Every finding on record at Careone at Parsippany

Complaint NJ #409369Based on interview and record review, it was determined the facility failed to; a.) ensure that the acute transfer must be documented in the resident's medical record and appropriate information was communicated to resident or resident representative (RR) including the reserve payment for 1 of 2 residents (Resident #106) reviewed and b.) ensure the discharge summary must include accurate information of the resident and was acknowledged by the RR to ensure safety and orderly discharge for 1 of 1 resident (Resident #110) reviewed.The deficient practice was evidenced by the following: 1.On 12/16/25 at 9:43 AM, Surveyor #1 (S #1) reviewed the hybrid medical records (combination of electronic and paper medical records) of Resident #106, and revealed: A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 9/9/24 and 11/28/25, reflected that the resident had an unplanned transfer to acute hospital. A review of the electronic medical record, under forms, there were two Notice of Transfer to Acute Care Facility (NTACF), form date 9/9/24, that was created and locked (completed) on 3/31/25, and form date 11/29/25, that was created and locked on 12/1/25. Both NTACF forms were created and revised by the Director of Nursing (DON). The two NTACF's did not include information about the RR, including contact information, to whom the notices were provided and there were no documentation about the reserve payment. Further review of the hybrid medical records revealed, there was no documented evidence that the facility included documentation and information conveyed to the RR about notice of bed hold policy and the reserve payment. On 12/16/25 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON informed S #1 that it was the DON's responsibility to notify the resident or RR of the notice of transfer to acute care or hospital including the bed hold notice, and it was the Director of admission (DA) responsibility upon admission for bed hold notice. On 12/16/25 at 11:33 AM, S #1 interviewed the DA, who informed S #1 that as part of facility's process, she was responsible for obtaining the resident or RR's signature in the admission packet that contained the rate that facility bill the resident upon admission. She also stated that she would provide a copy of the resident's admission packet. On 12/16/25 at 11:47 AM, S #1 asked the DON to review the paper closed records that was provided to S #1. The DON confirmed that there should be a reserve payment information in the NTACF for 9/9/24 and 11/28/25. She also stated that there was a typographical (typo) error in the 11/29/25 NATCF and that date should have been 11/28/25. On 12/18/25 at 12:11 PM, the survey team met with the LNHA and DON, and S #1 notified them of the above findings and concerns with regard to Resident #106's NATCF about RR's incomplete information, and reserve payment. On 12/19/25 at 11:42 AM, the survey team met with the LNHA, the DON, and the LNHA stated that the facility acknowledged not filling up the form completely including adding the rate. S #1 then asked the LNHA if the transition for the new billing rate was completed or fulfilled according to the regulation, and the LNHA stated not. A review of the facility's Bed-Holds and Returns Policy that was provided by the LNHA, with a revision date of October 2022, revealed under Policy Statement, residents and/or RR are informed (in writing) of the facility and state bed-hold policies. Policy Interpretation and Implementation: 1. All residents/RR are provided in written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: 1. Notice 1: well in advance of any transfer (e.g. in the admission packet); and b. Notice 2: at the time of transfer (or, if the transfer was emergency, within 24 hours). 2. Reissuance of notice 1 must occur if either the bed-hold policy under the state or facility policy changes after the notice is issued. 3. Multiple attempts to provide the RR with notice 2 should be documented in cases where staff were unable to reach and notify the RR timely. 4. The written bed-hold notices provided to the residents/RR explain in detail:.b. the reserve bed payment policy as indicated by the state plan. On 12/19/25 at 12:48 PM, the survey team met with the LNHA, DON, and the Clinical Support Coordinator (CSC) for an exit conference, and there was no additional information provided by the LNHA. 2. On 12/18/25 at 10:04 AM, Surveyor #2 (S #2) reviewed the medical records of Resident #110, and revealed: A review of the discharge (d/c) summary dated 8/23/24, revealed that the document did not contain the signature of the resident or the RR. There was no documented evidence that the resident or the RR acknowledged the d/c summary. In addition, there was no documented evidence that the facility communicated to the resident or RR the d/c summary information and instructions. Further review of the d/c summary dated 8/23/24, revealed that the vital signs (key measurements of the body's most basic functions (Temperature, Pulse, Respiration, Blood Pressure, plus often Oxygen Saturation, and Pain) that provide a snapshot of a patient's health status, help detect changes, monitor treatment effectiveness, and identify emergencies, forming a fundamental part of patient assessment from admission to ongoing care) captured were from date 8/14/24. A review of the August 2024 physician orders revealed that there was no documented evidence that the facility obtained an order for d/c. On 12/18/25 at 12:25 PM, S #2 notified the LNHA and DON of the above findings and concerns about Resident #110's d/c. On 12/19/25 at 11:43 AM, the LNHA provided documentation of vital signs taken on the morning of the d/c (8/23/24), as well as a Progress Note (PN) completed by the nurse on the day of d/c. S #2 reviewed in the presence of the survey team and the LNHA and DON the provided vital signs and PN documentation and revealed, the last documented vital signs prior to d/c were recorded at 9:47 AM of 8/23/24, while the time of d/c occurred at 7:30 PM, as noted on the Discharge Summary. At that time, the LNHA acknowledged the above findings and issues with the resident's d/c documentation and stated, The expectation is for d/c documentation to include current vital signs, a physician's d/c order, and signatures from the resident or RR, along with documentation of safe d/c procedures. A review of the facility's Discharging the Resident Policy, included .Assess and document the resident's condition at d/c . On 12/19/25 at 12:48 PM, the survey team met with the LNHA, DON, and the CSC for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-4.1; 27.1(a)

Based on interview and review of other facility documentation, it was determined that the facility failed to thoroughly complete in writing the issued required beneficiary notice for 2 of 2 residents reviewed for Beneficiary Protection Notification, (Residents #7 and #44). This deficient practice was evidenced by the following:1.On 12/17/25 at 9:45 AM, the surveyor reviewed the provided Skilled Nursing Facility (SNF) Beneficiary Protection Notification (SNFBPN) Review completed by the facility for Resident #44, and revealed: -The SNFBPN Review indicated Resident #44 last covered Medicare A day was 12/3/25, and Resident #44 remained in the facility. The SNFBPN Review further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form with blanks (no information provided) for the following information to be filled out in the form:=care(s) area that no longer occurring daily (to determine why the services were to stop for Medicare A coverage),=the estimate cost in dollar amount per day per item or service,=the options to check to determine what the resident or resident representative (RR) decided to proceed after ending the coverage for Medicare A. A review of the MDS (minimum data set) of Resident #44, revealed end of PPS (Prospective Payment System), the assessment reference date (ARD) was 12/3/25. The term end of PPS referred to the assessment period that occurred at the conclusion of a resident's Medicare Part A stay. 2.On 12/17/25 at 10:20 AM, the surveyor reviewed the provided SNFBPN Review completed by the facility for Resident #7, and revealed: -The SNFBPN Review indicated Resident #7 last covered Medicare A day was 5/31/25, and Resident #7 remained in the facility. The SNFBPN Review further revealed that a SNFABN form with blanks for the following information to be filled out in the form:=the estimate cost in dollar amount per day per item or service with handwritten information Medicaid rate, instead of the dollar amount=the options to check to determine what the resident or resident representative (RR) decided to proceed after ending the coverage for Medicare A. Further review of the above SNFABN revealed that there was no documented evidence in the residents' medical records as to why the information were blanks, to include a written information about the reason for ending the Medicare Part A (for Resident #44), dollar amount that the resident or RR would incur if they decided to continue with the services, and the resident or RR's decision were provided to had an option (option box were left blank). A review of the MDS of Resident #7, revealed end of PPS, the ARD was 5/31/25. On 12/17/25 at 10:28 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of admission (DA) the above findings and concerns with regard to required beneficiary notices of Residents #7 and #44. On 12/17/25 at 11:23 AM, the surveyor interviewed the Licensed Practical Nurse Clinical Reimbursement Coordinator (LPNCRC) in the presence of the Registered Nurse MDS Coordinator (RNMDSC). The LPNCRC informed the surveyor that she covered for the Social Worker to notify the resident or RR of the required beneficiary notice. She further stated that it was the responsibility of the social services department the beneficiary notices given to the resident and RR. On that same date and time, the LPNCRC acknowledged that the SNFABN form should be thoroughly filled out. She further stated that she was unsure if the dollar amount should be in the form or the word Medicaid rate was enough. She also acknowledged that the Medicaid rate changes. The surveyor then notified of the above findings and concerns, the LPNCRC had no response as to why there were blanks in the form. On 12/17/25 at 11:33 AM, the surveyor interviewed the Director of Social Worker (DSW), who informed the surveyor that she was responsible for sending and providing the resident or the RR of the beneficiary notices for NOMNC (Notice of Medicare Non Coverage) and SNFABN. She stated that she was unaware of the rates in the facility, and that rates at the facility changes for private pay. The DSW was also unaware of the Medicaid and other insurances rates. The DSW had no response when asked by the surveyor how she was able to relay the Medicaid and other facility's rates in the SNFABN when communicating to the resident or RR when providing the beneficiary notices. At that same time, the surveyor notified of the above findings and concerns with the beneficiary notices of Residents #7 and #44. The DSW confirmed that she did not speak with the RR and just left a message in their phone and did not receive an email and electronic signature as well confirming of the receipt and acknowledgment of beneficiary notices. She did not have an answer as to why there were blanks in the forms. She also stated that there was no way they can input the money or actual dollar amount in the form that was why she handwritten the Medicaid rate in the SNFABN. On 12/17/25 at 11:43 AM, the surveyor interviewed the Business Office Manager (BOM), who informed the surveyor that private pay rate was $675, Medicaid had a fixed rate a day that changes once a year, and it was from a state letter that they receive annually. The surveyor asked for a copy of the most recent letter. She also stated that the Medicare rates differs and depends on each resident's MDS RUG (Resource Utilization Groups (RUG), which are components of the Nursing Home Reform Act. The MDS is a standardized assessment tool used to evaluate residents' needs and guide individualized care plans), once the resident transitioned back to Medicaid or became LTC (Long Term Care) with pending Medicaid they get the rate of Medicaid, and private pay rate may change. On that same date and time, the surveyor asked the BOM if it was an expectation that the dollar amount in the SNFABN form had a specific dollar rate if the above information of rates changes and depends on the resident's insurance, and the BOM had no response. On 12/18/25 at 12:11 PM, the survey team met with the LNHA and Director of Nursing (DON), and the surveyor notified them of the above findings and concerns. On 12/19/25 at 11:42 AM, the survey team met with the LNHA, the DON, and the LNHA stated that the facility acknowledged not filling up the form completely including adding the rate. He further stated that both residents were admitted under Medicare, the RR decided to transition to Medicaid. The surveyor then asked the LNHA if the transition for the new billing rate was completed or fulfilled according to the regulation, and the LNLHA stated not. A review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices Policy that was provided by the LNHA, with a revision date of September 2024, revealed, under policy statement, a resident is informed in advance and in writing when Medicare payment denial or change in coverage is likely. Policy Interpretation and Implementation: .3. The resident/beneficiary receiving the notice must: a. be able to read, understand, act on his/her rights, and comprehend the notice; .4. Written notices are provided in person to the beneficiary when possible. A copy of the notice is provided to the beneficiary immediately after the notice is signed. Skilled Nursing Facility Advance Beneficiary Notice: 1. The facility will issue SNFABN to any Medicare resident prior to providing care that Medicare usually covers, but m ay not pay for under the current circumstance because the care is not medically necessary or considered custodial. 2. The SNFABN provides information to the resident so that he or she can decide whether to get the care that may not be paid for by Medicare and assume financial responsibility . On 12/19/25 at 12:48 PM, the survey team met with the LNHA, DON, and the Clinical Support Coordinator for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-4.1(a)(8); 5.