Every finding on record at Bridgeway Care and Rehab Center at Bridgewater

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.This deficient practice was evidenced by the following:On 08/03/2026 at 10:27 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following:1. The FSD was not wearing facial hair restraints while walking through food preparation (prep) areas. 2. Dietary Aide #1 was not wearing facial hair restraints while drying dishes to serve food on.3. Food debris and a grease-like film covered approximately half of the primary stovetop backsplash.On 08/03/2026 at 10:00 AM, the FSD stated during an interview that all staff were expected to wear hair restraints to cover all exposed hair while in the kitchen. On 08/05/2026 at 11:15 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following:1. Upon entering the kitchen, the surveyor donned (put on) a facial hair restraint. An onlooking Dietary Aide #2 stated that the surveyor did not need to wear a facial hair restraint in the kitchen if the surveyor did not intend to directly handle food. 2. The FSD was not wearing a facial hair restraint while plating food in the food prep area. 3. Food debris and a grease-like film covered approximately half of the primary stovetop backsplash in the same position as what had been observed two (2) days prior. On 08/06/2026 at 12:00 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that anyone who entered the kitchen should have worn hair restraints as a measure of infection control. The LNHA further stated that it was the responsibility of kitchen staff to maintain a food prep area that was free of grime and debris as a measure of infection control. A review of the facility's Cook's Daily & Weekly Cleaning Record, dated from 08/02/2026 through 08/08/2026, indicated that stoves and stove ovens are only cleaned once weekly. A review of the facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, last revised October 2017, included that all employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. The policy also included that hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. A review of the facility's Sanitization policy, last revised November 2022, included that all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris. A review of the facility's Dress Code policy, last revised September 2025, included that for dietary staff, head coverings must be worn during food preparation and serving. NJAC 8:39-17.2(g)

C#: 2679544Based on interviews, medical record review, and review of other pertinent facility documentation on 04/08/2026 and 04/09/2026, it was determined that the facility failed to provide a resident's (Resident #2) responsible party (RP) a written summary and resolution of the investigation regarding a grievance filed by the RP on 08/29/2025; failed to follow its policy titled Grievance/Complaints, Filing. The deficient practice was identified for 1 of 4 residents reviewed for grievance.This is evidenced by the following:According to the admission Record, Resident #2 had diagnoses which included but were not limited to: unspecified dementia (a decline in mental ability), heart failure (a chronic progressive condition where the heart cannot pump enough blood to meet the body's needs) and major depression (a serious mood disorder causing persistent sadness).According to the resident's Minimum Data Set (MDS), an assessment tool dated 02/09/2026, Resident #2 had a Brief Interview Mental Status (BIMs) score of 9/15, which indicated that Resident #2's cognition was moderately impaired. The MDS also indicated that the Resident required assistance with activities of daily living (ADLs).A review of a facility document titled Grievance/Complaint Form dated 08/29/2025, with date of occurrence on 08/25/2025, revealed that Resident #2's RP informed the facility about a grievance she filed regarding Resident #2's pain medication administration.A review of the Summary of Pertinent Findings/Conclusion section of the grievance form revealed the form to be as left blank on the question of Corrective Action taken/To be Taken by the facility. There was no information regarding Resident/Family Response to Outcome, and no Grievance official's Signature and Date. There was also no Administrator's or Director of Nursing's Signature and date on the grievance form.During interview on 04/09/2026 at 12:07 PM with the Social Worker (SW), she acknowledged the grievance form was not complete. She further stated, a complete grievance form report should have a summary of findings/conclusion and should be signed by the grievance official, administrator and director of nursing with a date of review. She stated the family should be notified through written communication of the outcome of the grievance. The SW acknowledged the facility grievance policy was not followed for the grievance filed by Resident #2's RP on 08/29/2025.An interview was conducted on 04/09/2026 at 2:30 PM with the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing. The LNHA stated that the family member or resident who filed the grievance should be informed of the resolution, and that it should be documented on the grievance form. She further stated for the grievance filed by the resident's RP on 08/29/2025, it was not addressed properly and that the facility policy on grievances and complaints was not followed.Review of facility's policy titled, Grievances/Complaints, Filing with a Date Reviewed of 11/15/2025, under Policy Interpretation and Implementation, 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues or resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 8. Upon receipt of a grievance and/or complaint the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and /or complaint. 11. The administrator will review the findings with the grievance officer to determine what corrective actions, if any, need to be taken. NJAC 8:39-13.2(c)

C#: 2679544Based on interviews, medical record review, and review of other pertinent facility documentation on 04/08/2026 and 04/09/2026, it was determined that the facility failed to a) honor Resident #2's family representative's (Responsible Party (RP) decision to request and/or refuse laboratory test on the resident and b) failed to follow the facility's policy titled Requesting, Refusing and/or Discontinuing care or Treatment. This deficient practice was identified for 1 of 4 residents reviewed for resident right.The evidence was as follows:This deficient practice was evidenced by the following:According to the admission Record Resident #2 had diagnoses which included but were not limited to: unspecified dementia (a decline in mental ability), heart failure (a chronic progressive condition where the heart cannot pump enough blood to meet the body's needs) and major depression (a serious mood disorder causing persistent sadness).According to the resident's Minimum Data Set (MDS), an assessment tool dated 02/09/2026, Resident #2 had a Brief Interview Mental Status (BIMs) score of 9/15, which indicated that Resident #2's cognition was moderately impaired. The MDS also indicated that the Resident required assistance with activities of daily living (ADLs).A review of a document titled Care Profile Report under Special Instructions revealed the following: Call the RP before any blood work.A review of Resident #2's progress notes (PN) dated 08/28/2025, and timed at 4:49 PM, indicated that the Registered Nurse (RN#1) spoke to Resident #2's RP regarding blood test for the resident and that the RP refused for the blood test to be done on the resident.A review of the medical record revealed that the facility completed a laboratory test on Resident #2 on 08/29/2025 at 8:31AM.During an interview on 04/08/2026 at 2:26PM, RN #2 stated that since the RP declined laboratory blood tests, the test should not have been carried out. RN#2 stated the facility policy was not followed on 08/29/2025 when Resident #2 had blood drawn without their RP consent.During interview on 04/09/2026 with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator, the DON stated that if the RP declined blood test, the test should have been cancelled.A review of the facility policy titled requesting, Refusing and/or Discontinuing care or Treatment with a revised date of February 2021 revealed under: Policy Statement residents and resident representatives have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms. N.J.A.C. 8:39-13.1(a)(d)

