Every finding on record at Buckingham at Norwood, The

Complaint #2790946Based on observation, interview and record review it was determined that the facility failed to accurately document and administer pharmaceuticals in accordance with physicians' orders for 4 residents (#14, 67, 108, 156) of 32 reviewed. Specifically, Resident #14 received late administration of insulin, Resident #67 received late administration of pain medications, Resident #108 had documentation discrepancies regarding the administration of antianxiety medication, and Resident #156 had documentation discrepancies regarding the administration of narcotic pain medication. The findings are as follows.1.On 3/26/26 at 10:37 am, the surveyor observed Resident #67 awake in bed. Two certified nursing assistants were assisting the resident with morning personal care. The resident appeared agitated. On 3/30/26 at 11:00 am and 3/31/26 at 10:34 am, the surveyor again observed the resident in bed. The resident was calm, conversant, and denied discomfort. On 3/26/26 at 10:40 am, the surveyor observed Licensed Practical Nurse Unit Manager #1 (LPN UM #1) administering medications ordered for 9 am. She stated she had a callout and was covering for medication administration. On 3/27/26 at 10:22 am, the surveyor observed LPN #2 administering 9 am medications. LPN #2 stated it is difficult to give out all the 9 am medications between the 2-hour window of 8 am to 10 am (the standard of nursing practice is a 2-hour window, 1 hour before and 1 hour after the plotted administration time). On 3/27/26 at 10:24 am, the surveyor observed Registered Nurse #1 (RN #1) administering 9 am medications. RN #1 stated it is difficult to complete 9 am medication pass in 2 hours. On 3/27/26 at 10:26 am, the surveyor interviewed LPN UM #1. She confirmed the 3/26 and 3/27 medication administration ran at least 1/2 hour late. She confirmed this has become routine to run over the acceptable time of administration. She stated the physician has not been made aware of the late administered medications. A review of Resident #67's electronic medical record revealed the following information. The admission Record included diagnoses of rheumatoid arthritis and osteoarthritis. The 1/2/26 quarterly Minimum Data Set (MDS) assessment tool indicated the resident was able to understand verbal content and able to express ideas and wants (Section B), however, the resident answered all questions incorrectly in the Brief Interview for Mental Status (Section C). Section J indicated the resident received scheduled pain medication during the 5-day look back period. The resident was able to complete the pain assessment interview which indicated the resident had not experienced pain in the previous 5 days. The Pain Care Plan, last reviewed by the facility on 1/2/26, indicated that the resident experienced pain related to arthritis and was able to request pain medication and verbalize the severity of the pain. The Order Summary Report listed the following physician's orders for routine pain management. Tizanidine HCl oral tablet 2 mg. with meals for pain (scheduled 8 am, 12 pm, 5 pm). Tylenol 325 mg. give 2 tablets with meals for pain (scheduled 8 am, 12 pm, 5 pm). Lidocaine External Patch 4% to left upper back topically once a day for pain management (scheduled 9 am). Lidocaine External Patch 4% to left knee topically once a day for pain management (scheduled 9 am). The February 2026 Medication Administration Audit Report (a report documenting medications administered outside of the acceptable 2-hour window) revealed numerous late administrations of routine pain medications. A summary of late pain medications during the month of February 2026 follows. Tizanidine was administered late 43 times, Tylenol was administered late 36 times, Lidoderm patch to the back was administered late 18 times, and Lidoderm patch to the left knee was administered late 17 times. The medications which were scheduled to be administered at the beginning of the morning shift (Tylenol and Tizandine at 8 am and Lidoderm patches at 9 am) were frequently documented by the nurse as having been administered after 2 pm. The surveyor reviewed the facility policy titled Pain Management and Assessment, dated 5/1/25. Step 6 reads The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications. The surveyor reviewed the facility policy titled Administering Medications, revised 4/2019. Step 4 reads Medications are administered in accordance with prescriber orders, including any required time frame. Step 7 reads Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. On 3/31/26, the surveyor spoke with the Licensed Nursing Home Administrator, the Director of Nursing (DON), and the Chief Nursing Officer regarding the discrepancies between scheduled times and administration times of routine pain medications. On 4/1/26, the DON responded to the survey team stating that the interdisciplinary team met along with the resident's family member to address the times of administration of pain medications. 2. On 3/27/26 at 12:55 PM, the surveyor, in the presence of LPN #3, began the inspection of the narcotic medications, which were stored in a separately locked, permanently affixed compartment of the medication cart (narcotic box), located on the west side of the second floor. A review of the Individual Patient's Controlled Substance Administration Record (IPCSAR; declining inventory sheet used to track removal of a controlled drug from inventory) for Resident #108's Alprazolam 0.5 milligram (mg) tablets (generic for Xanax) revealed the following documentation by the nurses: -On 3/17/26 at 9, a dose was signed removed. -On 3/18/26 at 9 PM, a dose was signed removed. -On 3/20/26 at 9 PM, a dose was signed removed. -On 3/21/26 at 9 PM, a dose was signed removed. A review of the March 2026 Medication Administration Record (MAR) for Resident #108 revealed the following: -On 3/17/26, no administration of Alprazolam was documented. -On 3/18/26 at 11:32 PM, the administration of Alprazolam was documented. -On 3/20/26, no administration of Alprazolam was documented. -On 3/21/26 at 10:51 PM, the administration of Alprazolam was documented. -On 3/22/26, the effectiveness of Alprazolam was not documented. A review of the Care Plan with a start date of 3/8/26 revealed Resident #108 uses antidepressant medication Xanax 0.5mg related to depression. Interventions included but were not limited to, Administer Antidepressant medications as ordered by physician. Monitor/Documented side effects and effectiveness Q-SHIFT. A review of the Order Summary Report for Resident #108 revealed the following orders: -Alprazolam Oral Tablet 0.5 mg Give 1 tablet my mouth every 24 hours as needed for anxiety for 14 days Xanax 0.5 mg 1 tablet by mouth nightly q 24H with a start date of 3/8/26. -Alprazolam Oral Tablet 0.5 mg Give 1 tablet by mouth one time only for anxiety until 3/22/26 23:59 with a start date of 3/22/26. On 3/27/26 at 1:30 PM, the surveyor discussed the concerns with the LNHA, DON, and [NAME] President (VP) of Clinical Services. The VP of Clinical Services stated the protocol is the nurse signs the declining inventory sheet when they remove the controlled medication from the bingo card. The nurse signs the MAR after they administer the controlled medication. On 3/31/2026 at 1:40 PM, the survey team met with the LNHA and the DON. The surveyor, in the presence of the survey team, interviewed the DON who stated that the expectation is to sign the declination sheet after popping the tablet out of the bingo card and to sign the MAR right away after administering the medication. The DON also acknowledged that the effectiveness of Alprazolam administered on 3/22/26 should have been documented on the MAR in accordance with Resident #108's Care Plan. The DON stated that the nurses admitted they did not act according to the standard of practice. A review of the facility's Administering Medications policy, revised 4/2019, revealed the following: -The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. -As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug. 3. On 4/1/26 at 9:26 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #156. The admission Record revealed Resident #156 had diagnoses that included but were not limited to, dementia, osteoarthritis (chronic degenerative joint disease in which the tissues in the joint break down over time), and left knee pain. A Comprehensive MDS assessment dated [DATE], indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #156 scored 0 out of 15, which indicated the resident had severe cognitive impairment. The resident was also coded as receiving a scheduled pain management regimen. A physician's order dated 10/5/24 indicated to give Tramadol 50 mg tablet, one tablet by mouth one time a day for knee pain. The medication was scheduled to be administered at 9 AM. A physician's order dated 12/19/25 indicated to give Tramadol 50 mg tablet, half a tablet (equaling 25 mg) by mouth two times a day for moderate to severe pain. The medication was scheduled to be administered at 2 PM and 10 PM. A review of the March 2026 Medication Administration Record (MAR) revealed for the above Tramadol 25 mg order there were two entries left blank and unsigned on 3/21/26 for the 2 PM dose and 3/26/26 for the 10 PM dose. On 4/1/26 at 10:58 AM, the surveyor asked LPN #5, who was assigned to care for Resident #156, to review the resident's Controlled Substance Administration Record (CSAR; an accountability log, used to track the chain of custody, usage, and disposal of controlled substances). The CSAR was completed by the nurses who wrote the date, the time, and their signature when a medication dose was removed for administration. The CSARs currently in use were in a binder on the medication cart. The surveyor with LPN #5 reviewed the Tramadol 50 mg tablet CSAR which had entries dated from 3/25/26 to 4/1/26 and revealed the following: There were two entries on 3/25/26, one signed for 9 AM and another signed at 9 PM. There were two entries on 3/26/26, one signed for 9 AM and another signed at 9 PM. LPN #5 confirmed the signature at 9 AM was their signature and was not sure which nurse signed at 9 PM. LPN #5 stated Resident #156 received Tramadol 50 mg at 9 AM and Tramadol 25 mg at 2 PM and 10 PM as ordered by the physician. The LPN could not speak to why there were entries for 9PM on the Tramadol 50 mg CSAR. The surveyor with LPN #5 reviewed the Tramadol 50 mg, half tablet (Tramadol 25 mg) CSAR with entries dated 3/10/26 to 3/26/26 stored in Resident #156's hard copy chart which revealed the following: On 3/21/26 at 2 PM, LPN #5 confirmed that was their signature which indicated Tramadol 25 mg was removed for administration to Resident #156. On 3/25/26 and 3/26/26 there was no entry for 10 PM that the medication was dispensed for administration. The surveyor discussed with LPN #5 that review of the March 2026 MAR revealed unsigned entries on 3/21/26 at 2 PM and 3/26/26 at 10 PM. LPN #5 reviewed the MAR for 3/21/26 on the EMR, confirmed they had worked on the 7AM-3PM shift, and that the entry was unsigned. The LPN did not know why the entry was left unsigned and acknowledged it should have been signed for the medication's administration. The surveyor and LPN #5 were joined by the Registered Nurse Unit Manager (RN/UM) who was informed of the missing signatures on the MAR for Tramadol 25 mg and the concerns found upon the CSAR review for Tramadol. The RN/UM and the surveyor reviewed the above Tramadol 50 mg and Tramadol 25 mg CSAR forms which indicated the nurses on 3/25/26, 3/26/26, and 3/30/26 at 10 PM signed for Tramadol 50 mg being dispensed as administered instead of Tramadol 25 mg. The RN/UM stated an investigation would be initiated to determine what happened. On 4/1/26 at 11:15 AM the surveyor informed the Director of Nursing (DON) regarding the above concerns. The DON replied that the RN/UM had just informed her, and she was on her way to the unit to investigate. The DON acknowledged if the Tramadol 50 mg dose was scored (an indented line on a medication pill designed to allow it to be safely and easily split into smaller, equal doses) and the nurse cut the pill to provide a Tramadol 25 mg dose it would be expected for there to be two nurse signatures for the entry on the CSAR to indicate a witness for the disposal of one half of the cut tablet. None of the entries identified documented disposal or a second nurse as a witness. On 4/1/26 at 1:17 PM, the surveyor informed the DON, the LNHA, and the CNO of the above concerns for the missing signed entries on the MAR; and the discrepancies identified of the nurses dispensing Tramadol 50 mg for administration instead of Tramadol 25 mg. The DON stated an investigation was initiated. The surveyor requested copies of the Tramadol CSARs for February 2026 and March 2026. Additional review and summary of discrepancies identified for Tramadol CSARs in February 2026 and March 2026 revealed: On 2/5/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the February 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 2/12/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the February 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 2/19/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the February 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 2/23/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the February 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 2/26/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the February 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 3/13/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the March 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 3/25/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the March 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 3/26/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the March 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 3/30/26 for the Tramadol 25 mg 10 PM dose, the nurse signed as dispensed Tramadol 50 mg and not Tramadol 25 mg. The surveyor reviewed the March 2026 MAR which revealed the Tramadol 25 mg medication dose entry at 10 PM was signed as administered. On 4/2/26 at 10:12 AM, the LNHA, the DON, and the CNO met with the survey team. The DON stated Resident #156's CSARs for Tramadol were reviewed and acknowledged the concern found as the records reflected that Tramadol 50 mg was administered instead of Tramadol 25 mg. The DON stated the physician and the resident's representative were notified of the occurrences; there were no signs or symptoms of adverse effect to the resident; no negative clinical impact noted; and nursing staff education was initiated regarding documentation and medication handling errors. There was no additional information provided by the facility's management. A review of the undated, facility provided policy titled, Administering Medications, under Policy Interpretation and Implementation revealed: . 4. Medications are administered in accordance with prescriber orders. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the undated, facility provided policy titled, Documentation of Medication Administration, under Policy Interpretation and Implementation revealed: A nurse documents all medications administered to each resident on the resident's MAR. Administration of medication is documented immediately at least within the hour after it is given. 4.) On 3/26/26 at 11:15 AM, the surveyor observed Resident #14 in a wheelchair in the nursing unit dining room awake and alert. The resident was participating in an activity with staff in attendance. The resident responded to greeting from surveyor with the assistance of the facility's interpreter. A review of Resident #14's admission record reflected the resident was admitted to the facility with diagnoses including but not limited to type 2 diabetes, dementia and chronic kidney disease. A review of Resident #14's annual Minimum Data Set (MDS), an assessment tool dated 12/24/25, reflected that the resident was severely cognitively impaired. A review of Resident #14's Physicians orders (POs) reflected physician's orders for 2 types of insulin in 3 orders. PO #1 dated 7/18/25: Insulin Aspart Injection solution 100 unit/milliliter. Inject per sliding scale: if blood glucose is 0-150 = 0 units, if 151-200 = 2 units, if 201-250 = 4 units, if 251-300 = 6 units, if 301-350 = 8 units, if 351-400 = 10 units, if above 400 give 10 units and notify the provider, Give subcutaneously three times a day (8:00AM, 11:30 AM and 4:30PM). PO #2 dated 9/23/25: Insulin Glargine Inject 8 units subcutaneously in the morning (9:00 am), discontinued on 3/26/26. PO #3 dated 3/26/26: Insulin Glargine Inject 4units subcutaneously in the morning (9:00 am). A review of Resident#14's medication administration record (MAR) and the Medication audit summary report for February and March of 2026 reflected that aspart insulin, PO #1 was administered more than one hour after the ordered administration time on 54 of the ordered 93 occurrences in March 2026. The MAR reflected that insulin glargine, PO #2 dated 9/23/25 was administered more than 1 hour after the ordered administration time on 16 of 31of the ordered occurrences in March 2026. The MAR reflected insulin glargine PO #3 dated 3/26/26 was administered more than 1 hour after the ordered administration time on 3 of 5 ordered occurrences. On 4/1/26 at 11:45 AM, the surveyor interviewed LPN #3 concerning Resident #14's insulin orders and administration, The LPN confirmed she administered the residents aspart insulin ordered for 4/1/26 at 8:00 AM and the administration time of 9:17 AM was accurate in the (EHR). The LPN acknowledged medication should have been administered between 1 hour prior to and 1 hour after ordered administration time. The surveyor asked the LPN about procedure for administering medications late and the LPN explained she should have notified the provider and obtained an order for administering the medication at the later time. On 4/1/26 at 1:28 PM, The Survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator and the Chief Nursing Officer. The DON acknowledged that all nurses should have administered the ordered Insulin within an hour of the ordered administration time. NJAC 8:39-29.1; 29.2; 29.5; 29.7

Based on observation, interview, and record review it was determined that the facility failed to ensure call devices were positioned within reach of a resident who was at risk for falls. The deficient practice was cited for 1 resident (Resident #59) and evidenced by the following. On 3/26/26 at 11:30 am, the surveyor observed Resident #59 standing in the doorway of their room next to their bed. The resident told the surveyor that they needed help because there was spilled water in the room. The surveyor inquired whether the resident pushed the call device to summon help. The resident replied she did not know where the device was. The call device was observed on the floor under the bed near the roommate's bed.On 3/27/2026 at 10:37 am, the surveyor observed the resident lying on their bed. The surveyor observed the call device under the bed near the roommate's bed. When asked by the surveyor where the call bell was, the resident replied they did not know. On 3/30/26 at 9:50 am, the surveyor observed the resident lying on their bed. The surveyor observed the call device on the floor under the bed near the roommate's bed. The resident indicated they did not know where the call device was and stated it's important that I have it in case I need to use it.On 3/30/26 at 10 am, the surveyor spoke with the Licensed Practical Nurse Unit Manager explaining the call bell was on the floor under the bed on 3/26, 3/27, and 3/30. She stated it should have been clipped to the bed where the resident could reach it. She stated staff is to make rounds to be sure call bells are accessible to residents.A review of the resident's medical record revealed the following information.The admission Record included diagnoses of altered mental status, difficulty in walking, and dementia. The Care Plan Report included a 6/9/24 fall risk care plan related to confusion and antidepressant use. Fall prevention interventions included providing a working and reachable call device.The 12/26/25 quarterly Minimum Data Set assessment tool indicated the resident was severely cognitively impaired.The facility's policy titled Answering the Call Light, revised September 2022, noted in general guideline #5 Ensure that the call light is accessible to the resident when in bed.On 3/30/2026 at 1:18 pm, the surveyor spoke with the Licensed Nursing Home Administrator, the Director of Nursing (DON), and the Chief Nursing Officer regarding the concern of the call placement for 3 days of the survey.NJAC 8:39-27.1(a)

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to continue to assess a resident after a fall to ensure the resident had no adverse effects from the event in 1 of 3 residents reviewed for falls (Resident #80).This deficient practice was evidenced by the following:On 3/26/26 at 10:52 AM, the surveyor observed Resident # 80 in room seated in chair, interviewable, and stated that they are pleased with the care. A review of the Resident # 80's electronic health record (EHR) reflects the resident was admitted with diagnoses that included but were not limited to a fracture of the right femur, dementia, difficulty walking and unsteadiness on feet.A review of Resident #80's annual Minimum Data Set (MDS), dated [DATE], an assessment tool, reflected that the resident is moderately cognitively impaired. The MDS reflected that the resident used a wheelchair for mobility and needed assistance with transfers.A review of the progress notes for Resident #80 reflected the resident was discovered to have sustained an unwitnessed fall on 12/31/25 at 3:30 PM. The nursing progress note dated 12/30/25 at 3:32 PM reflected the resident was found on the bathroom floor of room [ROOM NUMBER] and assessed with blood on the resident's face and on the floor. The note also documented the resident was unable to provide details as to what had occurred. A nursing note on 12/30/25 at 4:13 PM, reflected the Assistant Director of Nursing acknowledging receipt of a report of Resident #80's fall. A nursing progress note dated 12/30/25 at 10:14 PM documented a post fall assessment of resident performed by the Registered Nurse assigned to Resident 80's care on 12/30/25 for the 3 PM to 11 PM shift. The review of the EHR did not reveal any further documentation of follow up assessments on Resident #80's 12/30/25 unwitnessed fall.On 3/27/26 at 1:30 PM, the surveyor interviewed the Director of Nursing (DON). The DON provided the facility's fall prevention program policy dated 5/1/25 and confirmed the policy required nurses to chart on a resident that suffered an unwitnessed fall be assessed by the nurse assigned to the resident every shift for 72 hours post fall. The DON further confirmed this documentation should include neurological checks and an assessment of the resident's status. The DON confirmed no nursing post fall resident assessments were documented after 12/30/25 at 10:14 PM and nursing assessments were required to be documented every shift until 1/2/26 at 3:30 PM.A review of the facilities policy titled Fall Prevention Program, dated 5/1/25 reflected after a resident had sustained a fall.Each nurse, each shift will observe the resident and document for 72 hours in the resident's medical record. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to monitor the nutritional status for 1 of 1 residents reviewed for nutritional status (Resident #137), by not following a physician's orders for monitoring of the resident's weight.The deficient practice was evidenced by the following:On 3/26/26 at 10:46 AM, the surveyor observed resident in bed, awake and responsive with the call bell placed within the resident's reach. A review of Resident #137's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes, obesity, essential hypertension (high blood pressure) and urinary retention.A review of Resident #137's annual Minimum Data Set (MDS), an assessment tool dated 2/20/26, reflected that the resident was moderately cognitively impaired.A review of the resident's Physician Order Summary report reflected the following physician's order (PO): Weigh resident daily and notify provider if resident gains more than 3 lbs. in 24 hour period or greater than 5 lbs. in one week, initiated on 11/11/25.A review of Resident #137's medical record does not indicate a weight was obtained on 50 of 59 days in the Months of February and March of 2025 as required by the PO. A review of electronic health records (EHR) reflects the following weights were obtained and documented: 2/5/26 235.4 lbs., 2/8/26 235.4 lbs., 2/14/26 235.2 lbs., 2/15/26 235.3 lbs., 2/17/26 235.3 lbs., 2/18/26 235.3 lbs., 2/28/26 235.5 lbs., 3/8/26 230 lbs., 3/29/26 234.5lbs. A review of the resident's EHR does not reflect documentation that the recorded weights were discussed with the provider during the months of March or April 2026.On 4/1/26 at 11:00 AM, the surveyor interviewed Resident #137 with assistance of the facility's interpreter. The resident demonstrate he was poor historian on his health status. The resident could not recall being weighed by staff and did not verbalize a reason that the physician may have ordered a daily weight.On 04/1/2026 at 11:35 AM, the survey interviewed the Registered Nurse (RN) assigned to Resident #37s care. The RN confirmed a physician's order was present in the resident's EHR to obtain the resident's weight daily. The RN confirmed nurses are required to documents weights in the vital signs section of the resident's EHR and sign the Medication Administration Record (MAR) that they were obtained. The RN acknowledged that residents should always have weights assessed and documented according to the physician's orders. A review of the facility policy, Weight Assessment and Documentation, reflected .residents are weighed at admission and at intervals established by the interdisciplinary team.weights are recorded in the weight record chart in the individual's medical recordOn 4/1/26 at 1:30 PM, the survey team met with Licensed Nursing Home Administrator and the Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that the weights were not obtained and documented per the PO for Resident #137 on 50 of 59 days in March and April 2026.NJAC 8:39-17.1(c); 17.2(d); 27.2(e), (k)

