Every finding on record at Careone at Livingston

Complaint NJ # 2599517 Based on interview and review of medical records, it was determined that the facility failed to ensure there was no delay in implementing a physician recommendation for a burn treatment, and failed to ensure the treatment was ordered for the physician recommended frequency. This deficient practice was identified for 1 of 2 residents reviewed for treatment orders (Resident #1) and was evidenced by the following:On 10/23/2025 at 10:00 AM, the surveyor reviewed the closed Electronic Medical Record (EMR) for Resident #1 which revealed the following: The admission Record (an admission summary) Resident #1 was admitted with diagnoses which included, but were not limited to; alcohol abuse with intoxication, anxiety disorder, bariatric surgery, burns, skin grafts on 79% total body surface area (TBSA) for 2nd and 3rd degree burns. The admission Minimum Data Set, an assessment tool dated 8/14/25, indicated that Resident #1 scored a 15 out of 15 on the Basic Interview for Mental status which indicated that the resident was cognitively intact. On 10/23/25 at 10:30 AM, the surveyor reviewed a physician Consolation Report dated 8/22/25, which revealed under Finding: s/p [status post] 78.5% TBSA 2/3-degree scald burn with extensive Split-Thickness Skin Graft (STSG) to bilateral lower extremities. Please apply Cocoa Butter to all healed areas three times daily. A review of the Physician Order Summary Report dated 8/24/25, revealed the following order: apply Cocoa Butter to bilateral arms every day shift, apply Cocoa Butter to right leg, and apply compression stockings every day shift. (This order was two days after Resident #1 returned from the consultation at the Burn/Wound center and did not match the recommended frequency of three times per day). A review of the Medication Administration Record (MAR), revealed an order to: Apply [NAME] Butter to B/L (bilateral) Arms every day shift -Start Date- 08/25/2025 0700, and an order to apply Cocoa Butter to Right leg and apply compression stockings every day shift. Start Date- 08/25/2025 at 0700 [7:00 AM]. On 10/23/25 at 9:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the process when a resident returned with a consultation report. The LPN stated, When a resident returned with recommendations from a consultation visit, the Physician would be contacted to obtain approval for the orders, then the LPN would enter the orders into the EMR. The LPN further stated, if the pharmacy did not have the medication available, the LPN would inform the physician and obtain a hold order until the medication arrived from the pharmacy. The LPN stated the medication should have arrived the same day it was ordered, or the next day. The LPN stated it depended on the time of day that the medication was ordered. The LPN recalled Resident #1's order for Cocoa Butter the LPN then stated she obtained approval for the orders on 8/22/25 (the date of the consultation), and she entered the orders into the EMR. She then stated she was off for a few days and when she returned to work on 8/25/25 the Cocoa Butter was available. She could not recall any further details regarding the order. On 10/23/25 at 12:35 p.m., the surveyor interviewed the Director of Nursing (DON), who stated that she had not been aware that the Cocoa Butter arrived two days after the order was sent to the pharmacy. In addition, the DON stated that she was not aware that the Cocoa Butter was not ordered in the frequency that the Burn/Wound center physician recommended (three times per day), and confirmed it was administered only once per day. The DON acknowledged that the medication should have been available for the resident the day it was ordered, 8/22/25, or the next day depending on the time of day it was ordered. She also acknowledged that the Cocoa Butter should have been ordered three times a day as recommended by the Physician from the Burn/Wound Center. NJAC 8:39 29.2 (d)

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a) a resident who was identified as being at Low Risk for developing pressure ulcers did not develop a pressure ulcer, and b) upon the identification of a facility acquired pressure ulcer, a documented wound assessment was completed and new interventions were implemented to prevent further skin breakdown. The deficient practice was identified for 1 of 2 residents reviewed for wounds/skin treatments (Resident #3) and was evidenced by the following:On 10/23/25 at 10:00 AM, the surveyor reviewed the Electronic Medical Record for Resident #3 which revealed the following: A Nursing Progress note dated 7/28/25 at 15:02 (3:02 PM), documented Resident #3 had blanchable thick hard indurated skin on the Left buttock. The skin was not open and no pain was present. The Physician and family were made aware. There was no documented wound assessment completed upon identification of the wound. A Progress Note documented by the Advanced Practice Nurse as a Late Entry and dated 7/30/35 at 14:00 (2:00 PM), failed to address the new wound identified on 7/28/25. A Nursing Monthly Summary, dated 8/1/25 at 11:16 AM, documented There is no skin breakdown or skin condition present. The note failed to address the new wound identified on 7/28/25. A Nursing Progress Note dated 8/7/25 at 21:34 (9:34 PM), documented while on wound rounds the resident was noted to have a partial thickness (extends through the epidermis of the skin) stage 2 sacral Pressure Ulcer, .5-centimeter X .5-centimeter X .2 centimeter (cm) .small amount of serous drainage noted. Placed on a [specialty mattress], provided a [specialty cushion] for the wheelchair, new order provided for every shift zinc oxide . The interventions were added 10 days after the Left buttock wound was identified.The Wound Assessment Report dated 8/7/25, and completed by the wound specialist physician identified the Initial Exam for the above-mentioned Stage 2 Wound. The Initial Exam for the Left buttock identified the Left buttock was identified as an Unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) Pressure Injury Obscured full-thickness skin and tissue loss. The wound measured 10 cm X 7 cm X 0 cm. The Area (square cm based on Length and Width) was 10 square cm and the Volume (cm based on area Depth was 1.A Skin Note, dated 8/10/25, dated 8/10/25, and completed by the Licensed Practical Nurse Unit Manager (LPNUM) revealed: 2.Left buttock is firm to touch,? abscess verse pressure ulcer. (This documentation conflicted with the assessment completed by the wound specialist physician on 8/7/25).A review of the 44-page Care Plan with current and resolved Focus areas revealed a focus area for being at risk for alteration in skin integrity related to decreased physical mobility, history of MASD [Moisture Associated Skin Damage-inflammation and erosion of the skin, resulting from prolonged exposure to moisture such as feces and urine] and incontinence; Date Initiated: 6/18/21. An additional Focus was added by the Director of Nursing (DON) on 7/29/25 which documented on 7/28/25, Blanchable redness to left buttock, area hard to touch. The Goals revealed: Skin will remain free of breakdown within limits of disease process; Date Initiated: 9/14/21; Will decrease/minimize skin breakdown risks, Date Initiated: 6/18/21; Skin will remain intact, free from erythema, breakdown, excoriation or bruising until next review, Date Initiated: 2/9/25. An intervention The Interventions included barrier cream to peri-anal/buttocks as needed and provide preventative skincare routinely and as needed; Date initiated 6/18/21. There were no new interventions added to the Care Plan upon the identification of the wound on 7/28/25. A review of the Physician Orders for July 2025, along with the Medication Administration Record revealed a treatment order dated 8/3/25, to cleanse left buttock with normal saline, cover with dry dressing everyday shift for abscess. The first administration of the order was 8/4/25 (7 days after the wound was initially identified). There were no other treatment orders related to the wound that was identified on 7/28/25 and presented as an unstageable wound on 8/7/25. On 10/23/25 at 12:40 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of another surveyor regarding Resident #3's Left buttock wound identified on 7/28/25. The DON confirmed it was a facility acquired wound. The surveyor asked the DON when the wound was identified, was it assessed or measured? The DON stated, we thought it was an abscess (pocket of pus). The surveyor asked if there was an initial assessment completed when the wound was identified on 7/28/25? The DON stated, I told the nurse to document it because it might open up not something, and the nurse didn't document it. When asked if interventions for wound healing were added when the wound was identified, and the DON stated, barrier cream was already in place. The surveyor asked what should occur when a new wound was identified? The DON stated, there should be a documented assessment. The surveyor inquired if that would be important and the DON stated the wound would be measured as part of the process of documentation. The surveyor asked the DON if the cause of the left buttock wound was identified on 7/28/25. The DON provided an incident report dated 7/28/25 at 15:01 (3:01 PM) completed by a Licensed Practical Nurse (LPN). The description was documented as a blanchable thick hard indurated skin on left buttock. The skin was not open and no pain present. There were no wound measurements documented. A handwritten note dated 7/28/25, and documented by the LPN Unit Manager revealed a [specialty mattress] was provided and a [specialty cushion], however, that documentation conflicted with the Nursing Progress Note dated 8/7/25 at 21:34 (9:34 PM), that indicated those items were added that day. There were no physician orders or entries on the Care Plan for a [specialty mattress] or [specialty cushion] on 7/28/25.The Prevention of Pressure Injuries Policy dated April 2020 revealed the under Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. The Pressure Injuries Overview dated March 2020 revealed A pressure injury will present as intact skin and may be painful. NJAC 8:39-27.1(a)

Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that three residents out of three resident (Resident (R) 28, R50 and R67) out of 22 sampled residents' Minimum Data Set (MDS) assessments were transmitted in a timely manner.Findings include:Review of Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, dated 10/23 revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS.RAI OBRA-required assessment summary for.discharge return not anticipated assessment.MDS completion date (Z0500B) no later than discharge date + 14 calendar days.Transmission date no later than MDS completion date + 14 calendar days.for annual assessment.MDS completion date no later than Assessment Reference Date (ARD) + 14 calendar days.Transmission date no later than care plan completion date + 14 calendar days.for quarterly assessment.MDS completion date no later than ARD + 14 calendar days.Transmission date no later than MDS completion date + 14 calendar days. 1.Review of R28's admission Record, located under the Profile tab in the Electronic Medical Record (EMR) revealed R28 was re-admitted to the facility on [DATE] with a diagnosis of dementia.Review of discharge return not anticipated MDS assessment with an ARD of 04/29/25 revealed MDS completed on 05/05/25. However, there was no evidence that this assessment was submitted.Review of R28's Assessment History, dated 04/29/25, provided by the facility, revealed Discharge Return Not Anticipated assessment was never added to a batch. 2.Review of R50's admission Record, located under the Profile tab in the EMR revealed R50 was re-admitted to the facility on [DATE] with a diagnosis of dementia.Review of quarterly MDS assessment with an ARD of 07/15/25 revealed MDS completed on 07/29/25. However, there was no evidence that this assessment was submitted.Review of R50's Assessment History, dated 07/15/25, provided by the facility, revealed Quarterly assessment was never added to a batch. 3.Review of R67's admission Record, located under the Profile tab in the EMR revealed R67 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease.Review of annual MDS assessment with an ARD of 10/10/24, located under the MDS tab in the EMR revealed MDS completed on 10/31/24 and submitted on 11/04/24.Review of Assessment History, dated 10/10/25, provided by the facility, revealed Annual assessment was batched and accepted on 11/04/25.Interview on 08/21/25 at 1:00 PM, the MDS Specialist Registered Nurse (RN) confirmed that the assessments for R28 and R50 were not submitted within the appropriate timeframe. The MDS Specialist Registered Nurse (RN) confirmed that R67's assessment was completed and submitted late and stated that her regional knew. She said that she does not have a check and balance system and was unable to state the last time she checked the missing assessment report. NJAC 8:39-11.2

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of 22 sampled residents (Resident (R)4) was provided with a meaningful, individualized activity program. R4 was not further assessed when the Minimum Data Set (MDS) triggered and indicated she had little interest/pleasure in doing things. The MDS indicated a care plan would be developed to address the care area of activities; however, this was not completed. R4's interests were not fully assessed and she did not have an activity program in place based on her interests and needs. This created the potential for R4 to have a decreased quality of life.Findings include:Review of the facility's Activity Evaluation policy dated February 2023 and provided by the facility revealed, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident. The activity evaluation is used to develop an individual activities care plan. Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs.Review of the admission MDS with an Assessment Reference Date (ARD) of 07/25/25 in the electronic medical record (EMR) under the MDS tab revealed R4 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of muscle function in the lower half of the body) and stage four pressure ulcer. R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was intact in cognition. R4 was identified as having little interest or pleasure in doing things half or more of the days in the assessment period. The interview for activity preferences indicated it was very important for R4 to listen to music and be around animals such as pets. It was somewhat important to have books, newspapers, and magazines to read, keep up with the news, go outside to get fresh air, and participate in religious services.Review of the Care Area Assessment (CAA) Summary dated 07/31/25 in the EMR under the MDS tab revealed R4 triggered for further assessment under the care area of Activities and the care area of Activities would be addressed on the Care Plan. Review of the Activity CAA Worksheet dated 07/31/25 revealed R4's activity preference prior to admission was for group activities. No other activity preferences were identified. Health issues resulting in R4's reduced activity participation included depression or anxiety and unstable health problems.The EMR was reviewed and no activity assessment (besides the MDS/CAA), progress notes, or activity care plan were found in R4's record.During an interview on 08/18/25 at 2:46 PM, R4 stated she would like to go to group activities and would love to go outside. R4 stated she had not participated in any group activities since she was admitted and had not gone outside. R4 stated she stayed in bed most of the time and did not know if the facility allowed stretcher bound residents to go to activities. R4 stated her daily activity primarily consisted of participating in therapy, she had a television in her room that she watched occasionally and had some books if she wanted to read.During the survey, R4 was observed to be lying in bed without any activity stimulation in the room on:08/18/25 at 3:05 PM 08/19/25 at 10:38 AM 08/19/25 at 3:13 PM 08/20/25 at 3:49 PM 08/20/25 at 4:45 PM 08/21/25 at 11:37 AM 08/21/25 at 1:42 PM During an interview on 08/20/25 at 3:52 PM Certified Nursing Assistant (CNA)1 stated R4 was alert and oriented and could voice her needs. CNA1 stated R4 stayed in bed and was dependent on staff for most activities of daily living and required a Hoyer lift to get out of bed. CNA1 stated she had not seen R4 attend or participate in any activities; however, stated R4 had a TV and her family visited her in the afternoon/evenings. During an interview on 08/20/25 4:04 PM the Recreation Assistant (RA) stated she made rounds, let residents know what was going on, and took an activity cart to all residents' rooms daily. RA stated R4 had not come out of her room to any activities but on a previous admission, R4 liked to attend trivia. RA stated she did not have planned one-to-one visits based on R4's interests when she went into R4's room. RA stated she offered supplies such as books or puzzles and visited with R4 when she went into her room. During an interview on 08/20/25 at 4:51 PM, the Director of Recreation stated her normal process for newly admitted residents was to meet with them within the first five days of admission and show them where the activity calendar was located. The Director of Recreation stated she completed the Activity Evaluation form to determine what their interests were. The Director of Recreation stated after completing the Activity Evaluation she created an activity care plan and this was done for all residents. The Director of Recreation reviewed R4's EMR and stated there was no Activity Evaluation created for R4, further stating she was not sure what happened. Additionally, the Director of Recreation reviewed the EMR and could not find an activity Care Plan for R4. In regard to R4's interests, the Director of Recreation stated R4 specifically liked dogs, but it was not important for R4 to attend group activities. The Director of Recreation verified R4 had not attended any group activities since admission. The Director of Recreation stated one to one visits were completed daily by the RA and they lasted at least 15 minutes. The Director of Recreation stated the RA brought newspapers, magazines, crosswords, and coloring pages on her cart. The Director of Recreation stated she did not know what items R4 asked for when the RA brought the activity cart to her room.Review of a generic Activity Evaluation form revealed the form was comprehensive in identifying pertinent background information about the resident such as: information about family, voting, education, former occupation, spiritual involvement, language spoken, speech, activity preferences, an extensive list of past and current activity pursuit patterns, preference for activity participation by time of day, preferred activity setting, interest in a job assignment, dietary considerations, communication limitations, behaviors, mode of transportation, etc.Review of the One-to-One Activity Participation Log for R4 revealed visits were conducted daily except for: 07/19/25 - 07/22/25, 07/26/25, 07/27/25, 08/02/25, 08/03/25, 08/08/25 - 08/13/25, 08/16/25, and 08/17/25. They type of visit was noted in each instance as wellness visit.During an interview on 08/21/25 at 11:53 AM, MDS Specialist Registered Nurse (RN) reviewed R4's admission MDS in the EMR and stated R4 triggered in the area of activities due to R4's lack of interest in things. MDS Specialist stated there should have been a Care Plan developed as the MDS Section V indicated activities would be care planned. MDS Specialist RN verified no care plan had been developed until 08/21/25, after the surveyor's inquiries.During a follow up interview on 08/21/25 at 11:42 PM, R4 stated the RA came into her room and talked with her frequently, but they had not done any activities together. R4 stated the RA provided her with an activity calendar and asked if she needed anything in her room. R4 stated she enjoyed pets and today was the first day she had been asked if she was interested in pet visits, stating that she responded that she was interested. R4 stated she had not been provided with pet visits through the activity programming. NJAC 8:39-7.3

