Every finding on record at Birchwood Rehabilitation and Healthcare Center

Based on observations, staff interviews and review of the facility policy, the facility failed to promote a dignified dining experience by serving resident meals on an overbed table in a small common area in front of the nurse's station for four residents (Resident (R)5 R23, R72 and R125) out of 21 residents residing in the memory care unit and reviewed for dignity while dining.Findings include:Observation of the evening meal on 12/09/25 at 05:30 PM in the Memory Unit revealed residents were seated in front of the Nurse's Station in a small common area that served as the dining room, activity room, and TV room. The room did not have a dedicated dining table or chairs to encourage or promote dignity during their meals. A Christmas movie was loudly playing on the television in the room during the evening meal. The following residents were observed: R5 was seated in a Geri chair in front of the nurse's station with his/her evening meal placed on an overbed table. The table was positioned in front of him/her and across the arms of his/her chair. The back of the resident's chair was not placed in an upright position which forced the resident to lean up to reach his food. Food spills were noted on the resident's shirt. R23 and R72 were seated in chairs in front of the window with their evening meal placed on an overbed table in front of his/her. The resident ate his/her meal without any interaction from staff or other residents. R125 was seated in his/her wheelchair with his/her meal tray on an overbed table in front of him/her. The table was placed across the arms of the chair. His/her chair was positioned in front of the nurse's station next to R5 and facing the television. The resident was slowly feeding himself/herself, looking down and was not engaging with any staff or other residents during the meal. During an interview with Unit Manager (UM)1 on 12/09/25 at approximately 06:00 PM, he/she stated that the resident dining area in the Memory Unit has always been this way. During an interview with Licensed Practical Nurse (LPN) 4 on 12/10/25 at 12:35 PM, he/she stated that the residents always had their meals in the same area because they did not have a dining room. During an interview with the Administrator on 12/11/25 at 09:52 AM, he/she stated that there was not a dining room in the Memory Unit and that he/she was not aware it was a concern. Review of the facility's policy titled, Preparing the Resident for a Meal dated 2001, indicated, The purpose of the procedure is to prepare the resident and the environment in order to help make mealtime pleasant for the resident.3. Residents should be encouraged but not forced to eat in the dining room. This provides each resident with an opportunity to socialize and make new friends.5. Be sure that the room is comfortable (i.e., Not too cold or warm) and has a relaxing environment (i.e., free of unpleasant odors, loud noises, bright lights, etc.) NJAC 8:39-4.1(a)NJAC 8:39-27.1(a)

Based on observations, interviews and policy review, the facility failed to provide a homelike environment in good repair for six of 21 residents (Resident (R) 4, R5, R23, R72, R114 and R125) residing on the Memory Care Unit. Specifically, the facility failed to maintain cabinets, nightstands, windowsills, heating units, cubicle curtains, baseboards, bedroom doors and overbed table stands in good repair and safe operating condition. The failure to maintain an environment in good repair and homelike had the potential to affect the residents' psychosocial needs. Findings include:Observation of the Memory Care Unit on 12/08/25 at 11:13 AM revealed the following areas of concern:1.R4's room: the cover for the air conditioner/heating unit was missing; two of three drawers inside the closet were broken and would not close leaving the drawer partially open; laminate was missing from the edge of the windowsill; and half of the privacy curtain was not attached to the tract in the ceiling causing the curtain to touch the floor. 2.R5's room: The nightstand in the resident's room had three broken drawers. The drawers were not fitting inside the cabinet and were partially open. The bottom right side of the door to the room was noted with chipped pieces of the wood were missing.3.R23's room: two drawers inside the closet were broken and would not close leaving the drawer partially open. Approximately 6-8 feet of baseboards were missing from the wall between the bathroom and the resident's bed and behind the door of the room to the bathroom door. The door to the resident's room had multiple black marks across the top part of the door. 4.R72's room: Chipped and missing paint on the stand of the overbed table.5.R114's room: The laminate cover across the length of the windowsill was missing and a large piece of laminate was chipped and missing from the bottom shelf in the cabinet next to the closet. 6.R125's room: The top part of the air conditioner/heating unit cover was missing. The stand on the overbed table contained chipped and missing paint. In the common area in front of the Nurse's Station:One of two heating units' cover was missing; two of six chairs positioned in front of the unit, were noted with torn sections of vinyl in the bottom cushion of the chair; and a brown, orange colored dried substance was noted on several areas on the wall under the windowsill, behind the chairs. During an interview with the Maintenance Director on 12/10/25 at 11:20 AM, regarding the areas of concern noted in the residents' rooms and the common area of the Memory Care unit, he/she stated that he/she will fix the furniture, air conditioner vent covers and residents will tear them up again. He/she stated that staff will put the items that need repair in the logbook and he/she and his/her staff review the book every day at the beginning of the shift and indicate when it was completed.During an interview with Licensed Practical Nurse (LPN) 4 on 12/10/25 at 12:00 PM, he/she stated that when anything needs repair, staff will write it in the maintenance logbook, and he/she makes sure it is completed. If he/she had a problem getting resolution, he/she would go to his/her supervisor or the Director of Nursing (DON). During an interview with Certified Nursing Assistant (CNA) 1 on 12/10/25 at 12:30 PM, he/she stated that he/she will put his/her concerns in the maintenance logbook when something is broken and they will fix it. On 12/10/25 at 01:30 PM, the DON confirmed the observations on the unit. Review of the facility's policy titled, Maintenance Service, revised 2009 indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operatable manner at all times.2.b) maintaining the building in good repair and free from hazards . NJAC 8:39-4.1(a)(11)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)146 reviewed for side rails out of 30 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include Review of R146's admission Record in the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnosis of dementia. Review of R146's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R146's Care Plan located under the Care Plan tab of the EMR revised 12/04/25, revealed R146 used enablers for increased independence and mobility. Review of R146's Physician Orders located under the Orders tab in the EMR dated 04/05/24 revealed, 1/2 rails while up in bed as a mobility enabler.Review of R146's Side Rail/Enabler/Entrapment Evaluation located under Assessments tab in the EMR dated 05/22/25 and 10/31/25 revealed no documentation that alternates were explored prior to bed rail/side rail use. Observation of R146 on 12/09/25 at 8:00 PM, revealed R146 lying in bed with side rails in the up position. During an interview on 12/10/25 at 5:04 PM, Unit Manager (UM)3 stated residents used side rails for bed mobility and not as a restraint. He/she stated that he/she was unsure if there was signed informed consent and that they did not explore alternatives prior to bed rail use. He/she stated that maintenance assessed for risk of entrapment. During an interview on 12/11/25 at 4:07 PM, Registered Nurse Supervisor (RNS)2 said staff did not look at alternates prior to bedrail use. He/she was also unsure about risk for entrapment or who assessed it for that. During an interview on 12/11/25 at 5:55 PM, the Director of Nursing (DON) stated he/she expected staff to explore alternates prior to bedrail use for residents. The DON stated that he/she expected staff to document in the EMR risk versus benefits and a signed consent obtained.Review of the facility's policy titled Bed Safety and Bed Rails dated August 2022 revealed that resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed physician dietary orders for one of five residents (Resident (R)146 reviewed of 30 sampled residents. This deficient practice has the potential for resident not to receive sufficient calories to prevent further nutritional problems. Findings include:Review of R146's admission Record in the Profile tab of the electronic medical record (EMR) revealed he/she was admitted to the facility on [DATE] with diagnoses of dementia and type II diabetes. Review of R146's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/12/25 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating severe cognitive impairment. Review of R146's Care Plan located under the Care Plan tab of the EMR dated 12/12/24, revealed R146 has a potential for nutritional problems with intervention to provide Ensure supplement as ordered. Review of R146's Physician Orders located under the Orders tab in the EMR dated 09/10/25 revealed, Ensure plus supplement twice daily at 9:00 AM and 5:00 PM for Protein Calorie Malnutrition (PCM).Observation on 12/09/25 at 6:00 PM, R146 was in bed with the dinner tray in front of him/her. Unit Manager (UM)3 was assisting the resident at bedside. Ensure not provided.During an interview on 12/09/25 at 7:30 PM UM3 stated he/she was unsure why R146 had not been provided his/her 5:00 PM Ensure plus. UM3 stated there was no Ensure plus on the medication cart, so he/she obtained the Ensure plus and gave it to Licensed Practical Nurse (LPN)7. During an interview on 12/09/25 at 7:35 PM LPN7 stated he/she had not given R146 his Ensure Plus because there was none on the medication cart. He/she stated it was the nurse's responsibility to ensure the cart was stocked. During an interview on 12/11/25 at 5:55 PM the Director of Nursing (DON) stated he/she expected staff to follow physician orders and administer timely. NJAC 8:39-27.1(a)

Complaint #: NJ178726 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to sanitize and ensure that the frying pan was cleaned to prevent microbial growth. This deficient practice was evidenced by the following: On 11/14/24 at 11:36 a.m. the surveyor, who was accompanied by the Director of Food Services (DFS), observed in the kitchen, Dietary Aide (DA #2) washed a frying pan, rinsed, and then dipped the frying pan in the sanitizer for less than 3 seconds and removed and placed the frying pan on the side of the sink to drain. During an interview with the Director of Food Services (DFS) at 11:09 a.m., he stated that the sanitizing step should not be missed because it was the most important step, and it killed the bacteria and the germs. During an interview with DA #2 at 11:48 a.m., he stated that the frying pan should be sanitized for 20 seconds and that he did it for less than 20 seconds. DA #2 further stated it was important to disinfect the frying pan so that it does not have any germs, and that if there were germs, it was not good for serving food. During an interview with the DFS at 11:53 a.m., who also observed DS #2 washed the frying pan, he stated that the staff did not let the frying pan sit for the full 20 seconds. DFS stated that staff should have let the frying pan sat for a full 20 seconds and then pull the frying pan out to let it air dry. DFS further stated that it was important for staff to dip the frying pan in the sanitizer for 20 seconds to kill any bacteria or germs to prevent infecting residents. During an interview with Dietary supervisor (DS #1) at 12:08 p.m., he stated that staff should not have dipped the frying pan in the sanitizer taken it out immediately. DS #1 stated that staff should have held or placed the frying pan for at least 20 seconds in the sanitizer to make sure the frying pan was free of germ and bacteria. DS #1 further stated that the sanitizer killed the germs, and that germs could spread and cause sickness to the residents and employees who must consume the food. During an interview with the Infection Preventionist Nurse (IPN) at 2:20 p.m., she stated that if the sanitizing process was not followed as directed by not sanitizing for the length of time, the item was still dirty, could attract pest, was unsanitary, and not fit for cooking in, which could result in people potentially getting sick. Review of undated policy titled Cleaning Dishes - Manual Dishwashing that dishes should be placed in the sanitizing sink and allow to stand according to the manufacturer's guidelines for sanitizer. Review of the Ecolab Smartpower Sanitizer Instruction revealed, EPA-registered sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and ware, kills food borne organisms as listed on product label. Review of the Ecolab Smartpower Sanitizer instructions revealed, Apply SMARTPOWER Sanitizer at proper solution. Expose all surfaces of equipment, ware or utensils to the sanitizing solution for a period of not less than one minute. Air dry. NJAC 8:39 - 17.2 (g)

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to a.) store potentially hazardous foods (PHFs) in a manner to prevent food borne illness and b.) maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: (PHFs) are foods that must be kept at certain temperatures to minimize the growth of pathogenic microorganisms that may be present in the food or to prevent the formation of toxins in the food. Generally, PHFs are moist, nutrient-rich and have a neutral ph.) On 7/24/24 at 10:05 AM in the presence of the Food Service Director (FSD) and the Administrator in training (AIT) the surveyor observed the following: 1. The surveyor and FSD went into the walk-in freezer, during observation it was noted that there were sheets of ice on the floor, icicles hanging from the ceiling, the condenser fans and food boxes. The kitchen supervisor was actively scraping the ice off the floor with a long-handled ice scraper. 2. In the walk-in freezer, the surveyor observed several boxes of opened, not labeled with open or expiration dates, and unsealed food items. The items are as follows: croissants, turkey burgers, and breaded eggplant. All the items in the freezer were covered with snow, frost, and ice crystals. 3. On 7/22/24 at 10:18, the surveyor observed that the walk-in refrigerator #1 had inconsistent temperature readings from 3 different thermometers. ~44 degrees Fahrenheit (F) interior built in thermometer, ~46 degrees F, exterior built in thermometer, ~42 degrees F, portable interior thermometer, ~Survey reviewed Refrigerator #1 temperature log which revealed a written temperature of 36 degrees F on 7/21/24 at 730pm. 4. Further observations in Refrigerator #1 by the surveyor was a box of bacon that was opened, unsealed and unlabeled. 5. Walk-in refrigerator #2, was out of service and not working, upon surveyor entry on 7/22/24 there was not a plan for it to be repaired. Surveyor reviewed service order # 4548236, dated 6/26/24 and two emails dated 6/26/24 and post survey team entry on 7/23/24. All three indicated communication FROM the repair service. There were NOT any emails or documents provided to the surveyor indicating correspondence FROM the facility or that repairs were in the process of being initiated or waiting for parts. 6. On 07/22/24 at 01:17 PM, the FSD, Surveyor #1 and Surveyor #2 took temperatures of 2 items in walk-in refrigerator #1. FSD stated that the kitchen thermometers had been calibrated. ~Heavy Cream: 1 liter container, The FSD inserted the calibrated thermometer into the center of the container, it read 46.7 degrees F. ~Cottage Cheese: 32-ounce container. The FSD inserted the calibrated thermometer straight down in the center of the container. The temperature read 50.4 degrees F with the first thermometer. The FSD inserted a second calibrated thermometer that read 49.4 degrees F. 7. The microwave interior ceiling was covered with multi-color splatter debris. The FSD acknowledged that it had not been cleaned correctly. 8. The meat slicer was covered in a plastic bag which the FSD indicated it meant that it was clean. Upon removal of the bag the slicer pusher spikes were soiled with caked on brown debris. The FSD stated that it should have been cleaned and then covered with the bag. 9. The shelf under the griddle had sediment and debris. The FSD acknowledged it had not been clean thoroughly. On 7/22/24 at 11:00 AM, the surveyor interviewed the FSD. who stated, the freezer items should have been labeled with an opening date and if only partial of a bag was used it should be resealed and labeled. He further stated, the cooking equipment should be cleaned and maintained in a sanitary way to prevent food borne illness and contamination. On 7/22/24 at 10:44 AM the surveyor interviewed the kitchen supervisor (KS), who stated, the ice and frost in the freezer is a reoccurring issue. He acknowledged that the frost and snow in the freezer and on the products can degrade the food quality and has the potential to cause food borne pathogens. On 7/22/24 at 11:26 AM, the surveyor interviewed the clinical dietary manager (CDM) who stated, the freezer has been an issue for last 4 months. It is discussed in morning meeting. On 7/24/24 at 10:33 AM, the surveyor interviewed the licensed nursing home administrator (LNHA) who stated, the refrigerators and freezer need to be in working condition because it can cause potentially hazardous food, food borne illnesses and degrades the quality of the food. I acknowledge what the survey team saw. A review of the policy titled, Food Safety Requirements Policy dated 4/9/24, which was provided by the LNHA read . Policy: Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definition: food service safety refers to the handling, preparing, and storing food in ways that prevent food borne illness. Food borne illness refers to an illness caused by the ingestion of contaminated food or beverages. Policy Explanation and Compliance Guidelines: #1-b) Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. e) Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. #3-c) Refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in the freezer whichever is applicable. Practices to maintain safe refrigerated storage include: iv.) labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used-by date, or frozen (where applicable) /discarded. v.) Keeping food covered or in tight containers. #6) all equipment used in the handling of food shall be cleaned and sanitized and handled in a manner to prevent contamination. a) Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment. #8) Additional strategies to prevent foodborne illness include but are not limited to: d) Proper refrigeration of meat, poultry, and pasteurized dairy products. A review of the policy titled, Physical Environment: Electrical Equipment dated 7/2024, which was provided by the LNHA read . #4) Essential equipment shall be repaired or replaced as soon as practicable. e) Kitchen refrigerator /freezer. A review of the policy titled, Monitoring of Cooler / Freezer Temperature dated 7/2024, which was provided by the LNHA read . Policy: It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. Policy Explanation and Compliance Guidelines: #2) Thermometers shall be placed inside each cooler/ freezer and calibrated at least once per week. #3) All refrigerated storage must be maintained at or below 41 degrees F, unless otherwise specified by law. #5) If temperatures are above 41 degrees F for coolers or 10 degrees F for freezer, the supervisor will be notified immediately for corrective action. a) The unit will be repaired as soon as possible. If the problem cannot be corrected within 2 hours, all food items will be relocated to another unit that can hold foods in an acceptable temperature range. b) Internal temperature readings of all perishables of potentially hazardous food shall be taken and discarded if not in an acceptable range. 11) Refrigerated food shall be labeled, dated, and monitored so that it is used by the use-by date, frozen or discarded, whichever is applicable NJAC 8:39-17.2(g)