Based on observation, interview, and record review, it was determined that the facility failed to clarify oxygen therapy orders to ensure a resident was provided with care, consistent with professional standards of practice, for 1 of 1 resident (Resident #16) reviewed for respiratory care. The deficient practice was evidenced by the following:On 3/26/26 at 11:11 AM, the surveyor observed Resident #16 sitting in a wheelchair, alert and sitting with other residents at a table for a recreational activity. The resident was not on any oxygen therapy and there were no observed concerns.On 4/1/26 at 9:09 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #16.The admission Record (a summary of important resident information) revealed Resident #16 had diagnoses that included but were not limited to, hemiplegia (a paralysis or severe weakness affecting one side of the body), and dementia.A Quarterly Minimum Data Set assessment, a tool used to facilitate management of care, dated 1/26/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #16 scored 5 out of 15, which indicated the resident had severe cognitive impairment.A physician's order dated 10/13/25 indicated to administer oxygen at 2-6 liters per minute (LPM) via nasal cannula as needed (PRN) for shortness of breath.A physician's order dated 10/13/25 indicated the resident was receiving hospice care services.A review of the March and April 2026 Treatment Administration Record (TAR) for the above oxygen order entry revealed the resident had not needed PRN oxygen therapy.On 4/1/26 at 10:50 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated oxygen therapy orders should have a specified LPM. The RN/UM further explained if the oxygen therapy ordered was not helping a resident, the physician could be called to obtain an order to increase the LPM of oxygen administered. The surveyor discussed with the RN/UM the concern for Resident #16's PRN oxygen order which indicated oxygen delivery at 2-6 LPM. The RN/UM stated there may be oxygen therapy recommendations for a range of LPM, especially for hospice care residents. The RN/UM acknowledged the nurses should clarify with the physician the oxygen therapy order as it should specify an LPM. The RN/UM stated she would review and clarify Resident #16's order with the physician.On 4/1/26 at 1:17 PM, the surveyor informed the Director of Nursing (DON), the Licensed Nursing Home Administrator, and the Chief Nursing Officer about the concern with Resident #16's PRN oxygen therapy order. The DON stated the expectation was for an oxygen therapy order to have a specific LPM and not a range to administer. The DON further explained that the RN/UM clarified the order with the physician after surveyor inquiry. There was no additional information provided by the facility's management.A review of the facility provided policy with the subject of Respiratory Care Policy revealed under Policy: .The facility shall provide safe, effective, and individualized respiratory care services to all residents in accordance with physician orders, a professional standards of practice, and regulatory requirements. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516.This deficient practice was evidenced by the following:According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program:(a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements:(1) Compliance with title XVIII of the Act and applicable Medicare regulations.(2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare.(3) Not employing or contracting with individuals or entities that meet either of the following conditions:(i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act.(ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes:(1) Within 30 days -(i) A change of ownership;(ii) Any adverse legal action; or(iii) A change in practice location.(2) All other changes in enrollment must be reported within 90 days.On 3/26/26 at 8:55 AM, upon arrival to the facility, the surveyor observed a sign outside the facility which revealed Excelcare at [NAME], not [NAME] at [NAME]. On 3/26/26 at 10:30 AM, the Licensed Nursing Home Administrator (LNHA) stated that the facility was now owned by Excelcare and that they sent in a request for name change to the state but they did not do the name change through CMS yet. The LNHA stated that he did not have a business card to provide the surveyor, yet, the Director of Nursing (DON) provided the surveyor with a business card. The DON's business card revealed that the facility name on the card was listed as Excelcare at [NAME]. The LNHA provided the surveyor with the Facility Assessment which revealed Excelcare at [NAME] documented on the cover page, and the Facility Assessment, which also revealed Excelcare at [NAME] documented on the cover page. On 3/27/26 at 10:40 AM, the LNHA provided the surveyor with a letter dated February 28, 2025 which revealed that the facility had sent written notification to the Assistant Commissioner to indicate the agreement for new management. The surveyor met with the facility LNHA and Director of Nursing (DON), to discuss the deficient practice of utilizing the facility name ExcelCare at [NAME] without CMS approval. No further information or documentation was provided to the survey team to refute these findings.NJAC 8:39-5.1 (a)

Based on interviews, and a review of pertinent facility documents, it was determined that the facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming. This was identified for 1 of 9 NAs reviewed (NA#1) who provided direct care to residents on 5 of 5 nursing units. NA #1 was hired on 6/17/24, as a Hospitality Aide. NA #1 began independent resident care assignments on 7/03/24, and was enrolled in a state approved Nurse Aide in Long-Term Care Facilities Training and Competency Evaluation Program (NATCEP) that began on 7/15/24, and worked 69 shifts with no evidence of completing the required skills and competencies prior to providing resident care. The facility's failure to ensure all NAs were trained with the appropriate competencies and skills required prior to receiving an independent resident care assignment posed a likelihood that serious injury, harm, impairment, or death could occur to residents since untrained staff were providing resident care. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 7/03/24, after NA #1 was assigned as a NA on the 2 North nursing unit. The facility Administration was notified of the IJ on 11/01/24 at 5:44 PM. The facility submitted an acceptable Removal Plan (RP) on 11/06/24 at 3:42 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 11/07/24. The evidence was as follows: A review of the facility provided Position Title: Nursing Assistant (NA) job description dated August 2005, included; the Nursing Assistant performs various resident care activities and related nonprofessional services essential to caring for the personal needs and comfort of resident .Job skills and requirements .must have knowledge of procedures and techniques in administering simple treatments and providing related bedside resident care services .must understand standard techniques used in providing personal services and in caring for equipment and supplies . A review of the undated facility provided Hospitality Aide job description included; a Hospitality Aide is responsible for assisting in the care of residents in a healthcare or long-term care facility. This may include helping patients with activities of daily living, serving meals, cleaning rooms, and providing companionship and emotional support. Key responsibilities: serve meals [ .] not allowed to feed; maintain a clean and organized living space for residents .greeting guests and aiding with their needs not allowed to change or bathe/shower residents .answer call light and report the request(s) to nurse or CNA .pass out water . On 10/29/24 at 11:02 AM, during the entrance conference with the Licensed Nursing Home Administrator (LNHA), Registered Nurse/Unit Manager (RN/UM), and Assistant Administrator (AA), the surveyor asked if the facility utilized non-certified Nurse Aides (NAs), and the Director of Nursing (DON) responded yes. The surveyor also asked if the NAs were providing direct care to residents, and the LNHA stated that the NAs were not providing direct care because they were not done in school, or did not have a license yet. The LNHA stated the NAs were only passing water and helping to transport residents. The LNHA further stated that he was unsure of how many NAs were in the facility and that he would provide a list. On 10/29/24 at 01:10 PM, the LNHA provided the surveyor with a list of NAs who worked at the facility. NA #1 was included on the list with a date of hire (doh) of 6/17/24. On 10/30/24 at 01:14 PM, the surveyor reviewed NA #1's employee file which revealed the following: -Human Resources New Hire Form: doh 6/17/24. Position: Hospitality Aide, hourly, full time with benefits, scheduled hours 7:00 AM to 3:00 PM (7-3). -Job Title and Description: Hospitality Aide. Key responsibilities: did not include direct care. Signed by NA #1 on 6/17/24. -Job Description, Position Title: Nursing Assistant (NA), signed by NA#1 on 10/06/24. -School letter dated 5/15/24: This letter is to certify NA #1 will be attending the CNA training course at [name of school redacted] starting July 15th, 2024 to [August] 15th, 2024, Monday through Friday from 9:00 AM to 2:30 PM. Ninety hours were required in order to complete this program. Signed by the School Director (SD). -Personnel Change Form: doh 6/17/24, today's date 10/09/24, change effective date 10/06/24. Nature of change: reclassification, new title: Nurse Aide. Signed by Human Resources (HR): changes completed 10/09/24. Further review of NA #1's employee file did not include documented evidence that NA #1 completed the 16 hours or 90 hours of required education, training, and competencies in order to provide direct care to residents. A review of NA #1's time sheets provided by the Human Resource Regional Director (HRRD #1) revealed NA #1 worked the following: -From 6/17/24 to 7/14/24, NA #1 worked the 7:00 AM to 3:00 PM (7-3) shift Monday through Friday. In addition, NA #1 worked the 7-3 on 6/29/24; the 7-3 and 3:00 PM-11:00 PM (3-11) double shifts on 7/04/24, and the 7-3 and 3-11 double shifts on 7/13/24. -From 7/15/24 to 8/15/24, NA #1 worked the 7-3 shift Monday through Friday. In addition, NA #1 worked the 7-3 and 3-11 double shifts on 7/19, 7/29, 7/31, 8/05, 8/09, and 8/14/24. NA #1 also worked on 7/27/24 and 8/03/24, the 7-3 shift. A review of the corresponding Certified Nursing Aide (CNA) assignments sheets provided revealed the following: On the 7/01/24, 7-3 shift, NA #1 was independently assigned to Assignment #2 which included 13 residents in total and showers for three residents (rooms: 128 A, 136 A, and 138 A). A review of the additional CNA assignment sheets confirmed NA #1 worked on all five nursing units with independent resident care assignments that corresponded with their timesheets. According to NA #1's school letter, NA #1 was attending the CNA school Monday through Friday from 9:00 AM to 2:30 PM, beginning 7/15/24 through 8/15/24. According to the facility's CNA assignment sheets and NA #1's time card, NA #1 was working at the facility providing resident care during the same dates and time NA #1 was supposed to be attending school. On 10/31/24 at 9:49 AM, the surveyor conducted a telephone interview with NA #1, who stated she was unsure when she started and ended nurse-aide training school. NA #1 confirmed that she was not currently enrolled in school and did not complete school. NA #1 stated that she was unable to finish the school program because she was at the facility working double shifts most of the time. NA #1 further stated that when she started working in the facility, she had three weeks maybe of orientation following a CNA, and then afterwards she had her own independent resident care assignment providing direct care which included; washing, toileting, feeding, and transferring residents from bed to wheelchair and vice versa. NA #1 stated that according to HRRD #1, she was not allowed to return to work until she was able to provide documentation that she completed the required NATCEP program because the facility did not have those documents. On 10/31/24 at 12:02 PM, the surveyor interviewed HRRD #1 and HRRD #2. HRRD #1 stated that according to the information received from the school, NA #1 was scheduled to start on 7/15/24. HRRD #1 continued that NA #1 would have completed their 16 hours of competency skills on 7/18/24. HRRD #2 stated that NA #1 could provide resident direct care supervised by a CNA. HRRD #2 also stated in regards to NA #1's title change in October, that on 7/15/24, NA #1's title should have changed then from Hospitality Aide to NA because she was enrolled in school, and the delay in title change was an error. At that time, the facility was unable to provide documentation that NA #1 completed their competency skills. HRRD #1 and HRRD #2 did not respond to surveyor inquiry how the facility would know NA#1 completed their competency skills with no documentation. On 10/31/24 at 01:51 PM, the surveyor interviewed the RN/UM, who stated that NA #1 went to school, did not pass, or take the test, and cannot be a CNA. The surveyor then reviewed with the RN/UM the CNA assignments for the 2 North unit where NA #1 on 10/8, 10/11, 10/14, 10/15, 10/16, and 10/18/24, was assigned with room numbers below NA #1's name and the surveyor asked what that meant. The RN/UM responded that the assignments indicated that NA#1 was assigned to provide direct care to those residents in the corresponding rooms. The RN/UM confirmed NA #1 was not supposed to have an assignment because she was a NA, and it was the nurses in the unit who assigned NA#1 to a resident care assignment. On 10/31/24 at 02:24 PM, HRRD #1 and HRRD #2 provided a letter from NA#1's school dated 10/31/24, that included Sorry she (NA #1) did not complete her program. She missed the Test one and the Final. Additionally, she failed to pay her balance. She did not complete the class. The letter was signed by the SD. On that same date and time, HRRD #1 confirmed that NA #1 should not have an assignment on their own. The surveyor showed HRRD #1 and HRRD #2 the CNA assignment sheets where NA #1 had resident care assignments, and they both acknowledged that NA #1 should not have had their own care assignment. On 10/31/24 at 3:25 PM, the surveyor reviewed the CNA Assignment sheets with the 7-3 Registered Nurse (RN) and the 3-11 Licensed Practical Nurse (LPN) in the 2 North nursing unit. The RN confirmed that NA #1 worked independently with assigned residents providing direct care on 7/03, 7/17, and 7/18/24, for the 7-3 shift. The LPN confirmed that NA #1 worked independently with assigned residents providing direct care on 10/4, 10/11, and 10/15/24, during the 3-11 shift. At that same time, both nurses stated that as per facility practice, they (nurses) assigned the aides when they received the schedule for the day on their shifts. Both further stated that it did not matter if they were CNAs or NAs, both aides had their own assigned residents and assignments to provide direct care, i.e. feeding, toileting, transferring, and bathing/washing of the residents. The RN confirmed that NA #1 had their own assignments and provided direct care independently. The surveyor asked how they knew that NA #1 could work independently on their assignment, and both the RN and LPN stated that when they received the schedule for their shifts, they divided the assignments accordingly and nobody told them, they just knew. On 11/01/24 at 8:13 AM, the surveyor followed up with HRRD #2 regarding the requested policies for Hospitality Aides and Nursing Aides. The surveyor also requested the facility's policy regarding the onboarding process. HRRD #2 stated she would get back to the surveyor. On 11/01/24 at 8:21 AM, the surveyor asked the DON what the facility's process for onboarding NAs was, and the DON stated the usual process, was the NA applied, a criminal background check was performed, health physicals and testing was done, and the facility verified they were in school. The DON stated the facility needed to receive the documentation that the NA was attending school. She further stated, I think when they're in school, they have to take the skills test they have to submit the skills test and whatever they are doing in school. On that same date and time, the surveyor asked the DON why it was important that the facility received documentation that the NA completed their skills test, and the DON stated because the NAs needed to be competent to do the care. The surveyor also asked the DON if the facility provided competencies skill to the NAs, and the DON stated that there was no specific time when the facility provided or checked NAs competency skills. She further stated that if NA brought their skills test from school, the NA could provide direct care as soon as the facility received it. The DON confirmed the skills test and competencies should be included in their employee file. The surveyor asked the DON if she checked the NAs' files to ensure they had their completed requirements, and the DON stated that the nurses and herself checked the files. On 11/01/24 at 9:32 AM, HRRD #2 stated that the facility did not have a policy for Hospitality Aides and NA; that the facility followed their job description. On 11/01/24 at 10:40 AM, the surveyor interviewed HRRD #1, who stated that she was responsible for ensuring all required newly hired employee documents were together; ran background checks; called the NA for orientation; and entered all the NA's information into the system. HRRD #1 stated that it was the Staffing Coordinator's (SC) responsibility to verify the NA's school requirements and documents prior to date of hire and resident care. The SC was also responsible for ensuring a copy of the verification was included in the NA's employee file. HRRD #1 confirmed NA #1 did not have the skills test and NA #1 should not have been providing direct resident care. HRRD #1 stated the SC was out of the facility on leave. On 11/01/24 at 11:19 AM, the surveyor asked the LNHA what the facility required the NAs to submit prior to hire and be able to provide direct resident care, and the LNHA stated he was not involved in the NA onboarding process. The LNHA stated his role as the administrator was to approve and sign documents for the onboarding of newly hired employees so he was unaware of what was included in the process. On 11/04/24 at 9:39 AM, the surveyor met with the LNHA, DON, and Regional Director of Operations (RDO). The DON stated that the facility was only responsible for receiving the information from the NA that they were enrolled in school; that we go by the information provided by the NA. An acceptable Removal Plan (RP) on 11/06/24 at 3:42 PM, indicated the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including NA #1 was removed from employee schedule pending confirmation of successfully passing exam; staff education on hiring Hospitality Aides and the process for hiring and scheduling Nursing Aides; DON reviewed all current NA onboarding requirements; and DON reviewed all NAs to confirm they had the required competency skills. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 11/7/24. N.J.A.C. 8:39-43.1 (a)(2,3); 43.2(a)(1,3)(b)

Based on the interview and review of pertinent facility documentation, the facility failed to have the Infection Preventionist present for three (3) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 156 residents who currently live in the facility. The deficient practice was evidenced by the following: On 10/29/24 at 11:02 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Registered Nurse/Unit Manager during an Entrance Conference meeting. The LNHA confirmed that day census (total number of residents) of 156. The LNHA stated that it was the Regional Infection Preventionist Nurse (RIPN) the facility's Infection Preventionist (IP), and the LNHA was unsure when the RIPN started to be the IP. The surveyor asked for the IP timeline since the last recertification (7/14/23), and the LNHA responded that he would get back to the surveyor. On 11/06/24 at 01:48 PM, the Director of Nursing (DON) provided the last three-quarters of QAPI Attendance sheets and revealed the following: QAPI Attendance: 5/29/24=the LNHA, Medical Director (MD), DON, Pharmacy Consultant (PC), and other Interdisciplinary Team (IDT) signed the QAPI Attendance sheet. There was no documented evidence in the sign-in sheet that the IP attended the meeting. 7/23/24=the LNHA, MD, DON, IDT, and vendor representatives signed the QAPI Attendance sheet. There was no documented evidence in the sign-in sheet that the IP attended the meeting. 10/22/24=the LNHA, MD, DON, IDT, and vendor representatives signed the QAPI Attendance sheet except for the IP. There was no documented evidence that the IP attended the meeting. A review of the facility's QAPI Time and Date schedule revealed: 4/23/24=1st QAPI Report due (January 2024-March 2024) 7/23/24=2nd QAPI Report due (April 2024-June 2024) 10/23/24=3rd QAPI Report due (July 2024-September 2024) 01/25/25=4th QAPI Report due (October 2024-December 2024) On 11/06/24 at 02:06 PM, the surveyor interviewed the RIPN who informed the surveyor that she recently assumed the IP position of the facility in October 2024. The surveyor asked for the IP timeline since the last recertification, signed job description, and certification for IP and she said she would get back to the surveyor. At that same time, the surveyor asked the RIPN to confirm who was the IP in the submitted copies for QAPI attendance sheets on 5/29/24, 7/23/24, and 10/22/24. The RIPN confirmed that there were no IPs on the last three quarters' QAPI attendance sheets. On 11/07/24 at 9:35 AM, two surveyors met with the LNHA for a QAPI interview. The surveyor notified the LNHA of the above findings and concerns that there were no IPs attended the last three quarters QAPI meeting which was confirmed as well by the RIPN as the attendance sheets were reviewed. The surveyor asked the LNHA who reported about infection control in the QAPI meeting in the absence of the IP, and the LNHA responded that it was the DON who reported about the facility's infection control. The LNHA acknowledged that the facility did not comply with the requirement that the designated IP should be dedicated solely to the IPCP (Infection Prevention Control Program). A review of the facility's QAPI Plan that was provided by the LNHA did not include information that must be composed of at a minimum who the QAPI Committee was. On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, Regional Director of Operations, Regional Clinical Operations, and AA for the Exit conference. The facility did not provide additional information and did not refute the findings. NJAC 8:39-33.1(b)