Complaint #: 2648621 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/23/2025, it was determined that the facility failed to implement their abuse policy to ensure all residents were protected from abuse, when Resident #2 alleged the Certified Nursing Assistant (CNA #1) physically abused them, and CNA #1 was taken off the resident's assignment, but remained on that nursing unit assisting other residents as well as having access to Resident #2. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #2) and had the potential to affect all residents. On 10/19/2025 at approximately 6:00 PM, Resident #2 reported to the facility's Nursing Supervisor (NS#1) that CNA #1 pulled their arms and punched them. NS #1 removed CNA #1 from Resident #2's care and reassigned another CNA. CNA #1 remained on that nursing unit providing care to other residents as well as having access to Resident #2 until the end of the shift at 11:00 PM that same evening. On 10/23/2025 at 9:51 AM, an interview was conducted with Resident #2, who stated an aide was rough with them, so the resident told the people in charge. An interview with NS #1, on 10/23/2025 at 1:00 PM, revealed that Resident #2 did approach her about the alleged abuse by CNA #1 and she did re-assign another CNA to provide care to the resident. CNA #1 was not sent home after the allegation of abuse and continued to care for other residents for the remainder of that shift. An interview with the Director of Nursing (DON) on 10/23/2025 at 1:37 PM, revealed that she became aware of the abuse allegation on 10/20/2025 and according to the facility policy, CNA #1 should have been sent home, pending the completion of the investigation. The facility's failure to implement their abuse policy and to protect residents from potential abuse, by not immediately removing CNA#1, who continued to work having access to Resident #2 and other residents until an investigation was completed, placed Resident #2 and all residents at risk for abuse. This posed the likelihood of serious physical and psychosocial harm, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/19/2025 at approximately 6:00 PM, after Resident #2 informed NS #1 that they were punched and had their arms pulled by CNA#1. The facility Administration was notified of the IJ on 10/23/2025 at 4:02 PM. The facility submitted a Removal Plan (RP) on 10/30/2025 at 2:00 PM. The Surveyor verified the implementation of the RP on-site during a continuation survey on 10/30/2025. The evidence was as follows: The facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with a revised date of April 2021, was reviewed. Under, Policy Interpretation and Implementation, the policy revealed, The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; This section of the facility policy further revealed 2. Develop and implement policies and protocols to prevent and identify a. abuse or mistreatment of residents; [.] 10. Protect residents from further harm during investigations. A review of the Facility Reportable Event (FRE) dated 10/20/2025, revealed the following:On 10/19/2025 at approximately 6:00 PM, Resident #2 made an accusation to facility staff that CNA #1 hurt them and does not help them. The FRE included that the accused CNA was removed from the assignment pending investigation.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: heart failure (condition where the heart muscle does not pump blood as well as it should); bipolar disorder (mental health condition that causes extreme mood swings); low back pain; depression (mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety disorder (intense, excessive and persistent worry and fear about everyday situations); and fracture of superior rim of the left pubis (broken bone in the pelvis).According to the Minimum Data Set (MDS), an assessment tool dated 09/03/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. The MDS further revealed that Resident #2's speech was clear, and the resident had the ability to make their ideas and wants understood. A Progress Note (PN) written by Registered Nurse #1 (RN #1), dated 10/19/2025 at 11:44 PM, was reviewed. The PN revealed that Resident #2 complained to the Supervisor on duty (NS #1) that CNA #1, hurt and doesn't help them. The PN revealed that CNA #1 was removed from Resident #2's care and replaced with a different CNA (CNA #2). The PN further revealed that a skin assessment was performed on Resident #2 which revealed no visible injuries but showed the presence of old bruising to the resident's upper extremities.An undated facility Investigation Summary and Conclusion: document was reviewed. Under Investigation Summary, the document revealed that on 10/19/2025, Resident #2 reported that during care, CNA #1 pulled their wrist and caused them pain. The resident also reported that they yelled out in response and CNA #1 immediately stopped providing care. The investigation summary revealed that Resident #2 later reported the incident to NS #1, who promptly removed [CNA #1] from his assignment pending further review. The investigation summary further revealed that the Director of Nursing (DON) was notified on 10/20/2025 and she initiated a full investigation according to facility policy. The summary revealed that CNA #1 was removed from direct care duties of Resident #2 pending outcome of the investigation.A facility document, Investigation Report (IR) dated 10/19/2025, which was completed by CNA #1 was reviewed. CNA #1's written statement revealed that at approximately 6:00 PM, he assisted Resident #2 to sit up in bed. CNA #1's statement revealed that suddenly the nurse on duty informed him of Resident #2's accusation that he (CNA #1) was trying to hurt them. CNA #1's statement revealed that Resident #2 did not complain of discomfort at the time he assisted them.A facility IR document completed by the Registered Nurse (RN #1), dated 10/19/2025 was reviewed. RN #1's written statement revealed that Resident #2 went to RN #1 and requested to see the Supervisor because their CNA hurt them and does not help them. RN #1's statement indicated that the Supervisor changed the assignment.A facility document titled: Individual Statement Form which was completed by NS #1 and dated 10/23/2025, was reviewed. The statement revealed that Resident #2 reported that CNA #1 pulled the resident's arms and punched them. The statement further revealed that NS #1 immediately removed CNA #1 from caring for Resident #2.The Pay-Period Summary, for CNA #1 for the pay period 10/09/2025 to 10/22/2025 was reviewed. The timecard revealed that on 10/19/2025, CNA #1 punched in at 2:38 PM, and punched out at 11:00 PM.The surveyor conducted an interview with Resident #2 on 10/23/2025 at 9:51 AM. Resident #2 stated that an Aide was rough with them, so they told the people in charge, and the Aide had not been back since then. Resident #2 stated that a different CNA provided their care after the alleged incident. Resident #2 stated that during the previous week, .an Aide pulled my arm, he yanked me when he was getting me ready for bed. Resident #2 stated that the CNA hurt their arm and back while he assisted them to sit up in bed. An interview was conducted with NS #1 on 10/23/2025 at 1:00 PM. NS #1 confirmed that Resident #2 approached her and told her that CNA #1 was pulling their arms and punching them. NS #1 stated that she obtained statements from RN #1 and CNA #1. NS #1 stated that she assigned a different CNA (CNA #2) to care for Resident #2. NS #1 stated that CNA #1 was not sent home after the abuse allegation was made against him and continued to care for other residents for the remainder of that shift. NS #1 stated I guess not, when asked if her actions followed the facility policy. NS #1 further stated, I should have called the DON, I should have sent the CNA home.An interview on 10/23/2025 at 1:20 PM with CNA #1 confirmed that he was assigned to care for Resident #2 during the 3:00 PM to 11:00 PM shift on 10/19/2025. CNA #1 stated at approximately 5:30 PM or 6:00 PM, Resident #2 called him to assist them to the chair. CNA #1 stated that he assisted the resident to the edge of the bed, and then to the wheelchair and the resident did not complain of pain at that time. CNA #1 stated that later in the shift he was informed that Resident #2 stated he (CNA #1) hurt them. CNA #1 stated that after he learned of the resident's accusation, he provided a written statement to RN #1. CNA #1 further stated that NS #1 switched his assignment, and he cared for other residents until he finished his shift at approximately 11:00 PM on the night of the alleged incident.An interview was conducted with the DON on 10/23/2025 at 1:37 PM. The DON stated that the expectation when a staff member was accused of abuse was that statements were obtained immediately, and the accused staff member should be sent home pending investigation. The DON further stated that sending the accused staff home after an allegation of abuse was to keep residents safe. The DON stated that re-assigning CNA #1 to care for other residents following an allegation of resident abuse, was not in keeping with the facility's abuse policy. The DON confirmed that CNA #1 continued caring for residents on 10/19/2025 after the abuse allegation was made against him. An acceptable Removal Plan (RP) was submitted on 10/30/2025 at 2:00 PM, indicating the actions the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: assessment of Resident #2; completion of the investigation; Resident #2's care plan (CP) was updated for two-person care; re-education provided to CNA #1 prior to his return to work; re-education provided to NS #1; education was provided to all staff on the facility abuse policy and procedures for resident protection; alert and oriented residents on CNA #1's assignment were interviewed to rule out unreported allegations; all residents with a Brief Interview for Mental Status (BIMS) score of 9 or above were interviewed; non-alert and oriented residents on CNA #1's assignment and throughout the facility had skin assessments completed.The surveyor verified the implementation of the RP on-site during the continuation of the survey on 10/30/2025 and determined that the immediacy for F 600 was removed on 10/26/2025.NJAC 8:39-4.1(a)5

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food to prevent food-borne illness. This deficient practice was evidenced by the following: On 3/25/25 from 9:58 AM until 10:51 AM, the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD): 1. In the bay [NAME] refrigerator, on a shelf, there was a chicken salad sandwich labeled with a use-by date of 3/21/25. The FSD stated that the sandwich can be stored for three (3) days after it was prepared and should be discarded by the Use by date. The FSD stated that she would discard the chicken salad sandwich. 2. In the same refrigerator, there was an unlabeled large block of a white, round, solid food item wrapped in white paper on the shelf. The FSD was unable to identify the food item. At that time, the Chef Manager approached the surveyor and FSD and stated that it was a block of cheese that belonged to the kitchen staff. The FSD stated that staff were not supposed to store their personal food in the bay [NAME] refrigerator. The FSD removed the cheese. 3. In the dry food storage area, there was a bag of tricolor pasta that did not have an opened date. At that time, the FSD stated that the tricolor pasta was no longer on the menu because they were now using a different menu for the summer. She further stated that the pasta should have been dated when it was opened and that she would discard the pasta. On 3/31/25 at 11:41 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that staff members' personal food items should not be stored in the kitchen refrigerator designated for resident food. He also stated that prepared foods should not be kept for longer than 3 days and should be discarded if not consumed by the use-by date. A review of the facility's Food Receiving and Storage policy, revised November 2022, revealed, Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date), and, Refrigerated/Frozen Storage 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. NJAC 8:39-17.2(g)

Complaint #: NJ177346 Based on interview, record review, and review of facility documents, it was determined that the facility failed to report the results of an allegation of resident-to-resident abuse to the New Jersey Department of Health (NJDOH) within five working days for 2 of 2 residents (Resident #74 and Resident #195) reviewed for abuse. This deficient practice was evidenced by the following: On 3/25/25 at 10:42 AM, the surveyor observed Resident #74 who was seated in a wheelchair with a transfer pad beneath of him/her and the resident was engaged in a group activity. When interviewed at that time, the Activity Aide stated that the resident frequently called out for the nurse. On 3/25/25 at 1:09 PM, the surveyor reviewed the medical record of Resident #74. A review of the Admission Record, and admission summary, revealed that the resident had diagnoses which included, but were not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side and anxiety disorder, unspecified. A review of the the resident's quarterly Minimum Data Set (MDS) , an assessment tool used to facilitate the management of care, dated 12/26/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/19/23, which indicated that the resident had a behavior problem of calling out for the nurse without knowing what he/she wanted. Interventions included: providing a program of activities that was of interest and accommodated the resident's status. A review of the resident's Progress Notes (PN) included an entry dated 8/2/24 at 11:27 PM, which revealed that while the Certified Nursing Assistant (CNA) propelled the resident back to his/her room, they passed by Resident #195. Resident #195 slapped the notebook that he/she was holding on Resident #74's left arm. The supervisor was made aware of the incident and a body check was done with no visible injury noted. Resident #74 was wearing a long sweat shirt at the time of the incident and denied pain. On 3/26/25 at 10:18 AM, the surveyor requested and reviewed a copy of the abuse investigation which included a Reportable Event Record (RER). The RER indicated that on 8/3/24, the facility notified the NJDOH of a Resident-to-Resident Abuse event that occurred on 8/2/24 at 7:00 PM, which involved both Resident #74 and Resident #195. Further review of the RER revealed that as Resident #74 was being brought back to their room, Resident #195 reached out and softly hit Resident #74 on the left forearm with a notebook he/she was holding. Interventions included that the residents were separated with supervision, a skin assessment was conducted and the Medical Doctor and Family were notified. At that time, the surveyor noted that there were no employee statements included in the investigation and notified the Licensed Nursing Home Administrator (LNHA). The LNHA stated that he had the employee statements in his email account and he agreed to provide them. On 3/26/25 at 11:57 AM, the LNHA provided the surveyor with two employee statements that were written by both Registered Nurse (RN) #1 and RN #2 that were sent to the LNHA via email on 8/2/24. A review of the email that was written by RN #1, dated 8/2/25 at 11:58 PM, indicated that Resident #195 hit Resident #74 in the arm with a notebook when Resident #74 was shouting for a nurse as Resident #195 was passing by in his/her wheelchair. Resident #195 told Resident #74 to shut up as Resident #195 hit Resident #74 lightly on the arm. Further review of the investigation revealed an undated Summary of Resident-to-Resident Abuse Investigation related to Resident #74 and Resident #195. A review of the undated Summary included the conclusion: After investigation it was concluded that the allegation of abuse was substantiated. On 3/31/25 at 9:38 AM, the surveyor interviewed the LNHA and asked him if he sent a copy of the summary and conclusion of the allegation of Resident-to-Resident abuse that occurred on 8/2/24 between Resident #74 and Resident #195 to the Department of Health, and the LNHA stated that he waited until he had all of the information that was requested and sent it to the DOH on 10/4/24, 64 days later. When the surveyor asked the LNHA what the required time frame was to submit a summary and conclusion was, he stated that he was required to submit the summary and conclusion within five days of the reportable event submission. A review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, included: Investigate and report any allegations within timeframes required by federal requirements. NJAC 8:39-9.4(e)(2)