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)70) reviewed for nutrition out of a total of 22 residents was provided with a therapeutic minced and moist diet texture as prescribed by the Physician. R70 was served regular texture food which created the potential for choking or aspiration (accidentally inhaling food or liquid into the airway).Findings include:Review of the facility's Therapeutic Diets policy dated October 2017 and provided by the facility revealed, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R70 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing).Review of the EMR revealed that as of the survey, the Minimum Data Set (MDS) assessment had not been completed for R70.Review of Order Summary Report dated 08/13/25 in the EMR under the Orders tab revealed R70's admission diet order was, Heart healthy diet, minced and moist texture.Review of all the Diet Order & Communication forms (dated 08/14/25, 08/17/25, 08/18/25) between nursing and dietary for R70 revealed she was prescribed a heart healthy diet, minced and moist texture diet during her entire stay through from admission on [DATE] through 08/21/25 (date of survey exit). R70's diet texture had not been changed at any time.Review of a Nursing Progress Note dated 08/15/25 in the EMR under the Progress Notes tab revealed R70 was sent to the hospital on [DATE] at 3:29 AM due to R70 not being herself per her family member who was present and because she was experiencing chest pain.Review of a Nursing Progress Note dated 08/15/25, R70 was readmitted to the facility on [DATE]; she was out of the facility for less than 24 hours.Review of a Nutrition Evaluation dated 08/17/25 in the EMR under the Assessment tab revealed R70 weighed 113.6 pounds and with within the normal weight range with a Body Mass Index (BMI) score of 24. R70 was prescribed a Heart Healthy Minced and Moist diet. R70 was documented with, Functional issues noted affecting the ability to eat. Noted holding food in mouth/cheeks or residual food in mouth after meals. Dining ability: Assistance.Dental/oral issues identified that may impact eating include the following: missing teeth. Identified nutritional problems are as follows: swallowing difficulty; self-feeding difficulty. Nutritional Interventions include the following: Therapeutic diet. Review of the nutrition Care Plan dated 08/17/25 in the EMR under the Care Plan tab revealed a goal of, Will tolerate diet, texture and fluid consistency without signs and symptoms of aspiration. Intervention in pertinent part included, Diet Texture: Minced & Moist.During an interview on 08/18/25 at 3:45 PM, Family Member (F)1 stated R70 was served regular texture foods over the weekend on 08/16/25 and on 08/17/25. F1 stated R70 was served a hot dog on a bun for lunch on Saturday 08/16/25 and for lunch on Sunday she was served a regular piece of chicken. F1 stated there was at least one family member present at all meals to assist R70 with eating and the family had prevented R70 from eating the hot dog and the chicken. F1 stated she reported to the facility nurse manager on the weekend that R70 was not served the correct textured food and she reported her concern to the Speech Therapist on Monday 08/18/25 and the diet order had since been corrected. Review of R70's Tray Card for lunch on 08/17/25 provided by the facility revealed her diet order was Heart Healthy regular texture. The minced and moist texture prescribed by the Physician had been replaced with regular texture. Review of the Daily Spreadsheet dated 08/16/25 for lunch provided by the facility revealed a resident on a regular texture diet would receive a hot dog as the meat entree for lunch. A resident on a minced and moist texture diet would receive a ground hot dog. Review of the Daily Spreadsheet dated 08/17/25 for lunch provided by the facility revealed a resident on a regular texture diet would receive a piece of baked chicken as the meat entree for lunch. A resident on a minced and moist diet would receive ground chicken with gravy or sauce. During an observation on 08/20/25 at 9:26 AM revealed R70's tray card read Heart Healthy Minced and Moist texture diet. She had been served diced scrambled eggs, oatmeal, orange juice and milk and had eaten 50% of her meal. During an interview on 08/20/25 at 11:43 AM the Dining Room Lead and Registered Dietitian (RD) verified that R70 had been served inappropriate food for lunch on 08/17/25. The Dining Room Lead stated she was working in the kitchen and R70's diet slip said regular and not moist and minced. The Dining Room Lead stated the Unit Manager Licensed Practical Nurse (LPN) came to the kitchen on Sunday and informed the dietary staff that the diet texture for R70 was incorrect. The Dining Room Lead stated the dietary staff went by the diet slip provided by nursing which did not include the minced and moist texture. The RD stated R70 went to the hospital on [DATE] and came back late at night and this accounted for the diet texture change. The RD stated it was corrected at lunch on 08/17/25 when R70 had been served regular chicken. The RD stated R70 was on minced and moist texture prior to going to the hospital. During an interview on 08/21/25 at 12:50 PM, Unit Manager (UM) Licensed Practical Nurse (LPN) stated R70 had swallowing problems and her family fed R70 her meals. The UM stated she had been working on 08/17/25 and was called to R70's room by R70's family. The UM stated when she went to the room, she observed that R70 had been served a whole untouched piece of chicken and her tray card indicated regular texture instead of minced and moist. The UM stated she took the tray card to the kitchen and the dietary staff told her that is how the tray card printed out of the tray card system. The UM stated she wrote a new Diet Order & Communication form on 08/17/25 and provided it to dietary staff with minced and moist texture. The UM stated nothing had changed with R70's physician's orders and she did not know how the texture became altered in the tray card system, further stating something in the tray card system had a glitch. The UM stated orders remained in place if the hospitalization was less than 24 hours. The UM stated she notified the RD of the situation. During a follow up interview on RD 08/21/25 at 2:46 PM, the RD stated the UM had sent her an email over the weekend letting her know what happened and asked her to double check it on Monday. The RD stated she did not know how the diet texture got changed in the tray card system as only a few people such as herself and the Dietary Manager (who was on vacation) had access to update the tray cards. The RD stated there was no mechanism to track who or when the change to R70's texture was changed in the tray card system. The RD verified that R70 was not actually admitted to the hospital and her stay was less than 24 hours so there was nothing that would have triggered a new diet slip with a different diet texture. The RD retrieved all the Diet Order & Communication Forms from nursing and verified none specified a regular texture. During an interview on 08/21/25 at 2:09 PM, the Speech Therapist (ST) stated she was working with R70 on eating/swallowing issues and verified R70's diet texture was minced and moist and it had not been changed during her stay. The ST stated she had not been aware that R70 received regular texture foods over the weekend and indicated she was not in the facility on the weekend of 08/16/25 and 08/17/25. The ST stated serving regular texture foods created a potential choking or aspiration risk for R70. The ST stated R70 had a lot of weakness and pocketing on the left side and she only had a couple teeth. The ST stated it was difficult for R70 to tolerate solid foods. The ST stated R70 could somewhat feed herself such as she could lift the cup and spoon but was not able to eat much independently. The ST stated R70's family was with R70 consistently during meals. During an interview on 08/21/25 at 4:15 PM, the Director of Nursing (DON) stated R70 had not been removed from the computer system with a hospitalization of less than 24 hours so there should not have been a different diet order after returning from the hospital on [DATE]. The DON stated the nurses did not have access to the tray card system and could not have changed the diet order. The DON stated she had been made aware of the situation on 08/18/25 and had seen a photograph of the regular diet chicken meal R70 received on 08/17/25 and had also seen a photograph of the tray card that read regular diet instead of minced and moist. The DON stated the situation had been corrected. NJAC 8:39- 17.1

Based on interview, record review, and facility policy review, the facility failed to ensure one of six residents (Residents (R) 72) reviewed for medication administration out of a sample of 22 residents received medications from the pharmacy as ordered by the physician for administration. This failure had the potential to cause residents to have unmet care needs. Findings include:Review of the facility's policy titled, Medication and Treatment Orders, dated July 2016 revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing.Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.Review of R72's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed the resident was originally admitted to the facility on [DATE] with diagnoses including wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing, chronic myeloid leukemia, protein-calorie malnutrition, and congestive heart failure.Review of R72's EMR under the Physician Orders tab revealed an order, dated 08/07/25, for Cyanocobalamin Oral Tablet 250 MCG (microgram), give one tablet by mouth in the evening for supplement. This order was discontinued on 08/21/25.Review of R72's EMR under the Medication Administration Record (MAR) tab, revealed the medication was not administered on 08/11/25, 08/12/25, 08/14/25, 08/15/25, 08/16/25, and 08/17/25 at 6:00 PM, and was administered for only eight out of fourteen opportunities. The Progress Notes located in the EMR under the Progress Notes tab, revealed that on 08/11/25, 08/12/25, 08/14/25, 08/15/25, 08/16/25, and 08/17/25 the medication was unavailable for administration. Review of R72's Progress Notes located in the EMR under the Progress Notes tab, revealed on 08/21/25, Call placed to (physician) to make him aware.wound that she was admitted with has resolved. Explained to the MD (medical doctor) that currently she has an order for Vitamin B12 250 MCG, which is not available. Made aware that 100 MCG and 500 MCG is available. Per MD since her wound has healed 100 MCG is sufficient. Order placed in chart. Review of R72's EMR under the Physician Orders tab revealed an order, dated 08/21/25, for Cyanocobalamin Oral Tablet 100 MCG (microgram), give one tablet by mouth in the afternoon for supplement. This was the only documented note that the physician was aware that the medication was not consistently available at the previously ordered dosage. During a concurrent interview on 08/21/25 at 9:15 AM, Licensed Practical Nurse/Unit Manager (LPN/UM) stated that she was not aware of why R72 was not consistently getting her Cyanocobalamin Oral Tablet 250 MCG medication, but would find out.During a concurrent interview on 08/21/25 at 10:30 AM, Licensed Practical Nurse/Unit Manager (LPN/UM) and the Director of Nursing stated that they had contacted the physician, and he had changed R72's medication order to one with a dosage that they kept in stock, at 100 MCG instead of 250 MCG, which they did not. The Director of Nursing stated that the EMR had shown that the nurse was calling the pharmacy each day and had contacted the physician. The Director of Nursing and LPN/UM both confirmed that there was no indication documented in the EMR that the physician had wanted to adjust or hold the medication or had been documented as aware that the dosage of the medication was not readily available. They both confirmed that there was no additional documentation in the EMR that any additional steps had been taken to ensure the resident received their ordered supplement. The Director of Nursing said that if a resident had been missing serious medication, she would have expected the nurse to tell her right away so the facility could resolve the problem. The LPN/UM and Director of Nursing stated that they had constantly reminded the nurses to inform them if there was a pharmacy problem. During an interview on 08/21/25 at 12:50 PM, LPN2 said that if a resident's medication was not available for administration, she would contact the pharmacy and then contact the physician. She said if there was going to be a delay in getting the medication, they would ask the doctor to change the time of administration to later in the day so the resident would not miss their medication. LPN2 stated that this would be documented in the resident progress note. She said that if it was an over-the-counter drug, they might not have the right dosage because they did not carry every medication dosage. LPN2 said that if the physician ordered a medication for a dosage the facility did not have, she would contact the physician to let them know what dosages they did have in stock. LPN2 confirmed that you had to let the physician know so they could adjust the order.During an interview on 08/21/25 at 1:30 PM, LPN1 said that if she was going to administer a medication that was not available, she would call the pharmacy. She said sometimes the medication would come that day, but sometimes it would not. LPN1 said she would call the physician to let him know, and to see if they would want to hold the medication or give the resident something different. LPN1 stated that sometimes the physician would get back with them, and sometimes they would not, it depended on the physician. LPN1 said this should all be documented in the resident's EMR. During an additional interview on 08/21/25 at 2:25 PM, LPN/UM confirmed that the nurses should have communicated with her and the Director of Nursing if they were having difficulty getting medication in from the pharmacy, but they had not. She stated that the pharmacy did not carry all of the medication doses that they needed, and that it could sometimes be difficult to communicate well with them. She confirmed that there had been some concerns getting the pharmacy to send the medications. LPN/UM said that R72's medication was changed on 08/21/25 to 100 MCG, since they had that more readily available. During an interview on 08/21/25 at 3:55 PM, the Consultant Pharmacist confirmed that the facility had a problem with getting medications from the pharmacy. She stated that the problem came from the medications not being delivered properly. The Consultant Pharmacist said that if a nurse was unable to administer a medication because of some reason, such as the dosage, then they should contact the physician to get the medication order changed, if possible. She again confirmed there had been an ongoing concern with pharmacy delivery. NJAC 8:39-29.2

Based on observation, interview, record review, and policy review, the facility failed to ensure medical records were accurate for two out of two residents (Resident (R)4 and R71) reviewed for activities of daily living (ADLS) out of a total sample of 22 residents. Neither R4 nor R71 had received a tub bath or shower since admission; their medical records indicated they had received tub baths and/or showers. This created the potential for residents not to receive necessary care because their records indicated they had already received the care.Findings include: Review of the facility's Charting and Documentation policy dated July 2017 and provided by the facility revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facility communication between the interdisciplinary team regarding the resident's condition and response to care.1. Review of the admission MDS with an Assessment Reference Date (ARD) of 07/25/25 in the electronic medical record (EMR) under the MDS tab revealed R4 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of muscle function in the lower half of the body) and stage four pressure ulcer. R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was intact in cognition. R4 was dependent on staff showers. Review of R4's undated Kardex provided by the facility revealed R4 was to receive showers on Tuesdays and Fridays. Review of the Documentation of Survey Report for 07/18/25 through 08/18/25 and provided by the facility revealed R4 received showers on 08/01/25, 08/05/25, 08/08/25, and 08/12/25. Review of the POC [Point of Care] Response History report from 07/23/25 - 08/20/25 in the EMR under the Tasks tab revealed R4 received tub baths on 07/23/25, 07/24/25, 07/25/25, 07/28/25, 07/29/25, 08/02/25, 08/03/25, 08/04/25, 08/07/25, 08/08/25, 08/12/25, 08/13/25, 08/16/25, 08/17/25, and on 08/18/25. During an interview on 08/18/25 at 2:38 PM, R4 stated she received bed baths daily; however, had not received a shower or tub bath since she was admitted to the facility. R4 verified she was dependent on staff for showers/baths and she rarely got up and out of bed due to significant pressure ulcers/her medical condition. During an interview on 08/21/25 at 12:09 PM, the Unit Manager (UM) Licensed Practical Nurse (LPN) stated R4 had rarely gotten out of bed since she had been admitted to the facility and could only be up for short periods of approximately 30 minutes. The UM stated R4 had not received any showers or tub baths since admission due to her complex medical condition and discomfort being up. The UM stated the facility did not have a tub for tub baths. When informed of documentation of R4 receiving showers and tub baths, the UM stated the documentation was inaccurate. During an interview on 08/21/25 at 4:10 PM, the Director of Nursing (DON) stated R4's bath and shower records were inaccurate. The DON stated R4's Certified Nursing Assistant (CNA) told her she gave thorough bed baths and had therefore coded them as showers. The DON stated a bed bath was not a shower. 2. Review of the undated admission Record in the EMR under the Profile tab revealed R71 was admitted to the facility on [DATE]. Diagnoses included a cerebrovascular accident (stroke) with hemiplegia (paralysis and inability to move one side of the body) and hemiparesis (partial weakness or loss of strength on one side of the body). Review of the admission MDS with an ARD of 08/14/25 in the EMR under the MDS tab revealed R71 was unimpaired in cognition with a BIMS score of 15. R71 required substantial/maximal assistance with showers/bathing self. Review of R71's undated Kardex provided by the facility revealed R71 was to receive showers on Mondays and Thursdays. Review of the Documentation of Survey Report for R71 from 08/07/25 through 08/20/25 provided by the facility revealed she received showers on 08/11/25, 08/14/25, and 08/18/25. Review of the POC [Point of Care] Response History report from 08/07/25 - 08/21/25 in the EMR under the Tasks tab revealed R4 received a shower on 08/12/25. During an interview on 08/19/25 at 11:16 AM, R71 stated that although she had received bed baths, she had not received a shower or tub bath since she had been admitted to the facility. R71 stated she had a recent stroke and had weakness on one side. R71 stated she would need extensive assistance from staff to get up and take a shower. During an interview on 08/21/25 at 12:20 PM, the UM stated R71 received her first shower today and that she had received only bed baths previously. When informed the record showed she had received four showers prior to today, the UM stated the records were not but should be accurate. During an interview on 08/21/25 at 4:10 PM, the DON stated R71's aide had not coded the shower records accurately and confirmed R71 had not received showers prior to 08/21/25. The DON stated it was her expectation that staff document the provision of care accurately During an observation of the facility's only shower room on 08/21/25 at 4:52 PM, it was determined that there were three shower stalls in the room; however, there were no tubs for taking tub baths. NJAC 8:39-4.1(a)NJAC 8:39-27.1(a)

Based on the interview and record review, it was determined that the facility failed to a.) electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 3 of 24 residents (Resident #25, 26, and #39), and b.) complete the discharge assessment for 1 of 24 residents (Resident #48) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. On 3/4/24 at 10:30 AM, the surveyor observed Resident #25 out of bed in a wheelchair, alert and oriented, sitting in the activity room. The surveyor reviewed Resident #25's medical record. A review of the Admission Record (an admission summary) (AR) documented that Resident #25 was admitted to the facility with diagnoses that included but were not limited to dementia (loss of memory). The resident's most recent Quarterly MDS (QMDS) assessment, dated 12/11/23, reflected that Resident #25 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognition impairment. Resident #25 was observed to have a QMDS with an Assessment Reference Date (ARD) on 12/11/23. The assessment was completed and will be transmitted no later than 12/25/23. However, the QMDS was not submitted until 1/9/24. A review of the undated Final Validation Report for Resident #25, provided by the MDS Coordinator/RN (MDSC/RN), revealed that Warning Assessment Completed Late: is more than 14 days after ARD. 2. On 3/4/24 at 11:42 AM, the surveyor observed Resident #26 sitting in a wheelchair inside the room beside the spouse. The surveyor reviewed Resident #26's medical record. A review of the AR documented that Resident #26 was admitted to the facility with diagnoses that included but were not limited to pneumonia (infection of the lungs). The resident's Admission MDS (AMDS) assessment, dated 2/13/24, reflected that Resident #26 had a BIMS score of 12 out of 15, indicating moderate cognition impairment. A review of AMDS with an ARD on 2/13/24. The assessment was completed and will be transmitted no later than 2/26/24. However, the AMDS was not submitted until 2/29/24. A review of the undated Final Validation Report for Resident #26, provided by the MDSC/RN, revealed Warning Assessment Completed Late: for this admission assessment is more than 13 days after the entry date. 3. On 3/4/24 at 10:00 AM, the surveyor observed Resident #39 standing beside the bed fixing the bedsheet. The resident declined to speak with the surveyor. The surveyor reviewed Resident #39's medical record. A review of the AR documented that Resident #39 was admitted to the facility with diagnoses which included but was not limited to unspecified dementia (loss of memory). The resident's most recent QMDS assessment, dated 12/11/23, reflected that Resident #39 had a BIMS score of 3 out of 15, indicating severe cognition impairment. Resident #39 was observed to have an Annual MDS with an ARD on 10/21/23. The assessment was completed and will be transmitted no later than 11/3/23. However, the Annual MDS was not submitted until 11/16/23. A review of the undated Final Validation Report for Resident #39, provided by the MDSC/RN, revealed that Warning Assessment Completed Late: is more than 14 days after ARD. Resident #39 was observed to have a QMDS with an ARD on 1/21/24. The assessment was completed and will be transmitted no later than 2/3/24. However, the QMDS was not submitted until 2/8/24. A review of the undated Final Validation Report for Resident #39, provided by the MDSC/RN, revealed Warning Assessment Completed Late: is more than 14 days after ARD. On 3/8/24 at 11:20 AM, the surveyor interviewed the MDSC/RN, who stated that he is working part-time. The MDSC/RN stated that they had not had a full time MDS Coordinator since December 2023 and added that the position is still not filled. On 3/11/24 at 11:24 AM, the surveyor interviewed the Regional MDSC/RN over the phone and stated she was aware that the assessments were all late. She is the one who pulled out the final validated reports, and they showed late. They haven't had a full MDS Coordinator since December 2023. There's one part-time MDS coordinator who is doing remote work. The full-time regionals look at the assessments and check if there are some due. 49078 4. On 3/7/24 at 10:39 AM, the surveyor reviewed the electronic medical record for Resident #48. The medical record reflected the resident was admitted to the facility on [DATE] and was discharged home with a family member on 11/30/24. The surveyor reviewed the resident's electronic MDS records. The records reflected Entry/MDS 3.0 accepted 11/17/23, Admission - None PPS/MDS 3.0 accepted 11/24/23, Medicare-5 day/MDS 3.0 Completed 11/24/23. The record did not reflect a discharge MDS. On 3/11/24 at 11:26 AM, the surveyor interviewed the Regional MDSC/RN by phone and stated she is accessed the record now and agreed that there was no discharge MDS present. She stated that she would open a discharge MDS right away. On 3/11/24 at 01:35 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing, and the facility management provided no additional information. According to the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After the transition of the MDS, a quality measure will be transmitted to enable a facility to monitor the resident's decline or progress. page 2-11 Discharge refers to the date a resident leaves the facility . There are two types of OBRA (Omnibus Budget Reconciliation Act) required discharges: return anticipated and return not anticipated. A Discharge assessment is required with all types of discharges. The manual on Pages 2-17, A Discharge Assessment - return not anticipated MDS must be completed not later than discharge date + 14 days. The assessment must also be transmitted to the QIES (Quality Improvement and Evaluation System) ASAP (Assessment Submission and Processing) system not later than the MDS completion + 14 days. NJAC 8:39 - 11.1