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for five (5) out of eight (8) newly hired staff prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed eight randomly selected new employee files. The review for reference checks for five of the eight new employees revealed the following: -Staff #1's file, a Registered Nurse (RN) who was hired on 5/27/24, revealed only 1 reference check in their file. -Staff #2's file, a RN who was hired on 9/10/24, revealed only 1 reference check in their file. - Staff #3's file, a Certified Nursing Assistant (CNA) who was hired on 10/30/23, revealed no reference checks in their file. - Staff #4's file, a CNA, who was hired on 10/16/23, revealed no reference checks in their file. - Staff #5's file, a CNA, who was hired on 10/16/23, revealed no reference checks in their file. On 11/06/24 at 01:21 PM, the surveyor interviewed the Human Resources Regional Director (HRRD) who stated if the facility was unable to reach the provided reference in the staff's file, they would ask the staff to provide another reference person. The HRRD also stated if the newly hired employee had no work history, they would require a personal reference as part of the background check. On 11/07/24 at 11:15 AM, the HRRD confirmed to the surveyor that the 5 newly hired staff did not have a reference background check completed. On 11/07/24 at 12:39 PM, the surveyor informed the Licensed Nursing Home Administrator, Director of Nursing, and Infection Preventionist regarding the above concern. There was no additional information provided by the facility. The surveyor reviewed the undated facility's policy titled New Hire Process revealed, NOTE: **Some New Hires will be urgent, the below MUST be done in this order and communication MUST be strong, otherwise no credentials will be created**. Further review of the policy revealed under the 3rd step, HR (Human Resources) to complete the below: Once Application and Applicant safe form is cleared: .send reference form. N.J.A.C. 8:39-9.3 (a), (b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly store medication (med) for one (1) of 38 residents, Resident #210, and b.) ensure that medications (meds) were stored and labeled appropriately for two (2) of four (4) med carts inspected and two (2) of four (4) med storage rooms inspected located on four (4) of five (5) nursing units according to facility's policy and standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 10/29/24 at 10:35 AM, the surveyor observed Resident #210 inside their room seated in a wheelchair. The resident was cognitively intact and informed the surveyor that they were at the facility for rehabilitation. The surveyor observed three containers of meds on top of the drawers, L-Lysine (an essential amino acid; a supplement) 1000 mg (milligram), Vitamin D3 (supplement supports healthy bones and glowing skin, boosts immunity, and promotes heart health) 2000IU (2000 international unit), and Vitamin B12 (supplement; is important for protein metabolism) 1000 mcg (microgram). The resident was in a private room by themselves. The resident stated that they were taking those home meds Vit D3 and Vit B12 once a day while at the facility for a while (unable to state the exact date). On 10/29/24 at 10:45 AM, the surveyor asked the Licensed Practical Nurse (LPN) for the resident's list of meds in the electronic Medication Administration Record (eMAR). The LPN showed the surveyor the resident's meds inside the medication (med) cart that belonged to Resident #210. The provided copies of the resident's meds and actual meds in the med cart for Resident #210 revealed that the resident had no order for L-lysine, Vitamin D3, and Vitamin B12. At that same time, the surveyor notified the LPN about the concerns that the resident had three containers of meds not properly stored. The LPN stated that he was unaware that the resident had meds on their own at the bedside. The LPN confirmed that there were no orders for L-lysine, Vitamin D3, and Vitamin B12 meds. The LPN further stated that there should be no meds left or stored in the resident's room. The surveyor reviewed the medical records of Resident #210 and revealed: The Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to other asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), unspecified diastolic (congestive) heart failure, and essential (primary) hypertension (occurs when abnormally high blood pressure that's not the result of a medical condition). The most recent comprehensive Minimum Data Set (cMDS) with an assessment reference date (ARD) of 10/04/24, under Section C Cognitive Patterns, reflected on a brief interview for mental status (BIMS) score of 15 out of 15 which showed that the resident was cognitively intact. On 11/06/24 at 11:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Operations (RDO). The surveyor notified the facility management of the above concerns and findings. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Assistant Administrator (AA), and the Regional Infection Preventionist Nurse (RIPN). The DON stated that the facility was considered a regulated environment and acknowledged that meds should be properly stored. A review of the Medication Storage Policy with a revised date of 10/2023 that was provided by the DON revealed: Meds housed on our premises are stored in the pharmacy and/or med rooms according to the manufacturer's recommendations. All meds are stored in designated areas which are sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, Regional Clinical Operations, and the AA for the Exit Conference, and facility management did not provide any additional information. 49078 2. On 11/04/24 at 11:47 AM, the surveyor, in the presence of the med nurse on duty, inspected the med cart located on the 1 [NAME] Unit. The surveyor observed one (1) foil package of Budesonide (Pulmicort) nebulizer solution (a steroid inhalant liquid used with a mechanical nebulizer to treat asthma) with no date documented on the foil package when opened containing one (1) remaining vial. The surveyor also observed three (3) loose unidentified tablets in the bottom of the second drawer of the med cart. The surveyor asked the med nurse if she could identify the tablets. The med nurse stated she could not. The surveyor asked the med nurse if there was a date identifying when the foil package of Budesonide was opened. The med nurse stated there was no date visible. The med nurse disposed of the unidentified tablets and undated foil package in the presence of the surveyor. The surveyor then accessed and inspected the med storage room (med room) and med refrigerator on the 1 [NAME] Unit in the presence of the med nurse. The surveyor observed a vial of influenza vaccine stored inside the refrigerator, and a refrigerator temperature log located on the outside of the refrigerator. The temperature log reflected documentation of internal temperatures once per day. The surveyor, in the presence of the med nurse, inspected the med cart located on the Penthouse Unit. The surveyor also observed one (1) box of Ipratropium/Albuterol (DuoNeb) nebulizer solution (an inhalant liquid used with a mechanical nebulizer to treat asthma), which contained one (1) open foil packet with no date documented on the foil package when opened containing two (2) remaining vials. The surveyor also observed one (1) loose unidentified tablet in the bottom of the second drawer of the med cart. The surveyor asked the med nurse if she could identify the tablet. The med nurse stated she could not. The surveyor asked the med nurse if there was a date identifying when the foil package of DuoNeb was opened. The med nurse stated there was no date visible. The med nurse disposed of the unidentified tablet and undated foil package in the presence of the surveyor. The surveyor, with the assistance of the Unit Manager, accessed and inspected the med room and med refrigerator located on the 2 South Unit. The surveyor observed a thermometer inside the med refrigerator that reflected a temperature of 30 degrees Fahrenheit. The surveyor also observed meds stored in the refrigerator. The surveyor observed a temperature log located on the outside of the refrigerator. The temperature log reflected an entry of 40 degrees Fahrenheit for 11/04/24. The surveyor reviewed the manufacturer packaging and labeling for Ipratropium/Albuterol nebulizer solution. The product packaging and labeling reflected under Storage Conditions: Once removed from the foil pouch, the individual vials should be used within one week. The surveyor reviewed the Budesonide manufacturer label and packaging which specified for Budesonide, once the foil pouch was opened, use ampules within (two) 2 weeks of opening. The surveyor reviewed the CDC (Centers for Disease Control and Prevention) guidelines for vaccine storage which reflected for Monitoring Vaccine Temperatures, to ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). On 11/06/24 at 11:45 AM, the surveyor, in the presence of the survey team, met with the LNHA, DON and RDO. The surveyor discussed the concerns with med storage. On 11/06/24 at 01:11 PM, the surveyor conducted an interview with the facility Consultant Pharmacist (CP) by telephone. The CP stated they were covering for the regular CP who was out on leave. The surveyor asked the CP if DuoNeb and Budesonide foil packs should be dated when opened. The CP stated, yes, they should have a date when opened. The surveyor asked the CP what the appropriate temperature range for med storage refrigerator was. The CP stated normal refrigerator temperature should be between 36 to 46 degrees Fahrenheit. The surveyor asked the CP how the refrigerator temperature should be monitored when storing flu vaccines. The CP stated that they were unsure if it was once or twice a day, but twice a day would be a good practice. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Regional Infection Preventionist Nurse (RIPN), and AA. The RIPN stated that educational in-services were implemented for dating of meds. On 11/07/24 at 01:07 PM, the survey team met with the LNHA. The LNHA stated there is no further information to be provided. A review of the facility's policy titled Medication Storage dated 9/2024 that was provided by the DON revealed: The Policy reflected on the first line, Meds housed on our premises are stored in the pharmacy and/or med rooms according to the manufacturer's recommendations. Under line 4. Refrigerated Products, b. Temperatures are maintained within 36-46 degrees F. The policy did not reflect anything regarding loose, unlabled or unidentifiable meds. NJAC 8:39-29.4(d)(g)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physician orders with regard to medications (meds) with parameters for five (5) of five (5) residents (Residents #28, #117, #131, #140, and #142) and b.) ensuring meds administered to a resident were not left at the bedside for one (1) of 38 residents (Resident #144 ), according to the standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 10/31/24 at 9:45 AM, the surveyor reviewed the hybrid (electronic and paper) medical records of Resident #28. The Admission Record (AR; admission summary) revealed that Resident #28 had diagnoses that included but were not limited to, End stage renal [Kidney] disease, hyperlipidemia (high levels of fats in the blood), and atherosclerotic heart disease (a disease that occurs with the buildup of fats, cholesterol and other substances in and on the heart's arteries, which may lead to chest pain, shortness of breath and heart attacks). A quarterly Minimum Data Set (qMDS) an assessment tool used to facilitate management of care, with an Assessment Reference Date (ARD) of 9/22/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #28 scored a 12 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order (PO) dated 9/28/24 documented hydralazine oral tablet (tab) 50 mg (milligram), give 1(one) tab by mouth two times a day every Monday, Wednesday, Friday, and Sunday for hypertension (high blood pressure) Hold if BP < 140 [Blood Pressure less than 140]. The medication (med) was scheduled to be administered at 9:00 AM (9 AM) and 5:00 PM (5 PM). A PO dated 9/28/24 documented hydralazine oral tab 50 mg, give 1 (one) tab by mouth two times a day every Tuesday, Thursday, and Saturday for hypertension Hold if BP < 140. The med was scheduled to be administered at 5:00 AM (5 AM) and 5 PM. A review of the October 2024 electronic Medication Administration Record (eMAR) revealed the nurses signed the hydralazine med as administered on 10/07/24 at 9 AM and 5 PM, 10/13/24 at 9 AM and 5 PM, and 10/27/24 at 9 AM. For these identified entries the BP was documented to be less than 140 and the hydralazine medication should have been held per the PO. On 10/31/24 at 10:19 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1) about the administration of meds with parameters. LPN #1 stated the vital signs, such as BP, would be checked first and the med's parameters should be followed as ordered by the physician. The surveyor reviewed with LPN #1 the hydralazine order entries in the October 2024 eMAR and the identified entries for the med administered outside of the orders' parameters. LPN #1 stated the med should not have been given as the med should have held per PO. On 10/31/24 at 01:13 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about the administration of meds with parameters. RN/UM stated if a med's parameters related to BP, the nurse would check the BP prior to administering the med and would hold the med according to the PO. RN/UM further explained it was expected that the nurses followed the PO. The surveyor reviewed with the RN/UM the identified hydralazine entries that were administered outside of the order parameters on the October 2024 eMAR. The RN/UM acknowledged the med should have been held by nurses according to the PO. 2. On 11/06/24 at 9:03 AM, the surveyor reviewed the hybrid medical records of Resident #131. The AR revealed that Resident #131 had diagnoses that included but were not limited to, Atherosclerotic heart disease, hypertension (high blood pressure), and type 2 diabetes mellitus (DM). A qMDS with an ARD of 8/08/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #131 scored a 13 out of 15, which indicated the resident was cognitively intact. A PO dated 9/10/24 documented Humalog Kwik pen subcutaneous solution pen-injector 100 Units/milliliters (Units/ml), inject 3 units subcutaneously before meals for DM three times a day before meals. Hold for glucose (blood sugar) below 110. The med was scheduled to be administered at 7:30 AM, 11:30 AM and 4:30 PM. A review of the October 2024 eMAR revealed the nurses signed the Humalog medication as administered when the blood sugar (BS) was less than 110 on the following entries: -On 10/02/24 at 4:30 PM with a documented BS of 87. -On 10/05/24 at 7:30 AM with a documented BS of 103. -On 10/14/24 at 7:30 AM with a documented BS of 95. -On 10/15/24 at 7:30 AM with a documented BS of 85. -On 10/17/24 at 11:30 AM with a documented BS of 103. -On 10/27/24 at 11:30 AM with a documented BS of 84. On 11/06/24 at 9:40 AM, the surveyor reviewed with the RN/UM the humalog entry on the October 2024 eMAR of Resident #131. The RN/UM acknowledged the PO were not being followed and stated when the BS was less than 110 the med should have been held. On 11/06/24 at 11:19 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Regional Director of Operations (RDO) of the concerns that the PO for the identified meds with parameters for Resident #28 and Resident #131 were not being followed. The DON acknowledged it was expected for the nurses to follow the PO. On 11/07/24 at 11:31 AM, the LNHA, the DON, and a regional LNHA met with the survey team. The DON stated the nurses received disciplinary action and education on the importance of following med parameters as ordered by the physician. There was no additional information provided by the facility. 48423 3. On 10/30/24 at 12:23 PM, the surveyor observed Resident #117 eating lunch in the dining room. The surveyor reviewed Resident #117's hybrid medical records that revealed the following: The AR reflected that the resident was admitted to the facility with diagnoses that included Dementia, depression, hypertension, and DM. The qMDS with an ARD of 9/15/24, reflected that Resident #117 had a BIMS score of 00 out of 15, which indicated that the resident's cognition was severely impaired. A review of the Order Summary Report (OSR) reflected that Resident #117 had an active PO dated 9/21/24 for a med: Midodrine HCL (hydrocholoride) Oral Tab 5 mg- Give 1 tab by mouth three times a day for low BP HOLD for SBP [systolic BP] greater than 140 with a start date of 9/22/24. The corresponding PO was transcribed into the September 2024 through November 2024 eMAR. Further review of the September - November 2024 eMARs for Resident #117 revealed that nurses signed and reflected a checkmark which means that the med was administered when the med should have been held for a SBP that was greater than 140 according to the PO, for the following dates and times: Date Time SBP 9/22 9 AM 145/76 9/24 1:00 PM (1 PM) 153/85 10/2 5 PM 146/84 10/10 5 PM 146/84 10/12 5 PM 146/78 10/18 5 PM 145/84 10/29 5 PM 145/84 11/1 5 PM 146/84 During an interview with the surveyor on 11/06/24 at 10:06 AM, Registered Nurse #1 (RN#1) stated that the Midodrine was for hypotension (for low BP) and if the BP was higher than 140, then we would not give the med. RN#1 further stated that after 30 minutes, she would re-check BP and if the BP was high (greater than 140) then she would hold the med and notify the physician. During an interview with the surveyor on 11/06/24 at 10:14 AM, Licensed Practical Nurse/Unit Manager (LPN/UM) stated that we would hold the med if SBP was outside the parameters and notify the doctor. The LPN/UM further stated if the med was given for SBP > 140 (greater than 140), then she would notify the physician and DON. The surveyor informed the LPN/UM of the above concerns. The LPN/UM acknowledged that it was considered a med error. On 11/06/24 at 11:19 AM, the surveyor discussed the above concerns with the LNHA, DON and RDO of the above concerns. The DON stated that the expectation from the nurses was to follow the protocol and the med should have held when the SBP was outside the parameters. A review of the facility provided Job Descriptions for Position Title: Registered Nurse and Licensed Practical Nurse reflected under Responsibilities/Accountabilities: *Dispenses med and performs treatments, as requested, and in accordance with policies and procedures; * Adhere to all facility policies and procedures. On 11/07/24 at 11:32 AM, the survey team met with the LNHA, DON, Regional Infection Preventionist Nurse (RIPN), and Regional Administrator. The DON stated that the nurses should check and follow the parameters before administering the BP meds. The DON acknowledged that it was a med error. On 11/07/24 at 01:30 PM, the survey team met with LNHA, DON, RIPN, RDO, Regional Administrator for an exit conference. The facility did not refute the findings. 38327 4. On 10/29/24 at 10:21 AM, the surveyor observed posted signs outside Resident # 140's room for oxygen (O2) in use, EBP (enhanced barrier precautions), and PPE (personal protective equipment) box hung outside the door. The resident was lying in bed with a nasal cannula (a device that delivers extra O2 through a tube and into the nose) and O2 at 2LPM (liters per minute) attached to the concentrator (a device for O2). The surveyor reviewed the hybrid medical records of Resident #140. The AR revealed that the resident was admitted to the facility that included a medical diagnosis that was not limited to essential hypertension (high blood pressure that is not due to another medical condition), chronic kidney disease, and DM. According to the comprehensive Minimum Data Set (cMDS) with an ARD of 10/12/24, Section C Cognitive Patterns revealed a BIMS score of 11 out of 15 which reflected that the resident's cognitive status was moderately impaired. A review of the PO with an order date of 10/23/24 for Midodrine HCl oral tab 5 mg give 1 tab via G-Tube (gastrostomy tube) three times a day for hypotension Hold if SBP>120 (systolic blood pressure less than 120) mmHg (millimeter of mercury) The above orders for Midodrine were transcribed to the October 2024 eMAR. There were five events that the med was administered beyond the parameters and did not follow the PO as shown below: Date Time Blood Pressure 10/26/24 9 AM 129/75 (SBP 129) 10/26/24 1 PM 128/72 (SBP 128) 10/26/24 5 PM 127/78 (SBP 127) 10/27/24 9 AM 126/72 (SBP 126) 10/27/24 1 PM 126/72 (SBP 126) On 10/31/24 at 9:08 AM, the surveyor notified LPN#2 of the above findings and concerns with the Midodrine. The LPN stated that the PO for Midodrine parameters not to administer the med if the SBP was above 120 should be followed. 5. On 10/29/24 at 10:31 AM, the surveyor observed a posted sign for EBP and PPE hung outside the door. Inside the resident's room, Resident #142 was in bed asleep. The surveyor reviewed the medical records of Resident #142. The AR showed that the resident was admitted to the facility that included a medical diagnosis that was not limited to essential hypertension, unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and DM. The cMDS with an ARD of 8/12/24, Section C Cognitive Skills for Daily Decision Making was coded #2 which reflected that the resident's cognition was moderately impaired. A review of the PO order date 10/04/24 for Amlodipine Besylate Oral Tab 10 mg Give 1 tab by mouth one time a day for HTN (hypertension) Hold if SYS<110 OR HR<60 (systolic less than 110 or heart rate less than 60) The above order for Amlodipine was transcribed to October 2024 eMAR. There were four events in the med was administered beyond the parameters and did not follow the PO as shown below: Date Time Blood Pressure HR 10/17/24 9 AM 119/71 56 10/20/24 9 AM 121/66 58 10/23/24 9 AM 113/70 59 10/25/24 9 AM 115/68 59 Further review of the October 2024 eMAR showed an order date of 10/04/24 for Losartan Potassium Oral Tab 100 mg Give 1 tab by mouth one time a day for HTN Hold if SYS<110 OR HR<60. The above order for Losartan was transcribed to October 2024 eMAR. There were four events in the med was administered beyond the parameters and did not follow the PO as shown below: Date Time Blood Pressure HR 10/17/24 9 AM 119/71 56 10/20/24 9 AM 121/66 58 10/23/24 9 AM 113/70 59 10/25/24 9 AM 115/68 59 On 10/31/24 at 9:08 AM, the surveyor notified LPN#2 of the above findings and concerns with the Amlodipine and Losartan. The LPN stated that the PO for Amlodipine and Losartan parameters not to administer the meds if the SBP was above 110 and HR below 60 should be followed. The LPN acknowledged that he was the nurse who signed the eMAR on 10/17, 10/20, 10/23, and 10/25/24 at 9 AM. On 11/06/24 at 11:19 AM, the survey team met with the LNHA, DON, and RDO. The surveyor notified the facility management of the above concerns and findings. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Assistant Administrator (AA), and RIPN. The DON stated that the PO for parameters should have been followed by nurses. 51226 6. On 10/29/24 at 10:25 AM, the surveyor observed Resident #144 lying in bed, awake, alert and not verbally responsive to surveyor's greeting. The surveyor observed a med cup filled with a mixture of meds and apple sauce on the overbed table. The Resident's Representative (RR) stated that they were the one who would give the meds to the resident. On 10/29/24 at 10:30 AM, the surveyor interviewed LPN #3 who was assigned to care for Resident #144. The LPN acknowledged that he left the meds for 9 AM scheduled meds mixed in the cup with applesauce on the Resident's overbed table. The LPN stated that the RR would give the meds to the resident. The surveyor asked what meds were on the cup. The LPN showed the surveyor the eMAR which included the following meds that were in the cup: Lexapro 10 mg (antidepressant), Acetaminophen 500 mg 2 tabs (pain med) and Memantine 10 mg (med for Dementia). The surveyor and LPN#3 went to the resident's room. The surveyor observed the RR administered the meds in the cup with applesauce to the resident under the supervision of the LPN after surveyor's inquiry. On 10/29/24 at 10:40 AM, the surveyor interviewed the RN/UM about med administration protocols. The surveyor notified the RN/UM of the above observation of meds left at the bedside of Resident #144. The RN/UM stated a RR needed to be assessed for the capability of administering meds to a resident and it should be care planned. The RN/UM further stated meds must be given an hour or an hour after the med was scheduled to be given. The surveyor and the RN/UM went to speak with LPN #3. The LPN confirmed to the RN/UM that the med was left at the bedside. The RN/UM educated LPN #3 about not leaving meds at bedside and ensuring meds were administered timely as per PO. On 11/04/24 at 11:05 AM, the surveyor reviewed the hybrid medical records of Resident #144. The AR revealed that Resident #144 was admitted to the facility and had diagnoses that included but were not limited to, atrial fibrillation and dementia (condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning). The cMDS with an ARD of 9/14/24 revealed the facility assessed the resident's cognition using a BIMS test. Resident #144 scored a 99, which indicated the resident was unable to complete the interview. The OSR included a PO dated 10/29/24 which indicated, may combine all crushable meds (according to manufacturer's guidelines) at one time mixed in (applesauce, pudding, etc.) every shift. A care plan (CP), initiated on 10/29/24 revealed that Resident #144's RR preferred to give meds after meals. There was no documented evidence that resident had a CP that the RR will administer meds. On 11/06/24 at 11:30 AM, the surveyor notified the DON, the LNHA, and RDO about the above concerns. On 11/07/24 at 11:50 AM, the DON, LNHA, and RIPN met with the survey team. The DON stated that family was educated not to give meds and that in-service education was conducted regarding med administration. A review of the facility's Medication Administration Policy with a revision date of 9/2023 that was provided by the RIPN revealed: Policy: Meds are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per PO. When applicable, hold med for those vital signs outside the physician's prescribed parameters . 10. Review MAR to identify med to be administered . 15. Observe resident consumption of med . On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, Regional Clinical Operations, and AA for the Exit Conference, and facility management did not provide any additional information and did not refute the findings. NJAC 8:39-11.2(b), 27.1 (a), 29.2(d)

