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

Based on record review, interview, and document review, the facility failed to ensure three of three residents and their resident representatives (R)10, R159, R1 and R164) reviewed for emergent hospital transfer out of a total sample of 31 residents were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: 1.Review of R10's admission Record located under the Profile tab in the electronic medical record (EMR) revealed admitted to the facility on [DATE]. Review of R10's Progress notes dated 11/22/25 revealed R10 was transferred to the hospital due to bladder prolapse and returned to the facility on [DATE]. R10 returned to the hospital on [DATE] for repair of bladder prolapse and returned on 01/14/26 Review of R10's Medicare five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R10's cognition was moderately impaired. 2.Review of R159's admission Record under the Profile tab in the EMR revealed admitted on [DATE]. Review of R159's Census located under the Census tab in the EMR revealed on 01/04/26 Hospital Paid Leave and on 01/16/26 returned to the facility. Review of R159's EMR located under the MDS tab revealed the admission MDS with an ARD of 11/18/25 revealed a BIMS score of 15 out of 15 indicating cognitively intact. Review of R159's Progress Note dated 01/04/26 located under the Progress Note tab of the EMR revealed R15 had altered mental status. New order received to send to hospital for evaluation and treatment. Ambulance in to transport resident. Review of Transfer/Bed Hold notice prior to Hospitalization or Therapeutic Leave provided by the facility for R10 and R159 revealed that the document did not include the appeal process. 3.Review of R1's admission Record located under the Resident tab in the EMR revealed admitted to the facility on [DATE] and readmitted on [DATE]. Review of R1's admission MDS with an ARD of 11/08/25 revealed a BIMS score of 11 out of 15 which indicated R1 was moderately cognitively impaired. Review of R1's Progress Note dated 12/16/25 located under the Resident tab of the EMR written by Unit Manager (UM) revealed received verbal order to send R1 to emergency room (ER) for further evaluation. Review of Notice of Emergency Transfer dated 12/27/25 revealed it did not indicate the appropriate appeal information. 4. Review of R164's Face Sheet located under the 'admissions tab revealed that R164's original admission date was 08/13/25 with a current admission date of 01/11/26. The Face Sheet indicated that R164's most recent hospital stay was from 01/01/26- 01/11/26. Review of R164's transfer notice located under the miscellaneous tab in the EMR revealed on 01/01/25, R164 was transferred to the hospital for abnormal hemoglobin. The transfer notice did not provide the appeal process. During an interview on 01/22/26 at 11:16 AM, the Admissions Director (AD) stated when a resident was transferred to the hospital she would contact their emergency contact and let them know. They would be provided with a bed hold letter, and information to reach out to the Ombudsman if they disagree with the transfer. No other information was provided to the family or resident regarding how to appeal other than the Ombudsman contact information. NJAC 8:39-4.1(a)

Based on observation record review and interview, the facility failed to ensure a resident's rights (R59) was honored when staff attempted to transfer the resident after the resident refused, causing a skin tear for one resident (Resident (R)59) of one resident reviewed for dignity in the sample of 31 residents. This had the potential to affect all residents receiving care. Findings include:Review of R59's admission Record located in the Profile tab of the electronic medical record (EMR) revealed on 11/23/25, with diagnosis of transient cerebral ischemic attack. Review of R59's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/26, and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident's cognition was severely impaired.Review of R59's Other Incident Report dated 12/14/25 at 4:30 PM, written by Registered Nurse (RN)3 and Nurse's Notes dated 12/14/25, in the EMR under the Notes tab revealed, writer and 2 CNA [Certified Nurse Aides] staff was transferring the patient from bed to chair.During transfer his right hand contacted the side rail and left hand contacted the wheelchair, 5 cm [centimeter] long and 1.2 cm wide skin tear with partial flap loss.During an interview 01/21/25 4:02 PM, CNA7 Stated on 12/14/25, R59 did not want to be transferred out of the bed. CNA7 said R59 was adamant and did not want to be messed with. He wanted to be left in the bed. CNA7 said staff should have respected his right to refuse care and left him in the bed. She said nothing was reported to the nurse about his refusal and the wife's demand until R59 got hurt. During an interview on 01/21/26 at 4:20 PM, RN3 said a resident has the right to refuse care, and staff should honor that right even when a family member demanded the care be given. On 12/14/25 she heard noise coming from R59's room. When she went into the room, she observed staff trying to transfer the resident, but he was holding onto the side rails and would not let go. He was leaning back into his bed. Staff continued to transfer him out of the bed, and he hit his arm on the side rail and was injured. During an interview on 01/22/26 at 1:26 PM, CNA8 stated that all residents have the right to refuse care. When a resident refuses care, CNAs are supposed to report it to the nurse. On 12/14/25, she observed two other CNAs going into the resident's room along with the wife. She said the wife wanted R59 taken out of the bed. She overheard one of the CNAs tell a nurse that R59 did not want to get out of bed, but the wife was agitated. She went into the resident's room and observed R59 holding onto the side rails refusing to get out of the bed. She left the room. During an interview on 01/22/26 at 5:22 PM, the Director of Nursing (DON) said staff should honor a resident's right to refuse care regardless of their cognition. NJAC 8:39:4.1(a)NJAC 8:39:5.1(a)NJAC 8:39:27.1(a)

Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by staff for one of five residents (Resident (R)178) reviewed for abuse out of 31sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include:Review of R178's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnosis of chronic obstructive pulmonary disease (COPD).Review of R178's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/25, and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact.Review of R179's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE], with diagnosis of heart failure.Review of R179's quarterly MDS with an ARD of 01/06/25 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.Review of R178's Nurse's Note dated 01/13/26 at 7:00 PM, and located in the EMR under the Notes'' tab written by Registered Nurse (RN) 4 revealed, On 1/11/25 around 7:00 PM resident has a care concern with her CNA [Certified Nurse Aide]. CNA immediately removed from assignment. Skin assessment done, family and primary made aware of the incident.Review of the undated Facility's Five Day Follow Up indicated the incident was on 01/11/25 at 7:00 PM. Further, review revealed, R178 reported to the supervisor that she was looking for her cell phone when the assigned aide [CNA9] walked into the room for PM [evening] care. R178 told the aide that she needed to find her phone before being put into bed but that the aide insisted on putting her to bed first, then looking for her phone. R178 stated that the aide proceeded to grab her arm and remove her dress with force. R178 started screaming that she was hurting her arm. The summary and conclusion indicated, The facility is substantiating staff to resident abuse at this time. [CNA9] was placed on our do not return list and has been blocked to pick up further shifts. The Agency has also been made aware.During an interview on 01/21/26 at 1:45PM, CNA9 stated that on 01/11/25, at bedtime she went into R178's room. She said R178 was looking for her phone, so she helped her look for phone. She said R178's roommate [R179] was in the room. CNA9 told R178 she would put her in bed and then she would look in wheelchair for phone. At that time, the roommate [R179] yelled No, help her find her phone first and don't touch her. At that time, she left the room and found a registered nurse [(RN)4] and reported that R178 was refusing to be put in bed. RN4 told her to give R178 about forty minutes and try again. She went back and RN4 went into room with her and she told R178 that she wanted to change her and get her in bed. The roommate [R179] again yelled at her that R178 wanted her phone. RN4 closed the curtain separating the residents, and the roommate [R179] opened the curtain, and said to keep it open so she could see. At that time, CNA9 walked out of the room and RN4 came out and continued passing medications. About three minutes later, R178 came out of the room in her wheelchair and appeared to be looking around for the phone and went back into her room. RN4 went into the room at which time R178 started screaming and crying, stating that CNA9 broke her hand. The roommate [R179] was screaming that yes, she hurt her. RN4 asked CNA9 if she hurt R178. CNA9 said No. She was told not to go back into R178's room. During an interview on 01/21/26 at 3:37PM, RN4 said on the night of 01/11/25, R178 was looking for cell phone. The phone was found on the resident's wheelchair underneath R178. RN4 stated that another staff member said that R178 was upset. He spoke with R178 who appeared very emotional and she told him that CNA9 was trying to hurt her. The roommate [R179] confirmed she witnessed CNA9 hurt R178. CNA9 was taken off the floor and asked to leave. During an interview on 01/22/26 at 5:22 PM the Director of Nursing (DON) said they substantiated the staff to resident abuse. Review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation PreventionProgram revised 06/23/25 revealed, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from.physical abuse. NJAC 8:39-4.1(a)NJAC 8:39-5.1(a)NJAC 8:39-9.4(f)NJAC 8:8:39-27.1(a)

Based on record review, interviews, document review and policy review, the facility failed to report an allegation of injury of unknown origin for one (Resident (R) 104) of two abuse allegations reviewed in the sample of 31 residents to the State Agency (SA) immediately, but no later than 2 hours after the incident. This failure had the possibility to negatively impact residents currently residing at the facility. Findings include: Review of facility's policy titled, Investigation, Incident and Reporting, revised 02/19/25, indicated, [name of the facility] is committed to. abuse-free environment. All staff are required to report any allegation or suspicion of abuse, neglect, exploitation, or mistreatment immediately. The facility will ensure that all incidents are reported to the appropriate regulatory agencies.Policy Interpretation and Implementation: The [name of state] Department of Health.via the online reporting system or hotline, Initial report must be made within 2 hours if the incident involves serious bodily injury and/or is related to abuse/neglect.Review of R104's admission Record in the electronic medical record (EMR) under the Census tab revealed R104 was re-admitted to the facility on [DATE] with the diagnosis of dementia. Review of R104's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/12/25 in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R104's cognition was severely impaired. Review Nursing Note dated 09/14/25 provided by the facility indicated, 11:20 PM: Certified Nursing Assistant [(CNA) 2] informed writer [Licensed Practical Nurse (LPN) 4] while giving report, R104 has hematoma on the left elbow. [CNA4] assigned to R104 on the 3-11 PM shift was informed and verbalized he did not see the hematoma as R104 was wearing arm sleeves on both hands. 7-3 AM nurse did not verbalize any skin changes while giving report. No evidence of injury of unknown origin is being reported to the supervisor. Review of facility provided [name of state] Department of Health Facility Information Reporting Category Long Term Care, (initial report) dated 09/15/25, indicated, .R104 was reported to have a bruise on his left elbow. R104 is unable to say what occurred. BIMS-03 [Brief Interview for Mental Status], relevant dx: dementia, muscle weakness, bone density disorder. R104 is on anticoagulant and has been care planned for risk of bruising and bleeding There is no evidence that this injury of unknown origin was reported to the SA within the two-hour timeframe. During interview on 01/20/26 at 3:00 PM, the Administrator indicated that there is a two-hour reporting timeframe to report any initial abuse allegations to the SA; however, the Administrator stated that the [name of the state] Department of Health does not include injury of unknown origin within that two hour timeframe to report unless the resident cannot tell staff what happened. Stated that [name of the state] has 24 hours to report injury of unknown origin. In addition, the Administrator said that the facility does not contact the police. Said that the facility leaves that up to the resident, and/or the family. Interview on 01/21/26 at 2:17 PM, LPN4 stated that he worked the 3-11 shift on 09/14/25, and that R104 was noticed throughout the evening shift, pulling on his Geri-sleeves. LPN4 confirmed that the Supervisor was not made aware and indicated that if an incident is unwitnessed, it should be reported immediately. LPN4 stated that he spoke with the Director of Nursing (DON) the next morning. Interview on 01/22/26 at 8:45 AM, CNA2 said that upon beginning her 11-7 shift, she went to change R104 and discovered that R104 had a bruise to the left elbow area. CNA2 reported the bruise immediately to LPN4. Interview on 01/22/26 at 6:15 PM, the DON indicates that he was not unaware that an injury of unknown origin should be reported to the SA within two hours after having knowledge of the incident. NJAC 8:39-9.4(f)

Based on observation, interviews, record review and policy review, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one (Resident (R) 104) of one resident and failed to thoroughly investigate an allegation of physical abuse for R178, out of two residents reviewed for abuse in a sample of 31 residents. This failure had the potential to negatively impact all residents residing at the facility. Findings include: 1.Review of R104's admission Record in the electronic medical record (EMR) under the Census tab revealed R104 was re-admitted to the facility on [DATE] with the diagnosis of dementia. Review of R104's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/25 located in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R104's cognition was severely impaired. Interview on 01/19/26 at 1:40 PM, attempts to interview R104; however, R104 was confused and unable to answer any questions. During interview, observed his skin, which appeared to be paper thin. R104 was wearing Geri-sleeves on bilateral arms. Review of the facility provided Nursing Note dated 09/14/25 indicated, 11:20 PM: Certified Nursing Assistant [(CNA) 2] informed writer [Licensed Practical Nurse (LPN) 4] while giving report, R104 has hematoma on the left elbow. No evidence of injury of unknown origin was reported to the supervisor. Review of facility provided [name of state] Department of Health Facility Information Reporting Category Long Term Care, (initial report) dated 09/15/25 indicated, .R104 was reported to have a bruise on his left elbow. R104 is unable to say what occurred.R104 is on anticoagulant. Review of facility provided undated Reportable Event Summary (5-day summary) indicated, History: On 09/14/25 at around 11 PM, [CNA 2] was providing care to R104 when she noticed discoloration on his left elbow. Conclusion: A thorough investigation was conducted, including skin assessment, resident interview, review of risk factors and care plan interventions. The bruise was first noted on 09/14/25 at around 11:00 PM, and no injuries were observed the day prior during bathing, making the shower the most probable cause . Review of the investigation revealed that there was no evidence of residents' interviews, and no evidence of LPN4's interview. Interview on 01/21/26 at 2:17 PM, LPN4 stated that he worked the 3-11 shift on 09/14/25 and that throughout the evening shift, R104 was pulling on his Geri-sleeves. LPN4 indicated that he wrote a progress note after he was notified of the bruised area on R104's left elbow area. LPN4 stated that he spoke with the Director of Nursing (DON) the next morning. Interview on 01/22/26 at 8:45 AM, CNA2 said that at the beginning her 11-7 shift, she went to change R104 and discovered that R104 had a bruise to left elbow area. CNA2 reported the bruise immediately to LPN4. Interview on 01/22/26 at 6:15 PM, the DON confirmed that LPN4 was not spoken to during the investigation. Interview on 01/22/26 at 6:50 PM, the DON indicated since this was an injury of unknown origin, no resident interviews would be conducted. 2.Review of R178's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD). Review of R178's annual MDS with an ARD of 11/01/25 and in the EMR under the MDS tab revealed a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Review of R178's Nurse's Note dated 01/13/26 at 7:00 PM and located in the EMR under the Notes'' tab written by Registered Nurse (RN) 4 revealed, On 1/11/25 around 7:00 PM resident has a care concerned with her CNA [CNA9]. CNA immediately removed from assignment . Review of the undated Facility's Five Day Follow Up revealed the incident was 01/11/25 at 7:00 PM, R178 reported to the supervisor that she was looking for her cell phone when the assigned aide, [CNA9] insisted on putting her to bed first, then looking for her phone. R178 stated that the aide proceeded to grab her arm and remove her dress with force. R178 started screaming that she was hurting her arm. The summary and conclusion indicated, The facility is substantiating staff to resident abuse at this time. Further review of the investigation revealed not all staff working were interviewed, there was no documentation of the roommate's interview or other residents' interviews. During an interview on 01/22/26 at 5:22 PM, the DON stated that they did not document the roommate or other residents' interviews, but they were done. He stated they did not interview additional staff since the roommate confirmed the abuse, they did not feel the need to do additional interviews. Review of the facility's policy titled, Investigation, Incident and Reporting revised 02/19/25, indicated, [name of the facility] is committed to.abuse-free environment. All staff are required to report any allegation or suspicion of abuse, neglect, exploitation, or mistreatment immediately. The facility will ensure that all incidents are. investigated promptly and thoroughly, and that corrective actions are taken, as necessary. Policy Interpretation and Implementation.3. Initiation of Investigation: The Administrator or designee will initiate a thorough investigation within 24 hours of receiving the report. The investigation may include: Interviewing the resident(s), witnesses, and involved staff Reviewing medical records, assignments, and surveillance (if available) Examining physical evidence or the environment All interviews and findings will be documented in a confidential investigation report. NJAC 8:39-9.4(f)

Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed for one resident (Resident (R) 9 one of resident reviewed for PASARR out of 31 sampled residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed.Findings include:Review of R9's''admission Record'' located in the ''Profile'' tab of the EMR revealed R9 admitted to the facility on [DATE] with diagnoses including bipolar disorder and post-traumatic stress disorder (PTSD). Review of R9's Diagnosis List revealed bipolar disorder, and post-traumatic stress disorder (PTSD) dated 12/27/25. Review of R9's NJ [New Jersey] Department of Human Services Pre-admission Screening and Resident Review (PASRR) Level I screen dated 12/24/25 and located in the EMR under the Miscellaneous tab revealed no indication of mental illness was identified. During an interview on 01/22/26 at 9:45 AM, the Social Services Director (SSD) reviewed R9 PASARR Level I. She was unable to provide an additional Level I that was completed accurately and timely. During an interview on 01/22/26 at 5:22 PM, the Director of Nursing (DON) said he expected staff to complete assessments timely and accurately. NJAC 8:39-5.1(a)

Based on observation, record review, interview and policy review, the facility failed to ensure an active physician order for oxygen administration for one of one resident (Resident (R) 93) reviewed for oxygen administration of 31sample residents This failure had the potential for the residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen).Findings include:Review of R93's admission Record located in the Profile tab of the electronic medical record (EMR) revealed admitted on [DATE] with diagnosis of acute and chronic respiratory failure. Review of R93's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/29/25, revealed a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R1 was severely cognitively impaired. Review of R93's Care Plan located under the Care Plan tab of the EMR dated 12/29/25 revealed the resident was not care planned for oxygen. Review of R93's Physician Orders located under the Orders tab in the EMR, dated 01/20/25, revealed no current order for oxygen. During observations on 01/19/25 at 8:13 AM, 01/20/25 at 10:15 am and on 01/22/26 at 8:35 AM the resident was lying in bed using a nasal cannula and the oxygen cannister was set at two liters per minute (LPM). During an interview on 01/22/25 at 8:45 AM, Registered Nurse (RN)1 confirmed R9 received oxygen and that a resident should not receive oxygen without a physician order. During an interview on 01/22/26 at 5:22 PM, the Director of Nursing (DON) stated that a resident should not received oxygen without a physician order. Review of the facility's policy titled Oxygen Administration dated 11/15/25 revealed the purpose of this procedure is to provide guidelines for safe oxygen administration'. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocolfor oxygen administration. Review the resident's care plan to assess any special needs of the resident. NJAC 8:39-27.1(a)