REPEAT DEFICIENCY Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during medication pass on 1of 2 units (Unit 3 Low side) and b.) follow Center for Disease Control recommendations and guidelines for Hand Hygiene. This deficient practice was evidenced by the following: On 7/24/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN) prepare medication for administration to an unsampled resident in room [ROOM NUMBER]. The RN opened the drawer of the medication cart, retrieved the blister packs (multi-use medication packs), and removed the medications amlodipine besylate10mg tablet, colace 100mg tablet and doxazosin mesylate 2mg tablet. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the electronic medical record (eMR) indicating the medications had been administered. The RN did not perform hand hygiene before preparation or after administration of the medications. On 7/24/24 at 8:06 AM, the surveyor observed the RN prepare medication for administration to Resident #47. The surveyor observed signage posted to the left of the entrance door to Resident #47's room which read: Enhanced Barrier Precautions STOP. Everyone must clean their hands before entering and exiting the room. Providers and staff must also wear gloves and gown during high-contact resident care activities. The surveyor observed the RN open the drawer of the medication cart, retrieve the blister packs and remove the medications duloxetine hcl 60mg caplet, furosemide 40mg tablet and vitamin C 500mg tab from the blister packs. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the eMR indicating the medications had been administered. The RN did not perform hand hygiene before preparation or after administration of the medications. On 7/24/24 at 8:14 AM, the surveyor observed the RN prepare medication for administration to Resident #117. The surveyor observed signage posted to the left of the entrance door to Resident 47's room which read: Enhanced Barrier Precautions [EBP] Stop. Everyone must clean their hands before entering and exiting the room. Providers and staff must also wear gloves and gown during high-contact resident care activities. The surveyor observed the RN opened the drawer of the medication cart, retrieved the blister packs and removed the medications buspirone 30mg tablet, citalopram 40mg tablet, Keppra 750mg tablet, clozapine 100mg tablet, colace 100mg tablet, from the blister packs. The RN administered the medications, returned to the medication cart, opened the drawer, removed the blister packs from the cart, and utilized the computer to sign the eMR indicating the medications had been administered. The RN did not perform hand hygiene before leaving Resident #117's room or after administration of the medications. On 7/24/24 at 8:27 AM, the surveyor discussed the breaks in technique with the RN. The RN stated that she had not performed hand hygiene during the medication administration because she didn't touch the residents. The surveyor asked the RN if she should perform hand hygiene before preparing medications and after handling the cups that the residents had also handled. The RN acknowledged that she should have performed hand hygiene before preparing medications and after administration of medications. The surveyor showed the EBP signage outside of Resident #47 and Resident #117's rooms. The RN acknowledged that she should have performed hand hygiene before entering and exiting a resident's room who was on EBP to prevent the spread of infection. The surveyor reviewed the facility policy titled, Medication Administration last reviewed 6/7/24, which revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .wash hands prior to administering medication per facility protocol and product. The surveyor reviewed the facility policy titled, Enhanced Barrier Precautions last reviewed 3/20/24 which revealed the following: Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves. 34421 2. On 7/22/24 at 02:00 PM, in a conference room inside the facility, the surveyor observed a House Keeper (HK) go to the sink to wash his hands. The surveyor observed the HK put soap on his hands and rubbed his hands together for 12 seconds, then, with his soapy hands, he turned the faucet on and rinsed his hands off. The surveyor observed the HK turn the faucet off with his bare hands and the surveyor observed the HK rub his hands directly onto his pants to dry his hands off. A review of the Hand Hygiene policy and procedure, dated 5/29/24, revealed that All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility .including between resident contacts .before preparing or handling medications. And, Hand Hygiene technique when using soap and water: wet hands with water, apply to the hands the amount of soap recommended by the manufacturer, rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers, rinse hands with water, dry thoroughly with a single-use towel, use clean towel to turn off the faucet. On 7/24/24 at 2:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations. The DON acknowledged that the RN was expected to wash her hands or use Alcohol Based Hand Rub (ABHR) prior to handling medications, between residents and before entering and exiting resident rooms who were on EBP. On 7/29/24 at 10:42 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the HK was recently educated on hand hygiene and should have known how to properly wash their hands according to CDC and facility policy. The IP also stated that nurses during medication pass should also be performing hand hygiene between residents, especially those who are on any type of precautions. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, and this should be done outside the water when rubbing your hands, then rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take approximately 20 seconds. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to assess for complications upon residents' return from the renal dialysis (RD) center for 2 of 5 residents (Resident #55 and Resident #146) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. On 7/22/24 at 11:07, AM the surveyor observed Resident #55 lying in bed with the television on, wearing glasses, call light within reach. The resident stated, I go to dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) M-W-F, but I refused to go today because I don't feel good. I usually get my medication and meal before I leave for dialysis. I have my access on left arm and the nurses checks on this at times. A review of the medical record revealed the following information: The Resident #55 had a diagnosis of but not limited to end stage renal disease (esrd); dependence on renal dialysis. End stage renal disease is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life. A review of the order summary in the electronic health record (EHR) revealed orders for: Dialysis treatment 3 times a week on Mon, Wed, Fri at 10:00am. Pick-up at 9:45am, one time a day every Mon, Wed, Fri; Monitor dialysis access site Left Arm for signs & symptoms of bleeding, infection and pain every shift. Notify provider if abnormal findings and document in progress note every shift; AV (arterial venous) Fistula Left Arm, monitor bruit/thrill every shift, report any abnormal findings to medical doctor (MD). A review of the Quarterly Minimum Data Sheet (MDS), an assessment tool used to facilitate the management of care, dated 5/17/24 reflected the Resident #55 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating the resident had severe impaired cognition. The RD Care Plan initiated on 1/12/24 instructed nursing staff to monitor AV fistula for a bruit, thrill, signs of infection, bleeding, patency, etc. Refer to MD as needed. On 7/24/24 at 12:15 PM, the surveyor interviewed the registered nurse (RN) in Unit 3, who has been working at the facility for [AGE] years, who stated, Resident #55 was in the hospital a couple of times because resident refused dialysis at least 4x a month and was sent out to hospital due to refusing dialysis. This is resident's typical self, and all the doctors are aware. The resident goes to dialysis M-W-F. A review of the nurses' progress notes for post dialysis access site assessment when resident was agreeable to go to dialysis, revealed inconsistent nursing assessment done from 5/17/2024 through 7/26/24 (two months-18 days total). The missing nursing documentations for post dialysis access site assessment were: 5/17/24; 5/27; 5/31; 6/10; 6/12; 6/14; 6/17; 6/19; 6/24; 6/26; 6/28; 7/3; 7/5; 7/15; 7/17; 7/19; 7/24; and 7/26. 2. On 7/22/24 at 10:20 AM, the surveyor observed Resident #146 lying in bed, appears neat and dressed, call light within reach. The resident stated, I have an access on my left arm for dialysis, I'm supposed to go today. A review of the medical records for Resident #146 revealed diagnosis but not limited to: end stage renal disease and dependence on renal dialysis. The order summary revealed: Continue to monitor Dialysis Access site wound every shift for bleeding; Dialysis treatment 3 times a week on Tu/Th/Sat; L-arm AV Shunt, monitor shunt for s/s of infection, bleeding, bruit/thrill every shift. NO BP ON LEFT ARM, Monitoring Report any abnormal findings to MD; Monitor left arm for signs & symptoms of bleeding, infection and pain every shift every shift ordered 3/6/24. The Quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe cognitive impairment. Care plan dated 2/23/24 reflected to monitor AV fistula. A review of the nursing progress notes revealed the resident received renal dialysis on T-TH-Saturdays and then changed to M-W-F on 7/22/24. The surveyor reviewed nurses progress notes for post dialysis access site assessment which revealed inconsistent nursing assessment done from April 2024 through 7/19/24 (three months-32 days total). The nursing progress notes revealed missing documentation for post dialysis access site assessment for the dates of: 4/20/24, 4/23, 4/25, 4/27, 4/30, 5/2, 5/7, 5/11, 5/14, 5/16, 5/18, 5/21, 5/23, 5/25, 5/30, 6/1, 6/4, 6/6, 6/8, 6/13, 6/15, 6/18, 6/22, 6/27, 7/2, 7/4, 7/6, 7/9, 7/11, 7/18, 7/22, and 7/24/24. On 7/24/24 at 2:15 PM, the surveyor interviewed the director of nursing (DON), who has been working in the facility since last October of 2023, in the presence of the Licensed Nursing Home Administration (LNHA) and the survey team regarding the Dialysis Communication Worksheet to clarify pre and post dialysis access site evaluations. The worksheet did not include post dialysis assessments. Requested the DON to provide additional documentation for access site assessments by nursing staff. On 7/25/24 at 8: 45 AM, the DON provided documentation of Dialysis Worksheet for pre assessment of dialysis access for residents but did not provide documentation for post dialysis access site assessments. The DON stated in the presence of another surveyor, The documentation in this place is really bad. The post dialysis access site assessment documentation should be in the nursing progress notes in the computer if the nurses did them. On 7/25/24 at 11:03 AM, interviewed the RN who stated, The process is you have to check the dialysis site every shift for drainage, bruit, thrill and bleeding, and we also check it before and after dialysis and document in the computer. I don't see any post dialysis access site assessment documentation for the Resident #55 in the EHR for the last few weeks and Resident #146, I see one time documentation in progress notes for 6/25/24 only. The RN acknowledged that there should be documentation every time the resident comes back after dialysis. On 7/25/24 at 1:30 PM, the surveyor discussed findings and concern with post dialysis site nursing assessment, in the presence of the survey team, the DON, LNHA and the Regional Director of Operations. No additional documents were provided by the facility. A review of the facility policy and procedure titled Hemodialysis with a revision date of 3/2024 revealed, The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. NJAC 8:39-27.1(a); 2.9

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), according to the physician's order to meet the needs of the resident. The deficient practice was identified for one (1) of 34 residents, (Resident #55) reviewed for medication management. The deficient practice was evidenced by the following: On 7/22/24 at 11:07 AM, the surveyor observed the Resident #55 in the Unit 3 North Wing in their room, lying in bed with the television on, wearing glasses, and call light within reach. On 7/24/24 at 9:34 AM, the surveyor reviewed the electronic health records (EHR) for Resident #55 which revealed diagnosis that included but not limited to hypotension, the pressure of blood circulating around the body is lower than normal. Blood pressure (BP) is the pressure of blood on the walls of your arteries as your heart pumps blood around your body. A review of the Quarterly Minimum Data Sheet (MDS), an assessment tool used to facilitate the management of care, dated 5/17/24 reflected the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating the resident had severe impaired cognition. A review of the resident's Order Summary Report reflected a physician's order dated 5/10/24 for Midodrine HCl Oral Tablet 5 MG (Midodrine Hydrochloride) Give 1 tablet by mouth at bedtime for Hypotension Hold for SBP>130. The systolic blood pressure (SBP) is the first number, it is the pressure caused by your heart contracting and pushing out blood. A review of the electronic medication administration (eMARS) from April 2024 through July 2024 (three months) revealed Midodrine HCL was administered and not held for parameters of SBP>130 as ordered for: April 2024, received 13 dosages (4/1, 3, 4, 5, 9, 12, 13, 14, 15, 16, 17, 18, 19}; May 2024 received 11 dosages (5/12, 13, 15, 16, 18, 20, 21, 22, 23, 25, 30); June 2024 received 15 dosages (6/1, 5, 7, 8, 9, 10, 14, 17, 18, 19, 20, 21, 22, 26, 28); and on July 2024, received 17 dosages (7/2,, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 19, 21, 23, 24). A review of the resident's blood pressure at its highest revealed the resident's BP on 5/18/24 was 172/81 and on 7/12/24 BPwas 168/71. The resident had no indication of a negative outcome from Midodrine administration when given above the parameter of SBP >130 during those times. Reviewed the primary physician's progress notes dated 7/15/24 who stated, Reviewed medications and vital signs with no changes. On 7/25/24 at 11:13 AM, the surveyor interviewed the registered nurse (RN) from Unit 3 North Wing who has been working in the facility for [AGE] years. She stated, The evening nurse should have held the Midodrine medication at night because the SBP is above 130. The nurse didn't pay attention because you can make the blood pressure go higher. On 7/25/24 at 11:35 AM, interviewed the Unit 3 Unit Manager (UM), who has been working in the facility for five months. The UM stated, The Midodrine should had been held when the SBP was above 130 as ordered. I see that it was the evening shift nurse who has been giving it. The resident has had no problems with his BP or had complained to me that he doesn't feel well. On 7/25/24 at 1:30 PM, in the presence of the survey team, the surveyor discussed findings with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA) and the Regional Director of Operations regarding the concern of Midodrine administration outside the SBP parameters. On 7/26/24 at 8:48 AM, interviewed the 3-11 shift Licensed Practical Nurse (LPN), regarding Midodrine administration on his shift. The LPN stated, Midodrine is a medication for a low blood pressure. The resident sometimes has a low or high BP. I take the BP to make sure it's in range before giving it. I've been making mistakes in the computer; I've been holding the medication, but I didn't know that I had to go back to strike it out. The DON showed me yesterday how to hold it in the computer. I didn't know I had to document in the progress notes if I held a medication. I've been working with this EHR for about three years. If I sign a medication, it means it was given, but I made a mistake with the Midodrine on how to cancel it in this EHR. I've been working in the facility for four years. I didn't know I had to notify anyone when a medication has been held for a couple of times. On 7/26/24 at 10:30 AM, the surveyor received from the DON, the Scriptive Consultants Medication Administration Observation competencies for the LPN dated 5/24/23, 2/5/24 and 7/25/24 which revealed competencies for blood pressure check and cautionaries for the preparation and administration of medications were met by the LPN. On 7/26/24 at 10:40 AM, interviewed the registered pharmacy consultant (RPH), who has been a consultant in the facility for four years, stated, They get their Medication Review Report (MRR) once monthly. We follow up a month later to make sure it was done. If it was a med error, we call them up to look into it. If I get the report again the next month, the facility needs to follow it up, that's the expectation. A review of the Consultant Pharmacist's MRR dated 5/19/24, and 6/25/24 revealed Midodrine was signed numerous times as given when it should have been held for SBP >130. Please reevaluate the resident's need for Midodrine and consider discontinuing. On 7/26/24 at 11: AM, the surveyor in the presence of the survey team discussed with the DON the MRR process and recommendations above and she stated, The unit manager follows through the MRR recommendations, unfortunately in this case it fell through the cracks for the 5/19/24 and 6/25/24 MRR. I did speak to the LPN involved yesterday and he did not know how to work the screen of EHR, but the expectation is, if something is held for a few days, the LPN should have told his manager, the primary doctor and should have documented in the progress notes when medications were held. No additional documentation was provided by the facility. A review of the facility policy and procedure titled, Medication Administration revised on 6/7/24 revealed, Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. NJAC 8:39-29.2 (d)