Complaint # NJ167164 and #167919 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and facility policies and procedures for one (1) of 38 residents, Resident #360, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/31/24 at 12:44 PM, the surveyor reviewed a facility reported event investigation for Resident #360 who was no longer a resident at the facility. A report dated 9/01/23 was submitted to the Department of Health (DOH) for an event that occurred on 8/30/23. The Resident's representative (RR) reported to the facility regarding the care of Resident #360 and wounds found on the resident's right foot. The investigation included written statements from nursing staff, a summary and conclusion as well as in-service education provided to the Licensed Practical Nurse (LPN). The summary of the facility's investigation detailed Resident #360 was found on 8/29/23 with ulcers to the dorsum [top of] right foot, near the right toes, the right 5th toe, and sole of the right foot. The wounds were noted with serosanguineous (contains both blood and serum, the liquid part of blood) drainage. The nurse practitioner (NP) examined the resident the same day. The NP ordered x-rays of the foot, intravenous (IV) antibiotics, a wound consult, podiatry consult, and infectious disease (ID) consult. The physician then called and gave the order for Resident #360 to be sent to the hospital emergency room (ER) for further evaluation. The RR was also notified. The resident was admitted to the hospital after ER evaluation with a diagnosis of osteomyelitis (an inflammation of bone caused by an infection). The resident returned to the facility on [DATE]. The conclusion of the facility's investigation determined that weekly skin checks had not been completed for two weeks prior to the wounds' identification. Additionally, nursing management were to conduct weekly audits to ensure that weekly skin checks would being completed on time and accurately documented. The education in-service provided to the LPN included review of the importance of completing weekly skin checks, poor outcomes of a resident's condition if skin checks were not completed, and the importance of reporting any new findings including communication with the physician and RR. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #360. The Admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, quadriplegia (a condition that causes a person to lose all or most motor function in their arms, hands, trunk, legs and pelvic organs), major depressive disorder, contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscle/joint, peripheral vascular disease (PVD; a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), neuromuscular dysfunction of bladder (a condition that causes bladder control issues due to a brain, spinal cord or nerve problem), and hypertension. A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/20/23, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #360 scored a 14 out of 15, which indicated the resident was cognitively intact. In Section G (Functional Status) of the MDS, Resident #360 was coded requiring one person assist with activities of daily living (ADLs) such as bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The resident was coded as: dependent on staff for bed mobility and toilet use; needing extensive assistance with personal hygiene and dressing; and limited assistance for eating. Additionally, Resident #360 was coded for impairment in range of motion to both lower extremities. A physician's order (PO) dated 01/06/22 documented bunny boots heel protector/apply to both heels while in bed every shift for protection. A PO dated 01/06/22 documented offload heels with one pillow under calves while in bed every shift for skin integrity. A PO dated 3/16/23 documented to apply moisturizer cream to the resident's legs everyday every day shift for skin care/dryness. A PO dated 1/6/22 documented skin assessment weekly every Wednesday on 7-3 shift every day shift for monitoring. A review of the Evaluation section of the EMR revealed there was one Skin Evaluation documentation completed on 8/02/23 for August 2023. There was no other skin evaluation completed for the month. A physician progress note (PN) dated 8/29/24 at 1:00 PM by the NP detailed then nurse reported the resident had a wound to their right foot and the resident was assessed. After initial plan of orders for treatment including x-rays, IV antibiotics, and consults, the primary physician ordered for the physician to be sent to the ER for further evaluation. A nurses' PN written by the LPN dated 8/29/24 at 02:26 PM, revealed the resident was found with a wound to the right foot, it was cleaned with normal saline solution and reported to the primary physician. The primary physician ordered for the resident to be transferred to the hospital ER for further evaluation and the resident was transferred at 2:00 PM. A review of August 2023 PN revealed there were no notes prior to August 29th regarding the resident's skin assessment or refusal by the resident to complete. A care plan with an initiation date of 6/11/2020 had a focus of risk for impaired skin integrity related to the resident's immobility, PVD, history of pressure ulcers, and refusal of care. Interventions of the care plan included but were not limited to: Perform routine skin assessments, date initiated 6/11/2020; and Provide skin care per facility guidelines and PRN (as needed), date initiated 6/11/2020. On 11/06/24 at 9:55 AM, the surveyor interviewed the LPN who had cared for the resident and signed the weekly skin assessments in August 2023. The LPN recalled Resident #360 and stated the resident was alert and wheelchair bound. The resident was out of bed on Monday through Thursday and from Friday to Sunday preferred to stay in bed watching television. The LPN stated Resident #360 was cooperative with care for the most part but refused care occasionally. The LPN further explained the resident hands and feet were a little contracted and allowed staff to assess them. The surveyor asked about assessing the resident's skin. The LPN replied that the Certified Nurse Assistant (CNA) would provide morning care to resident and notified the nurses of any skin impairment. The nurses performed weekly skin assessments, checking head to toe and documented in the EMR of the findings. The surveyor asked about when the resident was found with wounds and had to be sent to the hospital. The LPN recalled the resident was found with a wound to their foot that was oozing prior to being sent to the hospital. The LPN could not recall specific dates or times and stated he found the resident's sock was sticky, removed their sock, found wounds to their toes, and reported to the NP who was visiting. The LPN could not recall any additional details. On 11/06/24 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) about Resident #360's investigation. The DON confirmed that the incident occurred prior to her and the current Licensed Nursing Home Administrator (LNHA) starting at the facility. The surveyor asked about any additional information related to the investigation. The DON stated she would review what was on file and could not speak to the investigation that was conducted by the previous administration. On 11/06/24 at 11:19 AM, the surveyor notified the LNHA, the DON, and the Regional Director of Operations (RDO) of the concern that there were no skin evaluations documented for the two weeks prior to the wounds to the resident's foot was identified by the staff. There was no verbal response by the facility at this time. On 11/07/24 at 11:31 AM, the DON, the LNHA, and the regional LNHA met with the survey team. There was no additional information or verbal response provided by the facility. The DON stated they could not speak to specifics as it was during the previous administration's time. The surveyor reviewed the undated facility policy titled Skin Check Policy. Under Procedure it specified, . 2. Skin checks will be conducted by CNA's during daily care .3. Skin checks by Licensed Nurses will be conducted weekly on all residents in addition to daily checks by CNA's .4. Findings will be documented in the Weekly Skin Evaluation form and the Interdisciplinary Notes . N.J.A.C. 8:39-3.2 (a), (b); 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) sufficient nursing staff and b.) incontinence care was provided for two (2) of two (2) residents (Residents #67 and #214) in a timely manner, during the incontinence tour. This deficient practice was evidenced by the following: 1. On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7:00 AM-3:00 PM (7-3), current Census 158, total of 13 CNAs, and staff to resident ratio of 1 CNA:12.2 Residents. On 10/29/24 at 10:21 AM, the surveyor observed Resident #140 lying on the bed with the responsible party (RP) at the bedside. The RP informed the surveyor that there were no care issues except that the facility was short of staff. The RP stated that yesterday morning, only one Certified Nursing Aide (CNA) worked in the unit (Penthouse) for a total of 18 residents. The RP further stated that it had been a struggle at the facility especially on the weekends. A review of the provided nursing schedule for 10/28/24 revealed census 158, Penthouse unit 18 residents, and one CNA. On 10/30/24 at 8:25 AM, the Receptionist provided a copy of the NHRCSR's census and staff-to-resident ratio, and revealed the following: -NHRCSR 10/26/24 (Saturday) 7-3 Day Shift: census 159, 1 RN:32.6 Residents, 1 LPN:30.3 Residents, 1 CNA:15.9 Residents -NHRCSR 10/26/24 (Saturday) 3:00 PM-11:00 PM (3-11) Evening Shift: census 159, 1 RN:24 Residents, 1 LPN:36.9 Residents, 1 CNA:19.9 Residents -NHRCSR 10/26/24 (Saturday) 11:00 PM-7:00 AM (11-7) Night Shift: census 159, 1 RN:66.9 Residents, 1 LPN:37.4 Residents, 1 CNA:22.7 Residents -NHRCSR 10/27/24 (Sunday) Day Shift: census 159, 1 RN:33 Residents, 1 LPN:37.4 Residents, 1 CNA:19.9 Residents -NHRCSR 10/27/24 (Sunday) Evening Shift: census 159, 1 RN:37.4 Residents, 1 LPN:30.3 Residents, 1 CNA:22.7 Residents -NHRCSR 10/27/24 (Sunday) Nigh Shift: census 159, 1 RN:70.7 Residents, 1 LPN:36.9 Residents, 1 CNA:22.7 Residents On 11/04/24 at 6:26 AM, the surveyor entered the facility in the presence of Registered Nurse #1 (RN#1). There was no receptionist at the desk. The surveyor observed the posted NHRCSR dated 11/03/24 with the census of 158 and revealed the following information: -Night Shift, 11-7 shift, -Staff Category: RN, #of Staff: 3, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: 1 RN:47.7 Residents -Staff Category: LPN, #of Staff: 3, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: 1 LPN:48.6 Residents - Staff Category: CNA, #of Staff: 6, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: CNAS:26.3 Residents On 11/04/24 at 6:30 AM, the surveyor met with the RN Supervisor (RNS) from the 11-7 shift in the 1 South unit. The RNS informed the surveyor that the census from midnight was 161 and stated the following: -1 West=census 18 with 1 LPN and 1 CNA -2 North=census 47 with 1 nurse and 1CNA -2 South=census 37 with 1 LPN and 1CNA -1 South=census 40 with 1 nurse and 1CNA -Penthouse=census 18 with 1 RN and 1CNA A review of the facility's assignments of the CNAs by unit that was provided by the DON showed: -11/03/24 Sunday total census of 161 -11-7 Penthouse=1 CNA and 1 LPN On 11/04/24 at 6:55 AM, the surveyor interviewed LPN#1 from 1 South in the nursing station. The LPN informed the surveyor that she was the assigned nurse at 1 South for the 11-7 shift last night (Sunday), and confirmed that there was one nurse and 1 CNA (CNA#1). The LPN stated that usually there were 2-3 CNAs at the 11-7 shift. The LPN stated that for the last three months probably 3x it happened that only one CNA worked for the 11-7 shift. She further stated that it usually happened during weekends but not on weekdays. On 11/04/24 at 7:35 AM, the surveyor interviewed LPN#2 from 1 West. LPN#2 informed the surveyor that he was the 11-7 nurse last night (Sunday, 11/03/24). The LPN stated that the 1 [NAME] census was 18, one nurse (himself) and one CNA (CNA#2). The LPN further stated that was the usual staffing at 1 West, one nurse and one CNA. 2. On 11/04/24 at 6:42 AM, the surveyor and the RNS went to Resident # 67's room, with the door closed. There was a strong smell of urine outside the door. The surveyor asked the RNS and she confirmed that there was a smell of urine. Upon entry to the room, CNA#1 was inside the room providing morning (am) care to Resident #67. The surveyor asked the RNS to check the used diaper of the resident and the incontinence pad. The RNS, inside the resident's toilet room, showed the surveyor two soaked and wet diapers (yellow), a white bedsheet, and a blue chuck (cloth type) soaked and wet urine. The surveyor asked the RNS if the resident should have a double diaper and the RNS responded that they were not allowed to wear double diapers and CNA should not do that. The RNS confirmed that the double diaper and incontinence pads (sheet and the blue chuck) were soaking wet. During an interview with CNA#1, the CNA confirmed that she was the only CNA for the 11-7 shift. The CNA was unable to further talk to the surveyor because she had to finish the am care. Outside the resident's room, the surveyor interviewed the RNS. The RNS stated that the resident was cognitively impaired and incontinent of both bladder & bowel elimination. She further stated that the resident should not have double diaper. The RNS had no answer when asked by the surveyor why Resident #67 was soaking wet. On 11/04/24 at 6:50 AM, the surveyor and the RNS went to Resident #214's room and observed CNA#3 almost finish with am care with the resident. The surveyor asked the RNS and the CNA where the used diaper of the resident was. The RNS showed the surveyor the used diaper and the diaper was soaking wet with urine. The surveyor asked the RNS about the diaper and the RNS acknowledged that the diaper was soaking wet. At that time, the surveyor interviewed CNA#3. The CNA stated that she was the only CNA in the unit for the 11 PM-7 AM shift and had all residents in their assignment. CNA#3 was unable to state how many total residents. The surveyor asked how many times she had to change residents in the unit, and she stated that she should change them at least 2x in a shift. She further stated that she started the 1st round of incontinence care at 11:15 PM and then the next round at 3:45 AM and that she needed to start early in order to finish all residents. The CNA acknowledged it was hard for one CNA for the entire unit. Outside the resident's room, the surveyor interviewed the RNS. The RNS informed the surveyor that Resident #46 and Resident #214 were both cognitively impaired and incontinent. She further stated that Resident #214 was recently admitted maybe 2 or 3 weeks ago. The RNS informed the surveyor that there was a total of 37 residents in 2 South unit with 1 LPN and 1 CNA, and CNA#3 had all 37 residents in her assignment. The surveyor asked for a copy of the schedule for 11 PM-7 AM and the assignment and she stated that she will get back to the surveyor. On 11/06/24 at 11:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Operations (RDO). The surveyor notified the facility management of the above concerns with staffing and concerns with the incontinence care tour that Residents#67 and #214 were soaking wet. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Assistant Administrator (AA), and the Regional Infection Preventionist Nurse (RIPN). The DON stated that the residents should not be soaking wet. A review of the facility's Incontinence Policy with a revised date of 8/2023 that was provided by the DON revealed: Policy: Based on the resident's comprehensive assessment, all residents who are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, RCO, and AA for the Exit conference. The facility did not provide additional information and did not refute the findings. NJAC 8:39-25.2(a,b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of residents' quality of life specifically by not providing a.) breakfast meal in a timely manner for one (1) of nine (9) residents in 2 South dining area and b.) privacy during eye consultation and/or treatment for one (1) of eight (8) residents in 1 South dining area. The deficient practice was evidenced by the following: 1. On 10/31/24 at 8:25 AM, the surveyor observed the breakfast in the 2 South dining room. The surveyor observed nine residents inside the dining room, one Recreation Aide (RA), one Director of Recreation (DoR), and one Quality Assurance Corporate Aide (QACA). The three facility staff were all standing, the DoR and the QACA were talking inside the dining room. Upon entry to the dining room, there was a resident on one table with no breakfast tray seated in a wheelchair, next table were four residents with no breakfast tray, and last table were another four residents with their breakfast trays. At the table where there were breakfast trays, there was one Certified Nursing Aide (CNA) feeding one of the residents. Next to the resident with no breakfast tray, seated on the table by themselves was the food truck with one breakfast tray covered. On that same date and time, the surveyor asked the facility employees who was the breakfast tray on the food truck. The QACA checked the breakfast tray, read the diet slip in the tray, and informed the surveyor that the tray was for Resident #25. Resident #25 was the one seated by themselves at one of the tables. The surveyor then asked why Resident #25's breakfast tray was not served to the resident. The CNA responded that she was still feeding the other resident on another table which was why Resident #25 had to wait to be fed. The CNA confirmed that Resident #25 was also a feeder. The QACA then immediately performed hand hygiene with the use of alcohol-based hand rub (ABHR), took Resident #25's tray, sat with the resident, and started feeding the resident. At that time, the surveyor asked when the food truck was delivered to the dining room and why the other resident had no breakfast tray. The QACA asked the CNA, and the CNA stated that it was around 8:10 AM that the 1st breakfast truck came. The CNA confirmed that at 8:10 AM residents at one table were served breakfast at that time and that the 2nd breakfast truck would come soon. On that same date at 8:34 AM, the Registered Nurse/Unit Manager (RN/UM) entered the dining room. The surveyor asked the RN/UM how long the residents should wait for their breakfast tray to be served when they were available. The RN/UM stated that they should immediately provide the resident with their breakfast tray if they were available. The surveyor then notified the RN/UM of the above findings and observations with Resident #25's breakfast tray which was not provided until the surveyor's inquiry. On 10/31/24 at 8:40 AM, the surveyor and the RN/UM observed that food truck #2 came and the remaining residents received their breakfast trays in the 2 South dining room. Four out of nine residents received their breakfast trays after 30 minutes while the rest of the five residents had started eating. 2. On 10/31/24 at 8:49 AM, both the surveyor and the RN/UM went to the 1st-floor dining room in 1 South. The surveyor asked the RN/UM how long the residents should wait for their breakfast tray, when the 1st food truck came at 8:10 AM at 2 South, and was 30 minutes an appropriate time for the residents should wait for their breakfast while other residents were eating in the same room. The RN/UM stated No, the tray should come earlier. On that same date and time, inside the 1 South dining room, there were a total of seven residents during breakfast. Two residents were done with their breakfast and the rest were still eating their meals. Resident #67 was seated at one table by themselves and just finished their meal. A person came near Resident #67 and immediately donned (applied) gloves, took a piece of equipment, and was about to use the equipment near the resident's eye. The surveyor asked the RN/UM who was the person with Resident #67. The RN/UM immediately approached the person and addressed the person as a doctor. The RN/UM informed the doctor to remove his gloves and to have the eye consultation in the resident's room. Afterward, the surveyor interviewed the RN/UM. The RN/UM stated that the person was the eye doctor. The RN/UM further stated that the doctor should not wear gloves and start treating the resident in the dining room. On 11/04/24 at 12:05 PM, the surveyor in the presence of the survey team interviewed the Regional Infection Preventionist Nurse (RIPN) and notified the above findings and concerns. The RIPN stated that the eye doctor should provide privacy during consultation and treatment, and not wear gloves in the dining room. On 11/06/24 at 11:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Operations (RDO). The surveyor notified the facility management of the above concerns and findings. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Assistant Administrator (AA), and the RIPN. The RIPN stated that facility staff and the eye doctor were educated. A review of the facility's Serving a Meal Policy with a revision date of 11/2023 that was provided by the DON revealed that it is the policy of the facility to serve meals that meet the nutritional needs of residents. Policy Explanation and Compliance Guidelines: diets should be served in accordance with the physician's order. Residents should be encouraged to eat in the dining room, however, requests to remain in the room should be honored A review of the facility's Resident Rights Policy with a revision date of 11/2024 that was provided by the RIPN revealed: Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Respect and dignity. The resident has a right to be treated with respect and dignity. On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, Regional Clinical Operations, and AA for the Exit Conference, and there was no additional information provided by the facility management. NJAC 8:39 - 4.1(a)11, 12, 16, 28