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to update and revise a comprehensive care plan to reflect the current status of the residents, a.) with regard to appropriate infection control precautions for 1 of 4 residents, (Resident #83) reviewed for infection control and b.) specifically discontinue a care plan for a resident with discontinued indwelling catheter for 1 of 2 residents (Resident #4) reviewed for urinary catheter. This deficient practice was evidenced by the following: 1. On 12/15/25 at 10:09 AM, Surveyor #1 (S #1) observed Resident #4 sitting up in bed. S #1 interviewed Resident #4, in the presence of the resident representative (RR), who stated that when they first were admitted to the facility that they had an indwelling catheter but that it was removed and that they were recently hospitalized . A review of Resident #4's admission Record or face sheet (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; multiple fractures of pelvis, multiple fractures of ribs right side, and anemia (blood disorder in which the blood has a reduced ability to carry oxygen). A review of Resident #4's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #4's cognition was intact. Further review reflected Resident #4 had an indwelling catheter. A review of Resident #4's comprehensive care plan (CP) included the following focus area: Use of indwelling urinary catheter related to [redacted] edema with interventions and had an initiated date of 9/30/25. A review of Resident #4's Order Summary Report (physician's orders) of active orders as of 12/1/25, did not include a physician's order (PO) for an indwelling catheter. A review of Resident #4's Progress Notes (PN) reflected the following note dated 10/20/25, which indicated Resident #4's indwelling catheter was removed without complication. Further review of Resident #4's PN reflected that Resident #4 was hospitalized and returned to the facility on [DATE], and did not have an indwelling catheter. On 12/16/25 at 11:56 AM, S #1 asked the Registered Nurse/Unit Manager (RN/UM who was responsible for updating CP, and she stated that the Director of Nursing (DON), Assistant Director of Nursing, Unit Managers and case manager would update the CP. On 12/16/25 at 11:58 AM, S #1 interviewed the Registered Nurse (RN) regarding Resident #4. The RN stated that the resident was admitted in September from the hospital after a motor vehicle accident and had an indwelling catheter. The RN stated that Resident #4 did not have an indwelling catheter now. The surveyor asked the RN if a resident's indwelling catheter was removed if the CP should be updated. The RN stated that she did not update CP. The RN stated that the resident had recently been sent to the hospital and came back. On 12/16/25 at 12:04 PM, S #1 interviewed the RN/UM regarding Resident #4's CP, and the RN/UM stated that when a resident returned from the hospital a new CP should be made. She further stated that when Resident #4 returned from the hospital, the nurse should have resolved the indwelling catheter CP. The RN/UM also stated that she was going to resolve the indwelling catheter on Resident #4's CP. On 12/18/25 at 12:14 PM, S #1 notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident # 4's indwelling catheter was removed on 10/20/25 and the resident's CP was not updated and that when the resident returned from a hospitalization in December 2025, and did not have an indwelling catheter, the resident's CP also was not updated. On 12/19/25 at 11:44 AM, in the presence of the DON, the LNHA stated that there was a failure to update the CP. The LNHA stated that care was delivered according to PO and the resident's condition at all times. The LNHA stated that education was ongoing to prevent recurrence. The LNHA stated that once the issue was identified by the surveyor, Resident #4's CP was immediately updated to accurately reflect their current status. The LNHA did not provide any additional information. 2.On 12/15/25 at 9:45 AM, Surveyor #2 (S #2) met with the LNHA and the DON during an entrance conference, and both stated that they would get back to S #2 regarding residents on TBP (transmission based precautions) who were currently on contact precautions. S #2 reviewed the medical records of Resident #83 and revealed: A review of Resident #83's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection (UTI) site not specified, cognitive communication deficit, other specified cough, and neuromuscular dysfunction of bladder (commonly referred to as neurogenic bladder, occurs when nerve damage affects bladder control, leading to issues with urine storage and release) unspecified. A review of Resident #83's most recent comprehensive MDS), with an ARD of 9/28/25, reflected that the resident had a BIMS score of 11 out of 15, which indicated that Resident #66's cognition was moderately impaired. A review of Resident #83's comprehensive CP included the following focus area, infection of urinary tract: ESBL (Extended-Spectrum Beta-Lactamase) in urine indicates the presence of bacteria that produce enzymes making them resistant to many common antibiotics, often leading to difficult-to-treat UTIs) UTI, initiated on 10/13/25. The interventions included but was not limited to maintain contact isolation precautions as indicated, date initiated on 10/13/25. Further review of the CP revealed that there was no other infection control precautions except for contact isolation (contact isolation precautions are essential in healthcare settings to prevent the spread of infections through direct or indirect contact with patients or contaminated items. Some of the key points to follow for contact isolation precautions: place a contact isolation signs on the patient's room to inform others of the precautions). A review of the provided Order Listing Report, that was provided by the LNHA, for the list of residents maintained on contact isolation revealed, Resident #83 was not included on the list. On 12/16/25 at 12:07 PM, S #2 asked the DON to accompany S #2 to Resident #83's room. Both S #1 and DON observed from outside of resident's room one employee and one visitor talking to the resident inside the room, and there was a posted sign for EBP (enhanced barrier precaution) outside the resident's door. The DON informed S #2 that the employee was a Speech Therapist, and the visitor was a Resident's Representative (RR). At that time, S #2 asked the DON who revised and initiated CP, and she responded that it was a collaboration between nursing management that included herself. S #2 notified the DON of the above concerns that there was no EBP CP in resident's medical records and the CP that was documented was about to maintain contact isolation. The DON had no response as to why the CP was not revised to reflect the current status of the resident as both S #2 and DON observed an EBP posted sign outside resident's room. On 12/17/25 at 12:11 PM, S #2 observed Resident #83 inside their room on their phone and there was a posted sign for EBP outside the resident's door with PPE hung on the door. On 12/18/25 at 12:11 PM, the survey team met with the LNHA and DON, and S #2 notified them of the above findings and concerns with regard to Resident #83's CP that was not revised to reflect EBP. On 12/19/25 at 11:42 AM, the survey team met with the LNHA, the DON, and the LNHA and DON did not address S #2's concern with regard to Resident #83's CP. A review of the facility's Care Plans, Comprehensive Person-Centered Policy with a revised date of March 2022, included the following: Policy, a comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered CP for each resident.7. The comprehensive, person-centered CP:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being,.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the CP:a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay. On 12/19/25 at 12:48 PM, the survey team met with the LNHA, DON, and the Clinical Support Coordinator for an exit conference, and there was no additional information provided by the LNHA. N.J.A.C. 8:39-11.2(e), (f), (g), (h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 5 days of observation. This deficient practice was evidenced by the following:On 12/15/25 at 9:00 AM, the survey team entered the facility, and the surveyor observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the receptionist. The NHRCSR posted was dated 12/15/25 with a census of 85, for the [7:00 AM - 3:00 PM] day shift. On 12/15/25 at 9:41 AM, in the presence of the survey team, the License Nursing Home Administrator (LNHA) provided a copy of the alphabetical census (total number of residents) with the total census listed as 90. LNHA confirmed the total census of residents in the facility and stated, The census is 90. On 12/16/25 at 9:00 AM, the NHRCSR posted in the lobby of the facility documented the current Resident census as 90. The LNHA then provided a Daily Attendance Report for 12/16/25, with the total census listed as 94. The LNHA informed the survey team and stated, there was one bed hold, and therefore 93 residents present in the facility. On 12/16/25 at 9:40 AM, the surveyor interviewed the LNHA and stated that the Staffing Coordinator (SC) was responsible for posting the staffing report (NHRCSR) in the morning. The LNHA further stated that the SC post the projected census and then updated it when she gets in. The surveyor then asked the LNHA if the posted census and the alphabetical census list should be consistent, and the LNHA stated, It was not consistent, I understand what you are saying. On 12/16/25 at 10:09 AM, the Director of Nursing (DON) provided an updated copy of the NHRCSR for 12/16/25 with a revised census of 94. On 12/19/25 at 11:40 AM, the LNHA and DON confirmed that the posted staff census was incorrect for the two observed days. The LNHA stated that moving forward, the 11:00 PM-7:00 AM nurse will document the census on the staffing report, which will then be updated by the Admissions Director upon arrival in the morning. NJAC 8:39-41.2 (a), (b), (c), (d)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 5 residents (Resident #113) observed on the medication pass observation. The deficient practice was evidenced by the following:On 12/16/25 at 9:24 AM, the surveyor, while conducting the medication pass (med pass) observation, observed the Registered Nurse (RN) assigned to the medication (med) cart administer medications (meds) to Resident #113. The resident told the RN that they had leg pain and that it was a level 4. At that time, the surveyor observed the RN prepare and administer acetaminophen (a med commonly used to treat pain, commonly known as Tylenol), 325 mg (milligram), 2 tablets (tabs).The surveyor concluded the med pass observation. The surveyor reviewed Resident #113's electronic medical record (EMR), which revealed an Order Summary report (OSR) and an electronic medication administration record (eMAR) each of which reflected the following physician order (PO): Acetaminophen tablet (tab) 325 mg, give 2 tabs by mouth every 6 hours as needed (PRN) for pain, do not exceed 3 grams in 24 hours. Total 650 mg. Further review of the OSR and eMAR revealed the following PO:Acetaminophen oral tab 325 mg, give 2 tabs by mouth every 6 hours PRN for moderate pain for 10 Days, dated 12/12/25.Tramadol oral tab 50 mg, give 1 tab by mouth every 12 hours PRN for moderate pain, dated 12/12/25.Tramadol tab 50 mg, give 1 tab by mouth every 12 hours PRN for severe pain, monitor for respiratory depression sedation constipation, dated 12/15/25. Further review of the Resident #113's eMR revealed an admission Record (an admission summary) which reflected that the resident was admitted to the facility with diagnoses which included but were not limited to fracture of right femur (broken bone in leg) and essential hypertension (high blood pressure). A review of the progress note (PN) by nursing, titled Resident Assessment, dated 12/12/25, reflected the resident had a BIMS (Brief Interview for Mental Status) a tool used to screen and identify cognitive condition, Score of 15, which indicated the resident was cognitively intact. The eMR did not reveal that the resident had any PO for a pain scale (a scale that differentiates pain into different levels that can be expressed as number or other quantifier). A review of the common pain scales and descriptions which revealed that the most common pain scale was a numeric scale. Numeric Rating Scale (NRS): Asks you to rate pain from 0 (no pain) to 10 (worst pain ever). 0: No pain. 1-3: Mild (annoying, barely noticeable). 4-6: Moderate (distracting, interferes with activities). 7-9: Severe (limits activities, hard to sleep/talk). 10: Unspeakable, worst possible pain. On 12/18/25 at 10:59 AM, the surveyor interviewed the facility Consultant Pharmacist (CP) by phone. The surveyor asked the CP if they review as needed med orders for proper indication and duplication. The CP stated yes, they do. On that same date and time, the surveyor reviewed the CP electronic pharmacist information consultant review (a faxed review of meds) dated 12/15/25, which reflected:9. There was a duplicate order for Tylenol PRN pain. Please clarify and update. 11. Missing indication for mild and severe pain with current PRN pain orders. Please clarify or update orders, so that all levels of pain are covered. On 12/18/25 at 12:20 PM the survey team met with Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), and the surveyor notified them of the concern with PRN pain meds on the med pass observation. The surveyor notified the DON that the resident had an unspecific order for pain, orders for two different meds for moderate pain, and two identical med orders, one for moderate pain and one for severe pain. The surveyor asked how the staff would differentiate which to give. The DON stated that they would get back to the surveyor. On 12/19/25 at 12:26 PM, the DON stated they called the resident's physician who gave new orders that were more specific. The DON provided a copy of an order dated 7/23/24 from another resident that listed a pain scale with 4 indicating mild. The surveyor asked the DON if the acetaminophen order the RN gave at the time had no indication. The DON stated yes. The surveyor asked the DON if there was a duplicate order for moderate pain. The DON stated yes. A review of the facility's Administering Medications Policy, dated April 2019, the policy did not reflect anything regarding duplicate orders or sequencing of PRN orders. The LNHA did not provide any further pertinent information. N.J.A.C. 8:39- 11.2(b), 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified for 1 of 1 emergency medication kits (e-kit) on 1 of 1 medication storage areas observed in the facility. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 11:48 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following:The surveyor observed, on Unit 1, an e-kit located on the bottom shelf of the bookcase that also contained the resident charts. The surveyor observed an inventory sheet attached to the e-kit, which reflected a date of [DATE], for the shortest expiration date for a med contained in the e-kit. The sheet also reflected the name of the facility and the identification of the e-kit as #47. The surveyor reviewed the facility's Consultant Pharmacist (CP) report for [DATE]. The report revealed a Unit Inspection Report (UIR) dated [DATE], for Unit 1. The UIR reflected, under e-kit: Contents of each kit were in date, YES. On [DATE] at 10:59 AM, the surveyor interviewed the facility CP by telephone. The surveyor asked the CP if they did Unit Inspections in the facility, including checking the e-kit expiration. The CP stated, yes, they did check it, and if it was due to expire or expired, they would tell the facility to replace it and send it back the pharmacy. The surveyor notified the CP about the expired e-kit. The CP stated that the facility had been having difficulty getting the pharmacy to pick up expired e-kits, but it should have been taken off the unit.On [DATE] at 12:20 PM, the survey team met with Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), and the surveyor notified the facility of the expired e-kit.On [DATE] at 12:26 PM, the survey team met with the LNHA and DON, and the DON stated that the expired e-kit would be returned to the pharmacy today. A review of the facility's Medication Labeling and Storage Policy, dated February 2023, reflected, under 3. If the facility has.outdated.medications (meds) or biologicals, the dispensing pharmacy is contacted for.returning.these items.A review of the facility's Pharmacy Services - Role of the Consultant Pharmacist,Policy, dated [DATE], reflected, under 3. d. Determine the contents of the emergency supply of meds and monitor the. disposition of the supply. Under 5. c. regular review of the emergency med supply. 5. d. review of med storage areas at least monthly. for proper storage.and expired meds. The LNHA did not provide any further pertinent information. NJAC 8:39-29.4(d)3(e)(g)

