) the accuarate accountability of a controlled drug ([MEDICATION NAME] Patch) for the administration, removal and destruction from the facility's controlled drug back-up supply, and c.) an accurate accountability for the dose of a controlled drug ([MEDICATION NAME] concentrate) removed from the facility's back-up supply. This deficient practice was identified during the controlled drug inventory review for 1 of 1 storage rooms (Main) for the back-up supply of controlled drugs. The evidence was as follows: On 5/23/19 at 10:12 AM, the surveyor met with the Director of Nursing (DON) who stated that the Assistant Director of Nursing (ADON) would be able to complete a controlled drug inventory for the facility's-controlled drug back up supply. On 05/23/19 at 10:18 AM, the surveyor with the ADON reviewed the controlled drug back up supply. The ADON stated that every shift she completed an inventory of the controlled drug back up supply. The surveyor and ADON reviewed the Controlled Drug Inventory form dated and signed for that day on 05/23/19. The ADON stated that an inventory had been done in the morning by the outgoing nurse from the 11 PM to 7 AM shift and the incoming Nursing Supervisor (NS) for the 7 AM to 3 PM shift. At that time, the surveyor with the ADON reviewed the Controlled Drug Record (CDR) for a controlled narcotic [MEDICATION NAME], [MEDICATION NAME] 100 microgram (MCG) per hour (hr) patches dated as dispensed on 4/11/18 for five (5) patches. The form indicated that one (1) [MEDICATION NAME] 100 MCG/hr patch was removed from inventory on 6/22/18 and on 5/04/19. The CDR also revealed that the patch that was removed from inventory and applied on 6/22/18 was removed and destroyed by two (2) nurses on the same day. In addition, the [MEDICATION NAME] 100 MCG/HR patch signed as removed from inventory and applied on 5/04/19 had no removal and destruction date. The ADON stated that she thought the nurses were supposed to sign on the CDR for the removal and destruction of the [MEDICATION NAME] Patches but was not sure if that was the same for the [MEDICATION NAME] Patches from the back-up supply. Also, neither date indicated the name of the resident that the [MEDICATION NAME] Patches were ordered for and applied. The ADON stated that she thought the nurses were supposed to indicate the room number of the resident in which the [MEDICATION NAME] Patch was removed. The ADON could not speak to who the residents were that the [MEDICATION NAME] Patches had been dispensed for accordingly. The surveyor and ADON reviewed the CDR for [MEDICATION NAME] 50 MCG/hr with a date dispensed on 2/08/18 for ten (10) patches. The CDR revealed that on 2/25/19 one (1) patch was removed from inventory and applied. There was no resident name or resident identifier written for application and there was no date of removal and/or destruction. The surveyor and ADON reviewed the CDR for [MEDICATION NAME] 25 MCG/hr with a date dispensed on 08/31/18 for 20 patches. The CDR revealed that on 2/25/19 one (1) patch was removed from inventory and applied. There was no resident name or identifier written for the application of the patch, and there was no date of removal and/or destruction. On 5/23/19 at 10:30 AM, during the controlled drug inventory count, the surveyor with the ADON, reviewed the CDR for [MEDICATION NAME] 25 milligrams (MG) capsules which revealed that the declining inventory count indicated that there were three (3) capsules remaining. The surveyor and the ADON observed that there was one (1) capsule in the active inventory. The ADON could not speak to why the inventory of [MEDICATION NAME] 25 MG capsules was incorrect and would need to find out. On 5/23/19 at 10:40 AM, during the controlled drug inventory count, the surveyor with the ADON reviewed the CDR for 30 milliliters (ML) of [MEDICATION NAME] concentrate 20 MG per ML dated as received on 08/31/18. The CDR indicated that on 11/07/18 a dose of two (2) MG of [MEDICATION NAME] concentrate was removed and administered and the amount remaining was 28 ML. At that time, the surveyor with the ADON reviewed that 2 MG of [MEDICATION NAME] concentrate would be 0.1 ML and not 2 ML that would have been removed from inventory. The surveyor with the ADON observed the [MEDICATION NAME] Concentrate remaining liquid inventory was 28 ML. The ADON stated that she thought there was an error in the dosage and that the nurse might have meant that 2 ML were removed which would be a dosage of 40 MG. The ADON acknowledged that a dose of 40 MG didn't seem accurate. There was no