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility's interdisciplinary team (IDT) failed to ensure the facility policy was followed to ensure the person-centered care plan was revised to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and to ensure the resident was (invited to participate) involved in the care planning process. The deficient practice was identified for one (1) of 38 residents reviewed for care planning (Resident #131) and was evidenced by the following: On 10/29/24 at 10:29 AM, during initial tour, the surveyor observed Resident #131 lying in bed in their room. Resident #131 expressed concern with their discharge (d/c) plans. The resident explained that they had been in the facility for several months, was there to receive rehabilitation (rehab) therapy, and did not have a place to stay outside the facility. Resident #131 stated that they had completed rehab therapy and was independent with activities of daily living. The resident stated when they last spoke with the social worker (SW) about d/c planning, the SW stated something about it was not safe for them to be d/c and did not know anything else about their d/c care plan (CP). The resident stated that they could do more things for their self, compared to other residents, and did not want to stay at facility. On 10/30/24 at 11:42 AM, the surveyor reviewed the hybrid (electronic and paper) medical records of Resident #131. The Admission Record revealed that Resident #131 had diagnoses that included but were not limited to, Atherosclerotic heart disease (a disease that occurs with the buildup of fats, cholesterol, and other substances in and on the heart's arteries, which may lead to chest pain, shortness of breath and heart attacks), hypertension (high blood pressure), schizophrenia, and type 2 diabetes mellitus (DM). The resident had one emergency contact (EC) listed and they were indicated as the care conference person. A Quarterly MDS assessment, dated 8/08/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #131 scored a 13 out of 15, which indicated the resident was cognitively intact. A CP for Resident #131 with a focus related to the resident was for LTC (Long Term Care) vs d/c home to community, was initiated 5/06/24. An intervention with an initiation date of 5/06/24 detailed, Resident #131 and their family will make their wishes known. A social service (SS) note dated 8/12/24 indicated the IDT met for a quarterly care conference for Resident #131. The EC was invited but did not respond to the facility. There was no documentation of the resident being invited to the CP meeting. Additionally, there was no documentation which indicated the resident was present for the CP meeting or was aware of the discussion from the CP meeting. A nurse progress note dated 10/01/24, indicated Resident #131 verbalized not wanting to stay in the facility and desired to be d/c. The SW was informed by the nurse that resident stated they did not want to stay in the facility. The nurse further indicated the SW was to follow up with the resident and their status. There were no additional notes from the SW, or any further notes related to the resident's d/c planning. On 10/30/24 at 12:41 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to care for Resident #131. The LPN stated the resident was alert and oriented, independent, and cooperative with staff. The LPN stated that the resident did not have a place to stay, and the plan was for the resident to remain in the facility for LTC. The LPN stated the SW was responsible for following up with the resident regarding their living situation. On 10/30/24 at 01:03 PM, the surveyor interviewed the SW who started working in the facility a couple of months ago about resident care planning. The SW stated care plan meetings were held quarterly and as needed. The CP meeting was attended by the SW, the Director of Nursing (DON), the dietician, recreation staff, the Director of Rehab, the resident, if they were alert and oriented, and the resident representative. The surveyor asked the SW what the process for care planning for a resident was that did not have a place to live. The SW stated the process would be to attempt to find a next of kin or friend who would be able to assist. If no one could be found, the resident had Medicaid and nowhere else to go then they would be transitioned to LTC. The surveyor discussed the concern that Resident #131 expressed they did not want to remain in the facility for LTC and there was no documentation regarding the resident being invited to CP meetings or discussions with the resident about their CP. Additionally, the indicated EC listed had not returned any calls to the facility. The SW confirmed the resident had no place to live and no family or friends involved to help. The SW stated the plan was for the resident to remain for LTC, and discussions with the resident were with Spanish translation. The SW could not speak to referrals or care planning by previous SWs. The SW stated she would review the resident's records and provide additional information. On 10/31/24 at 10:31 AM, the SW met with the surveyor. The SW stated she spoke with the resident yesterday evening to discuss possible d/c plans. The SW stated she discussed with the resident about a referral to another LTC facility as a d/c back to the community at this time would be difficult. The resident was agreeable to the referral to the other facility as it would have a similar resident population who spoke their language and they could continue to assist with a possible community d/c. The SW further stated she explained to the resident it may take some time for the d/c to the other facility to be approved. The surveyor asked if there were any referrals for the resident during the several months the resident was at the facility. The SW stated there were no referrals as the resident was receiving sub-acute rehab therapy. The SW further stated upon admission the resident signed a LTC agreement which indicated the resident would be transitioned to LTC. The surveyor asked if there was any documentation of the resident being invited or participating in their CP meetings. The SW provided hospital d/c notes for the resident and the LTC admission agreement signed by the resident, which was handled by the Admissions department. The SW stated she would provide the SS documentation for Resident #131. A review of the hospital d/c notes for Resident #131 indicated the resident did not have a place to live and would be d/c to the facility from the hospital for SAR [Subacute Rehab]. On 10/31/24 at 11:23 AM, the SW provided SS documentation which included, a SS note written by the SW dated 10/30/24 regarding her discussion with the resident about the referral to another facility. Additionally, there was the SS note by the previous SW on 8/12/24, and a BIMS evaluation by another previous SW, dated 5/3/24. There was no additional documentation provided. On 10/31/24 at 12:50 PM, the surveyor visited Resident #131 in their room who confirmed that the SW spoke with them yesterday. The resident stated they were agreeable with being transferred to another facility as there was a different resident population. The resident verbalized they understood it would still be a LTC facility, and that they would continue to assist with d/c to the community. Resident #131 further explained they understood it may take time. The resident was satisfied and agreeable to the CP. On 11/06/24 at 11:19 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Director of Operations (RDO) of the concern for Resident #131 not being invited to participate in their care planning. There was no verbal response from the facility at this time. On 11/07/24 at 11:31 AM, the DON, LNHA, and a regional LNHA, met with the survey team. The DON stated Resident #131 did not have a place to stay when they arrived at facility and had not previously expressed not wanting to be at facility. The DON continued that the SW went to the resident, was referred to other facility and had since been d/c. The surveyor asked the DON about SW documentation when care plan meeting with residents. The DON stated that the SW was responsible for initiating CP meetings and would invite residents/resident representatives to participate in the meeting. The DON acknowledged it should be documented in the resident's medical records when a resident was invited to CP meetings and participated in CP discussions with the SW. There was no additional information provided by the facility. The surveyor reviewed the facility's policy titled, Discharge Planning Process Policy, with a last review date of November 2024. Under Policy Explanation and Compliance Guidelines it documented: . 1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for d/c . 3. If d/c to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why . 8. The facility will document any referrals to local contact agencies or other appropriate entities made for the purpose of the resident's interest in returning to the community . 11. The evaluation of the resident's d/c needs and d/c plan will be completely documented on a timely basis in the clinical record . The surveyor reviewed the facility's policy titled, Comprehensive Care Plans, with a last review date of September 2024. Under Policy Explanation and Compliance Guidelines it documented: .4. The comprehensive CP will be prepared by an IDT team, that includes, but not limited to .e. The resident and the resident's representative, to the extent practicable . The surveyor reviewed the facility's policy titled, Resident Rights, with a last review date of November 2024. Under Residents Rights Acknowledgement, Planning and implementing care, it documented: .The resident has the right to be informed of, and participate in, his or her treatment including .b. the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to .the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care . NJAC 8:39-4.1(a); 27.1(a)

Based on the interview and record review, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within the 14th calendar day of the resident's admission (admitted plus 13 calendar days) in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for three (3) of 38 residents (Resident #125, #132, and #212) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: The Admission Record (AR; an admission summary) documented that Resident #125 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (a disease that affects the brain). The most recent comprehensive MDS (cMDS) with an Assessment Reference Date (ARD; the last day of the observation period) of 02/04/24, reflected that Resident #125 had a Brief Interview for Mental Status (BIMS) score of 0 (zero) out of 15, indicating severe cognitive impairment. The cMDS was completed on 02/14/24. The assessment was more than 13 days after the entry date on 01/28/24. A review of the MDS 3.0 Final Validation Report dated 02/21/24 given by the MDS Coordinator/Registered Nurse (MDSC/RN) on 11/04/24 revealed that The Assessment Completed Late: For this Admission assessment (AO310A equals 01), ZO500B (completion date) was more than 13 days after A1600 (entry date). 2. On 11/04/24 at 10:27 AM, the surveyor reviewed the medical records of Resident #132 and revealed: The AR documented that Resident #132 was admitted to the facility with diagnoses that included but were not limited to unspecified dementia (memory loss), unspecified severity, without behavioral disturbance, psychotic (mental illness) disturbance, mood disturbance, and anxiety. Resident #132's most recent cMDS assessment, with an ARD of 5/17/24, reflected that Resident #132 had a BIMS score of 7 out of 15, indicating severely impaired cognition. The cMDS was completed on 5/30/24, more than 13 days after the entry date, 5/10/24. A review of the MDS 3.0 Final Validation Report dated 6/10/24 given by the MDSC/RN on 11/04/24 revealed that The Assessment Completed Late: For this Admission assessment (AO310A equals 01), ZO500B (completion date) was more than 13 days after A1600 (entry date). 3. On 11/04/24 at 10:27 AM, the surveyor reviewed the medical records of Resident #212 and revealed: The AR documented that Resident #212 was admitted to the facility with diagnoses that included but were not limited to rhabdomyolysis (a condition in which muscle tissue breaks down). Resident #212's most recent cMDS assessment, with an ARD of 10/17/24, reflected that Resident #212 had a BIMS score of 8 out of 15, indicating moderate cognition impairment. The cMDS was completed on 11/03/24, more than 13 days after the entry date, 10/10/24. A review of the MDS 3.0 Final Validation Report dated 11/4/24 given by the MDSC/RN on 11/04/24 revealed that The Assessment Completed Late: For this Admission assessment (AO310A equals 01), ZO500B (completion date) was more than 13 days after A1600 (entry date). On 11/07/24 at 12:57 PM, the surveyor interviewed the MDSC/RN regarding the above concern. The MDSC/RN acknowledged that the admission assessment was not completed on time and should have been completed within 14 days from the entry date. The MDSC/RN stated that the facility followed the RAI (Resident Assessment Instrument) Manual (a tool that helps gather information about a resident's strengths and needs, used to create an individualized care plan). According to the CMS's RAI Version 3.0 Manual of October 2024, it was revealed on pages 5-2. CH (chapter) 5: Submission and Correction of the MDS Assessments. 5.2 Timeliness Criteria: In accordance with the requirements long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: For the Admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). NJAC 8:39-11.2(e)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer the medication to Resident #45 due to unavailability of the medication. The deficient practice was identified for one (1) of four (4) residents (Resident #45) observed during medication administration. The Resident did not received medication for mood disorder at the prescribed time. The deficient practice was evidenced by the following: On 11/04/24 at 7:50 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepared medication (med) of Resident #45. The LPN was unable to administer the med Seroquel 12.5 mg (milligram) to the Resident due to unavailability. The LPN acknowledged that the Seroquel 12.5 mg was not available in the med cart. The LPN informed the surveyor that she would call the pharmacy to deliver the med as soon as possible (ASAP). The surveyor reviewed the medical record of Resident #45. The Admission Record revealed that the resident was admitted to the facility and had a diagnoses of Alzheimer's Disease (condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning.) The quarterly Minimum Data Sets (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15 which indicated that the resident's cognitive status was severely impaired. A review of the November 2024 electronic Medication Administration Record (eMAR) revealed that Seroquel 12.5 mg at 9:00 AM was not administered as scheduled on 11/04/24. Further review of the November 2024 eMAR revealed that the Seroquel was administered at 01:39 PM on 11/04/24. A physician order (PO) dated 11/04/24 revealed an order to administer the Seroquel 12.5 mg when the med becomes available. A review of the med delivery receipt copy revealed that the last med delivery for Seroquel 12.5 mg was on 10/24/24. On 11/06/24 at 11:30 AM, the surveyor notified the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Regional Director of Operations (RDO) of the above concern that the Seroquel 12.5 mg med was not available for Resident #45 during med administration observation. NJAC 8:39-29.6

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for three (3) of seven (7) days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 10/29/24 at 9:04 AM, the survey team entered the facility and met with the Receptionist who instructed surveyors to use the stand-alone thermometer and fill out the paper for COVID screening. The surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) dated 10/29/24 Day Shift, 7 AM-3 PM, current census of 158 that included 13 CNAs (Certified Nursing Aides) with staff to resident ratio of 1 CNA:12.2 Residents. On 10/29/24 at 9:20 AM, the Registered Nurse Supervisor (RNS) informed the surveyor in the presence of the survey team that the census (total number of residents) was 156. On 10/30/24 at 8:17 AM, the surveyor entered the facility and met with the Receptionist who provided a copy of the NHRCSR dated 10/30/24. The NHRCSR dated 10/30/24 census was 158 and revealed the following information: -Day Shift 7 AM-3 PM -1 RN (Registered Nurse):26.9 Residents, -1 LPN (Licensed Practical Nurse):17.7 Residents, -11 CNA, 1 CNA:14.4 Residents. On 10/30/24 at 12:18 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of another surveyor regarding staffing. The surveyor verified and asked the LNHA what the asterisk meant in the schedule that was previously provided to the surveyor. The surveyor showed the schedule dated 10/29/24. The LNHA stated the asterisk meant that they were noncertified nursing aides (NA). On that same date and time, the surveyor asked the LNHA why there was a discrepancy with the submitted Nursing schedule for 10/29/24 for a total of 11 CNAs, and on the posted NHRCSR it showed that there were 13 CNAs in the 7-3 Day shift on 10/29/24. The LNHA counted the CNAs and the NAs in the schedule for 10/29/24. The LNHA stated that two NAs equals one CNA. The surveyor then asked the LNHA, if two NAs equal one CNA, it was not accurate for the 13 CNAs because the schedule had a total of seven NAs for the 7 AM-3 PM shift. At that same time, the surveyor asked the LNHA why there was a discrepancy on the census list provided during entrance conference and what was posted on 10/29/24 NHRCSR. The LNHA had no answer. Furthermore, the surveyor asked the LNHA who was responsible for posting the NHRCSR, and he said it was the Staffing Coordinator (SC). On 10/30/24 at 12:34 PM, the surveyor interviewed the SC in the presence of the two surveyors, and the Regional Clinical Operation (RCO). The SC informed the surveyor that she was covering for the full-time SC for almost two weeks. She further stated that she was also a Unit Clerk (UC). The UC stated that the full-time SC was on vacation since 10/11/24 and will be back in December. On that same date and time, the surveyor asked the UC what the facility's process with regard to NHRCSR was. The UC informed the surveyor that when she comes in at 8 AM, go online to check payroll to determine who clocked in, goes to the NHRCSR site, and puts the numbers according to the clocked-in of the staff. She stated that for example, for 10/30/24 today, the UC will review the 10/29/24 punches (time in and out of staff), and then estimate from 10/29/24 information the information that will be entered for 10/30/24 for census and staff that was why the census and number of staff did not match when the surveyor observed the posted NHRCSR on 10/29/24 because those information were from the day before. At that time, the RCO stated that to the UC that was not how it should be done. The RCO acknowledged that the posted NHRCSR should be accurate and not estimated. The surveyor asked the UC how she came up with 13 CNAs for 10/29/24 for the Day shift. The UC stated that according to what was explained to her by the full-time SC before, she counted NAs (the one with an asterisk while checking the paper for 10/29/24), and two NAs equal one CNA. The RCO also stated that it was not correct to count two NAs equal to one CNA, and that education would be provided to the UC. A review of the provided Nursing schedule of the LNHA on 10/29/24 at 12:10 PM revealed: -Week 2, Tuesday, 10/29/24: total of 11 CNAs A review of the provided Nursing schedule of the LNHA on 10/30/24 at 02:02 PM revealed: -Week 2, Wednesday, 10/30/24: total of 9 CNAs A review of the provided alphabetical list and census list of the LNHA on 10/29/24 at 10:20 AM showed a total census of 156 from midnight census. A review of the provided alphabetical list and census list of the LNHA on 10/31/24 at 9:55 AM showed a total census of 158 from midnight census. On 11/04/24 at 6:26 AM, the surveyor entered the facility in the presence of the Registered Nurse (RN). There was no Receptionist at the desk. The surveyor observed the posted NHRCSR dated 11/03/24 with the census of 158 and revealed the following information: -Night Shift, 11-7 shift, -Staff Category: RN, #of Staff: 3, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: 1 RN:47.7 Residents -Staff Category: LPN, #of Staff: 3, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: 1 LPN:48.6 Residents - Staff Category: CNA, #of Staff: 6, Start & End Times: 11 PM-7 AM, Staff to Resident Ratio: 1 CNA:26.3 Residents On 11/04/24 at 6:30 AM, the surveyor met with the RNS from the 11-7 shift in the 1 South unit. The RNS informed the surveyor that the census from midnight was 161 and stated the following: -1 West=census 18 with 1 LPN and 1 CNA -2 North=census 47 with 1 nurse and 1 CNA -2 South=census 37 with 1 LPN and 1 CNA -1 South=census 40 with 1 nurse and 1CNA -Penthouse=census 18 with 1 RN and 1 CNA A review of the facility's assignments of the CNAs by unit that was provided by the DON showed: -11/03/24 Sunday total census of 161 -11-7 Penthouse=1 CNA and 1 LPN -11-7 1 West=1 CNA and 1 RN -11-7 1 South=1 CNA and 1 LPN -11-7 2 South=1 CNA and 1 LPN -11-7 2 North=1 CNA and 1 RN On 11/06/24 at 11:19 AM, the survey team met with the LNHA, Director of Nursing (DON), and Regional Director of Operations (RDO). The surveyor notified the facility management of the above concerns with the posted NHRCSR discrepancies on 10/29, 10/30, and 11/03/24. On 11/07/24 at 9:29 AM, the DON provided a copy of the NHRCSR and stated that the top portion of the form which showed Notice to Consumer was what the facility followed for posting Nurse Staffing report and there was no other policy. A review of the Notice to Consumer from the NHRCSR revealed: P.L. 2005 c. 21, $$1, 2 and 3 (the Act), approved on January 24, 2005, codified at N.J.S.A 26L2H-5f, 5g, and 5h, required long-term care facilities, commonly known as nursing homes, licensed in accordance with the Health care Facilities Planning Act, N.J.S A 26:2H-1 et seq., to post and make available to the public direct resident care staffing levels within the facilities and to report staffing level information to the Department. This information shall be displayed in a place where residents and the general public can easily view it. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, Assistant Administrator (AA), and the Regional Infection Preventionist Nurse (RIPN). The DON stated that the facility followed the guidelines in posting the NHRCSR that was previously provided and explained to the surveyor. The surveyor asked the facility management should the posted NHRCSR be accurate. The DON stated that it depends, and it changes, but updated daily by SC (also known as the UC). The DON further stated that on Friday the UC does the prediction and if there was a call out then she communicated to the supervisor and the supervisor should update the staffing the same day. On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, RCO, and AA for the Exit conference. The facility did not provide additional information and did not refute the findings. N.J.A.C. 8:39-41.2 (a)(b)(c)(d)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen and nebulizer, according to the standard of clinical practice and the facility's policy and procedure, specifically a.) that respiratory equipment was stored in accordance with facility policy and infection control measures for two (2) of two (2) residents reviewed for respiratory care, Resident #210 and #213, b.) clarify the oxygen therapy order and ensure staff followed the appropriate hand hygiene and use of personal protective equipment (PPE) for a resident with contact precautions and oxygen posted sign for one (1) of one (1) of resident, Resident #213, reviewed for tracheostomy care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 10/29/24 at 10:35 AM, the surveyor observed Resident #210 inside their room seated in a wheelchair. The resident was cognitively intact and informed the surveyor that they were at the facility for rehabilitation. The surveyor observed the nebulizer (neb) mask was not properly stored and was placed on top of the nightstand table near the window next to the neb machine. The date of the neb mask was 10/28/24. At that time, the resident informed the surveyor that the nurse administered neb to the resident and confirmed the neb mask on top of the nightstand was not properly stored and should have been inside a bag. The surveyor reviewed the medical records of Resident #210 and revealed: The Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to other asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), unspecified diastolic (congestive) heart failure, and essential (primary) hypertension (occurs when abnormally high blood pressure that's not the result of a medical condition). The most recent comprehensive Minimum Data Set (cMDS) with an assessment reference date (ARD) of 10/04/24, under Section C Cognitive Patterns, reflected on a brief interview for mental status (BIMS) score of 15 out of 15 which showed that the resident was cognitively intact. The cMDS also included that the resident received respiratory therapy for 225 minutes in a seven-day look-back period (the time period over which the resident's condition or status was captured by the MDS assessment). A review of the October 2024 Order Summary Report (OSR) revealed a physician's order (PO) for the following: -order date 10/01/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (3 milligrams/3 milliliters) 3 ml inhale orally every 6 hours for wheeze. -order date 9/28/24 to Change neb administration set up (tubing, nasal cannula/mask, etc) weekly one time a day every Mon (Monday). The above order for Ipratropium-Albuterol inhalation was transcribed and plotted to the October 2024 electronic Medication Administration Record (eMAR) and signed by nurses as administered at 0000 (12 midnight), 0600 (6 AM), 1200 (12 noon), and 1800 (6 PM). On 10/31/24 at 9:07 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN informed the surveyor that the neb mask should be stored in a plastic bag when not in use. The surveyor then notified the LPN of the above concern with the resident's neb mask observed on 10/29/24 which was not properly stored. 2. On 10/29/24 at 10:17 AM, the surveyor interviewed the LPN in the Penthouse unit. The LPN informed the surveyor that there was no resident on contact precaution (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment). The LPN stated that there were residents on EBP (Enhanced Barrier Precautions), residents who had tube feeding (TF), wounds, and tracheostomy (a procedure to help air and oxygen (O2) reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). He further stated that the Staff and visitors must wear PPE, i.e. gown, gloves, and mask (when tracheostomy or splashes) when providing direct care like wound care morning care, and toileting for EBP residents. The LPN stated that Resident #213 was on EBP due to TF and tracheostomy (trach). On 10/29/24 at 10:26 AM, the surveyor observed Resident # 213's room with a Stop sign, Contact Precaution sign, PPE hung outside the door, and O2 in use sign. The surveyor observed the resident was lying on the bed. The Recreation Aide (RA) was inside the room without PPE, exited the resident's room, and did not perform hand hygiene. The posted Contact precaution sign included information that whoever enters and exits the room must perform hand hygiene, and enter with a gown, gloves, and mask. On 10/29/24 at 10:30 AM, the surveyor asked LPN again if Resident #213 was on contact precaution and what kind of infection. The surveyor also notified the LPN of the above concerns that there was a posted sign for contact precautions outside the door of the resident. The LPN stated that he would get back to the surveyor and verify the records. On 10/29/24 at 10:42 AM, the surveyor interviewed the LPN and asked again about the resident's posted contact precaution sign and the LPN confirmed the resident on contact precaution for positive MRSA (Methicillin-resistant Staphylococcus aureus is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans) in the trach and nares. He stated that staff and visitors must use complete PPE that included mask, gown, and gloves when entering the room and perform hand hygiene. At that time, the surveyor notified the LPN of the concern regarding the RA. The LPN immediately called the RA and education was provided. The RA confirmed that she did not put on PPE before entering the resident's room and informed the LPN that she did not touch anything when she entered the room. The LPN told the RA that she had to read the posted sign and that meant she had to do hand hygiene before entering put on PPE, remove PPE before exiting, and perform again hand hygiene. On 10/29/24 at 11:02 AM, the surveyor met with LNHA in the presence of two other surveyors, the Assistant Administrator (AA), and a Registered Nurse/Unit Manager (RN/UM). The LNHA and the RN/UM informed the surveyor that there were transmission-based precautions (TBP; Transmission-based precautions are used when patients already have confirmed or suspected infections) other than COVID which was one resident with MRSA in the Penthouse unit. The surveyor reviewed the medical records of Resident #213 and showed: The AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (a common subtype of stroke with a poor prognosis, high mortality, and long-term morbidity) unspecified, chronic respiratory failure (a condition that occurs when the lungs cannot get enough O2 into the blood or eliminate enough carbon dioxide from the body) unspecified with hypoxia (an absence of enough O2 in the tissues to sustain bodily functions) or hypercapnia (a buildup of carbon dioxide in bloodstream), and tracheostomy status. The most recent cMDS with an ARD of 10/28/24, under Section C BIMS score of 00 out of 15 showed that the resident's cognition was severely impaired. The cMDS also included that the resident received respiratory therapy for 375 minutes in a seven-day look-back period. A review of the personalized care plan (CP) showed a focus CP for MRSA in trach that was created on 10/22/2024. The CP interventions included but were not limited to contact isolation, educate resident/family/caregivers regarding the importance of hand washing, and instruct family/visitors/caregivers to wear disposable gowns and gloves during physical prolonged contact with the resident, and discard in the appropriate receptacle and wash hands before leaving the room that was initiated on 10/22/24. A review of the October 2024 OSR revealed a PO for the following: -order date 10/21/24 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 6 hours for SOB (shortness of breath). -order date 10/21/24 for Isolation /Contact precaution in Single Room for MRSA every shift for MRSA. -order date 10/21/24 to administer humidified air every shift to ensure that the water chamber and/or water bag are not allowed to run out of sterile water administer humidified air every shift via [name] machine at (20 ) degrees Celsius (4) L (liters)/minute ( )% O2 on at all times. The above order for Ipratropium-Albuterol was transcribed and plotted to the October 2024 eMAR and signed by nurses as administered at 12 midnight, 6 AM, 12 noon, and 6 PM. The above order for Contact Precaution was transcribed and plotted to the October 2024 eMAR and signed by nurses at 7-3 Day shift, 3-11 Evening shift, and 11-7 Night shift from 10/22 through 10/29/24 7-3 shift. The above order to administer humidified air was transcribed and plotted to the October 2024 electronic Treatment Administration Record (eTAR) and signed by nurses at 7-3 Day shift, 3-11 Evening shift, and 11-7 Night shift from 10/21 through 10/31/24 7-3 shift. On 10/31/24 at 8:57 AM, the surveyor interviewed the LPN. The LPN informed the surveyor that Resident #213's contact precaution for MRSA was discontinued and just forgot to remove the signs when the surveyor observed it on 10/29/24 when the RA exited the room. He further stated that the physician clarified that there was a history of MRSA and no active MRSA in the nares and trach. The LPN also stated that the order should have been an EBP and not contact precaution on 10/29/24. He further stated that still, the RA should have performed hand hygiene before exiting the resident's room. On 10/31/24 at 9:00 AM, the surveyor and the Unit Clerk (UC) entered the resident's room and both observed the resident lying on the bed with a visitor at the bedside. The resident was awake but nonverbal. The surveyor also observed the neb mask was not in use, not inside a bag, and not stored properly. The neb mask was on top of the neb machine on top of the nightstand table, and the neb mask tubing was dated 10/28/24. The resident's O2 was set at 35 FIO2 (the fraction of inspired oxygen (FiO2) is the concentration of O2 in the gas mixture) attached to a humidified bottle via trach. On 10/31/24 at 9:03 AM, the surveyor interviewed the LPN regarding Resident #213's O2 order and neb mask. The surveyor asked the LPN what was the order for O2 of the resident. The LPN checked the electronic medical records and showed: administer humidified air every shift ensure that water chamber and/or water bag are not allowed to run out of sterile water administer humidified air every shift via [name] machine at (20) degrees Celsius (4) L/minute ( )% O2 on at all times. The surveyor asked what was the 35 in the humidified bottle of the resident's O2 meant. The LPN stated that it was not in the order. The LPN further stated that the PO for O2 was incomplete, and it should have been clarified. At that same time, the LPN stated that the Respiratory Therapist (RT) comes in once a week and will be at the facility tomorrow. He further stated that he would call and verify the order with the physician. The LPN stated that the neb mask when not in use should be stored in a bag and he will notify the other shift about it that should be in a bag. On 11/04/24 at 12:05 PM, the surveyor in the presence of the survey team interviewed the Regional Infection Preventionist Nurse (RIPN) regarding the facility's standard of practice and procedure with neb mask or other respiratory care equipment and supplies in the resident's room when not in use how it should be stored. The RIPN stated that the neb mask when not in use should be inside a bag and changed weekly by the 11-7 shift nurse. She further stated that she had to verify what specific date they change it. The surveyor then notified the RIPN of the above concerns and findings about the neb mask not being stored properly for Residents#210 and #213. The RIPN stated that the neb mask when not in use should be stored inside a bag for infection control. On that same date and time, the surveyor also asked if the resident had posted a sign for contact precautions by the door and what would be the expectation for the staff and visitors to do. The RIPN stated that it was expected for visitors and staff to don (put on) PPE prior to entry room. The RIPN further stated that they should go to the nurse to verify the posted signs and instructions on what to do. She also stated that visitors and staff should perform hand hygiene prior to entering and exiting the room. The RIPN stated that for the contact precaution sign and concerns about Resident #213, the RA should have followed the posted sign to perform hand hygiene before entering and leaving the room and donned PPE. The RIPN also stated that the status of the resident should have been clarified and updated with either Contact or EBP. She further stated that RA did not put on PPE and did not perform hand hygiene while Resident #213 had an order and posted signs for contact precautions. The RIPN also stated that there was no negative adverse effect. Furthermore, the RIPN informed the surveyor that the RT came and discussed the O2 order and clarified the order. The RIPN further stated that according to the RT, the FIO2 at the time of observation had nothing to do with the resident's O2 intake and had no negative effect on the resident. At that same time, the surveyor asked the RIPN what the expectation from visitors and staff for residents on EBP would be. The RIPN stated that it was expected that PPE was required on high contact care, and best practice to do hand hygiene prior to and before exiting the room. On 11/06/24 at 11:19 AM, the survey team met with the LNHA, Director of Nursing (DON), and Regional Director of Operations (RDO). The surveyor notified the facility management of the above concerns and findings. On 11/07/24 at 11:31 AM, the survey team met with the LNHA, DON, AA, and RIPN. The DON stated that Resident #210 neb was not bagged because it was air drying. The RIPN stated that it was best practice after use to clean the mask with soap and water and put it on top of a clean paper towel, and once dry store it in the bag. The facility management acknowledged that the neb mask upon the surveyor's observation was not on a clean paper towel, it was directly placed in the resident's environment which was the nightstand table and neb machine. On that same date and time, the RIPN stated regarding Resident #213, the facility immediately corrected the concerns about O2 orders and respiratory equipment use and obtained appropriate order for the trach resident. She further stated that the facility will initiate a performance improvement plan. The RIPN further stated that the order for contact precaution of Resident #213 should have been clarified to change it to EBP, otherwise, the RA should have followed the order and posted a sign for contact precaution. A review of the facility's Nebulizer Therapy Policy with a revised dated 10/2023 that was provided by the DON revealed: Policy: It is the policy of this facility for neb treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: 2. Care of the Equipment: g. Once completely dry, store the neb cup and the mouthpiece in a zip lock bag. A review of the facility's Transmission-Based Precautions with a revised date of 7/23/24 that was provided by the DON revealed: Policy: Definitions: TBP are group of infection prevention and control practices that are used in addition to standard precautions for residents who may be infected or colonized with infectious agents that require additional control measures to prevent transmission effectively. There are three categories of TBP: contact, droplet, and airborne. Policy Explanation and Compliance Guidelines: 3. Contact Precautions- a. Intended to prevent transmission of infectious agents including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . d. Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . A review of the facility's Contact Precautions posted sign that was provided by the DON showed: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . A review of the facility's Enhanced Barrier Precautions Policy with a revised date of 3/07/2024 that was provided by the DON revealed: Procedure: b. Perform hand hygiene before entering and when leaving the room. A review of the facility's Tracheostomy Care with a revision date of 9/2024 that was provided by the DON showed: Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and resident goals and preferences. Policy Explanation and Compliance Guidelines: 4. Based upon the resident assessment, attending PO, and professional standards of practice, the facility collaboration with the resident/resident's representative will develop CP that includes appropriate interventions for respiratory care. On 11/07/24 at 01:29 PM, the survey team met with the LNHA, DON, RDO, Regional Clinical Operations, and AA for the Exit Conference, and facility management did not provide any additional information. NJAC 8:39-11.2(a)(b); 19.4(a); 27.1(a)