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring administration of a medication, (Procrit)(an injectable medication used to stimulate bone marrow to produce more red blood cells), according to a physician's order. This occurred for one (1) of five (5) residents, (Resident #21), reviewed for medication management. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 3/4/24 at 11:53 AM, the surveyor observed Resident #21 in the facility lobby area self-propelling him/herself and talking with the receptionist. At that time, the surveyor interviewed Resident #21 at a nearby private area in the lobby. The resident stated that he/she was very happy with the care at the facility. The surveyor reviewed the medical record for Resident #21. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/21/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the Admission Record revealed diagnoses which included anemia and chronic kidney disease. A review of the Order Summary Report (OSR) revealed a physician's order (PO) with a start date of 11/8/23 for Procrit solution 20000 unit/milliliter (ML), (Epoetin Alfa), Inject 1 ML subcutaneously in the evening every Wednesday for anemia of chronic disease hold for hemoglobin (Hgb) 10 or greater. A review of the February electronic Medication Administration Record (eMAR) revealed the corresponding above PO for Procrit scheduled for administration at 6 PM on Wednesdays. The administration documentation on the dates of 2/7/24, 2/14/24, 2/21/24 and 2/28/24 indicated the number nine (9) which correlated with the Chart Codes for Other/See Nurses Notes. There was no indication on the eMAR as to the Hgb laboratory results that corresponded to the PO. A review of the electronic nursing Progress Notes (ePN) for Procrit administration for the dates of 2/7/24 and 2/14/24 revealed Held HGB 10.5. In addition, the ePN for Procrit administration for the dates of 2/21/24 and 2/28/24 indicated Waiting for supply. A review of the resident's February laboratory results for the following dates revealed: - a collection dated of 2/14/24 and received date of 2/15/24 had a Hgb result of 8.6. - a collection date of 2/21/24 and a received date of 2/21/24 had at Hgb result of 9.4. - a collection date of 2/26/24 and a received date of 2/26/24 had a Hgb result of 8.5. There were no Hgb laboratory results found corresponding to the 2/7/24 Procrit administration day which was contradictory to the ePN for 2/7/24. In addition, the 2/14/24 collection date with a received date of 2/15/24 Hgb results had not correlated with the 2/14/24 ePN. A review of the March eMAR revealed the corresponding above PO for Procrit scheduled for administration at 6 PM. The administration documentation on 3/6/24 indicated that the Procrit was administered at 6 PM. There were no corresponding Hgb laboratory results indicated on the eMAR. A review of the resident's March laboratory results collected on 3/6/24 indicated that the Hgb was 8.1. On 3/7/24 at 1:21 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The surveyor requested that the DON provide documentation of the Hgb laboratory results and nurses notes that correlated with the administration documentation of Procrit for the month of February. On 3/13/24 at 12:50 PM, the survey team met with the LNHA and DON. The DON stated that the Hgb lab results would usually be obtained the day before or day of the date of administration of Procrit to fulfill the PO. The DON explained that on 2/6/24 there were no lab results obtained because Resident #21 had gone to the hospital and had returned the next day so there were no results to base whether the Procrit should have been administered according to the PO. The DON added that she would have expected the nurse to call the physician for follow up orders. The DON also explained that the lab results for the administration of Procrit on 2/14/24 were obtained on 2/14/24 but were not posted until 2/15/24. The DON added that she would have expected the nurse to call the physician and move the PO to 2/15 for administration. The DON further explained that the LPN had indicated in the EPN that the Procrit was held for a Hgb greater than 10 because the LPN was using the Hgb results from 1/30/24. The DON acknowledged that the LPN had made an error. The DON also stated that there were Hgb lab results that were less than 10 for 2/21 and 2/28 which indicated according to the PO that the Procrit should be administered. The DON also stated that according to the EPN the LPN had documented that there was no supply of the medication and therefore the medication was not administered. The DON added that she would have expected the LPN to follow up with the pharmacy to obtain the Procrit or call the physician for follow up orders. The DON was unable to speak to what the issue was with obtaining the Procrit from the provider pharmacy because the LPN had not documented the reason the medication was not available or followed up with the pharmacy or gave a report to the next shift to follow up. The DON stated that the LPN was the same LPN for all the dates in February for the Procrit administration. The DON acknowledged that the LPN had not followed proper procedure for making sure the lab results were obtained according to the PO and ensuring the Procrit was administered according to the PO. In addition, the DON stated that on 2/12/24 there was an inservice explaining the procedure to follow when a medication was not available that the LPN had attended but had not followed the procedure. The DON and LNHA stated that moving forward any medication that was not available from the provider pharmacy was to be reported by the nurses to administration so that additional follow up would be able to be completed to ensure either obtaining the medication or follow up by a physician. A review of the current facility policy for Administering Medications with an edited date of 5/21/19 provided by the DON reflected that Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation included; Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. In addition, Medications are administered in accordance with prescriber orders, including time frame. Also, As required or indicated for a medication, the individual administering the medication records in the resident's medical record: .Any results achieved and when those results were observed. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.3(5)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 3/6/24, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 25 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 12%. This deficient practice was identified for two (2) of six (6) residents, (Resident #26 and an unsampled resident), that were administered medications by two (2) of four (4) nurses that were observed. The deficient practice was evidenced by the following: 1. On 3/6/24 at 7:56 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse #1 (LPN #1) preparing to administer medications to an unsampled resident which included a tablet of Glipizide 5 milligrams (mg) (a medication used to treat diabetes). The surveyor observed LPN #1 administer the medication to the resident and observed there was no meal tray at the resident's bedside. At 8:04 AM, the surveyor observed LPN #1 preparing to administer remaining medications with an administration time of 9:00 AM to the same unsampled resident. Upon re-entering the resident's room in the presence of LPN #1, the surveyor observed the resident with a meal tray and consuming food. The surveyor reviewed the electronic Medication Administration Record (eMAR) which reflected the physician's order as Glipizide 5mg 1 tablet by mouth one time a day for DM Give before meals, 30mins before meals, with an administration time of 7:00 AM. The surveyor asked LPN #1 if the Glipizide was given thirty (30) minutes before the residents AM meal as reflected in the physician's order. LPN #1 stated the Glipizide was not given thirty (30) minutes before the meal as stated in the physician's order. 2. On 3/6/24 at 8:39 AM, during the medication administration observation, the surveyor observed LPN #2 preparing to administer medications to resident #26. The surveyor observed the resident's eMAR which reflected an order for Colace oral capsule (a medication used to soften the stool), give 2 capsules by mouth one time a day for constipation. The order did not indicate a strength or dosage. The surveyor observed LPN #2 prepare two (2) capsules of Docusate (the generic equivalent to Colace) 100mg. The surveyor asked LPN #2 how they knew that was the correct dose. LPN #2 stated that those were the standard ones the facility always uses. 3. The surveyor continued to observe LPN #2 prepare medications for Resident #26. The surveyor observed the resident's eMAR which reflected an order for Lidocaine External Patch 5% (a topical anesthetic medication used to treat pain). The surveyor observed LPN #2 remove and prepare a Lidospot patch 4%/1% for administration. The surveyor asked LPN #2 if that was the correct item and strength. LPN #2 stated was since 4% plus 1% equals 5%. The surveyor observed the packaging for the Lidospot patch which indicated active ingredients of lidocaine 4% and menthol 1% (a topical analgesic used to treat pain). The surveyor asked LPN #2 if the Lidospot patch contained 5% lidocaine. LPN #2 stated the package label says it contains 4% lidocaine. The surveyor did not observe any lidocaine 5% external patches present in the medication cart. On 03/6/24 at 12:13 PM, the surveyor interviewed the Consultant Pharmacist (CP) by phone and asked if a Lidospot 4%/1% patch was equivalent to a lidocaine 5% patch. The CP stated they are not equivalent. They are different products. The surveyor asked the CP what the appropriate administration timing for Glipizide would be in relation to meals. The CP stated that Glipizide should be given at least 30 minutes before the meal. The surveyor reviewed the medication information sheet for Colace capsules (docusate sodium). The information indicated Colace capsules are available in multiple strengths, including 50mg, 100mg and 250mg. The information also indicated the daily dose can be from 50mg to 300mg per day. The surveyor reviewed the packaging and ingredient list for Lidospot patch and the medication information sheet for lidocaine 5% patch. The surveyor observed the Lidospot patch contains 4% lidocaine and 1% menthol as active ingredients, while the lidocaine 5% patch contains only lidocaine 5% as the active ingredient. On 3/6/24 at 12:30 PM, the Director of Nursing (DON) provided the surveyor with the facility policy on Administering Medications, revised April 2019, edited 5/21/19. The policy indicated at line 4. Medications are administered in accordance with prescriber orders, including any required time frame. It also indicated at line 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). And line 10. indicated 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. N.J.A.C 8:39-29.2 (d)

C: #NJ00166633 Based on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to implement the facility's policy titled, Admission Agreement (AG). This deficient practice was identified for 1 of 6 (Resident #3) residents reviewed as evidenced by the following: According to the facility Admission Record (AR), Resident #3 was admitted on [DATE], with diagnoses that included but were not limited to: Spinal Stenosis, Dementia, Type 2 Diabetes. Resident was discharged on [DATE]. The facility was unable to provide Resident #3's AG. On 11/9/23 at 11:59 a.m., the surveyors interviewed the facility's Admission Director (AD) who stated, AG for Resident # 3 can't be found. On 11/9/23 at 1:23 p.m., the surveyors interviewed the Administrator (LNHA) and AD. LNHA stated, I'm unable to locate Resident # 3's AG. The AD stated, there should be an AG done, but I can't to find it. A review of the facility's policy titled, Admission Agreement, revised on 8/2018, indicated all residents have a signed and dated Admission Agreement on file. Further review of the policy under Policy Interpretation and Implementation .4. A copy of the Admission Agreement is provided to the resident .and a copy is placed in the resident's permanent file. NJAC 8:39-4.1(a)8

COMPLAINT # NJ00166633 Based on interviews, and review of medical records (MR) and other facility documentation on 11/8/23, 11/9/23, and 11/13/23, it was determined that the facility failed to provide the resident's representative (RR) a 30-day written notice in advance of an impending discharge prior to the facility-initiated discharge. In addition, the facility failed to follow their policy on Discharging the Resident and Admission Agreement who was discharged on [DATE] and 8/14/23 for 2 of 6 residents (Residents #3 and #4) reviewed for discharge. This deficient practice is evidenced by the following: The surveyor reviewed facility 8/1/23 to 11/8/23 Discharges on 11/8/23. The 8/2023 Discharges revealed that Residents #3 was discharged from the facility (F1) to another facility (F2) on 8/10/23 and Residents #4 was discharged from the facility (F1) to another facility (F3) on 8/14/23. Review of the facility policy titled Discharging the Resident, edited on 4/28/17, reflected Purpose The purpose of this procedure is to provide guidelines for the discharge process .4. F. Why the discharge is necessary . 1. According to the admission record (AR), Resident #3 was admitted to the facility on [DATE] and was discharged on [DATE] to F2. Diagnoses included but were not limited to: Dementia and Difficulty in Walking. The Minimum Data Set (MDS), an assessment tool dated 7/23/23, revealed a Brief Interview for Mental Status (BIMS) score of 3/15, which indicated that her/his cognition was severely impaired needed help with Activities of Daily Living (ADL). The quarterly assessment MDS, dated [DATE], revealed in Section Q, the Resident, RP, and the Power of Attorney (POA) did not participate, however, the discharge plan under Q0400, the discharge plan was active and already occurring for the resident to return to the community. During the surveyor's interview on 11/13/23 at 11:43 with Social Worker (SW #1), who completed 7/23/23 Section Q MDS, revealed that he made a mistake of coding Q0400, he stated that he should have had coded to 0 to indicated that the discharge plan was not active. A care plan (CP), initiated on 4/29/21, indicated that Resident #3 was a Long-Term Care Resident. Interventions included but were not limited to; Provide referrals to area centers upon request., reassess care needs and potential for discharge as needed, and support patient, family and/or representative as needed. The facility was unable to provide Resident #3's AG. The facility was unable to provide a Physician order to indicated that the Physician was notified and agreed for the Resident's discharge to F1 prior to 8/10/23. A review of Resident #3's progress notes (PN), documented by SW #2, on 4/28/21 at 10:46 p.m., documented that Resident #3 was recently approved for Medicaid and planned to remain for Long-Term Care (LTC), on 7/20/21 at 11:32 a.m. Resident #3 continued to be a LTC resident, on 10/11/21 at 10:52 a.m. documented Plan remains to be LTC and 10/28/21 at 9:33 pm, documented Plan remains for LTC placement. Further review of the PN, SW #3 documented that Resident #3 remained appropriate for LTC on 3/2/22 at 2:45 p.m., 11/10/22 at 12:56 p.m., 5/1/23 at 3:25 p.m., and 5/4/23 at 3:45 p.m. The PN revealed that on 8/11/23 at 5:13 p.m., documented by registered nurse (RN) wrote Resident transferred F2 at 4 p.m. The Resident's PN and MR revealed no documented evidence that facility-initiated discharge requirements were given to the RR. The PN further revealed there was no documentation indicating the plans for discharge to F2. The General Notes Report (GNR), provided by the facility on 11/9/23, according to the Administrator the GNR was an internal staff communication and was not part of the resident's MR. The GNR, dated 8/11/23 at 10:16, documented by the facility's Regional Marketing and Business Development (RMBD), indicated that she spoke to the Resident's family member (RP) and left a message and texted the Resident's Power of Attorney with message. The RMBD further documented Told [RP] due to issue at the facility we have to transfer [Resident #3] to [F2]. RP asked if this will be permanent and let her know that we do not have a date as to when she can return. We do not know if the issue will ever be fixed, but we'll keep her posted. patient transferring today. The RMBD further documented at 10:46 [POA], called me and [she/he] was concerned about [Resident #3's] transfer, but after I spoke to [her/him] [she/he] understands. [she/he] know that we do not have a transfer back dated, and I explained that I could not disclose the maintenance issue. At 4:20 p.m., RP further documented, Spoke to [POA] and [RP], they both expressed concern about the transfer . The surveyor conducted a telephone interview with Resident #3's POA on 11/13/23 at 9:13 a.m. The POA stated that she/he received a call from the facility (unable to recall exact time and date) on the same day to inform her/him that Resident #3 was being discharged to F2. POA stated that when she/he arrived at the facility, Resident #3's was about to leave, Resident's belongings were already packed, and the transportation was already outside the building waiting for the Resident. The POA explained that the facility did not give her/him a chance to say no or to check other facility that was closer to his/her home. The POA further stated that the facility was unable to explain a reason for the discharge, according to the POA the facility stated, maintenance issue. 2. According to AR, Resident #4 was admitted to the facility on [DATE] and was discharged on [DATE] to F3. Diagnoses included but were not limited to: Pervasive Developmental Disorder, Schizophrenia, and Need for Assistance. The MDS, dated [DATE], revealed that Residents BIMS was not performed because the Resident was unable to complete the interview. Section Q of the MDS revealed the Resident #4 participated and under Q0400 that an active discharge planning was not occurring for the resident to return to the community. A CP, initiated on 11/21/2020, indicated that Resident #4 was planning to remain in LTC. There was no indication on the CP that the resident was to be discharged to F3. Review of the Resident #4's ADMISSION AGREEMENT (AG), signed on 2/10/22 at 1:33 p.m. indicated that the Resident was acknowledging the involuntary and voluntary discharge requirement. The AG under ARTICLE X1 TERMINATION OF AGREEMENT, TRANSFER AND DISCHARGE 1. Involuntary Discharge. Facility may transfer or discharge Resident upon thirty (30) days advance written notice for one or more of the following reasons: (a) the transfer or discharge is necessary for Resident's welfare and Resident's needs cannot be met in the facility; (b) Resident's medical condition no longer requires Facility's care or services; (c) the safety of individuals in the Facility is endangered; (d) the health of individuals in the Facility would otherwise be endangered; (e) Resident Parties have not paid (or made arrangements to have paid) the fees Resident Parties are obligated to pay for items and services Resident received; (f) Resident has been terminated to be mentally ill, in accordance with Federal or State law, and Resident requires specialized services for mental illness; (g) Facility ceases to operate; or (h) Facility ceases to participate in the Medicare or Medicaid programs, for any reason, and Resident's stay at the Facility is being paid for by Medicare or Medicaid .4. Voluntary Discharge. Resident Parties may transfer or discharge Resident from the Facility upon the provision of thirty (30) days written notice to terminate this Agreement. All payments to the Facility for care and services to the Resident shall become immediately due and owing as of the Resident's final day at the Facility . The facility was unable to provide a Physician order to indicated that the Physician was notified and agreed for the Resident's discharge to F3 prior to 8/14/23. A review of Resident #4's PN, documented by SW #2, on 11/22/20 at 10:21 p.m. indicated that Resident #4's plan was to remain in LTC. On 11/22/20 at 10:43 p.m. indicated Anticipated length of stay: LTC, on 3/5/21 at 6:07 p.m. indicated that Resident #4's legal guardian plans was for her/him to remain a LTC resident, on 5/27/21 at 10:44 a.m. documented, :Plan remains for LTC at this time as [Resident #4] requires total care, on 11/23/21 at 11:07 a.m., 10/11/22 at 12:38 p.m., and 2/24/23 at 9:19 indicated that Resident #4 remained LTC. Further review of Resident #4's PN, dated 8/11/2023 at 12:32 p.m. documented by the former Administrator indicated that she had spoken to Resident #4's Guardian and agreed for the transfer to F3. Resident #4 was discharge to F3 on 8/14/23. The Resident's PN and MR revealed no documented evidence that facility-initiated discharge requirements were given to the RR. The PN further revealed there was no documentation indicating the plans for discharge to F2. The surveyors conducted an interview with Maintenance Director (MD) on 11/9/23 at 9:15 a.m., the MD stated there was no maintenance issues between 8/2023 through 11/9/23. The review of facility's maintenance log sheet (MLS) from 7/23/23 to 10/3/23, the MLS revealed there was no indication in the MLS that the facility was having a maintenance issue in room [ROOM NUMBER] and 143. The surveyor conducted an interview with SW #1 on 11/8/23 at 1:20 p.m., the SW stated that the residents were discharged to another facility in 8/2023 because the facility was transitioning from Long-term care to Subacute Rehabilitation. The SW further stated that he did not call or arranged the resident's discharges in August because he was new. The surveyor conducted an interview with RMBD on 11/9/23 at 11:31 p.m. RMBD stated that the [NAME] President of Operation (VPO) had provided her list of family members (FMs) to call for possible transfer to another facility because of a maintenance issue, the RMBD was unable to explain what was the maintenance issue and to provide the list of residents who was discharged to another facility. The RMBD further stated that when the 4 FMs agreed, the former Administrator and Director of Nursing (DON #1) were informed and arranged for the transfer. The surveyor conducted a telephone interview with DON #1 on 11/9/23 at 1:25 p.m. DON #1 stated that she received a notification from the RMBD and VPO that Resident #3 and Resident #4 were moving to another facility. DON #1 further stated that she instructed the Unit Clerk to set up the transportation on the same day when she received the instruction from the Corporate. DON #1 revealed that the 30-day notice was not provided to the Residents or to their FMs and she was not aware that there was a maintenance issue. The former Administrator was not available for interview on 11/8/23, 11/9/23, and 11/13/23. The surveyor conducted an interview with the VPO on 11/13/23 at 10:01 a.m. The VPO confirmed the transfers occurred on 8/2023. VPO explained that the discharges were voluntary discharge because when the facility offered the FMs agreed for the residents to be discharged to another facility. The VPO further explained due maintenance issue such as sprinkler issues, trying to repair and remodel the F1 was trying to condense to opening up the rooms to repair of what was happening, we barely have short term patient to cycle out, so we offered LTC patient to be transferred to another facility or a room change. The VPO further stated that a 30-day notice was not necessary because they were ready to go home and agreed. The surveyor conducted an interview with Resident #4's Guardian on 11/13/23 at 3:26 pm. The Guardian revealed that F1 provided a list of facilities to choose from on 8/11/23 and Resident 4 was discharge to F3 on 8/14/23. The Guardian stated that there was no clear understanding or explanation of why [Resident #4] was being transferred and there was no 30-day discharge notice given. The Guardian further stated that I didn't have the choice, the discharge process was not there, and I wish more time was given. The surveyor conducted an interview with Resident #3 and Resident #4 primary physician on 11/13/23 at 4:03 p.m. The residents Primary Physician (PCP) stated that she/he was not aware that the residents were transferred to another facility. The PCP further stated that she/he was made aware when the residents was not in their rooms. NJAC 8:39- 4.1(a)31 NJAC 8:39- 4.1(a)32