resident name on the CDR for the removal of the [MEDICATION NAME] on 11/07/18. On 5/23/19 at 11:04 AM, the surveyor met with the DON. The DON stated that she knew the outgoing 11 PM to 7 AM shift nurse had removed two (2) [MEDICATION NAME] 25 mg capsules from the controlled drug back up supply for a resident that morning. The DON stated that she thought the nurse had signed the CDR for the [MEDICATION NAME] 25 mg when she removed the two (2) capsules. The DON also added that [MEDICATION NAME] Patch removal and destruction documentation was supposed to be done on the CDR. The DON also stated that the resident's room number who was to receive the controlled drug from the back up supply should be indicated on the CDR. The DON added that she had been the DON since (MONTH) (YEAR) and would have to review the controlled drug back up supply system. On 5/23/19 at 12:47 PM, the survey team met with the incoming NS for the 7 AM to 3 PM shift. The NS stated that she was usually the supervisor for the 3 PM to 11 PM shift but was helping out this morning. The NS also stated that she had completed the facility's-controlled drug back up supply inventory with the outgoing 11 PM to 7 AM nurse at approximately 6:40 AM this morning and the inventory count was correct. The NS added that the CDR was to be signed at the time that the controlled drug was removed from inventory. On 5/23/19 at 12:55 PM, the surveyor team met with the facility administrative team. The DON stated that the [MEDICATION NAME] was not signed at the time of removal from inventory and had called the nurse in to complete the CDR. The DON added that she thought the nurse who signed for the [MEDICATION NAME] concentrate had meant that 2 ML were administered and would have to review the physician's orders [REDACTED]. She stated she would need to investigate. On 5/23/19 at 2:07 PM, the survey team met with the DON who stated that she did not have any further information regarding the facility's-controlled drug back supply inventory. The DON could not provide the resident names of the [MEDICATION NAME] Patch applications and the dates and signatures of the removal and destruction that were removed from the controlled back up supply. The DON also could not speak to which resident had an order for [REDACTED]. NJAC 8:39-29.2 (d), 29.7 (c)(d)

Based on observation, interview, and record review, it was determined that the facility failed to a.) perform a skin treatment in accordance with a physician's orders [REDACTED].) ensure the care plan addressed the resident's impaired skin integrity. This deficient practice was identified for 1 of 18 resident reviewed for quality of care (Resident #254), and was evidenced by the following: On 05/19/19 at 10:54 AM, the surveyor observed Resident #254 sitting in his/her room. The resident informed the surveyor that he/she had a wound on their foot that needed treatments. The resident stated that he/she went to the Doctor on Thursday night 5/16/19, and that the doctor wanted a treatment of [REDACTED]. The resident voiced to the surveyor that the treatment was not being done and the resident stated he/she had to scream last night to get the treatment. The surveyor reviewed the medical record for Resident #254. A review of the Admission Record face sheet (an admission summary) reflected that Resident #254 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/07/19, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had fully intact cognition. A review of a Report of Consultation dated 5/15/19 indicated that the resident had [MEDICAL CONDITION] to the right foot and blisters. The Consulting Physician recommended to apply Mupirocin Ointment 2% (antibiotic cream used to treat skin infections) and a gauze bandage to the site. A review of the physician's orders [REDACTED]. [REDACTED]. A review of the (MONTH) 2019 Treatment Administration Record (TAR) that corresponded with the physician's orders [REDACTED]. The order for the treatment was plotted to be done and signed during the Day and Evening shift. Further review of the TAR did not reflect evidence of a wound treatment to the right and left blisters on 5/15/19, 5/16/19 after the blisters were identified and treatment recommendations were made by the consulting Physician. In addition, the TAR reflected a blank for the treatment on 5/17/19 for the Evening shift. A review of the resident's individualized, comprehensive care plan initiated upon admission 04/30/19 did not address the resident's skin condition of the [MEDICAL CONDITION], blisters and/or that he/she was