Complaint #: NJ00153370 Based on interview, medical record review, and review of other pertinent facility documentation on 09/19/23 and 09/20/23, it was determined that the facility failed to: a.) complete daily weights in accordance with a physician's order and b.) follow care plan (CP) interventions for a resident with congestive heart failure (CHF). The resident gained 31 pounds (Lbs.) of fluid in 10 days and was transferred to the hospital in respiratory distress where they were admitted to the intermediate care unit. The deficient practice was identifed for Resident #1, 1 of 5 residents reviewed for quality of care and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #1: According to the Admission Record, Resident #1 was admitted on [DATE] with diagnoses which included but were not limited to Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (a condition where the heart can't pump well enough to give the body a normal blood supply), Unspecified Atrial Fibrillation (irregular heart rhythm), and Type 2 Diabetes Mellitus (inadequate blood sugar control). The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/21, indicated that Resident #1 had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident weighed 178 lbs. Review of Resident #1's CP revealed a Focus, initiated on 05/18/21, that Resident #1 was at risk for acute exacerbation of CHF. Under the Interventions/Tasks section, included the following interventions, initiated on 05/18/21: Assess for shortness of breath and notify physician of new or worsening shortness of breath, aucultate (listen to) lung sounds daily and notify physician if adventitious breath sounds observed and daily assessment of peripheral edema. Review of Resident #1's Order Recap Report (ORR) did not include physician's orders (PO) to assess for shortness of breath and to notify the physician of new or worsening shortness of breath, auscultate lung sounds daily and notify physician if adventitious breath sounds observed, or to complete daily assessment of peripheral edema. Review of the May and June 2021 Treatment Administration Records failed to include documentation of assessment for shortness of breath, daily lung sound auscultation, or daily assessment of peripheral edema. Review of Resident #1's Progress Notes (PN) revealed a 06/14/21 Q8hr [Every 8 hour] Respiratory Surveillance note that indicated the resident was noted as having shortness of breath. The PN revealed that the resident had Shortness of breath or trouble breathing is present with exertion (e.g. walking bathing, transferring) Shortness of breath or trouble breathing is present when lying flat (reported by the resident/resident representative and/or observed by staff) Shortness of breath is a new symptom. [ .] The PN failed did not include documentation that the nurse auscultated the resident's lung sounds or notified the physician of the new onset shortness of breath. Review of Resident #1's medical record failed to reveal that Resident #1's breath sounds were auscultated on 05/18/21, 05/19/21, 05/28/21, 05/29/21, 05/30/21, 06/01/21, 06/02/21, 06/05/21, 06/09/21, 06/11/21, 06/12/21, 06/12/21, 06/13/21, 06/14/21, 06/16/21, 06/17/21, 06/18/21, 06/19/21, 06/20/21, 06/21/21, or 06/25/21. Review of Resident #1's medical record failed to reveal that Resident #1's peripheral edema was assessed on 05/18/21, 05/19/21, 05/28/21, 05/29/21, 05/30/21, 06/02/21, 06/05/21, 06/09/21, 06/11/21, 06/12/21, 06/13/21, 06/14/21, 06/17/21, 06/19/21, 06/20/21, or 06/26/21. The CP revealed an intervention, initiated on 05/18/21, for daily weights and to notify the physician if weight gain of 2 Lbs in one day or 5 Lbs. in one week is noted. The ORR revealed that physician's orders for CHF Protocol: Daily Weights. were active from 05/19/21 to 5/26/21 and from 06/10/21 to 06/27/2. Review of the May 2021 Medication Administration Record (MAR) revealed the following weights: 05/19: 178.2 Lbs. 05/20: 178.2 Lbs. 05/21: hospitalized Review of the Patient Care Summary from the resident's 05/21/21 hospitalization indicated that Resident #1 weighed 87.2 KG (192.2 Lbs.) 05/22: hospitalized 05/23: hospitalized 05/24: hospitalized The Patient Care Summary from 05/24/21 indicated that Resident #1 weighed 84.4 KG (186.0 Lbs.) 05/25: hospitalized 05/26: hospitalized Review of the 05/26/21 Clinical Admission Evaluation did not include documentation of Resident #1's readmission weight. Review of the ORR did not include a PO for daily weights from 05/26/21-06/09/21 Further review of the May and June 2021 MARs did not include daily weights documented from 05/27/21-06/09/21. The June 2021 MAR recorded the following weight: 06/10: 178.2 Lbs. 06/11: 178.2 Lbs. 06/12: 178.2 Lbs. 06/13: 178.2 Lbs. 06/14: 178.0 Lbs. 06/15: 178.0 Lbs. 06/16: No weight recorded. 06/17: 178.0 Lbs. 06/18: 178.0 Lbs. 06/19: 178.0 Lbs. 06/20: Refused 06/21: No weight recorded. 06/22: No weight recorded. 06/23: 209.6 Lbs. 06/24: 205 Lbs. 06/25: 209.4 Lbs. Review of the 06/22/21 Emergency Department Triage Hospital paperwork indicated that Resident #1 weighed 221.78 Lbs. The 06/16/21 Q8hr Respiratory Surveillance note indicated, [ .] Yes, shortness of breath is noted. Shortness of breath or trouble breathing is present with exertion (e.g. walking, bathing, transferring) Shortness of breath or trouble breathing is present when lying flat (reported by the resident/resident representative and/or observed by staff). Shortness of breath is not a new symptom. [ .]. Further review of the PN failed to indicate that the nurse auscultated the resident's lung sounds. The 06/20/21 Q12hr [Every 12 hour] Respiratory Surveillance Progress Note indicated, [ .] Yes, shortness of breath noted. Shortness of breath or trouble breathing is present with exertion (e.g. walking, bathing, transferring) Shortness of breath is not a new symptom [ .]. Further review of the PN failed to indicate that the nurse auscultated the resident's lung sounds. Review of the PNs revealed a 06/23/21 Physician Note-Narrative that the resident had a questionable weight gain of 31 pounds over 10 days and lower extremity edema in both legs. Review of the PNs revealed a 06/25/21 Physician Note-Narrative that the resident had a weight gain of 31 pounds over 10 days, wheezing in their lungs, and lower extremity edema in both legs. Review of the PNs revealed a 06/26/21 Nursing Note-Narrative (NN) that at 12:30 PM, Resident #2's oxygen saturation dropped to 70% (normal oxygen saturation is 90-100%), that the doctor was called, and that the resident was ordered to be sent to the hospital. Further review of the the PNs revealed a 06/27/21 NN that Resident #2 was admitted to the intermediate care unit with a diagnosis of CHF. During an interview with the surveyor on 09/19/23 at 12:25 PM, the Certified Nursing Assistant/Unit Secretary (CNA/US) stated that they do daily weights on residents with CHF. The CNAs weighed the residents and would write it in a weight binder or give the weight verbally to the nurse. The CNA/US added that the nurse documented the weights in the electronic medical record. The CNA/US continued that CHF could cause retention of fluids and that the daily weights are completed to make sure that the residents were not retaining any fluids. During an interview with the surveyor on 09/19/23 at 1:42 PM, the Licensed Practical Nurse (LPN) #1 stated that care for a resident diagnosed with CHF was driven by whatever was specified by the CP. LPN #1 added that CHF residents were weighed more frequently and, in the morning, when the resident woke up. LPN #1 stated CNAs tell the nurses the weight and that the nurses put the weights onto the MAR. LPN #1 stated that there could be little fluctuations with a resident's weights day to day. LPN #1 stated that drastic changed in the resident's weight would be a problem. LPN #1 further stated that if a resident had new onset shortness of breath, the nurse would notify the Unit Manager and notify the physician to get an order for oxygen. LPN #1 added that the resident could be sent to the emergency room because shortness of breath could be an emergency. During an interview with the surveyor on 09/19/23 at 2:02 PM, the Registered Nurse (RN) #1 stated that the physician would usually with order daily weights for residents with a CHF diagnosis. RN #1 stated the resident would be weighed in the morning before breakfast and that if there was a weight gain or loss, the nurse would communicate with the physician for interventions. The surveyor asked if RN #1 would expect for several weights to be exactly the same day after day. RN #1 stated that the weight usually fluctuates and that, today is different from tomorrow. RN #1 stated that it was important to monitor residents with CHF to prevent an exacerbation of CHF. RN #1 stated that if a resident is ordered daily weights that they should be done and documented. RN #1 continued that if there was a new onset of shortness of breath in a CHF resident, the nurse would check their oxygen saturation, communicate with the doctor, and document the communication in the resident's PN. During an interview with the surveyor on 09/19/23 at 2:33 PM, the Licensed Practical Nurse/UM (LPN/UM) stated that staff needed to be monitoring residents with CHF by following the CHF protocol to determine if the resident experienced any changes. The LPN/UM stated that residents with CHF could be ordered daily weights and that they would have to be completed the same time and would have to be documented. The LPN/UM stated that the nurse would also monitor the resident for breathing or edema and would tell the doctor. The LPN/UM stated that there should not be instances on Resident #1's MAR where no weight was recorded. During an interview with the surveyor on 09/20/23 at 12:55 PM, the Licensed Practical Nurse (LPN) #2 stated that a care plan reflected cooperation between all the different disciplines on how to fully care for a resident. During an interview with the surveyor on 09/20/23 at 2:58 PM, the Director of Nursing (DON) stated residents admitted with CHF would have a CP developed to manage their CHF. The DON stated that the purpose of monitoring residents with CHF was to check for fluid overload. The DON added that ultimately death could be caused if a resident had too much fluid backed up. The DON stated that she expected weights to be recorded daily for a resident who was ordered daily weights. The DON continued that if a resident had a new onset of shortness of breath that she would expect to see at least a phone call to the resident's care provider. The DON stated that the purpose of a CP was to provide communication between the nursing team regarding the customized needs of a resident. The facility policy, Congestive Heart Failure Protocol dated 11/01/2012 indicated under the Procedure section, The nurse, in consult with the attending physician shall initiate measures to assess and manage residents who are admitted with a primary diagnosis of CHF, or develop new onset CHF. These may include: Daily Weights, Daily assessment of peripheral edema [ .], Daily auscultation of lungs [ .]. The policy continued, The nurse will notify the physician at early onset if the following are present: [ .] New or worsening shortness of breath [ .]. The 11/28/17 facility policy, Baseline and Comprehensive Care Plans indicated under the Procedure section, The comprehensive care plan must describe the following: A. The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being [ .] All care plans will be reviewed quarterly by each discipline and interdisciplinary team members, unless needed sooner due to a significant change in condition. The 04/20/12 facility policy, Weight and Height inidcated under the Procedure section, A resident's height and weight will be taken and recorded upon admission/readmission on the nursing admission assessment. NJAC 8:39-27.1(a) NJAC 8:39-11.1.