Complaint # NJ00167683 Based on observation and interview, it was determined that the facility failed to maintain the residents' environment and living areas in a sanitary and homelike manner. This deficient practice was identified for 1 of 5 nursing units observed for the facility environment task. This deficient practice was evidenced by the following: On 7/22/24 at 10:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/23/24 at 11:30 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/24/24 at 9:49 AM, the surveyor observed dark dirty appearing areas in hallway on the 400 hallway and doorways. On 7/22/24 at 11:29 AM, the surveyor interviewed the porter who stated the floors are done daily. He also stated the rotunda was done already and that he has not done 400 wing yet. He further stated that he's usually the only porter and a floor tech works the weekends only. On 7/24/24 at 1:04 PM, the surveyor interviewed the Director of Housekeeping who stated that the procedure for cleaning the floors included both a wet mop machine and a mop /bucket. The mop machine was used during the night and a was used during the day. She also stated that both were done twice daily. The surveyor showed her a few doorways on the 400 hallway and she stated this is from wax. She further stated We are in the process of stripping and re waxing the floors. This will come up with floor stripper. This is from years of wax on top of wax. It should've been stripped before waxing. The floors have been waxed once in past 3 years. When asked for a policy regarding the floors, she stated she has never seen one. On 7/25/24 at 10:34 AM, the surveyor observed the shower room on the 400 wing with items on the floor including a used towel, used gloves, a clothing item and a used mask. There was also noted an opened adult brief on a shower chair. On 7/25/24 at 10:40 AM, the surveyor interviewed a CNA who was shown the shower room. She stated, this is not what is supposed to be. She stated that when someone gives a shower, the CNA should clean up after done with shower. On 7/25/24 at 10:43 AM, the surveyor interviewed an LPN who was shown the shower room and stated that's terrible, it's unacceptable. She further stated that when finished with a shower, the CNA should clean up afterward. She stated she was not sure how often the shower room is checked. She further stated that housekeeping cleans the shower room, but she was not sure how often. On 7/25/24 at 11:00 AM, the surveyor interviewed the Director of Housekeeping, regarding the dark areas on the floor and the tiles. She stated that it is probably from old. She further stated, this is clean as its going to get. When asked if she would want to take a shower on that shower stall, she stated no. She also stated that she tries to check the shower room twice a day. She further stated that maybe it needs new tiles and caulking. A loose tile was noted. On 7/25/24 at 12:04 PM, the surveyor interviewed the maintenance director, regarding the 400 wing shower room. He stated he does rounds monthly and walks through weekly to see what he could see. He further stated that he was in that room earlier this week to fix a broken tile near scale. He also stated he did not see tile in photo. He stated the brown stuff is housekeeping, and that it is not acceptable, and should've been scrubbed. On 7/25/24 at 1:33 PM, the surveyor interviewed the Administrator who stated they are working on the floors and doorways on the weekends. On 7/26/24 at 9:51 AM, the surveyor observed doorways on 400 hallway show faded areas where dark dirty areas were noted previously. The shower room on the 400 hallway noted with new caulking and broken tile replaced. Dark brown areas still noted in the shower stall. On 7/26/24 at 10:16 AM, the surveyor interviewed the Administrator regarding 400 wing shower room. Shown a photo and asked if the work was completed in the shower room. He stated he would check on it. On 7/26/24 at 11:31 AM, the surveyor interviewed the Director of Nursing who stated she reminded the staff to keep the shower rooms clean and tidy and housekeeping to clean. The Administrator stated, we are finishing up that shower room. N.J.A.C. 8:39-31.4 (a) (f)

Complaint # 173271 Based on interview, record review and review of pertinent facility documentation it was determined that the facility failed to a.) thoroughly assess a skin discoloration that was identified on an admission assessment and, b.) implement a care plan for a resident identified as a high risk for skin breakdown. This deficient practice was identified for 1 of 4 residents (Resident #585) reviewed for pressure ulcers and was evidenced by the following: According to the Admission Record, Resident #585 was admitted to the facility with the diagnoses which included but was not limited to; spinal stenosis cervical region, muscle wasting and atrophy and type two (2) diabetes mellitus. The admission Minimum Data Set (MDS), an assessment tool that facilitates a resident's care dated 3/29/24, reflected that the resident was frequently incontinent of bladder and bowel and required maximum assistance with activities of daily living (ADLs). The MDS also reflected that the resident was at risk for developing pressure ulcer and injuries and had no skin or ulcer injury treatments. Review of the Nurses Notes dated 3/22/2024 at 23:29 (11:29 PM) indicated that the resident was admitted from the hospital to the facility and was incontinent of bladder and bowel and had no wounds. Review of the Admission Assessment (AA) dated 3/22/24 at 19:48 (07:48 PM) indicated that the resident had discolorations on the groin and sacrum. There was no size, color or description of the discoloration documented in the medical record. The AA also reflected that the resident was always incontinent of bladder and bowel. The Braden scale (the most frequently used pressure injury risk assessment tool in the United States) was completed on the AA dated 3/22/24 which revealed the following: The resident scored a 12 on the BS and if the total score was 12 or lower, the resident should be considered at high risk for skin breakdown. The AA indicated that prevention protocol should be initiated immediately and documented on the care plan. The AA indicated that the following intervention would be implement on the CP: turn and reposition, apply moisture barrier with incontinence care, wheelchair cushion, change bedding as needed, and to monitor nutrition/hydration status. Review of Resident #585 care plan (CP) revealed that a CP was not implemented for potential for skin breakdown and no skin prevention interventions were put in place to prevent deterioration of the resident's skin. Review of the Treatment Administration Record (TAR) dated 3/1/24-3/31/24, the surveyor could not find any documentation any preventive protective skin care treatments were ordered by the physician. The TAR dated 3/26/24 at 7:00 AM, reflected a physician's order for weekly skin checks to be completed under the assessment area in the electronic medical record (EMR). The nurse signed the TAR indicating that the residents skin check was completed, however there was no documentation on the assessment section of the EMR. On 7/23/24 at 11:20 AM, the surveyor interviewed the facilities wound care nurse who identified herself as a Licensed Practical Nurse (LPN). The LPN explained that her responsibilities included all wound care in the facility and that she performed all treatments in the facility from Monday through Friday. The LPN/Wound Care nurse stated that when the nurse completed and admission assessment and identified that the resident was at risk for skin breakdown, the nurse would be responsible to initiate the care plan with interventions to prevent deterioration of the skin. She continued to explain that any skin impairments or discolorations were to be described on the assessment such as color and size. On 7/23/24 at 11:41 AM, the surveyor interviewed the Director of Nursing (DON), reviewed Resident #585's AA dated 3/22/24 with the surveyor and confirmed that the AA indicated that the resident had discoloration on the groin and sacral area. The DON stated that the nurse should have been more descriptive on the admission assessment to include the color and size of the skin impairment. The DON also confirmed that when the resident was identified as a high risk for skin breakdown on admission, a CP should have been implemented with interventions to prevent skin breakdown. She confirmed that a CP was not implemented at that time. On 7/24/24 at 11:06 AM, the surveyor interviewed a Registered Nurse Unit Manager (RN/UN) who stated that standard skin care practice in the facility included antipressure relieving mattresses, skin protectant cream to be applied as needed for skin protection (do not need a physician's order) turning and repositioning every two hours, and frequent skin checks. She stated that if a resident was identified as a risk for breakdown on admission to the facility a CP should be initiated to include all skin breakdown prevention interventions. She explained that the interdisciplinary team wound also be notified that a resident was admitted to the facility and was at risk for breakdown. She added that the wound care team would also be notified if a resident had any discolorations so that they could determine a cause and identify the type of skin issue the resident had. She stated this would help to determine the appropriate interventions that would need to be initiated on the CP. On 7/24/24 at 11:13 AM, the surveyor interviewed and Certified Nursing Assistant (CNA #1) who has been employed in the facility for [AGE] years. She stated that standard skin care in the facility wound include application of protective skin care cream. She stated that the cream would only be applied if the resident was at risk for skin breakdown or was incontinent of bladder and bowel. She stated that she did not think that a physician's order was required for this type of care. She stated that the cream was only applied for protection. She continued to explain that incontinent resident required changing more frequently and that the staff were required to turn the residents every two hours. She stated that she was unsure if the mattresses utilized in the facility were antipressure mattresses. On 7/24/24 at 11:20 AM, the surveyor interviewed CNA #2 who had been employed in the facility for 3 years. She stated that if a resident was incontinent, they were changed frequently, and zinc oxide could be applied as needed to protect the resident's skin. She stated that if a resident had any skin impairments or discolorations it would be reported to the nurse and the nurse would be responsible to order treatments, write a CP and consult the wound care team. On 7/24/24 at 11:24 AM, the surveyor interviewed a Licensed Practical Nurse Unit Manager (LPN/UM) who explained that if a resident was admitted with a discoloration on the buttocks, a detailed description should be documented. A discoloration could be anything. She stated that skin assessments were done weekly on the electronic medical record under skin assessments. She stated that a CP with interventions to prevent breakdown should be initiated if a resident was identified as a high risk for breakdown. She explained that all mattresses in the facility were antipressure mattresses and that house stock zinc oxide was applied by the CNAs as a preventative treatment when a resident was incontinent of bowel and bladder. On 7/24/24 at 2:08 PM, the DON stated that the admission nurse should have described the wound in better detail such as color and size when the nurse completed the admission assessment. She stated that a second skin check was usually conducted on day two and the nurse should have put in a physicians order for the second skin check. On 7/25/24 at 8:30 AM, the surveyor interviewed the DON who explained that when a nurse completed the weekly skin checks, the nurse needed to go into the assessment section of the EMR to complete the documentation describing the resident's skin. The DON reviewed Resident 585's medical record in the presence of the surveyor and stated that this was not completed as per facility protocol on 03/26/24. On 7/25/24 at 8:30 AM, the surveyor interviewed the DON who explained that when a nurse completed the weekly skin checks, the nurse needed to go into the assessment section of the EMR to complete the documentation describing the resident's skin. The DON reviewed Resident 585's medical record in the presence of the surveyor and stated that this was not completed as per facility protocol on 3/26/24. On 7/25/24 at 10:09 AM, the surveyor interviewed the LPN #3 that performed the AA dated 3/22/24. LPN #3 stated that when she observed the discoloration on Resident #585's sacrum she should have documented the color and size of the discoloration. She also stated that a CP should have been implemented for potential for skin impairment with interventions to prevent skin breakdown, especially since the resident was a high risk for skin breakdown. On 7/25/24 at 10:31 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she had been employed in the facility for approximately 5 (five) years. The RN stated that when she performed the skin assessment for Resident #585 on 03/26/24, she forgot to complete the skin assessment. The RN stated that had recollection that the resident had a skin discoloration on the sacral area. She stated that she must have overlooked that she was supposed to complete the skin assessment in the EMR. She stated that it would have been important to complete the skin assessment because it would give a more detailed picture of what the discoloration looked like. She stated that the resident frequently refused to be turned and repositioned and that the resident had skin prevention interventions. She stated that it would have been important to initiate a Care Plan for the resident to include all preventive skin interventions. Review of the facility policy titled, Pressure Injury Prevention and Management with a revised date of 11/29/23 that the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and development of additional pressure ulcers/injuries. -The policy specified that licensed nurses would conduct a pressure risk injury assessment on all residents upon admission/readmission, weekly times four weeks, then quarterly. -Licensed Nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury and findings would be documented in the medical record. -After completing a thorough assessment, the interdisciplinary team shall develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Care plan interventions would be based on specific factors identified in the risk assessment, skin assessment and any pressure ulcer assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging and wound characteristics). The facility policy titled, Baseline Care Plan with a revised date of 9/18/23 reflected that a baseline care plan would be developed within 48 hours of a resident admission. Interventions shall be initiated that address the resident's current needs including: pressure ulcer risk. NJAC 8:39-27.1 (e)

NJ 00167683 NJ 00172468 Repeat Deficiency Based on observation, interview, and record review it was determined that the facility failed to ensure the accurate assessment of residents using the Minimum Data Set (MDS) assessment tool. The deficient practice was identified for 3 of 34 residents (#94, 37, 586) reviewed for MDS accuracy and is evidenced by the following. 1. The surveyor observed Resident #94 on 7/23/24 at 11:58 AM, lying in bed with eyes closed. A review of the hybrid medical record revealed the resident was admitted with diagnoses including but not limited to cerebral infarction, gastrostomy, and seizure disorder. Wound Care Consultant reports from 5/6/24 through 7/22/24 documented chronic moisture associated skin damage (MASD) of the sacral area. Section M - Skin Conditions of the 7/14/24 annual MDS indicated the resident had no skin conditions (pressure ulcers, other ulcers, wounds and skin problems). Section M1040 - H MASD (incontinence associated dermatitis) was unchecked to indicate MASD was not present during the assessment reference date of 7/14/24. On 7/24/24 at 11:00 AM, the surveyor interviewed the MDS Coordinator. She stated the 6/14/24 quarterly MDS Section M1040; H. MASD should have reflected that the resident had MASD. She stated a correction MDS would be done immediately. The corrected MDS was provided to the surveyor. On 7/24/24 at 2:10 PM, the surveyor discussed the MDS inaccuracy with the Director of Nursing and the Administrator. 48964 2. The surveyor observed resident #37 on 7/23/24 at 11:45 AM, sitting in a chair in room next to the bed with call bell within reach. A review of the hybrid medical record revealed the resident was admitted with diagnoses including but not limited to anemia (low levels of red blood cells), hypertension (high blood pressure), and rectal cancer. The care plans included anemia related to disease process: colon/duodenum cancer, I have duodenum/rectal cancer, and risk of pain related to history of malignant neoplasm of duodenum and rectum. A consult dated 6/12/24 indicated there were no plans for chemo, resident hospice appropriate, but not ready yet. A consult dated 2/21/24 indicated iron deficiency anemia / rectal cancer follow up. Section I - Active Diagnoses of the 5/17/24 annual MDS indicated the resident did not have cancer. Section I0100 - Cancer was not checked, nor was it included in I8000 indicating cancer was not an active diagnosis during the assessment reference date of 5/17/24. On 7/24/24 at 2:10 PM, the surveyor discussed the MDS inaccuracy with the Director of Nursing and the Administrator. On 07/25/24 at 9:16 AM, the surveyor interviewed the MDS Coordinator. She stated the cancer diagnosis should have been coded, indicating the resident had cancer. She stated she would modify the MDS. 3. A review of the electronic medical record revealed Resident #586 was admitted with diagnoses including but not limited to hypertension (high blood pressure and Alzheimer's disease (a progressive disease that impairs memory and other functions). Progress notes indicated that on 3/21/24 it was noted that the resident was unable to ambulate. An x-ray was completed, and a left femur fracture was noted. A review of facility reported investigation dated 3/26/24 indicated the conclusion was that fracture was the result of an unwitnessed fall by the resident. Section J - Health conditions of the 3/26/24 discharge MDS indicated the resident had no falls since the prior MDS assessment. Section J1800 was coded 0, indicating no falls since the prior assessment. On 7/24/24 at 2:10 PM, the surveyor discussed the MDS inaccuracy with the Director of Nursing and the Administrator. On 7/25/24 at 9:20 AM, the surveyor interviewed the MDS Coordinator regarding the conclusion of the investigation that an unwitnessed fall caused the fracture and the coding of the MDS. She stated that she will check with her regional about the fall and get back to me on their decision. On 7/26/24 at 11:13 AM, the MDS Coordinator stated that she was modifying the discharge MDS to include the fall. N.J.A.C 8:39-11.1

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan to address the anticoagulant medication prescribed for 1 of 3 residents (Resident # 115) reviewed for anticoagulant medications and evidence by the following: On 7/22/24 at 12:54 PM, the surveyor observed Resident #115 in room and the resident stated takes an anticoagulant medication. The surveyor reviewed the Electronic Medical Records for Resident # 115 that revealed the following: According to the Admission Record indicated that Resident # 115 was admitted with diagnoses that included Atrial Fibrillation. According to the Physician's Order Summary Sheet, the resident had the following physician's order for by mouth administration of medications: -Apixaban Tablet (a medication which thins the blood and is used to reduce the risk of stroke and heart attack) 2.5 mg 1 tablet by mouth every two days. The surveyor reviewed the resident's care plans and observed that there was no care plan to address the care needs for Resident #115 with an anticoagulant. On 7/25/24 at 11:03 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the Unit Manager completes the care plans and that there should be a care plan in place for this resident who receives anticoagulant medication. The LPN stated that she was not sure why there was no care plan created. On 7/25/24 at 1:16 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing. No additional information was provided. NJAC 8:39-11.2 (e)

Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician signed and dated monthly medication orders. The deficient practice was identified for 5 of 34 residents reviewed (#2, 84, 115, 32 and 33) and occurred over a 3 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident # 2 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 2. A review of the hybrid medical record for Resident # 84 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 3. A review of the hybrid medical record for Resident # 115 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. 19106 4. A review of the hybrid medical record for Resident #32 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April or June 2024. 5. A review of the hybrid medical record for Resident #33 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for April, May or June 2024. On 7/26/24 at 10:51 AM, the Wing 2 Unit Manager stated to the surveyor that the physicians should sign their monthly orders electronically. On 7/26/24 at 12:49 PM, the surveyor discussed with the Director of Nursing (DON) and the Administrator concerns of physicians not signing their monthly orders. The DON stated the physicians should be signing orders electronically. NJAC 8:39-23.2