receiving a wound treatment for [REDACTED]. On 5/20/19 at 11:31 AM, the surveyor interviewed the Nursing Supervisor who worked the 3:00 PM to 11:00 PM shift on 5/17/19. The Nursing Supervisor informed the surveyor that a Licensed Practical Nurse (LPN) was assigned to the unit day evening. The Nursing Supervisor provided the surveyor with the LPN's phone number. At 11:34 AM, the surveyor attempted to conduct a phone interview with the LPN #1. The surveyor left a voicemail in request for a return callback. At 11:46 AM, LPN #2 informed the surveyor that the nurses preformed wound and skin treatments. LPN #2 stated that Resident #254 had a blister on his/her foot. He/she went to the Orthopedic on Thursday and had a new order for Mupirocin ointment. The LPN #2 added that the resident had an orthopedic shoe that he/she will wear when he/she felt like it. The LPN #2 stated that when the nurse performed the treatment, the nurse signed in the TAR. If the TAR was not signed, it meant that the treatment was not performed. The LPN #2 stated that if the resident refused the treatment, then the nurse needed to document that the treatment was refused. The LPN stated that if the nurse had forgotten to sign the treatment, then the nurse could sign at a later date that the treatment was completed. At 11:51 AM, the Director of Nursing (DON) informed the surveyor that the nurse would sign the TAR when a treatment was performed. If the resident refused the treatment, the nurse would document that the treatment was refused. If the TAR was blank, it could indicate that the nurse forgot to sign rather than the treatment was not performed. The surveyor informed the DON that the resident stated that on 5/17/19, he/she had not received the treatment as ordered. The surveyor reviewed the (MONTH) 2019 TAR with the DON. The DON observed the blank on the treatment for 5/17/19. The DON stated that she would follow-up with the nurse to find out why the treatment was not performed. On 5/22/19 at 11:32 AM, the surveyor interviewed the LPN #1 who was assigned the resident on 5/17/19 for the evening shift. The LPN #1 informed the surveyor that she believed that the resident refused the treatment on 5/17/19. The LPN further stated that she tried to give his/her treatment later, but the resident was outside and added that the resident could stay outside until 08:00 PM. The LPN stated that she forgot to sign the TAR that the resident refused the treatment and that she did not document this in the nursing progress notes. She further stated that she verbally told the oncoming nurse at 11:00 PM that the resident had not received the wound treatment. The LPN was unsure who she told. The LPN could not speak to if treatments had been performed on 5/16/19 to the blisters when the blisters had been identified and the consulting Physician had made recommendations on 05/15/19. At 11:56 AM, the surveyor conducted a follow-up interview with the resident who stated that no one came to perform his/her treatment on 05/17/19, and that no one had asked him/her about having the treatment done. The resident indicated that he/she wouldn't refuse a wound treatment and denied refusing it. At 11:02 AM, the Assistant Director of Nursing (ADON) informed the surveyor that she was responsible for the care plans. The nurses could also update the care plans as needed. If there was an order for [REDACTED].#254's care plan. The ADON confirmed there was no care plan for the foot treatment and/or evidence that he/she had a history of [REDACTED]. On 5/23/19 at 1:17 PM, the DON confirmed that the resident had not received his/her foot treatment on 5/17/19. The DON was unable to provide additional documentation that a wound treatment had been performed on 5/16/19 after the blisters had been identified and wound treatment recommendations were made on 5/15/19. NJAC 8:39-27.1 (a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) accurately assess a resident for smoking, b.) implement the facility's smoking policy and procedure for residents who smoked, and c.) appropriately assess, implement, and evaluate the effectivness of interventions to prevent falls for a resident who had a history of [REDACTED]. This deficient practice was identified for 2 of 2 residents reviewed for smoking (Resident #13 and #152) and 1 of 1 residents reviewed with falls (Resident #103) and was evidenced by the following: 1. On 5/19/19 at 11:22 AM, the surveyor observed Resident #13 sitting in his/her room. The resident stated that he/she smoked cigarettes, but was trying to cut back on the amount