Based on observation, interviews, and a review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents to ensure adequate facility resources to provide resident care and services, specifically a contingency plan for staffing and the mandatory staffing ratios. These failures had the potential to affect all 90 residents who currently live in the facility during the time of the survey. This deficient practice was evidenced by the following:During the entrance conference on 12/15/25 at 9:45 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and both the LNHA and DON (Director of Nursing) stated that the facility's census (the number of residents currently under the care of a specific facility) was 90 plus 1 bed hold (1 resident was in the hospital) and their licensed bed number (the number of beds the facility has to admit residents) was 118. On 12/15/25 at 11:45 AM, the LNHA provided the surveyor a 17 page FA (Facility Assessment) which included the following:Purpose: To determine what resources are necessary to care for residents competently during regular 24/7/365 operations and during emergencies to ensure that each resident maintains or attains their highest practicable physical, mental, and psychosocial well-being.Dates of assessment: 9/11/25Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies3.1 Based on the above information and programming goals, a staffing plan has been developed to meet the professional, technical and administrative needs of the center. The plan is informed by historical experience, and projected changes. The approach takes into consideration both the type of staff (licensure or other credential) and number required. SEE ATTACHMENT 1-Staffing by ShiftAttachment consisted of staffing grid based on a Census of 98 broken down by Unit 1 with a census of 48 and Unit 2 with a census of 50. It had listed CNA (Certified Nursing Aide) with a blank line after it and listed how many CNA required for each unit and each shift. The FA did not contain the required ratio of CNA to resident which was 1 CNA to 8 residents on the day shift which remains the same regardless of what the census of facility was. The FA did not contain any information regarding a contingency plan for staffing. On 12/19/25 at 9:13 AM, the surveyor asked the LNHA if the FA that was provided was complete. The LNHA stated that that there was ongoing education and the emergency plan book that was part of the FA which was not given to the surveyor but the plan was complete. The surveyor asked if the FA was complete regarding staffing. The LNHA showed the blank assignment sheet that was in the FA and stated that the sheet showed the estimated staffing required. The surveyor asked the LNHA if he was aware of the updated regulation requirement of a contingency plan in the FA. The LNHA stated that the plan was to the meet the staffing requirements of the state and in an event where we were not meeting the requirement, our contingency plan was to reach out to our agency partners, continue to hire and offer referral bonuses. He added that it was not specific in the facility assessment but that it was their general plan. On 12/19/25 at 11:35 AM the surveyor notified the LNHA the concern that the FA did not have the required contingency plan or the staffing ratios. The LNHA stated that he had a binder for FA and that it had the contingency plan in it. The LNHA provided the surveyor a binder labeled FA which included a FA that was labeled DRAFT on the first page. The FA was dated 6/9/24. This previous FA included some information about a staffing contingency plan which was not included in the updated 9/11/25 FA (the most up to date). On 12/19/25 at 12:16 PM, the surveyor asked the LNHA, in the presence of the DON, the reason why the most up to date FA, dated 9/11/25 did not contain a contingency plan that was in a previous version, dated 6/9/24, in the binder. The LNHA stated that the FA continued in the assessment because it was in the book. A review of the facility's Facility Assessment Policy with a revised date of June 2024, included Policy, a facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies.Policy Interpretation and Implementation:1. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure the resources are available to meet the specific needs of residents.Facility Assessment2. The facility assessment is used to identify current or potential gaps in care or services due to misalignment or lack of appropriate resources. 3. The facility assessment is also used to help the facility plan for and respond to changes in the needs of the resident population, and the determine budget, staffing, training, equipment, and supplies needed. 4. The facility assessment is used to inform staffing decisions. a. The facility assessment is used to ensure there is enough staff with appropriate competencies and skills sets to meet the needs of the residents identified through the review of resident assessments and plans of care. (1) Staffing needs are considered for each unit and adjusted as necessary based on changes in the resident population. (2) Staffing needs are considered for each shift, including day, evening and night shifts, and adjusted as necessary based on changes in the resident population. b. The facility assessment is used to develop and maintain a direct-care staff recruitment and retention plan. c. The facility assessment is used to evaluate the facility's ability to maintain continuity of operations during an emergency, .d. The facility assessment is used to inform contingency planning for situations that do not require activation of the emergency plan but do have the potential to affect resident care (for example, the availability of direct care nursing staff or other resources needed for resident care). The LNHA did not provide any additional information. N.J.A.C. 8:39-5.1(a); 27.1

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurate, and readily accessible medical records for a resident's History and Physical. This deficient practice was identified for 1 of 21 residents reviewed, Resident #109.This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident #109, and revealed that the resident was in the facility for respite care (temporary relief for family caregivers by providing short-term substitute care for a loved one). A review of the diagnoses included but not limited to anoxic brain damage not elsewhere classified and depression. \ A review of the Minimum Data Set (MDS), an assessment tool which facilitates the plan of care, with an assessment reference date of 10/8/25, revealed short term memory problem and cognitive skills for daily decision making-moderately impaired. On 12/16/25 at 10:11 AM, the License Nursing Home Administrator (LNHA) provided the closed record-paper chart for Resident #109 for review, which revealed no evidence of a physician's History and Physical (H and P). The surveyor asked the LNHA if there were any additional papers and he confirmed that there were no other records. On 12/16/25 at 10:14 AM, the surveyor reviewed the Electronic Health Records (EHR) for Resident #109, and no physician H and P found in the electronic charting. On 12/17/25 at 11:28 AM, the surveyor interviewed the Director of Nursing (DON) in the Unit 2 nursing station, regarding Resident's #109's EHR and closed records which revealed no physician H and P completed. The surveyor and the DON reviewed the electronic system under Forms and Document tabs and the DON confirmed the primary physician did not complete an H and P. The surveyor asked the DON what was the expectation regarding the physician's initial comprehensive visit on all admission regardless of payer source, and the DON replied that it was an expectation from the physicians to complete an H and P. The DON further stated that H and P's should be done for all admissions. The surveyor requested from the DON the policy on Physician Services regarding admissions. On 12/17/25 at 1:15 PM, the surveyor reviewed Resident's #109's EHR and noted under the Forms tab, the primary physician's progress notes which was created on 12/17/25, for effective date of 10/7/25, that was done after surveyor's inquiry. On 12/18/25 at 9:00 AM, the surveyor interviewed the DON, who stated that she called the physician yesterday and the physician informed her that the H and P was previously done on paper after admission but failed to put it in the resident's medical record. The DON confirmed that the PN that was created on 12/17/25 for effective date of 10/7/25 was done after surveyor's inquiry, and still in progress (not completed). There was no paper copy of the H and P given to the surveyor. On 12/18/25 at 12:12 PM, the survey team met with the LNHA and the DON, and the surveyor notified them of the above concern with regard to the resident's H and P. On 12/19/25 at 11:41 AM, the survey team met with the LNHA and the DON, and the LNHA stated The H and P was located in the medical records; I looked yesterday in all the resident's medical records and found it between files in other medical records. The LNHA further stated that the H and P should have been in the resident's medical records. The LNHA also stated that when we asked the physician about the H and P, that was when the physician opened it in (EHR system). The LNHA added that the DON oversees Medical Record Staff to ensure resident's medical records were filed correctly, and that the H and Ps were completed. On 12/19/25 at 12:17 PM, the LNHA provided the physical paper of the H and P that was found. The surveyor reviewed the physical paper which revealed, physician's H and P dated 10/5/25. The LNHA stated, it was not found until yesterday, it was found in between other files that was why it was not provided to the surveyor or accessible and should have been part of the medical records. A review of the facility's Maintenance of Hybrid Health Record Policy which revealed under Process #4, original medical records that are created and maintained on paper will be stored in accordance with state law/regulation. A review of the facility's Physician Services Policy revealed under Policy Statement, the medical care of each resident is supervised by a licensed physician. The Policy Interpretation and Implementation revealed #6. Physician progress notes are maintained in accordance with current regulations and facility policy . NJAC 8:39-35.2(d)4

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 1 of 18 resident's (Resident #9) call bell was within reach and able to use to accommodate the residents' needs. This deficient practice was evidenced by the following:On 12/15/25 at 11:20 AM, while conducting the initial tour of the facility, the surveyor observed Resident #9 in their room, and in bed. The surveyor also observed the call bell was on the floor, not on the bed, and not within the reach of the resident if needed to use. The surveyor then asked the resident if they used the call bell if they needed help and if the staff came to help, and the resident shrug their shoulders. At this time, a Certified Nurses Aide (CNA), came into the room and notices the surveyor looking for the call bell device. The CNA then placed the call bell device on the bed next to the resident, after surveyor's observation. The surveyor reviewed the electronic medical record (eMR) of Resident #9, which revealed the following: A review of the admission Record (an admission summary) reflected that the resident had diagnoses of but not limited to; malignant neoplasm of the brain (brain cancer), essential hypertension (high blood pressure), and generalized muscle weakness. A review of Resident #9's Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 11/20/25, reflected that the resident had a brief interview for mental status (BIMS) score of 99, which indicated the resident was unable to complete the interview. A review of the comprehensive Care Plan (CP) dated 11/11/25, revealed a focus that the resident was at risk for falls and an intervention to reinforce the need to call for assistance.On 12/18/25 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), and the surveyor notified the LNHA and DON of the observation of Resident #9's call bell not within the resident's reach. On 12/19/25 at 11:42 AM the survey team met with the LNHA and DON, and the LNHA stated in response to the call bell concern that the call bell was only temporarily hanging off the bed, it was corrected immediately, and the resident could call for help otherwise.On 12/19/25 at 12:21 PM, the survey team met with the LNHA and DON, and the LNHA stated that the call bell device was not within reach of the resident at the time of the surveyor's observation.On 12/19/25 at 12:49 PM, the survey team met with the LNHA, DON and Clinical Service Coordinator (CSC) for an exit conference. The LNHA and DON did not provide any further pertinent information.A review of the facility's Answering the Call Light Policy, dated 9/2022, the policy reflected, under General Guidelines, line 5, ensure that the call light is accessible to the resident when in bed.NJAC 8:39-31.8 (c)(9)

Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 2 unsampled residents during the lunchtime meal in the 2 of 3 dining rooms observed. The deficient practice was evidenced by the following. 1.The surveyor observed the lunchtime meal in unit 2 dining room on 12/15/25 at 12:44 PM, there were seven residents and Certified Nursing Aide #1 (CNA #1). CNA #1 at that time was standing while feeding Resident #44 (unsampled resident) with use of a weighted spoon. The resident had three compartment dish plate. On that same date, the surveyor went to the nursing station just across the dining room, to find a nurse, and the Registered Nurse/Unit Manager (RN/UM) was at the phone at that time. The Unit Clerk (UC) then assisted the surveyor, both the surveyor and the UC went back to the dining room and both observed CNA #1 still standing while feeding Resident #44. Outside the dining room, both the UC and the surveyor observed CNA #1 standing and continued to feed the resident. The UC acknowledged that CNA #1 was standing while feeding the resident. On 12/15/25 at 12:47 PM, the surveyor interviewed the Registered Nurse (RN), who informed the surveyor that she was a nurse for unit 2, and the surveyor notified the above observation and concerns with CNA #1. Both the surveyor and the RN went to the dining room and observed CNA #1 still standing and feeding Resident #44. The RN then waived to CNA #1 and used hand gestures to tell CNA #1 to sit down, and that was the time CNA #1 sat down. Afterward, the surveyor in the presence of the RN, notified the RN/UM of the above findings and concern. The RN/UM and the RN had no answer as to why staff should not be standing while feeding a resident. Then, the Director of Nursing (DON) came and was notified of the above concern and confirmed that the staff should not be standing while feeding. A review of Resident #44's care plan (CP) revealed that the resident was not care planned for staff to stand while feeding the resident nor the resident's preference was for the staff to stand while feeding. Further review of the medical records revealed there were no documented evidence that the staff should stand while feeding the resident as resident's preference. 