Based on observations, policy review, and interviews, the facility failed to ensure that staff changed gloves when going from a soiled to a clean area while providing wound care for one of two residents (Resident (R) 78) reviewed for wound care to prevent possible cross contamination. In addition, the facility failed to ensure that staff cleansed the indwelling urinary catheter and changed gloves when going from a soiled to a clean area, for one of two residents (R78) observed for catheter care, to prevent possible urinary tract infections. Findings include: 1. During catheter observation on 01/21/26 at 9:33 AM with Registered Nurse (RN) 1, gathered all the catheter items, applied her personal protective equipment (PPE). RN1 sanitized her hands and donned gloves. RN1 unfastened R78's incontinence brief and completed peri-care; however, RN1 did not clean the catheter. Without changing her gloves, RN1 rinsed R78's perineal area, and patted dry. RN1 removed the basins, doffed the gloves, and sanitized her hands. 2. During wound care on 01/21/26 at 9:38 AM, RN1 gathered supplies and placed the items on the barrier. RN1 sanitized her hands and donned gloves. RN1 cleansed the wound, patted the wound dry and dressed the wound per physician orders, while wearing the same gloves. Afterwards, RN1 adjusted R78's bed linen and R78's incontinence brief. RN1 doffed the gloves and sanitized her hands. Interview on 01/21/26 at 5:18 PM, RN1 confirmed that she should have changed her gloves when going from a soiled to a clean area during the catheter care and wound care. RN1 said that during catheter care she mainly focused on washing the resident and not the catheter unless the catheter is visually soiled. RN1 denied R78's catheter was soiled. Interview on 01/22/26 at 9:10 AM, the Director of Nursing (DON) confirmed that gloves are to be changed when going from a dirty area to a clean area. In addition, the DON confirmed that staff are to clean the catheter when completing catheter care. Review of the facility's policy titled, Catheter Care, Urinary revised 11/15/25 indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Steps in the Procedure .f. If indwelling catheter is in place .v. Anchor the catheter with one hand and clean the catheter where it exits the urethra by wrapping the catheter in the washcloth/wipe and using a twisting motion, vi. Move your hand to where you just cleaned and wash the reminder of the catheter to beyond where securement device will be.Review of the facility's policy titled, Personal Protective Equipment-Using Gloves revised 02/16/25 indicated, To establish guidelines for the proper use of gloves to ensure hygiene, safety, and infection control in healthcare settings.Guidelines for Glove Use.4. Use non-sterile primarily to prevent contamination of the employee's hands when treating patients or cleaning contaminated surfaces. NJAC 8:39-19.4

Complaint: 268245 Based on interviews, review of medical records, and review of pertinent facility documentation, it was determined that the facility failed to notify the resident's physician of a change in condition for 1 of 3 residents (Resident #3) reviewed. This deficient practice was evidenced by the following:A review of Resident #3's Closed Medical Record's admission Record revealed that Resident #3 was admitted to the facility with diagnoses which included but were not limited to acidosis, unspecified (condition in which there is too much acid in the body fluids); major depressive disorder, recurrent, unspecified (mood disorder that causes a persistent feeling of sadness and loss of interest); difficulty in walking, not elsewhere classified; muscle weakness (generalized); need for assistance with personal care; other lack of coordination; and cognitive communication deficit (condition that affects a person's ability to communicate effectively and efficiently). A review of the Minimum Data Set (MDS), an assessment tool dated 09/29/2025, revealed that Resident #3 had a brief interview for mental status (BIMS) score of eight out of 15, which indicated that the resident had moderately impaired cognition. A review the Care Plan (CP) for Resident #3 revealed a focus area of, RISK FOR PAIN: [Resident #3] needs pain monitoring/management [related to]: generalized discomfort. With an initiation date of 09/22/2025. Interventions initiated on 09/22/2025 included to administer non-pharmaceutical pain relief measures; administer pain medications as per orders; encourage reporting of breakthrough pain to staff before it escalates; monitor for complaints of pain and encourage reporting of pain before it escalates; and monitor for effectiveness of pain interventions and, Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Further review of the CP for Resident #3 revealed a focus initiated on 10/02/2025 that the resident had communication problems related to making their self understood and understanding others. Interventions initiated on 10/02/2025 included but were not limited to anticipating and meeting the resident's needs. A review of Physical Therapy Encounter Notes (PTEN) for Resident #3 with a date of service of 10/10/2025, revealed that Resident #3 stated that they had constant left hip pain rated as five out of ten at rest, and eight out of ten pain with movement. The PTEN further revealed that Resident #3 was unable to move their left leg through its full range of motion due to pain. A review of the Progress Notes (PNs) for Resident #3 was conducted. The PNs included a Nursing Note (NN) written by a Licensed Practical Nurse (LPN #1), dated 10/10/2025 at 2:33 AM, which revealed that Resident #3 had an unwitnessed fall at 1:45 AM, and denied pain. The PN further revealed that Resident #3's family and physician were notified. A late entry NN written by the Unit Manager (UM #1) dated 10/10/2025 at 11:17 AM, revealed that Resident #3 complained of pain, and it was endorsed to the resident's primary nurse to obtain a physician order (PO) for pain medication, and administer pain medication as per doctor's orders. A PN by the Nurse Practitioner (NP #1) dated 10/10/2025 at 2:58 PM, revealed that Resident #3 had mild discomfort to their left hip and x-rays were requested. A PN by the Director of Nursing (DON) dated 10/10/2025 at 5:06 PM, revealed that a family member of Resident #3 reported that the resident was in pain that morning. The PN further revealed that Resident #3 reported five out of ten pain when attempting to move their left leg. A PN written by LPN # 2 dated 10/10/2025 at 7:32 PM, revealed that Resident #3 was sent to the hospital for left hip pain at approximately 6:00 PM. The PNs revealed no documentation that a physician was notified that Resident #3 developed constant left hip pain that worsened with movement and limited the resident's ability to move their leg as usual. A review of the Order Summary Report (OSR) for Resident #3 revealed the following POs: X-ray of the left hip and knee to rule out fracture (broken bones) after a fall. The order date was 10/10/2025. Send to the emergency department for evaluation of left hip pain. The order date was 10/10/2025. The OSR revealed no orders for pain medications or non-pharmaceutical methods for pain relief. On 11/05/2025 at 1:16 PM, a telephone interview was conducted with LPN #3, the nurse assigned to care for Resident #3 on day shift on 10/10/2025. LPN #3 stated that on 10/10/2025 she was assigned to give medication at the facility and was assisted by UM #1. LPN #3 stated that she did not remember details related to Resident #3. On 11/05/2025 at 1:35 PM, a telephone interview was conducted with the Unit Manager (UM #1). UM #1 stated that on 10/10/2025 he evaluated Resident #3 with NP #1 in the morning and the resident seemed to be in pain. UM #1 stated that he instructed LPN #3 to give pain medication to Resident #3 because the resident's family member reported that the resident was in pain. UM #1 stated that it was the responsibility of the resident's primary nurse to contact the resident's physician, inform them that the resident was in pain, and obtain POs for medication. UM #1 further stated that LPN #3 confirmed that she would notify the resident's physician that the resident was in pain and would get an order for pain medication. An interview was conducted with the DON on 11/05/2025 at 2:24 PM. The DON stated that it was LPN #3's responsibility to follow up with a physician about Resident #3's reports of pain. The DON stated that UM #1 could also have followed up with the resident's physician. The DON stated that physician notification of the Resident #3's pain was not documented, and no order was obtained for pain medication. The DON stated that LPN #3 did not follow the policies and procedures that the facility had in place. The DON further stated that if those things were not done harm could have been caused to the resident. An interview was conducted with NP #1 on 11/05/2025 at 3:46 PM. NP #1 stated that although her PN was timed at 2:58 PM, she had actually seen Resident #3 and ordered an x-ray in the morning. NP #1 could not recall if she had ordered pain medication for Resident #3. NP #1 further stated that at around dinner time on 10/10/2025 the DON called to request a prescription for tramadol (an opioid medication used to treat moderate to severe pain) for Resident #3, then asked her to disregard the request because the resident was going to the emergency department. A review of the facility policy, Change in a Resident's Condition or Status, with a date reviewed/revised of 06/23/2025 was conducted. The facility policy revealed under Policy Statement, that the facility promptly notifies the resident, their attending physician, and the resident representative of changes in the resident's medical/mental condition or status. Under, Policy Interpretation and Implementation, the facility policy revealed, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): [.] d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; [.] 2. A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'). A review of the facility policy, Pain Assessment and Management, dated 09/04/2025 was conducted. Under, Reporting, the facility policy revealed, Report the following to the physician or practitioner: 1. New pain or significant changes in the level of the resident's pain post incident; N.J.A.C. 8:39-13.1 (d)

COMPLAINT #: 2648245 Based on interviews, review of medical records, and review of pertinent facility documents, it was determined the facility failed to a.) assess and document a resident's pain level; b.) obtain orders for pain management; and c.) re-evaluate and document the effectiveness of pain management in accordance with professional standards of practice. This deficient practice was identified 1 of 3 residents reviewed for pain management (Resident #3), and was evidenced by the following:A review of Resident #3's Closed Medical Record's admission Record revealed that Resident #3 was admitted to the facility with diagnoses which included but were not limited to acidosis, unspecified (condition in which there is too much acid in the body fluids); major depressive disorder, recurrent, unspecified (mood disorder that causes a persistent feeling of sadness and loss of interest); difficulty in walking, not elsewhere classified; muscle weakness (generalized); need for assistance with personal care; other lack of coordination; and cognitive communication deficit (condition that affects a person's ability to communicate effectively and efficiently). A review of the Minimum Data Set (MDS), an assessment tool dated 09/29/2025, revealed that Resident #3 had a brief interview for mental status (BIMS) score of eight out of 15, which indicated that the resident had moderately impaired cognition. A review of the Care Plan (CP) for Resident #3 revealed a focus area of, RISK FOR PAIN: [Resident #3] needs pain monitoring/management [related to]: generalized discomfort. With an initiation date of 09/22/2025. Interventions initiated on 09/22/2025 included to administer non-pharmaceutical pain relief measures; administer pain medications as per orders; encourage reporting of breakthrough pain to staff before it escalates; monitor for complaints of pain and encourage reporting of pain before it escalates; and monitor for effectiveness of pain interventions and, Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Further review of the CP for Resident #3 revealed a focus initiated on 10/02/2025 that the resident had communication problems related to making their self understood and understanding others. Interventions initiated on 10/02/2025 included but were not limited to anticipating and meeting the resident's needs. A review of the Order Summary Report (OSR) for Resident #3 revealed the following physician's orders (POs): X-ray of the left hip and knee to rule out fracture (broken bones) after a fall. The order date was 10/10/2025. Send to the emergency department for evaluation of left hip pain. The order date was 10/10/2025. The OSR revealed no orders for pain medications or non-pharmaceutical methods for pain relief. A review of the October 2025 Medication Administration Record (MAR) for Resident #3 revealed no documentation that pain medication was administered to Resident #3. A review of the October 2025 Treatment Administration Record (TAR) for Resident #3 revealed no documentation that non-pharmaceutical methods of pain relief were provided to Resident #3. A review of the Progress Notes (PNs) for Resident #3 was conducted. The PNs included a Nursing Note (NN) written by a Licensed Practical Nurse (LPN #1), dated 10/10/2025 at 2:33 AM, which revealed that Resident #3 had an unwitnessed fall at 1:45 AM, and denied pain. A late entry NN written by the Unit Manager (UM #1) dated 10/10/2025 at 11:17 AM, revealed that Resident #3 complained of pain, and it was endorsed to the resident's primary nurse to obtain a PO for pain medication, and administer pain medication as per doctor's orders. A late entry NN written by UM #1 dated 10/10/2025 at 11:20 AM, revealed that Resident #3 expressed pain in their left leg and it was endorsed to the resident's primary nurse to assess for pain and administer pain medication. A PN by the Nurse Practitioner (NP #1) dated 10/10/2025 at 2:58 PM, revealed that Resident #3 had mild discomfort to their left hip and x-rays were requested. A PN by the Director of Nursing (DON) dated 10/10/2025 at 5:06 PM, revealed that a family member of Resident #3 reported that the resident was in pain that morning. The PN further revealed that Resident #3 reported five out of ten pain when attempting to move their left leg. Resident #3 and their family member agreed to have the resident sent to the emergency department for evaluation. A PN written by LPN # 2 dated 10/10/2025 at 7:32 PM, revealed that Resident #3 was sent to the hospital for left hip pain at approximately 6:00 PM. The PNs revealed no documentation that non-pharmaceutical pain relief methods or pain medications were provided to Resident #3 after facility staff became aware that the resident complained of pain on 10/10/2025 at 11:17 AM, prior to the resident's transfer to the emergency department at 6:00 PM that day. A review of Physical Therapy Encounter Notes (PTEN) for Resident #3 with a date of service of 10/10/2025, revealed that Resident #3 stated that they had constant left hip pain rated as five out of ten at rest, and eight out of ten pain with movement. The PTEN further revealed that Resident #3 was unable to move their left leg through its full range of motion due to pain. A telephone interview was conducted with LPN #1 on 11/05/2025 at 12:29 PM. LPN #1 stated that after Resident #3 fell in the early morning of 10/10/2025 no orders were obtained because the resident did not have any symptoms. LPN #1 stated that he did not recall who he endorsed the resident's care to the next morning but stated that he explained the resident's situation and needs. On 11/05/2025 at 1:16 PM, a telephone interview was conducted with LPN #3, the nurse assigned to care for Resident #3 on day shift on 10/10/2025. LPN #3 stated that on 10/10/2025 she was assigned to give medication and was assisted by UM #1. LPN #3 stated that she did not remember Resident #3 or whether she gave the resident pain medication. LPN #3 stated that if she had administered any medication, it would have been documented in the electronic medical record. LPN #3 further stated that if a medication administration was not documented in the electronic record that meant that she did not administer the medication. A telephone interview was conducted with UM #1 on 11/05/2025 at 1:35 PM. UM #1 stated that on 10/10/2025 he instructed LPN #3 to give pain medication to Resident #3 because the resident's family member reported that the resident was in pain. UM #1 stated that it was the responsibility of the resident's primary nurse to contact the resident's physician, inform them that the resident was in pain, and obtain POs for medication. UM #1 further stated that LPN #3 confirmed that she would notify the resident's physician that the resident was in pain and would get an order for pain medication. An interview was conducted with a Certified Nursing Assistant (CNA #1) on 11/05/2025 at 1:55 PM. CNA #1 stated that Resident #3 was in a lot of pain on 10/10/2025 and she informed UM #1. CNA #1 stated that when she attempted to sit Resident #3 up in bed the resident was, screaming ouch, and informed her and UM #1 that they had pain in their left hip and leg. CNA #1 stated that throughout the day on 10/10/2025, Resident #3's pain did not improve. CNA #1 further stated that the next day Resident #3's family member informed her that the Resident #3 had broken their hip. An interview was conducted with the DON on 11/05/2025 at 2:24 PM. The DON stated that it was LPN #3's responsibility to follow up with a physician about Resident #3's reports of pain. The DON stated that UM #1 could also have followed up with the resident's physician. The DON stated that assessment of Resident #3's pain was not documented, physician notification of the resident's pain was not documented, and no order was obtained for pain medication. The DON stated that LPN #3 did not follow the policies and procedures the facility had in place. The DON further stated that if those things were not done harm could have been caused to the resident. A review of the facility policy, Pain Assessment and Management, dated 09/04/2025 was conducted. Under General Guidelines, the policy revealed, 1. The pain management program is based on a facility-wide commitment to the appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences related to pain management. Under Pain Management: the facility policy revealed, 1. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Under, Documentation the facility policy revealed, Document the resident's reported level of pain with adequate detail [.] as necessary and in accordance with the pain management program. Under Reporting, the facility policy revealed, Report the following to the physician or practitioner: 1. New pain or significant changes in the level of the resident's pain post incident; NJAC 8:39-27.1(a)

Complaint #NJ00172165 REFER to F610 Based on observations, interviews and record review, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and follow facility policy and procedures for reporting for a) allegations of abuse (Sampled Resident #6, unsampled Resident #25 and #54), and b) a missing wallet with a resdient's identification (Resident #15). The deficient practice was identified for four (4) of nine (9) residents reviewed for investigations and was evidenced by the following: 1. On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time. The surveyor reviewed the medical record for Resident #6. According to the quarterly Minimum Data Set (MDS) (an assessment tool) dated 5/8/24, reflected that the resident had diagnoses which included but not limited to; depression, morbid obesity and heart failure. The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated an intact cognition. On 8/6/24 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#2). The form indicated Resident does not feel safe when CNA#1 and CNA#2 were caring for him/her and does not want them on his/her assignment. Resident stated they are mean and rude. The form was referred to nursing and signed by the Director of Social Work (DOS), who was the Grievance Official (GO), on 5/24/24. According to the form, the corrective action taken to rectify the concern, indicated that Education provided to CNAs regarding: abuse prevention, resident's rights, customer service and reassignment. It was signed by the Director of Nursing (DON). The form had a Final Review by Grievance Official: Nature of Concern/Grievance: CNA interaction signed by the LNHA and GO and dated 5/28/24. There was no indication that a report was sent to the NJDOH. Further review of the attached Investigation Statement Form revealed that the date of the incident was 5/18-5/19 (reported 5/23/24) and the type of investigation was issues with CNA #1 and CNA #2. The SW documented follow up interviews with two alert and oriented residents, unsampled Residents #25 and #54 on 5/23/24, that were under the care of CNA #1 and CNA #2. The SW indicated on the form that unsampled Resident #54 made a statement that CNA #2 is just not compassionate. He/She doesn't want CNA #2 on his/her assignment as he/she does not feel good with CNA #2. The unsampled Resident #54 made a statement that CNA #2 took soda and chips from the resident's tray and the resident had to ask for them back. In addition, the Investigation Statement Form revealed a follow up interview with unsampled Resident #25 who, according to the statement, indicated that CNA #1 made him/her feel humiliated by being exposed during care. The form reflected that the unsampled Resident #25 had requested that CNA #1 not be on their assignment. There was no indication that a report was sent to the NJDOH. On 8/6/24 at 10:17 AM, the surveyor interviewed the LNHA regarding the Complaint/Grievance Form dated 5/23/24 for Resident #6. The LNHA confirmed that there was no report to the NJDOH. The LNHA stated that the incident was treated as a grievance and not reported because Resident #6 had a history of fixating on their care and was saying that the CNAs were rude and mean and unsure what that meant because the resident had requested specific CNAs in the past. The LNHA stated that both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents. The LNHA acknowledged that after reading the wording on the form, that she should have completed a report to the NJDOH. The LNHA stated that the DOSW/GO and SW had done the statements. The LNHA stated that the Director of Nursing (DON) was currently not available and the DOSW/GO was currently on leave. The LNHA added that she could not recall why a report was not done and needed to do a review. On 8/6/24 at 10:49 AM, the LNHA returned to discuss Resident #6 in the presence of the survey team. The LNHA stated that she had not reported because Resident #6 is usually very selective with CNAs and had asked for reassignments of CNAs in the past. The LNHA added that in general the alert and oriented residents on the floor were particular about who they want to care for them and it is not unusual for the residents to request certain CNAs. The LNHA stated that none of the three residents had initiated a concern and Resident #6 had been told in the past to immediately report any issues. The LNHA acknowledged that according to the wording on the form, the incidents should have been reported to the NJDOH. On 8/6/24 at 11:09 AM, the surveyor interviewed the LNHA in the presence of the survey team. The LNHA stated that the required timeframes referred to in the facility Abuse Policy were to report any allegation of abuse immediately within 2 hours to the NJDOH and complete a NJDOH reportable form within 24 hours. On 8/13/24 at 9:13 AM, the survey team met with the LNHA and DON, the LNHA stated that she was responsible for reporting to the NJDOH. The LNHA also stated that she could not remember back in May why the incident was not reported and stated based on the wording of the report that she should have reported it. 48964 2. The surveyor reviewed the medical record for Resident #15. According to the Annual MDS, dated [DATE], the resident had diagnosis including but not limited to; arthritis and hypertension. The MDS reflected a BIMS score of 11, indicating moderate cognitive impairment. On 08/06/24 at 01:38 PM, the surveyor reviewed the facility's investigation report which indicated that the resident's daughter reported Resident #15's wallet was missing on 03/10/24. The wallet did not contain any money, but did contain Resident #15's driver's license, social security card, and insurance cards. A police report was filed on 03/13/24. After inquiry to the NJDOH by the facility on 03/13/24, the facility reported the above incident. A review of the facility policy for Grievances/Complaints, Filing dated 6/21/24 provided by the LNHA included 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. In addition, The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under the guidelines for reporting abuse, neglect and misappropriation of property, as per state law. A review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/4/23 provided by the LNHA included to investigate and report any allegations within timeframes required by federal and state requirements. N.J.A.C. 8:39-4.1(a)(15), 9.4(f)