smoked per day. The surveyor observed an opened pack of cigarettes on the resident's table. The surveyor observed a lighter stored in the pack of cigarettes on the resident's bedside table. The resident stated that he/she could hold their own cigarettes and lighter, and that he/she was able to smoke outside independently. The resident added that after 6:00 PM, a pass was required to go outside to smoke. At 1:10 PM, the surveyor observed the resident independently self-propel toward the exit to go outside. The resident confirmed to the surveyor that he/she was going outside to smoke. The surveyor reviewed the medical record for Resident #13. A review of the Admission Record face sheet (an admission summary) reflected that Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/06/19, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had a fully intact cognition. It further reflected that the resident was not currently a tabacco user. A review of admission Smoking Safety Screen dated 3/30/19 indicated that the resident was a current tabacco user and was identified as an at-risk smoker and required supervision to smoke due to having a PICC line. A review of the resident's individualized, resident-centered care plan initiated on 4/01/19 and revised on 4/24/19 indicated that the resident was a smoker. Interventions included to instruct the resident about the facility policy on smoking and the resident can smoke unsupervised. This contradicted the Smoking Safety Screen dated 3/30/19. A review of an updated Smoking Safety Screen dated 5/20/19, indicated that the resident was an at-risk smoker who required supervision to smoke due to having a PICC line. There was no evidence that the care plan was updated on 05/20/19 to reflect the resident was to smoke supervised due to having a PICC line. On 5/22/19 at 11:09 AM, the Assistant Director of Nursing (ADON) informed the surveyor that she updated the resident's smoking assessment recently. The ADON stated that the resident was not smoking many cigarettes when he/she first arrived at the facility. The surveyor reviewed with the ADON the smoking assessments and the care plan that contradicted the supervision necessary for the resident. The ADON stated that she would need to follow-up with the Director of Nursing (DON) if the resident should be a supervised smoker. The ADON stated that unsupervised residents could hold onto their cigarettes, but regardless, residents could not hold onto their lighters. All lighters were locked in the medication carts. In order to smoke, an unsupervised resident would need to ask the nurse for his/her lighter. The ADON stated that residents should not hold their own lighters, but sometimes residents will still hold onto them. At 11:27 AM, the Licensed Practical Nurse (LPN) informed the surveyor that the resident had a PICC line. When the resident first arrived at the facility, he/she received antibiotic medication through the PICC line, but the resident was no longer using the PICC line for that purpose. The LPN further stated that the resident was a smoker and that the cigarettes and lighter were held in the medication cart. The LPN added that the resident did not hold onto their own cigarettes and lighter. The surveyor inquired about the location of the resident's cigarettes and lighter. The LPN opened the medication cart and the resident's cigarettes and lighter were not in the the cart. The LPN could not speak to the location of the resident's smoking supplies. At 11:52 AM, the resident was in his/her room eating lunch. The resident confirmed that he/she was smoking since first arrival at the facility. The resident stated that they held onto their own cigarettes and lighter. At 12:50 PM the DON in the presence of the Administrator and survey team stated that the residents were suppose to give their cigarettes and lighter to the nurse upon admission to hold and that the facility continued to educate the residents on this, and that it was the responsiblility of the admisison nurse to go over this with the residents. The DON stated that the facility had a younger population of residents that feel they should be able to hold onto their own cigarettes and lighters. On 5/23/19 at 1:03 PM, the DON confirmed that Resident #13 should have been a supervised smoker because of the PICC line. The DON confirmed the resident was not being supervised during smoking and that the care plan was not accurate to the two smoking assessments performed for the resident. The surveyor reviewed the facility's Smoking Policy & Procedure dated 