2.On 12/17/25 at 12:19 PM, the surveyor observed unit 1 dining area for lunch, there were 15 residents with four staff feeding residents, and the Recreation Staff (RS) (was not feeding) assisting other residents. The surveyor also observed that one table where the RS was assisting other residents, 3 of 4 residents were eating, and one was not eating (Resident #115). There was another table with two lunch trays, one of the tray was used and another tray was untouched and covered. On that same date and time, the surveyor observed Resident #39, who was seated in a Geri chair (often referred to as a medical recliner, blends the advantages of recliners and wheelchairs ) with side table and had no meal tray. Resident #39 was seated facing all residents who were eating their lunch except Resident #39 and Resident #115. At that same time, the surveyor asked the RS if Residents #115 and #39 were served with lunch and as to why they did not have a meal tray in front of them. The RS informed the surveyor that all residents inside the dining area received and started to eat at around 12:00 PM, except for Resident #39, because they were waiting for the nurse to feed the resident. She also stated that Resident #115 had received lunch tray and was finished eating. She also confirmed that the two trays on the side on top of the table were for Residents #39 and #115. At 12:23 PM, after surveyor's inquiry, the Licensed Practical Nurse (LPN) came and took the lunch meal on the table where the other used tray was, and placed on top of the side table near Resident #39. The LPN left the dining room without feeding the resident. At 12:25 PM, CNA #2 started to feed Resident #39. A review of the provided Meal Delivery Times, that was provided by the Licensed Nursing Home Administrator (LNHA), included that the dining room service during lunch was at 12:15 PM. It also included information that the scheduled times may vary by +/- (plus or minus) 10 minutes. On 12/17/25 at 12:50 PM, the surveyor asked the LNHA for copy of dining services and resident rights policies. On 12/17/25 at 1:18 PM, the surveyor notified the DON of the above findings and concern with dining observation in units 1 and 2. The surveyor asked the DON if it was appropriate for the resident to wait to be fed when everyone was eating, and what the expectation was. The DON stated that it was not appropriate, everybody should be eating at the same time. The DON acknowledged that it was an expectation that it was resident's rights to be respected including the right to be served meals at the same time. On 12/18/25 at 12:11 PM, the survey team met with the LNHA and DON, and the surveyor notified them of the above findings and concerns. On 12/19/25 at 11:42 AM, the survey team met with the LNHA, the DON, and the LNHA stated that both residents identified during dining observation both required behavior to be managed prior to start feeding. A review of the facility's Resident Rights Policy that was provided by the LNHA, edited 5/30/24, revealed, that employees shall treat all residents with kindness, respect, and dignity. A review of the facility's Dining Room Audits Policy that was provided by the LNHA, with a revision date of October 2017, revealed, that the facility audits the food and nutrition services department regularly to ensure that resident needs are met, and that dining is safe and pleasant experience for residents. Policy Interpretation and Implementation: 2. The auditor will assess: d. whether residents at each table are served together; . On 12/19/25 at 12:48 PM, the survey team met with the LNHA, DON, and the Clinical Support Coordinator for an exit conference, and there was no additional information provided by the LNHA. N.J.A.C. 8:39-4.1(a)(5,12,28), 27.1(a)

Complaint #409367Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the facility's policies and procedures for 1 of 2 residents, Resident #1, reviewed for wound care. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 11/7/25 at 10:30 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #1. The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, type 2 diabetes mellitus, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), hypertension (high blood pressure), heart failure, difficulty walking, and generalized muscle weakness.A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/11/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #1 scored a 15 out of 15, which indicated the resident was cognitively intact. In Section M (Skin Conditions) of the MDS, Resident #1 was coded as having diabetic foot ulcer(s). A nurse progress note by Licensed Practical Nurse (LPN) #1, dated 9/28/24, indicated the resident's left heel during wound care was noted with a foul odor and dark colored tissue inside the wound bed. LPN #1 documented she informed the Assistant Director of Nursing (ADON) and the primary physician. The resident was to be seen by the Wound Care Consultant (WCC) on Monday (9/30/24). A WCC note dated 9/30/24 revealed the resident was being treated for a left plantar heel diabetic ulcer and a right, medial, plantar heel diabetic ulcer. The wounds were both classified as chronic. The left plantar heel ulcer was assessed as being 6 centimeter (cm) x 10 cm x 0.3 cm in size with no odor and sero-sanguineous drainage (wound fluid that is a mixture of blood and a clear, yellowish fluid called serum) and noted as improving. The resident's right heel ulcer was assessed as being 4 cm x 3 cm x 0 cm in size with no odor or drainage. The WCC made additional recommendations to consult with the primary physician to consider antibiotics and a bone scan. A WCC note dated 10/7/24 revealed the resident was being treated for a left plantar heel diabetic ulcer and a right, medial, plantar heel diabetic ulcer. The left plantar heel ulcer was assessed as being 6 cm x 10 cm x 0.3 cm in size with no odor and sero-sanguineous drainage; and noted with no change. The resident's right heel ulcer was assessed as being 4 cm x 3 cm x 0 cm in size with no odor or drainage; and noted with no change. The WCC made additional recommendations to consult with the primary physician to consider antibiotics and a bone scan. There was no follow up note to indicate communication with the primary physician regarding the WCC's additional recommendations. A nurse progress note by LPN #1 dated 10/8/24 documented that during wound care the resident's wound [unspecified location] had worsened with dark color inside wound and odor. LPN #1 indicated the ADON was made aware and would reach out to wound care for orders. There was no follow up note to indicate communication with the primary physician or the WCC at this time regarding the resident's wound status. A WCC note dated 10/14/24 revealed the resident was being treated for a left plantar heel diabetic ulcer and a right, medial, plantar heel diabetic ulcer. The left plantar heel ulcer was assessed as being 6 cm x 10 cm x 0 cm in size with no odor and no drainage. The resident's right heel ulcer was assessed as being 0.5 cm x 0.5 cm x 0.1 cm in size with no odor or drainage. Both wounds were noted as improving. The WCC made additional recommendations to consult with the primary physician to consider antibiotics and a bone scan. There was no follow up note to indicate communication with the primary physician regarding the WCC's additional recommendations. A WCC note dated 10/21/24 revealed the resident's left plantar heel ulcer had a measurement of 8 cm x 10 cm x 0 cm in size with no odor and no drainage. The resident's right heel ulcer was assessed as being 1 cm x 0.5 cm x 0.2 cm in size with no odor and small amount of serous drainage. The WCC recommended to continue current treatment orders with no additional orders.A WCC note dated 10/28/24 revealed the resident's left plantar heel ulcer had a measurement of 9 cm x 13 cm x 0 cm in size with a strong odor and no drainage. The resident's right heel ulcer was assessed as being 0.5 cm x 0.5 cm x 0.1 cm in size with no odor and small amount of serous drainage. The WCC recommended to change wound treatment to cleanse left heel wound with Dakin's solution; betadine; Flagyl (an antibiotic) powder; wrap with kerlix dressing daily and as needed (PRN); offload with heel booties; and monitor for changes. The WCC additionally recommended for a vascular consult. A nurse progress note dated 10/28/24 revealed the resident had a vascular consult with recommendation for angiogram to be done. An Infectious Disease (ID) consult note dated 10/30/24 indicated the resident was seen for possibly worsening wound. The ID Advance Practice Nurse (APN) indicated the resident's wound was assessed and did not appear acutely infected. The APN had no recommendations for antibiotic treatment; to monitor the resident off antibiotics at this time; pending angiogram with the vascular consultant, and to continue wound care treatment. A review of progress notes revealed there was no documentation of follow up with the primary physician regarding the WCC additional recommendations to consider antibiotics and a bone scan. There were no progress notes written by the primary physician found in the resident's medical record regarding follow up for their wounds. On 11/7/25 at 12:54 PM, the surveyor interviewed the ADON who stated if a resident had a worsening wound an incident report would be completed. It would be reported to the physician and the WCC for treatment orders and the resident representative (RR) would also be notified. The ADON explained a worsening wound was indicated by a wound larger in size, pus-like drainage, strong foul odor, new pain, and/or swelling. The ADON stated the physician should be notified as soon as possible regarding WCC recommendations to determine if they agreed or disagreed with the recommendations. Additionally, the notification to the physician should be documented in the EMR, under progress notes. The surveyor asked the ADON about Resident #1. The ADON recalled the resident's left wound had episodes of healing then worsened and the resident had a problem with edema (swelling). The ADON could not recall specifics from September and October 2024 about the WCC's recommendation and communication with the physician. The ADON stated she would have to look in the resident's medical record to provide additional information. The ADON stated the WCC no longer consulted at the facility. On 11/7/25 at 1:06 PM, the surveyor interviewed LPN #1 who stated if a resident had a worsening wound it would be reported to the physician and the WCC for treatment orders. The LPN stated the ADON would conduct wound care rounds with the WCC and follow up on their recommendations. The surveyor asked LPN #1 about Resident #1. The LPN recalled the resident and that they had a left foot wound which received wound care; the WCC and ID was consulted. LPN #1 could not recall specifics from September and October 2024 regarding the WCC's recommendation and communication with the physician. On 11/7/25 at 1:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated if a resident had a worsening wound an incident report would be completed; it would be reported to the physician and the WCC for treatment orders; and the resident and/or RR would be notified. The DON stated the physician should be notified regarding WCC recommendations to determine if they agreed or disagreed with the recommendations. The DON further explained the notification to the physician should be documented in the EMR under progress notes. The surveyor informed the LNHA of the concern there was no documentation of follow up with the physician regarding WCC recommendations and the resident's wound status. The DON stated she would review the resident's medical records to provide additional information. On 11/7/25 at 3:14 PM, the DON and the LNHA met with the surveyor. The DON stated she did not find any incident report for Resident #1's wound, physician progress notes, or documentation of notification to the primary physician regarding WCC recommendations for possible antibiotics and bone scan. There was no additional information provided by the facility. The surveyor reviewed the facility policy titled Physician Orders for Consultation with a last revised date of 1/5/22. Under Purpose revealed: .Ensure that attending physicians are timely apprised of the findings and recommendations of consultants and specialists.The surveyor reviewed the facility policy titled Physician Progress Notes with a last revised date of February 2008. Under Policy Statement revealed, Physician progress notes must be maintained for each resident. Under Policy Interpretation and Implementation revealed: .2. Physician progress notes reflect the resident's progress and response to his or her care plan, medications, etc.The surveyor reviewed the facility provided policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol with a last revised date of April 2018. Under Monitoring revealed: .1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds.2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.N.J.A.C. 8:39-3.2 (a), (b); 19.4; 27.1 (a)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 8/7/24 at 09:43 AM, the surveyor entered the kitchen for the follow up tour with the Director of Culinary Service (DCS). On 8/7/24 at 10:38 AM, the surveyor observed Chef (Chef #1) perform hand hygiene. Chef #1 scrubbed their hands with soap for 12 seconds and then rinsed their hands under running water. At 10:44 AM, the surveyor observed Chef #1 again perform hand hygiene. The surveyor observed Chef #1 scrubbed their hands with soap for 8 seconds and rinsed under running water. The surveyor interviewed Chef #1, who stated, I thought I scrubbed my hands for 20 seconds. I will wash my hands again. On 8/9/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled Handwashing/Hand Hygiene, with a revised date of 10/2023. Under the procedure section and sub section washing hands it revealed, 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. On 8/9/24 at 12:58 PM, the survey team met with the LNHA, Director of Nursing (DON), and Regional Clinical Nurse (RCN#2). The surveyor reviewed the kitchen concerns. No further information was provided. NJAC 8:39-17.2(g)

Complaint #: NJ165579 Based on observation, interview, and record review, it was determined that the facility failed to initiate a baseline care plan (CP) for a resident who was admitted with a stage 2 pressure ulcer (PU) (an open wound that affects both the top and bottom layers of the skin but has not yet reached the fatty tissue). This deficient practice was identified for 1 out of 3 residents reviewed, Resident #62, and was evidenced by the following: On 08/08/24 at 01:47 PM, the surveyor reviewed Resident #62's medical records, which revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to Nontraumatic Intracerebral Hemorrhage (bleeding inside the skull), Acute Respiratory Failure, and Dysphagia (difficulty swallowing). Resident #62 was discharged to the hospital on 07/07/23. A Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate management of care, dated 07/06/23 under section C0700, C0800, C1000, revealed that the resident had severely impaired decision-making skills, with short and long-term memory problems. Further review of the MDS under section M revealed that Resident #62 had one (1) stage 2 PU that was present on admission. A review of the admission nursing assessment dated [DATE] under section H revealed Resident #62 had a sacral stage 2 PU measuring 3.0 cm. x 2.0 cm. x 0.1 cm. A review of Resident #62's interdisciplinary person-centered comprehensive CP did not identify that the resident had a PU present on admission. On 08/13/24 at 09:50 AM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that the CP did not address the pressure ulcer on admission. A review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of December 2016 with an edited date of 04/25/22 revealed under section 2. The care plan interventions are derived from a thorough analysis of the information gathered in the comprehensive assessment. Under section 9. Revealed that areas of concern identified during the resident's assessment will be evaluated before interventions are added to the care plan. NJAC 8:39-11.2 (d)