REFER to F609 Based on observation, interview and record review, it was determined that the facility failed to conduct a timely and thorough investigation for three (3) of nine (9) residents, (Resident #6 and unsampled Residents #25 and #54), reviewed for alleged violation investigations. The deficient practice was evidenced by the following: On 8/5/24 at 12:10 PM, the surveyor observed Resident #6 participating in conversation and eating lunch at a table with three other residents. The resident stated that they were willing to talk with the surveyor at another time. On 8/6/18 at 10:06 AM, the surveyor reviewed a Complaint/Grievance Form, dated 5/23/24, provided by the Licensed Nursing Home Administrator (LNHA). The form was completed by the Social Worker (SW) and revealed that Resident #6 reported issues and concerns with two CNAs, (CNA#1 and CNA#2). The form indicated Resident does not feel safe when CNA#1 and CNA#2 are caring for him/her and does not want them on his/her assignment. Resident stated they are mean and rude. The form was referred to nursing and signed by the Director of SW (DOSW), who was the Grievance Official (GO), on 5/24/24. According to the form, the corrective action taken to rectify the concern indicated that Education provided to CNAs regarding: abuse prevention, resident's rights, customer service and was signed by the Director of Nursing (DON). The form had a Final Review by Grievance Official: Nature of Concern/Grievance: CNA interaction signed by the LNHA and DOSW/GO and dated 5/28/24. Further review, revealed an attached Investigation Statement Form revealed that the date of the incident was 5/18-5/19 (reported 5/23/24) and the type of investigation was issues with CNA #1 and CNA #2. The SW documented follow up interviews with two alert and oriented residents under the care of CNA #1 and CNA #2. The SW spoke with two unsampled Residents #25 and #54 on 5/23/24. The SW indicated that the unsampled Resident #54 made a statement that CNA #2 is just not compassionate. He/She doesn't want CNA #2 on his/her assignment as he/she does not feel good with CNA #2. The unsampled Resident #54 made a statement that the CNA #2 took soda and chips from the resident's tray and the resident had to ask for them back. In addition, the Investigation Statement Form revealed a follow up interview with unsampled Resident #25 who according to the statement indicated that CNA #1 made him/her feel humiliated by being exposed during care. The form reflected that the unsampled Resident #25 had requested that CNA #1 not be on their assignment. Additionally, attached with the form was another Investigation Statement Form, dated 5/25/24, completed by CNA #2 which indicated that whenever CNA #2 was assigned to Resident #6 they were rude and cursed at CNA #2. The CNA #2 included that the resident had accused her of not paying attention to them. Also attached to the Grievance/Complaint Form was an In-service: Customer Service/Resident Dignity and an In-Service: Abuse Prevention dated 5/25/24 and signed by both CNA#1 and CNA #2. On 8/6/24 at 10:17 AM, the surveyor interviewed the LNHA regarding the Complaint/Grievance Form dated 5/23/24 for Resident #6. The LNHA confirmed that there was no report to the NJDOH and that the Complaint/Grievance Form was complete and there was no further follow up investigation documented. The LNHA stated that the incident was treated as a grievance and not reported because Resident #6 had a history of fixating on their care and saying that the CNAs were rude and mean and unsure what that meant. The LNHA stated that both CNAs were not working on 5/23/24 and were immediately reported to be reassigned from all three residents. The LNHA acknowledged that after reading the wording on the form, that she should have completed a report to the NJDOH. The LNHA stated that the DOSW/GO and SW had done the statements and acknowledged that further investigation documentation was needed. The LNHA stated that the Director of Nursing (DON) was currently not available and the DOSW/GO was currently on leave. The LNHA added that she could not recall why a report was not done and needed to do a review. On 8/6/24 at 10:49 AM, the LNHA returned to discuss Resident #6 in the presence of the survey team. The LNHA stated that she had not reported because Resident #6 was usually very selective with CNAs and had asked for reassignments in the past. The LNHA added that in general the alert and oriented residents on that floor were particular about who they want to care for them, and it was not unusual for the residents to request certain CNAs and/or request not to have certain CNAs. The LNHA stated that none of the three residents had initiated an issue and Resident #6 had been told in the past to immediately report any issues and in general was a very vocal resident. The LNHA acknowledged that according to the wording on the grievance form, the incidents should have been reported to the NJDOH and further investigation documentation should have been done. The LNHA also stated that she was very familiar with Resident #25, who was a very private person, and the resident was educated to report any issues immediately. The LNHA added that Resident #54 was fairly new to the facility and was also educated to report any issues immediately. The LNHA stated that when there were reports regarding CNAs that part of the process was to investigate what had occurred. The LNHA added that it was handled as a grievance because the residents were not in danger and that the residents were not satisfied with the care that they received. The LNHA stated that both CNAs were reassigned immediately as per the request of the residents. The LNHA further explained that the grievance process was used for anything not considered abuse such as a CNA that was rushing them or the CNA was task oriented, and more customer service was needed. The LNHA acknowledged that the way the grievance report read that, there should have been further documentation of the investigation completed. On 8/6/24 at 12:34 PM, the surveyor interviewed the LNHA and the SW regarding the Complaint/Grievance Form. The SW stated that she was the covering DOSW as of 7/8/24. The SW added that she had completed the form and remembered the discussion clearly. The SW stated that she was performing a quarterly care plan discussion with Resident #6 when the resident voiced a concern about the 2 CNAs. The SW stated that she remembered Resident #6 just had not wanted the CNAs to be assigned to them and had not thought that was odd because Resident #6 had asked in the past for certain CNAs to be assigned to them. The SW stated that she completed the form and as a follow up, randomly selected two alert and oriented residents, (unsampled Residents #35 and #54), to interview regarding the 2 CNAs. The SW was unable to speak to whether there were more alert and oriented residents on the CNA's assignments. The SW stated that she always asks the residents if they feel safe and when the answer was no, then she reports that to the LNHA. The SW added that Resident #25 had said she felt humiliated because they were a very private person and does not like having to be cared for and the resident felt strongly that they had not wanted to get anyone in trouble. The SW added that besides not wanting CNA #1, Resident #25 felt safe. The SW added that she should have documented more. The LNHA stated that the DON was also part of the investigation and was returning the next day. The surveyor reviewed the medical record for Resident #6. According to the quarterly Minimum Data Set (MDS) (an assessment tool), dated 5/8/24, reflected that the resident had diagnoses which included but were not limited to; depression, morbid obesity and heart failure. The MDS assessment reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated an intact cognition. On 8/6/24 at 1:46 PM, the surveyor interviewed Resident #6 who stated that they were able to make their needs known and told the nurses which aides they wanted and which aides they did not want. The resident was able to identify two CNAs that they felt were very good and would want all the time. The resident stated that CNA #1 gives them anxiety but was unable to speak to a specific incident or occurrence and stated that they just felt that CNA #1 was reluctant to help them. The resident then added that CNA #1 was friends with CNA #2 and that together they were not good. The resident added that as long as they did not have the aides that they did not want, then they were fine. The resident was not specific as to what the aides that they did not want had done. The resident stated, I can just tell which aides are not good. The resident then stated that he/she has a tendency to get anxious over everything. The resident added that they felt comfortable and was very vocal with the staff. The resident added that they had no recollection of any discussion with the SW. The surveyor reviewed the medical record for Resident #25. According to the quarterly MDS (an assessment tool) dated 5/24/24 reflected that the resident had diagnoses which included but were not limited to; hypertension (high blood pressure) and diabetes (high blood sugar). The MDS assessment reflected that the resident had a BIMS score of 15 out of 15 which indicated an intact cognition. On 8/6/24 at 2:05 PM, the surveyor interviewed the unsampled Resident #25, who stated that she had nothing to say and had no concerns. The resident added that she felt comfortable and could tell the staff their needs. The surveyor reviewed the medical record for Resident #54. According to the quarterly MDS (an assessment tool) dated 7/8/24 reflected that the resident had diagnoses which included but were not limited to; heart failure and pressure ulcers of the right and left heels. The MDS assessment reflected that the resident had a BIMS score of 13 out of 15, which indicated an intact cognition. A review of the medical record for the unsampled Resident #54 revealed that the resident had been sent to the hospital after an outside physician's appointment on 7/30/24 and had not returned to the facility. On 8/9/24 at 10:53 AM , the surveyor interviewed the LNHA and DON regarding the Complaint/Grievance Form. The DON stated that when CNAs were reassigned, the staffing coordinator was informed, and assignment sheets were updated, and all supervisors were made aware and the CNA themselves were aware. The DON added that there were no changes to the assignments allowed unless approved by a supervisor. The DON added that CNA#2 was moved to the second floor. The DON confirmed that both CNAs were inserviced prior to returning to work. The DON acknowledged that there should have been more documentation and statements included when the concerns were reported. The DON and LNHA stated that they had been working on completing the investigations after surveyor inquiry. The LNHA stated that Resident #25 had not wanted to discuss anything further and felt there were too many people in their room looking at them on 5/19/24 but had not wanted to report the issue. The DON added that Resident #25 understood the reason was that the CNA #3 was being helped by CNA #1 because CNA #3 was very new, and CNA #1 noticed some redness on their sacrum and asked CNA #3 to get the nurse who verified the redness. The LNHA added that Resident #25 understood that there was 2 CNAs and a nurse trying to provide care for a medical reason and just preferred not to have CNA #1 assigned to them. The LNHA and DON acknowledged that there was no documentation provided in the Grievance/Complaint form. On 8/9/24 at 11:00 AM, the surveyor was provided investigations for Resident #6 and unsampled Residents #25 and #54 by the LNHA. The LNHA stated that CNA #2 removed a finished meal tray from Resident #54 containing the chips and soda. Then, when the resident expressed wanting the items they were provided. The LNHA acknowledged that the Grievance/Complaint Form had not explained the above. A review of the investigations for Residents #6 and unsampled Residents #25 and #54 were completed and thorough after surveyor inquiry. On 8/9/24 at 12:33 PM, the survey team met with the LNHA and DON. The LNHA stated that she felt that they had made sure all residents were safe, that the identified CNAs were reassigned as per resident requests. The DON added that CNA #2 was assigned to a different floor to separate the 2 CNAs. On 8/13/24 at 9:13 AM, the survey team met with the LNHA and DON. The LNHA stated Based on the wording of the report and no further documentation of statements that there should have been a documented further investigation. A review of the facility policy for Grievances/Complaints, Filing dated 6/21/24 provided by the LNHA included 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. In addition, The grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under the guidelines for reporting abuse, neglect and misappropriation of property, as per state law. A review of the facility policy for Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 10/4/23 provided by the LNHA included to investigate and report any allegations within timeframes required by federal and state requirements. NJAC 8:39-4.1(a)(5), 9.3(d), 13.4(c)2(i-vi)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/05/2024 from 09:30 AM to 10:01 AM, the surveyor, accompanied by the Food Service Director (FSD) of another facility, toured the kitchen, and observed the following: In the walk-in freezer, the surveyor observed two opened packages of biscuits with no dates or labels. The surveyor also noted a tied shut, clear plastic bag of spinach lasagna rolls with no label or dates when opened. The FSD stated there should be opened and use by labels and dates on all opened food in the freezer. On a storage rack, the surveyor observed a stack of three 3rd pans wet nested and a stack of four 6th pans wet nested. The FSD stated they should not be stacked wet. A review of facility provided undated policy titled Food Receiving and Storage revealed under Refrigerated/Frozen Storage: 1.All food stored in the refrigerator or freezer are covered, labeled and dated (use by date) 8. Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Frozen foods will be used by the manufacturer expiration date. If an item has been opened, and open date label will be placed, and the item will follow the manufacturer's expiration date or discarded after 6 months of the open date. A review of facility provided policy titled Sanitization, revised 7/23/2023 revealed: 12. Observe for wet nesting (accumulation of moisture) when pots, pans, and other kitchen products are put to dry. N.J.A.C. 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 8/6/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 26 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.69 %. This deficient practice was identified for one (1) of four (4) residents, (Resident # 268), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: On 8/6/24 at 8:57 AM, the surveyor observed the Registered Nurse (RN) preparing to administer the morning medications to Resident #268. The RN stated that according to the electronic medication administration record (EMAR), the resident had two insulin (a medication used to lower blood sugar) pens (medication provided in the form of an injector pen) to prepare. The RN explained that the pens had to be primed with two (2) units to see the function of the needle. The RN removed the resident's Glargine (Lantus) (a long-acting insulin) 100 units (U)/milliliter (ML) solution pen-injector (a disposable single-patient-use prefilled insulin pen) from the medication cart and removed the pen cap and replaced the cap with a needle cap and placed the Lantus on top of the medication cart in a horizontal position. The RN then removed the Lispro (a short-actin insulin) Kwikpen (a disposable single-patient-use prefilled insulin pen) 100 U/ML solution pen-injector and removed the pen cap and replaced it with a needle cap and placed the Lispro on top of the medication cart in a horizontal position. The RN explained that the pens had to be primed with 2 units to see the function of the needle. The RN then explained to the surveyor that she was not going to be administering all the morning medications at this time because there was an intravenous medication and a Voltaren gel (topical medication to relieve joint pain) until after the resident had finished breakfast. The surveyor observed the RN preparing a total of seven (7) medications for the resident which included the Lispro pen-injector and the Lantus pen-injector. The RN then showed the surveyor that she was dialing a dose of 36 U for the Lantus insulin pen according to the physician's order (PO) on the EMAR. Next, the RN showed the surveyor that she was dialing a total of seven (7) U of the Lispro insulin pen according to a standing PO for five (5) U plus another 2 U according to a sliding scale PO for a blood sugar result of 161. On 8/6/24 at 8:40 AM, the surveyor observed the RN inject the resident's left arm subcutaneously (SC) with the Lispro insulin pen injector that was dialed to 7 U and then the Lantus insulin pen injector that was dialed to 36 U. The surveyor had not observed the RN prime the Lantus and the Lispro insulin pens before administration. (ERROR #1 and #2) Upon returning to the medication cart, the surveyor asked the RN when she had primed the insulin pens. The RN stated that she primed the insulin pens when she removed them from the medication cart and after she put on the needle cap. The RN stated that she dialed the pens to 2 U and pushed the plunger and the plunger went back to zero 0. The RN acknowledged that she had not shown the surveyor the priming of the 2 U and thought that she had done the priming quickly. The RN added that she had primed the insulin pens when they were horizontal on top of the medication cart and with the needle cap on. The RN stated that the only time she removed the needle cap was just before she injected the resident in their room. The RN explained that when she primed the insulin pens by dialing the 2 U and pressing the plunger, the injector pen returned to zero 0 and that meant the pen was working properly. The RN added if there was resistance, or the pen had not returned to 0 then she would have to change the needle. The RN added that she had shown the surveyor that the plunger was at zero 0 before dialing to the doses needed for each insulin pen injector. The RN added that she had training on the technique for insulin pen use but was unsure who had performed the training. On 8/6/24 at 11:24 AM, the surveyor interviewed the Staff Development/Advanced Practice Nurse (SD/APN) who stated that she was employed less than two (2) months at the facility. The SD/APN explained that she would be involved in training the nurses the proper techniques for the medication pass. The SD/APN stated that she was familiar with the proper technique for using an insulin pen injector. The SD/APN explained that the pen injector had to be primed before injecting the dose to make sure the needle was working, and air bubbles were out of the needle. The SD/APN further explained that the pen was primed by dialing two (2) to five (5) units, then taking the needle cap off and holding the pen injector in the vertical position and pushing the plunger. The SD/APN added that this would allow visualizing the insulin liquid come out of the needle. The SD/APN added that all insulin pen injectors were to be primed in the same method. The SD/APN stated that seeing the insulin pen injector plunger return to zero was not an indication that the needle was working and you would have to visualize the insulin liquid. On 8/6/24 at 2:20 PM, the surveyor interviewed the RN who stated that she had spoken with the SD/APN. The RN also stated that she was unaware of needing to hold the insulin pen injector vertically and removing the needle cap to see the insulin liquid when priming. The RN added that she thought the needle was working because the plunger went back to zero. On 8/6/24 at 2:45 PM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that he had done a medication pass inservice in March but was unsure if the inservice included insulin pen technique. The CP also stated that he was aware that priming a pen injector had to be done prior to injecting the dose. The CP also stated that it would be obvious to see the insulin liquid if the needle cap was off but thought leaving the cap on would be acceptable. The CP added that he thought if there was an issue while priming then there would be resistance from the plunger and the plunger would not go back to zero. The CP was unable to speak to whether the instructions indicated that when the plunger returns to zero the priming was completed and would have to check. An inservice titled Med Pass and Expiring meds dated 3/5/24 was performed by the CP was provided by the SD/APN. The inservice included a handout titled Medication Pass and reflected for Injectable Administration to Prime insulin pen prior to each dose. The surveyor reviewed the medical records for Resident #268. A review of the resident's Admission Record reflected that the resident had diagnoses which included but not limited to: type 2 Diabetes (high blood sugar). A review of the resident's Order Summary Report reflected the following: - a PO with a start date of 7/30/24 for Insulin Glargine (Lantus) 100 U/ML solution, inject 36 units SC in the morning for diabetes. -a PO with a start date of 7/29/24 for Insulin Lispro (1 unit dial) subcutaneous solution Pen Injector 100 U/ML (Insulin Lispro), inject 5 units SC with meals for diabetes in addition to sliding scale coverage. -a PO with a start date of 7/29/24 for Insulin Lispro (1 unit dial) subcutaneous solution Pen Injector 100 U/ML (Insulin Lispro), inject as per sliding scale: if 150-199 (blood sugar) = 2 u; 200-249=4 u; 250-299=6 u; 300-349=8 u;350-400=10 u; Call MD for blood sugar greater than 400 or less than 70, SC before meals and at bedtime for diabetes. On 8/7/24 at 1:13 PM, the surveyor interviewed the SD/APN who stated that she had completed a step-by-step safe administration of insulin via insulin pen administration inservice with the RN. The SD/APN had used a manufacturer's specification handout for the Instructions For Use Humalog KwikPen (insulin lispro). On 8/7/24 at 1:46 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and the DON acknowledged that by not following the manufacturer's specifications for priming an insulin pen injector or incorrectly priming an insulin pen injector could affect the dosage of the insulin. (ERROR #1 and #2) On 8/8/24 at 10:36 AM, the surveyor interviewed the CP, who stated that he had looked into the priming of the insulin pen injector and that the needle cap was clear, and that the RN was able to see the insulin liquid in the cap. At that time, the surveyor with the CP interviewed the RN who demonstrated that when the two (2) U were pushed with the plunger and the needle cap was on there was liquid that was able to be seen through the needle cap. The RN acknowledged that during the medication pass, neither insulin pen was held upright and that she had not shown the surveyor the priming. Upon finishing the demonstration, the surveyor and the CP left the medication cart. The CP stated that he thought resistance of the plunger went hand in hand with visualizing insulin and thought there would be resistance when priming the insulin pen if the 2 U had not come out. The CP was unsure if there was documentation regarding the resistance if the 2 U was not visualized. The CP added that he felt the dosage disparity was not significant by not holding the insulin pen vertical and was unsure if there was documentation supporting that. The CP acknowledged that there were specific manufacturer instructions for the use of insulin pen injectors that included instructions on priming and provided the surveyor with a handout on the instructions for the Insulin Lispro KwikPen. The surveyor, with the CP, reviewed the handout and the CP acknowledged that the instructions were specific to hold the pen injector upright (vertically) when visualizing the two (2) U of insulin liquid. The CP was unable to provide any further documentation. A review of the Insulin Pen Injections handout of information provided by the CP reflected that the steps required to properly administer an insulin pen included Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The handout also revealed Step 6: To prime your pen, turn the dose knob to select 2 units. Step 7: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with the needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the Dose Knob in and count to 5 slowly, You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8. A review of the facility policy Medication Administration Guidelines: Insulin Pens, dated as effective 2/2/22, provided by the LNHA reflected that Insulin will be administered in a safe and accurate manner. In addition, the policy reflected for Insulin administration: .j) Remove outer then inner needle caps, k) Prime pen by dialing 2 units or units recommended by manufacturer, with needle pointing up, press injection button with thumb. Look for drops of insulin to come out of tip of needle. A review of Patient & Caregiver Education specifications for How to use an insulin pen revealed Do a safety test (prime the pen). Priming the insulin pen will help you make sure your pen and needle are working like they should. This will also help you make sure that the needle fills with insulin, so you get your full dose. It's important to do a safety test before every insulin injection. NJAC 8:39-11.2(b), 29.2(d)