Complaint #: NJ00151859 Based on interview, medical records review, and review of other pertinent facility documentation on 09/19/23 and 09/20/23, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) for a resident with recurrent urinary tract infections (UTI). The deficient practice was identified for Resident #2, 1 of 3 residents reviewed for CP and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the Admission Record, Resident #2 was admitted on [DATE] with medical diagnoses which included but were not limited to Metabolic Encephalopathy (a problem in the brain caused by an imbalance in the blood), Chronic Kidney Disease, and UTI. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/06/21, revealed that Resident #2 had a Brief Interview for Mental Status Score of 13, which indicated the resident was cognitively intact. The MDS further revealed that the resident was incontinent of bowel and bladder and required extensive assistiance of two staff persons for toileting. The MDS also indicated that the resident had a UTI in the last 30 days. 1. Review of Resident #2's Progress Notes (PN) revealed a 10/30/21 Nursing Note-Narrative (NN) that the resident's family member stated that the resident was hallucinating. The NN also indicated that the doctor was made aware and that the resident was sent to the hospital for altered mental status. Review of Resident #2's PN revealed a 10/30/21 NN that a call was placed to the Emergency Department and that the resident was being admitted for a UTI. Review of Resident #2's 11/2/21 Discharge Summary from the hospital revealed that the resident's urine cultures came back positive for Salmonella (type of bacterial infection) and that antibiotics were initiated. Review of Resident #2's PN revealed a 11/2/21 NN that Resident #2 had returned with a physician order (PO) for Keflex (antibiotic) 500 milligrams (MG) and that the Advance Practice Nurse (APN) was informed. Review of the Order Recap Report (ORR) for November 2021 revealed a 11/03/21 PO for Cephalexin Tablet 500 MG Give 1 tablet by mouth every 12 hours for salmonella UTI for 4 Days. Review of the November 2021 Medication Administration Record (MAR) revealed that Resident #2 was administered Cephalexin (Keflex) Tablet 500 MG Give 1 tablet by mouth every 12 hours for salmonella UTI for 4 Days from 11/03/21-11/06/21. 2. Review of Resident #2's PN revealed a 11/19/21 NN that the resident was noted to be more confused than at baseline. The physician was made aware and gave an order to send the resident to the hospital. Review of Resident #2's PN revealed a 11/20/21 NN revealed that the resident was admitted to the hospital for altered mental status. Review of Resident #2's PN revealed a 11/26/21 NN indicated that Resident #2 was readmitted to the facility from the hospital on 11/25/21 and that they were receiving Keflex 500 MG for 4 days for a UTI. Review of the ORR for November 2021 revealed a 11/25/21 PO for Cephalexin Tablet 500 MG Give 1 tablet by mouth every 12 hours for infection for 4 Days. Review of the November 2021 MAR revealed that Resident #2 was administered Cephalexin Tablet 500 MG every 12 hours for four days, from 11/25/21-11/29/21. 3. Review of Resident #2's PN revealed a 01/11/22 NN which indicated that the resident's temperature was 100.8 (normal temperature is 97.6-99.6 F) and that the resident did not feel well. The note also indicated that the APN was made aware. Review of the 01/11/22 Physician Note Narrative indicated that the APN discussed with the MD and the nurse arranged for transport to the hospital. Review of the 1/14/22 Discharge Summary from the hospital Medical Doctor (MD) indicated that Resident #2 presented to the hospital on 01/11/22 with reports of lethargy. The resident was also found to have evidence of a urinary tract infection. The urine sample grew Proteus (bacteria) and Resident #2 was started on antibiotics for the UTI. The resident would be transitioned to oral antibiotics on discharge. Review of the Clinical Physician Orders revealed a 01/14/22 PO for Cefuroxime Axetil (antibiotic) 500 MG Give 1 tablet by mouth two times a day for UTI for 7 Days. Review of the January 2022 MAR revealed that Resident #2 received Cefuroxime Axetil 500 MG two times a day or 7 days, from 01/14/23-01/18/22. 4. Review of Resident #2's PN revealed a 1/19/22 NN that the resident had a temperature of 99.9 F and the resident had a new onset of altered mental status and mumbling. The physician and APN were notified and a new order was given to send the resident to the hospital. Review of Resident #2's PN revealed a 1/19/22 NN that the emergency department Registered Nurse called and stated that Resident #2 was admitted to the hospital with diagnoses which included acute encephalopathy and cystitis (inflammation of the bladder usually caused by an infection). Review of the Resident #2's CP failed to address the resident's recurrent UTIs or include interventions to treat or prevent it's recurrence. During an interview with the surveyor on 09/20/23 at 12:55 PM, the Licensed Practical Nurse (LPN) #1 stated that a CP reflected cooperation between all the different disciplines on how to fully care for a resident. LPN #1 added that actual problems would be included on the CP. LPN #1 continued that a UTI could be added to a care plan and that it would the Unit Manager's responsibility to add it to the care plan. During an interview with the surveyor on 09/20/23 at 1:53 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that new orders, new procedures, or new resident behaviors would be added to a resident's CP. The LPN/UM stated that a UTI would go on the CP. The LPN/UM continued that the purpose of putting this on the CP was so that everyone could be aware of the issue and put interventions in place to resolve it. During an interview with the surveyor on 09/20/23 at 2:58 PM, the Director of Nursing (DON) stated that the purpose of a care plan was to provide communication between the nursing team regarding the customized needs of a resident. The DON stated that a resident's UTI would be placed on the CP. The 11/28/17 facility policy, Baseline and Comprehensive Care Plans indicated under the Procedure section, that The comprehensive care plan must describe the following: A. The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being [ .]. All care plans will be reviewed quarterly by each discipline and interdisciplinary team members, unless needed sooner due to a significant change in condition. NJAC 8:39-11.2(f).