2/19/19. The policy included that residents who are not independent must be accompanied by a staff to smoke in the designated area at scheduled time specified by the facility. The policy also included that no resident was allowed to have cigarette lighters in their possession. Lighters or matches will be kept in the medication cart and will be returned after use. 2. On 5/19/19 at 10:48 AM, the surveyor asked an LPN regarding resident's who smoke on the unit. The LPN was not sure and stated that she floats between units, and that it was better to ask the Certified Nursing Aide (CNA). At 10:51 AM, the surveyor interviewed a Certified Nurse Aide (CNA) who stated that she saw Resident #152 with a pack of cigarettes. The CNA stated to the LPN that she saw the resident with a pack. The CNA stated to the surveyor that the residents have to ask the nurse to go out, and they get a pass and hand it to the Receptionist and are out smoking for 10 or 20 minutes. The CNA stated The residents hold their own cigarettes and I think they have their own lighter. On 05/20/19 at 11:47 AM, the surveyor interviewed Resident #152 in the resident's room. The resident stated that he/she was a smoker and told the facility they didn't want a nicotine patch or anything like that. The resident added they were still smoking and keeps their own cigarettes and matches in the room in their [NAME]et pocket and staff would assist to go outside to smoke. The surveyor reviewed the medical record for Resident #152 and the following was revealed: A review of the Admission Record (an admission summary) revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Written Summary of The Plan of Care dated 5/14/19, reflected that the resident's initial goals were to increase strength and endurance and to be discharged to home. The Care Plan form was signed by the resident and LPN. There was a section for staff assistance will be provided to help with your activities of daily living (ADL's), and it was left blank. The surveyor reviewed the resident's individualized comprehensive care plan initiated on 5/14/19 which revealed Focus areas that did not address smoking. A review of the medical record revealed there was no evidence of a smoking assessment upon admission. A review of the admission MDS dated [DATE] reflected that the resident had a BIMS score of 15 out of 15, indicating the resident had a fully intact cognition. It further reflected that the resident was not currently a tabacco user. On 5/21/19 at 11:23 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the care plans. She stated the initial care plans were completed by the admitting nurse and that she would go in the next day or so and review the chart and add or adjust the care plan. Then the team would meet with the resident a day after the admission, if it is a weekend, the whole interdisciplinary team (IDT) would meet on the Monday. The care plan was reviewed with the ADON and confirmed the baseline care plan (to be completed within 48 hours of admission) was incorporated into the resident's individualized comprehensive care plan. The ADON stated she was familiar with Resident #152 and had met with the resident in therapy. The ADON stated that she did not know she was a smoker until yesterday (5/20/19) and she was unaware that she held her own cigarettes and matches. The ADON acknowledged that the resident did not have a care plan for smoking and that it should have been included in the baseline care plan initiated by the admitting nurse on 5/13/19. On 5/22/19 at 11:40 AM, the surveyor interviewed the ADON a second time. The smoking assessment had not been done when the resident was admitted . She stated if she was told about the smoking, which the CNA's and nurses should have told her about upon admission, it should have been done. The ADON stated that she did the assessment because she now became aware of the smoking and it needed to be corrected. On 5/22/19 12:52 PM, the DON stated that an unsupervised smoker was not supposed to have cigarettes and a lighter/matches with them in their room and the cigarettes and lighter should be with the nurse and the resident can get them whenever they want. The DON stated that sometimes the resident's might get them from visitors, but stated that the nurses should educate the resident on the policy. On 5/23/19 at 01:03 PM, the surveyor interviewed the DON a second time in the presence of the survey team. The DON stated that they had not attempted to have Resident #152 sign the smoking policy agreement until surveyor inquiry. The DON stated that Resident #152 was resistant to the agreement and that the DON was still working with the resident. The DON acknowledged that the Resident #152 should have had a smoking assessment done upon admission and a care plan to address smoking for Resident #152 as part of the resident's medical record. 