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for one of seven Quality Assurance and Performance Improvement (QAPI) meetings and was evidenced by the following: A review of the facility provided QAA (Quality Assessment and Assurance) Committee Information updated 06/07/24 revealed: Name: Vacant; Title: Infection Preventionist. A review of the the facility provided In-Service Attendance; Date: 7/12/24; Topic: Q 2024 QAPI Meeting sign in sheet had not revealed the IP attended the meeting. On 08/13/24 at 09:52 AM, during an interview with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated that the required members of the QAPI committee were the administrator, the DON, the IP, the Medical Director, and 2 other staff members. The LNHA acknowledged that the IP had not attended the July 2024 meeting. A review of the facility's Job Description and Performance Standards, Position Title Infection Preventionist RN (Registered Nurse) revealed: The primary functions and responsibilities of this position are as follows: .40. Provide monthly, quarterly, and annual; reports for the Quality Assurance and Performance Improvement Committee to the Administrator. A review of the facility policy 2024 Quality Assurance Performance Improvement Plan revealed: Governance and Leadership .The QAA Committee and its members provide the framework or structure for QAPI. Committee members include the administrator, director of nursing, medical director, infection preventionist . NJAC 8:39-33.1(a)(b)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to have an Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP) who worked at least part-time and had completed specialized training in infection control and prevention (ICP) from 06/08/24 to present. This deficient practice was evidenced by the following: Reference: According to the NJ Executive Directive 21-012 (revised 12/22/22) included The facility's designated individual(s) with training in infection prevention and control shall assess the facility's IPCP by establishing or revising the infection control plan, annual infection prevention and control program risk assessment, and conducting internal quality improvement audits. According to the CMS QSO-22-19-NH Memo dated 6/29/22 and Fact Sheet, Updated Guidance for Nursing Home Resident Health and Safety dated 6/29/22, effective date on October 24, 2022, Overview of New and Updated Guidance, Summary of Significant Changes, included that in Infection Control, requires the facilities to have a part-time IP. While the requirement is to have at least a part-time IP, the IP must meet the needs of the facility. The IP must physically work onsite and cannot be an off-site consultant or work at a separate location. IP's role is critical to mitigating infectious diseases through an effective infection prevention and control program. IP specialized training is required and available. 08/05/24 at 10:50 AM, during entrance conference, the Licensed Nursing Home Administrator (LNHA) stated the facility does not have an Infection Preventionist (IP) at the moment. She further stated that there was no one certified in ICP. On 08/06/24 at 08:53 AM, in the presence of the survey team, the LNHA confirmed that the last day of work for the IP was 06/07/24. On 08/09/24 at 08:57 AM, during an interview with the surveyor, the LNHA stated, I believe the Nursing Supervisor (NS), who does staff education for Personal Protective Equipment (PPE), COVID surveillance and testing, is ICP certified. On 08/09/24 at 12:33 PM, in the presence of the survey team, the LNHA and the Director of Nursing (DON) were made aware of the concerns of no IP since 06/08/24. On 08/13/24 at 08:45 AM, the LNHA provided the surveyor with the NS Center for Disease Control and Prevention (CDC) certification dated 5/16/23. At that time, she confirmed that the NS was not the designated IP. A review of the facility's job description for the Infection Preventionist RN (Registered Nurse) revealed: Purpose of this position: The Infection Preventionist (IP) shall be responsible for contributing to the development of policies, procedures, and training curriculum for the long-term care facility staff based on best practices and clinical expertise. They shall monitor the implementation of infection prevention and control policies and recommending disciplinary measure for staff who routinely violate those policies. The IP will assess the facility's infection prevention and control program by conducting internal quality improvement audits. A review of the facility's policy, Surveillance for Infections reviewed on 01/10/24, revealed: Policy Statement: Surveillance is an essential component of an effective Infection Prevention Control Program. The facility performs surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection. NJAC 8:39-19.1 (b), 19.4(d) (e)

COMPLAINT # NJ 165398 Based on interviews and review of the medical records (MR) it was determined that the facility failed to revise/update a person centered Care Plan (CP) for 1 of 3 residents sampled (Resident #2) who was wandering on another unit. The facility also failed to follow their policy Incident Report. This deficient practice is evidenced by the following; 1. According to the facility Admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to; Alzheimer's disease, dementia, anxiety disorder, Major Depressive Disorder (MDD), and psychosis. A Minimum Data Set (MDS), an assessment tool, dated 6/6/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated severe cognitive impairment, was independent with walking and needed extensive assistance with most activities of daily living (ADLs). A CP, initiated 7/03/2020 and revised on 3/24/23, included the resident had a history of dementia with behaviors which included: 1) Wandering, 2) Poor judgement, 3) Suspicious of others - he/she will think people took his/her belongings and wander into other resident's rooms and take items. The Goals revealed: Will be easily directed and have less incidences of inappropriate behavior of wandering into other's rooms and taking belongings. Interventions/Tasks included: Intervene as necessary to protect the rights and safety of others. Divert attention. Remove from situation and take to alternate location as needed. A 5/2018 Physician Order Summary (POS) revealed an order, initiated on 4/10/2021, for Monitor behavior but did not address wandering as one of the behaviors to be monitored. During an interview on 7/6/23 at 9:28 AM, the Licensed Nursing Home Administrator (LNHA) stated residents on 2 North are supervised by all staff so they will not access the elevators or walk into other resident's rooms and staff are instructed to redirect them. The LNHA further stated, Resident #2 wandered into another resident's room on 2 South and took a nap on the resident's chair. The nursing staff redirected Resident #2 back to his/her room. A review of the Complaint/Grievance form dated 6/26/23, noted Resident #2 was found sleeping on a chair in another resident's room on 2 South by the resident's spouse. Under Corrective Actions Taken to Rectify Concern, Resident #2 was redirected back to his/her room with no further issues. A review of the Summary Statement written by the Director of Nursing (DON) noted We will continue to closely monitor Resident #2 and redirect him/her to the 2 North side of the facility. His/her care plan has been updated to reflect that he/she has the tendency to wander into other resident's rooms. During an interview on 7/6/23 at 12:46 PM, the DON stated the Certified Nursing Assistants (CNAs) monitor residents in 2 North, but they don't have a rounding schedule, it was developing at this time. The DON further stated during the overnight shift, hourly rounding was done to make sure everyone was where they are supposed to be. However, there was no documentation to support this. The DON stated he did a written report about Resident #2 being in another resident's room, for him to file and keep track. Further review of Resident #2's CP revealed no further updates to address the wandering incident on 6/26/23. There were also no new interventions put in place to prevent further wandering into the other unit. A review of the facility policy, Incident Report, under 11. The licensed nurse or other departmental staff member completing the incident report should also update the resident's care plan to include the issue/problem and new interventions. NJAC: 8:39-11.2 (e) (2) NJAC: 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified in 1 of 3 nursing units during 4 of 4 meal observations and was evidenced by the following: 1. On 10/26/22 from 12:11 PM to 12:52 PM, the surveyor made the following meal observations in the dining room on the Third-Floor: There were 18 residents observed, who were all seated at dining tables. The Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that the first lunch truck usually arrived around 11:30 AM. At 12:14 PM, the surveyor observed the first dining truck arrived in the Third-Floor dining room. The staff began serving the trays immediately. At 12:30 PM, the surveyor observed Resident #10 in the dining room, watching other residents eat lunch, and communicating to their tablemate that they were hungry. At 12:30 PM, the surveyor observed Resident #20 watching other residents eat lunch, stated they were still waiting for their lunch tray. The Certified Nursing Aide (CNA) replied that the North food truck had not yet arrived and further stated that there were two other residents still waiting as well. At 12:30 PM, the surveyor observed the second dining truck arrived in the Third-Floor dining room. The staff began serving the trays immediately. At 12:47 PM, the surveyor observed the third dining truck arrived in the Third-Floor dining room and food was immediately served by the staff. At 12:48 PM, the surveyor observed Resident #10 was served their lunch tray. At 12:49 PM, the surveyor observed Resident #7 was served their lunch tray. At 12:50 PM, the surveyor observed Resident #20 was served their lunch tray. 2. On 10/27/22 between 11:28 AM and 12:05 PM, the surveyor made the following meal observations in the dining room on the Third-Floor: At 11:28 AM, the surveyor observed the first dining truck arrived in the Third-Floor dining room. The staff began serving the trays immediately. Eight of the nine residents were served. At 11:35 AM, the surveyor interviewed the Activity Aide (AA) who stated that the residents should be served by tables, but that it was not possible because the trays do not arrive on the floor at the same time; they come up on different trucks. At 11:45 AM, the surveyor observed Resident #115 watching other residents eat lunch, stated that they were hungry. The Licensed Practical Nurse (LPN) replied, where is your food? At 12:01 PM, the surveyor observed Resident #115 was served their lunch tray. 3. On 10/28/22 from 11:15 AM to 12:19 PM, the surveyor made the following meal observations in the dining room on the Third-Floor: At 11:15 AM, the surveyor observed the first meal truck arrived in the Third-Floor dining room. The staff began serving the trays immediately. The surveyor observed nine of the eleven residents in the dining room received their lunch trays. At 11:37 AM, the surveyor observed the second dining truck arrived in the Third-Floor dining room. At 11:40 AM, the surveyor observed two residents (Resident# 69 and #72 ) still had not received their lunch tray. At 11:45 AM, the surveyor observed Resident #69 was served their lunch tray. At 12:02 PM, the surveyor observed Resident #72 was served their lunch tray. 4. On 10/31/22 from 11:23 AM to 11:48 AM, the surveyor made the following meal observations in the dining room on the Third-Floor: At 11:23 AM, the surveyor observed the first meal truck arrived in the Third Floor dining room. The staff began serving the trays immediately. The surveyor observed eleven of the twelve residents in the dining room received their lunch trays. At 11:32 AM, the surveyor observed the second dining truck arrived in the Third-Floor dining room. At 11:38 AM, the surveyor observed the third dining truck arrived in the Third-Floor dining room. At 11:46 AM, the surveyor observed Resident #221 watching another resident who was assisted to the dining room and be served immediately. At 11:48 AM, the surveyor observed Resident #221 was served their lunch tray. Resident #221 stated he/she had chosen the chef's salad from the menu, not chicken. At that time, the Dietary Aide (DA) went to the kitchen to get the chef's salad. At 11:53 AM, thirty minutes after the meal service began and several of the residents had finished their lunch, the surveyor observed Resident #221 received their chef salad. On 10/31/22 at 11:55 AM, the surveyor interviewed the LPN/UM who acknowledged that Resident #221 should have been served at the same time as the other residents. The LPN/UM further stated that she had provided the kitchen with a list of residents who eat in the dining room so that all of those trays would be delivered at the same time and that they were still working on it. A review of the Meal Times List revised 2/1/2020, provided by the Licensed Nursing Home Administrator (LNHA) on 10/26/22 at 9:34 AM, reflected that residents on the Third-Floor who ate in their rooms were served lunch trays at 11:30 AM and residents who ate in the dining room were served lunch trays at 12:15 PM. The list further indicated that residents who ate in their rooms were served dinner at 4:30 PM, and residents who ate in the dining room were served at 5:00 PM. On 10/27/22 at 9:30 AM, the surveyor interviewed the LNHA who stated that the facility had new mealtimes and provided the surveyor with another Meal Times List revised 8/15/22, which reflected that lunch meal service on the Third-Floor started at 11:00 AM; 3-South meal times were 11:20 AM/11:30 AM and 3-North meal times were 11:40 AM/11:50 AM. The list further indicated that residents who resided on 3-South received dinner at 4:20 PM/4:30 PM and residents who resided on 3-North received dinner trays at 4:40 PM/ 4:50 PM. The list did not include the meal service times for residents who ate in the dining rooms. A review of the Resident Meal Service and Meal Times policy dated effective 1/1/19 included to ensure meals are served in a manner that provides quality service and enhances the meal experience for all residents; to ensure that meals are served I a timely and efficient manner while offering a sufficient span of time for residents to obtain their meals . On 11/2/22 at 11:15 AM, the LNHA in the presence of the Director of Nursing (DON), and survey team acknowledged that residents who ate in the Third Floor dining room should have been served at the same time. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 11 out of 14 day shifts reviewed during a two-week period prior to survey and for 3 of 5 day shifts observed on the Third-Floor nursing unit. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. On 10/25/22 at 10:45 AM, the surveyor requested from the Director of Nursing (DON) to complete the Nurse Staffing Report for the past two weeks at the facility. On 10/25/22 at 11:41 AM, the surveyor asked CNA #1 on the Third-Floor nursing unit what her assignment was for the day. CNA #1 stated she was on light duty, so she did not have an assignment, but provided the surveyor with a copy of the Third-Floor CNA Assignment sheet for 10/25/22. The sheet revealed there were three CNAs assigned to fifty-two residents. On 10/25/22 at 11:43 AM, the surveyor interviewed CNA #2 who stated the facility was short staffed today, so he was assigned to residents on both sides of the Third-Floor nursing unit. When asked how many residents he was assigned for the day, he replied eighteen. At this time, the surveyor reviewed the CNA Assignment sheet for 10/25/22, which confirmed CNA #2 was assigned eighteen residents for that shift. On 10/26/22 at 11:11 AM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility used two Agency staffing companies to provide nursing staff as needed. At this time, the LNHA provided the requested Nurse Staffing Report completed by the facility for the weeks of 10/9/22 to 10/15/22 and 10/16/22 to 10/22/22, which revealed the staffing to resident ratios that did not meet the minimum requirement of 1 CNA to 8 residents for the day shift as documented below: 10/9/22 had 12 CNAs for 120 residents on the day shift, required 15 CNAs. 10/11/22 had 13 CNAs for 120 residents on the day shift, required 15 CNAs. 10/12/22 had 14 CNAs for 120 residents on the day shift, required 15 CNAs. 10/14/22 had 13 CNAs for 120 residents on the day shift, required 15 CNAs. 10/15/22 had 11.5 CNAs for 120 residents on the day shift, required 15 CNAs. 10/16/22 had 12 CNAs for 123 residents on the day shift, required 15 CNAs. 10/18/22 had 14 CNAs for 122 residents on the day shift, required 15 CNAs. 10/19/22 had 13 CNAs for 119 residents on the day shift, required 15 CNAs. 10/20/22 had 14 CNAs for 119 residents on the day shift, required 15 CNAs. 10/21/22 had 12 CNAs for 119 residents on the day shift, required 15 CNAs. 10/22/22 had 12.5 CNAs for 119 residents on the day shift, required 15 CNAs. On 10/28/22 at 11:07 AM, the surveyor interviewed CNA #3 on the Third-Floor nursing unit who stated she was behind on providing morning care for residents. When asked how many residents were on her assignment for the day, she responded eleven. CNA #3 stated when there were six CNAs scheduled for the day, each CNA was assigned eight residents, but when there were five CNAs, they were assigned eleven residents. When asked if the nursing unit scheduled less than five CNAs ever, CNA #3 confirmed there had been times when there were less than five CNAs. The surveyor reviewed the CNA Assignment Sheet for 10/28/22, which revealed there were five CNAs assigned to 52 residents. The sheet also confirmed CNA #3 was assigned eleven residents. On 10/31/22 at 11:26 AM, the surveyor interviewed CNA #2 who stated his usual resident assignment was ten residents, but today he had thirteen residents assigned to him. CNA #2 stated the facility usually had five CNAs assigned for the Third-Floor nursing unit. The surveyor reviewed the CNA Assignment Sheet for 10/31/22, which revealed there were four CNAs assigned to fifty-two residents. The sheet also revealed CNA #2 was assigned to thirteen residents. On 10/31/22 at 11:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated there was usually six CNAs assigned to the Third-Floor nursing unit with three CNAs assigned to either side. The LPN stated if a CNA called out, the facility usually tried to have another aide come in to help. On 10/31/22 at 11:31 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated there were usually five or six CNAs assigned to the Third-Floor nursing unit for the day shift. The LPN/UM stated the number of CNAs needed was determined by the resident census for that day. The LPN/UM confirmed today there were four CNAs with resident assignments plus CNA #1 who was on light-duty and had no residents assigned to her. When asked how many CNAs should be scheduled during the day shift, the LPN/UM stated there should be one CNA for every eight residents. At this time, the surveyor reviewed the CNA Assignment Sheet for 10/31/22, and the LPN/UM confirmed CNA #2 had thirteen residents assigned, CNA #4 had fourteen residents assigned to her; CNA #5 had twelve residents assigned to her; and CNA #6 had thirteen residents assigned to her. The LPN/UM stated when the floor was short, CNAs were assigned more residents. On 10/31/22 at 11:36 AM, the surveyor observed CNA #7 arrive at the Third-Floor Nurse's Station and he informed the LPN/UM he was an Agency CNA scheduled to help. On 10/31/22 at 11:51 AM, the surveyor interviewed the Acting Staff Coordinator who stated she came to the facility from another facility to help. The Acting Staff Coordinator stated she made the nursing schedules, but she was unsure how the number of CNAs needed was determined. The Acting Staff Coordinator stated for the day shift, she usually scheduled five to six CNAs for the Third-Floor nursing unit. The Acting Staff Coordinator stated if the facility staff could not cover the shift, then she called for Agency staff. The Acting Staff Coordinator confirmed there were four CNAs assigned to the Third-Floor nursing unit today and that an Agency CNA (CNA #7) had just arrived. On 10/31/22 at 12:02 PM, the surveyor interviewed the DON who stated CNAs were scheduled based on resident census. The DON continued for the day shift, there should be one CNA for every eight residents. The DON stated the Third-Floor nursing unit which was a long-term care unit usually had fifty-two residents and required six CNAs for the day shift. The DON stated on the weekends and holidays, staffing was challenging because of callouts. The DON stated CNA #1 should be coming off of light duty and confirmed Friday 10/28/22 five CNAs assigned to the Third-Floor nursing unit residents because Friday was a weekend so it would be lower. On 10/31/22 at 12:19 PM, the surveyor reviewed the CNA Assignment Sheet for 10/25/22 which indicated there were three assigned CNAs for the Third-Floor nursing unit. The DON acknowledged the three CNAs and stated there was a callout and this was not usually how operate. NJAC 8:39-5.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) provide privacy when receiving and delivering mail and b.) deliver mail within a reasonable timeframe. This deficient practice was identified for 2 of 31 residents reviewed for privacy and timeliness with their mail delivery (Resident #13 and #80) and was evidenced by the following: On 11/1/22 at 10:13 AM, the surveyor interviewed Resident #13 who stated that he/she had ordered some items from their insurance company's catalog about a month ago and he/she still had not received the items. At this time, the surveyor interviewed Resident #80 who stated that he/she had also ordered some items from his/ her insurance company's catalog about a month ago and he/she still had not received the items. The surveyor reviewed Resident #13's most recent quarterly Minimal Data Set (MDS), an assessment tool, dated 10/11/22 which reflected that the resident had a brief interview for mental status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. The surveyor reviewed Resident #80's most recent quarterly MDS dated [DATE], which reflected the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. On 11/1/22 at 10:18 AM, the surveyor interviewed the License Nursing Home Administrator (LNHA) who stated that the facility's mail delivery procedure included that the mail was delivered to the Receptionist. It was the Receptionist's responsibility to notify the Activities Department when the mail was available and ready to be delivered. The mail was to be delivered within 24 to 48 hours of receipt. On 11/1/22 at 10:22 AM, the surveyor interviewed the Social Worker (SW) who stated that Resident #13 and Resident #80 brought this concern to her attention a few minutes ago. The SW further stated that she had placed the order for both of these residents on 10/3/22 just prior to her vacation. The SW stated she had called the company a few minutes ago and they confirmed that the packages were delivered to the facility on [DATE]. On 11/1/22 at 10:35 AM, the surveyor interviewed the Director of Activities (DOA) who stated that the SW just notified her about the missing packages. She stated that her staff were responsible for the mail delivery, and she would begin an investigation. On 11/1/22 at 10:45 AM, the DOA stated that on 10/19/22 the boxes were not delivered to the Receptionist, but instead were mistakenly delivered to the Purchasing Director where the facility's medical treatment supplies were delivered. The DOA stated that the Purchasing Director delivered the boxes to the Third-Floor Unit Manager's (UM) office. The surveyor asked the DOA if the packages were addressed to Resident #13 and Resident #80. The DOA replied that she was not sure, but that they may have been addressed to the facility. On 11/1/22 at 12:00 PM, the DOA located the empty box with the label which confirmed that the package was in fact addressed to Resident #13, not the facility. The DOA was unable to locate the box with the label for Resident #80. On 11/1/22 at 12:40 PM, the surveyor interviewed the Director of Purchasing (DOP) who stated that she received the packages for Resident #13 and Resident #80 on 10/19/22. The DOP stated that she saw the [name redacted] company logo on each of the boxes, which was the same company that delivered the medical supplies so she didn't even look at the labels and opened the boxes. She further stated that as soon as she saw the packing slips were addressed to Resident # 13 and #80, she realized she had made a mistake in opening them. The DOP stated that she put the slips back into the boxes and delivered the packages to the Third-Floor Licensed Practical Nurse/Unit Manager's (LPN/UM) office. The surveyor asked the DOP when she had put the boxes in the office, if she had informed the LPN/UM the packages were there and mistakenly opened? The DOP replied, I can't remember when I brought the boxes up or when I told the nurse that they were there. I didn't inform the residents; I don't even know them. On 11/1/22 at 1:00 PM, the DOP provided the surveyors with copies of the Packing Lists which indicated that the packages were shipped and addressed to Resident #13 and Resident #80. On 11/1/22 at 2:42 PM, the LNHA in the presence of the Director of Nursing and survey team, stated that the DOP should have gone directly to each of the residents, explained what happened and apologized for the mistake. On 11/2/22 at 10:55 AM, the surveyor conducted a phone interview with the Third-Floor LPN/UM who stated that the DOP informed her that she had left the packages in her office for Resident #13 and #80. The LPN/UM stated, I can't recall when the Central Supply lady told me, either this week or last week. The surveyor asked the LPN/UM why she did not deliver the packages to the residents. The LPN/UM replied, I just forgot about them. The LPN/UM further stated that she should have delivered them as soon as she was made aware they were there. A review of the Mail Delivery policy dated effective 11/28/19 included the facility would deliver mail to residents within 24-48 hours of receipt .the mail is to remain sealed until it has been delivered to the intended recipient . A review of the Resident Rights policy dated effective 8/1/21 included . the residents have the right to communications, including mail and telephones to receive and send your mail in unopened envelopes; request and receive assistance in reading and writing correspondence, communicate in person and by mail, email, and telephone with privacy . On 11/2/22 at 11:15 AM, the LNHA acknowledged that the DOP and LPN/UM should have followed facility policy and delivered the mail unopened within 24-48 hours of receipt. NJAC 8:39-4.1(a)(19)