Complaint # NJ00164556 Based on interviews, medical records review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #3) exhibited aggressive behaviors and was sent to the hospital for a behavioral evaluation. When the resident was discharged from the hospital, the facility would not permit a return back to the facility. The deficient practice was identified for Resident #3, 1 of 3 residents reviewed for transfer and discharge, and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #3: According to the Admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Parkinson's Disease, Major Depressive Disorder, Bipolar Disorder, and Generalized Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE], revealed that Resident #3 had a Brief Interview for Mental Status score of 5, which indicated the resident had severe cognitive impairment. The MDS failed to indicate that Resident #3 had any behavioral symptoms. Review of Resident #3's Clinical Census revealed that their Primary Payer at the facility was Medicaid-Managed Care. The [DATE] Pre-Admission Screening And Resident Review (PASRR) Level I Screen (a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long trem care) indicated that Resident #3 had a diagnosis of a major mental illness but that the resident did not have a significant impairment in functioning related to the diagnosis. The PASRR also indicated that Resident #3 should be admitted to the nursing facility. The care plan dated [DATE] indicated focuses for difficulty relating to staff and other residents in stressful situations, trouble coping with change, risk for social isolation due to a behavior problems, physical aggression, verbal aggression, use of lithium (mood stabilizing medication), antidepressant, and antianxiety medications. Review of the [DATE] Physician Note- Narrative (PNN) written by the Attending Physician revealed that Resident #3 was aggressive at times, was followed closely by psych, and was less anxious. The PNN did not include any physician documentation of the specific needs that could not be met at the facility for Resident #3. Review of the [DATE] Psychiatry Progress Note (PPN) completed by the Advanced Practice Nurse (APN) revealed, [ .] LTC resident with history of bipolar disorder, depression, Parkinson's disease, and insomnia. Patient is evaluated following episodes of behavior outbursts including physical aggression and mood lability. Staff reports that pt [patient] has become a danger to others, as [he/she] is attacking other residents who are [NAME] [vulnerable] and unable to proactively avoid contact or protect themselves from [his/her] random aggression. At this time pt needs an emergency high level of care for stabilization and safety. When pt returns and if medications are not adjusted at the hospital, will recommend increasing the Vraylar [antipsychotic medication] to 3 mg, and if behavior persist an in-patient admission for medication management will be appropriate [ .]. The PPN did not include any documentation of the specific needs that could not be met at the facility for Resident #3. According to the [DATE] Nursing Note-Narrative, [ .] Due to circumstances of aggressive behavior and for the safety of the other residents and discussion with Psych [ .] APN, it was determined to send out 911 to ER for evaluation. Called 911. [ .] Resident was picked up via stretcher at 11:15 am. According to the communication chain from the facility's Admission's Clinical Liaison to the hospital on [DATE], Status changed to Decline. [He/She] is from our facility but [he/she] has surpassed [his/her] 10 day Medicaid bed hold. Also we are unable to take [him/her] back with the need of a [1 to 1 monitoring system] and [his/her] behaviors under control. No Bed Available. According to the [DATE] Daily Census (census sheet), there were 151 available beds, 134 total residents, and 17 empty beds. According to the Psychiatric Consultation completed by the Psychiatric Nurse Practitioner (NP) at the hospital on [DATE], Patient does not have acute psychiatric symptoms, warranting acute psychiatric care at this time. Patient is not a threat to self or others and is not psychotic. Patient required, not aggressive and responded to verbal stimuli very little[.] Patient adamantly denies any thought or intention to hurt self or anyone else. Patient doesn't meet commitment criteria and requesting discharge. Patient can be discharged , once medically clear to SAR [sub-acute rehabilitation], or group home. According to the communication chain from the hospital to the facility on [DATE], Attached is patient's psych clearance. [He/she] clearly does not meet criteria for a facility with a higher level of behavioral support. This would not be an appropriate referral. [ .] It is not the responsibility of the hospital to place one of your long term care residents that has resided with you for over 2 years. According to the communication chain from the facility's Director of Admissions (DOA) to the hospital on [DATE], [He/She] could be on the wait list should [he/she] be appropriate at that time. Thank you. According to the [DATE] communication chain from the hospital to the facility, According to the law, [he/she] is to receive the NEXT available bed, not placed back on your waiting list. [ .] This is where expecting the hospital to pursue alternate placement for you is unacceptable. During an interview with the surveyor on [DATE] at 12:36 PM, the DOA stated the main reason for the resident's discharge from the facility was a nursing decision because of the resident's wellbeing, behaviors, and the safety of the other residents and staff at the facility. The DOA stated that when Resident #3 was sent out, there was a 10-day bed hold in place. The resident was not safe to return to the facility before the bed hold expired. The DOA continued that once the resident's bed hold expired, the family wound have to pay to keep the bed held for longer. The DOA stated the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) would know more about the resident's discharge because it was a clinical decision. During an interview with the surveyor on [DATE] at 2:03 PM, the LNHA stated that on [DATE] that the facility had denied the hospital's referral to readmit Resident #3 because of their behaviors and out of concern for the safety of the other residents. The LNHA stated that Resident #3's bed was occupied on ,d+[DATE] but there were open beds available at the facility. The LNHA continued that the facility's Admissions Clinical Liaison and DOA did not give accurate information to the hospital that no beds were available. Review of the [DATE] census sheet revealed that Resident #3's room was documented as Empty. During an interview with the surveyor on [DATE] at 2:58 PM, the DON stated that a resident who had a psychiatric episode would be allowed to return to the facility when they were cleared to return to the facility. A psychological assessment would show that they were not a danger to themselves or others, and that their treatment was managed. The DON stated that a resident would be radmitted as long as the facility had the medications and could meet the resident's needs. The DON continued that according to the Psychiatric NP's assessment on [DATE] in the hospital, the resident should have been readmitted . The facility policy, Transfer and discharge date d [DATE] indicated under the, Policy Section, To permit each resident to remain the facility, and not transfer or discharge the resident from the facility unless: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered [ .]. The facility policy continued, Residents who are sent emergently to the hospital are considered facility-initiated transfers because their return is generally expected, and will be permitted to return to the facility, unless they meet one of the criteria under which the facility can initiate discharge. The facility polices, Admissions Policies, and Admission Criteria failed to address readmission to the facility following hospitalization . The undated Notice of Bed Hold Policy and Return to Facility, sent to Resident #3's resident representative indicated, If Medicaid or Managed Medicaid, Bridgeway will reserve the resident's accommodations for up to ten (10) days, with Day 1 being the date of discharge. [ .] If the therapeutic leave or transfer exceeds the bed-hold period, and payment for bed hold is not made, the resident will be allowed to return to their previous room, only if available. If the previous room is not available, they will be offered a bed in another semi-private room. NJAC 8:39 5.1(d) gbbbbbbbbbbbbbbbbbbbbbbbbm

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure respiratory equipment was dated properly. This deficient practice was identified for 1 of 2 residents (Resident #1) reviewed for respiratory care and the evidence was as follows: On 2/7/23 at 10:33 AM, the surveyor observed Resident #1 in his/her room. The resident was in bed and had on an oxygen nasal cannula (a device used to deliver supplemental oxygen) which was attached to an oxygen concentrator with a pre-filled humidifier bottle (a medical device that increases the humidity in oxygen while using supplemental oxygen). Neither the nasal cannula nor the bottle of humidifier solution were dated with the date they were changed. On 2/14/23 at 11:21 AM, the surveyor observed Resident #1 in his/her room resting in a geriatric chair (a large, padded chair that was designed to help seniors with limited mobility). The resident was receiving oxygen therapy via nasal cannula and pre-filled humidifier bottle. Neither the nasal cannula nor the humidifier were dated. At this time, the surveyor found the Licensed Practical Nurse Unit Manager (LPN/UM) to confirm that these devices were not dated. On 2/14/23 at 11:57 AM, the surveyor interviewed the LPN/UM who stated nasal cannulas were changed every one to two weeks by the 11 PM - 7 AM shift and must be dated. The LPN/UM further stated that properly dating this equipment is important especially with having agency staff which is all the time, to know when and if it was changed. At this time in the presence of the surveyor, the LPN/UM inspected Resident #1's nasal cannula and humidifier bottle and confirmed that they were not dated. The surveyor reviewed the medical record for Resident #1: A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in October of 2021 with diagnoses which included but were not limited to pneumonia, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 2/2/2023, reflected a brief interview for mental status (BIMS) score of 10 out of 15, which indicated moderately impaired cognition. A further review reflected the resident utilized oxygen therapy. A review of the resident's individualized resident-centered Care Plan initiated on 2/7/2023, included a focused care area for shortness of breath (SOB) related to hypoxia (decreased amount of oxygen in the blood). A review of the resident's physician's orders (PO) included an active order started on 2/7/2023 for oxygen at three (3) liters per minute (L/min) by nasal cannula continuous inhalation every shift for SOB. Review of the facility's Oxygen Concentrators and Accessories policy and procedure with effective date 4/15/19 included under the section labeled procedure: 1. Nursing is responsible for changing tubing, cannulas, masks, humidification devices in accordance with the following: a. the following accessories should be changed and dated as needed but at least a minimum of weekly on Sundays by the night shift (or as needed); this includes cannula or masks, pre-filled humidifier bottles. NJAC 8:39 - 25.2(c)4