Based on interviews, record review, and review of other pertinent facility documents on 11/8/23, 11/9/23, 11/13/23, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 6 (Resident #3) residents reviewed. This deficient practice was evidenced by the following: According to the admission record (AR), Resident #3 was admitted to the facility on [DATE] and was discharged on [DATE], with diagnoses that included but were not limited to: Dementia and Difficulty in Walking. A review of Resident #3's care plan documented Resident #3 is a long-term care (LTC) resident, initiated on 4/29/21. A review of the Progress Notes (PN) dated 5/3/23 at 11:08 a.m. documented under Care Conference Note, Resident #3 remains appropriate for LTC. Review of the Quarterly Minimum Data Set (Q/MDS), an assessment tool used to facilitate the management of care dated 7/23/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident had a severely impaired cognition. Further review of the MDS Section Q0400 Discharge Plan was coded 1, indicating an active discharge planning is already occurring for the resident to return to the community. During the surveyor's interview on 11/13/23 at 11:43 with Social Worker (SW), who completed 7/23/23 Section Q MDS, revealed that he made a mistake of coding Q0400, he stated that he should have had coded to 0 to indicated that the discharge plan was not active. NJAC 8:39-33.2(d)

C#: NJ 618 Based on interviews, and record review, as well as review of pertinent facility documentation on 5/12/22, it was determined that the facility failed to consistently implement their policy on Charting and Documentation for 2 of 3 residents (Resident #1 and #2) reviewed for documentation. This deficient practice is evidenced by the following: 1. According to the ADMISSION RECORD (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) an assessment tool dated 3/27/22, Resident #1's cognition was impaired and required total assistance from staff with Activities of Daily Living (ADL). The Care Plan (CP), dated 3/22/22, showed that Resident #1 had ADL self-care deficit related to physical limitations. The Documentation Survey Report v2 [Version 2] (DSR) for the month of 4/2022 and 5/2022, and the progress notes (PN) showed no documented evidence by staff was completed about Resident #1 assistance with ADLs on the following dates and shifts which was not according to their policy. The facility policy describes how staff should document about rendering care and services to residents. On Bed Mobility and Dressing the following dates and shifts were blank as evidenced by: During 7:00 am-3:00 pm shift on 4/2/22, 4/7/22, 4/14/22 to 4/17/22, 4/21/22, 5/7/22, and 5/8/22. During 3:00 pm-11:00 pm shift on 4/1/22, 4/16/22, 4/18/22, 4/21/22, 4/27/22, and 5/6/22 During 11:00 pm-7:00 am shift on 4/11/22, 4/25/22, and 5/9/22 On Personal Hygiene the following dates and shifts were blank as evidenced by: During 7:00 am-3:00 pm shift on 4/2/22, 4/7/22, 4/14/22 to 4/17/22, 4/21/22, 5/7/22, and 5/8/22. During 3:00 pm-11:00 pm shift on 4/1/22, 4/16/22, 4/18/22, 4/21/22, 4/27/22, and 5/6/22 On Toilet Use the following dates and shifts were blank as evidenced by: During 3:00 pm-11:00 pm shift on 4/1/22, 4/18/22, 4/21/22, 4/27/22 During 11:00 pm-7:00 am shift on 4/11/22 and 4/25/22 2. According to the AR, Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Resident #2's cognition was impaired and required total assistance from staff with ADL. The CP dated 3/22/22, showed that Resident #2 had ADL self-care deficit related to physical limitations. The DSR and the PNs for the month of 5/2022 showed no documented evidence by staff was completed about Resident #2 assistance with ADL on the following dates and shifts which was not according to their policy. The facility policy describes how staff should document about rendering care and services to residents. On Bed Mobility, Dressing, and Toilet use the following dates and shifts were blank as evidenced by: During 3:00 pm-11:00 pm shift on 5/10/22 During 11:00 pm - 7:00 am shift on 5/2/22 On Personal Hygiene the following date was blank as evidenced by: During 3:00 pm-11:00 pm shift on 5/10/22 The surveyor conducted an interview with Certified Nursing Assistant (CNA #1) on 5/12/22 at 3:45 pm. The CNA stated that CNAs should document care provided to the Resident to indicate that it was done. The surveyor conducted an interview with the Nurse Supervisor (NS #1) on 5/12/22 at 11:50 am. The NS stated that CNAs should document and the NS should ensure that they document to indicate that the care was provided to the residents. The Job Description for Nurse Supervisor, dated 2003, showed The primary purpose of your position is to supervise the date-to-day nursing activities of the facility during your tour of the duty. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services, to ensure that the highest degree of quality care is maintained at all times .As Nurse Supervisor you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Service Procedure Manual .Ensure that all nursing service personnel are in compliance with their respective job descriptions . The facility's policy titled Charting and Documentation edited on 2/27/2018, showed Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .1. Documentation in the medical record may be electronic, manual or a combination . NJAC 8:39-27.1(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain accountability for oxygen therapy for 1 of 1 resident reviewed for respiratory care, Resident # 32. The deficient practice was evidenced by the following: On 12/13/21 at 10:39 AM, the surveyor observed Resident #32 sitting in the hallway in a wheelchair by the window looking out. The resident was wearing oxygen via a nasal cannula (a tube in the opening of the nostrils that delivers oxygen). The surveyor was unable to see the setting on the portable oxygen concentrator. On 12/14/21 at 10:04 AM, the surveyor observed Resident #32 in the doorway of their room, seated in a wheelchair, without the nasal cannula on, it was hanging off one ear. The surveyor asked the resident if they needed help putting it on. The resident said no, I can do it, it just takes time. On 12/14/21 at 10:19 AM, the surveyor observed the resident sitting in their wheelchair at the end of the hall looking out the French doors to the outside field. The resident was wearing the nasal cannula at that time that was attached to the oxygen concentrator. The surveyor asked the Unit Manager/Registered Nurse (UM/RN) to confirm the oxygen setting on the oxygen concentrator on the back of the resident's wheelchair. The UM/RN checked it and stated it was set at 2 liters per minute (lpm). On 12/14/21 at 10:30 AM, the surveyor reviewed the residents electronic medical record which revealed the following: A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 8/20/21. The December 2022 Electronic Medication Administration Record (EMAR) read Oxygen 2 liters via N/C as needed for SOB. There were no signatures on the EMAR that accounted for the resident's oxygen usage. On 12/14/21 at 11:39 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) about the oxygen for Resident #32 and where they accounted for its use. The LPN showed the surveyor the EMAR and stated that it was a PRN (used as needed). The LPN confirmed that she should have signed for it there. She then proceeded to sign for the oxygen as being used on 12/14/21 at 7:30 AM. The LPN said the resident usually wore it when out of bed, and when in bed. She further stated [The resident] has had it on all morning since I came in. The surveyor asked the LPN if they should have been signing for the oxygen use. She said yes. She didn't know why it hadn't been signed for. She said it was used for comfort. On 12/14/21 at 12:11 PM, the surveyor asked the UM/RN if the nurse should have been accounting for the use of the oxygen by signing the EMAR. She said she wasn't sure if they were supposed to be signing for the oxygen when used. The UM/RN further stated that the resident usually used the oxygen when out of bed, not usually when in bed. The surveyor told the UM/RN that the LPN just said the resident wore the oxygen when in bed and when out of bed. The surveyor asked her how often the resident wore the oxygen when out of bed. She said she didn't know. On 12/16/21 at 2:00 PM, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the concern with the facility not accounting for the use of the oxygen for Resident #32. On 12/20/21 at 10:38 AM, the LNHA said the facility clarified the oxygen order for Resident #32 with the doctor. He then stated the doctor changed the order to continuous instead of as needed. On 12/20/21 at 11:00 AM the surveyor reviewed the facilities Policy and Procedure titled Oxygen Administration. Under Purpose it read The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Documentation it read; After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. NJAC 8:39-27.1 (a)

Based on observation and interview, it was determined that the facility failed to store medication at the appropriate temperature and failed to store controlled substances in a manner that would prevent loss or diversion. This was found with 1 of 2 medication refrigerators inspected. The deficient practice was evidenced by the following: On 12/14/21 at 11:31 AM, the surveyor inspected the Medication refrigerator in the med room on the Sub Acute unit with Licensed Practical Nurse #1 (LPN #1). There was an unopened box that contained one single dose pre-filled syringe of [MEDICATION(S)] (an extended-release injection used to treat [CONDITION(S)]). On the box the storage instructions read: Store at room temperature 77 degrees Fahrenheit. The temperature in the refrigerator was 42 degrees. LPN #1 confirmed that the [MEDICATION(S)] should not have been stored in the refrigerator. Further inspection found a locked narcotic box attached to a shelf that was removable. LPN #1 did not have the key to the narcotic box. LPN # 2 opened the narcotic box. Inside of the box was an unopened 30 ml bottle of [MEDICATION(S)] Concentrate (A schedule IV-controlled liquid antianxiety medication). On 12/14/21 at 2:27 PM, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the [MEDICATION(S)] which was improperly stored. The DON said the [MEDICATION(S)] that was in the refrigerator was discarded and there was another box of [MEDICATION(S)] in the medication cart they would use. On 12/20/21 at 2:15 PM, the surveyor reviewed the facility's policy and procedure titled Storage of Medications. Under Policy Interpretation and Implementation it read; 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls and 8. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. NJAC 8:39-29.4 (h)