Based on observation, interview, review of medical records and review of other facility documentation, it was determined that the facility to failed follow professional standards of clinical practice by administering blood pressure (BP) medications consistently outside of the physician ordered BP parameters when 33 nurses on 3 units for 6 of 32 residents (Resident #104, #71, #362, #82, #366, and #18), disregarded ordered BP parameters for administration of medications from (MONTH) (YEAR) to (MONTH) 2019. The facility's failure to administer medications according to physician ordered BP parameters and clinical standards of nursing practice had the likelihood to affect all residents receiving medications with physician ordered parameters. On 5/6/19 at 3:20 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was put into place and accepted on 5/6/19 at 6:20 PM for Resident's #104, #362, #366, #82, #71 and #18. The Administrator ensured that current residents on medications with a hold parameter were reviewed and cross-referenced with the respective Medication Administration Record (MAR) to identify additional occurrences. According to the IJ removal plan, the facility identified 17 additional residents who could likely be affected. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) According to the Admission Record (AR) dated (MONTH) 25, 2019, Resident # 104 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS), an assessment tool (that assess a resident's functional capabilities and identify health problems) dated 4/16/19, indicated that the resident had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's). On 04/25/19 at 9:30 AM the surveyor was not able to interview the resident due to severe cognitive impairment. On 04/25/19 at 10:05 AM, the surveyor reviewed Resident # 104's physician order [REDACTED]. The Medication Review Record reflected a physician's telephone order entry dated 4/2/19, for [MEDICATION NAME] HCL 5 mg one tablet before meals for blood pressure (BP) support. The physician ordered a medication precaution for this medication to be held if SBP was greater than 120. The MAR reviewed from 5/25/18 to 4/25/19 revealed the following: - 5/25/18 to 5/31/18, the medication was administered outside of the physician ordered parameters 1 time out of 21 opportunities by 1 nurse. -6/1/18 to 6/30/18, the medication was administered outside of the physician ordered parameters 5 times out of 90 opportunities by 3 nurses. -7/1/18 to 7/31/18, the medication was administered outside of the physician ordered parameters 3 times out of 93 opportunities by 1 nurse. -8/1/18 to 8/31/18, the medication was administered outside of the physician ordered parameters 6 times out of 93 opportunities by 3 nurses. -9/1/18 to 9/30/18, the medication was administered outside of the physician ordered parameters 11 times out of 90 opportunities by 6 nurses. -10/1/18 to 10/31/18, the medication was administered outside of the physician ordered parameters 1 time out of 93 opportunities by 1 nurse. -11/1/18 to 11/30/18, the medication was administered outside of the physician ordered parameters 9 times out of 90 opportunities by 5 nurses. -12/1/18 to 12/31/18, the medication was administered outside of the physician ordered parameters 7 times out of 90 opportunities by 5 nurses. -1/1/19 to 1/31/19, the medication was administered outside of the physician ordered parameters 3 times out of 93 opportunities by 3 nurses. -2/20/19 to 2/28/19, the medication was administered outside of the physician ordered parameters 2 times out of 27 opportunities by 2 nurses. -3/1/19 to 3/17/19, the medication was administered outside of the physician ordered parameters 5 times out of 54 opportunities by 4 nurses. -4/3/19 to 4/25/19, the medication was administered outside of the physician ordered parameters 3 times out of 75 opportunities by 2 nurses. The monthly Pharmacist Consultant's (PCR) Report dated 5/7/18, 7/16/18, 8/20/18, 9/18/18, 11/27/18, reflected recommendations from the pharmacist that the medication [MEDICATION NAME] was not always held as required by the physician's hold order. On 04/26/19 at 10:16 AM, the surveyor interviewed the primary care Registered Nurse (RN #1) who worked on 4/7/19 on the 7:00 AM to 3:00 PM shift, who confirmed that the initials on the MAR on 4/7/19 at 0730 AM were hers and also confirmed that the medication [MEDICATION NAME] HCL 5 mg was administered. The RN also added that the SBP on that date and time was 126/75 and was out of the physician ordered parameters and should have not been administered. On 04/30/19 at 09:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she administered the medication [MEDICATION NAME] 5 mg outside of the physician ordered SBP parameters for Resident #104 on 4/4/19 and 4/18/19 at 07:30 AM. She added that it was human error. On 04/30/19 at 09:57 AM, the surveyor interviewed the Registered Nurse Staff Educator/Employee Health who confirmed that that the medication [MEDICATION NAME] 5 mg was administered by the nurses on 4/4/19, 4/7/19, and 4/18/19 at 07:30 AM which was outside the physician ordered SBP parameters and was done so in error. She added that the last time the staff was in serviced on the use of this medication was in the year (YEAR) and that there was no quality assurance program that the facility was working on at this time to address the issue. On 04/30/19 at 11:34 AM, the surveyor interviewed the facility Pharmacist Consultant (PC) who stated that she had made recommendations dated 5/7/18, 6/11/18, 7/16/18, 8/20/18, 9/18/18 and 11/27/18 to watch holds. When I recommended to watch holds, I was referring to the medication [MEDICATION NAME], because the medication was sporadically being administered to the resident out of the physician ordered parameters. I did not personally in-service the staff about the nurses administering the [MEDICATION NAME] outside the physician ordered parameters, but I would have in-serviced them if the facility asked. It's usually the DON that would in-service the staff when a medication was administered in error. On 04/30/19 at 01:05 PM, the surveyor interviewed the DON who stated that when she received the monthly PCR, she forwards it to the Registered Nurse Unit Manger (RN/UM) so that the RN/UM could address the pharmacist recommendations. I should have followed up with the (RN/UM) to ensure the issue with the [MEDICATION NAME] was addressed and in-services were provided to the staff. I dropped the ball and should have done more. There was no QI process in place to address this issue. The DON also added that the facility did not have a policy or process for the pharmacy consultant recommendations. On 04/30/19 at 01:48 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she spoke with the nurses that gave the medication out of the physician ordered parameters, however she could not provide anything to the surveyor in writing that the nursing staff was in-serviced or counseled. The RN/NM also stated that the physician did receive the monthly PCR, but did not make any recommendations. I usually keep the monthly PCR in a binder, but I lost it. On 05/01/19 at 09:40 AM, the surveyor interviewed Resident # 104's primary care physician who stated that she was not aware that the nursing staff were sporadically giving Resident # 104 the medication [MEDICATION NAME] outside the ordered parameters. She also stated that she did not receive any monthly PCR that indicated that the resident was receiving this medication outside the ordered parameters. She added that she has a folder on each nursing unit which the nursing staff places information such as the monthly PCR for her review. She revealed she would sign them and write any orders that she needed to and stated I did not receive any pharmacy recommendations for this resident and I was not notified by staff that the resident received this medication outside the ordered parameters. 2.) The AR date (MONTH) 2, 2019 reflected that Resident # 71 had the medical [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], reflected that Resident # 71 was cognitively intact , had [DIAGNOSES REDACTED]. On 05/03/19 at 11:18 AM, the surveyor attempted to interview Resident #71, however, the resident was with a visitor and declined. The Medication Review Report (MRR) for Resident # 71 was reviewed and revealed a physician's orders [REDACTED]. The MAR dated 6/18/18 until 6/30/18 and revealed the following: The medication was administered outside the ordered parameters 1 time out of 39 opportunities by 1 nurse. The MRR was reviewed and revealed a physician's orders [REDACTED]. The MARs were reviewed from 8/2/18 until 4/30/19, and revealed the following: -8/2/18 until 8/31/18, revealed that the medication was administered outside the physician ordered parameter 8 times out of 30 opportunities by 5 nurses. -9/1/18 until 9/30/18, revealed that the medication was administered outside of the physician ordered parameter 3 times out of 30 opportunities by 2 nurses. -10/1/18 until 10/31/18, revealed that the medication was administered outside of the physician ordered parameter 1 time out of 31 opportunities by 1 nurse. -11/1/18 until 11/30/18, revealed that the medication was administered outside the physician ordered parameter 3 times out of 30 opportunities by 2 nurses. -12/1/18 until 12/31/18, revealed that the medication was administered outside the physician ordered parameter 7 times out of 31 opportunities by 6 nurses. -1/1/19 until 1/31/19, revealed that the medication was administered outside the physician ordered parameters 7 times out of 31 opportunities by 6 nurses. -2/1/19 until 2/28/19, revealed that the medication was administered outside the physician ordered parameters 6 times out of 28 opportunities by 3 nurses. -3/1/19 until 3/31/19, revealed that the medication was administered outside the physician ordered parameters 3 times out of 31 opportunities by 2 nurses. -4/1/19 until 4/30/19, revealed that the medication was administered outside the physician ordered parameters 6 times out of 30 opportunities by 4 nurses. The last monthly PCR provided by the facility to the surveyor for Resident # 71 was dated 8/20/18 and indicated that the medication [MEDICATION NAME] was not always held by the physician ordered parameters. The medication continued to be sporadically given outside the physician ordered parameters until 4/2019 but it was not reflected in the monthly PCR. In addition, there was no mention on the PCR that the medication [MEDICATION NAME] was also given out the physician ordered parameters. 3.) The AR reflected that Resident # 362 was admitted to the facility with the medical [DIAGNOSES REDACTED].# 362 was cognitively intact required extensive assistance with ADL's. The MAR reflected a physician's orders [REDACTED]. The physician's orders [REDACTED]. The MAR dated 4/2019 was reviewed from 4/1/19 until 4/29/19 and revealed that the medication was administered outside the physician ordered parameters 7 times out of 40 opportunities by 5 nurses. The PCC monthly report dated 4/24/19, reflected a recommendation that the medication [MEDICATION NAME] is not always held as required by the physician's hold order. 4.) According to the AR dated (MONTH) 2, 2019, Resident # 82 was admitted to the facility with the medical [DIAGNOSES REDACTED].#82 required extensive assistance with activities of daily living (ADLs). On 05/03/19 at 11:00 AM, the surveyor was unable to interview Resident #82 due to severe cognitive impairment. The MMR dated 4/28/18, revealed a physician's orders [REDACTED]. The MAR was reviewed from 4/29/2018 to 8/25/18, and revealed that there were no parameters documented on the MAR or BP taken. The MAR was reviewed from 8/26/18 to 2/27/19 and revealed the following: 8/26/18 until 8/31/18, revealed that the medication was administered outside of the physician ordered parameters 2 times out of 6 opportunities by 2 nurses. 9/1/18 until 9/30/19, revealed that the medication was administered outside of the physician ordered parameters 1 time out of 30 oppotuniities by 1 nurse. 10/1/18, revealed that the medication was given outside of physician ordered parameters 2 times out of 31 opportunities by 2 nurses. 12/1/18 until 12/31/18, revealed that the medication was given outside of the physician ordered parameters 1 time out of 31 opportunities by 1 nurse. 2/1/19 until 2/28/19, revealed that the medication was given outside of the physician ordered parameters 2 times out of 28 opportunities by 3 nurses. 3/1/19 until 3/31/19, revealed that the medication was given outside of the physician ordered parameters 2 times out of 30 opportunities by 2 nurses. The monthly PCC dated 9/18/18 and 2/27/19, indicated that the medication [MEDICATION NAME] is not always held as required by the physicians hold order. 5.) The AR dated 5/2/19 reflected that the Resident # 366 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated that Resident # 366 had moderate cognitive impairment and required extensive assistance with ADL's. The MRR revealed a physician's orders [REDACTED]. Review of the MAR from 4/1/19 until 4/30/19, revealed that the medication was administered outside the physician ordered parameters 1 time out of 3 opportunities by 1 nurse. On 5/6/19 at 1:00 PM, the surveyor interviewed the RN/UM #1 for the 2nd floor unit who stated that she did not have any monthly PCR for Resident # 366 because the resident was in and out of the hospital and every time the PCR would come to review the resident's medical records and medications the resident was not in the building. 6.) The AR dated 5/2/19, reflected that Resident # 18 was admitted with the medical [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], indicated that Resident # 18 was cognitively intact and required extensive assistance with ADL's. The MRR reflected a physician's orders [REDACTED]. The MAR reviewed from 8/21/18 to 4/30/19, revealed the following: -1/1/19 until 1/31/19, the medication was administered outside of the physician ordered parameters 1 time out of 31 opportunities by 1 nurse. -2/1/19 until 2/29/19, the medication was administered outside the physician ordered parameters 3 times out of 28 opportunities by 3 nurses. -4/1/19 until 4/30/19, the medication was administered outside the physician ordered parameters 1 time out of 30 opportunities by 1 nurse. The MMR reflected a physician's orders [REDACTED]. The MAR reviewed from 7/30/18 until 4/30/19, revealed the following: -1/1/19 until 1/31/19, indicated that the medication was administered outside of the physician ordered parameters 1 time out of 31 opportunities by 1 nurse. -2/1/19 until 2/29/19, indicated that the medication was administered outside of the physician ordered parameters 1 time out of 28 opportunities by 1 nurse. -3/1/19 until 3/31/19, indicated that the medication was administered outside the physician ordered parameters 3 times out of 31 opportunities by 1 nurse. The MMR reflected a physician ordered dated 3/10/19 for the medication Losartan Potassium 100 mg one tablet 1 time a day for high blood pressure and to hold the medication for SBP less than 110 and diastolic blood pressure (DBP) less than 70. The MAR reviewed from 3/10/19 to 4/30/19, revealed the following: -3/10/19 until 3/31/19, indicated that the medication was administered outside the physician ordered parameters 5 times out of 31 opportunities by 2 nurses. -4/1/19 until 4/30/19, indicated that the medication was administered outside of the physician ordered parameters 9 times out of 30 opportunities by 3 nurses. The monthly PCR that were provided by the facility dated 3/29/19 and 4/24/2019 indicated that Losartan was not always held as required by the physician's hold order. There was no mention on the PCC monthly reports that the medication [MEDICATION NAME] and [MEDICATION NAME] were also administered outside the physician ordered parameters. On 05/02/19 at 09:32 AM, the surveyor interviewed the Risk Management Registered Nurse RM/RN who stated, I generate a New Order Report on [MEDICATION NAME] to make sure the order entry is written properly. I do not check that it was administered correctly according to the physician ordered parameters. We review med error reports when something comes up as a trend and then I would put an action plan in place, unfortunately the report would not have indicated that the medication was being given out of physician ordered parameter. We did not have a QI in place because we did not know this was an issue. On 05/02/19 at 09:35 AM, the surveyor interviewed the DON who stated that she did not look at the Pharmacy Consultant (PC) report in detail page to page. I just scanned through the monthly pharmacy report, but in hindsight I should have looked at it with more detail. I should have followed up with the charge nurse to ensure that these issues with residents receiving blood pressure medications outside of physician ordered parameters were addressed. She added that the monthly PCR had pertinent information that addressed recommendations and concerns that the pharmacist wanted addressed. The pharmacy consultant did not always discuss her concerns with her after her monthly visit, and she was not sure why I was not made aware that this was a trend and that is was happening for quite a while. We did not have a Quality Improvement (QI) or Quality Assurance (QA) review for this issue because I didn't realize it was this big of a problem. On 05/02/19 at 09:46 AM, the surveyor conducted an interview with the facility PC who stated that she reviewed the residents charts monthly and that before she exited the building she would discuss the concerns about the nurses not following the physician ordered BP parameter holds with the DON, the RN/UM or any other person that was in charge. She stated I never leave the building without discussing my concerns with someone in charge. The monthly report is my documentation that informs the facility of my concerns and it is send to the DON, Administrator and the Medical Director. So, they were aware of my findings and that there was an issue that medications were being administered to residents on BP medications outside the physician ordered parameters. On 05/02/19 at 09:52 AM, the surveyor interviewed the Registered Nurse Unit Manager on the second floor (RN/UM #1) who stated that it was her responsibility to follow up with the recommendations of the PC and was aware of her recommendations that the nurses were administering the medication [MEDICATION NAME] out of the physician ordered parameters. She added that she spoke with the nurse concerning the administration of the medication out of the physician ordered parameters but did remember if she filled out any medication error reports. She also added that she usually put copies of the monthly pharmacy consultant reports in a binder, however she stated she lost the binder. I do not remember if I notified the DON or the MD that the nurses were administering BP medications out of the ordered parameters. On 05/02/19 at 01:35 PM, the surveyor interviewed the Administrator who stated that the PCR should have been reviewed by the DON and then DON emailed the PCR to the RN/UM who should have reviewed the reports and acted upon them. When the RN/UM identified an issue on the PCR sheets that indicated that residents were receiving medications outside of the physician ordered parameters, a medication error report should have been written for every nurse that made the error. The RN/UM should have then assessed the resident to assure that the residents were not harmed. They then should have notified the physician, filled and educated the nurse that were involved. From there we would have started the QI process to assure that this did not happen again. At this time the DON agreed with the Administrator. On 05/02/19 at 02:12 PM, the surveyor interviewed LPN# 2 who stated that she is not designated to work on a particular floor or unit and that she floats (goes to other units) around the facility and covers floors and shifts as needed. I did make a medication error a while back when I gave a medication [MEDICATION NAME] out of the physician ordered parameters and I was educated by the (name redacted RN/UM #1) in (MONTH) (YEAR). I do not have the specific dates that I was told about this issue, but I really think this was a system issue with the computer software. I may have clicked the wrong button indicating that I gave the medication when I know I did not. On 05/02/19 at 02:22 PM, the surveyor interviewed LPN #3 who stated that she was trained on computer software for medication and had competencies on how to use computer software program when administering medications. If the blood pressure is out of the physician ordered parameters, I would hold the medication. I would put a code 5 or 4 indicating that the medication was not given. If there's a check in the signature box, then I gave the medication. Maybe I clicked it wrong because I was moving too quick. On 05/02/19 at 02:32 PM, the surveyor attempted to interview the physician who had patients in the facility, Resident #18, #75 and #50. The physician was unable to be reached by phone for an interview. A message was left by the surveyor. On 05/03/19 at 12:02 PM, the surveyor interviewed one of the facility's Nurse Practitioners (NP) who has worked for the facility since 2013. The NP stated that she was not made aware until today (5/3/19) that some residents were receiving blood pressure medications out of the ordered parameters. The nurses would usually give the physicians or the NP's copies of the pharmacy consultants recommendations directly so that they could be reviewed and signed, or they would put them in our folders located at each nursing station. If the consultant's sheets were not given to us, then we would not know that there were concerns. The surveyor showed the NP a copy of the monthly PCR that was in the medical record of Resident # 18 and she stated that she never saw that form before. The NP added that parameters are in place so that the blood pressure does not drop too low or go up too high. She added that the medication [MEDICATION NAME] for example, increased the blood pressure. If the blood pressure is high and the medication is given it would increase the blood pressure. If the blood pressure goes up too high the worst-case scenario that could happen to the resident would be a stroke. On 05/03/19 at 01:32 PM, the surveyor interviewed the Medical Director (MD) who stated that he did not know the magnitude of the of this error until the facility started to investigate the problem. I do receive the monthly PCR by e-mail, but I do not scrutinize them because they are so lengthy. I guess these errors could have been caused by the unintended consequences of technology. I think this is more of a process issue or maybe complacency and human error. The MD added that if he knew this was happening then it would have been discussed in the Pharmacy and Therapeutic Committee meeting where trends were reviewed. On 05/06/19 at 11:31 AM, the surveyor interviewed the Administrator who stated that he did not get the monthly PCR even though his name was on the inside address of the report. He was not sure why he did not get the report. He stated that there were no trends identified on the coversheet of the report and that he needed to find out why. He also added that the PC never discussed any concerns/recommendations with him and that if she knew there was a concern she should have spoken with him to make him aware. On 05/06/19 at 01:02 PM, RN/UM #2 for the first-floor sub-acute unit stated, When we get the monthly PCR and therapeutic suggestions which is e-mailed to the first-floor unit, we print out the recommendations and call the physician with the recommendations. Once the recommendations are acted upon, we would keep a copy. I sign off on the form and keep and copy. The DON also gets a copy. The recommendations are not part of the permanent medical record. The RN/UM #2 stated that the recommendations for the first -floor sub-acute unit, did not come until (MONTH) 1, 2019 but she has not had the opportunity to review it. She stated that when the PC was at the facility on 4/24/19, she did not hold an exit meeting with her nor did she make her aware of the errors with blood pressure parameters. On 05/06/19 at 01:14 PM, the surveyor interviewed the LPN Unit Coordinator (LPN/UC) on the 3rd floor who stated she had been working as an LPN/UC since (MONTH) (YEAR). She stated she was not put on the e-mail to receive the monthly PCR sheets until five months ago. When she saw that the recommendation from the PCR regarding blood pressure medications given outside the ordered parameters, she did not know that it was a medication error. She added I know now, how serious it was, but I did not know at the time that it was something I had to review and act on. I thought they were just a FYI (for our information) kind of thing. I should have taken that information differently and filled out a medication error report and notified the doctor. When the surveyor asked what was done regarding the recommendations from the pharmacist, the LPN/UC indicated that she had nothing else that she could provide to the surveyor. On 05/06/19 at 01:28 PM, the surveyor interviewed the Registered Nurse Clinical Manager (RN/CM) for the 3rd floor who stated that she was sharing duties with LPN/UC of the 3rd floor since (MONTH) 2019. I would follow the Pharmacist Consultant's recommendation and would call the doctor. When the pharmacist recommended to watch holds, I would have reviewed the medications and notified the doctor. When I addressed it with the doctor for one of the residents that was administered the [MEDICATION NAME] outside the ordered parameters, he did not change the orders. She stated she addressed the issues with the nurses involved but did not write it as a medication error report. The RN/CM revealed that she did not keep the completed copies of the monthly PCR but would give the DON copy but was unaware of what the DON did with them. On 05/06/19 at 02:11 PM, the surveyor interviewed the PC who verified that the reports are generated by the main office and sent to the facility, however, she did not personally send the reports. She stated that the monthly PCR sheets are sent as attachments to the Medical Director, Administrator and DON. These reports are generated by the main office and then are emailed by pharmacy consultant office to the Administration. She added she does not personally email the Administration. According to the PC Agreement dated (MONTH) 2012, the PC performs monthly onsite review of the drug regime of each resident on the facilities unit census and reports any irregularities to the nurse in charge, attending physician and Administrator. The PC performs ongoing assessments of all areas of pharmacy services, including recommendations and plans for implementation and prepares dated, signed reports which are given to and retained by the Administrator for follow-up and evaluation of performance. Prepares written reports as needed, on the status of the facility's pharmaceutical services and staff performance for QA and Pharmacy and Therapeutics Committees. The agreement also revealed that the facilities Administrator must retain all reports prepared by the consultant including those regarding consultant's assessment of all area of pharmacy services. The facility policy titled Blood Pressure and Pulse Monitoring 2.6 dated (MONTH) 2010, indicated that nursing will monitor blood pressure and/or pulse prior to administering any medication that specifically indicated a hold parameter in the physician's orders [REDACTED]. The facility policy titled Medication Administration 5.2.8 dated 3/12/12 indicated that there are special considerations to be followed with administration of certain medications. Cautionaries are located on the medication box and nurses are required to administer the medications accordingly. This deficiency is continued at a scope and severity of a Level D: Based on observation, interview and record review the facility failed to ensure that cautionary precautions affixed on the medication box were observed during administration of medications. This deficient practice was identified for 1 of 3 residents (Resident #45) observed during administration of medications and evidenced by the f (TRUNCATED)