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice by a.) ensuring a physician order was in place to check for proper feeding tube placement and residual stomach contents, and b.) accurately document feeding tube placement and residual stomach content for 1 of 25 residents (Resident #65) reviewed for professional standards of nursing practice. 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 casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: On 2/7/23 at 10:08 AM, on initial tour of the facility, the surveyor observed Resident #65 in his/her room sitting in a wheelchair having just returned from therapy. The resident was unable to verbally communicate with the surveyor but was able to nod his/her head and use hand gestures to say hello. The surveyor observed that Resident #65 had a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the wall of the abdomen directly into the stomach, used for tube feeding) placed. On 2/8/23 at 10:08 AM, the surveyor reviewed the medical record for Resident #65. A review of the Face Sheet (an admission summary) reflected that the resident was originally admitted to the facility in December of 2022 with diagnosis which included but not limited to convulsions (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) following cerebral infarction (stroke), and hemiplegia and hemiparesis (a severe or complete loss of strength or a mild or partial weakness leading to paralysis) following cerebral infarction affecting the right dominant side. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 12/8/2022, reflected a brief interview for mental status (BIMS) score of 99 which indicated the resident was unable to complete the interview. A further review reflected the resident was receiving 51% or more of their nutrition by PEG tube feeding. A review of the resident's individualized resident-centered Care Plan initiated on 12/2/2022, included a focused care area for tube feeding related to dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), indicating the resident had a PEG tube placed on 11/28/22. This care area had a goal that the resident will remain free of side effects or complications related to tube feeding and will be free of aspiration (when something swallowed enters your airway or lungs). Upon initial review of the resident's care plan, there was no interventions to check PEG tube placement or check for stomach content prior to initiating feeding or instilling medication or fluid. On 2/13/23, after surveyor inquiry, the facility provided a care plan which included intervention to check Peg tube proper placement, visual inspection of aspirated stomach content prior to instilling medication, initiating feeding when there is an interruption of feeding every shift. A review of the resident's physician's orders (PO) included an active order started on 12/2/2022 for nothing by mouth (NPO) diet, an active order on 12/2/2022 for enteral feeding every four (4) hours: hydration flush: bolus with 200 milliliters (mL) water (H2O) for a total of 1200 mL per 24 hours, an active order for enteral feeding every shift to start at 10 PM pump feeding: administer Glucerna 1.2 per PEG tube via pump rate 98 mL per hour to provide 1500 mL total in 24 hours, and an active order dated 12/2/2022 to maintain head of bed elevated 90 degrees while feeding and for 1 hour after meals. On 2/8/23 at 12:23 PM, the surveyor interviewed the Registered Nurse Supervisor (RNS) in the presence of the Licensed Practical Nurse Unit Manager (LPN/UM). The RNS stated nurses should be checking PEG tube placement and residual between feedings, before hanging new feedings, and at the end of each shift. The RNS stated this should be documented on the medication administration record (MAR) or treatment administration record (TAR) but would require a physician order to appear in the MAR or TAR to be signed off. The RNS and the LPN/UM looked through Resident #65's electronic medical record and were unable to locate any documentation from nursing indicating this was being done. The RNS confirmed there was no order in place for checking PEG tube placement or residual stomach content and stated, there should be an order for it. On 2/15/23 at 12:09 PM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, the surveyor interviewed the Director of Nursing (DON). The DON stated nurses look at the length of the tube and should aspirate stomach content to check for placement and residual prior to initiating feeding or administering medication or fluids to ensure the PEG tube is in place in the stomach and administered supplements or medication are not going to be administered into the abdominal cavity or cause aspiration. The DON further stated this is part of nursing and had to have an order to show up and be signed on the MAR or TAR, and that there should have been and order to check for placement and residual. Review of the facility's Tube Feeding policy and procedure updated 11/10/2019 included under the section labeled procedure: .4. Verify that the tube is functioning before beginning a feeding and before administrating medications. Some methods include: patient interview - for alert patients able to report symptoms that indicate a feeding is not well tolerated such as bloating, nausea, abdominal pain. Checking gastric residual volume (GRV). Observing changes in length of tubing if the exit site was marked upon initial placement . 6. Documentation in the medical record includes physician order and implementation and volume of infusion over designated time periods. NJAC 8:39- 27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to accurately a.) assess a resident for pressure ulcers, and b.) properly code a resident for contractures in the Minimum Data Set (MDS)assessments. This deficient practice was identified in 2 of 27 residents reviewed for MDS, Residents #7 and #181, and was evidenced by the following: a.) Review of the Admission Record showed that Resident #7 was admitted to the facility on ,d+[DATE]. Medical diagnosis included, but were not limited to Parkinson's disease (neurological disease), kidney disease, hypertension (high blood pressure), heart failure, and depression. Review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 11/21/22, indicated that Resident #7 had a Brief Interview of Mental Status of 7, meaning the resident had severe cognitive impairment. Review of Section G, Functional Status showed the resident was a two-person assist for mobility, transfers, and toilet use, and was a one-person physical assist for eating and dressing. On 02/08/22 at 11:15 AM, the surveyor reviewed Resident #7's current care plan which included a focus of Pressure Ulcer, indicating the resident had a sacral pressure ulcer. On 02/08/23 at 12:00 PM, the surveyor reviewed Resident #7's Treatment Administration Record (TAR) for the months of August 2022 and November 2022. For the month of August, there were multiple wound care orders to the resident's sacral area, the care was being provided and the nursing staff were signing the orders as completed, meaning the resident did have a wound in the month of August. The surveyor then reviewed the TAR for the month of November and there were two wound care orders. 1.) cleanse open area to medial right back with normal saline solution, apply hydrogel and cover with a bordered gauze twice daily, and 2.) Cleanse sacral area with wound cleaner, apply Medi honey and over with border gauze twice daily. The nursing staff were signing the TAR as completed, indicating the resident had two pressure wounds that were receiving treatments. On 02/09/23 at 10:16 AM, the surveyor reviewed the 8/22/22 quarterly MDS, under section M, skin conditions (M0210) it was documented as No unhealed pressure ulcers. The surveyor then reviewed the 08/18/22 weekly skin evaluation, completed four days before the quarterly MDS was completed and it was documented that the resident had an 11 centimeter (cm) by 6 cm sacral pressure ulcer. The surveyor then reviewed the Comprehensive MDS dated [DATE], section M, skin conditions, section M0210. It was documented No for unhealed pressure ulcers. On 02/09/23 at 11:00 AM, the surveyor then reviewed the weekly skin evaluation completed 11/22/22, the same day the comprehensive MDS was completed. It was documented that the resident had two pressure ulcers. One medial back, full thickness skin loss (meaning open wound), and one sacral wound, full thickness skin loss. On 02/16/23 at 11:23 AM, the surveyor interviewed the MDS coordinator regarding pressure ulcers. The MDS coordinator said she receives information about wounds from the unit manager or the nurse. The surveyor asked the MDS coordinator how the resident had a pressure ulcer on 7/27/22 and then did not have a pressure ulcer on 08/22/22 when the quarterly MDS was done and then the pressure ulcer was again documented as present on 11/04/22, and then the resident did not have a pressure ulcer on 11/21/22, the time the Comprehensive MDS was completed. The MDS Coordinator told the surveyor Sometimes the wounds heal or become moisture associated disorders. NJAC 8:39-33.2 (d) b. On 2/07/23 10:32 AM the surveyor observed Resident #181's left hand contracted with a gauze roll in place for positioning. A family member was present. Review of the Admission Record showed that Resident #181 was admitted to the facility with medical diagnosis that included but were not limited to Alzheimer's Disease and muscle weakness. Review of the quarterly Minimum Data Sets (MDS), an assessment tool dated 7/13/22, 10/12/22, and 1/7/23, indicated that Resident #181 had long and short-term memory deficits. The section for Functional Limitation in Range of Motion was coded as 0 indicating there was no limitation in the range of motion of the upper extremity. Review of the physician narrative notes dated 7/11/22, 9/15/22, and 1/6/23 reflected that Resident #181 had a left-hand contracture. During an interview on 2/14/23 at11:58 AM the MDS Coordinator acknowledged that Resident #181 had a contracture of the left hand which should have been coded on the 7/13/22, 10/12/22, and 1/7/23 Quarterly MDSs. NJAC 8.39-11.1 40744

Based on observation, interview and record review, it was determined that the facility failed to maintain infection control practices to minimize the potential of cross contamination 1.) when storing an urinary drainage bag and tubing for Resident #5, 1 of 5 residents reviewed for urinary catheter use and 2.) during a wound care treatment for [REDACTED]. This deficient practice was evidenced by the following: 1. On 6/24/19 at 10:56 AM, the surveyor observed Resident #5 who was in the piano room, seated in a wheel chair with eyes closed. Review of the Admission Records indicated the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 11/5/18, the resident had severe cognitive impairment and required extensive assistance with personal hygiene and bed mobility. Review of the Order Summary Report revealed an order, dated 10/29/18, for a suprapubic catheter. On 6/26/19 at 8:44 AM, the surveyor observed the resident seated in a wheelchair in the resident's room. The surveyor observed an undated urinary drainage bag and tubing hung in the bathroom, on a hook next to the toilet. The drainage bag and tubing were not in a bag. The drainage bag contained urine and the drainage port was uncapped. At 8:45 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA), who was in the resident's room at the time. The CNA stated she usually disconnected the urinary drainage bag and hung it on the hook in the bathroom when she changed it to a leg bag. The surveyor showed the CNA the urinary drainage bag on the hook next to the toilet. The CNA stated the urinary drainage bag and tubing should be placed in a plastic bag with a cap at the end of the tubing. She stated the hospice CNA must have left the urinary bag uncapped. The surveyor observed the CNA as she removed a plastic trash bag from a garbage can in the room, placed the urinary drainage bag into the trash bag and then hung the bag on the hook. She did not cap the end of the urinary tubing and did not drain the urine from the drainage bag. On 6/26/19 at 9:23 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated the urinary drainage bag should be labeled and dated. The surveyor showed the RN/UM the urinary bag in the bathroom, and she stated the urinary bag should be cleansed with a vinegar and water solution and capped before storing in a new plastic bag. Review of the facility's Urinary Catheters policy, dated 11/19/15, indicated the urinary drainage bag should be capped before storing in the plastic bag. The policy also reflected the bag should be changed monthly and labeled with the resident's name. On 6/27/19 at 9:25 AM, the surveyor informed the Administrator of the findings. On 6/28/19 at 10:00 AM, the surveyor reviewed an in-service document titled, Linen Handling Policy and Changing Indwelling Catheter Bags, dated 5/20/19. The document revealed the resident's CNA attended the in-service training which included a review of the procedure for the cleaning and storage of the urinary drainage bag. 2. On 6/24/19 at 10:00 AM, the surveyor interviewed Resident #70 who stated he/she had a wound on his/her tailbone. Review of the admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS, an assessment tool dated 5/5/19, the resident was cognitively intact and required extensive assistance for bed mobility and transfer. The surveyor reviewed the Order Summary Report which revealed a physician order [REDACTED]. On 6/27/19, from 10:30 AM to 10:48 AM, the surveyor observed the wound treatment provided by the Licensed Practical Nurse (LPN). The surveyor observed the nurse sanitize the overbed table and apply a barrier cover to the table. The LPN then placed the treatment supplies on top of the barrier. The supplies included one skin prep pad, one 250 cc bottle of NSS, one 473 ml bottle of Dakin's solution, a stack of 4 x 4 gauze, one border gauze dressings, and a marker. With gloved hands, the nurse opened the bottle of NSS, poured it onto a piece of gauze, and cleansed the wound. While wearing the same gloves, she then picked up the bottle of Dakin's solution, poured it onto a folded a piece of gauze, applied the gauze to the wound, and then covered it with a border gauze. While still wearing the same gloves, the LPN used the marker to write the date on the dressing directly on the resident. The nurse removed the barrier and her gloves and then washed her hands. She disposed of the barrier into the garbage. She then left the room and placed the bottle of NSS and Dakin's solution into the treatment cart. The surveyor observed that the LPN did not clean the overbed table after the barrier was removed and did not clean the bottles prior to returning them to the treatment cart. After the treatment, the surveyor interviewed the LPN who stated she should not have touched the treatment supplies with soiled gloved hands and place them back into the treatment cart. She also stated she should have cleansed the overbed table after completing the wound treatment. On 6/27/19 at 1:19 PM, the surveyor interviewed the Director of Nurses (DON) who stated the facility did not have a specific policy for wound care performance and that the nurse should follow nursing standard of practice guidelines. The surveyor reviewed a skill performance evaluation for treatment competency dated 11/16/18, for the observed LPN. The competency revealed a satisfactory performance by the nurse. On 6/27/19 at 9:25 AM, the surveyor informed the Administrator of the findings. NJAC 8:39-19.1