Based on observation, interview, and record review it was determined that the facility failed to consistently provide coordination between facility staff and hospice agency staff to meet the resident's nursing needs. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for hospice/end of life care and was evidenced by the following. On 12/13/21 at 11:47 AM, the surveyor observed Resident #136 awake and alert in bed. A review of the resident's hybrid medical record revealed the following information: According to the Admission Record the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/30/21 Admission Minimum Data Set assessment tool indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 and was enrolled in a hospice program. The 12/4/21 facility hospice care plan included interventions to provide comfort and supportive care and hospice staff visitation to provide care, assistance, and evaluations. The resident's paper chart contained a tab for hospice documentation. The Hospice Care Face Sheet indicated the resident was admitted to the hospice program on 11/29/21 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the paperwork failed to reveal a hospice agency nursing care plan or hospice nurse progress notes. A staff sign in sheet located on the resident record indicated hospice nurse visits occurred on 11/29/21, 12/1/21, 12/8/21, and 12/13/21. On 12/16/21 at 10:09 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM). When asked where the hospice nursing progress notes and hospice care plan were filed, the RNUM replied, they usually leave their notes, but I don't see them. I'll get back to you. The RNUM did not provide the notes to the surveyor. On 12/16/21 at 12:09 PM, the facility Administrator provided the surveyor with hospice agency progress notes and care plan which had been sent to the facility by the hospice agency several minutes earlier. On 12/21/21 the surveyor reviewed the facility policy for the Hospice Program, revised 7/2017, provided by the Administrator. The policy indicated the facility will communicate and collaborate with the hospice representatives and coordinate care between the facility and the hospice agency. The most recent hospice plan of care specific to each resident must be obtained by the facility. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed with 1 of 1 Lab Technician and 1 of 1 dietary aide and was as evidenced by the following: On 12/14/21 at 9:10 AM, the surveyor observed a Lab Technician (LT) enter a resident's room wearing two surgical masks and no eye protection. The LT placed a large bag which contained her supplies on the bed next to the resident. The LT put gloves on her hands with no hand hygiene first and then drew the resident's blood. The LT then took her cell phone out of her pocket with her gloved hand and put it to her face to answer a phone call. The LT placed the phone back into her pocket and removed her gloves. The LT did not perform hand hygiene when she removed her gloves. The LT took the bag of supplies and walked down the hallway to another resident's room. At 9:15 AM, the surveyor observed the LT enter another resident's room, still wearing two surgical masks and no eye protection. The LT put on new gloves without any hand hygiene, grabbed supplies, the LT drew the resident's blood. The LT removed her gloves, and this time did perform hand hygiene with alcohol-based hand rub (ABHR). At 9:22 AM, the surveyor interviewed the LT who stated, I don't work here, I work with the hospital and I have one more resident's blood to draw. The surveyor asked about hand hygiene before and after wearing gloves, the LT stated that she should have performed hand hygiene before and after wearing gloves and that she forgot. The LT stated that she should not have grabbed her phone with her soiled gloved hands. At 9:50 AM, the surveyor observed the LT enter another resident's room, who was on droplet precautions which was identified with a sign outside the resident's door indicating Quarantine droplet/contact precautions. There was also Personal Protective Equipment (PPE) outside of the resident's room. The droplet/contact precautions sign indicated that a person entering the room must wear a gown, gloves, N95 respirator mask and eye protection. The surveyor observed the LT put on gloves, gown, a face shield and did not put on a N95, she only had two surgical masks on. The LT entered the resident's room and closed the door and prior to exiting the room the LT removed the gown, gloves and face shield and performed hand hygiene with ABHR. At 10:00 AM, the surveyor interviewed the LT who stated that she is fit tested for a N95 mask but that she did not have the N95 mask with her. The LT stated that she had two surgical masks on and that should be enough to wear into the resident's room who is on droplet/contact precautions. At 10:06 AM, the surveyor discussed the above concerns with Administrator, Director of Nursing (DON) and the Infection Preventionist (IP), who stated that the LT should have performed proper hand hygiene before and after wearing gloves, the LT should not have touched her phone with gloved hands and the LT should have worn a N95 mask when entering a resident's room who is on droplet/contact precautions. At 1:05 PM, the surveyor observed a Dietary Aide (DA) bring a tray of food to a resident's room who was droplet/contact precautions. The DA knocked on the door and entered room with only a surgical mask on, no eye protection, no gown and no gloves. The DA placed the tray on bedside next to resident and asked the resident if there was anything else needed, the DA then exited the room and closed door. There was no observed hand hygiene. At 1:07 PM, the surveyor interviewed the DA, who stated that she does only brings trays into the resident's room when a tray is ordered between mealtimes. The DA stated that she did not think that PPE should have been worn since there is no COVID positive resident in the building. The surveyor pointed out the sign on the resident's door which read droplet/contact precaution wear gown, gloves, eye protection and N95 respirator when entering the room. The DA said that she should have worn all the proper PPE, including eye protection, N95, gown and gloves. The DA also state that she should have cleaned her hands after leaving the room as well. At 1:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the DA should not have been passing out trays and that the nursing staff are the ones who pass out the trays, the LPN stated that the DA should have worn a N95, gown, gloves and eye protection if entering a resident's room who is on quarantine with droplet/contact precautions. At 12/14/21 on 2:15 PM, the surveyor discussed above concerns with Administrator and DON, who stated that the DA should not be passing trays out to residents and that if she had to enter the resident's room, she needed to wear proper PPE. The surveyor reviewed the policy and procedure titled Handwashing/ Hand Hygiene which was reviewed 1/20/21. The policy and procedure indicated that hand hygiene is to be performed before and after applying gloves. The surveyor reviewed the stop sign placed on resident's door which was titled Quarantine Droplet/Contact Precautions. The sign indicated that personnel entering the room must clean hands when entering and exiting, wear gown, N95 respirator, eye protection and gloves. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) accurately assess the skin and obtain a physician order for [REDACTED].) apply a wound treatment in accordance with a physician's order, and d.) maintain the proper functioning of two low-air loss mattresses used for skin protection. This deficient practice was identified for 3 of 5 residents reviewed with pressure ulcers (Resident #40, #53, and #166). The evidence was as followed: 1. On 1/27/2020 at 10:42 AM, the surveyor observed Resident #40 in bed and lying on a low air-loss mattress with the head of the bed slightly elevated. There was an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine) secured to the resident's bed frame with the collection bag in a blue privacy cover. The catheter was draining clear yellow urine. At that time, the resident wouldn't speak specifically to the surveyor's inquiry. The resident was unsure if he/she had any wounds that the nurse was treating. On 1/28/20 at 9:54 AM, the surveyor observed the Certified Nursing Aide (CNA) in the resident's room preparing to provide morning care to Resident #40. At that time in the presence of the CNA, the surveyor asked the resident's permission to observe morning care with the CNA, and the resident refused. The surveyor then exited the resident's room to allow the CNA to continue with the care. The surveyor reviewed the medical record for Resident #40. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the hospital records printed on 12/18/19 reflected that the resident had an extended hospitalization for acute [MEDICAL CONDITIONS], and [DIAGNOSES REDACTED] with complications including a right lower leg blood clot. The hospital records reflected that the resident had a right gluteal fold ulcerating wound which was proximal to the posterior thigh and measured 3.5 centimeters (cm) x 4 cm, and that there was another small ulceration to the inferior aspect of this ulceration. The hospital records reflected that the resident had multiple wounds to the right gluteal fold/sacral (tailbone) area, and that the resident had an indwelling urinary catheter to promote wound healing due to the multiple wounds and bowel incontinence. The hospital records did not include documented evidence of wound staging (used to determine depth and severity). A review of the Universal Transfer Form (UTF) (a communication tool to summarize transfer information) dated 12/24/19 indicated that the resident had a right groin wound ([DIAGNOSES REDACTED]) but no other pressure ulcers or ulcerations. A review of the electronic Progress Notes (ePN) dated upon admission on 12/24/19 at 11:38 PM included that the resident was admitted with current skin breakdown/skin conditions: refer to the completed evaluation and physician orders for type and location. A review of the Resident Evaluation/initial nursing admission assessment dated [DATE] included that the resident had an indwelling urinary catheter for the contamination of a stage 3 or 4 pressure ulcer with urine, and that the resident had a front right thigh stage III wound that was 20 centimeters (cm) long and extended in the right inner thigh. Under the Skin Evaluation section, the space to record additional observations/comments was blank. There was no documented evidence of additional pressure ulcers or gluteal ulcerations present upon admission. A review of the physician's orders sheet with a start date of 12/25/19 included a physician order (PO) to cleanse the right leg thigh wound with normal saline solution, pack with gauze and cover with a dry dressing every shift. There was no documented evidence of a physician order for [REDACTED]. A review of the electronic Treatment Administration Record (eTAR) for (MONTH) 2019 included the PO dated 12/25/19 for the right leg wound, but there was no documented evidence upon admission for the accountability for a wound dressing or treatment to gluteal ulcerations for the dates of 12/24/19, 12/25/19 or 12/26/19. A review of the subsequent ePN's dated 12/25/19 and 12/26/19 did not reflect documented evidence to address the gluteal ulcerations or a treatment to those areas. A review of a ePN dated three days after admission on 12/27/19 at 4:30 PM, reflected that the Registered Nurse/Unit Manager documented that Resident #40 was admitted on [DATE] with wounds to right buttock, left buttock, and right leg with wound care treatment orders as follows: cleanse right buttock with NSS (normal saline solution), pat dry, and apply a wet to dry dressing daily; cleanse left buttock with NSS, pat dry, apply xeroform, and cover with a dry dressing daily . The RN/UM then documented at 5:10 PM that day that the left buttock wound was a stage II (partial thickness tissue loss) pressure ulcer measuring 1.5 cm x 1.5 cm x 0.2 cm with moderate serous drainage. She documented the right buttock was a stage II ulcer that measured 2.0 cm x 1.5 cm x 0.2 cm with moderate serous drainage. (This was the first time the gluteal ulcerations were addressed). There was no documented evidence for the identification or a treatment order for the buttock wounds on 12/24/19, 12/25/19 and 12/26/19 upon admission to the facility. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/31/19 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating a moderate to severe cognitive impairment. The assessment further included that the resident was admitted with two stage III (full thickness tissue loss) pressure ulcers. A review of the wound consultant initial Visit Report dated 12/31/19 reflected that the resident had a right thigh wound, in addition to a right and left gluteal fold stage III (full thickness tissue loss) pressure ulcers. The right gluteal fold measured 1 cm x 1 cm x 0.2 cm and had moderate serous (clear) drainage and the left gluteal fold measured 1.5 cm x 2 cm x 0.2 cm and also had moderate serous drainage. The wound consultant/Nurse Practitioner (NP) indicated that the stage III pressure ulcers had 100% granulation tissue (indicating signs of healing) and recommended to apply [MEDICATION NAME] (a [MEDICATION NAME] ointment), calcium alginate (an absorbent dressing), and cover the wounds with a foam dressing daily. On 1/28/20 at 11:20 AM, the surveyor interviewed the RN/UM who had documented three days after admission that the resident was admitted with two stage II pressure ulcers on the right and left gluteal folds. The surveyor asked the RN/UM about the note she wrote on 12/27/19, and the RN/UM stated that the resident was admitted on [DATE] and that usually she does a skin check on new admissions. She stated that she did a skin check on 12/27/19 and saw the wounds, and she reviewed the hospital records and saw that the resident had skin breakdown while at the hospital. She confirmed the hospital records did not include what stage the gluteal wounds were, so she could not speak to if the gluteal wounds had improved, stayed the same, or worsened since admission. The RN/UM confirmed that the UTF reflected that the resident did not have a stageable pressure ulcer, and she suggested maybe it was an error by the transferring hospital. The RN/UM acknowledged that the admission Resident Evaluation assessment dated [DATE] did not address the gluteal pressure ulcers or that Resident #40 had any behaviors that would have limited staff's ability to inspect the resident's skin. The RN/UM stated that upon admission, the LPN's are expected to perform a head-to-toe skin assessment and document the findings within the resident's medical record. The RN/UM stated that she documented that the resident came to the facility with the wounds. The surveyor asked if she spoke to the Licensed Practical Nurse (LPN) who performed the admission assessment, or if the CNA's who had performed incontinence care had observed the presence of the wounds, and the RN/UM stated that she had not spoken to those staff prior to writing her note, and that she had just assumed that it had been there based solely on the hospital record. She confirmed the hospital records were vague in the assessment stage of the gluteal ulcerations. She acknowledged that the wound consultant/NP documented the wounds as stage III pressure ulcers on 12/31/19. The RN/UM stated that she had brought this situation up to the the Director of Nursing (DON) on 12/27/19. The RN/UM confirmed there was no physician order for [REDACTED]. The RN/UM stated that she did not perform an investigation but that the surveyor could ask the DON. On 1/28/20 at 11:46 AM, the surveyor interviewed the CNA who stated that she was always the CNA assigned to care for Resident #40 since admission, and that she worked full time during the day shift (7 AM to 3 PM). The CNA stated that the resident was always cooperative with care for her, and that he/she was incontinent of bowel and had a bowel movement this morning. The CNA stated that the resident came in to the facility with wounds to the buttocks, and that he/she always had a treatment over top of the buttock wounds that she could recall, even on Christmas day when she worked. On 1/28/20 at 12:04 PM, the surveyor interviewed the MDS Coordinator/Registered Nurse who stated her primary full time role was to complete the MDS assessments for each resident in the building. The MDS Coordinator stated that she does not directly observe skin during her assessments, but that she relies on the initial nursing Resident Evaluation assessment done on admission and the wound flow sheets which reflect if the wounds were present upon admission. At that time, the MDS Coordinator/RN provided the surveyor a copy of the Pressure Injury Record for the right and left buttock gluteal fold ulcerations with dates of origin identified as 12/24/19. The boxes were checked that the resident was admitted with these wounds. The MDS Coordinator stated that she relies on the accuracy of the wound flow sheets when completing the MDS assessments, to determine if the resident was admitted with the wounds or if a wound was facility-acquired. She stated that since the flow sheet indicated that the resident was admitted with the gluteal pressure ulcers, then she documented in the MDS dated [DATE] that the resident came with the wounds. On 1/28/2020 at 2:27 PM, the surveyor interviewed the full time Registered Dietician (RD), who stated that Resident #40 had some dementia, keeps snacks in the room, and that the resident gets added protein with medication pass due to multiple wounds. The RD stated that she completed an initial assessment on 12/27/19 and when a resident is forgetful or an unreliable historian, she relies on the admission nursing assessment/Resident Evaluation to be accurate when reviewing skin conditions to determine if she should make recommendations for vitamins or supplements to aid in wound healing. She acknowledged that her initial evaluation on 12/27/19 did not reflect the gluteal pressure ulcers because it was not in the Resident Evaluation dated 12/24/19. She stated that she knew the resident had a right thigh wound and had made recommendations based on that wound to promote wound healing through nutritional means. She added that she also recommended labs to determine nutritional status which were done. The RD stated she adjusted the resident's nutritional plan after the pre-[MEDICATION NAME] lab (lab used to determine recent nutrition status) came back slightly low 14 (normal is 17-34) collected on 12/31/19. On 1/28/2020 at 1:16 PM in the presence of the survey team, the DON stated that there was no investigation conducted for the gluteal pressure ulcers. On 1/29/20 at 10:44 AM, the surveyor interviewed the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that she spoke to the admitting LPN who told her that the resident refused to turn on the side to do a full skin inspection, and therefore the skin could not be adequately visualized. The DON stated that if a resident refuses to turn for the admission assessment, that the physician should be notified when obtaining orders, and it should get reported on the 24 hour report to check the skin at the next incontinence care change or at the next most convenient time when the resident was getting up, such as for physical therapy. The DON acknowledged that she did not get statements from the CNA's or nurses who cared for the resident on 12/24/19, 12/25/19 and 12/26/19 to see if wounds were identified during incontinence care, and if so, did they report the wounds to the nurse or the supervisor, because there had been no treatment order in place one those dates. The DON acknowledged that there was no treatment order in place on 12/25/19 and 12/26/19 to the two gluteal stage III pressure ulcers. The DON stated that the resident was admitted with the wounds and that as of yesterday 1/28/2020, the right and left gluteal pressure ulcers wounds had both healed. The DON and LNHA were unable to provide documented evidence from the hospital as to what stage the gluteal pressure ulcers were upon admission to the facility. On 1/29/2020 at 12:32 PM, the surveyor conducted a phone interview with the wound consultant/Nurse Practitioner (NP) who stated that she started consulting with the facility in (MONTH) or (MONTH) of 2019. The NP stated that she makes wound rounds every Tuesday. The NP added that Resident #40 had a large surgical right thigh wound with [DIAGNOSES REDACTED] and two pressure ulcers to the gluteal region that she believed were present on admission. The NP stated that the resident had been on an air mattress every since she started seeing the resident (12/31/19), otherwise she would have recommended one. The NP stated that she doesn't document where the wounds are acquired but that the RN/UM tells her, and that she makes recommendations based on that information provided. The NP stated that when she made rounds yesterday on 1/28/2020, both gluteal ulcers were healed, and that she just recommended a barrier cream to the buttocks for skin protection. On 1/29/2020 at 12:02 PM, the surveyor attempted to conduct a phone interview with the LPN who admitted the resident on 12/24/19. The LPN did not answer the phone nor return the surveyor's request for a return call. On 1/30/2020 at 12:36 PM, the surveyor conducted a phone interview with the Registered Nurse/Supervisor (RN/S) for the evening shift of 12/24/19. The RN/S stated that she went into the resident's room with the LPN that evening to assess the resident's skin but the resident was refusing to be turned to fully check the skin, even with family attempting to encourage the resident to turn. The RN/S stated that she believed there were open areas to the buttocks due to the fact the resident had an indwelling urinary catheter from the hospital, and that the hospital records reflected evidence of a history of wounds to the buttocks and sacrum. She stated that she did not recall communicating with anyone (nurse or physician) that the resident's skin was not fully assessed due to his/her refusal to turn in bed to adequately visualize the skin. The RN/S stated that she believed the resident was admitted on an air mattress due to the resident's condition and risk factors. The RN/S confirmed to the surveyor that there had been no investigation done prior to surveyor inquiry to evaluate why there had been no treatment in place to the gluteal ulcerations for two full days when the resident allegedly was admitted with two stage III pressure ulcers. 2. On 1/27/20 at 10:58 AM, the surveyor observed Resident #166 in bed with the resident's family representative at the bedside. A CNA (CNA #1) and Occupational Therapist (OT) were in the resident's room, and CNA #1 was preparing to turn the resident to the left side to perform incontinence care. At that time, the surveyor observed CNA #1 and OT turn the resident and remove an incontinent brief soiled with a moderately sized loose bowel movement (BM). CNA #1 removed the BM from the resident's skin using a terry cloth towel and with each long motion of the cloth against the raw reddened skin, the resident flinched forward, saying It hurts. The surveyor and CNA #1 observed the resident's peri-rectal area which was bright pink and raw in appearance, but the skin was intact. The sacral (tailbone) area had a large bright reddened area about the size of a softball. There was no evidence of residual barrier cream or zinc oxide ointment observed on the skin. At that time, CNA #1 stated to the surveyor that this was the first time that she has worked with Resident #166. The resident was not assigned to her, she was just covering for the resident's assigned CNA #2 who was assisting with another resident at that time. CNA #1 stated that the resident's skin was very reddened and didn't know what the redness was from. At that time, the CNA #1 removed personal protective equipment (PPE), washed her hands and told the surveyor that she wanted to get a nurse to assess the resident's raw, reddened skin. At 11:09 AM, the surveyor observed the resident's assigned CNA #2 apply PPE and enter the resident's room with LPN #1. LPN #1 introduced herself stating that she was not the resident's assigned LPN today, but that she would assess the resident's skin. At that time CNA #2 stated to the surveyor that she performed morning care for Resident #166 before 8:00 AM. She stated that the resident had a formed bowel movement this morning and that she hadn't yet been back until now. CNA #2 confirmed it had been three hours since she was last checked for an incontinence episode. At that time, the CNA #2 secured the new incontinent brief and pulled up the resident's pants without applying a barrier cream, and before the LPN #1 could inspect the skin. At 11:14 AM, LPN #1 stated she needed to assess the resident's skin. At that time, LPN #1 and CNA #2 removed the incontinence brief to inspect the skin. LPN #1 just looked at the area without touching and stated, it's reddened so (Resident #166) needs to get barrier cream to the area. LPN #1 stated that the resident was not assigned to her but that she believed the resident had an order for [REDACTED].#1 removed the PPE and washed her hands and exited the room to get barrier cream. LPN #1 stated there was no barrier cream in the room and that barrier cream was not kept in individual resident rooms, only the treatment cart. The LPN #1 returned to the resident's room with LPN #2 who was assigned to care for the resident. Wearing a gown and gloves, LPN #2 came into the room with a medicine cup filled with barrier cream and handed it to LPN #1 to apply. LPN #2 stood by the doorway while LPN #1 and CNA #2 went over to the resident to apply the barrier cream. LPN #1 then applied a thick layer of barrier cream to the bright reddened area on the sacrum using a tongue blade. She did not apply barrier cream to any other areas of the resident's perineal area or pinkened raw areas of the peri-rectal region. She then secured the resident's incontinent brief and CNA #2 assisted in adjusting the resident's pants and repositioning the resident. The facility staff then obtained a mechanical lift to transfer the resident into a chair. At 11:30 AM, the surveyor interviewed LPN #1 who stated that she just applied the barrier cream only to the reddened area. The surveyor asked what the reddened area was, and she stated stated it is a non-blanchable redness and thinks it might be from pressure. The surveyor asked LPN #1 how she knew it was non-blanchable (a condition of the skin that remains red when pressed, typically indicative of a stage I pressure ulcer) and LPN #1 could not speak to it, as the surveyor did not observe LPN #1 press or palpate the area. LPN #1 stated that the wound team came every Tuesday (tomorrow) to evaluate wounds, and that they would be able to better evaluate what the redness was. She stated that in the mean time, the barrier cream would protect the area. She didn't speak about protecting the rest of the perineal area from incontinence episodes when asked. At approximately 11:32 AM, the surveyor interviewed LPN #2 who stated that Resident #166 was on transmission based precautions for infectious diarrhea and was currently only on an antibiotic to treat it since admission to the facility. LPN #2 stated the resident had a bowel movement this morning when the CNA #2 changed her. LPN #2 acknowledged that she had not done an incontinence check between when CNA #2 had last been in the room at the beginning of the shift until now at 11:00 AM. LPN #2 confirmed it was approximately three hours since the resident had last been checked. She couldn't speak to how often a resident with infectious diarrhea should be checked for incontinence episodes for the purpose of protection of the skin. At approximately 11:35 AM, the surveyor interviewed CNA #2 who stated that she keeps the residents skin protected by applying a moisturizing lotions to her body when she does care, including the buttocks area. She stated she applied lotion to the resident this morning. The surveyor asked where the lotion was kept, the CNA #2 stated that it was kept at the bedside. The CNA #2 acknowledged that barrier cream that the nurse applied today was not kept at the bedside, and that nurses apply the barrier cream. The surveyor reviewed the medical record for Resident #166. A review of the Admission Record reflected that the resident was recently admitted to the facility with [DIAGNOSES REDACTED]. The surveyor attempted to review the admission MDS, but the resident was admitted less than 14 days ago. A review of the resident's individualized care plan initiated on 1/22/2020 included that the resident was admitted with a risk for alteration in skin integrity related to impaired mobility. The goal specified, will decrease/minimize skin breakdown risks. Interventions included, to apply Barrier cream to perianal/buttocks as needed. Provide preventative skin care routinely and as needed. (The care plan did not address the resident's bowel incontinence or how often incontinent checks should be performed with a CDI). A review of the CNA kardex (communication tool for CNA's addressing resident-specific needs and preferences) with a print date of 1/23/2020 included toileting and elimination needs. The kardex indicated, Apply barrier cream after incontinence/peri care and as needed (FYI) (For Your Information). A review of the nursing admission assessment/Resident Evaluation dated 1/21/2020 included that the resident was admitted with excoriation noted to groin and perineal area A review of a physician's order dated 1/22/2020 included to apply a barrier cream to the sacrum after routine cleansing every shift for wound. A review of the electronic Treatment Administration Record (eTAR) for (MONTH) 2020 revealed that nurses were signing every shift for applying barrier cream to the sacrum every shift (day, evening and night shift) A review of the wound consultant/NP initial Visit Report dated 1/28/2020 included that the resident had a 7 cm x 7 cm stage I pressure injury to the sacral region with non-blanchable redness. The NP recommended zinc oxide barrier cream to continue to the region with each shift change and maintain a turning and repositioning program as per facility protocol. On 1/29/20 at 10:22 AM, the surveyor interviewed a third LPN (LPN #3) who stated that We apply barrier cream every shift and with each incontinence care. LPN #3 stated it should be applied to the sacrum and the entire buttocks area, and not just the reddened area. At approximately 10:30 AM, the surveyor interviewed the RN/UM who stated that barrier cream was to be applied to the peri-area with each incontinent episode and not just on reddened areas. The RN/UM added that the residents are checked every 2-3 hours for incontinence. On 01/29/2020 at 10:34 AM, the surveyor interviewed the DON who stated that incontinence care checks should be done every every 2-3 hours routinely. The surveyor asked if incontinence checks get performed any more frequently for a resident with a CDI, and the DON stated it was dependent on how often the resident was having a bowel movement. The DON could not speak to how often the resident was having BM or if they were loose. The DON stated that the barrier cream was kept in the treatment cart of the nurse and not in individual resident rooms. CNA's can carry the individual barrier ointment cream packs in their pockets. She could not speak to if they do that, but confirmed that that the packs are kept in the locked treatment cart. The DON stated resident's are not assigned bottles of barrier cream but that it is dispensed into a medicine cup from a stock supply or they had individual packets. She was not exactly sure why barrier cream was not kept at the resident bedside, but thought it might be for safety reasons. The DON stated that with each incontinence care, CNA's should apply the barrier cream over the entire peri-area to protect the skin, and not just on the reddened area. She confirmed if the barrier cream was only applied to the reddened areas, it would not protect the non-reddened areas. On 1/29/2020 at 12:38 PM, the surveyor conducted a phone interview with the wound consultant/NP who stated that Resident #166 had a stage I pressure injury to the sacrum. The NP stated that the expectation was that direct care staff apply barrier cream over the entire surface of the peri-area to protect the skin from moisture and incontinent/moisture associated [MEDICAL CONDITION] (moisture rash). She stated that the expectation to prevent skin breakdown or prevent recurrence of skin breakdown would be to [MEDICATION NAME] apply the barrier cream after each incontinence episode. The NP could not speak to the accessibility of the barrier cream for CNA's. On 1/30/2020 at 10:45 AM, the surveyor interviewed the DON and the LNHA in the presence of the survey team. The DON acknowledged that the barrier cream must be applied to the entire peri-area, everywhere and not just the reddened area. The DON provided the surveyor copies of in-service education from 5 CNAs regarding incontinence care, titled Urinary Management. The education included, understanding the proper procedure for perineal and catheter care is important to prevent odors, infections, and skin breakdown. A review of the facility's Diarrhea and Fecal Incontinence policy revised 3/4/19 included that barrier creams and lotions (as indicated) was a supply necessary when performing care. After providing incontinence care, rinse well and pat dry. The next step specified to Apply barrier creams or lotions as indicated. (The policy did not specify where the barrier cream would be applied) A review of the facility's Perineal Care policy revised (MONTH) (YEAR), did not include use of a barrier cream. 3. On 1/27/2020 at 11:24 AM, the surveyor observed Resident #53 sitting upright in a wheelchair in his/her room. The surveyor observed that the resident had a low-air loss mattress. The resident told the surveyor that he/she had a sore on his/her bottom that occurred at the facility and the nurses performed a treatment to it every day. On 1/29/2020 at 10:50 AM to 11:35 AM, the surveyor observed a LPN with the assistance of the RN/UM, perform a wound treatment to Resident #53's right buttock wound. Prior to performing the wound dressing change to the resident's right buttock area, the LPN reviewed the Physician's Order (PO) with the surveyor. The LPN told the surveyor that she was going to cleanse the Moisture Associated Skin Damage (MASD) (moisture rash) with normal saline, apply a Xeroform petroleum gauze (a sterile wound dressing that does not stick to the area and is comfortable and soothing to the skin), and then cover with a foam dressing. The surveyor observed the resident positioned on his/her right side. The surveyor observed a white border dressing attached to the resident's right buttocks. The dressing was observed to be smaller than the affected area on the resident's right buttocks and did not completely cover the MASD on the resident's right buttocks. The surveyor further observed that the dressing was not dated, timed, and there were no initials on it. At 11:20 AM, the LPN removed the dressing attached to the resident's right buttocks. The surveyor observed that when the LPN removed the white border dressing, there was no Xeroform petroleum gauze attached to the resident's right buttocks or the white border dressing. The surveyor asked the LPN to describe what the wound looked like to the surveyor. The LPN stated that the wound was MASD, had irregular borders, was linear in length and consisted of granulation (new connective tissue) tissue. The surveyor asked the LPN to look at the dressing she had just removed from the resident's right buttocks and describe what the drainage looked like. The LPN stated that there was a moderate amount of serous (clear) drainage on the dressing. The surveyor reviewed the medical records for Resident #53. A review of the resident's Admission Record record face sheet reflected that the resident had [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly MDS dated [DATE] reflected that the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact with some forgetfulness. A review of the resident's (MONTH) 2020 Order Summary Report (OSR) reflected a PO dated 1/14/2020 to cleanse the right buttocks with normal saline, pat dry, apply Xeroform Petroleum 4 x 4 pad, and cover with a foam dressing daily for MASD. A review of the resident's undated comprehensive care plan reflected a focus area that the resident had actual skin breakdown on the right buttocks related to MASD. The goal reflected that that resident's right buttocks would heal without complications. The interventions included to administer a treatment in accordance with physician's orders and provide follow-up care with the physician as ordered. On 1/29/2020 at 11:56 AM, the surveyor interviewed the resident's LPN who stated that the resident was alert and oriented and could make their needs known. The LPN stated that the resident was incontinent of urine at times and needed assistance with repositioning in bed. The surveyor explained to the LPN the observations made during the wound care treatment. The surveyor asked about the dressing she removed from the resident's right buttock which was small, didn't cover the affected area, was undated/timed, and there was no Xeroform petroleum gauze to the resident's right buttocks or on the border dressing when removed. The LPN responded, You're right. I noticed that too when I took off the dressing. The LPN stated that the wound care nurse came to the facility on [DATE] so she wasn't su (TRUNCATED)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to investigate a full thickness tissue-loss pressure ulcer identified three days after admission to the facility. This deficient practice was identified for 1 of 5 resident's reviewed with pressure ulcers (Resident #40), and the evidence was as follows: On 1/27/2020 at 10:42 AM, the surveyor observed Resident #40 in bed and lying on a low air-loss mattress with the head of the bed slightly elevated. The resident would not speak specifically to the surveyor's inquiry. The resident was unsure if he/she had any wounds that the nurse was treating. On 1/28/20 at 9:54 AM, the surveyor observed the Certified Nursing Aide (CNA) in the resident's room preparing to provide morning care to Resident #40. At that time in the presence of the CNA, the surveyor asked the resident's permission to observe morning care with the CNA, and the resident refused. The surveyor then exited the resident's room to allow the CNA to continue with the care. The surveyor reviewed the medical record for Resident #40. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/31/19 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, indicating a moderate to severe cognitive impairment. The assessment further included that the resident was admitted with two stage III (full thickness tissue loss) pressure ulcers. A review of the Universal Transfer Form (UTF), a communication tool to summarize transfer information, dated 12/24/19 indicated that the resident had a right groin wound ([DIAGNOSES REDACTED]) but no other pressure ulcers or ulcerations. A review of the electronic Progress Notes (ePN) dated upon admission on 12/24/19 at 11:38 PM included that the resident was admitted with current skin breakdown/skin conditions: refer to the completed evaluation and physician orders for type and location. A review of the Resident Evaluation/initial nursing admission assessment dated [DATE] included that the resident had an indwelling urinary catheter for the contamination of a stage 3 or 4 pressure ulcer with urine, and that the resident had a front right thigh stage III wound that was 20 centimeters (cm) long and extended to the right inner thigh. Under the Skin Evaluation section, the space to record additional observations/comments was blank. There was no documented evidence of additional pressure ulcers or ulcerations present upon admission. A review of the physician's orders sheet with a start date of 12/25/19 included a physician order (PO) to cleanse the right leg wound with normal saline solution, pack with gauze and cover with a dry dressing every shift. There was no documented evidence of a physician order for [REDACTED].>A review of the electronic Treatment Administration Record (eTAR) for (MONTH) 2019 included the PO dated 12/25/19 for the right leg wound, but there was no documented evidence upon admission for the accountability for a wound dressing to any other non-intact skin areas for the dates of 12/24/19, 12/25/19 or 12/26/19. A review of the subsequent ePN's dated 12/25/19 and 12/26/19 did not reflect documented evidence of an open wound or treatment to an open wound other than the right thigh wound. A review of a ePN dated three days after admission on 12/27/19 at 4:30 PM, reflected that the Registered Nurse/Unit Manager documented that Resident #40 was admitted on [DATE] with wounds to right buttock, left buttock, and right leg with wound care treatment orders as follows: cleanse right buttock with NSS (normal saline solution), pat dry, and apply a wet to dry dressing daily; cleanse left buttock with NSS, pat dry, apply xeroform, and cover with a dry dressing daily . The RN/UM then documented at 5:10 PM that day that the left buttock wound was a stage II (partial thickness tissue loss) pressure ulcer measuring 1.5 cm x 1.5 cm x 0.2 cm with moderate serous drainage. She documented the right buttock was a stage II ulcer that measured 2.0 cm x 1.5 cm x 0.2 cm with moderate serous drainage. This did not correspond with the UTF, the Resident Evaluation nursing assessment upon admission on 12/24/19, or subsequent ePN's dated 12/25/19 and 12/26/19 that the resident had been admitted with the pressure ulcers to the left and right buttocks. There was no documented evidence for the identification or a treatment order for the buttock wounds on 12/24/19, 12/25/19 and 12/26/19. A review of the wound consultant initial Visit Report dated 12/31/19 reflected that the resident had a right thigh wound, in addition to a right and left gluteal fold stage III (full thickness tissue loss) pressure ulcers. The right gluteal fold measured 1 cm x 1 cm x 0.2 cm and had moderate serous (clear) drainage and the left gluteal fold measured 1.5 cm x 2 cm x 0.2 cm and also had moderate serous drainage. The wound consultant/Nurse Practitioner (NP) indicated that the stage III pressure ulcers had 100% granulation tissue (indicating signs of healing) and recommended to apply [MEDICATION NAME] (a [MEDICATION NAME] ointment), calcium alginate (an absorbent dressing), and cover the wounds with a foam dressing daily. On 1/28/20 at 11:20 AM, the surveyor interviewed the RN/UM who documented three days after admission that the resident was admitted with two stage II pressure ulcers on the right and left gluteal folds. The surveyor asked the RN/UM about the note she wrote on 12/27/19. The RN/UM stated that the resident was admitted on [DATE] and that usually she does a skin check on new admissions. She stated that she did a skin check on 12/27/19 and saw the wounds, and she reviewed the hospital records and saw that the resident had skin breakdown. She was not sure where within the hospital documents it established that the resident had stageable wounds, or if the wounds had healed prior to discharge from the hospital. The RN/UM confirmed that the UTF reflected that the resident did not have a stageable pressure ulcer, and the admission Resident Evaluation assessment dated [DATE] did not address the gluteal pressure ulcers or behaviors that would have limited staff ability to inspect the skin. The RN/UM stated that upon admission, the LPN's are expected to perform a head to toe skin assessment and document the findings with in the resident's medical record. The RN/UM stated that she documented that the resident was admitted with the wounds. The surveyor asked if she spoke to the Licensed Practical Nurse (LPN) who performed the admission assessment, or if the CNA's who had performed incontinence care had observed the presence of the wounds, and the RN/UM stated that she had not spoken to those staff prior to writing her note, and that she had just assumed that it had been there. She confirmed the hospital records were vague in the assessment of the skin/pressure ulcers and did not document evidence of what stage the stageable wounds were to the buttocks. She acknowledged that the wound consultant/NP documented the wounds as stage III pressure ulcers on 12/31/19. The RN/UM stated that she had brought this situation up to the the Director of Nursing (DON) on 12/27/19. The RN/UM confirmed there was no physician order for [REDACTED]. The RN/UM stated that she did not perform an investigation but that the surveyor could ask the DON. On 1/28/20 at 11:46 AM, the surveyor interviewed the CNA who stated that she was always the CNA assigned to care for Resident #40 since admission, and that she worked full time during the day shift (7 AM to 3 PM). The CNA stated that the resident was always cooperative with care for her, and that he/she was incontinent of bowel and had a bowel movement this morning. The CNA stated that the resident came in to the facility with wounds to the buttocks, and that he/she always had a treatment over top of the buttock wounds that she could recall, even on Christmas day when she worked. The CNA stated that she did not have to write a statement regarding the resident's skin and that no one had asked her about the condition of the resident's skin upon admission. On 1/28/2020 at 1:16 PM in the presence of the survey team, the DON stated that there was no investigation conducted for the lack of documentation related to the buttocks pressure ulcers for the three days after admission to the facility. On 1/29/20 at 10:44 AM, the surveyor interviewed the DON and the Licensed Nursing Home Administrator (LNHA). The DON stated that she did not conduct an investigation at the time the wounds were first documented. She stated that she had since spoke to the admitting LPN who told her that the resident refused to turn and therefore the skin could not be adequately visualized. The DON stated that if a resident refuses to turn for the admission assessment, that the physician should be notified and it should get reported on the 24 hour report to check the skin at the next incontinence care change or at the next most convenient time when the resident was getting up, such as for physical therapy. The DON acknowledged that she did not get statements from the CNA's or nurses who cared for the resident on 12/24/19, 12/25/19 and 12/26/19 to see if wounds were identified during incontinence care, and if so, did they report the wounds to the nurse or the supervisor, because there had been no treatment order in place on those dates. The DON understood the surveyor's questions, and confirmed had she had obtained statements through an investigation, she would be able to demonstrate that the pressure ulcers to the buttocks were actually there or not there upon admission. She provided the surveyor hospital records that reflected the resident had gluteal and sacral wounds during a hospital stay, but she could not speak to if the wounds had healed and subsequently reopened or if the resident was admitted with the wounds. The DON stated that as of yesterday 1/28/2020, the right and left gluteal pressure ulcers wounds had healed. On 1/29/2020 at 12:02 PM, the surveyor attempted to conduct a phone interview with the LPN who admitted the resident on 12/24/19. The LPN did not answer the phone nor return the surveyor's request for a return call. On 1/30/2020 at 12:36 PM, the surveyor conducted a phone interview with the Registered Nurse/Supervisor (RN/S) for the evening shift of 12/24/19. The RN/S stated that she was went into the resident's room with the LPN that evening to assess the resident's skin but the resident was refusing to be turned to fully check the skin. The RN/S stated that she believed there were open areas to the buttocks due to the fact the resident had an indwelling urinary catheter from the hospital, and that the hospital records reflected evidence of a history of wounds to the buttocks and sacrum. She stated that she did not recall communicating with anyone (nurse or physician) that the resident's skin was not fully assessed due to his/her refusal to turn in bed in order for staff to adequately visualize the skin. The RN/S stated that she believed the resident was admitted on an air mattress due to the resident's condition and risk factors. The RN/S confirmed to the surveyor that there had been no investigation done prior to surveyor inquiry to evaluate if the wounds had been present upon admission and if they were determined to be not present on admission, to determine if they were avoidable or unavoidable. A review of the facility's Investigating Injuries revised (MONTH) (YEAR) included that the Administrator will ensure that all injuries are investigated. It also included that if an incident/accident is suspected a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the Administrator and Director of Nursing Services. A review of the facility's Abuse Investigation and Reporting policy revised (MONTH) (YEAR) included that the individual conducting the investigation will, at a minimum include a review of the the resident's medical record to determine events leading up to the incident; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; review all events leading up to the alleged incident. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator. NJAC 8:39-9.4(f)

Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to a.) accurately transcribe a medication order and b.) failed to ensure that a resident was administered the correct medication according to nursing standards of practice for 1 of 18 resident's (Resident #10) reviewed for accuracy of physician's orders [REDACTED]. The inaccuracy of the transcription and the continuance of the order, created an immediate jeopardy situation for Resident #10, who had received the antipsychotic medication during the 3:00 p.m. to 11:00 p.m. shift on 8/8/13. The continuance of this order, increased the danger of the resident receiving this high risk medication. In addition, the facility failed question an order for [REDACTED]. The immediate jeopardy was identified by the survey team on 8/9/13 at 3:30 p.m. The facility was notified of the immediate jeopardy on 8/9/13 at 4 p.m. The facility submitted an unacceptable plan of correction on 8/9/13 at 5:11 p.m. An acceptable plan of correction was submitted by the facility at 5:30 p.m. and the immediacy was corrected. The deficient practice was evidenced by the following: A.) The surveyor reviewed Resident #10's medical record on 8/9/13 at 1:45 p.m. The record revealed the resident had been admitted to the facility following a recent hospitalization for abdominal surgery. Additionally, the resident had [DIAGNOSES REDACTED]. A Resident Evaluation Form for Admission and a Fall Risk Factors Assessment both dated 8/2/13, reflected the resident was alert and without cognitive impairment. A review of Resident #10's physician orders [REDACTED]., every 12 hours for [MEDICAL CONDITION] disorder and [MEDICATION NAME] (a narcotic [MEDICATION NAME]), 5/325 mg., every four hours as needed for moderate pain. On 8/5/13, the physician [MEDICATION NAME](an hypnotic), 10 mg. at bedtime as needed. On 8/6/13, [MEDICATION NAME], an (antidepressant and also used as a hypnotic), 50 mg. at bedtime was ordered. On 8/8/13, the physician ordered [MEDICATION NAME] (a narcotic [MEDICATION NAME]), 10 mg. by mouth every 12 hours for pain. On the same day at 4:40 p.m., the nurse practitioner (NP) changed [MEDICATION NAME] 10 mg. by mouth from "as needed" to "every night." an order for [REDACTED]. An additional order by the NP on 8/8/13 at 4:40 p.m., reflected that if the [MEDICATION NAME] is used it should be separated from [MEDICATION NAME] one hour. A review of Resident #10's physician order [REDACTED]. [MEDICATION NAME] 1 p.o. now." A Skilled Daily Nurses Note (SDNN) on 8/8/13 at 6:30 p.m., reflected the nurse documented that Resident #10 was seen by the NP and new orders were received. On 8/8/13 at 9:30 p.m. the nurse documented in a SDNN "[MEDICATION NAME] 40 mg. available, not 50 mg. One time order for 40 mg. received and noted." According to the "2008 Nursing Drug Handbook" and physician's "Monthly Prescribing Reference" dated 12/2012, [MEDICATION NAME] ([MEDICATION NAME]) was classified as a phenothiazine which causes central nervous system depression and may cause lowered [MEDICAL CONDITION] threshold. Additionally, its use was cautioned in patients with liver or kidney disease. On 8/9/13 at 1:50 p.m. the surveyor requested to see all medications stored in the medication cart for Resident #10. The medication nurse and Unit Manager showed the medications to the surveyor. [MEDICATION NAME] was not in the medication cart. The Director of Nursing (DON) came on to the unit and told the surveyor [MEDICATION NAME] is kept in the Pyxis machine (an automated medication dispensing system). At that time, the DON provided documentation printed from the Pyxis machine that indicated that four 10 mg. tablets of [MEDICATION NAME] were dispensed from the machine on 8/8/13 at "20:21:08" (8:21 p.m.) for Resident #10. A review of Resident #10's Medication Administration Record (MAR) dated 8/8/13, reflected a transcribed order for [MEDICATION NAME] 40 mgs one (tablet) now. The MAR was initialed by the nurse which indicated the medication had been administered. Another order dated 8/8/13 for [MEDICATION NAME] 50 mgs one tablet by mouth at hour of sleep was reflected on the MAR. The next scheduled dose was due on 8/9/13 at 9:00 p.m. In addition, the MAR indicated that Resident #10 was also administered [MEDICATION NAME] 10 mgs [MEDICATION NAME] mgs at 10:00 p.m. on the same date by the same nurse that administered the [MEDICATION NAME]. The surveyor interviewed Resident #10 on 8/9/13 at 2:10 p.m. The resident told the surveyor "I just couldn't sleep last night, I asked the nurse for meds. . . the medication didn't work, so I asked the nurse for more meds." The resident further stated, "I don't remember much after I got the meds, but it worked real good." The surveyor observed the resident with the eye lids half closed and appeared to have difficulty keeping the eyes open throughout the conversation with the surveyor. The resident said, "I'm very tired today, the medications last night worked good for me." The surveyor placed a telephone call to Resident #10's primary physician on 8/9/13 at 2:15 p.m. The physician was not available and a message was left with his office to return the call. The physician returned the telephone call to the surveyor on 8/9/13 at 4:30 p.m. He stated he gave the nurse an order for [REDACTED]. He stated, "I did not give an order for [REDACTED]. On 8/9/13 at 2:55 p.m. the surveyor spoke with the Registered Nurse/Supervisor (RNS) who was on duty the evening of 8/8/13. The RNS stated the Licensed Practical Nurse (LPN) called her and stated the facility did not have 50 mg. of [MEDICATION NAME] available. She revealed only 40 mg. of [MEDICATION NAME] was available. The RNS stated the NP working with resident #10's primary physician gave an order for [REDACTED]..what at first I thought looked like [MEDICATION NAME] but it says [MEDICATION NAME]." She further stated, "I'm in trouble, I'm going to get fired." On 8/9/13 at 3:08 p.m. the surveyor spoke with the LPN on duty the evening of 8/8/13. The LPN stated the RNS "wrote the order and I transcribed the order and gave the order." The LPN said she did not question the order for [MEDICATION NAME]. She stated she thought the medication would have the effect of calming the resident. The LPN stated the medication was not in the medication cart and was obtained from the Pyxis machine. The RNS was again interviewed by the surveyor on 8/9/13 at 3:18 p.m. The RNS stated she was on the other side of the building when the LPN called and told her there was an order for [REDACTED]. The RNS stated she then called the physician and informed him that [MEDICATION NAME] 50 mg was not available from the Pyxis machine, however, [MEDICATION NAME] 40 mg. was available. The RNS told the surveyor the order "was communicated to me as [MEDICATION NAME]. I did not look at the order." The RNS revealed she called the primary physician and told him [MEDICATION NAME] 50 mg. was not available. The physician gave her a verbal order for a one time order for [MEDICATION NAME] 40 mg. which she wrote on the Physician order [REDACTED]. The surveyor spoke with the DON and Clinical Services Consultant (CSC) on 8/9/13 and informed them of the immediate jeopardy situation for Resident #10 and explained the circumstances surrounding the issues. The DON and CSC expressed understanding of the immediate jeopardy. The immediate jeopardy was identified by the survey team on 8/9/13 at 3:30 p.m. after communication to the office. The facility was notified of the immediate jeopardy on 8/9/13 at 4 p.m. The facility submitted an unacceptable plan of correction on 8/9/13 at 5:11 p.m. An acceptable plan of correction was submitted by the facility at 5:30 p.m. and the immediacy was corrected at that time. The team verified the POC regarding the immediacy and continued to verify additional elements of the POC through 8/12/13 on completion. The citation continued at a D level until 8/12/13 at 10:00 a.m. when the survey team verified the staff's knowledge of the in-services and other elements of the POC. The POC, which was accepted and verified by the survey team, included the following elements: 1. Resident #10 was assessed by a Registered Nurse. 2. Resident #10 was monitored for the next 24 hours. 3. Resident #10's Physician was notified of the transcription error. 4. Resident #10 and the resident's responsible party were notified. 5. The physician's orders [REDACTED]. 6. The order was clarified for [MEDICATION NAME]. 7. A Medication Error Report was completed. 8. The facility initiated an investigation. 9. The nurses were educated on: transcription of physician orders, clarification of physician orders, verifying orders and knowledge of medications being administered until completed. 10. The physician and his nurse practitioner's orders have been verified. 11. Residents with orders for [MEDICATION NAME],[MEDICATION NAME] were reviewed for accuracy any new medication orders implemented since August recapitulation 2013, including like spelled named medications. 12. All nursing staff were in-serviced by the facility Nurse Educator beginning on 8/9/13 and continued through 8/12/13 until completion. 13. All medical records were audited for transcription errors by Unit Managers and Corporate Clinical Nurses at the time of discovery. Refer to F333. B. While the Immediate Jeopardy was corrected for Resident #10, this deficient practice continued at F 281 at a lower scope and severity (D) level as follows: Based on interview, record review and review of other facility documentation, it was determined that the facility failed to a.) transcribe medications onto a residents physician's orders [REDACTED].#8), b.) provide indications for the use of medications for 2 of 18 residents reviewed (Resident #8 and #15), and c.) perform a nursing assessment and/or document the condition of a wound for 1 of 5 residents reviewed for wounds (Resident #6), in accordance with clinical standards of nursing practice and facility policy. This deficient practice was evidenced by the following: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 5/26/13, indicated the resident was alert and required supervision with activities of daily living (ADL). The surveyor reviewed the medical record Physician order [REDACTED]." The order did not identify the clinical symptom(s) that indicated when to administer the medication. The August 2013 Medication Administration Record (MAR) showed Senna 17.2 mg at bedtime as needed, had not been administered in the month of August 2013. 2. The medical record for Resident #8 was reviewed by the surveyor on 8/8/13. According to the Admission Record, Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE], indicated the resident was alert and required extensive assistance with ADL. A review of Resident #8's Physician order [REDACTED]." The PO did not identify the clinical symptom(s) that indicated when to administer the medication. Furthermore, the PO for BID PRN did not specify the number of hours between administering doses for the PRN twice a day medication. The August 2013 MAR revealed [MEDICATION NAME] had not been administered PRN for the month of August. The surveyor reviewed the August PO recap for Resident #8 which revealed medication orders dated 7/25/13, for [MEDICATION NAME] Protein Powder one packet three times a day (TID), medication orders dated 7/30/13, for [MEDICATION NAME] 100 mg BID, and Ben Gay Cream daily at 6:00 p.m. to lower back that were not transcribed onto the August PO Form recap. However, the August 2013 MAR showed that [MEDICATION NAME] Protein Powder, [MEDICATION NAME], and Ben Gay Cream were transcribed onto the MAR and were all administered to Resident #8. The surveyor interviewed the Licensed Practical Nurse (LPN) on 8/9/13 at 9:40 a.m. who was the primary care nurse for Resident #8. When the surveyor inquired how the LPN would know when to administer the PRN [MEDICATION NAME] to the resident, the LPN stated "I didn't think [MEDICATION NAME] could be given PRN, but the doctor said it was OK and gave the order PRN BID." The surveyor then asked the LPN how the BID timing of [MEDICATION NAME] would be determined. The LPN stated that if Resident #8 had Gout pain, the resident would call for the medication. The LPN revealed the resident had not complained of any pain and had not received any medication since the order was changed. The LPN further stated if Resident #8 was administered the Cholchicine at 9:00 a.m. the next nurse should know not to administer the medication again "till at least 5:00 p.m." The surveyor interviewed Resident #8 on 8/9/13 at 12:50 p.m. Resident #8 stated "I really don't need the Gout medicine, my Gout was in my left knee and I got the above the knee amputation." "If I needed the med - I can tell if the Gout is coming because it would now be a pain in the left elbow." The surveyor interviewed the Director of Nurses (DON) on 8/12/13 at 10:00 a.m. regarding the [MEDICATION NAME] 0.6 mg PRN BID and the Senna PRN order that had no indication or symptom for use. The DON stated she would investigate the orders. On 8/13/13 at 11:50 a.m. the DON advised the surveyor that the physician had discontinued the [MEDICATION NAME] 0.6 mg PRN BID order. The DON then provided a copy of the PO form that showed the physician had discontinued the order. In addition, the DON provided the surveyor with a copy of a fax dated 8/13/13 at 6:51 a.m. sent to the facility pharmacy with a handwritten note that reflected that the physician orders [REDACTED]. A review of the facility's policy Medical Records and Reports; Receiving and Auditing Medical Records, effective 10/1998, indicated, any new orders or changes recorded after the records were printed will be noted on the new forms as appropriate. All entries will be dated and initialed by the nurse. In addition, if the physician has made any changes to the POS prior to signature, the POS is faxed to the pharmacy and the nurse then makes any corresponding changes and/or corrections to the MAR and Treatment sheets. There was no documented evidence this policy was consistently followed. 3. The medical record for Resident #6 was reviewed by the surveyor on 8/9/13. The Admission Record indicated the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident had a severe cognitive deficit, was non ambulatory, and required total assistance for activities of daily living. The care plan reflected the resident was at risk for skin impairment and skin integrity was impaired. Interventions included, but limited to; a treatment plan for the resident's wounds, weekly treatment documentation to include measurements of each area of the skin breakdown width, length, depth, type of tissue, exudate and any other notable changes or observations. The surveyor observed a treatment for [REDACTED]. During the treatment observation the surveyor noted a wound to Resident #6's anterior left foot. The RN applied skin prep to the area and left it open to air. A review of the Pressure Ulcer Record for Resident #6's top surface of the left foot (left anterior foot) dated 6/27/13, indicated a wound was identified as a deep tissue injury (DTI) measuring 3.7 cm (width) by 3 cm (length) with no depth and skin prep was applied as a treatment. A review of Resident #6's Physician order [REDACTED].#6's left foot. A review of the Pressure Ulcer Record dated 7/11/13 and 7/13/13, indicated Resident #6 had a wound to the left anterior foot that measured 3.5 cm (width) by 3 cm (length) with no depth and no stage indicated. On 7/18/13 documentation reflected a "discoloration" was noted to the resident's left anterior foot and skin prep was applied. The entry was not signed by the the nurse and did not indicate measurements or status of the wound. A review of a Pressure Ulcer Record dated 8/7/13, reflected a Stage I wound was identified on the same area noted above and measured 4.5 cm (width) by 3.5 cm (length) and skin prep was applied. There was no depth indicated. On 8/9/13 at 11:55 a.m., the surveyor interviewed the CSS and the RN. The surveyor asked the CSS about the area to Resident #6's left anterior foot and to describe the area to the surveyor. She confirmed that the area to the left anterior foot "does look like an abrasion." On 8/9/13 at 12:40 p.m., the surveyor reviewed the Pressure Ulcer Record for the left anterior foot dated 7/18/13 and 8/7/13 with the CSS. She confirmed that the nurse should have documented the measurement of the wound and/or indicated if the wound had healed. In addition, the CSS stated the nurse should have signed the Pressure Ulcer Record. On 8/12/13 at 12:50 p.m., the team met with the Director of Nursing (DON) and the Clinical Services Consultant (CSS) and requested any additional information regarding Resident #6's left anterior foot wound. On 8/13/13 at 10:10 a.m., the team met with the DON and CSS. The DON confirmed that the nurse should have signed the Pressure Ulcer Record and indicated the wound measurements or if the wound had healed. Furthermore, she revealed the wound to Resident #6's left anterior foot was not new and it was the same wound as noted on 7/13/13. The DON stated the nurse did not follow the procedures for wound documentation. The nurse, who documented on the Pressure Ulcer Record dated 7/18/13, was not available for interview. A review of the facility's policy "Skin Integrity Program: Evaluation and Documentation of Wounds" effective date 4/1/2010, reflected the purpose was "To accurately report observations to the primary care provider, guide treatment selection, and track wound healing through accurate observation and documentation of the size, type, location, appearance, characteristics and progress of wounds." In addition, reflected "Evidence of progress toward healing (improved wound bed, decrease in drainage or odor, decreasing size, ect.) or lack of progress toward healing, or deterioration of the wound." There was no documented evidence this policy was consistently followed. NJAC 8:39-27.1 (a) 8:39-29.2(d)