Based on interview and record review, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that all residents received the care needed to enhance their quality of life; a). related to recommendations from the Consultant Pharmacist for safe administration of medications that were not acted upon; b). the administrator failed to develop an action plan to address and correct medication errors identified monthly during a 12 month-period (April (YEAR) to (MONTH) 2019) in accordance with his/her job description. This deficient practice was evidenced by the following: Refer to F658, F756 and F865 related to Standards of Professional Practices, drug regimen review, irregularity, Quality Assurance Performance Improvement (QAPI). A review of the Administrators job description provided by the facility, revealed the following: -The Administrator's purpose was to establish and maintain systems . in a manner that safely met the needs of the resident . -The Administrator had a responsibility to develop a monitoring system to assure compliance with federal, state and local requirements. -The Administrator's duties listed included: 1. Supervising all department supervisors and administrative staff. 2. Reviewing and evaluating all recommendations of the facility's committees and consultants. 3. Establish systems to ensure compliance with all federal, state and local regulations. 4. Assume responsibility for implementation of an effective Quality Assurance program On 5/6/19 at 3:20 PM, the facility's Administrator was notified that an Immediate Jeopardy (IJ) situation had been identified related to the failure to ensure administrative oversight to address consistent medication administration errors and failure to implement corrective measures for a period inclusive of 12 months (April (YEAR) to (MONTH) 2019). During this period six residents (Resident #104, #362, #366, #82, #71 and #18) on three units were administered blood pressure medications outside the physician ordered parameters by 33 nurses over three shifts. On 5/6/19 at 6:20 PM, the IJ removal plan was accepted and the Administrator ensured that current residents on medications with a hold parameter were reviewed and cross-referenced with the respective Medication Administration Record [REDACTED]. The Administrator will require that the Pharmacy Consultant (PC) conduct a conference following his/her monthly visit to present trends related to administering medications that have hold parameter. The conference will be attended by the Director of Nursing (DON), Quality Assurance (QA) and Performance Improvement (QAPI), Registered Nurse Educator, Unit Managers, Administration and the Medical Director (MD). The survey team verified elements of the removal plan that addressed the immediate action taken by the facility and continued to do so throughout the survey. On 05/02/19 at 09:35 AM, the surveyor interviewed the DON who stated that she did not look at the Pharmacy Consultant Report (PCR) in detail page to page. I just scanned through the monthly pharmacy report, but in hindsight I should have looked at it with more detail. I should have followed up with the charge nurse to assure that these issues with residents receiving blood pressure medications outside of physician ordered parameters were addressed. She added that the monthly PCR's had pertinent information that addressed recommendations and concerns that the pharmacist wanted addressed. The pharmacy consultant did not always exit (discuss concerns prior to leaving the building) with me, but I'm not sure why I was not made aware that this was a trend and that it was happening for quite a while. We did not have a Quality Improvement (QI) or Quality Assurance (QA) for this issue because I didn't realize it was this big of a problem. On 05/02/19 at 09:46 AM, the surveyor conducted an interview with the facility PC who stated that she reviewed the residents charts monthly and that before she left the building she would discuss the concerns about the nurses not following the physician ordered BP parameter holds with the DON, the RN/UM or any other person that was in charge. I never leave the building without discussing my concerns with someone in charge. The monthly report is my documentation that informs the facility of my concerns and it is sent to the DON, Administrator and the Medical Director. So, they were aware of my findings and that there was an issue that medications were being administered to residents on BP medications outside the physician ordered parameters. On 05/02/19 at 09:52 AM, the surveyor interviewed the Registered Nurse Unit Manager on the second floor (RN/UM #1) who stated that it was her responsibility to follow up with recommendations from the PCR and was aware of the recommendations that the nurses were administering the medication [MEDICATION NAME] out of the physician ordered parameters. She added that she spoke with the nurse concerning the issue but did not remember if she filled out medication error reports. She also added that she usually put copies of the PCR monthly reports in a binder, however stated she lost the binder. I do not remember if I notified the DON or the MD that the nurses were administering BP medications out of the ordered parameters. On 05/02/19 at 01:35 PM, the surveyor interviewed the Administrator who stated that the PCR Reports should have been reviewed by the DON. The DON then should have emailed the PCR reports to the RN/UM who should have reviewed the reports and acted upon them. When the RN/UM identified an issue on the PCR sheets that indicated that residents were receiving medications outside of the physician ordered parameters, a medication error report should have been written for every nurse that made the error. She added that the RN/UM should have assessed the resident to assure that the residents were not harmed and should have notified the physician and educated the nurses that were involved. She further stated that the facility should have started the QI process to assure that the same issues did not happen again. At this time the DON agreed with the Administrator. On 05/03/19 at 01:32 PM, the surveyor interviewed the MD who stated he did not know the magnitude of the of this error until the survey and the facility started to investigate the problem. I do receive the monthly PCR reports by e-mail, but I do not scrutinize them because they are so lengthy. I guess these errors could have been caused by the unintended consequences of technology. I think this is more of a process issue or maybe complacency and human error. The MD added that if he knew this was happening then it would have been discussed in the Pharmacy and Therapeutic Committee meeting where trends were reviewed. On 05/06/19 at 11:31 AM, the surveyor interviewed the Administrator who stated that he did not get the monthly PCR report even though his name was on the inside address of the report. He was not sure why he did not get the report. He stated that there were no trends identified on the cover sheet of the report and that he needed to find out why. He also added that the PC never held an exit conference with him and that if she knew there were concerns, she should have spoken with him so that he could have been made aware of the extent of this problem. According to the pharmacy agreement (PA) dated (MONTH) 2012, the duties of the facility is to report irregularities, if any, including the facility census, and shall be acted upon by the nurse in charge and/or the attending physician and/or the Administrator. The PA revealed that the Administrator must retain all reports prepared by the Consultant, including those regarding Consultant assessments of all areas of pharmacy services. The facility's Quality Assessment Performance Improvement (QAPI) Plan dated 2019 indicated that its program is to develop a proactive approach to continually improve the care provided to their residents. The program is ongoing, comprehensive and addresses a full range of care and services provided by the facility. Support services include nursing services, rehabilitation services, respiratory services, medical services, food and nutrition services, pharmacy services etc. The QAPI Plan also indicated that the facility Administrator is accountable to the Board of Directors for ensuring that requirements for the QAPI program are implemented, documented as required and effective in achieving program objectives and meet all regulatory standards. According to the QAPI plan the Administrator is part of the committee that identifies and reviews data from areas that the organization believes needs monitoring and assures systems and processes important to quality are monitored. Also, that data sources are considered when developing a QAPI plan such as Drug Regime Review Summaries, Feedback from providers, medical staff and vendors, Medication Administration Audits, and Medication Errors. N.[NAME][NAME]C. 8:39-13.1(a-d)

Based on interview, record review and review of other pertinent facility documentation it was determined that the facility failed to ensure that monthly recommendations documented in the pharmacy consultant reports identifying blood pressure medications consistently administered outside of physician ordered parameters were reviewed by the Medical Director (MD). This failure to review was inclusive of a 12 month period of time (April (YEAR) to (MONTH) 2019) for six residents (Resident #104, #362, #366, #82, #71 and #18). The Medical Director's disregard to review pharmacy consultant notifications of blood pressure medications not being given in accordance with physician ordered parameters posed a serious and immediate threat to the safety and well-being of all residents in the facility. On 5/6/19 at 3:20 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was put into place and accepted on 5/6/19 at 6:55 PM. The removal plan indicated that the MD had been advised that Medication Error Reports were completed for the resident who received the medications outside of the ordered blood pressure parameters, Resident #104, #362, #366, #82, #71, #18. The Administrator advised the MD that a.) the MD and the Pharmacy Consultant (PC) will be required to present trends specifically related to administering medications that have hold parameters; b.) the MD will participate in the PC exit conferences and the PC written report will be forwarded to the MD. The survey team verified elements of the removal plan that addressed the immediate action taken by the facility and continued to do so throughout the survey. On 05/02/19 at 09:46 AM, the surveyor conducted an interview with the facility PC who stated that she reviewed the residents charts monthly and that before leaving the building she would discuss the concerns about the nurses not following the physician ordered BP parameter holds with the DON, the RN/UM or any other person that was in charge. The PC indicated she did not send any further documentation, stating, My report is my documentation. The PC further indicated the report was sent to the DON, Administrator and the Medical Director who should have been aware of medications being administered to residents on BP medications outside the physician ordered parameters. On 05/03/19 at 01:32 PM, the surveyor interviewed the Medical Director (MD) who stated that he did not know the magnitude of this error until the facility started to investigate the problem. I do receive the monthly reports by e-mail but I do not scrutinize them because they are so lengthy. I guess these errors could have be caused by the unintended consequences of technology. I think this is more of a process issue or maybe complacency and human error. The MD added that if he knew this was happening then it would have been discussed in the Pharmacy and Therapeutic Committee meeting where trends were reviewed. According to the Medical Director Agreement, the MD is responsible for a.) meeting with the Administrator and governing body, director of nursing and other professional staff to discuss clinical issues and offer solutions to problems and identify policies needed. b.) assist in the implementation of Resident Care Policies regarding use of medications c.) coordinate and oversee medical care and treatment, including physician services and services of other professionals as related to resident care d.) review recommendations and reports of drug regimen review efforts and appropriate and timely action to implement recommendations e.) advise the facility administration and governing body of current medical issues affecting the residents. Refer to F658, F835, F865 N.[NAME][NAME]C 8:39-23.1; 24.1