Based on observation, interview and record review, it was determined that the facility failed to ensure the implementation of physician orders [REDACTED]. This deficient practice was identified for Resident #82, 1 of 4 residents reviewed for aspiration precautions. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 5/9/19, indicated the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The resident's Brief Interview Mental Status (BIMS) was 5 which indicated the resident had a severely impaired cognition and had short and long term memory loss. On 6/25/19 at 12:02 PM, the surveyor observed that neither Resident #82 nor the roommate were in the room. The surveyor observed an 8 oz Styrofoam cup was on Resident #82's overbed table. The cup was half full with a thin clear liquid. review of the resident's medical record revealed [REDACTED]. Thin liquids have been found at the bedside as the resident reports that they get water from the bathroom tap. Please check any fluids at bedside to be sure that they are Nectar Thick. Review of the (MONTH) 2019 and (MONTH) 2019 Order Summary Reports (the physician orders [REDACTED]. Review of the (MONTH) 2019 and (MONTH) 2019 Treatment Administration Record (TAR) dated (MONTH) 2019 that had an entry for Aspiration Precautions every shift. On 6/25/19 at 12:20 PM, the surveyor returned to Resident #82's room and neither the resident nor the roommate were in the room. The surveyor observed that the Styrofoam cup with clear liquid was still on Resident #82's overbed table. The surveyor left the room and interviewed the unit Licensed Practical Nurse (LPN) who was at the nursing station. The surveyor reviewed with the LPN the note on Resident #82's record regarding the nectar liquids and checking the fluids at bedside. The LPN stated, Yes, that is what we do. At that time, the surveyor and the LPN went to Resident #82's room and observed the Styrofoam cup with thin clear liquid on Resident #82's overbed table. The LPN picked up the cup and easily swirled the liquid in the cup. The LPN then poured the clear thin liquid down the bathroom sink in the resident's room. The LPN confirmed that the liquid on the resident's table was not nectar thick consistency. The LPN stated, I don't know how this got here. It should not be here. The LPN stated she did not place the water cup on the resident's overbed table. On 6/25/19 at 12:25 PM, the surveyor spoke with the Certified Nursing Assistant (CNA) who stated she was assigned to Resident #82. The surveyor asked how the CNA was made aware of the resident's care needs. The CNA stated she would be made aware in the morning unit report and that the resident's care needs were also in the care tracker system. The CNA explained that the care tracker is a small computer located on the wall in the hall for CNAs to document care provided to the resident. The CNA said it is linked to the software system the facility uses for resident assessment and documentation. The CNA stated that the resident can drink from a cup independently and that the Styrofoam cup of water was not on the resident's overbed table when she provided care in the morning. The CNA stated she did not place the water cup on the resident's overbed table. On 6/25/19 at 12:40 PM, the surveyor attempted to interview Resident #82 about the water cup; however, due to impaired cognition, the resident was not able to explain how the cup of water got to the table or who placed it on the table. The resident was also not able to answer questions regarding fluid consistency. On 6/26/19 at 10:10 AM, the surveyor interviewed the Speech Therapist (ST) regarding Resident #82. The ST stated she knew the resident well and that the resident had been on a restorative program with ST from 4/28/19 through 5/3/19, and most recently from 5/3/19 through 5/24/19. The ST stated that nursing staff was made aware of the resident's fluid consistency. The ST stated she was aware of the 5/16/19 cautionary note on the resident's record regarding thin liquid at bedside. She added that she discussed the altered liquid with nursing staff and they decided to place the cautionary note on the resident's record. On 6/27/19 at 1:28 PM, the surveyor met with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing and informed them of the above observations. On 6/28/19 at 9:30 AM, the surveyor met with the DON who stated that resident's that require thickened liquids do not have a water pitcher at bedside. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to develop an individualized, comprehensive care plan to address resident's daily weight monitoring, intravenous access, oxygen therapy, and hospice services. This deficient practice was identified for Residents #81 and #129, 2 of 30 residents reviewed and was evidenced by the following: 1. On 6/24/19 at 8:47 AM, during the initial tour of the facility, the surveyor observed Resident #81 in bed with eyes open. There was an oxygen concentrator next to the resident's bed with oxygen tubing connected. The surveyor noted that Resident #81 was not wearing oxygen at the time. Upon interview, the resident stated he/she used oxygen at night and for episodes of shortness of breath. The surveyor also noted the resident had an Intravenous (IV) access (a small tube directly in the vein to receive medications or fluids) in the right hand. The resident stated he/she was receiving IV medication to get rid of fluid. On 6/26/19 at 11:30 AM, the surveyor interviewed the resident who was sitting in the room in the wheelchair. The resident informed the surveyor that he/she had lost 3.5 pounds of fluid in one day and that nurses checked his/her weights every evening. Review of the admission record reflected that Resident #81 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), an assessment tool dated 6/16/19, showed the resident had a Brief Interview of Mental Status (BIMS) of 15, meaning the resident was cognitively intact. The functional assessment on the MDS reflected the resident required one-person physical assistance for bed mobility, dressing, and personal hygiene and used oxygen therapy. Review of the physician's orders [REDACTED]. On 6/27/19 at 10:41 AM, the surveyor reviewed the resident's nursing care plan. The care plan did not include the use of oxygen, daily weight monitoring or the resident's intravenous access. On 6/27/19 at 12:34 PM, the surveyor interviewed the resident's Registered Nurse (RN) regarding the daily weights. The RN stated the night shift Certified Nurses Aide (CNA) checked the resident's weight every night. The surveyor asked how information about the daily weights was communicated with all staff members. The RN stated the weight monitoring was a physician's orders [REDACTED]. The RN reviewed the care plan together with the surveyor and she could not show the surveyor evidence that weight monitoring, IV access and oxygen were addressed on the care plan. When interviewed at 12:35 PM, the RN stated the Unit Manager was responsible for updating the care plan. 2. On 6/24/19 at 9:50 AM, during the initial tour of the facility the surveyor observed Resident #129 seated in a wheelchair in the room while being evaluated by the hearing aid representative. The surveyor noted the resident wore a nasal cannula with oxygen being delivered from an oxygen concentrator at 3 liters per minute. Review of the admission record indicated the resident was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of the most recent MDS, dated [DATE], showed a BIMS of 15, meaning the resident was cognitively intact. The resident's functional status on the MDS showed the resident was a one-person physical assistance for bed mobility, transfers, eating, dressing and personal hygiene was on hospice care, and used oxygen therapy. On 6/25/19 at 10:20 AM, the surveyor observed the resident in bed with eyes closed. Review of the physician's orders [REDACTED]. There was also an order [REDACTED]. A physician's orders [REDACTED]. On 6/27/19 at 11:07 AM, the surveyor reviewed the resident's care plan and noted the care plan did not address hospice/end of life care or nasal cannula oxygen. On 6/27/19 at 12:37 PM, the surveyor interviewed the Unit Manager (UM) regarding hospice residents and their care plans. The surveyor asked if hospice or oxygen would be included on the resident's care plan. The UM stated, hospice or end of life care does get added to the care plan and also oxygen therapy. NJAC 8:39-11.2 (d)