3. On 5/19/19 at 10:20 AM, the surveyor observed Resident #103 in bed with a family representative in the room. The family representative stated that the resident spoke another language but was forgetful and had [MEDICAL CONDITION]. The family representative added that the resident had fallen at home and was in the hospital prior to being admitted to the facility. The family representative added that the resident recently had several falls in the facility and wasn't sure if the alarms had worked and was concerned as to how the resident could be prevented from having further falls. At that time, the surveyor observed the resident's bed in a low position and safety floor mats on both sides of the bed. On 5/20/19 at 11:35 AM, the surveyor observed a Certified Nursing Assistant (CNA) wheeling Resident #103 in a wheelchair to the resident's room and speaking with the resident in his/her primary language. On 5/20/19 at 11:37 AM, the surveyor observed the resident calling out in the room. The surveyor observed the CNA state to the Licensed Practical Nurse (LPN) at the nursing station that the resident was in bed and was saying that he/she wanted to see their spouse and the CNA exited the room. On 5/20/19 at 11:38 AM, the surveyor observed Resident #103 in the room in bed. At that time, the surveyor observed the resident get up from the bed independently and sat him/her-self down in a chair adjacent to the bed. There were no alarms that sounded. On 5/20/19 at 11:39 AM, the surveyor immediately interviewed the CNA who was in the hallway walking toward the resident's room. The CNA observed the resident in the chair in the room and stated that the resident was confused and was not supposed to get up out of bed alone. The CNA stated that the resident required assistance for transfers and ambulation. The CNA went into the room with the surveyor. The CNA stated that she thought the resident had a bed alarm which was supposed to alarm if he/she moved from the bed surface and did not know why the alarm had not sounded. The CNA pressed on the bed alarm and there was no sound. The CNA spoke to the resident in his/her primary language and stated that the resident stated that he/she wanted to go to the window to see his/her spouse. The CNA added that the resident was very forgetful but was unaware of any other behaviors. At that time, the surveyor observed the LPN in the hallway who had stated that the resident had a bed alarm. The LPN acknowledged that it did not alarm, and that it should have activated when the resident positioned him/her-self from the bed. At approximately 11:45 AM, the Assistant Director of Nursing (ADON) came into the resident's room and stated that sometimes the batteries needed to be changed. The ADON pressed deeply onto the bed alarm more than once and the alarm eventually sounded. The ADON stated that sometimes there was a delay, and that she would have to replace the bed alarm. On 5/20/19 at 11:48 AM, the surveyor observed the ADON replace the bed alarm. The surveyor reviewed the medical record for Resident #103. A review of the Admission Record indicated that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the admission MDS dated [DATE] reflected that the resident had a BIMS score of 07 out of 15, indicating a moderately impaired cognition. The assessment further reflected that the resident required an extensive two-person physical assist for surface to surface transfers, and an extensive one-person physical assist for ambulation on the unit. The assessment included that the resident had a history of [REDACTED]. A review of the Morse Fall Scale risk assessment completed on 05/07/19 indicated that the resident had a total score of 75, a total score of 45 or higher reflected the resident was at high risk for falls. A review of the physician's orders [REDACTED]. A review of the resident's individualized, interdisciplinary care plan (IICP) dated 5/07/19 and revised on 5/08/19 revealed that the resident was a high risk for falls. Interventions dated 5/07/19 included to anticipate and meet the resident's needs, keep the call light in reach and encourage the resident to use it for assistance as needed. It further included that the resident needs prompt response to all requests for assistance