Based on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for two (2) of 38 residents (Resident #125, and #212) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 11/04/24 at 9:50 AM, the surveyor observed Resident #125 lying in bed with eyes open and unable to answer the surveyor's inquiry. On 11/04/24 at 11:00 AM, the surveyor reviewed the hybrid (paper and medical) records of Resident #125 and revealed: The Admission Record (AR; an admission summary) documented that Resident #125 was admitted to the facility with diagnoses that included but were not limited to encephalopathy (a disease that affects the brain). Resident #125's most recent comprehensive MDS (cMDS), with an Assessment Reference Date (ARD; the last day of the observation period) of 02/04/24, reflected that Resident #125 had a Brief Interview for Mental Status (BIMS) score of 0 (zero) out of 15, indicating severe cognitive impairment. Section O - Influenza Vaccine, A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 0. No. C. Influenza vaccine not received, state reason: 5. Not offered. And Pneumococcal Vaccine A. Is the resident's Pneumococcal Vaccination up to date? 0. No. B. If Pneumococcal Vaccine not received, state reason: 1. Not eligible-medical contraindication. A review of quarterly MDS (qMDS) dated [DATE] in section O- Influenza Vaccine, A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 0. No. C. Influenza vaccine not received, state reason: 5. Not offered. And Pneumococcal Vaccine A. Is the resident's Pneumococcal Vaccination up to date? 0. No. B. If Pneumococcal Vaccine not received, state reason: 1. Not eligible-medical contraindication. A review of recent qMDS dated [DATE] in section O- Influenza Vaccine, A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 0. No. C. Influenza vaccine not received, state reason: 5. Not offered. And Pneumococcal Vaccine A. Is the resident's Pneumococcal Vaccination up to date? 0. Yes. A review of the Resident Annual Influenza Vaccine Consent Form dated 01/28/24, given by the Regional Infection Preventionist Nurse (RIPN) on 11/07/24, revealed that the resident representative's (RR's) written check off and signature: I do not Consent for the vaccine be given to me or to the person named below for whom I authorized to sign. A review of the form titled Pneumococcal Vaccine -Informed Consent dated 01/28/24, given by the RIPN on 11/07/24, revealed that the RR's written check off and signature: I do not Consent for the vaccine be given to me or to the person named below for whom I authorized to sign. 2. On 11/04/24 at 10:27 AM, the surveyor reviewed the medical records of Resident #212 and revealed: The AR documented that Resident #212 was admitted to the facility with diagnoses that included but were not limited to rhabdomyolysis (a condition in which muscle tissue breaks down). Resident #212's most recent cMDS assessment, with an ARD of 10/17/24, reflected that Resident #212 had a BIMS score of 8 out of 15, indicating moderate cognition impairment. Section O - Pneumococcal Vaccine A. Is the resident's Pneumococcal Vaccination up to date? 0. No. B. If Pneumococcal Vaccine not received, state reason: 3. Not offered. A review of the form titled Pneumococcal Vaccine -Informed Consent dated 10/11/24, given by the RIPN on 11/07/24, revealed that the RR's with the written check off and signature: I do not Consent for the vaccine to be given to me or to the person named below for whom I authorized to sign. On 11/07/24 at 9:20 AM, the surveyor interviewed the RIPN, who acknowledged the incorrect MDS code. She stated that immunizations were offered to all the residents and staff. On 11/07/24 at 12:57 PM, the team of surveyors interviewed the MDSC/RN regarding the above concern. The MDSC/RN stated that the vaccine information should be reflected in the MDS assessment. The MDSC/RN stated that the facility followed the RAI (Resident Assessment Instrument) Manual (a tool that helps gather information about a resident's strengths and needs, used to create an individualized care plan). According to the CMS (Centers for Medicare & Medicaid Services) MDS 3.0 RAI Manual of October 2024, the RAI manual was revealed under Version 3.0 Manual, page O-12, under O0250: Influenza Vaccine. Steps for assessment: 1. Review the resident's medical record to determine whether an influenza vaccine was received in the facility for this year's influenza vaccination season. If the vaccination status is unknown, proceed to the next step. 2. Ask the resident if they received an influenza vaccine outside the facility for this year's influenza vaccination season. If the vaccination status is still unknown, proceed to the next step. 3. If the resident is unable to answer, then ask the same question of the responsible party/legal guardian and/or primary care physician. If influenza vaccination status is still unknown, proceed to the next step. 4. If influenza vaccination status cannot be determined, administer the influenza vaccine to the resident according to standards of clinical practice. On page O-16, under O0300: Pneumococcal Vaccine. Steps for assessment: 1. Review the resident's medical record to determine whether any pneumococcal vaccines have been received .3. If the resident is unable to answer, ask the same question of the responsible party/legal guardian and/or primary care physician. NJAC 8:39-33.2(a)

Based on observations, interview, and policy review, the facility failed to clean and disinfect glucometers per the manufacturer's recommendation. This facility failure to properly clean and disinfect multi-use glucometers has the potential to increase the likelihood of transmission of blood-borne pathogens for two of 30 residents (Resident (R) 351 and R 11) receiving blood sugar monitoring. On 7/13/23 at 2:59 PM, the Administrator and the Director of Nursing (DON) were notified of immediate jeopardy (IJ) in the following area: at F880-: Infection Control. The Immediate Jeopardy began on 07/13/23 when the licensed nursing staff failed to properly clean and disinfect multi-use glucometers for R351 observed on 07/12/23 and R11 observed on 07/13/23. The facility provided an acceptable plan for removal of the immediate jeopardy at F880 on 07/14/23 at 1:45 PM. On 07/14/23 at 3:00 PM, the immediacy was removed after the plan was verified to have been implemented. The deficient practice remained at a scope and severity of a D (Isolated, no actual harm with potential for more than minimal harm) The removal plan included: Administrator completed a root cause analysis. Director of Nursing/designee began education on 07/13/23 at 3:30 PM and will continue until education on disinfecting the glucometer per facility policy with the competency to show return demonstration and comprehension and will continue education until all nurses have been educated. Compliance on competencies to determine knowledge will be audited/monitored for completion by the Director of Nursing or designee weekly for four weeks, every two weeks for two months and monthly for three months. Audits will be discussed during Quality Assurance Performance Improvement (QAPI) meeting. Regional Director of Nursing/designee completed hand washing education and competency to show return demonstration and comprehension on 07/13/23 and will continue until all nursing staff have been educated prior to the next shift. The Director of Nursing identified all residents at risk, and those residents requiring blood glucose monitoring. A full house audit was completed on residents receiving blood glucose monitoring to ensure there are no known blood-borne infections with the identified residents. All glucometers were removed from the medication carts and disinfected according to the facility policy on 07/13/23. All medicine carts were disinfected with the Environmental Protection Agency (EPA) approved disinfecting solution. The removal plan was verified through interviews and observations. On 07/14/23, on the 2 North Unit at 2:29 PM; 1 [NAME] unit at 2:30 PM; 2 South unit at 2:51 PM; Penthouse unit at 3:00 PM; and 1 South Unit at 3:01 PM licensed nursing staff were interviewed regarding the removal plan and facility expectations for the cleaning/disinfecting of resident glucometers. The staff were able to verbalize the process for cleaning, with the correct number of disinfecting wipes and type, to be used. Findings include: During observation on the One [NAME] Unit on 07/12/23 at 4:46 PM, Licensed Practical Nurse (LPN) 2 was observed to remove a multi-use glucometer kit from the medicine cart located in the hallway. The glucometer kit contained a blood glucose meter, blood sugar test strips, lancets, and testing solution which were stored in a zippered pouch. LPN2 took the glucometer kit into R351's room, donned gloves, and performed R351's blood sugar test. With her gloves still on, LPN2 returned the glucose meter and container of test strips to the zippered pouch and left R351's room failing to remove her gloves and perform hand hygiene prior to leaving R351's room. LPN2 placed the glucometer kit on top of the medication cart located in the hallway and removed her gloves and performed hand hygiene at that time. After observing LPN2 document R351's blood sugar results in the electronic medical record, continued observation revealed LPN2 placed the glucometer kit in the medication cart drawer without cleaning or sanitizing it. During interview via telephone of LPN2 on 7/13/23 at 11:41 AM, LPN2 stated that before use the glucometer should be disinfected with a wipe from the purple container (Micro-Kill One Germicidal Alcohol Wipes). After use, she wipes everything before it is used for the next resident. LPN 2 stated one wipe is used to wipe front, back, and side of the glucometer. LPN2 stated gloves should be removed, and hands washed with soap and water after performing a blood glucose test. LPN2 confirmed that she failed to remove her gloves and sanitize her hands after performing R351's blood glucose test and prior to leaving the resident's room. LPN2 further confirmed she left R351's room after performing the blood glucose test and discarded her gloves at the medication cart. LPN2 would not confirm that she failed to clean and sanitize the glucometer before placing it back into the medication cart. During an interview on 07/12/23 at 4:54 PM the Penthouse Unit regarding cleaning and disinfection of glucometers, LPN4 stated that prior to performing a blood glucose test, he wipes the glucometer with an alcohol swab and after performing the blood glucose test, he wipes the glucometer with an alcohol swab. During an interview on 07/12/23 at 5:16 PM, LPN Unit Manager for the One [NAME] Unit (LPN1) stated that after glucometer use, staff should clean the glucometer with antiseptic bleach wipes and let sit for 1 minute. When asked about the policy and procedure for disinfecting glucometers, LPN1 was unable to locate it. During observation and interview on 07/13/23 at 7:33 AM, on the One South Unit, LPN5 performed a blood sugar test on R11. After performing the blood sugar test, LPN5 cleansed the glucose meter with a Micro-Kill One Germicidal Alcohol Wipe. LPN5 then wrapped the glucose meter in a Micro-Kill One Germicidal Alcohol Wipe and stated he lets it dry and then puts it away. Review of residents receiving blood glucose monitoring provided by the DON on 07/13/23 revealed there were 30 residents in the facility that used shared glucometers, and there were no residents with a confirmed blood-borne pathogen infection, such as Hepatitis B, Hepatitis C, or HIV infection. Observation of medication carts on 07/12/23, 07/13/23, and 07/14/23, revealed germicidals available for cleaning and disinfecting glucometers were: Micro-Kill One Germicidal Alcohol Wipes and Micro-Kill Bleach Germicidal Bleach Wipes. The alcohol wipes kill most pathogens after 1 minute. Continued review of the manufacturer's information revealed the alcohol wipes did not kill clostridioides difficile (C. difficile) spores. The bleach wipes kill most pathogens after one minute, and the C. difficile spore after 3 minutes. Therefore, if a resident has a C. difficile infection, the alcohol wipes were not effective in killing the C. difficile spore placing other residents at risk of contamination. Review of the manufacturer's guidelines entitled, Cleaning and Disinfecting Procedures for the Meter revealed: Cleaning Instructions: Cleaning is the removal of visible dirt and debris. Whenever your glucose meter is dirty, clean the outside of the meter with a new CaviWipes towelette or an EPA-registered disinfecting wipe. The cleaning process does not reduce the risk for transmission of infectious diseases. Disinfection Instructions: The meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The Disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Review of the facility's policy and procedure, Glucometer Disinfection dated 01/2012, and revised on 05/2023 revealed: Under Policy Explanation and Compliance Guidelines The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, then the meter should not be used for multiple patients. The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against, at the minimum, HIV, Hepatitis C and Hepatitis B virus. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Under Procedure the following is included after obtaining blood sampling: Remove and discard gloves, perform hand hygiene prior to exiting room. Reapply gloves is there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Discard disinfectant wipe in waste receptacle. Perform hand hygiene. The facility's policy and procedure does not specify whether to use the alcohol wipe or bleach wipe. NJAC 8:39-19.4(a)1