Based on observation, interview, and review of the medical record, it was determined that the facility failed to ensure that a resident was administered the correct medication for 1 of 18 residents reviewed for accuracy of physicians' orders (Resident #10). This resulted in an immediate jeopardy situation for Resident #10 who was administered an antipsychotic medication during the 3:00 p.m. to 11:00 p.m. shift on 8/8/13. The continuance of administration of this high risk medication, increased the danger to the resident's welfare. In addition, the facility failed to determine an indication or [DIAGNOSES REDACTED]. The immediate jeopardy was identified by the survey team on 8/9/13 at 3:30 p.m. The facility was notified of the immediate jeopardy on 8/9/13 at 4 p.m. The facility submitted an unacceptable plan of correction on 8/9/13 at 5:11 p.m. An acceptable plan of correction was submitted by the facility at 5:30 p.m. and the immediacy was corrected. The deficient practice was evidenced by the following: The surveyor reviewed Resident #10's medical record on 8/9/13 at 1:45 p.m. The record revealed the resident had been admitted to the facility following a recent hospitalization for abdominal surgery. Additionally, the resident had [DIAGNOSES REDACTED]. A Resident Evaluation Form for Admission and a Fall Risk Factors Assessment both dated 8/2/13, reflected the resident was alert and without cognitive impairment. A review of Resident #10's physician orders [REDACTED]., every 12 hours for [MEDICAL CONDITION] disorder and [MEDICATION NAME] (a narcotic [MEDICATION NAME]), 5/325 mg., every four hours as needed for moderate pain. On 8/5/13, the physician [MEDICATION NAME](a hypnotic), 10 mg. at bedtime as needed. On 8/6/13, [MEDICATION NAME], (an antidepressant and also used as a hypnotic), 50 mg. at bedtime was ordered. On 8/8/13, the physician ordered [MEDICATION NAME] (a narcotic [MEDICATION NAME]), 10 mg. by mouth every 12 hours for pain. On the same day at 4:40 p.m., the nurse practitioner (NP) changed [MEDICATION NAME] 10 mg. by mouth from "as needed" to "every night." an order for [REDACTED]. A review of Resident #10's physician order [REDACTED]. [MEDICATION NAME] 1 p.o. now." A Skilled Daily Nurses Note (SDNN) on 8/8/13 at 6:30 p.m., reflected the nurse documented that Resident #10 was seen by the NP and new orders were received. On 8/8/13 at 9:30 p.m. the nurse documented in a SDNN "[MEDICATION NAME] 40 mg. available, not 50 mg. One time order for 40 mg. received and noted." According to the "2008 Nursing Drug Handbook" and physician's "Monthly Prescribing Reference" dated 12/2012, [MEDICATION NAME] ([MEDICATION NAME]) was classified as a phenothiazine which causes central nervous system depression and may cause lowered [MEDICAL CONDITION] threshold. Additionally, its use was cautioned in patients with liver or kidney disease. On 8/9/13 at 1:50 p.m. the surveyor requested to see all medications stored in the medication cart for Resident #10. The medication nurse and Unit Manager showed the medications to the surveyor. [MEDICATION NAME] was not in the medication cart. The Director of Nursing (DON) came on to the unit and told the surveyor [MEDICATION NAME] is kept in the Pyxis machine (an automated medication dispensing system). At that time, the DON provided documentation printed from the Pyxis machine that indicated that four 10 mg. tablets of [MEDICATION NAME] were dispensed from the machine on 8/8/13 at "20:21:08" (8:21 p.m.) for Resident #10. A review of Resident #10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Another order dated 8/8/13 for [MEDICATION NAME] 50 mgs one tablet by mouth at hour of sleep was reflected on the MAR. The next scheduled dose was due on 8/9/13 at 9:00 p.m. In addition, the MAR indicated [REDACTED]. The surveyor interviewed Resident #10 on 8/9/13 at 2:10 p.m. The resident told the surveyor "I just couldn't sleep last night, I asked the nurse for meds. . . the medication didn't work, so I asked the nurse for more meds." The resident further stated, "I don't remember much after I got the meds, but it worked real good." The surveyor observed the resident with the eye lids half closed and appeared to have difficulty keeping the eyes open throughout the conversation with the surveyor. The resident said, "I'm very tired today, the medications last night worked good for me." The surveyor placed a telephone call to Resident #10's primary physician on 8/9/13 at 2:15 p.m. The physician was not available and a message was left with his office to return the call. The physician returned the telephone call to the surveyor on 8/9/13 at 4:30 p.m. He stated he gave the nurse an order for [REDACTED]. On 8/9/13 at 2:55 p.m. the surveyor spoke with the Registered Nurse/Supervisor (RNS) who was on duty the evening of 8/8/13. The RNS stated the Licensed Practical Nurse (LPN) called her and stated the facility did not have 50 mg. of [MEDICATION NAME] available. She revealed only 40 mg. of [MEDICATION NAME] was available. The RNS stated the NP working with resident #10's primary physician gave an order for [REDACTED]." She further stated, "I'm in trouble, I'm going to get fired." On 8/9/13 at 3:08 p.m. the surveyor spoke with the LPN on duty the evening of 8/8/13. The LPN stated the RNS "wrote the order and I transcribed the order and gave the order." The LPN said she did not question the order for [MEDICATION NAME]. She stated she thought the medication would have the effect of calming the resident. The LPN stated the medication was not in the medication cart and was obtained from the Pyxis machine. The RNS was again interviewed by the surveyor on 8/9/13 at 3:18 p.m. The RNS stated she was on the other side of the building when the LPN called and told her there was an order for [REDACTED]. was available. The RNS told the surveyor the order "was communicated to me as [MEDICATION NAME]. I did not look at the order." The RNS revealed she called the primary physician and told him [MEDICATION NAME] 50 mg. was not available. The physician gave her a verbal order for a one time order for [MEDICATION NAME] 40 mg. which she wrote on the Physician order [REDACTED]. The surveyor spoke with the DON and Clinical Services Consultant (CSC) on 8/9/13 and informed them of the immediate jeopardy situation for Resident #10 and explained the circumstances surrounding the issues. The DON and CSC expressed understanding of the immediate jeopardy. The immediate jeopardy was identified by the survey team on 8/9/13 at 3:30 p.m. after communication to the office. The facility was notified of the immediate jeopardy on 8/9/13 at 4 p.m. The facility submitted an unacceptable plan of correction on 8/9/13 at 5:11 p.m. An acceptable plan of correction was submitted by the facility at 5:30 p.m. and the immediacy was corrected at that time. The team verified the POC regarding the immediacy and continued to verify additional elements of the POC through 8/12/13 on completion. The citation continued at a D level until 8/12/13 at 10:00 a.m. when the survey team verified the staff's knowledge of the in-services and other elements of the POC. The POC, which was accepted and verified by the survey team, included the following elements: 1. Resident #10 was assessed by a Registered Nurse. 2. Resident #10 was monitored for the next 24 hours. 3. Resident #10's Physician was notified of the transcription error. 4. Resident #10 and the resident's responsible party was notified. 5. The physician's orders [REDACTED]. 6. The order was clarified for [MEDICATION NAME]. 7. A Medication Error Report was completed. 8. The facility initiated an investigation. 9. The nurses were educated on: transcription of physician orders, clarification of physician orders, verifying orders and knowledge of medications being administered until completed. 10. The physician and his nurse practitioner's orders have been verified. 11. Residents with orders for [MEDICATION NAME],[MEDICATION NAME] were reviewed for accuracy any new medication orders implemented since August recapitulation 2013, including like spelled named medications. 12. All nursing staff were in-serviced by the facility Nurse Educator beginning on 8/9/13 and continued through 8/12/13 until completion. 13. All medical records were audited for transcription errors by Unit Managers and Corporate Clinical Nurses at the time of discovery. NJAC 8:39-29.2(d)