COMPLAINT# NJ 5 REVISED Based on interviews, medical record (MR) review, and review of other pertinent facility documentation on 11/20/17, 11/22/17 and 11/29/17, it was determined that the facility failed to ensure that eleven (11) of (18) eighteen non-certified Nursing Aides (NA) sampled were attending or had completed a Nurse Aide Training and Competency Program (NATCEP). The facility put the health and safety of residents at risk by assigning non-certified/untrained staff to independently provide direct resident care, while unsupervised, from 1/1/2017 until 11/29/2017. This practice posed a serious and immediate threat to the residents, and was identified as an Immediate Jeopardy (IJ) situation at 9:40 p.m., on 11/29/17. The IJ was corrected and lifted on the day it was identified, based on an acceptable Plan of Correction (P[NAME]). This deficient practice was evidenced by the following: The surveyor reviewed the Nursing Staffing Report (NSR) which revealed the following: The week of 11/5/17 and 11/12/17, the facility had twelve (12) NAs. The week of 3/26/17 and 4/2/17, the NSR indicated that the facility had five (5) NAs. The week of 11/19/17, the NSR indicated that the facility had two (2) NAs. The surveyor reviewed the Employee File (EF) for NA #1 which indicated that NA #1 was hired on 11/21/16. The Printable Monthly Schedule revealed that NA #1 attended orientation on 11/21/16 and 11/22/16 from 9:00 a.m. to 5:00 p.m., on 11/23/16, 11/25/16, 11/26/16, 11/27/16, 11/29/16, 11/30/16, 12/01/16, 12/02/16, and 12/06/16, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily Certified Nursing Assistant (CNA) Assignment Sheet provided by the facility, showed that NA #1 independently provided direct resident care for a total of seventy nine (79), eight (8) hour shifts, from 1/01/17 to 4/05/17, on one (1) South and two (2) South, the Subacute units, and the third (3rd) floor, the Long Term Care (LTC) unit. There was no documentation in the NA's EF that NA #1 had enrolled in a NATCEP or that the facility had determined that NA #1 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #1 last day worked was 4/05/17. The surveyor reviewed the Employee File (EF) for NA #2 which indicated that NA #2 was hired on 11/21/16. The Printable Monthly Schedule revealed that NA #2 attended orientation on 11/21/16 and 11/22/16 from 9:00 a.m. to 5:00 p.m., on 11/23/16, 11/25/16, 11/26/16, 11/27/16, 11/29/16, and 11/30/16, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #2 independently provided direct resident care for a total of fifty (50), eight (8) hour shifts, from 1/01/17 to 3/30/17, on one (1) South and two (2) South, the Subacute units. There was no documentation in the NA's EF that NA #2 had enrolled in a NATCEP or that the facility had determined that NA #2 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #2 last day worked was 3/30/17. The surveyor reviewed the EF for NA #3 which indicated that NA #3 was hired on 7/24/17. The Printable Monthly Schedule revealed that NA #3 attended orientation on 7/24/17, 7/25/17, 7/26/17, 7/27/17, 7/28/17, 7/31/17, and 8/01/17 on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #3 independently provided direct resident care for a total of forty three (43), eight (8) hour shifts from 8/03/17 to 10/23/17, on one (1) South and two (2) South, the Subacute units, and on the third (3rd) floor, the LTC unit. There was no documentation in the NA's EF that NA #3 had enrolled in a NATCEP or that the facility had determined that NA #3 could provide safe and competent care. During an interview with NA #3 on 11/29/17 at 4:30 p.m., the NA stated that she became certified on 10/24/17. The surveyor reviewed the EF for NA #4 which indicated that NA #4 was hired on 5/08/17. The Printable Monthly Schedule revealed that NA #4 attended orientation on 5/08/17, 5/10/17, 5/11/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/22/17, 5/23/17, 5/24/17, and 5/25/17, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #4 independently provided direct resident care for a total of forty seven (47), eight (8) hour shifts from 6/02/17 to 8/23/17, on two (2) South, the Subacute unit, and on the third (3rd) floor, the LTC unit. There was no documentation in the NA's EF that NA #4 had enrolled in a NATCEP or that the facility had determined that NA #4 could provide safe and competent care. According to the EF, NA #4 was certified on 8/24/17. The surveyor reviewed the EF for NA #5 which indicated that NA #5 was hired on 12/19/16. The Printable Monthly Schedule revealed that NA #5 attended orientation on 12/19/17 and 12/20/17, from 9:00 a.m. to 5:00 p.m. The daily CNA Assignment Sheet provided by the facility, showed that NA #5 independently provided direct resident care for a total of forty two (42), eight (8) hour shifts from 1/01/17 to 4/17/17, one (1) South and two (2) South, the Subacute units, and on the third (3rd) floor, the LTC unit. There was no documentation in the NA's EF that NA #5 had enrolled in a NATCEP or that the facility had determined that NA #5 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #5 last day worked was 4/14/17. The surveyor reviewed the EF for NA #6 which indicated that NA #6 was hired on 5/08/17. The Printable Monthly Schedule revealed that NA #6 attended orientation on 5/08/17, 5/10/17, 5/11/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/22/17, 5/23/17, 5/24/17, and 5/25/17, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #6 independently provided direct resident care for a total of forty one (41), eight (8) hour shifts from 6/01/17 to 8/23/17, on one (1) South and two (2) South, the Subacute units, and on two (2) North and the (3rd) floor, the LTC units. There was no documentation in the NA's EF that NA #6 had enrolled in a NATCEP or that the facility had determined that NA #6 could provide safe and competent care. According to the EF, NA #6 was certified on 8/24/2017. The surveyor reviewed the EF for NA #7 which indicated that NA #7 was hired on 2/06/17. The Printable Monthly Schedule revealed that NA #7 attended orientation on 2/06/17 and 2/07/17, from 9:00 a.m. to 5:00 p.m., on 2/08/17, 2/09/17 and 2/12/17, on the 7:00 a.m. to 3:00 p.m. shift, and on 2/11/17 and 2/15/17, on the 3:00 p.m. to 11:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #7 independently provided direct resident care for a total of forty (40), eight (8) hour shifts from 2/21/17 to 5/31/17, one (1) South and two (2) South, the Subacute units, and on two (2) North and the (3rd) floor, the LTC units. There was no documentation in the NA's EF that NA #7 had enrolled in a NATCEP or that the facility had determined that NA #7 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #7 last day worked was 6/03/17. The surveyor reviewed the EF for NA #8 which indicated that NA #8 was hired on 10/09/17. The Printable Monthly Schedule revealed that NA #8 attended orientation on 10/09/17, 10/10/17, 10,11/17, 10/12/17, 10/13/17, 10/16/17, 10/17/17, 10/18/17, 10/20/17, 10/21/17, 10/22/17, 10/23/17, 10/25/17, 10/26/17 and 10/27/17, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #8 independently provided direct resident care for a total of eleven (11), eight (8) hour shifts from 11/04/17 to 11/17/17, on one (1) South, the Subacute unit. There was no documentation in the NA's EF that the facility had determined that NA #8 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #8 last day worked was 11/17/17. The surveyor reviewed the EF for NA #9 which indicated that NA #9 was hired on 8/07/17. The Printable Monthly Schedule revealed that NA #9 attended orientation on 8/07/17, from 9:00 a.m. to 5:00 p.m., and 8/09/17, 8/10/17, 8/12/17, 8/13/17, 8/14/17, on the 7:00 a.m. to 3:00 p.m. shift, and 8/16/17, 8/17/17, 8/18/17, 8/21/17, and 8/22/17, on the 11:00 p.m. to 7:00 a.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #9 independently provided direct resident care for a total of eleven (11), eight (8) hour shifts from 8/23/17 to 9/07/17, on two (2) North, the LTC unit. There was no documentation in the NA's EF that the facility had determined that NA #9 could provide safe and competent care. According to the EF, NA #9 was certified on 9/11/2017. The surveyor reviewed the EF for NA #10 which indicated that NA #10 was hired on 10/09/17. The Printable Monthly Schedule revealed that NA #10 attended orientation on 10/09/17, 10/10/17, 10,11/17, 10/12/17, 10/13/17, 10/16/17, 10/17/17, 10/18/17, 10/20/17, 10/21/17, 10/22/17, 10/23/17,10/25/17, 10/26/17 and 10/27/17 on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #10 independently provided direct resident care for a total of ten (10), eight (8) hour shifts from 11/04/17 to 11/17/17, on the third (3rd) floor, the LTC unit. There was no documentation in the NA's EF that the facility had determined that NA #10 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #10 last day worked was 11/14/17. The surveyor reviewed the EF for NA #11 which indicated that NA #11 was hired on 10/09/17. The Printable Monthly Schedule revealed that NA #11 attended orientation on 10/09/17, 10/10/17, 10/11/17, 10/12/17, 10/13/17, 10/16/17, 10/17/17, 10/18/17, 10/20/17, 10/21/17, 10/22/17, and 10/23/17, on the 7:00 a.m. to 3:00 p.m. shift. In addition, the daily CNA Assignment Sheet provided by the facility, showed that NA #11 independently provided direct resident care for a total of five (5), eight (8) hour shifts from 11/02/17 to 11/08/17, on the third (3rd) floor, the LTC unit. There was no documentation in the NA's EF that the facility had determined that NA #11 could provide safe and competent care. According to an undated and unnamed facility document presented to the surveyor, NA #11 last day worked was 11/08/17. During an interview with the Unit Manager Registered Nurse (RN #1) on 11/22/17 at 9:35 a.m., RN #1 stated that the NAs are oriented by the nurse and are given an assignment for those residents that only need one (1) aide to do care. In addition, RN #1 stated that if a resident required two (2) person assistance then the NA assigned to that resident would get assistance from a CNA. During an interview with CNA #3 on 11/29/17 at 4:20 p.m., CNA #3 stated that she was hired by the facility and began working in (MONTH) (YEAR), prior to starting her CNA class in (MONTH) (YEAR). The CNA continued to explain that she was oriented with different CNAs for one (1) week and after the first week of orientation, she was given her own assignments to care for residents prior to being certified. The surveyor conducted an interview with RN #2 on 11/29/17 at 4:55 p.m., RN #2 stated that the NAs are oriented by the CNAs for two weeks, then given their own assignments. In addition, RN #2 stated once the NAs complete their skills check list (a facility document), the NAs are able to provide care for residents independently prior to being certified. RN #2 continue to explain that initially the NAs can provide care for residents who require one person assist and residents who are not difficult. During a second interview with RN #1 on 11/29/17 at 5:06 p.m., RN #1 stated that during orientation the CNAs names are placed on the assignment sheet with the NAs. In addition, RN #2 stated that the CNAs oversee the nursing assistants for about 4 weeks thereafter. The RN continued to explain that once the NAs complete the skills checklist (facility document), they can provide care to residents independently. During an interview with the Director of Nursing (DON) on 11/29/17 at 8:22 p.m., the DON stated that the facility had twenty eight (28) new hires of NAs for (YEAR) and there were seven (7) NAs currently on staff at the facility. In addition, the DON continued to explain that there were no incidents regarding care with NAs. During a second interview with the DON on 11/29/17 at 9:30 p.m., the DON stated that the NAs are oriented for two to three (2-3) days in the classroom and for 2 weeks on the floor. In addition, the DON continued to explain that only after the NAs complete the competency checklist (facility document), that the NAs are given their own assignments. The facility's policy titled, Nurse Aide Certification Policy and Procedure, with an effective date of 12/10/14 under Policy documented the following: the facility will comply with the New Jersey Department of Health and Senior Services requirements for Certified Nurse Aides in Long Term Care Facilities as stipulated in Subchapter 43 of the State Standard Manual. The Immediately Jeopardy to residents' health and safety identified on 11/29/17 at 9:40 p.m., was corrected on 11/29/17 at 11:10 p.m., when an acceptable P[NAME] was received and implemented. The P[NAME] included: 1. The DON and Administrator reviewed the staffing schedule and immediately removed any NA's from the schedule. An email was sent to HR regarding the hiring of nursing assistants. There were no accidents or incidents involving NA's. 2. All residents who received care from an NA may have had the potential to be affected. 3. The Administrator issued an email regarding the hiring of nursing assistants on 11/29/17. In-service education was provided to the Human Resources (HR), Business Partner, DON and Director of Clinical Services on 11/29/17. A formal policy, which include the new practice of only hiring certified NA's will be written and distributed. Additional personnel involved in the hiring, scheduling, and assigning of nursing assistants will be in-serviced on the new policy by 11/30/17. 4. The HR Business Partner will audit 100% of all nursing assistant hires, prior to the employee's start date, to assure compliance with the policy. Results will be reported to the facility's Quality Assurance and Performance Improvement (QAPI) Committee. NJAC 8:39-43.1