and physical therapy (PT) to evaluate and treat the resident as ordered or as needed (PRN). A review of the fall investigative reports for Resident #103 provided by the DON revealed three (3) completed fall investigations with the following findings: The investigation dated 5/09/19 revealed that the resident had his/her first fall and was found on the floor in the resident's room at 04:15 AM with no injury. The current interventions in place indicated that the call bell was within reach, a physical therapy evaluation and treatment and a low bed were implemented. The new interventions to be implemented were to place floor mats on both sides of the bed, move the resident's room closer to the nursing station and a referral for a Psychiatric consult. A review of the IICP was updated with interventions initiated on 5/09/19 which included to change the resident's room closer to the nurse's station. (The IICP was not updated to address placing the floor mats on both sides of the bed). A review of the physician's orders [REDACTED]. A review of subsequent investigation dated 5/16/19 revealed that the resident had a second fall in the facility which was witnessed. The resident slid off the wheelchair at the nursing station at 10:45 AM and that his/her incontinent brief was soiled. An interview with the resident indicated that he/she was trying to go to the bathroom. The current interventions in place indicated that there were floor mats on the floor besides the bed and the resident's room was close to the nursing station. The new interventions to be implemented indicated to toilet the resident, provide supervision while in the wheelchair and encourage activities. The investigation did not evaluate the use of and/or effectiveness of the bed and chair alarm for safety as ordered by the Physician on 5/09/19 after the first fall. A review of the IICP did not reflect evidence that the care plan was updated to address the fall from the wheelchair on 5/16/19 with the new interventions to toilet, encourage activities, and provide supervision while in the wheelchair. The IICP also did not address the bed and chair alarm every shift for safety. A review of a third investigative report dated 5/18/19 revealed that the resident had a fall and was found on the floor in the resident's room at 5:50 AM with no injury. The current interventions in place indicated there was a low bed with safety floor mats, and interventions to encourage activities. The new interventions to be implemented to prevent recurrence were a bed and chair alarm. (This did not correspond with the PO dated 5/09/19, and there was no evidence in the investigative report to indicate that a bed and/or chair alarm had been in use and/or effective for the third fall.) A review of the IICP for falls reflected that the care plan was updated five days after the second fall, and three days after the third fall on 5/21/19. Interventions dated 5/21/19 included to encourage the resident to participate in activities and that the resident needs a safe environment with floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, bed in low position at night, and keep personal items in reach. It also included interventions dated 5/21/19 to use chair/bed electronic alarm, ensure the device is in place as needed. On 5/21/19 at 1:12 PM, the survey team met with the facility administrative team. The Director of Nursing (DON) stated that she would provide a timeline of interventions for Resident #103. On 5/23/19 at 12:55 PM, the survey team met with the facility administrative team. The DON provided a timeline of interventions implemented for the resident. The DON stated that the bed and chair alarms were instituted after the 5/18/19 fall occurrence. The DON added that bed and chair alarms were not always started for a resident with a high risk of falling and were instituted after an evaluation. The DON then stated that she was unaware of a physician's orders [REDACTED]. The DON could not speak to the discrepancy between when the intervention of bed and chair alarms were instituted. On 5/23/19 at 2:07 PM, the survey team met with the DON who stated that she did not have any further information regarding the fall interventions for Resident #103. She acknowledged that the care plan was not updated in a timely manner, and that the investigative report did not accurately evaluate the use of a bed/chair alarm when there was a physician's orders [REDACTED]. The DON was unable to provide documented evidence for the interventions in place to prevent falls and/or evidence that