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous and dry foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during multiple kitchen tours and was evidenced by the following: On 7/12/2022 at 9:45 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: A large ice machine with a brown and black substance along the entire baffle (device used to restrain the flow of ice or to prevent the spreading of ice in a particular direction) along with dripping condensation into the ice below. The FSD wiped the baffle with a paper towel which removed most of the substance. The FSD acknowledged it was not clean. FSD stated It should not be there, and I will shut it down. The shelf above the stove burners with crusted on drippings. When the surveyor asked what the shelf was used for? The FSD stated it is where the cook places the utensils and dirty pots while cooking. There were 4 of 4 crumb trays under the multi range stove top which were soiled with a black grease like substance and food debris on aluminum foil that covered the crumb tray. When the FSD removed the foil there was another layer of black sticky debris under the foil. One crumb tray had multiple burnt bowtie pasta on it. The FSD could not state when the last time the crumb trays were cleaned. The FSD could not provide a cleaning schedule for the stove or crumb trays. The commercial meat slicer covered with plastic. The FSD director removed the plastic and the surveyor observed brown particles on the shield and on and under the blade. The FSD stated, When a piece of equipment was covered with plastic that indicated the equipment was cleaned and sanitized. The FSD acknowledged the meat slicer was not cleaned and sanitized. The double stack oven with baked on debris on the interior surfaces and door on each unit. When asked what the FSD thought the sediment was? The FSD stated, Sweet and oily residue from splatter. The double stack steamer unit with black debris on bottom shelf and door of each unit. The Freezer had ice condensation build-up on 1 of 3 interior unit fans and ice deposits on the interior floor. The FSD stated she was having the service company come out again to look at it and fix it. Refrigerator Box #1, which had black debris on the ceiling, door frame, in between shelving unit holes and hanging off the fan in the unit. Refrigerator box #2 had black, crusted debris within the openings on the shelves in the unit. The juice dispenser tap placed in a metal holder with copious amounts of sticky red liquid and a white disposable cup lid in the metal holder with black debris on it. The FSD stated, The evening shift was responsible to clean it daily. The FSD stated, The purpose of the cleaning schedule is to prevent fruit flies and cross contamination. No cleaning schedule or check off list could be provided at the time of our tour. Steamer table had 10 of 10 steamer water pans. They were all filled with very dark discolored water with food debris. It was noted and agreed upon by two surveyors, FSD and Kitchen Supervisor, that the breakfast pancakes were served while being warmed by these steamer pans. The surveyor asked the FSD what the cleaning process was? The FSD stated, The steam table is to be broken down and cleaned nightly which clearly has not been done. At that time the FSD stated, Take your picture then I will have all the steam water replaced. A cleaning schedule and/or check off list couldn't be provided. The small trash bin under a sink located in the dishwasher room next to a rack of clean small brown bowls. The FSD asked the food service worker to remove the trash can and rewash the square tray of brown dishes. When asked why she gave that instruction? The FSD stated, The trash can should have a lid, and it is next to the clean dishes. During an interview with the FSD on 07/12/2022 at 10:34 AM, the FSD stated, There was no formal process for scheduled cleaning. There is no accountability, sign off log or checklists available at this time. On 7/25/22 at 11:17 AM, the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) acknowledged the kitchen concerns. A review of an undated [name redacted] cleaning and sanitizing instruction manual under the section cleaning the nozzle indicated, this means our dispenser can be soaked in lukewarm or cold water, which we recommend to be done, when necessary, without being damaged. A review of the [name redacted] Ice Machine cleaning and sanitizing instruction manual, section 4; Maintenance, dated 5/21/08 part # 4141, General indicated, Descale and sanitize the ice machine every 6 months for efficient operation. An extremely dirty ice machine must be taken apart for descaling and sanitizing. NJAC 8:39-17.2 (g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to: a.) appropriately perform hand hygiene during the medication pass observation for 1 of 5 nurses, and during incontinence care for 1 of 3 residents (Resident #158), b.) appropriately don (put on) Personal Protective Equipment (PPE) prior to entering and while providing care to residents on Transmission Based Precautions (TBP), c.) appropriate clean multi-use resident equipment, d.) follow appropriate sequential infection control practices when providing care to residents on TBP, and e.) follow the Center for Disease Control (CDC) guidelines and facility policies and procedures to prevent the spread of infection to residents. This deficient practice was identified for, (Resident #93, #158, #678) and on two out of five nursing units (unit three and five). This deficient practice was evidenced by the following: 1. On 7/14/22 at 9:06 AM, the surveyor observed Licensed Practical Nurse#1 (LPN#1) assisting Resident#149 to be wheeled outside the room after administering medications. On the same date and time, LPN#1 assisted Resident#98 inside the room by propelling the resident's wheelchair. LPN#1 did not perform hand hygiene in between direct contact with Resident #149 and #98, then LPN#1 immediately applied a new pair of gloves when the LPN started to disinfect the blood pressure (bp) cuff. The surveyor asked LPN#1 if she should be performing hand hygiene and the LPN stated I will do it later after I remove my gloves. Afterward, the surveyor observed LPN#1 after disinfecting the bp apparatus, removed gloves, performed handwashing for 7 seconds, and then scrubbed hands under running water. The LPN then checked the resident's vital signs, perform hand hygiene with the use of ABHR, and prepared and administered medications. On 7/14/22 at 9:46 AM, the surveyor interviewed LPN#1 in the presence of the Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1). LPN#1 stated that she received education and competency for hand hygiene that was provided by the facility Infection Preventionist Nurse (IPN). LPN#1 further stated that handwashing should be at least 20 seconds and scrubbing is done under running water. On that same date and time, the surveyor asked LPN#1 when to perform hand hygiene. LPN#1 stated that hand hygiene should be performed in between direct contact with residents with the use of alcohol-based hand rub (ABHR) and then on the 3rd or 4th resident, handwashing should be performed. She further stated that hand hygiene should be done after gloves removal. The surveyor then asked LPN#1 if she perform hand hygiene in between direct contact with Resident #98 and #149, LPN#1 responded I can not remember. Furthermore, the surveyor asked LPN#1 if she should perform hand hygiene after direct contact with Resident #98 and #149, before donning (putting on) gloves and disinfecting the bp apparatus, and she stated I think I should have, performed hand hygiene. On 7/19/22 at 02:22 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services/Registered Nurse (RDCS/RN). The Director of Nursing (DON) informed the surveyors that LPN#1 acknowledged that she washed her hounds under a stream of running water and did not perform hand hygiene in between direct contact with residents. The DON further stated that LPN#1 should have performed hand hygiene. 2. On 7/19/22 at 6:37 AM, the surveyor observed the Certified Nursing Aide (CNA) on the 500 unit perform incontinence care for Resident #158. After performing care, the surveyor observed the CNA place the soiled linen and garbage in a garbage bag, walk out into the hallway and put the linen and the garbage in the appropriate receptacles. The surveyor further observed the CNA walk into Resident #158's bathroom, wet her hands, apply soap, and wash her hands under running water for 12 seconds. On 7/18/22 at 10:21 AM, the surveyor interviewed the IPN who stated that the appropriate procedure for hand hygiene was to turn on the water to a comfortable temperature, wet hands, apply soap, rub hands together with friction for at least 20 seconds. The IPN further stated that staff had to rub hands outside the stream of water, otherwise the soap would wash off the persons hands and not clean them. The IPN told the surveyor that after lathering hands together for at least 20 seconds, staff were to rinse hands with fingers down, making sure their hands did not touch the sink. Then grab a paper towel, drying hands fingers to wrist, throw away that paper towel, grab a new paper towel, and turn off the water. A review of the CNA's Clinical Competency Validation revised 11/2017 titled, Hand Hygiene indicated that the CNA correctly washed her hands in the presence of the IPN on 6/14/22. 3. On 7/12/22 at 11:23 AM, the surveyor observed on the 500 unit a red sign attached to a plastic tarp with a zipper in the center of Resident #678's bedroom door. The zipper was zipped down to the floor and the resident's bedroom door was shut. The red sign indicated to, STOP that the resident was on droplet and contact precautions, staff were to clean their hands before entering and upon leaving the resident's room, doors were to remain closed, staff were to don gloves, gowns, eye protection, a fit-tested N95 mask, and use dedicated or disposable equipment prior to entering the resident's room. The surveyor donned the appropriate PPE and entered the resident's room. At 11:25 AM, the surveyor observed the resident's Temporary Nursing Aide (TNA) in the resident's room providing care, leaning over, and touching the resident. The TNA was observed wearing a surgical mask with her N95 mask over it. The surveyor reviewed the medical record for resident #678. A review of the resident's Admission Record reflected that the resident had resided at the facility for a few months and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's July 2022 Order Summary Report (OSR) reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/18/22 at 10:02 AM, the surveyor interviewed the resident's TNA who stated that she would don a gown, gloves, face shield, surgical mask and N95 mask prior to entering a resident's room who was on contact and droplet precautions due to COVID-19. The TNA stated that she would put on a surgical mask and then the N95 mask over the surgical mask. The surveyor asked the TNA if she had received education on how to appropriately don PPE prior to entering a resident's room who was on TBP related to being COVID-19 positive. The TNA told the surveyor that she was educated by the Administrator on how to don PPE. On 7/14/22 at 10:38 AM, the surveyor interviewed the resident's LPN#2 who stated while providing care to a COVID-19 positive resident staff were required to wear a N95, face shield, gloves, and a gown. On 7/18/22 at 10:11 AM, the surveyor interviewed the IPN who stated that prior to entering a resident's room who was COVID-19 positive and while proving care staff were to first perform hand hygiene and don a N95 mask, face shield, gown, and gloves. The surveyor asked the IPN if it was appropriate for staff to wear a surgical mask under their N95 mask in a COVID-19 positive resident room. The IPN stated, No and explained that the purpose of wearing a fit tested N95 mask was to create a seal that was better at preventing the transmission and spread of the COVID-19 virus. A review of the the TNA's Clinical Competency Validation revised 11/2017 titled, Putting on Personal Protective Equipment (PPE)/Taking Off PPE competency dated 05/26/22 indicated that she passed. A further review of the facility's Clinical Competency Validation Form did not reflect N95 masking procedures. 4. On 7/14/22 at 10:02 AM, the surveyor observed LPN#2 on the 500 unit enter a COVID-19 positive room with a mobile blood pressure machine. Upon entering the COVID-19 positive room, LPN#2 shut the door behind her. The surveyor observed a red sign which indicated to STOP that the resident was on droplet and contact precautions, staff were to clean their hands before entering and upon leaving the resident's room, doors were to remain closed, staff were to don gloves, gowns, eye protection, a fit-tested N95 mask, and use dedicated or disposable equipment prior to entering the resident's room. On 7/14/22 at 10:05 AM, the surveyor observed LPN#2 exit the COVID-19 positive room with the mobile blood pressure machine. The bottom of the mobile blood pressure machine was observed to have brown spillage throughout and the wheels were observed to have grey, blackish debris stuck to them. The surveyor observed LPN#2 wipe the blood pressure cuff with a bleach wipe. The surveyor did not observe LPN#2 disinfect any other part of the mobile blood pressure machine. On 7/14/22 at 10:10 AM, the surveyor observe LPN#2 push the mobile blood pressure machine in front of a resident's room who was on TBP. The surveyor observed LPN#2 perform hand hygiene, appropriately don PPE, enter the resident's room, and shut the door behind her. The mobile blood pressure machine remained in the hallway outside of the resident's room who was on TBP. At that time, the surveyor observed a yellow sign on the resident's bedroom door. The yellow sign indicated that the resident was on contact and droplet precautions related to being a Person Under Investigation (PUI) who was newly admitted to the facility and not fully vaccinated for COVID-19. On 7/14/22 at 10:33 AM, the surveyor observed LPN#2 push the mobile blood pressure machine into the resident's room who was on TBP related to being a PUI. On 7/14/22 at 10:38 AM, the surveyor interviewed #LPN2 who stated that there was no single use equipment for the COVID-19 positive or PUI residents who were on TBP and that was why she used the mobile blood pressure machine. LPN#2 told the surveyor that prior to taking the resident's blood pressure she would wipe down the top of the blood pressure machine and the blood pressure cuff. The surveyor observed the bottom of the blood pressure machine in the presence of LPN#2 who stated that she did not clean the bottom of the machine, only the top. LPN#2 explained that the residents who resided in the room with the yellow signs on the door just came from the hospital and were on observation. The LPN confirmed that she used the same blood pressure machine when going from the COVID-19 positive room to the PUI room and she did not wipe down the entire machine. The LPN acknowledged that the sign on the Covid-19 positive room indicated that equipment was designated to that room. On 7/14/22 at 12:35 PM, the surveyor interviewed LPN/UM#2 who stated that the COVID-19 positive resident's had disposable stethoscopes and blood pressure cuffs in their rooms to prevent cross contamination and the spread of infection. This interview with LPN/UM#2 contradicted the surveyor's observation. On 7/14/22 at 12:44 PM, the surveyor interviewed the IPN who stated that if a resident was COVID-19 positive the expectation would be that the multi-use equipment was disinfected between residents. The IPN told the surveyor that if the mobile blood pressure machine or multi-use equipment was appropriately disinfected, it could be used between resident rooms. The surveyor asked the IPN what part of the multi-use equipment should be disinfected? The IPN stated the staff was expected to disinfect the part of the equipment that came in contact with the resident. The IPN further stated that the signs outside the resident rooms indicated the type of precautions the staff should follow. At that time, the surveyor further asked the IPN if it mattered if the resident was COVID-19 positive and if the multi-use equipment could be used between resident rooms? The IPN stated that the staff would be expected to provide care from clean to dirty. The IPN explained that for example, the staff would provide care from non-ill, to PUI/TBP to COVID-19 positive. The IPN stated that LPN#2 brought it to her attention that there was no single use equipment provided for the COVID-19 resident, so she gave LPN#2 a single use stethoscope, blood pressure cuff, and thermometer. 5. On 7/14/22 at 10:38 A.M., the surveyor observed a Maintenance Staff (MS) going into PUI room with a surgical mask, gloves, and gown. A sign posted on the door of PUI room directs to wear a fit-tested N95 and face-shield. The MS did not have a N95 or a face-shield donned. On that same date and time during an interview of the surveyor, the MS stated that he has worked at the facility for a year. He further stated that he uses surgical mask all the time. On 7/14/22 at 10:38 AM, the surveyor interviewed LPN#2 who stated that when a staff member entered a residents who was PUI and on TBP staff must wear a N95 mask, gown, face shield, gloves, surgical mask over N95. LPN#2 explained that she observed the MS entered the PUI room and he should have donned a N95 mask prior to entry to protect himself and the residents from infection. On 7/18/22 at 10:32 AM, the surveyor interviewed the IPN who stated that when a staff member entered a resident's room who was on TBP related to being a PUI, the appropriate PPE to wear were gloves, gown, N95, face shield or goggles. A review of the MS Clinical Competency Validation revised 11/2017 titled, Putting on Personal Protective Equipment (PPE)/Taking Off PPE dated 03/23/22 indicated that he passed. A further review of the facility's Clinical Competency Validation Form did not reflect N95 masking procedures. A review of the facility's Cohorting COVID-19 Policy and Procedure revised April 2022 indicated that Cohort 1 - (Red Zone) included residents who were symptomatic or asymptomatic and tested positive for the COVID-19 virus regardless of vaccination status. The facility's Cohorting COVID-19 Policy and Procedure indicated that COVID-19 positive residents, should be placed in quarantine and cared for using full PPE (gowns, gloves, eye protection that covers the front and sides of face, and NIOSH approved N95 or equivalent or higher-level respirator. The Cohorting COVID-19 Policy and Procedure further indicated that Cohort 5 - (Yellow Zone) consisted of new or readmitted asymptomatic residents who were not up to date with COVID-19 vaccinations and tested negative for COVID-19 upon admission or re-admission to the facility. The facility's Cohorting COVID-19 Policy and Procedure indicated, These residents should be placed in quarantine and cared for using full PPE (gowns, gloves, eye protection that covers the front and sides of the face, and NIOSH approved N-95 or equivalent or higher-level respirator), even if they have a negative test upon admission. A review of the facility's Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy and Procedure revised 03/2022 revealed, Dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitoring equipment) are used, or if not available, then equipment is cleaned and disinfected according to manufacturer's instructions using EPA-registered disinfectant for healthcare setting prior to use on another resident. A further review of the facility's Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures Policy and Procedure did not indicate the sequence for care such as going from non-ill to ill with the usage of multi-use resident care equipment. A review of the facility's Hand Hygiene Policy and Procedure revised 03/2021 indicated that hand hygiene was always the final step after removing and disposing of PPE. The facility's Hand Hygiene Policy and Procedure reflected that the correct procedure when washing hands was to, vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds. NJAC 8:39-19.4; 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to assure that a.) a medications were available for administration during the medication administration observation for one (1) of four (4) residents (Resident #98) observed, b.) medications that were ordered by the physician were available for administration during the months of May, June and [DATE] for two (2) of five (5) residents, (Resident #12 and #93) who attended the resident council meeting and c.) a medication was removed from active inventory after being discontinued in [DATE] until surveyor inquiry for one (1) of five (5) medication carts inspected. 