Complaint #'s: NJ168223 NJ168554 Based on observation, interview, and record review, it was determined that the facility failed to: a.) clarify a physician's order (PO) for a medication route on a resident who was NPO (nothing by mouth); b.) document the colostomy care performed; and c.) document an assessment on a resident who was transferred to the hospital for a scheduled surgical procedure. This deficient practice was identified for 3 of 12 Residents (Resident #22, #64, and #262) reviewed. 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. This deficient practice was evidenced by the following: 1. On 8/6/24 at 10:10 AM, the surveyor observed Resident #22 in their room in bed with eyes closed. The surveyor interviewed Resident #22's family who stated the resident does not take any medications by mouth. On 8/6/24 at 11:16 AM, the surveyor reviewed Resident #22's paper and electronic medical chart which revealed the following: A review of the Resident #22's Admission Record (AR) (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: Dysphagia following Cerebral Infarction, Metabolic Encephalopathy, Muscle Weakness, and Type 2 Diabetes Mellitus. A review of Resident #22's Minimum Data Set (MDS), an assessment tool used for the management of care, dated 7/8/24, documented the resident had a Brief Interview for Mental Status (BIMS) and score of 9 out of 15, indicating that Resident #22 had moderately impaired cognition. A review of the August 2024 Order Summary Report (OSR) included a PO dated 6/27/24 for, NPO diet, NPO texture, for PEG-Tube feeding. (a medical device used to provide nutrition, hydration and medications directly into the stomach). Further review of the August 2024 OSR revealed the following PO: 1.Acetaminophen Tablet 325 MG, give 2 tablets by mouth every 6 hours as needed for Mild Pain (Pain Score 1-4), dated 6/27/24; 2. Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide). Give 30 ml by mouth every 24 hours as needed for no bowel movement for 3 days, dated 6/27/24; 3. Losartan Potassium Tablet 25 MG, give 1 tablet by mouth one time a day for HTN, dated 6/28/24. 4. Sertraline HCl Tablet 100 MG, give 1 tablet by mouth one time a day for depression, dated 6/28/24; 5.Loperamide HCl Capsule 2 MG, give 1 capsule by mouth every 8 hours as needed for Diarrhea, dated 7/30/24. On 8/7/24 at 10:31 AM, the surveyor interviewed Registered Nurse (RN#3), who was the regular 7-3 shift nurse for Resident #22. RN#3 acknowledged to the surveyor that the above five (5) medications route were incorrect and should have indicated to be administered via the PEG-tube route. All the other medications of Resident #22 were administered via PEG tube route. On 8/9/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Physician Services with a revision dated of 2/2021. Under the policy interpretation and implementation revealed under 6. Physician orders and progress notes are maintained in accordance with current OBRA regulations and facility policy. On 8/9/24 at 12:58 PM, the survey team met with the LNHA, Director of Nursing (DON), and Regional Clinical Nurse (RCN#2). The RCN stated acknowledged that the medication route was incorrect for Resident #22 who was NPO. No further information was provided. 37791 2. On 8/06/24 at 12:17 PM, the surveyor reviewed the closed medical records of Resident #64 which revealed the following: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to Hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), Hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone) Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and Hypertension (a condition in which the force of the blood against the artery walls is too high). A review of the Admission MDS, an assessment tool used to facilitate the management of care, dated 5/20/23, reflected that Resident #64 had a BIMS score of 4 out of 15, indicating a severe impaired cognition. A review of the facility Progress Notes (PN) revealed a Physician/Practitioner Progress Note dated 9/18/23 at 13:40 (1:40 PM) documented the following: Patient is scheduled for surgical debridement of the right leg on Friday, September 22. Patient needs to arrive at hospital [name redacted] by 11:00 AM. A further review of the resident's medical records revealed no written PN or nursing assessment on the morning of 9/22/23 that would indicate the resident was admitted to the hospital for a surgical procedure. There was no full body assessment, vital signs (measurements of the body's basic functions including temperature, heart rate, respiratory rate, blood pressure and oxygen saturation (the amount of oxygen circulating in your blood), documentation regarding the resident's disposition and a PN which would indicate if the resident's family were notified when the resident was transferred to the hospital for a surgical procedure. The PN revealed a PO administration note from the facility nurse dated 9/22/23 at 19:47 (7:47 PM) which revealed the following: out for surg (surgery). On 8/9/24 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) on the unit who stated that when a resident is being sent out to the hospital for a scheduled procedure, a nursing staff will review the resident's medical records and if they identify anything that could arise to a concern, the nurse will reach out to the physician. She also stated that all communication with the physician must be documented in the medical records. LPN #1 added that if a resident will be transferred out to the hospital, the nurses are also required to document in the resident's medical records. On 8/09/24 at 1:00 PM, the surveyor presented the above concerns to the LNHA, DON, and RCN#2. The DON acknowledged that the nurse should have written a PN documenting but not limited to full body assessment and vital signs prior to the resident being transferred to the hospital for the surgical procedure. There was no additional information provided. 3. On 8/05/24 at 12:17 PM, the surveyor reviewed the closed medical records of Resident #262 which revealed the following: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to encounter for attention to Colostomy (main purpose is to manage and care for a colostomy), Cognitive Communication Deficit (difficulties with communication that are caused by disruptions to cognition) and Dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of the Admission MDS, an assessment tool used to facilitate the management of care, dated 05/10/24, reflected that Resident #262 had a BIMS score of 15 out of 15, indicating that the resident was cognitively intact. A review of the OSR revealed the following PO: A PO dated 9/28/23, for Colostomy care every shift. A PO dated 9/28/23, for Colostomy output every shift. A review of the October 2023, electronic Treatment Administration Record (eTAR) and the October 2023 electronic Medication Administration Record (eMAR) did not indicate a PO for Colostomy care every shift and no PO for Colostomy output every shift. There were no documentation in the hybrid medical record which reflected that both Colostomy care or Colostomy output were documented every shift. A review of Resident #262's Comprehensive Care Plan dated 9/29/23, for Colostomy care which revealed the following interventions/tasks: -Change ostomy appliances as needed, dated 9/29/23. -Irrigate colostomy per physician's orders dated 9/29/23. -Record bowel movements and report abnormalities dated 9/29/23. On 8/9/24 at 8:30 AM, the surveyor interviewed LPN #1 regarding the process of documenting the colostomy care in the medical record. LPN #1 stated that a physician would write a PO for colostomy care and the nurses will document this in the eTAR. LPN #1 further stated that only the nurses can document colostomy care. LPN #1 added that changing a colostomy bag, documenting colostomy output, and assessing the colostomy stoma area (opening in your belly's wall that a surgeon makes for waste to leave your body if you can't have a bowel movement through your rectum) must be documented every shift in the eTAR. LPN #1 stated that assessing the stoma site around the colostomy is a separate assessment from the weekly skin assessments since nurses must assess the colostomy every shift. On 8/9/24 at 8:45 AM, the surveyor interviewed the Registered Nurse (RN) who stated to the surveyor that colostomy care must be documented in the resident's medical record and only the nurses could document. The RN added that it must be documented in the eTAR. On 8/09/24 at 1:00 PM, the surveyor presented the above concerns to the LNHA, DON, and RCN#2. Both the DON and RCN#2 acknowledged that nurses should have documented the colostomy care in the eTAR. There was no additional information provided. A review of the facility's policy for Colostomy/Ileostomy Care that was dated 10/2010 and was provided by the DON included the following: Under documentation: The following information should be recorded in the resident's medical record: 1. The date and time the colostomy/ileostomy care was provided. 2. The name and title of the individual (s) who provided the colostomy/ileostomy care. A review of the facility's policy for Charting and Documentation that was undated and was provided by the DON included the following: 4. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services performed. d. Changes in the resident's condition. e. Events, incidents, or accidents involving the residents; and f. Progress toward or changes in the care plan goals and objectives. NJAC 8:39-19.4 (a) (1) NJAC 8:39-11.2(b)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure a resident on hemodialysis (artificial means of removing waste from nonfunctioning kidneys) was consistently assessed, documented, and monitored after hemodialysis treatments. This deficient practice was identified for 1 of 1 resident's (Resident #10) reviewed for dialysis and was evidenced by the following: On 08/06/24 at 10:56 AM, the surveyor was touring the first-floor unit, and Resident #10 was not in their room and was informed that the resident was out at hemodialysis. On 08/07/24 at 11:15 AM, the surveyor observed Resident #10 in their room, but the resident declined to be interviewed. A review of the Admission Record face sheet revealed that Resident #10 had diagnoses that included but were not limited to End Stage Renal Disease (kidney failure), Diabetes (too much sugar in the blood), and Dementia (a group of symptoms that affects memory, thinking and social abilities). A review of the Order Summary Report under special instructions revealed the resident goes to dialysis every Tuesday, Thursday, and Saturday. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate resident care, dated 05/23/24, revealed a Brief Interview from Mental Status (BIMS) of 13 out of 15, which indicated the resident's cognition was intact. The MDS also indicated the resident received hemodialysis. A review of the resident-centered care plan included but was not limited to a focus area that the resident had Renal insufficiency related to Chronic Renal Disease and received hemodialysis on Tuesday, Thursday, and Saturday with interventions that included, confer with a physician and or dialysis treatment center regarding changes in medication administration time/dosage pre-dialysis as needed and coordinate dialysis care with the dialysis treatment center. A review of the form titled, Dialysis Center Communication Record for Resident #10 revealed the first section to be filled out by the facility nurse which included the resident's name, treatment date if the resident is receiving antibiotics, pain medication, had any emesis, diarrhea, or had fallen in the last 48 hours. An area was to be filled out for the resident's vital signs, including temperature, pulse, respirations, blood pressure, graft site, catheter site, and nurse signature-the following section was to be filled out by the Dialysis center nurse communication back to the center. The areas included the dialysis start and end time, the pre and post-weight, laboratory results, catheter size, treatment problems, medication administered, bowel movements, and the signature of the dialysis nurse. The last section, to be completed by skilled nursing facility nurse post-treatment, asked for information including blood pressure, temperature, pulse, bleeding at the access site, bruit, thrill palpated, receiving nurse signature, and date. A review of the Hemodialysis Communication binder, which started in May 2024 and documented the following: May 2024 included eight forms, and 6 out of 8 had incomplete post-treatment filled out. Further review revealed five forms dated 05/09/24 through 05/18/24 did not include the last section for the post dialysis treatment documentation. June 2024 included 13 forms in which 7 out of 13 forms had incomplete post dialysis treatment filled out. July 2024 included 13 forms in which 11 out of 13 forms had incomplete post dialysis treatment filled out. August 2024 included three forms in which 2 of the 3 forms had incomplete post dialysis treatment filled out. On 08/07/24 at 12:30 PM, the surveyor interviewed the Registered Nurse Supervisor (RN/S), who stated that the communication sheets in the book needed to be consistently filled out and that the nurses should fill them out. On 08/07/24 at 01:00 PM, the surveyor interviewed and reviewed the Communication binder with the Director of Nursing (DON), who stated that the nursing staff should be documenting on the sheets. On 08/13/24 at 11:03 AM, the surveyor interviewed the DON, who stated that the post-dialysis assessment was not completed on the communication sheet and acknowledged that it should have been filled out. The DON further stated that the forms for 05/09/24 through 05/18/24 were filled out but the nurses used the old forms which did not have the post dialysis treatment section area for documentation. The DON added that it was the reason why the facility changed the forms. A review of the facility provided policy titled, Hemodialysis Pre and Post Care policy dated 7/00 with a revision date of 3/2010, included but was not limited to; document all communications in the hemodialysis communication progress note or the dialysis center communication book .assess resident for vital signs .bleeding .significant change .Post dialysis care .the shunt should be assessed upon return ., and bandages should remain in place. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set ((MDS), an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 1 of 20 residents, (Resident #61) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 8/9/24 at 8:49 AM, the surveyor reviewed the closed medical chart for Resident #61. The Discharge Assessment MDS revealed that the resident was discharged to an acute hospital. The surveyor reviewed the nursing/clinical progress note dated 6/13/24, documented that Resident #61 Resident discharged home today. Review of Resident #61's Face Sheet (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility with diagnosis that included but not limited to Pneumonitis, Lyme disease, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes Mellitus. Review of Resident #61's Discharge MDS dated [DATE] under Section A revealed that section A2105 Discharge Status documented, 04. Short-Term General Hospital. On 8/9/24 at 9:15 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDS) who was responsible of completing the MDS's. The RN/MDS stated, The resident was discharged home from the facility. I made a mistake and miscoded that resident. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 2-page 39 . According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023). This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident was discharged to a hospital that is contracted with Medicare to provide acute, inpatient care and accepts a predetermined rate as payment in full. Code 99, Not Listed On 8/9/24 at 11:45 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Certifying Accuracy of the Resident Assessment with a revision date of 11/2019. Review of the policy interpretation and implementation section of the policy states, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. On 8/9/24 at 12:58 PM, the survey team met with the Regional Clinical Nurse (RCN#1), LNHA, and Director of Nursing (DON) regarding the above concern. The RCN#1 stated all MDS assessments must be filled out correctly. The RCN also acknowledged there was an error regarding Resident #61 Discharge MDS. On 8/12/24 at 10:03 AM, the surveyor team met with RCN#2, LHNA and DON. There were no further information was provided. NJAC 8:39-11.1, 11.2(e)(1)