the alarms were checked for functioning. A review of the facility's undated staff education for Fall safety provided by the Chief Nursing Officer (CNO) for: What Can Be Done? to prevent falls. The education included to address the risk factors, and utilize chair/bed sensor alarms to alert staff and ensure the monitor was properly applied and working. NJAC 8:39-11.2(b), 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to sequence physician orders [REDACTED]. This deficient practice was identified for 1 of 1 resident's reviewed for [MEDICAL TREATMENT], (Resident #202) and was evidenced by the following: On 05/19/19 at 9:45 AM, the surveyor observed Resident #202 in his/her room laying in bed and watching television. The resident stated that he/she was dependent on [MEDICAL TREATMENT] (the process of purifying the blood when the kidneys are not functioning properly) and went to the [MEDICAL TREATMENT] center on Tuesday's, Thursday's, and Saturday's. The resident further stated that he/she had been residing at the facility for about two weeks. The surveyor reviewed the medical records for Resident #202. A review of the resident's Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the MDS assessment was still in progress as the resident had been admitted to the facility for less than 14 days. A review of the resident's (MONTH) 2019 Order Summary Report (OSR) reflected that the resident had a Physician order [REDACTED]. The OSR further reflected a PO dated 05/08/19 for a fast-acting insulin medication, Insulin [MEDICATION NAME] Solution inject as per sliding scale before meals and at bedtime The order specified the following: If the blood sugar (BS) was 150 - 199 administer two units of insulin coverage. If the BS was 200 - 249 administer four units of insulin coverage. If the BS was 300 - 349 administer six units of insulin coverage. If the BS was 350 - 399 administer eight units of insulin coverage. If the BS was greater than 400 notify the MD. A further review of the (MONTH) 2019 OSR reflected a PO dated 5/08/19 for the medication [MEDICATION NAME]-[MEDICATION NAME] (numbing) Cream 2.5-2.5 %. The order specified to apply the cream to the left arm topically one time a day every Tuesday, Thursday, and Saturday for pain prior to [MEDICAL TREATMENT] at the center. A review of the resident's (MONTH) 2019 Medication Administration Record [REDACTED]. The resident's blood sugars were less than 150 on those dates and did not require insulin coverage in accordance with the physician's orders [REDACTED].) A further review of the (MONTH) 2019 MAR indicated [REDACTED]. A review of the resident's individualized comprehensive care plan revised on 5/20/19 reflected that the resident had a focus area for [MEDICAL CONDITION] related to end stage [MEDICAL CONDITION] and was on [MEDICAL TREATMENT]. The goal reflected that the resident would not have signs and symptoms of complications related to fluid deficit and would be free from infection through the next review date. The interventions included the importance of compliance with medications and [MEDICAL TREATMENT] treatment. On 5/22/19 at 10:28 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA). The CNA stated that the resident usually returned from the [MEDICAL TREATMENT] center at 10:00 AM on his/her scheduled [MEDICAL TREATMENT] days. On 5/22/19 at 11:09 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN). The LPN stated that the resident returned from [MEDICAL TREATMENT] between 10:00 AM and 11:00 AM. The surveyor reviewed the (MONTH) 2019 MAR indicated [REDACTED]. The LPN further stated that she would apply the resident's [MEDICATION NAME]-[MEDICATION NAME] Cream topically to the resident left arm when the resident returned from [MEDICAL TREATMENT]. The LPN acknowledged that she did not administer the medications according to the PO or the resident's [MEDICAL TREATMENT] schedule and confirmed the timing had to be changed. The LPN could not speak to why she was applying the cream after the [MEDICAL TREATMENT] when the order indicated before at the center. On 5/23/19 at 1:11 PM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the resident's medications were not appropriately plotted on the (MONTH) 2019 MAR indicated [REDACTED]. A review of the facility's Care of Resident Receiving [MEDICAL TREATMENT] Policy and Procedure dated 10/2018 included Provide diet and medications as ordered. Provide a boxed meal, if needed. Alter medication timing on [MEDICAL TREATMENT] days so to be times while resident is present in the facility. NJAC 8:39-27.1 (a)