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. The evidence was as follows: 1. On [DATE] at 9:06 AM, the surveyor observed Licensed Practical Nurse#1 (LPN #1) during medication pass observation for Resident #98. LPN #1 attempted to prepare the medications (meds) for Resident #98 which included the following meds: Delayed Release Aspirin 81 milligram, (mg; medication used as a blood thinner after a transcatheter aortic valve replacement), 1 tablet by mouth one time a day [MEDICATION(S)] HCl ([MEDICATION(S)]) 5 mg, (medication for memory), 1 tablet by mouth one time a day [MEDICATION(S)] ([MEDICATION(S)]) 75 mg, (medication used as a blood thinner), 1 tablet one time a day [MEDICATION(S)] ([MEDICATION(S)]) 25 mg, (a medication used to lower high blood pressure), 1 tablet by mouth two times a day for [CONDITION(S)] (hypertension) HOLD if SBP (systolic blood pressure) less than 100 or HR (heart rate) 60 At the same time, LPN #1 stated [MEDICATION(S)] was not available for Resident #98 and presented an empty [MEDICATION(S)] bingo card (a multidose card containing individually packaged meds) to the surveyor. The surveyor observed LPN #1 access the electronic Medical Record (eMR) and re-ordered [MEDICATION(S)]. The surveyor and LPN #1 reviewed the eMR together which reflected that [MEDICATION(S)] was last ordered on [DATE]. LPN #1 stated that she will get the medication (med) from the electronic back up supply machine (EBSM). During the same medication pass observation on [DATE] for Resident #98, LPN #1 stated [MEDICATION(S)] 25 mg was also not available. LPN #1 showed the surveyor a bingo card for [MEDICATION(S)] 50 mg. LPN #1 informed the surveyor that [MEDICATION(S)] was changed from 50 mg to 25 mg on [DATE] and that [MEDICATION(S)] 25 mg was not yet delivered. LPN #1 stated she will follow up on the med order for [MEDICATION(S)] 25 mg and will get the med from the EBSM . On [DATE] at 9:36 AM, the surveyor and LPN/Unit Manager#1 (LPN/UM #1) went to the EBSM located in wing 5. In the presence of the surveyor, LPN/UM #1 and LPN/UM #2 removed one tablet of [MEDICATION(S)] 25 mg and one tablet of [MEDICATION(S)] 75 mg from the EBSM. LPN/UM#1 and LPN/UM#2 reviewed the EBSM remaining quantity for [MEDICATION(S)] and [MEDICATION(S)]. The EBSM revealed a back-up quantity remaining of seven for [MEDICATION(S)] and a back-up remaining quantity of five for [MEDICATION(S)]. On [DATE] at 11:45 AM, the Director of Nursing (DON) provided a copy of Transactions Item: 0320 for [MEDICATION(S)] 75 mg tab page 1 of 1 with the following transactions: [DATE] 09:36:21 AM [DATE] 02:11:50 PM [DATE] 02:11:50 PM [DATE] 02:38:48 PM On [DATE] at 11:45 AM, the DON provided a copy of Transactions Item: 0305 for [MEDICATION(S)] ([MEDICATION(S)]) 25 mg T page 1 of 1 with the following transactions: [DATE] 09:36:04 AM [DATE] 02:00:16 PM [DATE] 02:33:25 PM On [DATE] at 12:09 PM, the surveyor interviewed LPN #2 who signed the electronic Medication Administration Record (eMAR) on [DATE] at 0800 (8 AM) as administered for [MEDICATION(S)] 25 mg. LPN #2 acknowledged that she administered the meds to Resident #98. LPN #2 also stated, she recalled that [MEDICATION(S)] 25 mg was not available on that day and that she had to borrow meds from Resident # 378. She further stated that I don't remember about [MEDICATION(S)], if it was available but she recalled signing the eMAR as administered. At the same time, the surveyor asked LPN #2 why [MEDICATION(S)] was not available, LPN #1 stated I don't know. LPN #2 stated that she attempted to call the pharmacy about the missing med but the phone was busy. The surveyor asked if she was allowed to borrow meds, and LPN #2 did not respond. During an interview of the surveyor on [DATE] at 12:12 PM, the DON stated I know the regulations does not allow facility to borrow meds, and the nurses have been borrowing meds for Resident #98. The DON also stated that the facility did not have a policy on borrowing meds. A review of the Pharmacy Delivery Manifest dated [DATE] reflected a delivery for Resident 98's [MEDICATION(S)]. A review of the Pharmacy delivery packing slip dated [DATE] included a delivery for Resident #98's [MEDICATION(S)] 50 mg. No additional information was provided for [MEDICATION(S)] 25 mg delivery prior to [DATE]. On [DATE], the Licensed Nursing Home Administrator (LNHA) provided the surveyor an electronic mail (email) from the pharmacy provider. A review of the email from the Pharmacist in Charge of the pharmacy provider dated [DATE] at 12:47 PM revealed an acknowledgement of an order received from the facility on [DATE]. The same email contained an admission of a dispensing error by the pharmacy which resulted in not sending the [MEDICATION(S)] until [DATE], after surveyor inquiry. A review of the eMAR revealed [MEDICATION(S)] 25 mg was administered on the following dates from [DATE]: [DATE] at 1700 (5:00 PM) [DATE] at 1700 (5:00 PM) [DATE] at 0800 (8:00 AM) [DATE] at 0800 (8:00 AM) A review of an investigation conducted by the DON on [DATE], revealed that LPN #2, LPN #3 and LPN #4 admitted to borrowing [MEDICATION(S)] 25 mg from another resident from [DATE] to [DATE] which reflected the 4 doses administered on the eMAR. 2. On [DATE] at 10:30 AM, during the resident council meeting, the surveyor interviewed five (5) residents who all acknowledged that they had experienced a time when they were told by nursing that their meds were not available. Three (3) of the five (5) residents were unable to identify a specific time or med but acknowledged that it had happened in the past. Two (2) of the five (5) residents were able to identify specific meds that they had been told were unavailable. Resident #12 stated that he/she routinely takes [MEDICATION(S)] (a controlled medication used for [CONDITION(S)]) at night and was told that the pharmacy had not delivered the med. The surveyor reviewed the eMAR for five (5) of the five (5) residents who attended the resident council meeting and identified meds that were not administered for two (2) of the five (5) residents due to not being available. The surveyor reviewed the medical record for Resident #12. The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. The [DATE] eMAR revealed a physician's order (PO) dated [DATE] for [MEDICATION(S)] 20 mg, give one tablet by mouth at bedtime for [CONDITION(S)]. On [DATE] and [DATE] at 9 PM the [MEDICATION(S)] PO had a medication administration entry 9 by LPN#5 which corresponded to the chart code of other/see nurses notes. Further review of the eMAR revealed a PO dated [DATE] for [MEDICATION(S)] capsule 200 MG, give one tablet by mouth two times a day for pain. On [DATE] at 5 PM the [MEDICATION(S)] PO had a med administration entry 9 by LPN#5 which corresponded to the chart code of other/see nurses notes. A review of the corresponding nursing progress notes dated [DATE] at 9:49 PM, [DATE] at 9:19 PM and [DATE] at 5:05 PM revealed that the meds were not administered because there was documentation awaiting for pharmacy to deliver. According to the resident's Individual Patient's Controlled Drug Record (IPCDR) for [MEDICATION(S)] 20 MG tablets with a received date of [DATE] for 10 tablets revealed that the last date that the med was removed from inventory was on [DATE] and the inventory was zero. A review of the resident's IPCDR for [MEDICATION(S)] with a received date of [DATE] for 10 tablets had the first date that the med was removed from inventory was on [DATE]. There were no entries on the IPCDR for the dates of ,d+[DATE], ,d+[DATE] and ,d+[DATE]. Further review of the [DATE] eMAR revealed that on [DATE] the [MEDICATION(S)] had a med administration entry of a checkmark which corresponded to mean that the med was administered at 9 PM which was inconsistent with the IPCDR entries. On [DATE] at 10:47 AM, the surveyor further interviewed Resident #12 who stated that he/she felt there were no repercussions from not getting the meds but could not understand why this would happen. On [DATE] at 11:28 AM, the surveyor interviewed LPN#5 via telephone. LPN#5 stated that she usually worked the 3 PM to 11 PM shift and that she had remembered meds not being available for Resident #12. LPN#5 stated that the meds were not in the facility back up supply, so she called the pharmacy and was told that the pharmacy had not delivered the meds because they were waiting for a prescription from the physician. LPN#5 then stated that she called the physician to let them know a prescription was needed and spoke to the resident to let them know. Then, LPN#5 added that the resident was okay when she explained the situation to the resident. LPN#5 stated that she had not discussed with the physician an alternative for the meds, but she told the next shift if the med came in that they can administer it. LPN#5 added that she had not documented what she had done and acknowledged the documentation awaiting for pharmacy to deliver. A review of the list of meds stored in the electronic back up supply machine provided by the DON revealed that [MEDICATION(S)] 20 MG and [MEDICATION(S)] 50 MG were not available in the back up supply. On [DATE] at 12:08 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that she had done inservices with the nurses regarding proper procedures for med administration and documentation. The CP added that she has instructed the nurses that the proper procedure if a med was not available in the med cart was to check if the med was available in the back up supply, then call the provider pharmacy to see why the med was not delivered to rectify the problem. The CP also stated that if the med was not in the back up supply, then the physician was to be called to notify them and get PO as to what to do until the med could be obtained. On [DATE] at 1:47 PM, the survey team met with the LNHA and DON. The DON stated that she was able to speak with the nurse who signed for the administration of [MEDICATION(S)] on [DATE] when there was no entry for removal of [MEDICATION(S)] on the IPCDR. The DON explained that the nurse had mistakenly signed that the med was administered when she had no supply of the med. The DON further stated that a med error report was completed for the nurse. The LNHA and the DON acknowledged that the nurses had not administered the identified meds because they were not available. The DON also stated that the nurses who had not administered meds because they were not available had not followed the proper procedure and were inserviced on the correct procedure. 3. On [DATE] at 10:30 AM, the surveyor reviewed the eMAR for five (5) of the five (5) residents who attended the resident council meeting and identified meds that were not administered for two (2) of the five (5) residents due to not being available. The surveyor reviewed the medical record for Resident #93. The qMDS dated [DATE], reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. The [DATE] eMAR revealed PO for the following: [MEDICATION(S)] 0.25 MG, give one tablet by mouth every 12 hours for anxiety with a start date of [DATE]. [MEDICATION(S)] ([MEDICATION(S)]) tablet 20 MG, give one tablet by mouth at bedtime for depression give with 10 MG tab to total 30 MG with a start date of [DATE]. [MEDICATION(S)] tablet 250 MG, give one tablet by mouth in the evening every Monday, Wednesday, Friday for upper respiratory infection (URI) dated [DATE]. [MEDICATION(S)] tablet 125 microgram (MCG), give one tablet by mouth in the evening for heart failure. Check apical pulse before administering medication. Hold for heart rate less than 60 with a start date of [DATE]. The following meds with times of administration had a med administration entry 9 by LPN#3 which corresponded to the chart code of other/see nurses notes for: [MEDICATION(S)] ([MEDICATION(S)]) on [DATE] at 9 PM. [MEDICATION(S)] 250 MG on [DATE] and [DATE] at 5 PM. [MEDICATION(S)] 0.25 MG on [DATE] at 9 PM, [DATE] at 9 AM and [DATE] at 9 PM. [MEDICATION(S)] 125 MCG on [DATE] at 5 PM. The following were the corresponding nursing progress notes completed by LPN#3 with the dates and times: for [MEDICATION(S)] on [DATE] 9:02 PM was waiting for the pharmacy. for [MEDICATION(S)] 250 MG on [DATE] at 5 PM was waiting for the pharmacy. for [MEDICATION(S)] 250 MG on [DATE]/at 6:58 PM was awaiting for the pharmacy. for [MEDICATION(S)] 0.25 MG on [DATE] at 8:55 PM waiting for the pharmacy. for [MEDICATION(S)] 0.25 MG on ,d+[DATE] at 10:03 AM waiting for the pharmacy. for [MEDICATION(S)] 0.25 MG on [DATE] at 8:59 PM awaiting for the pharmacy. for [MEDICATION(S)] 125 MCG on [DATE] at 7:42 PM waiting for pharmacy. The [DATE] eMAR revealed a med administration entry 9 by LPN #3 which corresponded to the chart code of other/see nurses notes for [MEDICATION(S)] 250 MG on [DATE] at 5 PM. A review of the corresponding nursing progress notes dated [DATE] at 6:12 PM revealed that the [MEDICATION(S)] was not administered because there was documentation waiting for the pharmacy. The [DATE] eMAR revealed a med administration entry 9 by LPN#6 which corresponded to the chart code of other/see nurses notes for [MEDICATION(S)] gel 4% on [DATE] and [DATE]. In addition, for the [MEDICATION(S)] gel 4% there was the same entry 9 by LPN #4 on [DATE] at 9 PM with the same corresponding chart code. A review of the corresponding nursing progress notes by LPN #6 dated [DATE] at 9:14 PM and [DATE] at 8:24 PM revealed an administration note for the [MEDICATION(S)] gel but there was no reason or documentation as to whether the [MEDICATION(S)] was administered. The corresponding nursing progress notes by LPN #4 dated [DATE] at 8:42 AM revealed that the [MEDICATION(S)] gel was not administered because there was documentation not available. On [DATE] at 10:56 AM, the surveyor interviewed Resident #93 who stated that he/she was told by the nurses that the meds were not available, and he/she would not receive the meds. The resident also stated that there were no repercussions from not receiving the meds but does not understand why this would happen. On [DATE] at 11:10, the surveyor interviewed the Staffing Coordinator who stated that LPN #3 was on vacation. On [DATE] at 11:35 AM, the surveyor attempted to contact LPN #6 but was unable to leave a voicemail. On [DATE] at 9:52 AM, the surveyor interviewed LPN #4 who stated that he remembered on [DATE] that he worked and was administering meds that day to Resident #93. The surveyor with LPN#4 reviewed the eMAR for [DATE] and LPN#4 stated that he had not administered the [MEDICATION(S)] gel 4% because the med was not in the treatment cart. LPN#4 stated that if he did not have a med then he would usually borrow from another resident, but he was recently instructed that he was no longer allowed to do that. LPN #4 stated that if he did not have the med then he could not administer it. LPN #4 was unable to speak to the procedure to follow when a med was not available. A review of the list of meds stored in the electronic back up supply machine provided by the DON revealed that [MEDICATION(S)] 0.25 MG tablets were in the back up supply machine. Further review revealed that [MEDICATION(S)] 0.125 MG tablets were in the back up supply machine, but [MEDICATION(S)] 0.25 MG tablets were not. In addition, [MEDICATION(S)] 250 MG tablets and [MEDICATION(S)] gel 4% were not in the back up supply machine. On [DATE] at 12:08 PM, the surveyor interviewed the CP via the telephone. The CP stated that she had done inservices with the nurses regarding proper procedures for med administration and documentation. The CP added that she has instructed the nurses that the proper procedure if a med was not available in the med cart was to check if the med was available in the back up supply, then call the provider pharmacy to see why the med was not delivered to rectify the problem. The CP also stated that if the med was not in the back up supply, then the physician was to be called to notify them and get PO as to what to do until the med could be obtained. On [DATE] at 01:47 PM, the survey team met with the LNHA and DON. The DON stated that she spoke with LPN #3 who had been on vacation but was called in. The DON stated that LPN #3 had said she had called the physician but had not documented what she had done. On that same date and time, the DON also stated that LPN #6 had said that the resident refused the med but had not documented properly. Furthermore, the DON stated that LPN#4 was a per diem nurse and was unaware of the procedure. The LNHA and the DON acknowledged that the nurses had not administered the identified meds because they were not available. The DON also stated that the nurses who had not administered meds because they were not available had not followed the proper procedure and were inserviced on the correct procedure. 