Complaint #: NJ00165681 Based on interviews and record review, as well as a review of pertinent facility documents on 4/4/24 and 4/8/24, it was determined that the facility failed to administer the medications in accordance with the acceptable standard of nursing practice and follow the facility policy on Medication Administration and Physician Services for 1 of 3 residents (Resident #1) reviewed for medication administrations. This deficient practice was evidenced by the following: 1. According to the ADMISSION RECORD (AR), Resident #2 was admitted with diagnoses including but not limited to Depression and Sepsis A review of Resident #2's care plan (CP), dated 4/27/23, indicated that Resident #2 was had Neurological deficiencies. Interventions included but not limited to administer medications per physician orders. A review of Resident #2's Order Recap Report (ORR) revealed an order for the following: On 4/26/23, Gabapentin Capsule 300 mg (milligram), give 2 capsules by mouth every 12 hours for Neuropathy. On 5/8/23, Vancomycin 125 mg, by mouth every 6 hours for Clostridium Difficile (is a bacterium that causes an infection of the colon, the longest part of the large intestine) for 10 days. A review of Resident #2's Medication Administration Report (MAR) for 05/2024 confirmed the abovementioned medications were scheduled and to be administered as follows: Gabapentin Capsule 300 mg at 9:00 a.m. and 9:00 p.m. Vancomycin 125 mg at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. A review of Resident #2's Medication Admin Audit Report (MAAR) indicated that the abovementioned medications were not administered according to the scheduled time. The medications were administered as follows: Gabapentin Capsule 300 mg was scheduled to be administered at 9:00 a.m. and 9:00 p.m., however, on the following days the medication was given late. 5/2/23 was administered at 10:46 a.m. 5/5/23 was administered at 10:58 a.m. 5/7/23 was administered at 10:36 a.m. and at 10:40 p.m. 5/9/23 was administered at 10:38 a.m. 5/12/23 was administered at 10:25 a.m. and at 11:29 p.m. 5/13/23 was administered at 10:56 a.m. 5/16/23 was administered at 10:53 a.m. Vancomycin 125 mg at 12:00 p.m., 5/11/23 was administered at 4:14 p.m. 5/12/23 was administered at 2:26 p.m. 5/15/23 was administered at 4:58 p.m. A review of Resident #2's progress notes (PN) from 5/1/23 to 5/16/23, there was no indication in the PN that the Resident's Primary Care Physician (PCP) was notified that the aforementioned medications were not administered according to the scheduled time. In addition, there was no documented evidence of harm to the resident from the late administration of medications. During an interview with Registered Nurse (RN #1) on 4/4/24 at 1:07 p.m., RN #1 stated that if the medications were not administered according to the scheduled time or running late with medications, RN would document that the medications were given late and would call the doctor to notify that the medications were not administered according to the scheduled time. During an interview with the Administrator and the Director of Nursing (DON) on 4/4/24 at 3:02 p.m., the DON stated that the nurses were to administer the medications according to the schedule. DON further stated that if the medications were not administered on scheduled time, the nurse was to notify the doctor and document in the residents' PN. A review of the facility's policy titled Administering Medication, dated on 5/21/19, indicated Policy Statement Medications are administered in a safe and timely manner, and as prescribed 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication .For centers utilizing electronic documentations (i.e., eMAR), utilize the appropriated documentation code . NJAC 8:39-29.2 (d)

Based on observation, interview, and record review it was determined that the facility failed to provide the mandatory annual dental care services. This deficient practice was observed for 1 of 17 facility residents reviewed for dental care services, (Resident #10), as evidenced by the following: On 10/12/2022 at 12:55 PM, the surveyor observed that Resident #10 had dentition issues. The resident's teeth were brown and discolored with front teeth being chipped. When the surveyor inquired if his/her mouth was sore or if he had any problems eating? Resident #10 stated, no he/she did not have pain or eating issues. On 10/18/22 11:39 AM, The surveyor observed the resident in bed and chewing on the corner of the bed blanket. A review of the Admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident is a recipient of Medicaid Wellcare MLTSS (Managed Long-Term Services and Support) insurance. A review of the Resident Evaluation with Covid-19 Screen, dated 07/30/2020 at 21:15, it revealed under section E. Oral /Dental and Hearing/Speech/Vision/Diet with #4 is checked as: obvious or likely cavity or broken natural teeth. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had Brief Interview for Mental Status (BIMS), score of 7, severe impairment. It further revealed under section L, Oral/Dental status that none of the above were present. A review of the annual MDS, dated 0 7/28/2022 revealed the resident had BIMS, score of 7, severe impairment. It further revealed under section L, Oral/Dental status that none of the above were present. A review of the Order Summary Report with the Regional Registered Nurse (RRN) on 10/19/2022 at 11:55, it revealed that there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A complete review of the resident's medical record did not reveal documentation that the resident was offered and refused dental care services. A review of the resident's Care Plan (CP), dated 07/30/2020, revealed an initiated revision date of 10/20/2022, to reflect a focus area for At risk for Dental or oral cavity health problem to carious teeth on admission. This care plan's revision date 10/20/2022, was initiated by the facility, post surveyor's inquiry. An interview on 10/19/2022 at 11:19 AM, with the RRN stated, that the dental consult should have been triggered from the Resident Evaluation with Covid-19 Screen, dated 07/30/2020 at 21:15. Upon record review with her during the interview, she was unable to find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a second interview 10/19/2022 at 12:06 PM, the Regional Registered Nurse stated, the resident has never been seen during his/her stay in the facility, but the unit manager reached out to the contracted dentist and faxed over his/her face sheet to start the process. An interview on 10/20/22 at 11:11 AM, the unit manager stated, after initial assessment of a newly admitted resident by the nurse, the nurse then calls the physician and gives a report of their findings, to include the medications the resident was on, and then telephone orders would be given according to the needs of the resident. The physician would then follow up either that day or the next day. During an interview with the Director of Nursing (DON) on 10/20/22 at 01:22 PM, he stated, The resident would have a PO for a referral for a dentist. If there was an issue they would reach out to the dentist. A Long-Term Care resident is required to be seen by a dentist every six months. Moving forward, the facility will audit all the residents to see if they need to be seen by a dentist for issues or annuals. The nurses would then request a PO for a dental consult, and document it. On 10/20/2022 at 01:34 PM, the above concern was discussed with the Assistant Director of Nursing (ADON) and Licensed Nursing Home Administrator (LNHA). A review of the facility's Routine Dental Care policy, revised April 2022, provided by the LNHA on 1/19/2022, indicated: 1.) Nursing care staff will conduct ongoing oral health assessments 2.) Attending physician will be notified of the resident's need for dental treatment and order dental consultation as appropriate. 3.) The attending physician will include, as part of the initial medical assessment, an assessment of the resident's dental needs. Finding will be included in the residents' medical record. 4.) Our facility's routine dental care includes, but is not limited to: a.) An initial evaluation of the resident's dental needs. b.) Consultation with the resident, staff, and dental consultant c.) Daily dental and oral hygiene plan of care d.) Inservice education; and e.) Preventative care and treatment A review of the Dental Services Agreement, dated June 6, 2006, provided by the LNHA on 10/20/2022 states: b) The dentist shall provide Dental Services in full compliance with all the applicable Federal, state, and local laws and regulations, including, without limitation, the applicable rules and regulations of any third-party reimbursement payors concerning Dental Services and that such licenses and certifications are in full force and effect. c.) The dentist shall maintain complete records at the facility of the dental services provided to the residents of the facility in accordance with applicable law . NJAC 8:39-15.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's oral/dental status on the resident's most recent quarterly and annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 1 of 20 residents, (Resident #10) reviewed for MDS assessments related to dental care services and was evidenced by the following: On 10/12/2022 at 12:55 PM, the surveyor observed Resident #10 in bed in his/her room watching television. The surveyor further observed that the resident's teeth were brown and discolored. The resident's front teeth were chipped and deteriorated. The surveyor asked the resident if he/she had soreness in their mouth and pain or discomfort when eating. Resident #10 stated that he/she did not have pain while eating. On 10/18/22 at 11:39 AM, The surveyor observed the resident in bed, chewing on the corner of his/her bed blanket. A review of the Admission Record revealed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident is a recipient of Medicaid Wellcare MLTSS (Managed Long-Term Services and Support) insurance. A review of the Resident Evaluation with Covid-19 Screen, dated 07/30/2020 at 21:15, it revealed under section E. Oral /Dental and Hearing/Speech/Vision/Diet with #4 was checked as: obvious or likely cavity or broken natural teeth. A review of the Quarterly MDS, dated [DATE], revealed the resident had Brief Interview for Mental Status (BIMS), score of 7, severe impairment. It further revealed under section L 0200, Oral/Dental status that no boxes were checked with any issues. A review of the Annual MDS, dated [DATE] revealed the resident had BIMS, score of 7, severe impairment. It further revealed under section L0200, Oral/Dental status that none of the above were present. A complete review of the resident's medical record did not reveal documentation that the resident was offered and refused dental care services. The surveyor conducted an interview with the Registered Nurse (RN) MDS coordinator, on 10/20/22 at 12:08 PM. The MDS Coordinator stated he had [AGE] years of experience performing MDS assessments and explained that he looked at all the documentation across the tabs, then based on his findings, he would interview the staff and the resident. The surveyor asked the RN MDS Coordinator if he assessed the resident's dentition during his assessment. The MDS Coordinator stated that he interviewed the resident and did not identify areas of concern regarding the resident's dentition. On 10/20/2022 at 01:34 PM, the above concern was discussed with the Assistant Director of Nursing (ADON) and Licensed Nursing Home Administrator (LNHA). A review of the facility's Routine Dental Care policy, revised April 2022, provided by the LNHA on 1/19/2022, indicated: 1.) Nursing care staff will conduct ongoing oral health assessments 2.) Attending physician will be notified of the residents need for dental treatment and order dental consultation as appropriate. 3.) The attending physician will include, as part of the initial medical assessment, an assessment of the resident's dental needs, Finding will be included in the residents' medical records. 4.) Our facility's routine dental care includes, but is not limited to: a.) An initial evaluation of the resident's dental needs. b.) Consultation with the resident, staff, and dental consultant A review of the Dental Services Agreement, dated June 6, 2006, provided by the LNHA on 10/20/2022 states: b) The dentist shall provide Dental Services in full compliance with all the applicable Federal, state, and local laws and regulations, including, without limitation, the applicable rules and regulations of any third-party reimbursement payors concerning Dental Services and that such licenses and certifications are in full force and effect. c.) The dentist shall maintain complete records at the facility of the dental services provided to the residents of the facility in accordance with applicable law . NJAC 8:39-33.2 (d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to: a.) acquire and administer a medication per Physician's Order (PO) for one of two residents', (Resident #229) reviewed for mood and behavior and b.) accurately reconcile a controlled substance stored in a medication cart. This deficient practice was identified during the controlled substance reconciliation count for one of two medication carts and identified for, (Resident #66 and #69). This deficient practiced was evidenced by the following: 1. On 10/12/22 at 12:25 PM, the surveyor observed Resident #229 in their room finishing up with his/her lunch. The surveyor asked the resident how they were, and the resident stated, No good, because I no sleep. On 10/13/22 at 1:10 PM, the surveyor observed Resident #229 walking in front of the nursing station on the sub-acute unit. The surveyor asked the resident how he/she slept last night, and the resident stated that he/she slept well because the nurse gave him/her the medication that helped them sleep. The surveyor reviewed the medical record for Resident #229. A review of the resident's Admission Record reflected that the resident was recently admitted to the facility and had diagnoses which included but were not limited to muscle weakness, [CONDITION(S)] (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and anxiety disorder. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/13/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. A review of the resident's October 2022 Order Summary Report (OSR) reflected a PO dated 10/12/22 for the antianxiety medication [MEDICATION(S)] ([MEDICATION(S)]) 1 milligram (mg), give 1 tablet by mouth at bedtime for anxiety. A review of the resident's October 2022 Medication Administration Record (MAR) revealed a PO for the antianxiety medication [MEDICATION(S)] ([MEDICATION(S)]) 1 milligram (mg), give 1 tablet by mouth at bedtime for anxiety. The October 2022 MAR reflected that on 10/11/22 Resident #229 was not administered the medication [MEDICATION(S)]. A review of the corresponding Nursing Progress Note (NPN) dated 10/11/22 and timed at 23:36 (11:36 PM) indicated that the medication [MEDICATION(S)] 1 mg was not administered to the resident and the facility was, awaiting delivery from pharmacy. A further review of the October 2022 MAR reflected that on 10/15/22 Resident #229 was not administered the medication [MEDICATION(S)]. A further review of the corresponding NPN dated 10/16/22 and timed at 00:21 (12:21 AM) indicated that the facility was awaiting delivery of the medication, [MEDICATION(S)] from the pharmacy. A review of the resident's Care Plan dated 10/11/22 reflected a focus area that the resident was at risk for changes in mood related to anxiety. The goal of the resident's Care Plan was the resident would accept care and medications as prescribed. The interventions within the resident's Care Plan included administer medications per physician orders. On 10/13/22 at 10:36 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated the resident was alert, oriented and able to make his/her needs known. The CNA further stated that when she started her shift at 7:00 AM that day, she observed the resident awake, lying in bed, and throughout the day the resident would freely walk around the unit. The CNA told the surveyor that the resident liked to joke around with staff and never mentioned to her that he/she did not get a good night sleep. On 10/18/22 at 11:14 AM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that the resident was alert and oriented and was able to tell staff his/her needs. The RN told the surveyor that the resident was capable of specifically asking for medications that he/she needed and gave the example that the day before, the resident had asked her for a medication for constipation. The RN further stated that the resident had a routine PO for the antianxiety medication [MEDICATION(S)] at nighttime. The RN explained that if a medication was not available, she would first check to see if the medication was available in the back-up at the facility and then let the resident's physician know if it wasn't. The RN stated that she would call the pharmacy to find out why the medication was not available and get a stat (immediate) delivery of the medication. The RN further explained that she would discuss with the resident's physician, resident, and resident representative an alternative medication or means to help the resident sleep in the meantime. The RN told the surveyor that after she implemented these interventions for the unavailable medication, she would then document what she did for the resident. On 10/20/22 at 11:57 AM, the surveyor conducted an interview with the Consultant Pharmacist (CP) over the telephone in the presence of the facility's Administrator. The CP stated that if a medication was not available, nursing should first check for availability in the back up medication dispensing machine at the facility. The CP further stated that the nurse should notify the supervisor working and the resident's physician if necessary. On 10/20/22 at 12:02 PM, the surveyor interviewed the facility's Administrator who stated that the nurse who was responsible for administering the medication should have followed facility protocol which included notifying the resident's physician and calling the pharmacy provider for a stat delivery. The Administrator further stated that the medication [MEDICATION(S)] was not in the back up medication dispensing machine. A review of the facility's, Administering Medication Policy and Procedure edited 5/21/22 indicated that it was the facility's policy to administer medications in a safe and timely manner as prescribed. The Administering Medication Policy and Procedure further indicated, Medications are administered in accordance with prescriber orders, including any required time frame. 2. On 10/14/22 at 10:30 AM to 10:42 AM, the surveyor inspected Medication Cart #1 on the 200 unit in the presence of the RN. The surveyor reviewed the bingo card that contained [MEDICATION(S)] 50 mg for Resident #66 and identified that 23 [MEDICATION(S)] 50 mg were present. At that time, the surveyor reviewed Resident #66's corresponding Controlled Drug Administration Record in the presence of the RN which indicated 22 [MEDICATION(S)] 50 mg should have been present in the bingo card. This documentation reflected that there was an excess of one [MEDICATION(S)] 50 mg for Resident #66. The surveyor reviewed the bingo card that contained [MEDICATION(S)] with Acetaminophen 37.5/325 mg for Resident #69 and identified that 23 [MEDICATION(S)] with Acetaminophen 37.5/325 mg were present. At that time, the surveyor reviewed Resident #69's corresponding Controlled Drug Administration Record in the presence of the RN which indicated 24 [MEDICATION(S)] with Acetaminophen 37.5/325 mg should have been present in the bingo card. This documentation reflected that there was one less [MEDICATION(S)] with Acetaminophen 37.5/325 mg for Resident #69. The RN stated that the medication [MEDICATION(S)] 50 mg was signed on the wrong Controlled Drug Administration Record and that was why there was a discrepancy. The RN further stated that the medication [MEDICATION(S)] 50 mg was not administered to the resident. The RN explained that the foil behind the [MEDICATION(S)] with Acetaminophen 37.5/325 mg bingo card was ripped, making it easy for the medication to fall out, so her and another nurse decided to dispose of the medication. A further review of the Controlled Drug Administration Record revealed that two nurses did not sign as witnesses for the destruction of the controlled medication for the [MEDICATION(S)] 50 mg or the [MEDICATION(S)] with Acetaminophen 37.5/325 mg as required on the Controlled Drug Administration Record. The RN stated that the Controlled Drug Administration Record for Resident #69 containing the [MEDICATION(S)] with Acetaminophen 37.5/325 mg should have had two nurses' signatures because that was the medication that was disposed of. On 10/14/22 at 11:00 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the nurses should have notified the supervisor as soon as they signed for the wrong medication and had the medication destroyed properly. The ADON stated that the correct way to dispose of a controlled medication was for two nurses to put the medication in the drug buster and both nurses should have signed the Controlled Drug Administration Record for the destruction of the medication. On 10/17/22 at 11:14 AM, the surveyor interviewed the CP in the presence of the Administrator who stated that the nurses would count the narcotic inventory on each medication cart at the beginning and end of each shift for accountability. The CP further stated that the nurses had to make sure the count on the medication bingo card matched the count on the Controlled Drug Administration Record. The CP told the surveyor that the appropriate procedure was for two nurses to witness and sign for the destruction of the narcotic medication on the Controlled Drug Administration Record. On 10/18/22 at 1:35 PM, the surveyor interviewed the Administrator who stated that it was the facility's policy for two nurses to sign as witnesses for the destruction of the narcotic. A review of the facility's, Controlled Drugs Record/Controlled Drug Index Policy and Procedure revised 5/1/22 indicated that maintaining an accurate inventory of controlled drugs must occur and the facility was to ensure that all controlled substances were accounted for in a manner that promoted proper security and accountability. The Controlled Drugs Record/Controlled Drug Index Policy and Procedure further indicated that any discrepancy in the count must be reported to the supervisor immediately for investigation and that all sections of the Controlled Drug Administration Record form must be completed. NJAC 8:39-29.2(d),29.4(c),29.7(c)

C #: NJ 571 Based on interviews and record review, as well as review of pertinent facility documents on 2/22/22, it was determined that the facility failed to provide a safe environment as well as follow their own protocol on door security for 1 of 5 residents (Resident #2) reviewed for elopement risks. Resident #2 exited the building (eloped) on 2/18/22 at 8:11 pm when the facility's main entrance door was left unlocked and unattended. At approximately 9:50 pm the staff noticed the Resident missing. Elopement protocol was initiated. The Resident was found dead on 2/19/22 by a staff member in the wooded area approximately 600 feet away from the Facility. This deficient practice was evidenced by the following: 1. According to the ADMISSION RECORD (AR) form, Resident #2 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Dementia with Behavioral Disturbance, [CONDITION(S)] and [CONDITION(S)]. The Minimum Data Set (MDS), an assessment tool dated 2/14/22, showed that Resident #2's cognition was impaired and required limited assistance from staff with Activities of Daily Living (ADL). The MDS showed that the Resident had a wandering behavior and could place the Resident at significant risk of getting to a potentially dangerous place. The MDS further showed that the Resident could ambulate independently; however, would require oversight and cueing when the Resident moves to and returns from off unit locations such as but not limited to dining, activities and distant areas. The Elopement assessment dated [DATE] showed that the Resident was identified for at risk for Elopement due to history of elopement and wandering behavior. The Care Plan (CP), initiated on 2/9/22, showed that the Resident was at Risk for Elopement related to Dementia with Behavioral Disturbance. Goals included were: will adjust to new environment and will not leave the center unattended. Interventions included but were not limited to: check for function of the wanderguard bracelet and when exhibiting exit seeking behavior redirect to an appropriate area. The CP further showed that the Resident had Wandering/pacing related to Dementia with Behavioral Disturbance. Interventions included but were not limited to: provide assistance in locating own room and provide directional cues. The Facility Reportable Event (FRE) dated 2/18/22 and reported to the New Jersey Department of Health (NJDOH)showed an elopement incident involving Resident #2. On 2/18/22 at approximately 9:50 pm, the Certified Nursing Assistant (CNA #1) was unable to locate Resident #2. Elopement protocol was initiated. Internal and External search was done with the help of the township Police and Firemen. Family was notified. Head count and doors were checked. Receptionist Staff (RS) was suspended pending investigation. On 2/19/22 at approximately 12:00 pm the Resident was found cold and unresponsive. Police officers and emergency personnel were on the scene. The Resident was pronounced dead. The family and the Primary Physician were notified. Attached with the FRE the INVESTIGATION REPORT (IR), dated 2/18/22, the facility showed the following timeline but were not limited to the following: At 7:45 pm, CNA #1 assisted the Resident to the bathroom. At 7:59 pm, RS locked the courtyard and rehab door, then proceeded to the bathroom. At 8:00 pm, Resident #2 informed CNA #1 that he/she wanted to watch the television in the Dayroom. At 8:20 pm, RS came back to the front desk after clocking out and left the front main entrance door. At 9:40 pm, CNA #1 noticed that the Resident was not in his/her room. She continued to look for the Resident but could not find the Resident. At 9:50 pm, CNA informed the nurse that she could not locate the Resident. Elopement protocol started. Administration notified. The IR further showed additional actions taken during the investigations: elopement risk reviewed, wanderguard system tested , environmental and equipment checked by on-site vendor on 2/19/22 at 12:30 pm and left at 4:00 pm. The vendor relocated the existing antenna from the ceiling height (which was approximately 12 feet high) to the left and right side of the sliding door 28 inches to the center from the floor. The surveyor viewed the security camera (SC) with the Administration on 2/22/22 at 11:52 am. The SC showed the following: At 8:00 pm, the RS was sitting at the front desk. There was no evidence that the RS locked the main entrance door. At 8:06 pm, the RS left the front desk unattended. The SC did not capture where the RS went at this time. At 8:11 pm, Resident #2 walking towards the front main entrance door. The door opened and the Resident exited the building. The Resident was wearing long sleeves shirt, pants and sneakers. At 8:12 pm, the RS returned to her front desk. At 8:16 pm, the RS stepped out and returned back inside using the front main entrance door. At 8:20 pm, the RS pressed the button on the side of the main entrance door to lock the door then exited the building. Reviewed of the Treatment Administration Record (TAR) for wanderguard and daily exit door log showed that Resident #2's wanderguard was checked for placement/function and exit door alarms were checked on 2/18/22. During an interview with the Administrator on 2/22/22 from 10:01 am to 12:27 pm, he confirmed what was written on the aforementioned FRE and IR. He revealed that the RS did not lock the front main entrance door between 7:45 pm to 8:00 pm. The main entrance door was locked at 8:20 pm according to the SC. In addition, the RS left the front desk area unattended. He stated that when he viewed the SC on 2/18/22, the Resident approached the front door and the wanderguard did not activate, and because it did not activate the front door did not go into the locked mode and no alarm sounded. The panel was visible in the SC and it did not appear to change color as it would when it detects the wanderguard. The surveyor attempted to conduct a telephone interview with the RS on 2/22/22 at 2:04 pm and 2:10 pm; however, the RS was not available. During an interview with CNA #1 on 2/22/22 at 2:10 pm, she confirmed what was on the FRE. She stated that Resident #2 was ambulatory, and confused. She stated that the Resident had wandering/exit seeking behavior and would require cueing/redirection. She stated that RS would know Resident #2 was at risk for elopement because the Resident's picture was posted on the front desk station. She further stated that it was everyone's responsibility including the RS to redirect residents who were exit seeking. Review of the Job Description for Receptionist dated 9/23/21 showed under Safety and Sanitation .Other(s) that may become necessary/appropriate to assure that the facility is maintained in a .safe .manner . The facility's Closing procedure, undated, showed *7:45 PM .LOCK MAIN ENTRANCE . NJAC 8:39-31.8(b)