Based on observation, interview and record review, it was determined that the facility failed to provide medical treatment in a timely manner. A resident sustained [REDACTED]. The burn, during that time, progressed to blisters and redness and required a topical burn treatment and eventually a debridemnt agent. This deficient practice was identified for 1 of 21 residents (Resident #14) reviewed for care and was evidenced by the following: The surveyor reviewed Resident #14's electronic medical record on 1/8/14. According to the record Resident #14 had [DIAGNOSES REDACTED]. Psychiatric Progress Notes (PN) dated 9/19/13 and 1/8/14 indicated the resident had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 12/24/13, indicated the resident had a severe cognitive deficit, was non-ambulatory and required extensive assistance of one person while eating. The Care Plan Activity Report (CPAR) initiated on 4/19/13, reflected the resident was alert with periods of confusion and forgetfulness due to Vascular [MEDICAL CONDITION] and behavioral disturbances. A review of a Nutrition Risk assessment dated [DATE], confirmed Resident #14's feeding ability need was "extensive assistance and one person physical assistance." According to Resident #14's Care Plan Activity Report (CPAR) initiated on 3/15/13, the resident was at nutritional risk and required "assistive/supportive dining" and may have possibly required cueing to take bites. A review of a PN dated 12/27/13 at 2:00 a.m., written by the Licensed Practical Nurse (LPN) indicated that around 5:15 p.m. Resident #16 was having dinner in the dining room and she was notified that soup had spilled in the resident's lap. The Nursing Supervisor was present at that time and poured cold water over the area. The resident was returned to their room right away and the resident's pants were pulled down to change the resident. The PN further reflected that "there was no redness or blisters present at the time." The resident was returned to the dining room and finished dinner. There was no documentation in the record of further/ongoing assessment of the burn area following the incident. The PN of 12/27/13 at 2 a.m. continued to reveal that at "bedtime" the LPN re-assessed the resident's skin and "blisters and redness" were noted on both inner thighs. There were three blisters on the right thigh that measured 2 cm (centimeter) wide by "3 in length." The redness was 12 cm long by "4 wide." There was one blister on the left thigh that was 3 cm long by "1 wide" and two areas of redness 3 cm wide by "4 in length." Tylenol was administered at 9:30 p.m. for "discomfort" with a positive effect. In addition, the PN reflected a telephone call was placed to the resident's physician at 9:00 p.m. There was a return call from another physician at 11:35 p.m. and orders were obtained for the application of cold compress and to have the resident evaluated by the wound care nurse on 12/27/13. There was no documentation or evidence that the wounld care nurse evaluated/assessed the resident on 12/27/13 as ordered. A review of Resident #14's Treatment Administration Record (TAR) dated 12/27/13 at 12:00 a.m., reflected a physician's order to apply cold compress to right and left inner thighs for redness until evaluated by wound care nurse. The TAR was initialed by nursing staff that indicated cold compresses were applied to the right and left inner thigh on 12/27/13 during the 11:00 p.m. to 7:00 a.m. shift. No specific time was noted. There was no documentation that reflected length of time the cold compresses were applied and how often they were changed. There was no documentation that indicated a treatment was initiated after the blisters/redness were observed at 9:00 p.m. on 12/26/13. A review of an Incident/Accident Report dated 12/26/13 at 5:30 p.m., reflected it was brought to the LPN's attention when Resident #14 was provided evening care that the resident had redness and blisters on both inner thighs. First aide "cold water" was provided by the Nursing Supervisor. In addition, the report indicated that the physician was called at 9:20 p.m. and returned the call at 11:35 p.m. The Injury Non-Fall Investigation Report dated 12/26/13 at 5:15 p.m. to 5:30 p.m., reflected Resident #14 had a burn injury to the left and right inner thighs. The area of pain was checked yes and described as mild. A review of a statement obtained during the course of the facility's investigation from the 3:00 p.m. to 11:00 p.m. Nursing Supervisor (NS) dated 12/26/13, revealed that she "found" the resident in the dining room yelling "help me, help me." Soup was in the resident's lap and the resident stated "it's hot." The NS documented she pulled the pants away from the resident's skin and poured cold water on the resident's thighs. The NS instructed the Aide to change the resident immediately. The "Charge Nurse was aware." The physician was called at 9:20 p.m. after the Aide notified the Charge Nurse and NS of an injury. At 10:00 p.m., the NS notified the responsible party and would involve the kitchen so they don't deliver soup until the Aide was at the table. At 10:26 p.m. a repeat call was placed to the physician. During a telephone interview on 1/8/14 at 2:30 p.m. with the NS, she confirmed the aforementioned statement. The NS revealed she walked into the dining room when she found Resident #14 "screaming out it hurts, it hurts." The NS revealed that no other staff were in the dining room when she arrived to assist Resident #14. The surveyor asked the NS if she evaluated and/or assessed Resident #14's bilateral thighs at any time during her shift she stated she "did not." She stated she informed the LPN to complete an incident report and asked the LPN to do the assessment. The NS was unaware the physician was not notified immediately after the incident occurred. The NS confirmed the physician should have been notified at the time of the incident. She stated she asked the LPN later about the resident's condition and was informed by the LPN the resident had redness and blisters. During a telephone interview with the surveyor on 1/8/14 at 2:10 p.m., the LPN who was on duty on 12/26/13 during the 3:00 p.m. to 11:00 p.m. shift stated that she was passing medications and did not witness the incident. She was informed that Resident #14 had spilled hot soup onto the lap. She also stated she observed the resident after the incident in the resident's room. The LPN revealed she removed the residents pants and no redness or blisters were present. She stated she applied a cold wet wash cloth on top of paper towels for approximately 5 minutes. The surveyor asked why a cold wet compress was applied to the resident's skin when no redness or blisters were present, the LPN had no response. LPN stated she did not re-evaluate and/or assess the resident between the initial evaluation at 5:00 p.m. and when the aide called her to the resident's room at 9:00 p.m. The surveyor interviewed the Director of Nursing (DON) on 1/9/14 at 12:22 p.m. regarding the incident. The DON stated she would have expected the NS to perform a nursing assessment of the resident's skin after the incident. On 1/8/14 at 2:45 p.m., the surveyor conducted an interview by telephone with the aide (not certified) that was assigned to care for Resident #14 on 12/26/13 during the 3:00 p.m. to 11:00 p.m. The resident stated he was not in the dining room when Resident #14 spilled the soup. The NS at 5:00 p.m., told him to take the resident back to the room to change the resident's clothes. The LPN came to the room to look at the resident's thighs. The Aide revealed he did not see redness at that time. He confirmed the LPN applied a cold compress to the thighs for about 2 minutes, then he re-dressed the resident and returned the resident to the dining room. He stated at 8:30 p.m., he took Resident #14 back to the room for bed and "I saw the redness and blisters to both legs" and he then notified the nurse. A review of a PN dated 12/29/13 at 10:30 a.m., written by the Unit Manager (UM) reflected the UM "spoke" to Resident #14's physician regarding the "burn blister to the left and right inner thigh." The physician ordered [MEDICATION NAME] cream (a burn treatment) to the affected area twice a day until healed. The PN reflected the wound nurse will see the resident on Monday (12/30/13). There was no documentation that reflected the UM assessed the wound and no documentation of the condition of the burn injuries. A review of a physician order dated 12/28/13 at 10:53 a.m., revealed to cleanse bilateral inner thighs with Normal Saline Solution (NSS), pat dry and apply [MEDICATION NAME] 1 % topical cream to wound bed and cover with border gauze twice daily until healed. A review of the December 2013 Treatment Administration Record revealed the aforementioned treatment was initialed by staff on 12/28/13 during the 3:00 p.m. to 11:00 p.m. shift which indicated the [MEDICATION NAME] cream was started at that time. A PN dated 12/30/13 at 7:16 p.m., written by the wound care nurse revealed the "...right inner thigh was assessed and presents with a 2 cm by 4.6 cm open blister with mixed dry [MEDICATION NAME] pink tissue with yellow slough. The left inner thigh presents as a 1.5 cm by 5 cm open blister with pink [MEDICATION NAME] tissue with scant yellow slough. " The wound nurse recommended to continue [MEDICATION NAME] cream. A physician PN dated 12/31/13 at 2:15 p.m. indicated the Registered Nurse (RN) related to the physician that Resident #14 had spilled soup on thighs. The physician documented that Resident #14 had a "rash on thighs with minimal blister." This notation/assessment by the physician was 19 hours after the wound care nurse's notation/assessment. A review of a wound nurse PN dated 1/2/14 at 3:26 p.m., indicated Resident #14's "...bilateral thighs were assessed secondary to recent thickness burn formation. The right inner thigh skin impairment measured 3.5 cm by 8 cm with moist adherent yellow slough cover. The left inner thigh measured 4 cm by 2.5 cm with yellow slough cover. Both wound beds had a moderate amount of serosangenous drainage." Santyl ointment (a debridement agent) with Calcium Alginate and border gauze dressing was recommended at that time. A review of a physician's order dated 1/2/14 indicated to cleanse right and left inner thigh full [MEDICAL CONDITION] Normal Saline Solution (NSS), pat dry, apply Santyl (a debridement agent) 250 unit/gram topical ointment nickel thick to wound beds and apply Calcium Alginate (an antimicrobial dressing) and cover with border gauze two times a day. During an interview with the Wound Nurse on 1/8/14 at 2:00 p.m., she revealed that the treatment to Resident #14's bilateral thighs was changed to Santyl on 1/2/14 because the wound had slough and that Santyl was a debridement agent. She confirmed the wound was no longer a blister. On 1/8/13 at 12:25 p.m., Resident #14 was observed in the dining room on the 3rd floor. The resident was seated at a table with three other residents. A Certified Nursing Assistant (CNA) was seated next to the resident and began to cut the resident's food. There was no soup served to the resident. The CNA left the resident at the table with the meal in fron of them. The resident made no attempt to feed themselves. The CNA returned to Resident #16 and began to feed the resident. On 1/8/14 at 1:50 p.m., the surveyor requested to observe Resident #14's bilateral thighs. The resident was placed in bed by staff. The surveyor, in the presence of the UM and an LPN, observed the left and right inner thigh burns. Both wounds had redness that surrounded the wound bed and yellow slough in the center of the wound. Measurements of the left and right thigh wounds were obtained by the UM. The wound measured 2 cm by 1.5 cm. The right thigh wound measured 6 cm by 3.5 cm. The UM confirmed slough was present and covered both wound beds. The resident was asked what happened to the right and left thighs but was unable to state what happened. A wound consultant evaluation dated 1/9/14 and completed by a Nurse Practioner, revealed Resident #14 had full thickness ulcerations to the left and right inner thigh. The wound measurements were 2.2 cm by 2.5 cm and 3.2 cm by 5.5 cm respectively. Both burn areas wound base had 100 % slough with serous drainage. A review of a "Wound Care Reference Binder Burn Treatment (not dated), indicated for treatment protocols [MEDICAL CONDITION] cool the burn.. apply cool water over the burned skin, apply cool compresses (moist towels to affected area, rationale: cooling the burn reduces swelling by conducting heat away from the skin. There was no indication in the policy of interval or duration of treatment as stated above upon discovery of a burn. A review of the facility policy "Incident Report" dated 3/28/2003, reflected "all incidents are reported to the physician and responsible party as soon as possible" and "following the incident, the resident is monitored every shift and documented on the 24-hour report and in the medical record should be made each shift for 3 days from the date/time of occurrence." There was no documented evidence that this policy was consistently followed. NJAC 8:39-27.1 (a)

A.) Based on observation, interview and record review it was determined that the facility failed to properly secure a kitchen/pantry area while a steam table was in operation and left unattended by staff for approximately one hour and 15 minutes. The 3rd floor unit was a secured memory unit with residents, as identified by staff and clinical record review, having altered cognition abilities at varying degrees. This deficient practice was identified for 1 of 2 kitchen/pantry service areas observed (the 3rd floor kitchen/pantry). This resulted in an immediate jeopardy situation for all cognitively impaired residents who resided on the 3rd floor memory care unit. The immediate jeopardy was identified on 1/6/14 at 10:45 a.m. and corrected on 1/6/14 at 4:35 p.m. based upon an acceptable initial plan of correction for immediacy and revised plan of correction on 1/7/14 at 12:20 p.m. The deficient practice for the Immediate Jeopardy situation was evidenced by: On 1/6/14 at 10:45 a.m., the surveyor entered an unlocked door leading to the 3rd floor kitchen/pantry. There were no staff present in the kitchen at the time. The surveyor observed a three-compartment steam table that was turned on and in operation. The lids that covered the steam table wells were hot to the surveyor's touch. On 1/6/14 at 10:50 a.m., the surveyor interviewed the LPN and asked if the kitchen/pantry door was locked during the day or night. The LPN stated the 3rd floor kitchen/pantry was unlocked by the time he starts his shift and he wasn't sure if it was locked at night. During an interview on 1/6/14 at 10:55 a.m. to 11:05 a.m., the UM informed the surveyor that, "They don't lock the kitchen." She also stated that there was one ambulatory resident on the 3rd floor. On 1/6/14 at 12:50 p.m., the surveyor observed the Dietary Chef (DC) in the third floor kitchen/pantry. The hot water had been drained from the wells to the steam table and he was cleaning the wells. The surveyor asked the DC what the procedure was for the steam table operation. He revealed that staff would refill the wells with water and turn the steam table back on again at 3:00 p.m. for supper which would be delivered to the kitchen/pantry at 4:15 p.m. In addition, the DC told the surveyor that the steam table wells are filled with water and turned on everyday at 9:30 a.m. The surveyor interviewed a Dietary Aide in the presence of the DC at that time. The DA revealed that she had turned the 3rd floor steam table on at 9:30 a.m. on 1/6/14. The DC stated that after the steam table was turned on he would return to the main kitchen on the first floor to prepare lunch and that he usually returned to the 3rd floor pantry between 11:15 a.m. and 11:20 a.m. He stated that staff from the kitchen would periodically enter the kitchen/pantry area on the 3rd floor to re-stock the kitchen/pantry with dishes, cups and other supplies for the next meal. The DC revealed that no staff was permanently stationed in the unlocked kitchen/pantry until lunch was served. On 1/6/14 at 1:00 p.m., the surveyor asked the DC to fill the steam table wells with water and turn on the 3rd floor kitchen/pantry steam table to evaluate the water temperature. On 1/6/14 at 2:07 p.m., (an hour and seven minutes later) the surveyor asked the Food Service Director (FSD) to obtain the temperature of the water located in the steam table. The FSD used a facility thermometer that was calibrated for accuracy in the presence of the surveyor at 2:00 p.m. The following temperatures were observed in the 3rd floor kitchen/pantry steam table at 2:07 p.m.: Steam table well #1: 184 degrees Fahrenheit (F), well #2: 191.4 degrees F and well #3: 189.9 degrees F. During initial tour on 1/6/14 at 8:30 a.m., the surveyor observed a resident attempt to exit the 3rd floor unit (a secured unit). The resident asked the surveyor, who was on the opposite side of the locked glass door, to open the door so that they could "get out." The resident also stated to the surveyor they wanted to go outside. A Licensed Practical Nurse (LPN) approached the door and used a keypad located near the door to open the door to allow the surveyor access to the 3rd floor unit. The resident then ambulated out through the door. The LPN then followed the resident and was able to coax them to return to the secured unit. The LPN identified the resident as Resident #6. On 1/6/14 at 9:30 a.m., during the tour of the facility, with the Unit Manager (UM), the UM informed the surveyor that Resident #6, a resident who resided on the 3rd floor unit, had a [DIAGNOSES REDACTED]. During an interview on 1/6/14 at 11:05 a.m., the UM revealed Resident #6 was the only ambulatory resident that resided on the unit. On 1/6/13 at 11:12 a.m., the surveyor interviewed the LPN who stated Resident #6 "just wanders the hallways" until the resident gets tired. The surveyor reviewed Resident #6's medical record on 1/6/14. According to the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 10/18/13, indicated the resident had a severe cognitive impairment and ambulated independently in the hall. The Care Plan Activity Report (CPAR) initiated on 3/5/13 reflected the resident had daily episodes of confusion and forgetfulness. A review of a Progress Note (PN) dated 12/31/13 at 7:50 a.m. reflected Resident #6 was alert/confused and was up most of the night asking to cook breakfast. In addition, the PN indicated the resident was "pacing in the hallway." The resident was encouraged to go to bed but refused. Safety precautions were maintained. The immediacy of the Jeopardy situation was corrected on 1/6/14 at 4:35 p.m. verified by survey staff. An expanded plan of correction was implemented on 1/7/14 at 2:20 p.m. and verified by the survey staff. The plan included the following: 1. The 3rd floor kitchen/pantry doors will be locked at times when kitchen is unattended. 2. All staff will be educated on kitchen/pantry door locking procedure. Staff will be tested to ensure knowledge of procedure. 3. All staff must check to ensure kitchen/pantry door is locked and service window closure will be responsibility of kitchen manager on duty. A closure checklist will be signed off daily. 4. The new policy titled "2nd & 3rd floor Pantry Security" education will be included in new employee orientation as well as dietary specific training. 5. Compliance monitoring will be included in weekly surveillance rounds led by the Directors of Maintenance, Dietary, Quality Assurance (QA) and the results will be included in quarterly QA assessments. 6. The Director of Dietary Services or designee will conduct daily monitoring of pantry service to assure all aspects of the revised policy are being implemented. A check list will also be utilized in this monitoring. Daily results will be reported to Administrator or designee. This deficiency continues at a lower scope and severity of G based on the evidence in Part B. B.) Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision during a dinner meal for a cognitively impaired resident. This resident, who required one person assistance with meals, was burned after hot soup was served without staff assistance. This deficient practice was identified for 1 of 21 residents reviewed (Resident #14), for accidents and injures and was evidenced by the following: The surveyor reviewed Resident #14's electronic medical record on 1/8/14. Resident #14's [DIAGNOSES REDACTED]. A Psychiatric Progress Note (PN) dated 9/19/13 and 1/8/14 indicated the resident had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 12/24/13 indicated the resident had a severe cognitive deficit, was non-ambulatory, and required extensive one person assistance while eating. According to Resident #14's Care Plan Activity Report (CPAR) initiated on 3/15/13 the resident was at nutrition risk and required "assistive/supportive dining and may have required "cueing to take bites." A review of a Nutrition Risk assessment dated [DATE], confirmed Resident #14's feeding ability need was "extensive assistance one person physical assistance." A review of a PN dated 12/27/13 at 2:00 a.m., written by the Licensed Practical Nurse (LPN) indicated that around 5:15 p.m. Resident #16 was having dinner in the dining room and she was notified that soup had spilled in the resident's lap. The Nursing Supervisor (NS) was present at that time and poured cold water over the area. The resident was returned to their room right away and the resident's pants were pulled down to change the resident. The PN further reflected that "there was no redness or blisters present at the time." The resident was returned to the dining room and finished dinner. The PN continued to reflect that on 12/27/13 at "bedtime" the LPN re-assessed the resident's skin and "blisters and redness" were noted on both inner thighs. There were three blisters on the right thigh that measured 2 cm (centimeter) wide by "3 in length." The redness was 12 cm long by "4 wide." There was one blister on the left thigh that was 3 cm long by "1 wide" and two areas of redness 3 cm wide by "4 in length." Tylenol was administered at 9:30 p.m. for "discomfort" with a positive effect. In addition, the PN reflected a telephone call was placed to the resident's physician at 9:00 p.m. There was a return call from another physician at 11:35 p.m. and orders were obtained for the application of cold compress and to have the resident evaluated by the wound care nurse on 12/27/13. There was no documentation that the would care nurse evaluated/assessed the resident on 12/27/13 as ordered. On 1/8/13 the surveyor requested the complete investigation of the burn injury for Resident #14. A review of an Incident/Accident Report dated 12/26/13 at 5:30 p.m., reflected it was brought to the Licensed Practical Nurse's (LPN) attention when Resident #14 was provided evening care that the resident had redness and blisters on both inner thighs. First aide "cold water" was provided by the Nursing Supervisor. In addition, the report reflected the physician was called at 9:20 p.m. and returned the call at 11:35 p.m. The Injury Non-Fall Investigation Report dated 12/26/13 at 5:15 p.m. to 5:30 p.m., reflected Resident #14 had a burn injury to the left and right inner thighs. The area of pain was checked yes and described as "mild pain." A review of a statement obtained during the course of the facility's investigation from the 3:00 p.m. to 11:00 p.m., on 12/26/13 the NS documented that she "found" the resident in the dining room yelling "help me, help me." Soup was in the resident's lap and the resident stated, "it's hot." The NS documented she pulled the pants away from the resident's skin and poured cold water on the resident's thighs. The NS instructed the Aide to change the resident immediately. The "Charge Nurse was aware." The physician was called at 9:20 p.m. after the Aide notified the Charge Nurse and NS of an injury. At 10:00 p.m., the NS notified the responsible party and "would involve the kitchen- so they won't deliver soup until the aide was at the table." During a telephone interview on 1/8/14 at 2:30 p.m. with the NS, she confirmed the aforementioned statement. The NS revealed she walked into the dining room when she found Resident #14 "screaming out it hurts, it hurts." The NS revealed that no other staff were in the dining room when she arrived to assist Resident #14. She revealed that she and the Certified Nursing Assistants (CNA) walked into the dining room together when the resident was yelling. In addition, she was "not sure" how the resident received the hot soup. On 1/9/14 at 12:22 p.m., the Director of Nursing (DON) and Administrator were made aware by the surveyor that the NS stated that no staff were present in the dining room when she arrived to Resident #14 yelling for help. One day later on 1/10/14, the DON provided the surveyor with additional statements that were not included in the facility's investigation that was given to the surveyor on 1/8/14. A review of the aforementioned statements; included one from a cook dated 12/30/13, who reflected "As far as I remember there are 2 nursing staff on the dining room when the accident happen,"; one undated statement from a Dietary Aide; two undated statements from two CNAs and a statement e-mailed to the facility wound nurse on 1/9/14 from an LPN, all reflected that staff were present in the dining room when the incident occurred. There was no documented evidence that reflected what the staff observed, who served Resident #14 the hot soup and/or that staff had supervised the resident when the hot soup was served. A telephone interview was conducted by the surveyor on 1/8/14 at 2:10 p.m., with the LPN on duty on 12/26/13 during the 3:00 p.m. to 11:00 p.m. shift. The LPN stated "on a few occasions" the resident will grab things on the table and that the resident doesn't know what belongs to them. In addition, she revealed Resident #14 "needs assist with meals and needs supervision and encouragement." When the Aide who was assigned to care for Resident #14 on 12/26/13 during the 3:00 p.m. to 11:00 p.m., was interviewed by the surveyor by telephone, he stated he was not in the dining when Resident #14 spilled the soup. He revealed the resident needs to be fed and "dietary served" the resident the soup. "No one was there to feed her." In addition, he stated he would not leave hot soup in front of the resident. He further stated the resident had grabbed napkins in past, but not food because it's not left in front of the resident without someone there." On 1/8/13 at 12:25 p.m., the surveyor observed Resident #14 in the dining room on the 3rd floor. The resident was seated at a table with three other residents and a Certified Nursing Assistant (CNA) seated next to the resident. The CNA cut the resident's food and no soup was served to the resident. The CNA left the resident at the table with the meal on the table. The resident made no attempt to feed his/herself. The CNA returned to Resident #16 and began to feed the resident. During an interview on 1/8/14 at 12:40 p.m., with the Unit Manager (UM) stated to the surveyor that Resident #14 required one person assistance with eating. On 1/8/14 at 1:50 p.m., the surveyor requested to observe Resident #14's bilateral thighs. The resident was placed in bed by staff. The surveyor in the presence of the UM and a LPN observed the left and right inner thigh burns. Both wounds had redness that surrounded the wound bed and yellow slough in the center of the wound. Measurements of the left and right thigh wounds were obtained by the UM. The wound measured 2 cm by 1.5 cm. The right thigh wound measured 6 cm by 3.5 cm. The UM confirmed slough was present and covering both wound beds. The resident was asked what happened to the right and left thighs. The resident was unable to state what happened. During an interview with an LPN on 1/8/14 at 1:55 p.m., he stated that occasionally Resident #14 will grab things from the dining table. NJAC 8:39-27.1 (a)