4. On [DATE] at 11:47 AM, the surveyor inspected wing four (4) South med cart in the presence of LPN#7. The surveyor found two bingo cards (a multidose card containing individually packaged meds) of [MEDICATION(S)] 400 mg of Resident #38. Each bingo card was dated [DATE], labeled 1 of 3 and 3 of 3. Both bingo cards found were opened with capsules remaining. At the same time, LPN#7 informed the surveyor that the [MEDICATION(S)] order for Resident #38 was discontinued. LPN#7 acknowledged that the [MEDICATION(S)] should have been removed from the med cart to prevent a med error. She stated that the nurse who received the order to discontinue the med, should have removed the med from the med cart. LPN#7 added that the med was placed in the over stock section of the med cart which was the reason she did not notice it was there. A review of the [DATE] eMAR for Resident #38 revealed that [MEDICATION(S)] 400 mg was discontinued on [DATE]. The PO for Resident #38 revealed [MEDICATION(S)] 400 mg was discontinued on [DATE]. A review of Resident #38's eMAR from [DATE] to [DATE], did not reveal a current order for [MEDICATION(S)] 400 mg. The CP unit inspection report in the past three months for 4 (four) South Medication cart revealed the following: [DATE] All expired and discontinued meds out of cart, N- not in compliance [DATE] All expired and discontinued meds out of cart, N- not in compliance [DATE] All expired and discontinued meds out of cart, Y-in compliance On [DATE] at 01:57 PM, during an interview with the surveyor, the DON stated that all nurses on all shifts, on the med carts were responsible to ensure all items in the med carts were current, expired meds and discontinued meds were removed. During a follow up interview on [DATE] at 01:05 PM, in the presence of the survey team and LNHA, the DON stated that the nurse who received the order to discontinue Resident #38's [MEDICATION(S)] should have removed the med from the med cart. The DON also stated that the Unit Manager should have doubled checked that the med was removed from the med cart. She added that the Assistant Director of Nursing also covered the units, to ensure that discontinued meds were removed from med carts. The DON acknowledged removal of discontinued med should have occurred to avoid med errors. The DON confirmed that the discontinued med for Resident #38 dated [DATE] should have been destroyed. A review of the facility's Administering Medications policy revised on [DATE], under section Policy heading revealed Medications are administered in a safe and timely manner and as prescribed. In addition, Policy Interpretation and Implementation number 26, reflected Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy and approved by the director of nursing services. Medications are administered in accordance with prescriber orders, including any required time frame. A review of facility policy titled Discontinued Medications revised [DATE] revealed under Policy Heading, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. The policy also reflected under Policy Interpretation and Implementation section 3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. A review of facility policy received from DON titled 3.0 Medication Disposal/Destruction under Procedure section 5. Indicated Discontinued medications shall be disposed of within 60 days of the date the drug was discontinued. Section 6 reflected The Consultant Pharmacist and Registered Nurse or two (2) nurses (one of who is a Registered Nurse) shall periodically destroy medications subsection b. Tablets, capsules and liquids will be disposed if according to local, state, and federal regulations. A review of facility policy received from the DON titled 6.0 Medication Storage under Procedure section F revealed Expired, discontinued/or contaminated medications will be removed form [from] the medication storage areas and disposed of in accordance with facility policy. A review of the inservice procedure provided by the DON reflected that the back up supply was to be checked and then the pharmacy contacted to make sure of the delivery time and if the medication could be delivered STAT (immediately). If the medication would not be available within an hour of the scheduled time, then the physician must be notified and receive a hold order for the medication or a new PO or a PO for an alternate medication that was available. NJAC 8:,d+[DATE].2(b), 29.2(d), 29.4(g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) develop a care plan for the use of O2 for 2 of 4 residents (Resident#93 and #678), and c.) date and store the O2 cannula for 1 of 4 residents (Resident #93) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 7/12/22 at 10:59 AM, the surveyor observed resident #150 in their bed with an oxygen nasal cannula (N/C; O2 tubing that is placed in the resident's nose) in place. The oxygen concentrator (a medical device that gives you extra oxygen) reflected the oxygen was set at 5 liters (L). The surveyor reviewed the medical records of Resident #150. The resident's Admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care dated 6/07/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The resident's MDS, Section O - Special Treatments, Procedures, and Programs revealed that the resident received O2 therapy. The July 2022 Order Summary Report (OSR) did not show an oxygen order for Resident #150. The July 2022 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) lacked evidence of oxygen administration. On 7/14/22 at 9:54 AM, the surveyor observed Resident #150 sitting upright in bed watching television. The resident's O2 concentrator was set at 5 L via N/C. The resident stated that he/she was not aware of their O2 order. The resident indicated that it was the nurse who check and operates the O2 concentrator. On 7/15/22 at 11:11 AM, the surveyor observed Resident #150 in their room with O2 N/C in place and the concentrator was set at 2 (two) L. On 7/21/22 at 10:18 AM, the surveyor interviewed Certified Nursing Aide#1 (CNA#1). CNA#1 confirmed that Resident #150 was on oxygen, but stated it was up to the nurse how much the resident is on and for monitoring the O2. CNA#1 stated that she removes the oxygen canula to wash the resident's face, but never touches the oxygen concentrator. On 7/21/22 at 10:23 AM, the surveyor interviewed Licensed Practical Nurse#1 (LPN#1) regarding Resident #150's oxygen administration. LPN#1 explained that the resident was receiving O2 at 2L. LPN#1 checked the electronic Medical Record (eMR), reviewed the physician orders, and confirmed there was an order dated 7/15/22 for O2 2L NC continuously every shift. On that same date and time, the surveyor asked LPN#1 if there was a previous order prior to 7/15/22 for O2. LPN#1 checked the eMAR, electronic eTAR, and OSR for July 2022 and stated that no order could be found prior to 7/15/22. LPN#1 further stated that there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time, the surveyor informed LPN#1 that the surveyor observed the resident on 7/12 and 7/14/22 with O2 at 5 L. On 7/21/22 at 10:41 AM, the surveyor informed the MDS Coordinator who was also the acting Manager of unit 5 that the surveyor observed the resident on 7/12 and 7/14/22 with O2 at 5L NC. The surveyor notified the MDS Coordinator of LPN#2's review of OSR, eTAR, and eMAR that did not show an O2 order prior to 7/15/22. The MDS Coordinator confirmed that the expectation is that if a resident is on O2, there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 7/12/22 at 11:25 AM, the surveyor observed Resident #678 lying in bed. CNA#2 was in the room at that time providing incontinence care to the resident. The surveyor waited till the CNA was done performing care and attempted to interview the resident. The resident had a thick accent and responded with yes and no answers. The surveyor observed the O2 concentrator and identified that O2 was being administered to the resident at five (5) Liters Per Minute (LPM) via N/C. The N/C tubing was attached to the O2 concentrator in the resident's room. On 7/14/22 at 10:26 AM, the surveyor observed the resident in their room watching television. The resident was observed wearing the N/C in their nares. The surveyor observed that the O2 concentrator in the resident's room was set at four (4) LMP. The surveyor asked the resident if he/she ever touched the O2 concentrator and the resident stated, No. The surveyor reviewed the medical record for Resident #678. The resident's Admission Record reflected that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's AMDS dated [DATE] reflected that the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The resident's MDS, Section O - Special Treatments, Procedures, and Programs revealed that the resident received O2 therapy. The resident's July 2022 OSR reflected a PO dated 7/05/22 for O2 at three (3) LPM via N/C continuous for shortness of breath. A review of the Resident #678's July 2022 eMAR revealed that the nurses were signing on the day, evening, and night shifts that the resident was administered O2 at three (3) LPM via N/C continuous for shortness of breath. A review of the resident Care Plan did not reflect a focus area for the care of and the O2 usage. On 7/14/22 at 11:52 AM, the surveyor interviewed the resident's CNA#2 who stated that the resident required O2 and received the administration of the O2 by way of the O2 concentrator. The CNA told the surveyor that she did not touch the O2 concentrator, and it was the nurses job to monitor the flow rate of O2 from the O2 concentrator. On 7/14/22 at 11:59 AM, the surveyor interviewed the resident's Licensed Practical Nurse#1 (LPN#1) who stated that the resident received O2 via the O2 concentrator and had a PO for the administration of O2 at three (3) LPM via nasal cannula. LPN#1 further stated that the resident would touch his/her nasal cannula tubing, but never the O2 concentrator. LPN#1 told the surveyor that if a resident had a PO for the use of O2, the O2 usage should be reflected in the resident's Care Plan. The surveyor asked who was responsible for creating the resident's Care Plan and the LPN told the surveyor that the Nursing Supervisor was responsible for creating the resident's Care Plan. On 7/18/22 at 9:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident's Licensed Practical Nurse/Unit Manager#1 (LPN/UM#1) was unavailable for an interview. The DON told the surveyor that if a resident had a PO for the administration of O2, the expectation was that the PO would be followed. The DON further stated that if a resident had a PO for the use of O2, it should be reflected in a focus area in the resident's Care Plan. The DON stated that the Unit Mangers were responsible for creating the Care Plans for the residents. 3. On 7/12/22 at 10:48 AM, the surveyor observed Resident#93 seated on their bed with O2 in use at 2LPM via N/C with a long O2 tubing attached to an oxygen concentrator. The O2 tubing was not dated. The resident informed the surveyor that the resident had been using O2 for a long time and was aware of the O2 order of 2LPM. The resident further stated that it was the respiratory therapist who changes the O2 tubing once a week. The surveyor reviewed Resident #93's medical records. The resident's Admission Record reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .). The July 2022 OSR showed an order dated 8/23/21 for O2 therapy for 2LPM via N/C every shift. The order for O2 therapy was transcribed in the eMAR and nurses were signing on the day, evening, and night shifts that the resident was administered O2 at three 2LPM via N/C. A review of the resident's Care Plan did not reflect a focus area for the care of and the O2 usage. According to the 5/6/22 Quarterly MDS (QMDS), with a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. The QMDS indicated that the resident was on O2. On 7/13/22 at 11:14 AM, the surveyor and LPN#2 both went inside Resident #93's room and observed O2 tubing on top of the resident's bed not stored in a bag. The resident was not in the room. LPN#2 stated to the surveyor that the O2 tubing should have been stored in a plastic bag when not in use. On that same date and time, LPN#2 looked around the resident's room and found a plastic bag, and immediately placed the O2 tubing that was found on top of the resident's bed. At that time, the surveyor and LPN#2 observed a N/C wrapped around the portable O2 tank inside the resident's room. The N/C was not stored inside a plastic bag and was not dated. LPN#2 then discarded the N/C and stated that it should have been stored in a plastic bag when not in use. Then the surveyor asked LPN#2 why she placed the O2 tubing that was found on top of the bed inside a plastic bag and did not discard it. LPN#2 stated that the surveyor was right and, Maybe I should throw that. On 7/13/22 at 11:46 AM, the surveyor interviewed LPN/UM#2 and was made aware of the above concerns. LPN/UM#2 stated that we have a clear baggy that we suppose to put in the O2 cannula when not in use. LPN/UM#2 further stated that the nurse should throw the O2 tubing because you don't know what was on the bed. At that same time, the surveyor asked LPN/UM#2 why is it important to store the O2 cannula and tubing inside a plastic bag when not in use and to date the O2 tubing, and LPN/UM#2 replied for infection control. On 7/18/22 at 11:38 AM, the survey team met with the LNHA and was made aware of the above concerns. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, Regional Director of Clinical Services/Registered Nurse (RDCS/RN), and the Director of Nursing (DON) and were made aware of the above concerns. The DON stated that O2 tubing should be stored if not in use and dated. The DON further stated that the nurse should discard the O2 tubing when found on top of the bed for infection control. A review of the facility Oxygen Administration Policy that was provided by the LNHA with a revised date of December 2021, included Policy I. Initiation of Oxygen A. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order shall include: i. Oxygen flow rate ii. Method of administration (e.g. nasal cannula) iii. Usage of therapy (continuous or prn) iv. Titration instructions (if indicated) v. Indication for use .III. Infection Control. A. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: i. Are for single resident use only. ii. Will be changed weekly and when visibly soiled, or as indicated by state regulation. B. Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment form dust and dirt when not in use IX. Turn off oxygen when not in use. A review of the facility's Oxygen Administration Policy and Procedure revised December 2021 indicated that a PO was required to initiate O2 therapy, except in an emergency and the PO should include the O2 flow rate, method of administration, usage of therapy, and indication for use. The facility's Oxygen Policy and Procedure further revealed to, Turn on the oxygen at the prescribed rate. NJAC 8:39-27.1(a)(b)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Residents #66 and #140 for a total of two quarters. This deficient practice was identified for 2 of 2 residents reviewed, and was evidenced by the following: 1. On 7/12/22 at 10:42 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM informed the surveyor that Resident#66 was cognitively impaired and a wanderer. On that same date at 11:00 AM, the surveyor observed the resident standing in the nursing station with the LPN/UM. The resident was not able to respond appropriately to the surveyor's questions. Later on, the Certified Nursing Aide (CNA) came and accompanied the resident to be toileted by hand-held assistance while walking. The surveyor reviewed the medical records of Resident #66: The resident's Admission Record (admission summary) disclosed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .). The Comprehensive Minimum Data Set (CMDS) dated [DATE], an assessment tool used to facilitate the management of care, indicated cognitive skills for daily decision-making were severely impaired. Section E Behavior of the CMDS showed that the resident was noted with physical behavioral symptoms directed toward others score of one which indicated that behavior of this type occurred one to three days. Section G Functional Status of the CMDS revealed that the resident's bed mobility and transfer were coded 3/3 (which means that the resident required extensive assistance with two staff), eating 4/2 (which means that the resident required total assistance with one staff), and toileting 4/3 (which means the resident required extensive assistance of two staff). The 01/28/2 Quarterly MDS (QMDS), indicated there were no changes in cognitive skills for daily decision-making. Section E Behavior of the 01/28/22 QMDS showed that the resident was noted with physical behavioral symptoms directed toward others and a wandering behavior both scores of one. Section G of the QMDS revealed that the resident's bed mobility and transfer were coded 2/2 (which means that the resident required limited assistance from one staff), eating 2/2, and toileting 3/2 (which means the resident required extensive assistance from one staff). The 4/25/22 QMDS, indicated there were no changes in cognitive skills for daily decision-making. Section E Behavior of the 4/25/22 QMDS showed that the resident was noted with other behavioral symptoms not directed toward others and a wandering behavior both scores of two which indicated that behavior of this type occurred 4 to 6 days but less than daily. Section G of the QMDS revealed that the resident's bed mobility and transfer were coded 2/2, eating 2/2, and toileting 3/2. Further review of the MDS revealed that there was no Significant Change (SC) MDSs completed when the resident was noted with a significant improvement in functional status and worsening of behavior on both QMDS dated [DATE] and 4/25/22. The personalized care plan focused on [CONDITION(S)] medications related to behavior management initiated on 12/02/21 and revised on 6/7/22. The care plan interventions date initiated on 12/02/21 and revised on 6/7/22 included to monitor/record the occurrence of for target behavior symptoms pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. The Occupational Therapy (OT) Discharge Summary dated 11/24/21 showed that the resident was discharged (d/c) from Skilled OT and met the goal for maximum assistance for toileting. The Physical Therapy (PT) Discharge Summary dated 11/24/21 revealed that the resident was d/c from Skilled PT and met the goal for the following: Bed mobility=stand by assist (the presence of another person within arm's reach required to prevent injury during the performance of one of the activities of daily living) Transfer=contact guard assist (CGA) (the assisting person has one or two hands on your body but provides no other assistance to perform the functional mobility task) According to the Therapy Screening Form (TSF) dated 01/26/22 for a Quarterly status revealed a comment that the resident was a minimum assist for safety with self-care and was supervision for transfers. The TSF dated 4/25/22 for a Quarterly status showed a comment that the resident was a minimum assist for safety with self-care and supervision for transfers. On 7/15/22 at 9:08 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) in the presence of the survey team. The MDSC/RN informed the surveyor that the facility had no specific policy concerning SC MDS and we follow the RAI (Resident Assessment Instrument) manual. The MDSC/RN stated that if there were two or more areas of a change within adls and a change in mood or behavior of the resident, we discuss it as a team, and a significant change assessment will be done. On that same date and time, the surveyor notified the MDSC/RN of the above concerns. The MDSC/RN stated that there were two opportunities that a SC should have been done on 01/28/22 and 4/25/22 where there were more than two areas of improvement with adls and the other one was worsening of behavior, and it was missed. She further stated that it was the part-time MDS nurse (PT/MDSN) who did the MDS on the above-mentioned MDS on 01/28/22 and 4/25/22. On 7/18/22 at 11:38 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and was made aware of the above concerns. On 7/19/22 at 02:22 PM, the surveyors met with the LNHA, Director of Nursing (DON), and the Regional Director of Clinical Services/Registered Nurse (RDCS/RN). The DON stated that SC should have been initiated for residents with improvements in ADL (activities of daily living) and worsening mood and behavior. On 7/21/22 at 9:44 AM, the surveyor interviewed the PT/MDSN via phone conference. The PT/MDSN informed the surveyor that the SC was missed. He further stated I do agree that a SC should have been done on two opportunities on two quarterlies on 01/28/22 and 4/25/22. 2. On 7/12/22 at 10:55 am, the surveyor observed Resident #140 lying in bed, awake, alert, and appropriately responded to the surveyor. The resident stated that he/she needed help from staff for care. A review of Resident #140's medical record reflected the following: The resident's Admission Record reflected that Resident #140 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The QMDS with an ARD of 3/9/22 reflected that Resident #140 had a brief interview for mental status (BIMS) score of 15 which indicated that the resident had an intact cognition. Section G Functional Status of the QMDS revealed that the resident's bed mobility and transfer were coded 3/3, toilet use 3/2 (which means that the resident required extensive assistance with one staff) and eating 1/1 (which means the resident required supervision with set up help only). The QMDS also reflected that the resident had a mood interview (PHQ-9(C)) that reflected Symptom presence of poor appetite or overeating with a Symptom Frequency of 1 (which means symptom frequency was 2-6 days), and the resident had 0 (which means behavior not exhibited) for verbal behavioral symptoms directed toward others. A review of the QMDS with an ARD of 6/9/22 reflected that Resident #140's cognition was the same. In comparison with March 2022 QMDS, there was an improvement in the resident's functional status and now the resident required 2/2 in bed mobility, transfer, and toilet use (which means limited assistance of one person) and eating 0/1 (which means independent with set up help only). Furthermore, there was a decline in mood which reflected that the resident's symptom frequency for poor appetite or overeating was now 2 (which means symptoms frequency was increased to 7-11 days). There was also a decline in resident's behavior which reflected that the resident's verbal behavior symptoms toward others was now 1 (which means behavior of this type occurred 1 to 3 days). There was no documented evidence that an SCSA (Significant Change in Status Assessment) was initiated when a significant improvement in functional status and decline in mood and behavior were identified on the June 2022 QMDS. On 7/19/22 at 12:35 PM, MDSC/RN informed the surveyor that SCSA should be done if there were at least two areas of either improvement or decline in ADLs and decline in mood and behavior. The surveyor informed her of the above concerns. The MDSC/RN stated that she will verify whether SCSA was missed or if there were MDS coding inaccuracies on the 6/9/22 QMDS assessments. On 7/19/22 at 02:22 PM, the survey team met with the LNHA, the RDCS/RN, and the DON. The DON stated that SCSA should have been initiated for residents with improvements in ADLs and worsening mood and behavior. In a follow-up interview with MDSC/RN on 7/20/22 at 8:51 AM, she acknowledged that the coding in 6/9/22 QMDS assessments were accurate and that SCSA should have been done and stated, that it was missed. On 7/21/22 at 9:52 AM the surveyor interviewed PT/MDSN via telephone. He acknowledged that SCSA should have been done on 6/9/22 MDS assessments and stated, I should have done a significant change. According to the RAI Manual Version 3.0 of CMS (Centers for Medicare & Medicaid Services) guidelines, updated October 2019, page 2-23 reflected that An SCSA is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; . It was also indicated on page 2-25 that an SCSA is appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). It reflected that Decline in two or more of the following: . - Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section E (Behavior); . While on page 2-26, it reflected that SCSA MDS is required if there is an Improvement in two or more of the following: - Any improvement in an ADL physical functioning area (at least 1) where a resident is newly coded as Independent, Supervision, or Limited assistance since last assessment and does not reflect normal fluctuations in that individual's functioning; On 7/25/22 at 12:45 PM, the survey team met with the administrative team. There was no additional information provided. NJAC 8:39-11.1