COMPLAINT#: NJ161036, NJ161038 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 2/3/2023, 2/6/2023, 2/7/2023, and 2/14/2023, it was determined that the facility failed to appropriately supervise and monitor a severely cognitively impaired resident (Resident #2), with a known history of wandering, and Aggressive Behavior. The facility failed to ensure Resident #2, who has a known diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Syncope, Collapse, Unspecified Lack of Coordination, and Wandering In Diseases Classified plan of care was implemented for monitoring the Resident's location every shift and as needed and to document observed behaviors and attempted intervention in the Behavior log, on 1/4/2023 on the 3-11 shift, at approximately 8:00 p.m. to 8:30 p.m., when the Resident was last seen by Certified Nursing Assistant (CNA #2) and Licensed Practical Nurse (LPN #2) in the dining room, watching television through approximately 9:30 p.m. when Resident #2 was seen again standing in the hallway by the Nurse's station with swelling and bruising to the left side of the face by LPN #1. LPN #1 notified LPN #2, the Resident's assigned Nurse, of the injuries. 911 was called, and the Resident was sent to the emergency room (ER), admitted , and hospitalized with a Subdural Hematoma. The facility also failed to follow its policies titled Abuse, Neglect and Exploitation, Behavioral Health Services, Documentation In Medical Record, and Incident/Accident Reporting. The facility's failure to keep Resident #2 safe on 1/4/2023 placed Resident #2 and all other residents with a history of wandering, aggressive behaviors, and falls who require monitoring/supervision at risk for an injury of unknown origin and in an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) on 2/7/2023 at 2:08 p.m. The Administrator was presented with the IJ template that included information about the issue. This Immediate Jeopardy ran from 1/4/2023 when Resident #2 was last seen at approximately 8:00 p.m. to 8:30 p.m., through approximately 9:30 p.m. when LPN #1 saw the Resident with injuries. On 2/14/2023, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating Staff on elopement, behavior monitoring, documenting behaviors, wandering with behaviors, updating the care plan for each Resident, and rounding every two hours. So, the noncompliance remained on 1/4/2023 at a lower scope and severity for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 4 residents ( Resident #2) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 01/04/2023 and a time of event of 9:30 p.m., revealed the following: On 01/04/2023 at approximately 9:30 p.m., Resident #2 was noted wandering the hallway on the adjacent unit, the Nurse [LPN #1] escorted patient [Resident] back to assigned unit and alerted primary Nurse that patients [Resident's] face noted with swelling and bruising. The FRE also revealed Resident #2 initially stated that someone hit him/her, then later said someone threw something at him/her. Resident #2 was sent to the hospital, admitted with a subdural hematoma, and has not returned to the facility. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Syncope, and Collapse, Unspecified Lack of Coordination and Wandering In Diseases Classified Elsewhere. According to the Minimum Data Set (MDS), an assessment tool dated 10/13/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 00/15, which indicated the Resident had severely impaired cognition. The MDS also showed Resident #2 only needed supervision with all Activities of Daily Living (ADLs), and the Resident had a wander/elopement alarm. A review of the Resident's Care Plan (CP) initiated on 1/11/2021 revealed under Focus: that Resident #2 is an elopement risk/wanderer AEB (as evidenced by) the Resident wanders aimlessly, Significantly intrudes on the privacy of other residents by entering their room. Under Goal, indicated Resident will not leave facility unattended through the review date. Target Date 1/11/2023. Under Interventions included: Assess for fall risk, Distract Resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book, Monitor location every shift and as needed, Document wandering Behavior and attempted diversional interventions in Behavior log, Wander alert: . Left ankle q (every) shift . Exp 10/2023/Monitor and document placement of wander guard q shift. Further review of Resident #2's CP initiated 09/10/2020, included under Focus: Resident #2 has potential to demonstrate physical and verbal behaviors AEB pushing another resident and yelling r/t (related/to) Confusion and Dementia with Behavioral Disturbance. Under Goal, included: Resident will not harm self or others through the review date, Target Date 1/11/2023. Under Interventions: included: Analyze of key times, places, circumstances triggers, and what de-escalates Behavior and document, Assess and address for contributing sensory deficits, Cognitive Assessment, Evaluate for side effects of medications, Monitor (every shift). Document observed Behavior and attempted interventions, Monitor/document/report to MD (Medical Doctor) of danger to self, and others, Psychiatric/Psychogeriatric consult as indicated, Room change to from 2 North 268B to 2 South 243B, Will continue to encourage and provide opportunities for active participation in acts of interest & socialization w (with)/peers. A review of Resident #2's Incident Reports (IRs) revealed the following: On 3/21/2022 at 3:00 a.m., revealed Under Incident Description (ID),: the Resident was asleep in bed. VSWNL (vital signs within normal limits), no s/s of distress. The Resident slept well until 3 a.m. (3:00 a.m.). The IR showed the Resident was noted walking in the hallway, holding his/her right arm. The Nurse asked the Resident to show the arm, pulled up the long sleeve sweater, and skin discoloration was noted in the Resident's arm, with no opening to the skin and no bleeding. Resident #2 was alert with confusion. The IR further showed a nurse asked Resident #2 what happened, but the Resident could not say. He/She was unable to give a Description. The Supervisor and Physician were notified. The Resident was administered pain medication with positive results. Under Predisposing Situation Factors: revealed wanderer. Under Other Info (information) revealed, Resident is on behavior monitoring due to medication increased to 75mg (milligrams). On 07/15/2022 at 11:23 p.m., revealed Under ID: Nursing Description: Activity aide reported to the nurse resident's Lt [left] hand bruise. No open wound or discharge was noted. Under Resident Description,: . Notes dated 7/16/2022 revealed Conclusion S/P (status/post) (after) Left-Hand Discolored Area: Activity aide called the Nurse as she noted a discolored area to the Resident's left hand; he/she is able to move the hand with no c/o [complaint] of pain at this time. According to the IR, the NP (Nurse Practitioner) was called and made aware and ordered an x-ray of the L left hand to r/o (rule/out) a fx (fracture)/family was made aware of above. The IR also included that Resident #2 was awake and confused to place and time/he/she ambulated freely around the unit. He/She would wander into other residents' rooms and be redirected by the Staff not to go into other residents' rooms. Resident #2 has the tendency to wheel other residents around and out of the dining room. The Resident has been observed hitting the door frame with his/her hand and the handle of the w/c (wheelchair) as he/she exits the dining room. The Resident receives an anticoagulant medication po [by mouth] and is at a higher risk of discoloring his/her skin by hitting an object. Resident #2 is reminded /redirected often by the Nurse and spoken to not to be wheeling or removing anyone from the dining room, but due to the Resident's decreased cognition r/t [related/to] Dementia; he/she continues to wheel residents into the hallway. The IDCP (interdisciplinary) team met and concluded this discolored area was not due to any abuse as Resident #2 has been noted to hit the hand on the door frame, which caused the discolored area to the hand. Further review of the IR showed the X-ray results were negative for a fx (fracture), and the Resident continued to deny any pain. He/She should not be wheeling the residents out of the DR (Dining Room). The CP was reviewed and updated. On 1/4/2023 at 10:43 p.m., written by LPN #2 revealed Under ID: Nursing Description: Unwitnessed occurrence at 9:30 p.m., LPN #1, RN advised LPN #2, LPN that he saw 2 South resident (Resident #2) ambulating by 2N nurse station and brought him/her to 2S (South), that is when her Nurse (LPN #2) notice the left side of [Resident 2's] check [cheek] was swollen with discoloration to the bridge of his/her nose and under his/her left eye. The IR also showed that Resident #2 spoke another language which was translated by the 2N Nurse (LPN #1). According to the IR, Resident #2 was unsure of how the injuries happened. The Resident refused skin assessment and vital signs, and his/her breathing was easy and nonlabored. Staff member stood with the Resident in the 2N dayroom while Dr. [Physician], Nurse Supervisor, and the Resident's family were made aware. A Doctor's [Physician's] order was received to send Resident #2 to the hospital for evaluation. 911 was called, and Resident #2 was transported via [by] ambulance to the emergency room . The Resident seemed his/her normal self, alert, confused, and verbally responsive. Able to follow simple commands with little resistance. Under Resident Description: Resident advised she does not know how it happened. A review of Resident #2's Progress Notes (PNs) revealed the following: On 12/1/2022 at 7:44 a.m. written by the Licensed Practice Nurse (LPN #3) revealed, Received elder [Resident] in bed. No s/s [signs/symptoms] of distress[,] [Resident] VSWNL (vital signs within normal limits), no complain [complaint] voiced. [Resident] refused to go back to bed [and was] redirected with negative results. [Resident] stayed in [the 2 North] dining room [and] slept intermittently. Refused x 2 urine collection(s). Wander guard in place. Will continue to monitor. On 12/8/2022 at 6:48 a.m. written by LPN #3 revealed, [Received] Resident in bed asleep no s/s of distress no complain [complaint] voiced. [Resident] stayed in his/her bed until 2 a.m. [2:00 a.m.], then [the] [Resident] wander(ed) in hallways calms (calm), no facial grimacing noted. Resident stayed in [the 2 North] dining room watching a show. The Staff attempted to redirect Resident #2 to his/her room, but the Resident refused. On 12/15/2022 at 8:35 a.m. written by LPN #3 revealed, Received [Resident] sitting in other Resident room eating fruit. [Resident] refused to go back to his/her room, wander in units, get into other residents' ['] room(s), and take other residents' ['] belongings. Several attempts to take supplies from [the] medication cart. Very difficult to redirect and does not follow direction(s). Denied pain or discomfort attempts to sleep in other residents' ['] bed and become [became] aggressive when redirected, yells, scream(s), and curses as per [unit] Staff. After several attempts, [the Resident] agreed to go to [2 North] dining room and stayed there most of [the] shift [,] slept intermittently sitting on a chair. Close monitoring [is] ongoing. Will continue to monitor. On 12/20/2022 at 6:41 a.m., written by LPN #3 revealed, Received [Resident] in bed asleep. [Resident] at 12:30 a.m., [was] noted wandering in [the] 2nd-floor units,[;] [Resident] gets into other residents ['] room and take(s) their belongings, [;] [Resident] became aggressive when this Nurse redirected yells, scream curses as per Staff also attempts to kick, punch and scratch to any staff that redirected, [Resident] is difficult to redirect and does not follow direction, Assist [Resident] to [2 North] dining room. Slept in a chair intermittently. Close monitoring ongoing. On 12/21/2022 at 7:13 a.m. written by LPN #3 revealed, Received [Resident] sitting at the edge of his/her bed. Noted talking with roommate [roommate] in their room, wander[wandering] in units, get into other residents' ['] room(s), and take [taking] other residents' ['] belongings. Several attempts to take supplies from [the] medication cart. [Resident] is very difficult to redirect and does not follow direction. Become aggressive when redirected, yells, screams, and curses as per [unit] Staff. After several attempts, [Resident] agreed to go back to his/her room (and) slept intermittently[,] sitting on a chair. Close monitoring [is] ongoing. Will continue to monitor. On 12/25/2022 at 6:52 a.m., written by LPN #3 revealed, Received [Resident] in bed asleep. [Resident] at 1:30 a.m. [a.m.] noted wandering in [the] 2nd-floor units, [;] [Resident] gets into other residents' room[s] and take[s] their belongings, [Resident] became very aggressive when this Nurse redirected yells, scream, curses as per[unit] Staff also attempts to kick, punch and scratch to any staff that redirected, [Resident] is difficult to redirect and does not follow direction . Assist [Resident] to [2 North] dining room. Slept in a chair intermittently. Close monitoring ongoing. On 12/29/2022 at 7:29 a.m. written by LPN #3 revealed, [Received Resident] in bed asleep no s/s of distress no complain [complaint] voiced. [Resident] stayed in his/her bed until 2 a.m. [2:00 a.m.], then Resident wander(ed) in the hallway calms, no facial grimacing noted. Resident stayed in [2 North] dining room talking with other Resident (s), slept intermittently [in] sitting chair, [and attempted] to redirect to his/her room but refused. Will continue to monitor. On 12/30/2022 at 5:30 a.m. written by LPN #3 revealed, eceived [Received] [Resident] in [2 North] dining room sitting in a chair, no s/s of distress no complain [complaint] voiced. Resident wander(s) in the second-floor unit. Episode x 1 of disturbing other Resident, redirected with positive results, no c/o [complaint] of pain or discomfort, no facial grimacing noted. Resident stayed in the dining room calmly watching . show, slept intermittently sitting in the chair, and was redirected to his/her room with negative results. On 1/3/2023 at 7:44 a.m. written by LPN #3 revealed, Received [Resident] in [2 North] dining room sitting in a chair, no s/s of distress no complain [complaint] voiced. Resident wander(s) in the second-floor unit. Episode x 3 of Resident getting agitated when other [Residents] went to the 2 North dining room, redirected each time with positive results, no c/o [complaint] of pain or discomfort, no facial grimacing noted. Resident stated in the dining room, he/she was calm, watching [2 North] show, slept intermittently sitting in the chair, and was redirected to her room several times with negative results. Refused snacks. Will continue to monitor. On 1/4/2023 at 11:22 p.m., written by the Licensed Practice Nurse (LPN #2), revealed Unwitnessed occurrence- at 8:30 p.m. 2 North Nurse (LPN #1), RN advised 2 South nurse (LPN #2) that he saw 2 South Resident ambulating by 2N (North) nurse station and brought him/her to 2S (South), that is when his/her Nurse (writer) notice the left side of his/her check [cheek] was swollen with discoloration to the bridge of his/her nose and under his/her left eye. The Resident spoke another language and was translated by 2N Nurse (LPN #1). Resident stated he/she is unsure of how it happened. The Resident refused skin assessment and VS (vital signs). Resident break [breath] easy and nonlabored. Staff member stood with Resident in 2N dayroom with Doctor. [Physician], Nurse Supervisor, and family made aware. Received Doctor's order to send Resident out for evaluation. 911 was called and transported [the] Resident out to ER via ambulance. Further review of the PN revealed the Resident seemed to be his/her normal self, alert, confused, and verbally responsive. Able to follow simple commands with little resistance. As requested, a follow-up call was given to the family member and advised her mother/father went to the hospital, and we will follow up with her regarding her mother/father status. On 1/5/2023 at 5:15 a.m., the PNs revealed at 5:00 a.m. A call was placed to the hospital regarding the Resident's status. Resident #2 was admitted DX (diagnosis): Subdural Hematoma. Further review of Resident #2's MR showed no evidence that the CP was followed for monitoring the Resident's location every shift and as needed; to document observed Behavior and attempted intervention and documented in the Behavior log. Also, no evidence was provided during the survey that a behavior log was implemented to document the Resident's Behavior. At the time of the survey, the facility could not provide monitoring sheets or assignment sheets that showed what Staff was assigned to monitor the residents in the dining/day room on 1/4/2023. During an interview on 2/3/2023 at 2:12 p.m., LPN #2 assigned to Resident #2 at the time of the 1/4/2023 incident stated the following: Resident #2 was in the 2 North dining room, the 2 North Nurse, LPN #1, notified me at [the] Nurse's station that something happened to the Resident. LPN #2 explained that he met LPN #1 and Resident #2 in the corridor by the elevator. Resident #2 was sitting on the bench with swelling to the face on the left cheek, [a] bruise by the bridge of [the] nose. He further stated, [the] Resident was calm and could not recall what happened or how it happened. He/she didn't say someone hit me or I fell . The last time I saw him/her was sitting in the dining room at 8:00 p.m.-8:30 p.m. Staff were in there [dining room] monitoring either an aide CNA or a nurse, and other residents were in there, but I don't know what Staff were in there that night. [The] Nurse (RN) brought this to my attention at 9:00 p.m.-9:30 p.m. I don't recall giving him/her meds [medications] or treatment that night. He/She would be sporadic with outbursts. I'm a float nurse . During the same interview, LPN #2 continued to say, Resident #2 got along with his/her roommate. He/She went into other Residents' rooms. I don't recall behaviors with other residents. When asked if there were any altercations with other residents, LPN #2 stated, No, I did not notice any altercation between other residents. The Resident has a wander guard and had it on that night. We monitor all our residents with rounds. The LPN further stated, rounds are done every hour, every half hour, by the Nurse or aide. We redirect [the Resident] from going into other rooms. The CP says to monitor and document; then it should be documented in the Nurse's PN on the computer. As far as I know, there is no behavioral monitoring sheet for him/her. I assessed him/her after the incident, Nursing Supervisor, Doctor [Physician] were made aware, and the family was also made aware. He further stated, between 8:30 p.m.-9:30 p.m.; I don't know where he/she was sitting or where he/she was between this time. I don't know [if] we are supposed to be monitoring all our residents. It's his/her home. He/She walks freely in his/her home. I don't recall the aides' name who worked with me that night. I saw him/her in the dining room sitting in an individual chair between 8:00 p.m.-8:30 p.m. During an interview on 2/3/2023 at 3:23 p.m., when the Surveyor asked about the incident with Resident #2, LPN #1 stated, around 9:00 p.m., after I did med [medication] pass, I saw the Resident standing on the side of the Nurse's station of 2 North. He/She wanders for 24 hours, and then I called over to 2 South Nurse (LPN #1). I didn't hear any yelling prior to seeing the Resident. I didn't hear anything . LPN #1 told the Surveyors that We have schedules of the Staff assigned in the dining room. He stated, it's either [an] aide or Nurse is in the dining room. However, the facility could not provide the assignment schedule during the survey. In the same interview, LPN #1 continued to say, After [the] med pass, I saw him/her, [the] Resident just standing there, took [the] Resident to 2 South, called ambulance and Supervisor. I asked [the] Resident what happened several times, [Resident] gave different answers, [said] bank person coming in, not reasonable. I couldn't understand what he/she was saying; he/she didn't make any sense, [the Resident] story [didn't make any sense]. I called 2 South Nurse (LPN #2) to come [to] get him/her. [Resident #2] just stood there. There was swelling on [the] left side and [a] light bruise on the left cheek area . No crying, [the] Resident said nothing. I just saw [the] face. I didn't check anywhere else. I didn't assess him/her. During a telephone interview on 2/6/2023 at 10:44 a.m., when the Surveyor asked the CNA assigned to Resident #2 about the incident, she stated, I was assigned to the Resident on 1/4/2023; Resident was walking around at 3:30 p.m., at 5:00 p.m. eating in the dining room, then at 8:00 p.m., he/she was sitting, watching TV then I was caring for other residents. Then at 9:40 p.m., Nurse (LPN #2) informed me of the incident. In the same interview, the CNA continued, in [the] dining room; there's the other aide that works on 2 North; I don't know the other aide's name. I was on 2 South with another aide giving care. I only know what I just told you. You need to talk to the DON. I only documented with my statement. When asked by the Surveyor if she documented on the Behavior Log for Resident #2, the CNA stated for monitoring, we do that, but I don't document on the Resident. I only document shower(s) and baths. If assigned to [a] Resident, document every 15 minutes, but I'd have to be told to do it, but I wasn't told to document [the Resident's] Behavior. The Nurse gives me a report on him/her. I don't know if I can see a care plan for him/her. I don't have access to the CP. We [aides] have just ADLs we document. From 8:00 p.m.- 9:00 p.m., I didn't see patient [Resident] because I was providing care. When Surveyor asked the CNA who was monitoring Resident #2 from 8: 00 p.m. through 9:00 p.m., I told [the] Nurse I was giving care. The CNA stated it was only her and the Nurse on the unit. So she assumed the Nurse was monitoring the patient [Resident]. During a second interview on 2/6/2023 at 11:47 a.m., LPN #2 stated, the only documentation I know for residents is the ADL(s) book; I don't know of a behavioral log; as long as the Resident is in the dining room, there should be Staff in there. The Resident was free to walk in this unit, 2 South, and the other unit, 2 North. No one was monitoring him/her. I was not aware. I last saw the Resident at 8:00 p.m.-8:30 p.m. When the Surveyor asked him what does the code 2 mean on the (MAR), the LPN replied, refused. I don't recall where I saw him/her when he/she refused the [9.00 p.m.] medication. If an aide [CNA] went to provide care or take a lunch break, another aide or activities [Staff] would monitor or watch a resident. Another staff should be monitoring him/her. He/She gravitates to the [other] 2 North dayroom. During an interview on 2/6/2023 at 12:30 p.m., in the presence of the Administrator, the DON stated, I know the nurses would monitor behaviors and document in [the] progress notes. The aides [CNAs] would note any behaviors and report it [them] to the Nurse. On the day of [the] incident, [Resident #2] was found in the dining room at 8:30 p.m., [the] last time he/she was seen in [the] dining room. The incident was at approximately 9:30 p.m. The dining room does connect both units. [Resident #2] was seen walking around the unit. Per the documentation, [there was] no aggressive behaviors noted, no need for redirection. In the same interview, the DON stated the Nursing Supervisors and other Nurses stated the patient [Resident] said initially he/she had been beaten up, [someone] hit him/her, then later he/she said someone threw something at him/her, always a different story stayed with the patient [Resident], called the Doctor [Physician], [due to the] extent of injuries, called 911 and sent out to the hospital. It had to have just happened. I don't remember the exact time. Another floor nurse came to help. Both nurses called me. LPN #2 was the Nurse that day. Normally, the Staff, CNAs take turns and monitor residents in the dining room at that time of night. When the Surveyor asked the DON what Staff was assigned to Resident #2 that day/night, the Administrator and DON replied, I can't say who was assigned to the Resident in the dining room that day/night. The DON continued to say, While the patients [residents] are in the dining room, yes, someone, a CNA usually, [is assigned] at that hour or could be a nurse should be in there. During a telephone interview on 2/7/2023 at 11:13 a.m., when asked about the behavioral log, the previous Unit Manager/Licensed Practical Nurse (UM/LPN) stated she created the behavioral log when she was the UM so that Staff could document Resident #2's wandering Behavior. She explained to the Surveyors that the CNAs documented and signed on the Behavior log every shift. When asked where the binder was located and about documenting in the binder, the UM stated the binder was located at the Nurse's station, and the CNAs would document. She said, Resident #2 did not stay in one place, the Resident would wander around the unit, and we [Staff] would divert him/her. If the Resident (Resident #2) went to the elevator or exit, we (Staff) would redirect him/her. Staff will always monitor his/her location during the shift and document any wandering behaviors in the Behavior log. A review of facility policy titled Abuse, Neglect and Exploitation dated 9/2022 revealed the following: Under Policy: included: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under Definitions: included: Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program and students from affiliated academic institutions, including therapy, social and activity programs. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Under Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling Behavior through corporal punishment.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death, involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty, requiring medical interventions such as surgery, hospitalization , or physical rehabilitation or an injury resulting from criminal sexual abuse . Under Mistreatment means inappropriate treatment or exploitation of a resident. A review of facility policy titled Behavioral Health Services dated 9/2022 revealed the following: Under Policy: included: It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Under Policy Explanation and Compliance Guidelines, included: 1. The facility will ensure that each Resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral health includes a resident's entire emotional and mental health, which includes the prevention and treatment of mental and substance use disorders. 3. The facility must have sufficient Staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure Resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each Resident determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility's resident population. 4. These competencies include but are not limited to knowledge of and appropriate training and supervision for: Caring for residents with mental and psychosocial disorders identified in the facility assessment and implementing non-pharmacological interventions 5. All residents who display or are diagnosed with mental disorders or psychosocial adjustment difficulty, or have a history of trauma or post-traumatic stress disorder will receive appropriate treatment and services to attain the highest practicable and psychosocial well-being . A review of the facility's policy titled Documentation In Medical Record with a revised date 10/2022 revealed the following: Under Policy: included: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Under Policy Explanation and Compliance Guidelines, included: Policy Explanation and Compliance Guidelines: 1. Licensed Staff and interdisciplinary team members shall document all assessments, observations, and services provided in the Resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and Resident centered. i. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. iii. Subjective information shall be recorded only as relevant, such as the Resident's verbalizations, in quotation marks. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the Resident's care and/or responses to care. c. Documentation shall be timely and in chronological order. d. Write legibly in black ink. e. Record date and time of entry. f. Sign each entry with name and credentials of the person ma [TRUNCATED]