Complaint # NJ 3543 Based on observation, interview, and record review, it was determined that the facility failed to immediately respond when notified that a cognitively impaired resident left the building unattended. The resident sustained [REDACTED]. The facility also failed to intervene to prevent a resident from sustaining a bruise after becoming agitated during care. This deficient practice occurred for Residents #8 and #13, 2 of 5 residents reviewed for falls and accidents, as evidenced by the following: 1. On 11/14/14 at 11:15 a.m. the surveyor observed Resident #13 who was seated in a chair in his/her room. The resident was alert, responsive, dressed appropriately and had a wanderguard on the right wrist. The surveyor reviewed Resident #13's medical record which indicated the resident was initially admitted on [DATE] to the facility for Respite Care Stay and with [DIAGNOSES REDACTED]. The Interdisciplinary (IDC) team assessed the resident utilizing the Admission Minimum Data Set (MDS), an assessment tool, as alert to self, confused, with long term memory within normal limits, and short term memory impaired with moderately impaired cognition. The IDC team assessed that the resident was able to walk with limited assistance of one person. The IDC team assessed the resident on 3/13/14, utilizing the Elopement Risk Assessment form, and identified the resident as an elopement risk. The staff observed the resident wandering towards the doors. The resident voiced the desire to go home. On 11/18/14 at 3:30 p.m. the Director of Nurses (DON) told the surveyor that Resident #13 was discharged from the facility 4/9/14 and readmitted to the facility on [DATE] after hospitalization following a fall at home. The IDC team assessed the resident on 6/7/14 utilizing the admission MDS Brief Interview for Mental Status as severely cognitively impaired with a score of 6 (0-7 indicated severe cognitive impairment). The IDC team assessed that the resident was able to walk with limited assistance of one person. The Licensed Practical Nurse documented in the facility's Elopement Risk Assessment form dated 5/31/14 that Resident #13 was not at risk for elopement at this time. This assessment indicated that there was no history of elopement; no expression of desire to leave or return home; no impaired cognition;and no wandering history - all of which had been documented in the resident's history. On 11/18/14 at 12 p.m. the surveyor reviewed the Interdisciplinary Care Plan (CP) for Elopement Risk initiated 6/5/14. The CP identified the resident's Focus/Problem as risk related to Alzheimer's Dementia and Cognitive Impairment and the goals section included that the resident will not leave center unattended... and will not exit, seek/elope from the facility. The resident's care plan dated 6/11/14 noted that the resident needed assistance to transfer and ambulate as needed. The nurse documented in the Progress Note dated 6/22/14 at 2:52 p.m. that Resident #13 was reported by a staff member to be on the ground in the driveway of the side parking lot. The resident sustained [REDACTED]. The Progress Note stated, "large amount of blood noted coming from left side of patient's head, unable to measure open area due to amount of blood." Staff called 911, and Resident #13 was transported to the hospital for evaluation. At the time of the incident, the resident had a chair alarm and wander guard in place. Resident #13 was readmitted [DATE] with generalized bruising and bruising around the eye. The surveyor reviewed the Incident and Accident investigation provided by the facility on 11/18/14. The facility documented that the resident fell on [DATE] after a visitor observed Resident #13 left the building pushing a wheelchair. The facility documented in the Investigation Report in the Summary of Critical Information Obtained During Investigation (dated 6/25/14) that on June 22, 2014 at approximately 1:55 p.m., a visitor told the receptionist that she observed a resident leaving the building pushing her/his wheelchair. As per written statement and interview with the visitor (who was another resident's family member) the receptionist stated "I will take care of it." Around 2:20 p.m., 25 minutes after first informing the receptionist of Resident #13's elopement, the visitor left the building and went to her car in the employee parking lot located at the side of the building. The visitor saw the resident on the ground and ran inside to inform the receptionist. The Investigation Report dated 6/25/14 also noted that on 6/1/14 the facility completed a Risk of Elopement/Wandering Assessment that identified the resident as an elopement risk and a wanderguard was placed on the resident. The report also stated that the receptionist on duty from 8 a.m. to 2 p.m. on 6/22/14 stated the resident tried to exit through the side employee door earlier in the day and the alarm sounded. The facility conclusion after the fall was that the wanderguard was checked and tested and the facility was unable to replicate any malfunction. The battery expiration dates were checked and were 1/20/17. The surveyor interviewed the receptionist at the desk on 11/18/14 at 2:50 p.m. (newly employed) who stated that as of mid-July all pictures of resident's at risk for elopement were at the front desk. On 11/19/14 at 10:10 a.m. the surveyor interviewed the Director of Maintenance (DM) who stated that prior to Resident #13's elopement of 6/22/14, all exits that automatically locked when wanderguard bracelets were near the door were checked weekly, and the wanderguard bracelets worn by the residents were checked monthly. 2. On 11/12/14 at 10:10 a.m. during the initial tour of the facility with the Unit Manager (UM) the surveyor observed Resident #8 seated out of bed in a wheelchair. The resident was alert, unable to speak but when spoken to, smiled at the surveyor. On 11/13/14 at 7:50 a.m. the surveyor reviewed the medical record for Resident #8 who was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The facility completed an Incident/Accident Report on 08/20/14 when the nurse noted the resident had bruising to the forehead and near the right eye. The Witness Statement completed on 08/20/14 by the nurse on duty indicated that Resident #8 was agitated at the start of the shift (11-7 night shift). The resident yelled and screamed and banged his/her head on the side rail while his/her feeding tube was flushed. At approximately 12:30 a.m. the bruising was noted while providing care. The nurse who completed the Incident/Accident report also documented at 7:45 a.m. in the corresponding nurse's note which covered the entire shift. The nurse documented that the feeding tube was flushed and the resident had no distress. The nurse did not document in the nurse's note that the resident was agitated or banging his/her head on the side rail. The nurse documented later in the same note that bruises were found and the resident was unable to state what happened. On 11/17/14 at 1 p.m. the surveyor spoke with the DON regarding this incident. The surveyor discussed the inconsistency of the statements written by the same nurse and the fact that no intervention such as side rail padding was put into place to prevent a future occurrence. The DON acknowledged that the statements written by the nurse were inconsistent and could not say why that would be. The DON stated that the resident did not like change in his/her environment and probably would not like side rail padding and therefore, it was not tried. The DON agreed that even though a resident may refuse an intervention, it should be attempted. She further agreed that if a resident does refuse an intervention, the refusal should be documented. NJAC 8:39-27.1(a)

Complaint #NJ 427 Based on observation, record review, and interview it was determined that the facility failed to provide resident supervision and/or assistance to prevent accidents which resulted in injuries. This deficient practice was identified for for 2 of 7 residents, Resident #3 and #6, reviewed for falls. Subsequently, Resident #3 fell from her wheelchair and sustained hip and thumb fractures. This was evidenced by the following: 1. On 9/8/10, 9/10/10 and 9/13/10, the surveyor investigated a facility reportable incident of Resident #3's fall from a wheelchair which resulted in a hip and thumb fracture, including a dislocation of that thumb, CN # NJ 427. According to record review Resident #3 was admitted to the facility on [DATE] for rehabilitation after a fall at home which resulted in a hip fracture. The resident's [DIAGNOSES REDACTED]. On 9/8/10 at 11:30 a.m., the surveyor observed Resident #3 lying in bed. The Registered Nurse who was touring with the surveyor stated that Resident #3 fell at home and sustained a left hip fracture. On 9/9/10 at 9: 30 a.m., the surveyor observed Resident #3 in bed with a cast on the right wrist. On 9/10/10 at 10:30 a.m. the surveyor reviewed Resident #3's Daily Skilled Nurse's Note dated 8/25/10 timed 11:00 a.m., which stated that Resident #3 sustained a fall at the facility. Resident #3 fell on [DATE] at 10:30 a.m., in the room. Another fall at the facility was documented in a Daily Skilled Nurse's Note dated 8/27/10 at 11:40 a.m. which revealed that Resident #3 fell in the room and sustained a right hip fracture and a fracture of the thumb. The Fall Investigation of 8/25/10 indicated that the resident stated that (the resident) stood up from the wheelchair, which was not locked, and slipped down. The chair alarm sounded; no injury was noted. The Interdisciplinary Care Team (IDT) revised Resident #3's Care Plan to include that the resident will be offered and and taken to an activity program after breakfast in order to maximize supervision. The Fall Investigation of 8/27/10 indicated that Resident #3 was unsupervised in the room at 11:40 a.m. and fell from the wheelchair and the chair alarm sounded. The facility's Fall Investigation indicated that the resident told the facility investigator that (the resident) needed help and was trying to get up. The Certified Nurse Aide's (CNA's) written statement indicated the resident had been taken to the toilet at 11:30 a.m. After the fall, Resident #3 complained of pain in the right hand and right leg. An X-Ray revealed an acute spiral fracture of the right distal femur and a fracture and dislocation of the right thumb. The resident was hospitalized for [REDACTED]. On 9/10/10 at 9:30 a.m., the surveyor interviewed the Certified Nurse Aide (CNA) assigned to Resident #3. The CNA stated that the resident was confused and forgetful and was always counseled to use the call bell. Later at 11:30 a.m. the surveyor interviewed the Unit Manager regarding the 8/27/10 fall. The Unit Manager said that Resident #3 was a high risk for falls and after the fall of 8/25/10 the resident was placed under close supervision which she defined, "The resident will be placed at the nursing station or in the dayroom where she can be visible at all times." The surveyor asked the Unit Manager how the nurse communicates to the CNAs about the level of care needed by the residents. The Unit Manager said that the Unit Manager gives a report to the Wing Nurse and then the Wing Nurse gives a verbal report to the CNA. She went on to state that the CNAs are responsible to write the verbal information on their accountability sheets. On 9/13/10 at 10:00 a.m., the surveyor and the Unit Manager reviewed a form titled, "24-hour change of status report," dated 8/26/10. The information on the form indicated that Resident #3 had range of motion and no pain after the 8/25/10 fall but there was no information regarding day room or nursing station placement for supervision for Resident #3. The surveyor also reviewed the 24 hour change of status report for 8/27/10 which also did not have any information regarding close supervision. On 9/13/10 at 12:30 p.m., the surveyor interviewed the CNA assigned to Resident #3 on 8/27/10. The CNA stated that Resident #3 was assigned to her (the CNA) that day, but Resident #3 was not her regular assignment. The CNA told the surveyor, "I did not know that (the resident) was supposed to be at the nursing station. The Nurse did not tell me, only after (the resident) fell , (the Nurse) told me (the resident) was supposed to be at the nursing station." The surveyor reviewed the CNA's Accountability sheet for her assignment and the sheet had only the room number. There was no specific information regarding care. 2. Resident #6 was admitted to the facility in 4/2010 with [DIAGNOSES REDACTED]. The resident had an indwelling catheter and nutrition via a [DEVICE]. The Minimum Data Set (MDS--a resident assessment document), dated 5/1/10, revealed that Resident #6's cognition was severely impaired and the resident was not able to make decisions. The MDS also revealed that Resident #6 had full loss of voluntary movement on both sides of her body. The MDS assessment also indicated that the resident was totally dependent on staff for all activities of daily living including transfers and personal hygiene, and required 2 persons for physical assistance with those activities. On 9/9/10 at 9:20 a.m., the surveyor observed Resident #6 who was in bed with 1/2 siderails up. The head of the bed was elevated. A family member was observed at the bedside. The resident's eyes were closed and the family member stated that the resident was very sick. On 9/9/10 at 11:00 a.m., the surveyor reviewed Resident #6's record which stated that the resident had a fall on 7/25/10 at 11:30 a.m. A review of the Incident/Accident Report revealed that Resident #6 fell during hygiene care. On 9/10/10 at 11:00 a.m., the surveyor interviewed the CNA assigned to the resident who stated that Resident #6 is totally dependent on staff for care and needs two persons to provide assistance. The CNA said that to wash the back of the resident's body she needed another CNA to assist her. On 9/10/10 at 11:30 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN) who was in the room when the resident fell off the bed. The LPN said that she was in the room getting ready to suction the resident. She stated that the CNA positioned the resident on (the resdient's) side and proceeded to wash the back area of Resident #6. The LPN said that suddenly she saw the resident rolling with a knee first and then ended up on the floor. Neither the LPN nor the CNA could prevent the fall as they were both on the left side of the bed. On 9/10/10 at 11:40 a.m. the surveyor interviewed the Registered Nurse who stated that she understood that Resident #6 needed a 2 person assist due to (the resident's) condition but the nurse did not know why the care plan was not followed. On 9/10/10 at 12:30 p.m., the surveyor interviewed the CNA who cared for the resident on 7/25/10 when the fall occurred. The CNA said that she had been providing care to Resident #6 by herself. The CNA said that she reached to get wipes on the table and when she turned she saw that the resident was sliding off the bed. She further stated that when the resident fell , the 1/2 side rail on the right side of the bed was raised but the CNA could not stop the fall because the resident's head had slipped past the 1/2 side rail. The surveyor reviewed the CNA's written statement in the facility's investigation. The CNA wrote, "I had (Resident #6) turned on the right side facing the wall, so that I could clean (the resident). I went to get the wipes to clean her and she started to tilt over to the side." The CNA told the surveyor that the wipes were on a table in the corner of the room with other supplies. The CNA's written statement continued, ".....went to grab (the resident) and so did the nurse. The nurse was able to grab (the resident's) lower body, but I was unable to grab (the resident's) upper body quick enough...the top of (the resident's) body fell over and (the resident) hit (the resident's) face on the floor." The Interdisciplinary Progress Notes dated 7/25/10 indicated that Resident #6 was transferred to hospital for evaluation and returned that same day. At 8:00 p.m. the Notes documented, "Facial redness noted on forehead, nose upon return." On 9/13/10 at 11:00 a.m., the surveyor interviewed the CNA again. The CNA said that she was never told that she needed 2 persons to provide care to the resident. the CNA stated, "I thought I could do it myself." She went on to state that after the fall she was told by a member of the Administrative staff and the Unit Manager that from now on 2 people must be present to turn the resident. NJAC:8-39 27.1(a)