C# NJ , & NJ Based on observation, interviews, review of medical records, and other facility documentation, it was determined that the facility failed to ensure that identified safety care plan interventions (tabs alarm, and/or seat belt, and/or, floor mat and/or, Dycem or non-skid pad) were consistently implemented, monitored and/or provided for 2 of 3 sampled residents (Resident #1 and Resident #3). In addition, the safety devices identified were not always included during the facility's fall investigations for both residents. On 4/7/12, Resident #1 who was identified as a fall risk and was care planned for a bed and chair alarm sustained a fall in her room without her bed and/or chair alarm in place during the fall. Subsequently, Resident #1 was noted with increased level of pain, received increased pain medication dosage for pain management, required x-rays, a hospital visit for further evaluation, and was diagnosed with [REDACTED]. In addition, on 4/20/12, Resident #1 was observed by the surveyor in bed without her safety devices in place (tabs alarm and a floor mat). On 2/22/12, Resident #3 who was identified on his care plan as a fall risk and needing a non-skid material (Dycem) on his wheelchair and a self release seat belt, sustained a fall with no injuries. There was no indication on the incident and/or fall investigation that the identified safety devices (seat belt and/or Dycem) were in place during his fall. In addition, a physician's orders [REDACTED].#1 was not transcribed on the treatment administration record (TAR) until 4/12. These deficient practices are evidenced by the following: A review of Resident #1 and Resident #3's medical records by the surveyor on 4/20/12 and 5/3/12 revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on 3/28/11 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated 4/5/12, reflected the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of "15", and required extensive assistance with transfers and walking. An interdisciplinary plan of care (IDCP) on falls for Resident #1 dated 1/12 to 4/12, reflected that she was at risk for falls due to impaired balance, coordination, and unsteady gait with cognitive impairment. The goal was to not have injury from falling x 90 days. Interventions included; a chair alarm, bed alarm at night, floor mattress next to bed, call bell within reach, and bed in lowest position. An IDCP update dated 4/8/12, documented interventions including; scheduled toileting, reeducate on call bell use, medication review, and.."bed alarm re-applied". A care card for Resident #1 dated 2/12 to 4/12 used by the Certified Nursing Assistants as their guide on how to take care of their assigned residents, documented "High Fall Risk" and TABS alarm at all times. A Reportable Event Record/Report (RERR) faxed by the facility to the Department of Health and Senior Services (DHSS) on 4/11/12, reflected that on 4/7/12 at 11:00 PM, Resident #1 was found by the 3-11 shift Registered Nurse/ RN on the floor in her room leading to her bathroom. The resident stated that she wanted to use the bathroom. Resident #1 complained of pain on her lower back and "butt area" that was relieved by Tylenol with no signs of injuries noted. On 4/9/12, it was further documented that Resident #1 complained of increased pain, the physician was made aware and ordered .."Stat X-ray of left hip and pelvis.." On 4/10/12, Resident #1 continued to complain of pain, with decreased movement of her left lower extremity, and was kept on bedrest. The physician was notified and ordered to send Resident #1 to the hospital for evaluation. The resident was not admitted , and returned to the facility on the same day with a CT-scan results of pelvis and both hips showing "Left inferior pubic ramus subtle nondisplaced fracture". Further review of the RERR statement summary from staff about the fall incident, documented the following: - A Registered Nurse/RN, revealed that she last observed Resident #1 in bed at 10:50 PM sleeping. Ten minutes later, the RN heard a loud scream and "thump". Resident #1 was found on the floor leading to the bathroom, was able to move all extremities, complained of pain to buttocks, was assisted back to bed by the RN and a Certified Nursing Assistant (CNA). The family and physician were notified, and the resident was monitored. - The CNA assigned to Resident #1 was interviewed by the Director of Nursing at 3:00 PM on 4/11/12 about the incident. The CNA revealed that he toileted Resident #1 at 8:00 PM, and put her to bed. At 10:00 PM, Resident #1 rang and asked the CNA to check the window. The CNA further revealed that he adjusted the temperature of the room for the resident's comfort, and Resident #1 had non-skid socks, her bed was on low position, her call bell was within reach, and the mat was next to her bed. The CNA became aware of the fall at 11:00 PM. There was no documentation and/or any statements obtained from both the RN and the CNA about Resident #1's alarms (bed/chair) placement and/or function during the 4/7/12 incident. The investigation findings on the RERR, reflected that the care plan interventions already in place prior to Resident #1's fall included a bed alarm at night and chair alarm. Further review of the RERR conclusion, reflected that the fall was unwitnessed, and it corroborated the RERR's description of event including the injury sustained by the resident after her fall. There was no mention about the placement and/or function of the bed/chair alarm at the time of the incident, and no concerns noted. It was further documented on the RERR, that the facility's follow up action included for her a Fentanyl patch for pain dose increased from 12.5 mcg/hr to 37 mch/hr every 72 hours, and the .."bed alarm reapplied". During a care tour by the surveyor on 4/20/12 at 10:45 AM and 10:57 AM with the RN/unit manager and/or the 7-3 shift CNA, the resident was observed by herself lying in bed with no bed alarm and no floor mat in place. The resident's bed alarm was found by the RN/unit manager on top of the roommate's bedside table, and was applied on Resident #1 in front of the surveyor. The resident's bed mat was not on the floor, and was placed on her right side by the CNA in the presence of the surveyor. During an interview by the surveyor on 4/20/12 at 11:02 AM with the RN/unit manager about Resident #1's bed alarm and floor mat, revealed that they should have been in place during our care tour. During an interview by the surveyor on 4/20/12 at 10:47 AM with the 7-3 shift CNA, revealed that she applied the resident's bed alarm at 8:00 AM, and claimed that the resident's daughter was in her room... "an hour ago". She was unable to explain why the resident did not have a bed alarm or a floor mat when observed by the surveyor. An interview by the surveyor on 4/20/12 at 11:00 AM with the 7-3 shift floor nurse (RN), assigned to Resident #1, revealed that the CNA's should check the placement of the resident's safety devices/ alarms every half hour. She further stated that Resident #1's family has no history of removing the resident's alarm. The 7-3 floor nurse could recall seeing the resident's bed alarm on the resident between 7:00 AM to 7:30 AM before the resident received her morning care from her CNA. Resident #1 refused to be interviewed by the surveyor. During an interview by the surveyor on 4/20/12 at 12:20 PM with Resident #1's 3-11 shift CNA from 4/7/12, revealed that Resident #1 had a bed mat next to her bed on the floor, but did not have a bed alarm at the time of the incident. According to the CNA he had Resident #1 on several occasions, and was not aware that the resident required a bed alarm , and denied applying a bed alarm on Resident #1 when he put her to bed on the night of the incident. During an interview by the surveyor on 4/20/12 at 12:30 PM with the 3-11 shift RN who found Resident #1 on the floor on 4/7/12, revealed that she did not hear an alarm sound and did not think think the resident had a bed alarm. She further stated that she had no knowledge of Resident #1 needing a bed alarm at that time. A review of the 4/12 TARS for Resident #1, reflected that the monitoring for the bed and chair alarm was not transcribed on the TARS until 4/8/12, the day after her fall. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], reflected the resident with a BIMS score of "0", and required limited to extensive assistance with her activities of daily living (ADL's) except for eating. The resident had a history of [REDACTED]. An interdisciplinary plan of care (IDCP) dated 1/11 to 1/12 for Resident #3, reflected that the resident has a self release seatbelt to his wheelchair. Further review of the IDCP, revealed that the resident was identified for potential for falls from 12/11 due to poor safety awareness and poor impulse control. Interventions also included; a non-skid material on his wheelchair implemented from 12/23/11, and fall risk assessment per facility policy. A most recent update (4/17/12) on the IDCP for falls, documented that the resident does not use the seatbelt appropriately. There was no documentation of a chair and/or tabs alarm on the 1/11 to 4/12 IDCP. A physician's orders [REDACTED]. Further review of the POS dated 4/16/12, documented a clarification order for the tabs. A review of the 2/12 to 4/12 treatment administration record sheets (TARS) for Resident #3, reflected that the order for the tabs placement and monitoring was not transcribed until 4/12. A care card for Resident #3, documented that his self release seat belt was discontinued on 4//17/12. The chair alarm was documented with no date when it was initiated. During a care tour by the surveyor on 4/20/12 at 10:40 AM with the RN/unit manager, Resident #3 was observed sitting in his wheelchair with a functioning TABS alarm on, and a non-skid pad. The resident was alert, but with confusion as verified by the RN/unit manager. A review of an incident report (IR) dated 2/22/12 with no time indicated, reflected that Resident #3 was found sitting on his buttocks in the facility hallway. The fall was unwitnessed with no injuries noted. The section for physical and chemical restraint was left blank. A fall investigation attached to the IR, reflected no equipment used by the resident except for his wheelchair. Under the section for recommendations to prevent further falls, it was documented by the RN/unit manager that..."staff will toilet pt immediately after meals & ensure seat belt is on & Dysom (non-skid pad) is in place on w/c (wheelchair)". A review of an IDCP (interdisciplinary) meeting summary related to Resident #1's 2/12 fall, signed by the IDCP team including the RN/unit manager, reflected that Resident #1 could not relay what happened and he sustained no injuries from the fall. It was further documented that....."the use of seatbelt and Dysom will be re-enforced". A CNA investigation dated 2/22/12 signed by the CNA assigned to Resident #1 at the time of the incident, did not indicate whether or not Resident #1 had on his seat belt and the Dycem pad. An individual statement form obtained from the RN on duty at the time of the incident dated 2/22/12, documented that the incident occurred on 2/22/12 at 6:55 PM in the hallway. The physician and the family were notified. There was no documentation about the resident's seat belt or his non skid pad from the RN's statement. There was no evidence and/or documentation that the resident's identified safety devices (seat belt and non-skid pad) from his fall care plan were implemented during his 2/11 fall for safety. During an interview by the surveyor on 5/3/12 at 12:30 PM with the CNA who was assigned to Resident #3 during the fall incident on 2/22/12, revealed that she could not remember if the resident had his seatbelt on or if the Dycem was on his wheelchair. The CNA further stated that she would have documented on her statement from the investigation if they were in place. During an interview by the surveyor on 5/3/12 at 12:20 PM with the RN who found Resident #3 on the floor on 2/22/12, revealed that he could not recall if the resident had his seatbelt at the time of the incident. He further stated that the resident always had Dycem pad on his wheelchair, and was sure it was in place. The LPN stated that the identified safety devices should have been documented if in place on the incident report investigation. During an interview by the surveyor on 4/20/12 at 10:30AM and 5/3/12 at 11:35 AM with the RN/unit manager, revealed that it was their practice to care plan on the resident's safety devices, and to document about the safety devices on the treatment administration record sheets (TARS) in order for staff to monitor for placement and function every shift by signing the TARS. Further interview by the surveyor with the RN/unit manager on 5/3/12 at 11:35 AM and 12:00 PM, revealed that she took the 2/12 order for the tabs and should have transcribed the order on the 2/12 TARS. She further stated that chart checks should be done by the 11-7 shift nurse, and the POS was not initialed as checked by the 11-7 nurse. The RN/unit manager, revealed that she wrote the 4/12 clarification order for the tabs when she noticed that the order was not on the TARS from 2/12. When questioned by the surveyor about the safety devices of Resident #3 during her fall investigation from 2/12, the RN/unit manager revealed that no one could tell her either the nurse or the CNA if the Dycem or the seatbelt were in place at the time of the fall. There was no documentation on the 2/12 RN/unit manager's fall investigation that the staff (RN and CNA) involved were unable to remember and/or say if the identified safety devices to prevent falls were in place. A review of the facility's policy and procedure on falls dated 1/1/09, documented that the purpose of the policy is to promote resident independence by providing an environment that is free from hazards over which the Center has control. Each resident is assisted in attaining or maintaining their highest practicable level of function through proving the resident supervision, education, functional programs and assistive devices/equipment , as appropriate to reduce the risks accidents. The process included implementing the appropriate devices such as; bed, chair, and/or sensor alarms on the care plan. The care plan will be reviewed quarterly and as needed for appropriateness, interventions, and will be updated to reflect any new interventions by the appropriate disciplines. Further review of the policy included that a fall investigation form will be utilized to determined probable causal factors. When a resident is found on the floor, the center is obligated to investigate and try to determine how he/she got there, and to put into place an intervention that will reduce the risk of this happening again. NJAC 8:39-27.1 (a) 8:39-27.1 (b)