Complaint #: NJ161036, NJ161038 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 2/3/2023, 2/6/2023, 2/7/2023, and 2/14/2023, it was determined that the facility failed to ensure care plan interventions were implemented for a resident (Resident #2) who is cognitively impaired and has a history of wandering, resulting in the resident being hospitalized with a Subdural Hematoma. The facility also failed to follow its policy titled Comprehensive Care Plans for 1 of 4 residents reviewed for CP (Resident #2). Review of the medical record (MR) was as follows: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Syncope, and Collapse, Unspecified Lack of Coordination and Wandering In Diseases Classified Elsewhere. According to the Minimum Data Set (MDS), an assessment tool dated 10/13/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 00/15, which indicated the Resident had severely impaired cognition. The MDS also showed Resident #2 only needed supervision with all Activities of Daily Living (ADLs). A review of the Resident's Care Plan (CP) initiated on 1/11/2021 revealed under Focus: that Resident #2 is an elopement risk/wanderer AEB (as evidenced by) the Resident wanders aimlessly, Significantly intrudes on the privacy of other residents by entering their room. Under Goal, indicated Resident will not leave facility unattended through the review date. Target Date 1/11/2023. Under Interventions included: Assess for fall risk, Distract Resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book, Monitor location every shift and as needed, Document wandering Behavior and attempted diversional interventions in Behavior log, Wander alert: . Left ankle q (every) shift . Exp 10/2023/Monitor and Document placement of wander guard q shift. During an interview on 2/3/2023 at 2:12 p.m., LPN #2 assigned to Resident #2 at the time of the 1/4/2023 incident stated the following: Resident #2 was in the Unit dining room, the 2 North Nurse, LPN #1, notified me at [the] Nurse's station that something happened to the Resident. LPN #2 explained that he met LPN #1 and Resident #2 in the corridor by the elevator. Resident #2 was sitting on the bench with swelling to the face on the left cheek, [a] bruise by the bridge of [the] nose. He further stated, [the] Resident was calm and could not recall what happened or how it happened. He/she didn't say someone hit me or I fell . The last time I saw him/her was sitting in the dining room at 8:00 p.m.-8:30 p.m. Staff were in there [dining room] monitoring either CNA or a nurse, and other residents were in there, but I don't know what Staff were in there that night. [The] Nurse (RN) brought this to my attention at 9:00 p.m.-9:30 p.m. I don't recall giving him/her meds [medications] or treatment that night. He/She would be sporadic with outbursts. I'm a float nurse . During the same interview, LPN #2 continued to say, Resident #2 got along with his/her roommate. He/She went into other Resident's rooms. I don't recall behaviors with other residents. When asked if there were any altercations with other residents, LPN #2 stated, No, I did not notice any altercation between other residents. The Resident has a wander guard and had it on that night. We monitor all our residents with rounds. The LPN further stated, rounds are done every hour, every half hour, by the Nurse or aide. We redirect [the Resident] from going into other rooms. The CP says to monitor and Document; then it should be documented in the Nurse's PN on the computer. As far as I know, there is no behavioral monitoring sheet for him/her. I assessed him/her after the incident, Nursing Supervisor, Doctor [Physician] were made aware, and the family was made aware as well. Between 8:30 p.m.-9:30 p.m., I don't know where he/she was sitting or where he/she was between this time. I don't know [if] we are supposed to be monitoring all our residents. It's his/her home. He/She walks freely in his/her home. I don't recall the aides' name who worked with me that night. I saw him/her in the dining room sitting in an individual chair between 8:00 p.m.-8:30 p.m. During an interview on 2/3/2023 at 3:23 p.m., when the Surveyor asked about the incident with Resident #2, LPN #1 stated, around 9:00 p.m., after I did med [medication] pass, I saw the Resident standing on the side of the Nurse's station of 2 North. He/She wanders for 24 hours, and then I called over to 2 South Nurse (LPN #1). I didn't hear any yelling prior to seeing the Resident. I didn't hear anything. No other residents were around him/her . LPN #1 explained to the Surveyors that We have schedules of the Staff assigned in the dining room. He stated, it's either [an] aide or Nurse is in the dining room. However, the facility could not provide the assignment schedule during the survey. In the same interview, LPN #1 continued to say, After [the] med pass, I saw him/her, [the] Resident just standing there, took [the] Resident to 2 South, called ambulance and Supervisor. I asked [the] Resident what happened several times, [Resident] gave different answers, [said] bank person coming in, not reasonable. I couldn't understand what he/she was saying; he/she didn't make any sense, [the Resident] story [didn't make any sense]. I called 2 South Nurse (LPN #2) to come get him/her. [Resident #2] just stood there. There was swelling on [the] left side and [a] light bruise on the left cheek area . No crying, [the] Resident said nothing. I just saw [the] face. I didn't check anywhere else. I didn't assess him/her. During a telephone interview on 2/6/2023 at 10:44 a.m., when the Surveyor asked the CNA assigned to Resident #2 about the incident, she stated, I was assigned to the Resident on 1/4/2023; Resident was walking around at 3:30 p.m., at 5:00 p.m. eating in the dining room, then at 8:00 p.m., he/she was sitting, watching TV then I was caring for other residents. Then at 9:40 p.m., Nurse (LPN #2) informed me of the incident. In the same interview, the CNA continued, in [the] dining room; there's the other aide that works on 2 North; I don't know the other aide's name. I was on 2 South with another aide giving care. I only know what I just told you. You need to talk to the DON. I only documented with my statement. When asked by the Surveyor if she documented on the Behavior Log for Resident #2, the CNA stated for monitoring, we do that, but I don't document on him/her. I only Document shower(s) and baths. If assigned to [a] Resident, document every 15 minutes, but I'd have to be told to do it, but I wasn't told to document [the Resident's] Behavior. The Nurse gives me a report on him/her. I don't know if I can see a care plan for him/her. I don't have access to the CP. We [aides] have just ADLs we document. From 8:00 p.m.- 9:00 p.m., I didn't see patient [Resident] because I was providing care. When Surveyor asked the CNA who was monitoring Resident #2 from 8:00 p.m. through 9:00 p.m., I told Nurse, I was giving care . A review of Resident #2's MR showed no evidence that the CP was followed for monitoring the Resident's location every shift and as needed; to document observed Behavior and attempted intervention and documented in the Behavior log. Also, there was no evidence provided at the time of the survey that a behavior log was implemented for documentation of the Resident's Behavior. During an interview on 2/7/2023 at 12:30 p.m., the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) stated, I can't say if there was someone [staff] monitoring the residents that day of the incident [1/4/2023]. When asked by the Surveyor if there should be someone watching the residents while in the dining room watching television, the DON said, 'yes, while the patients are in the dining room, someone [CNA /Nurse] should be in the dining room monitoring the resident. The DON further stated, the purpose of the CP is to be individualized so that we can provide care for the patients. When asked if the CP was followed for Resident #2, the DON responded, No, the CP was not followed. A review of the facility policy titled Comprehensive Care Plans with a revision date 09/2022 revealed the following: Under Policy: included: It is the policy of this facility to develop and implement a comprehensive person-centered care plan of each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under Definition: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Under Policy Explanation and Compliance Guidelines : .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, and psychosocial well-being .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the Resident's needs as identified in the Resident's comprehensive assessment. The objectives will be utilized to monitor the Resident's progress. Alternative interventions will be documented as needed .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. N.[NAME].C.: 8:39-11.2(e)(2) N.J.A.C.: 8.39- 27.1 (a)

Based on observation, interview and review of other pertinent facility documentation, it was determined that the facility staff failed to provide a safe environment to prevent the potential spread of infection by assuring that infection control practices were followed in accordance with the Centers for Disease Control during an outbreak of a [MEDICAL CONDITION] Covid-19 by; a.) safeguarding residents from the risk of infection by utilizing appropriate personal protective equipment (PPE); and b.) obtaining and providing staff with appropriate PPE during care and services for a resident with transmission based precautions to prevent the spread and exposure to the Covid-19 virus. On 04/29/2020 at 9:30 am, the surveyor toured the 1st floor of the facility and observed beauty shop services being provided to a resident. The beauty shop was located off the resident's living unit in a common area. The resident (Resident #1) was receiving beauty shop services in close proximity to the service provider (Beautician). The Beautician was observed curling Resident #1's hair and wearing a surgical mask pulled under her chin not covering her nose or mouth. The surveyor observed that the resident was not wearing a face-mask. According to the facility this service continued to be provided 2 to 3 times a week to 18 various residents from 3/24/2020 to 4/29/2020. There was no policy or adherence to abate these services during this time of possible Covid-19 virus exposure. On 04/29/2020 at 11:16 am, the surveyor toured the 3rd floor Penthouse Unit and observed two Certified Nursing Assistants (CNA's) applying (donning) large clear plastic garbage bags in preparation to enter a resident's room (316) who was reported to the care staff as being presumptive positive for the Covid-19 virus infection. The facility has adequate supply of PPE, however no request was made by the Licensed Practical Nurse (LPN) or CNA's to ensure that there was provision and proper utilization of appropriate PPE. The LPN stated to the surveyor that he entered the room earlier in the day with only a mask and gloves, but still did not request PPE provision. In accordance with a facility document dated 04/29/2020, titled: (Covid-19 Facility Outbreak Reporting Daily Survey) the surveyor learned that the facility had 28 Covid-19 positive residents and 5 presumptive (PUI's) residents. The Director of Nursing (DON) stated that there were 9 resident deaths associated with [MEDICAL CONDITION] and 45 staff members who contracted [MEDICAL CONDITION]. She also added that 44 staff members recovered and 1 remained hospitalized . The facilities failure to ensure residents and staff safety from exposure to a [MEDICAL CONDITION] Covid-19 during an outbreak by not applying and implementing appropriate PPE during care or services and not following infection control protocols for PPE, posed a serious and immediate threat to the safety and well-being of residents residing in the facility and staff caring for residents who could transfer the infection This resulted in an Immediate Jeopardy (IJ) situation began on 04/29/2020 at 5:32 pm, and the immediacy was removed on 04/30/2020 at 12:30 pm, based on acceptable IJ Removal Plan. This deficient practice was identified during a tour on 1st floor common area and on 1 of 6 nursing units (3rd floor Penthouse) conducted on 04/29/2020 and was evidenced by the following: a.) During a tour of the 1st floor common area on 04/29/2020 at 9:30 am, accompanied by the ADON, the surveyor observed a Beautician performing beauty services on Resident #1's hair. The Beautician was applying curlers in the resident's hair in closed proximity to the resident and was observed wearing a surgical mask pulled under her chin with her mouth and nose exposed. The surveyor observed the resident was not wearing a face-mask. On 04/29/2020 at 9:32 am the surveyor interviewed the ADON who stated that the Beautician should be wearing the mask appropriately to cover her nose and mouth while performing beauty services. She also stated that the resident should also be wearing a mask. At this time the ADON asked the Beautician to apply the mask correctly to cover her nose and mouth and then offered Resident #1 a mask to wear which the resident accepted. On 04/29/2020 at 9:40 am, the surveyor interviewed the Beautician who stated that the facility did educate her on Covid-19 and that she should always wear a mask when in contact with a resident because masks help stop the spread of infection. She said that only one resident was allowed in the beauty salon at a time. She also added that she was not aware that resident was required to wear a mask during beauty services and that she did not have extra mask in the beauty salon to offer residents. She admitted that she put her mask down and had her mouth and nose uncovered because she sometimes gets hot. On 04/29/2020 at 9:45 am, the surveyor interviewed the ADON who stated that the beautician should have followed infection control and surveillance and that the hairdresser and the resident were to be wearing masks. On 04/29/2020 at 10:10 am, the surveyor interviewed the Administrator who stated that residents were able to get their hair done and that only one resident is allowed in the hair salon at a time. He added that services have not stopped since the outbreak of Coronavirus. He further stated that beauty shop services were decreased and that residents were still able to get beauty shop services 2-3 times a week at various times. He stated that the beautician was in-serviced on infection control multiple times and that she should always have had the mask on appropriately and she should also be applying masks to the residents when performing services. I'm really surprised because as she was just in serviced yesterday on infection control. On 04/29/2020 at 12:30 pm, the surveyor interviewed the DON, who was also the Infection Preventionist, who stated that the beautician was educated on infection control. Wearing a mask while performing services on residents and ensuring residents wear a mask was reviewed. She also stated that all staff were educated on wearing masks, appropriate handwashing, donning (applying) and doffing (removing) PPE and wearing gloves. The staff had to do return demonstration to assure that it was done correctly. The DON added that there was not a facility policy on hairdressing. On 04/29/2020 at 3:05 pm, the surveyor interviewed Resident #1 who stated that when he/she was in the beauty salon this morning she was not offered a mask until surveyor inquiry. The facility provided the surveyor with a list of dates that the Beautician provided beauty services to the residents. Residents were provided with beautician services on the following dates: On 3/21/2020, services were provided to 3 residents On 4/1/2020, services were provided to 6 residents. On 4/23/2020, services were provided to 5 residents. On 4/28/2020, services were provided to 2 residents. On 4/29/2020, services were provided to 2 residents. The facility Administrator and DON provided the surveyor with a resource guide that the facility was following titled, Covid-19 Toolkit of Resources for Long Term Care Facilities Version 2 1 dated April 10,2020. -The resource guide page 5 indicated that resident movement in the facility should be restricted to the extent possible and that all communal dining and all group activities such as internal and external group activities (e.g., physical therapy, beauty shop) be canceled. It also indicated that all residents whether they have Covid-19 or not should cover their nose and mouth when around others. Alternate means of entertainment should be explored to engage residents and comply with social distancing orders. -The resource guide page 12 indicated that facility was to restrict visitors and non-essential healthcare personnel, except in certain [MEDICATION NAME] care situations. -The resource guide page 14 indicated that the facility was to implement use of universal facemask (i.e., source control) for staff while in the facility. b.) On 04/29/2020 at 10:10 am, the surveyor interviewed the Administrator who stated that he was in constant contact with the Local Health Department (LHD) and the Office of Emergency Management (OEM) in regard to obtaining PPE. He stated that he had received boxes of PPE from OEM such as gowns, face shields, N95 mask, surgical mask and hand sanitizer. On 04/29/2020 at 10:30 am, the surveyor accompanied the Administrator to the storage areas and observed boxes of PPE such as gloves, gowns, face mask and face shields that were available for staff use. On 04/29/2020 at 11:16 am, the surveyor toured the 3rd floor Penthouse Unit and observed one CNA wearing a clear plastic trash bag and another CNA donning (applying) a trash bag to enter a resident's room. The surveyor stopped the CNA at this time to be interviewed. The CNA stated that she was the primary care CNA for the resident in room [ROOM NUMBER] (private room). She indicated that she did not have any isolation gown to put on and that she was wearing the trash bag to be safe. She then added that there was a sign on the door of room [ROOM NUMBER] and that the nurse told her that the resident in that room may have the Coronavirus. The nurse didn't give me an isolation gown and did not set up an isolation cart, so I wear a trash bag when I go into the residents room. They should give us gowns to be safe. I wear a mask and gloves all the time. On 4/29/2020 at 11:20 am, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident in room [ROOM NUMBER] who was demonstrating symptoms of Covid-19. The LPN stated that the resident developed a productive cough and had presumptive signs and symptoms (s/s) of [MEDICAL CONDITION] Covid-19 during the 11 pm to 7 am shift. The LPN could not give a specific reason why there was not an isolation cart set up in front of the resident's room with appropriate PPE such as isolation gowns, gloves, and masks if the resident had presumptive s/s of [MEDICAL CONDITION]. The LPN then stated that the CNA's never asked him for PPE and that he did not know why they were wearing trash bags as PPE instead of the proper isolation gowns. He said that the Administrator or the DON supplied the PPE but admitted that he did not notify them that PPE was needed for this resident. The LPN then revealed that he went into the room earlier with only a face mask and gloves and stated he should have worn the appropriate PPE such as an isolation gown. He further stated, I did not apply an isolation gown when I went into the room, I only wore a mask and gloves. I guess I should have gotten the PPE or called someone to get it. On 04/29/2020 at 12:30 pm, the surveyor interviewed the DON who provided the surveyor with a timeline of events that described the failure of the nurse to obtain appropriate PPE on 4/29/2020 for staff usage in the care of a resident with potential Covid-19 to prevent the spread of infection. The timeline indicated that on 4/29/2020, the 7 am-3 pm nursing staff did not request gowns upon arrival to the unit and that the CNA's opted to wear the garbage bags as PPE because they were aware that this resident had symptoms for Covid-19. The DON stated that all staff were educated on hand hygiene, wearing mask and donning and doffing (removing) PPE. The DON also added that the facility had plenty of PPE if they needed it. On 04/29/2020, the surveyor reviewed the facility's Infection (Outbreak Response and Investigation) which indicated that symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician's orders [REDACTED]. The facility Administrator and DON provided the surveyor with a resource guide that the facility was following in response to the outbreak of Covid-19 titled, Covid-19 Toolkit of Resources for Long Term Care Facilities Version 2 1 dated April 10,2020. The resource guide page. 5 indicated that for suspect or confirmed Covid-19 cases Standard and Transmission-based precautions including use of a N95 respirator (or facemask, if unavailable), gown, gloves and eye protection is recommended. This IJ situation that began on 04/29/2020 at 5:32 pm, and the immediacy was removed on 04/30/2020 at 12:30 pm, based on acceptable Removal Plan which included the following: 1.) Beauty shop services were suspended as of 04/29/2020, and the Beautician was re-educated on the proper utilization of PPE during care and services with residents that mask must always be worn properly during such interaction. The Beautician demonstrated competency of wearing mask appropriately during care services with residents. The employee was given written warning and suspended pending investigation for non-compliance of wearing mask appropriately on 04/29/2020. 2.) The Assistant Director of Nursing (ADON) provided education with staff regarding the importance of safeguarding all residents with the risk of Covid-19 while providing care and services on 4/29/2020. 3.) The CNA's were given proper PPE and verbally re-educated by the ADON on the process of obtaining PPE in a timely manner and appropriate use of PPE on an undiagnosed presumptive infected resident on 04/29/2020. Re-education was confirmed by return demonstration (donning and doffing PPE) on 04/29/2020. 4.) All staff is re-educated on the proper utilization and use of PPE on 04/29/2020. The implementation of the Removal Plan was verified on site on 05/1/2020 at 11:15 am. On 5/1/2020 at 9:10 am, the surveyor toured all the units and verified though observation, interviews with facility staff and review of in-service education that the IJ Removal Plan had been implemented. NJAC 8:39-19.4; 27.1 (a)