Based on the interview, and review of medical and facility policy, it was determined that the facility failed to provide information in a manner easily understood by the resident or resident representative about the right to formulate an Advanced Directive (AD). This deficient practice was identified in 1 of 3 residents reviewed for AD (Resident #150) and evidenced by the following: During an interview of the surveyor on 7/15/22 at 11:11 AM, Resident #150 stated that he/she does not recall if staff offered them AD information. The surveyor reviewed the electronic Medical Record (eMR) for Resident #150. The resident's Admission Record (face sheet; an admission summary) indicated that the resident was admitted to the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), an assessment tool used for management of care dated 6/20/2022 revealed that Resident #150 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A social worker's (SW) Social History and Initial Assessment signed 6/12/2022 for Resident #150 indicated the resident did not have an AD and no AD information was given to the resident. A SW note dated 6/8/2022 reflects the SW met with the resident for the initial assessment. The SW note revealed that the resident was admitted for short term rehab and that the resident appeared to be alert but very difficult to understand due to their trachea. In addition, the 6/8/22 SW note indicated that the SW spoke with the family representative (FR) to complete the assessment and that a scheduled care conference for Friday at 11:30 to discuss projected plans. Further review of Resident #150's medical record showed that there was no document evidencing that an AD was offered and the resident or their representative was provided information on formulating an AD. On 7/19/22 at 10:13 AM, the SW for Resident #150 stated she came into the facility it was difficult to understand the resident with the [CONDITION(S)]. Furthermore, the SW confirmed that she did not offer the FR information on AD. NJAC 8:39-9.6(e)

Based on observation, interview and record review it was determined that the facility failed to provide adequate supervision to prevent falls from reoccurring, re-evaluate existing fall prevention interventions, and establish causal factors to prevent future falls and injuries. This deficient practice was evident for 2 of 12 residents, Resident #4 and 11. Resident #11 required hospitalization for a Subdural Hematoma and a head wound which required sutures. Resident #4 sustained 2 head lacerations which required sutures and transfers to the hospital. This deficient practice was evidenced by the following: 1. On 11/6/13 at 9:30 a.m., the Unit Manager stated that Resident #11 was confused and self propelled around the facility. She added that the resident could be agitated and impulsive, but was able to be redirected. On 11/7/13 at 9:35 a.m., the surveyor reviewed the medical record of Resident #11. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS, assessment tool) dated 3/4/13 indicated that the resident had a cognition score of 2 reflecting severe impairment and required 1 person assistance for transfers, bed mobility, ambulation and toilet use. On 1/8/13 at 11 a.m., the surveyor reviewed the resident's care plans. There was a care plan dated 2/4/13 and updated 10/30/13, for potential for falls, related to history of falls, confusion, dementia, and decreased mobility. Interventions included: 1) bed in lowest position, 2) restorative ambulation, 3) supervised activities and invite to green room and provide close supervision and assist to preventing falls, 4) bed alarm and self release seat belt, 5) place call bell within reach , with constant reminder for (name) to use it, 6) non-Skid socks, 7) added on 10/19: alarm will be checked that it is on and operating, and 8) added on 10/30: discontinue chair alarm and start sensor pad; move alarm box to middle of chair. On 4/19/13 the Universal Transfer Form indicated that the resident was transferred to the hospital status [REDACTED]. A review of the Interdisciplinary Progress Notes (IPN) dated 4/22/13, revealed that the resident went to the bathroom (BR) and slipped. Safety interventions in place were: call bell was within reach; the bed was alarmed and at its lowest position. The staff's plan at that time was, "We will continue to closely monitor resident and make sure she is wearing non-skid socks at all times." On 5/2/13 at 10 p.m., the nurse documented that while in the hallway she responded to the alarm and went to the resident's room where she found the resident sitting on the BR floor in front of the toilet, holding onto the wheelchair trying to get up from the floor. The nurse observed a small bruise on the resident's arm. The nurse added that the resident was assisted to the toilet immediately after fall, did not void, but constantly asked to use the toilet. On 5/3/13 at 12:30 a.m., the resident was assisted to the toilet and placed in front of the nurses' station. At 1:30 a.m., the resident was again assisted to the toilet and placed in bed. At 3:30 a.m., the nurse heard the alarm and found the resident trying to get out of bed and was again assisted to the toilet. At 7 a.m. , the nurse wrote for day shift to please follow up with the MD in the morning. On 5/3/13 the IPN reflected a nursing team note which provided a summary of the 5/2 fall. They documented that the resident had Dementia and was on Lasix 40 mg daily and was already being toileted at least every 1 hour. The last urine result was done on 3/18/13 and was negative. "Since resident already has all safety measures in place i.e. bed/chair alarms, padded rails, bed to lowest position, non skid socks and self release seatbelt, we will continue with care plan and close monitoring." On 5/4/13 the 11-7 nurse documented that the resident "constantly out of bed to bathroom times 5" and very combative. On 5/13/13 at 8 a.m., the 7-3 nurse documented that the resident was assisted to the BR 6 times. On 5/13/13 at 5 p.m., the nurse documented that the resident continued going to the bathroom without asking for assistance. The staff consistently redirected resident, but the resident knew how to remove seatbelt alarm. On 5/19/13 at 10 p.m., the nurse documented that the resident was constantly asking to go to the bathroom, sometimes 5 to 7 times within 30 minutes. On 6/7/13 the 11-7 nurse documented resident's behavior was the same, frequently out of bed to the BR with as unsteady gait. A review of the Annual MDS revealed that the resident's cognition score was a 3 indicating severe cognition impairment and continued to require 1 person assistance with activities of daily living. There was no significant change from the last assessment. On 6/9/13 at 5:30 a.m., the nurse documented that while giving medications on a different unit the Certified Nurses Assistant (CNA) reported that the resident was on the floor. The nurse found the resident was sitting on the floor next to the door. The resident said that he/she was going to the BR. The CNA stated in the investigative report that she was in another room and heard the alarm ringing. Upon responding the CNA found the resident on the floor. The team determined that again the " Action " to be taken was to closely monitor and remind resident to use call bell for assistance and a physical therapy screen initiated. On 6/11/13 the 11-7 nurse documented, "behavior the same gets out of bed to go to the BR and starts ambulating before someone reaches him/her, never use call light. Instructed how to use it." 6/12/13 at 6 p.m. the nurse wrote that the resident was asking to go to the bathroom constantly even when on the toilet and at 2 to 5 minute intervals. On 6/15/13 the 11-7 nurse documented that the resident could turn the bed alarm off and walk to BR before someone could reach him/her. The resident ' s ability to turn off the alarms, in spite of his/her cognitive impairment, had been documented at the time of the 5/13 fall. On 6/16/13 at 1 a.m., the nurse wrote that the resident got out of bed to go to the BR and fell down at right side of bed before the nurse could reach the resident. The bed alarm was sounding. The investigative report for this fall indicated that the resident would never use the call light and had behaviors of frequently asking to go to the BR. Actions to be taken were, "Frequently monitor resident for toileting and encourage (the resident) to use call bell for assistance." The staff continued to suggest that the resident to be encouraged to use the call bell for assistance as an intervention. This does not coincide with the MDS assessment that the resident has severe cognitive impairment and that this intervention has been unsuccessful for the previous falls. On 6/19/13 at 5:20 a.m., the CNA reported that the resident was found sitting on the floor by the bed. The conclusion was that the resident tripped on garments worn at night and staff would request different garments from the family. In addition the staff would continue to remind the resident to use the call bell for assistance. On 6/19/13 at 8 p.m., the nurse wrote that the resident was constantly asking to go to the BR at 3 to 5 minute intervals. Yelling and screaming at staff. The MD was called and ordered a psychiatric evaluation and urinalysis. On 6/20/13 the urinalysis was obtained and revealed less than 10,000 colony count and negative bacteriuria. The MD ordered an antibiotic for 5 days. From 6/20 to 6/29/13 the nurse documented that the resident with episodes of yelling and screaming and constantly asking to go to the BR. On 6/24/13 the psychiatrist recommended to continue to monitor the resident with no new medication. On 7/6/13 at 1 a.m., the nurse heard a noise and went to the resident's room. She found the resident lying on the right side on the bathroom floor with the alarm intact. The resident's right forehead was bleeding with a laceration to the lower arm. The resident complained of a head ache. The nurse stated that the resident again failed to use the call bell. The MD was called and the resident was sent to the emergency room (ER). On 7/7/13 at 5 a.m., the resident was still in the ER and the nurse wrote, " Please followup when resident comes back from ER to give resident non skid socks to prevent from falling. " At the time of the fall Resident #11 was wearing regular socks as opposed to the care plan intervention of non-skid socks and had hidden the sensor alarm under his/her arm to prevent its alarming. The investigative report indicated that the "Resident need to have non-skid socks and floor matt." The report further indicated that the resident removed the sensor alarm. The IDCP team note dated 7/7/13 concerning the fall noted that the resident was found on the floor in the bathroom with the alarm box and cord in his/her hand; and sustained a skin tear from it. On 7/7/13 at 1 p.m., the resident was admitted to the hospital with [REDACTED]. On 7/10/13 Resident #11 was readmitted from the hospital. The care plan revealed that no new interventions were implemented to prevent further injuries. On 7/17/13 Physical Therapy recommended a trial of a bedside commode to be used at night only. This intervention was not reflected in the fall care plan. On 7/22/13 the physician ordered Ditropan for Overactive Bladder. There was no evidence or rationale provided in the IPN to explain why this was not trialed before the resident's injury. On 7/31/13 at 10:45 a.m., the resident was found on the floor in the bathroom. The resident had left the activity room without the staff noticing. On 10/19/13 at 8:20 p.m. the resident was found on the bathroom floor. The investigative report revealed that when the nurse walked into the room the alarm was not sounding. The Conclusion and Action Taken was "nursing staff will continue to monitor resident closely to avoid injury, PT to evaluate for positioning and transfers. Resident might have silent the alarm or the safety release seat belt." The facility listed the Action that would be taken at this time was that the alarm would be checked that it was on and operating. On 10/29/13 at 3:15 p.m., the resident was found on the BR in another resident's room. The investigative report revealed the the self release seatbelt was working but not sounding. The resident may have silenced the alarm. The action to be taken was to remind resident "not to silent the seat belt alarm and a sensor pad alarm was recommended. The conclusions based on assessment was, "just monitor closely." On 11/7/13 at 3:15 p.m., the surveyor heard an alarm ring while at the nurses ' station. A CNA ran to Resident # 11's room where the resident was already in the bathroom. The CNA toileted the resident and assisted the resident back to the wheelchair. On 11/8/13 at 9:45 a.m., the surveyor interviewed the resident's regularly assigned CNA. She stated that the resident used the toilet multiple times during the day. She stated that even after toileting Resident #11 still demanded to use the BR. On 11/13/13 at 9:45 a.m., the surveyor reviewed the physician's progress notes dated 8/10/13 and 10/6/13 with the nurse. There was no documentation provided to explain the etiology or medical rationale for the resident's frequent BR requests. The psychiatric follow up on 7/17/13 addressed the resident's lethargy. There was no documentation regarding if there was a behavioral component to the resident's constant request to use the BR. On 11/13/13 at 10 a.m., the surveyor discussed with the Director of Nursing (DON) and Administrator concerns for ineffective fall prevention interventions and how the staff was closely monitoring the resident. They stated that they implemented an intervention on 11/11/13 for a staff member to sit near his/her bedroom door when the resident was in bed. Refer to F 279 2. On 11/6/13 at 10:25 a.m. during the initial tour the Director of Nursing (DON) told the surveyor that Resident #4 was on hospice. She stated that the resident was unsteady on his/her feet and had a history of [REDACTED]. On 11/8/13 at 8:45 a.m. Resident #4 was observed by the surveyor asleep in the bed after the hospice aide had given care and left the room. The lights were off and the resident was in the room by alone. A floor mat was in place and the bed was against the wall. On 11/8/13 at 11 a.m. the surveyor reviewed Resident #4's medical record. The resident was admitted to the Sub Acute unit on 2/13/13 with a [DIAGNOSES REDACTED]. At this time the resident was placed on Hospice services. The Quarterly Minimum Data Set, an assessment tool dated 10/30/13 indicated the resident had a cognition score of two reflecting severe impairment and required extensive assist of one person for transfers, bed mobility and ambulation. The Admission Nursing Assessment, dated 2/13/13, identified the resident as a "high fall risk" with a fall assessment score of 12. The most recent fall assessment, dated 11/3/13 indicated the resident fall risk had increased to a score of 16. A review of the Falls Care Plan dated 2/14/13 revealed that the resident had a potential for falls, was confused and agitated with [DIAGNOSES REDACTED]. Additionally there was a problem area that the resident," will sometimes remove bed or chair alarm or shut (it) off." Fall Interventions on the Care Plan included: 1) bed in lowest position, 2) non-skid foot attire, 3) call bell within reach with frequent reminders to call for assistance for transfers, 4) bed and chair alarms 9/5/13: check that alarms on and operating properly, 5) rotunda area for close supervision, 6) 9/5/13 pressure alarm to bed, place box out of reach. 7) self-release seat belt to W/C, and 8) 10/14/13 slipper socks. On 5/24/13 at 8:20 a.m., the bed alarm sounded. The resident was found on the floor by the bed. There were no injuries reported. On 9/5/13 at 6:45 a.m., the bed alarm sounded and Resident #4 was found on the floor next to the bed. The resident was bleeding from a laceration to the left forehead. The resident was sent to the ER and was readmitted after receiving sutures to the wound. A review of the investigative report for this fall revealed an Action to be taken was for a bed sensor alarm, and to keep the alarm control box out of the resident's reach to prevent the resident from removing it. On 9/15/13 at 6:10 p.m., the IPN indicated that Resident #4 was in a wheelchair at the nurses station. When the resident attempted to stand, the chair alarm sounded, and the resident fell . The resident struck his/her head on a cabinet prior to falling to the floor. Neurological checks were done. A psychiatrist follow up was ordered and done on 9/30/13. Seroquel 12.5 mg twice daily was discontinued and the resident was started on Depakote (mood stabilizer) 125 mg po twice daily. On 10/5/13 the IPN indicated that Resident #4 was found on the floor next to the recliner chair in the hallway at 7:40 a.m. According the fall investigation the chair tab alarm did not sound at the time of the fall. Action to be taken was to get the resident up by 10 a.m. and place in the rotunda area where supervision could be provided. There was no documentation provided to explain why the alarm did not sound. On 10/9/13 at 10 p.m., the IPN indicated the bed alarm sounded and Resident #4 was found sitting on the floor next to the bed. The resident was bleeding from a laceration to right side of the head and was transferred to the hospital. The resident was readmitted after receiving sutures. Action to be taken was a self releasing seat belt was to be added to the wheelchair. There was no assessment provided that indicated that the resident was able to release the belt. On 10/11/13 at 5:45 a.m., the IPN indicated that Resident #4 was found on the floor in the hallway. The wheelchair had fallen over with the resident in it and the self releasing seat belt attached. The facility Action to be taken was the self releasing seat belt was to be discontinued. During the initial tour the DON stated that the resident was unpredictable and had behaviors of climbing. There was no assessment to determine the risks versus the benefits of a restraint considering these behaviors. On 10/13/13 the IPN documented another fall. It noted that Resident #4 was sleeping when checked at 10 a.m. The alarm sounded at 10:30 a.m. and Resident #4 was found on the floor mat next to the bed. There was no revision to the care plan implemented. On 11/12/13 at 9 a.m. the surveyor interviewed the DON, who was unable to provide the surveyor with any other interventions the facility had put in place in an attempt to prevent falls. On 11/12/13 at 9:25 a.m. the surveyor interviewed Resident #4's family member concerning the care the resident was receiving at the facility. The family member stated that every facility doesn't meet the needs of every resident. Some residents need more supervision than others. The family member also stated that hospice recently met with her and discussed the possibility of her providing 1 to 1 care for her family member. The family felt that it was the facility's responsibility to keep the resident safe. NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to establish, implement and re-evaluate existing care plan interventions for 9 of 27 residents, Residents # 2, 3, 4, 8, 11, 12, 13, 14, and 15. The fall care plans for Resident #4 and 11, were ineffective to prevent reoccurring falls with injuries. The deficient practice was evidenced by the following: 1. On 11/6/13 at 9:30 a.m., the unit manager stated that Resident #11 was confused and was able to self propelled around the facility. She added that the resident could be agitated and impulsive, but was able to be redirected. This resident has fallen 7 times since April 2013. After 2 of these falls the resident was sent to the hospital for evaluation and was admitted after the most recent fall in October 2013. On 11/7/13 at 9:35 a.m., the surveyor reviewed the medical record for Resident #11. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the resident's care plans on 1/8/13 at 11 a.m. There was a care plan dated 2/4/13 and updated 10/30/13 that listed the resident ' s potential for falls related to a history of falls, confusion, dementia, and decreased mobility. The interventions listed to aid in preventing falls included: 1) bed in lowest position, 2) restorative ambulation, 3) supervised activities and invite to green room and provide close supervision and assist to preventing falls, 4) bed alarm and self-release seat belt, 5) place call bell within reach , with constant reminder for resident to use it, 6) non-Skid socks, 7) 10/19: alarm will be checked that it is on and operating, and 8) 10/30: discontinue chair alarm and start sensor pad; move alarm box to middle of chair. On 4/19/13 the Universal Transfer Form indicated that the resident was transferred to the hospital to be evaluated after a fall. A review of the Interdisciplinary Progress Notes (IPN) dated 4/22/13 concerning this fall revealed that the resident went to the bathroom (BR) and slipped. Safety interventions in place at the time included that the call bell was within reach, the bed was alarmed and in the lowest position. The staff noted that "We will continue to closely monitor resident and make sure she is wearing non-skid socks at all times." Non-skid socks had been listed on the care plan as an intervention. On 5/2/13 at 10 p.m. the nurse documented that she responded to Resident #11 ' s alarm and found the resident on the bathroom floor holding onto the wheelchair. The nurse observed a small bruise on the resident's arm. The resident was assisted to the toilet immediately after the fall, did not void, and yet constantly asked to use the toilet. A 5/3/13 IPN note provided a summary of the 5/2 fall. The team documented that the resident has Dementia, is on [MEDICATION NAME] 40 mg daily and is already being toiled at least every 1 hour. The last urinalysis was done on 3/18/13 and was negative. The team documented "Since resident already has all safety measures in place i.e. bed/chair alarms, padded rails, bed to lowest position, non-skid socks and self-release seatbelt, we will continue with care plan and close monitoring." There was no description or detail of how the resident was going to be closely monitored. On 5/13/13 at 5 p.m., the nurse documented that Resident #11 continues going to the bathroom without asking for assistance and that the resident was able to remove seatbelt alarm. The alarm remained on the care plan as an intervention. Its use was not re-evaluated for effectiveness. On 5/19/13 at 10 p.m., the nurse documented that the resident was constantly asking to go to the bathroom, sometimes 5 to 7 times within 30 minutes. On 6/7/13 the 11-7 nurse documented resident's behavior is the same; that is the resident is frequently out of bed to the BR with an unsteady gait. The resident's care plan was not updated to reflect the problem area of frequent requests to use the BR. There were no interventions concerning this behavior. On 6/9/13 at 5:30 a.m., the nurse documented that the Certified Nurse ' s Assistant (CNA) reported that the resident was on the floor. The resident was sitting on the floor next to the room door and stated that he/she was going to the BR. The action to be taken at this time was to continue to closely monitor and remind resident to use call bell for assistance and a physical therapy screen was initiated. On 6/11/13 the 11-7 nurse documented, "behavior the same gets out of bed to go to the BR and starts ambulating before someone reaches him/her, never use call light. Instructed how to use it." The resident's cognition level was not addressed as a problem area - the resident had Dementia and it was well documented that he/she does not use the call bell for assistance. On 6/12/13 at 6 p.m. the nurse wrote that the resident was asking to go to the bathroom constantly even when on the toilet, and at 2 to 5 minute intervals. On 6/15/13 the 11-7 nurse documented that the resident can turn the bed alarm off and walk to BR before someone can reach her. The bed alarm remained on the care plan. On 6/16/13 at 1 a.m., the nurse wrote that the resident got out of bed to go to the BR and fell down at right side of bed before the nurse could reach the resident. The bed alarm was sounding. The investigative report for this fall noted that the resident will never use the call light and has behaviors of frequently asking to go to the BR. The same interventions of " Frequently monitor resident for toileting and encourage her to use call bell for assistance" were again listed. On 6/19/13 at 5:20 a.m., the CNA reported that the resident was found sitting on the floor by the bed. The conclusion was that the resident tripped on garments worn at night and staff would request different garments from the family. In addition the staff would continue to remind the resident to use the call bell for assistance. Both of these actions had been shown to be ineffective. On 6/19/13 at 8 p.m., the nurse wrote that the resident was screaming at staff and constantly asking to go to the BR at 3 to 5 minute intervals. The MD was called and ordered a psychiatric evaluation and urinalysis. On 6/20/13 the urinalysis was obtained and revealed less than 10,000 colony count and negative bacteriuria. The MD ordered an antibiotic for 5 days. The care plan was not updated to include this as a causal factor or intervention. On 7/6/13 at 1 a.m., the nurse heard a noise and went to the resident's room. She found the resident lying on the right side on the bathroom floor with the alarm intact. The resident's right forehead was bleeding and there was a laceration to the lower arm. The resident complained of a head ache. The nurse stated that the resident again failed to use the call bell. The MD was called and the resident was sent to the emergency room (ER). On 7/7/13 at 5 a.m., the resident was still in the ER and the nurse wrote, "Please follow up when resident comes back from ER to give resident non-skid socks to prevent from falling. " At the time of this fall Resident #11 had on regular socks and had hidden the sensor alarm under an arm. The care plan intervention for non-skids socks was not followed. The resident continued to remove and/or silence the alarm while this intervention remained on the care plan without revision. On 7/7/13 at 1 p.m., the resident was admitted to the hospital with [REDACTED]. On 7/10/13 the resident was readmitted from the hospital. The care plan revealed that no new interventions were implemented to prevent further injuries. On 7/17/13 PT recommended to try a commode to be used at night only. This intervention was not reflected in the fall care plan. On 7/22/13 the physician ordered [MEDICATION NAME] for Overactive Bladder. There was no evidence or rationale provided in the IPN to explain why this was not trailed before the resident's injury. On 7/31/13 at 10:45 a.m., the resident was found on the floor in the bathroom. At this time Resident #11 had been in the activity room but left without being noticed by staff. The Activity Care Plan Intervention to supervise resident in all activity areas was not followed. On 10/19/13 at 8:20 p.m. the resident was found on the bathroom floor. The investigative report revealed that when the nurse walked into the room the alarm was not sounding. The Conclusion and Action Taken was that nursing staff would continue to monitor the resident closely to avoid injury and Physical Therapy would evaluate the resident for positioning and transfers. It was also documented that the resident " might have silent the alarm or the safety release seat belt." The action indicated that the alarm would be checked that it is on and operating. On 10/29/13 at 3:15 p.m., the resident was found on the floor in another resident's BR. The investigative report revealed the self-release seatbelt was working but not sounding. The resident may have silenced the alarm. The action to be taken was to remind resident "not to silent the seat belt alarm and a sensor pad alarm was recommended. The conclusions based on this assessment was again, "just monitor closely." There were no specifics as to how this close monitoring was to be accomplished. It has been documented that Resident #11 has the capability to remove and/or silence the alarm so the intervention of checking that it is working would be ineffective. On 11/8/13 at 9:45 a.m., the surveyor interviewed the resident's regularly assigned CNA. She stated that the resident uses the toilet multiple times during the day. She stated that even after she is toileted she still states that she wants to use the BR. Although the CNA described a problem area for the resident, this was not reflected in the care plan with individualized approaches. On 11/13/13 at 9:45 a.m., the surveyor reviewed the physician's progress notes dated 8/10/13 and 10/6/13 with the nurse. There was no documentation that addressed the possible etiology or medical rationale for the resident's frequent request to use the BR. The psychiatric follow up on 7/17/13 addressed the resident's lethargy but contained no documentation regarding if there was a behavioral component to the resident's constant request to use the BR. On 11/13/13 at 10 a.m., the surveyor discussed with the Director of Nursing (DON) and Administrator concerns for ineffective fall prevention interventions and how the staff was closely monitoring the resident. The stated that they implemented an intervention on 11/11/13 for a staff member to sit near her bedroom door when the resident is in bed. Refer to F 323 2. On 11/6/13 at 10:25 a.m. during the initial tour the Director of Nursing (DON) told the surveyor that Resident #4 had poor gait balance and a history of multiple falls. The resident's behavior was unpredictable, sleeping soundly one minute and then seconds later awake and attempting to climb out of the bed/chair. On 11/8/13 at 11 a.m. the surveyor reviewed Resident #4's medical record. The resident had a history of [REDACTED]. A fall prevention care plan was implemented, but not revised and updated to contain interventions as follows: On 2/17/13 at 4:30 a.m. the resident slid out of the wheelchair (WC) onto the floor in the hallway. The fall investigation did not reveal causal factors for the fall, but concluded that the resident should be kept near the nurse's station when out of bed. Upon transfer to the long term care (LTC) floor in March/2013, Resident #4's bed was moved against the wall and a floor mat was used daily when the resident was in bed. The care plan did not reflect these any of these interventions. On 9/5/13 at 6:45 a.m. the bed alarm sounded and Resident #4 was found on the floor next to the bed. The resident had a [MEDICAL CONDITION] injury (1.5 X 1.5 X 0.2) to the left forehead which required stitches. No causal factor was determined for the fall. The fall investigation dated, 9/5 concluded that the resident needed "1:1 supervision of staff." The care plan did not reflect this intervention. Refer to F323 3. On 11/6/13 at 11:30 a.m. the Unit Manager told the surveyor that Resident #15 had a [DIAGNOSES REDACTED]. At the time of the fall the intervention of a chair alarm was in place, but the resident had removed the chair alarm and walked to the bathroom without pressing the call bell and fell . The resident was transferred to the hospital and following surgery was readmitted to the facility. On 11/8/13 the surveyor reviewed the medical record. The 5 day readmission MDS dated [DATE] indicated that the resident had a cognitive score of 9 reflecting moderate cognitive impairment and required extensive assist of 2 staff for transfers and ambulation. On 10/26/13 the IPN indicated that Resident #15 was found sitting on the floor at the bedside with his back against the wall. Action to be taken was that the resident was to be at the nurses station with close supervision and monitoring. The care plan did not reflect this new intervention. 4. On 11/8/13 at 7:45 a.m. the surveyor reviewed the medical records of Resident #12. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. On 11/8/13 at 2 p.m. the surveyor spoke the DON who said the resident's primary physician prefers to manage his resident's psychoactive medications. On 11/8/13 at 10 a.m. the surveyor interviewed the resident. The surveyor discussed the resident's activity interests. The resident said that he/she doesn't get involved with the activities, likes to stay in bed and prefers to be "alone now a days." A review of the resident's care plans revealed that there was no evidence that the interdisciplinary team developed a care plan to address the two antidepressants the resident was taking and the resident's preference to be "alone now a days." On 11/8/13 at 11:45 a.m. the surveyor overheard the resident tell the treatment nurse and unit manager (UM) that he/she did not want to get out of bed. On 11/8/13 at 2 p.m. the surveyor spoke to the DON concerning Resident #12. The DON agreed that a care plan should have been developed to address the resident's behavioral needs. On 11/8/13 at 10 a.m. the surveyor interviewed the resident. The surveyor discussed the resident's activity interests. The resident said that he/she doesn't get involved with the activities, likes to stay in bed and prefers to be "alone now a days." 5. On 11/07/13 at 8 a.m. the surveyor reviewed the medical record of Resident #8. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record revealed that the resident's care plan indicated the use of bed and chair alarms. On 11/07/13 at 11:30 a.m. the surveyor observed the resident in his motorized wheelchair sitting in the recreation room. The resident did not have an alarm in place. On 11/07/13 at 11:35 a.m. the surveyor spoke with the resident's CNA and at 11:40 a.m. with the assigned nurse. Both told the surveyor that Resident #8 did not use an alarm in the chair or in bed. At 12:45 p.m. the DON told the surveyor that the resident was alert and oriented and refused to use the bed or chair alarm. The DON agreed that the care plan had not been updated to indicate the resident's refusal to use the alarms. 6. On 11/6/13 at 12:45 p.m. and 11/7/13 at 11:30 a.m. the surveyor observed Resident #2 out of bed seated in a geri chair. At both observations the resident's arms were exposed and there were no geri sleeves observed. On 11/7/13 at 12 p.m. the surveyor reviewed the resident's medical record. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident has a history of sustaining skin tears. A review of the Treatment Administration Record (TAR) revealed that the nurse signed that the geri-sleeves were applied. A review of the resident's care plans revealed that there was a care plan indicated for "Potential for skin breakdown" that did not include the physician's orders [REDACTED]. On 11/7/13 at 2:15 p.m. the surveyor spoke to the nurse in charge of the resident. The nurse said it was the CNA's responsibility to put the geri-sleeves on the resident and that she was unsure the resident was wearing the geri-sleeves. At 2:15 p.m. the surveyor spoke to the CNA in charge of the resident who said that she does not apply the geri-sleeves to the resident's arms because the family doesn't want the sleeves on. The CNA told the surveyor that she receives report about the resident from the nurse. On 11/8/13 at 2 p.m. the surveyor spoke to the Director of Nursing. There was no additional information provided. 7. On 11/6/13 at 12:30 p.m. the surveyor observed Resident #3 in the dining room for the noon meal. The surveyor did not observe geri sleeves on the resident's arms. On 11/6/13 at 1:40 p.m. the surveyor reviewed the resident's medical record. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]." A review of the Treatment Administration Record (TAR) revealed that the nurse signed that the geri-sleeves were applied. A review of the resident's care plans revealed that there was a care plan indicated "Potential for skin breakdown" that did not include the physician's orders [REDACTED]. On 11/7/13 at 12:15 p.m. the surveyor observed the resident in the dining room with the noon meal. The resident was not wearing geri sleeves. At 2 p.m. the surveyor spoke with the Home Health Aide (HHA) who was with the resident in the afternoons. The HHA said that she had not seen the resident wearing geri-sleeves. At 2:15 p.m. the surveyor spoke to the nurse in charge of the resident. The nurse said it was the CNA's responsibility to put the geri-sleeves on the resident and that she was unsure the resident was wearing the geri-sleeves. The surveyor then spoke to the CNA who was in charge of the resident. The CNA said that she does not put the geri-sleeves on the resident. The CNA said she receives report about the resident from the nurse. On 11/8/13 at 2:20 p.m. the surveyor spoke to the Director of Nursing. There was no additional information provided. 8. On 11/7/13 at 8:10 a.m. the surveyor observed Resident # 13 in bed awake. At 8:15 a.m. the surveyor reviewed the resident's medical record which revealed that the resident had been admitted to the facility on [DATE]. Review of the resident's weight revealed that the resident had a weight gain in April. The resident's weight had been 160.2 lbs in March but in April it went up to 166.5. There was a care plan dated 4/11/13 which listed the problem/need as significant weight gain. In June the resident's weight was 171.2 then began dropping: July 166.8, August 169.6, September 165.3, October 162.1, and November 162.4. The care plan for weight gain was still in effect despite the fact that the resident had been losing weight since July. 9. On 11/6/13 at 1:15 p.m., during the initial tour, the unit manager stated that Resident #14 had an unstageable pressure ulcer and had an indwelling catheter for wound healing. On 11/8/13 at 11 a.m., the surveyor reviewed the care plans for Resident #14. There were no care plans to address urinary catheter care and infection prevention. Refer to F315 NJAC 8:39-11.2(e)