Based on observation, interview and review of the medical record, it was determined that the facility failed to ensure restorative devices were in place to support proper positiong and maintain skin integrity. This deficient practice was identified for Resident #39, 1 of 2 resident reviewed for skin care and was evidenced by the the following: The surveyor reviewed the medical record which reflected that Resident #39 was admitted to the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) an assessment tool dated 3/13/2018, the resident's skin was intact and the resident had limitation in functional range of motion (ROM) in the bilateral upper and lower extremities. On 5/30/18 at 1:23 PM and on 5/31/18 at 10:29 AM, the surveyor observed Resident #39 in bed with without hand roll to the left hand. The right hand was under the cover and not visible to the surveyor. On 06/01/18 at 10:20 AM, the surveyor observed Resident # 39 in the day room seated in a reclined Geri-chair with eyes closed. The surveyor noted that the resident did not have a hand roll in either hand. On 6/1/18, the surveyor reviewed the Treatment Administration Record (TAR) which reflected a physician's orders [REDACTED]. The Care Plan dated 10/25/2016, reflected that the resident was prone to bruising secondary to fragile skin and that nursing was to apply geri-legs (sleeves) to bilateral lower extremities for skin prevention. The Care Plan dated 1/12/2017, indicated that the resident was at risk for altered skin integrety and that skin preventative measures/interventions would include placing a kling roll in each contracted hand, pillows would be placed under knees and arms at all times, and that a soft towel or blanket would be placed between contracted arms and chest wall to provide a barrier for skin protection. On 06/01/18 at 11:32 AM, the surveyor reviewed the TAR which reflected an physician's orders [REDACTED]. The surveyor noted that the Licensed Practical Nurse (LPN) had signed the TAR indicating that the hand rolls were on the resident's hands even though it was not. On 06/01/18 at 11:50 AM the surveyor went back to the day room and observed Resident # 39 in the day room with a Certified Nursing Assistant (CNA) sitting next to the resident. After asking for permission from the resident, the surveyor asked the CNA to check the hands for hand rolls. The CNA looked at the resident's hands and informed the surveyor that Resident #39 was not wearing hand rolls. On 06/01/18 at 11:56 AM the surveyor interviewed the CNA regarding the hand rolls. The CNA stated that she was not aware of the hand rolls or any other device that Resident #39 was supposed to wear and that she only knew of Geri-sleeves to the arms. The CNA was unaware that the resident was to wear the ger-sleeves on the bilateral legs. 06/01/18 at 12:05 PM the surveyor interviewed the LPN who cared for the resident. The LPN looked through the Electronic TAR and confirmed the order for hand rolls. The LPN did not have explanation for why the TAR was signed as if Resident #39 was wearing the hand rolls when the resident was not. On 6/5/18 at 1:00 p.m., the surveyor informed the administrator and the Director of Nursing of the findings. NJAC8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to follow standards of clinical practice with documentation of administered medication from December 2016 to March 2017 for a resident on [MEDICAL TREATMENT], Resident #4, 1 of 3 residents reviewed for [MEDICAL TREATMENT]. The facility also failed to clarify the indication for use of a medication for Residents #4 and #15. This deficient practice was identified for 3 of 24 residents reviewed and was evidenced by the following: 1. The surveyor reviewed the medical record of Resident #4 on 3/6/17. The record revealed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4 went to [MEDICAL TREATMENT] three days a week on Tuesday, Thursday and Saturday. The 1/30/17 significant change Minimum Data Set (MDS), an assessment tool, reflected that the resident was alert and oriented and had no cognitive impairment. On 3/7/17 at 10:15 a.m., the surveyor observed the resident seated in a wheelchair in the room. Upon interview, the resident stated that he/she normally left for [MEDICAL TREATMENT] by 2:15 p.m. and returned around 8 p.m. or 9 p.m. depending on transportation. A review of the March 2017 physician's orders [REDACTED]. A review of the current Medication Administration Record (MAR) revealed that the Insulin was scheduled for administration at 9 a.m. and 5 p.m. The surveyor reviewed the MAR from December 8, 2016 to March 7, 2017. The MAR reflected nurses' initials indicating that they administered the Insulin everyday at 5 p.m. During interview on 3/8/17 at 10 :10 a.m., the Registered Nurse Unit Manager (RN/UM) stated that Resident #4 returned from [MEDICAL TREATMENT] between 7:30 to 8 p.m. She also stated that they just realized the error in administration time and had adjusted it. She also stated that nurses should have adjusted the time for when the resident was at [MEDICAL TREATMENT]. The RN/UM then gave the surveyor a printed copy of medication administration history. This reflected multiple days when the Insulin was administered after 9 p.m. but documented on the MAR as if given at 5 p.m. 2. The surveyor reviewed the medical record for Resident #15 who was admitted to to the facility with [DIAGNOSES REDACTED]. A review of the March 2017 MAR showed a physician's orders [REDACTED]. The surveyor interviewed the RN/UM on 3/8/17 at 10:20 a.m., and asked how they determined when and for what [DIAGNOSES REDACTED]. The RN/UM stated that it was dependent on nursing assessment and also on the resident's description of discomfort. During interview with the facility administration on 3/9/17 at 10:30 a.m., the Director of Nursing stated that it was dependent on the resident. When the surveyor asked what discomfort meant, and if this could mean any type of discomfort. She stated that their Consultant pharmacist reviewed the order and did not recommend any changes as such order was not uncommon. According to the 3/10/15 facility policy for pain assessment and management, pain would be measured in terms of intensity/severity using mild,moderate, severe and very severe, or through the use of facial expressions for the residents that could not use the above scale. There was no evidence that the facility clarified the order to show what type of discomfort or pain and did not follow their policy. 3. The surveyor reviewed the medical record for Resident #3 and noted that the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 3/2/17 at 9:45 a.m. the surveyor observed the resident in bed. A review of the March 2017 MAR showed a physician's orders [REDACTED]. There was also another order for [MEDICATION NAME] 50 mg every 12 hours as needed for pain if Tylenol was not effective. The surveyor interviewed the RN/UM on 3/8/17 at 10:20 a.m., and asked how they determined when and for what [DIAGNOSES REDACTED]. The RN/UM stated that it was dependent on nursing assessment and also on the resident's description of discomfort. There was no evidence that the facility clarified this order to show a specific [DIAGNOSES REDACTED]. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. NJAC 8:39-11.2 (b)

Based on observation and interview, it was determined that the facility failed to consistently offer a bedtime snack to all residents. This deficient practice was identified for 6 of 6 alert and oriented residents who attended the Group Meeting and 5 alert and oriented residents who were individually interviewed, Residents #10, #18, #2, #3 and #19 and was evidenced by the following: During the Group Interview on 3/2/17 at 10:30 a.m., the surveyor asked about bedtime snacks. All 6 of 6 alert and oriented residents at the group meeting told the surveyor that they were not offered a bedtime snack. The residents stated that snacks were available at the nurse's station and that if they wanted a snack they would have to go to the nurse's station to get their own snack. The surveyor interviewed Resident #10 on 3/8/17 at 1:15 p.m. The resident stated: If you wanted a snack you have to go the nurses' station and get your own snack, and that staff did not not usually offer snacks. The surveyor interviewed Resident #18 on 3/8/17 at 1:30 p.m. The resident stated that sometimes the staff would offer a snack and sometimes the resident had to ask for a snack. On 3/8/17 at 1p.m. the surveyor interviewed the Registered Nurse (RN) Unit Manager (RN/UM). The RN/UM stated that bowls of snacks were usually brought up after dinner in the evenings from the kitchen and that some of the residents would come up to the desk for the snacks and some residents were offered. The surveyor interviewed Resident #2 on 3/8/17 at 1:25 p.m. and interviewed Resident #3 at 1:30 p.m. Both stated that snacks were not usually offered at night but staff would get it for them if they asked. The surveyor interviewed Resident #19 on 3/8/17 at 1:45 p.m. The resident stated that bedtime snacks were not usually offered but would be given to them if they asked for it. NJAC 8:39-17.2(f)ii

Based on observation, interview and record review, it was determined that the facility failed to maintain and/or store an indwelling catheter in a manner to prevent infection for Resident #15, 1 of 3 residents reviewed for catheter use. This deficient practice was evidenced by: During the initial tour on 3/1/17 at 10:30 a.m., the Registered Nurse Unit Manager(RN/UM) told the surveyor that Resident #15 was alert and oriented and had a Foley catheter (a flexible tube inserted into the bladder for urinary drainage). On 3/6/17 at 10:55 a.m. the surveyor observed Resident #15 in the hallway near the nurse's station seated in a wheelchair while two staff members attended to him/her. The surveyor noted that the resident's Foley catheter bag was inside a privacy bag and hanging under the wheelchair with the tubing dragging on the floor. On 3/6/17 at 12:50 p.m., the surveyor observed the resident seated in a wheelchair at the front desk speaking with the receptionist. The surveyor observed the Foley catheter bag inside a privacy bag under the wheelchair with the catheter tubing sticking out of the bag and dragging on the floor. On 3/8/17, the surveyor reviewed the medical record for Resident #15 which showed the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 3/8 at 11:45 a.m. during the lunch meal, the surveyor observed Resident #15 seated at a table and eating lunch. The surveyor noted the Foley catheter tubing again on the floor. At 11:50 a.m., the surveyor brought the Assistant Director of Nursing (ADON) to the dining room and showed her the Foley catheter tubing. The ADON stated that the she would fix it after the resident finished lunch. The surveyor observed as the resident self- propelled out of the dining room with the tubing dragging on the floor which presented a potential for cross-contamination. During interview with the facility administration on 3/9/17 at 10:45 a.m., the ADON stated that Resident #15 moved around the unit independently and moved his/her leg a lot which could cause the tubing to dangle out of the bag. The surveyor reviewed the care plan initiated on 1/24/17. There was no evidence that the facility addressed this tendency for the tubing to be sticking out and dragging on the floor until after surveyor inquiry. The surveyor reviewed the facility's Urinary Catheter policy dated 11/19/2015 which reflected that staff would maintain and manage indwelling catheter in a manner to prevent infection. NJAC8:39-27.2 (n)

Based on interview and record review, it was determined that the facility failed to notify the physician in a timely manner upon the discovery of a newly re-opened Stage III pressure ulcer, full thickness tissue loss. This deficient practice was identified for 1 of 21 residents reviewed, Resident #12 and was evidenced by the following: On 3/7/16 at 10:55 a.m. during the initial tour, the Unit Manager-Registered Nurse (UM-RN) told the surveyor that Resident #12 had a facility-acquired Stage III pressure ulcer to the sacrum. The resident was being seen weekly by Wound Healing Solutions with the advanced Practice Registered Nurse (APRN). On 3/8/16 at 11:25 a.m., the surveyor reviewed the medical record for Resident #12 who had a [DIAGNOSES REDACTED]. Review of the nursing progress note dated 8/20/15 at 11:08 p.m. reflected a new onset pressure ulcer to the intergluteal cleft (sacral area) measuring 1 cm by 0.5 cm with scant bloody drainage. The site was cleansed with normal saline solution (NSS) and zinc oxide was applied. There was no indication that the physician was notified of the ulcer. The physician progress notes [REDACTED].#12. The physician indicated that there was a new pressure ulcer to the resident's gluteal cleft at a Stage III level. There was no evidence that the physician was notified of the new onset pressure ulcer prior to the visit on 8/22. On 3/16 at 2:15 p.m., the surveyor interviewed the Director of Nursing (DON). The DON could not provide documented evidence that the physician was notified from 8/20 until the physician made the routine visit on 8/22. (Refer to F314). NJAC 8:39-13.1 (d)