Every finding on record at Careone at Ridgewood Avenue

Complaint #: NJ2639235Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 07/08/2026 and 07/09/2026, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices for medication administration and treatment administration for a resident (Resident #4). This deficient practice was identified for 1of 9 (Resident #4) residents reviewed for medication administration and treatment administration, and was evidenced by the following:According to Resident #4's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Bacteremia (the presence of bacteria in the bloodstream), Rheumatoid arthritis involving multiple joints (an autoimmune condition where the immune system mistakenly attacks the body's own tissues, particularly the lining of the joints, which leads inflammation, which can cause joint damage and deformities over time), and Benign Prostatic Hyperplasia (a condition in which the prostate gland (a small gland located just below the bladder that surrounds the urethra, the tube that carries urine and semen out of the body) grows larger than normal. According to the Minimum Data Set (MDS), an assessment tool dated 06/16/2026, Resident #4 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition is moderately impaired. The MDS also revealed the resident had an indwelling catheter. A review of Resident #4's Care Plan (CP) with an initiated date of 06/11/2026, revealed under Focus: Use of indwelling urinary catheter related to disease process (obstructive uropathy/benign prostatic hyperplasia).A review of Resident #4's Care Plan (CP) with an initiated date of 06/11/2026, revealed under Focus: has Infection of urinary tract. Interventions/Tasks included but were not limited to: Administer medication per physician orders. A review of Resident #4's Order Summary Report (OSR) Active Orders as of 06/10/2026, a physician order for the following medications: Cefazolin Sodium-Dextrose Intravenous Solution 2-4 GM/100ML-% (Cefazolin Sodium-Dextrose) Use 100 ml intravenously every 8 hours for Hematuria for 6 Weeks with a start date of 06/10/2026 at 06:00 A.M., 02:00 P.M., 10:00 P.M. Cefazolin Sodium-Dextrose Intravenous Solution 2-4 GM/100ML-% (Cefazolin Sodium-Dextrose) Use 100 ml intravenously every 8 hours for Hematuria for 6 Weeks. With a start date of 06/11/2026 06:00 A.M., 02:00 P.M., 10:00P.M. A review of Resident #4's Electronic Medication Administration Record (eMAR) for June 2026 revealed blank spaces, no documentation on:06/10/2026 at 10:00 P.M.06/17/2026 at 06:00 A.M. A review of Resident #4's progress notes for the mentioned date revealed no documentation related to the blanks on the eMAR.A review of Resident #4's progress notes revealed a Physician/Practitioner Progress Note on 06/11/2026 10:23 by [NAME] PA-C, marked as a LATE ENTRY, that noted ordered Cefazolin not yet started due to pharmacy delay. A review of Resident #4's Treatment Administration Record (TAR) for June 2026 revealed, Catheter Output every shift [Day, Evening, and Night] with start date of 06/11/2026, 03:00 P.M., with blank spaces, no documentation, on the following day shifts:06/13/202606/18/202606/25/2026 And night shift:06/16/2026 Review of Resident #4's progress notes for the mentioned dates revealed no documentation of urinary catheter output. An interview was conducted on 07/08/2026, at 10: 30A.M with Certified Nursing Assistant (CNA) who stated that the expectation is that the CNAs empty the resident's urinary catheter drainage collection bags when switching collection bags and at end of shift. The CNA stated that output is measured and reported to the nurses. The CNA further stated that CNAs are made aware of which residents have foley catheters when they receive report from the nurse at the beginning of shift.An interview was conducted on 07/08/2026, at 12:49 P.M. with Registered Nuse (RN) #1, who stated that foley catheter care and output is documented every shift in Progress Note and TAR, and that output and drainage is monitored. RN #1 also stated that when caring for patients with foley catheters, aides are told to empty the bag when half full. RN #1 further stated that report is given at beginning of shift, the aides always report output, and nurses are responsible to record it at end of shift.An interview was conducted on 07/09/2026, at 12:30 P.M., with a Unit Manager (UM) who stated that medication administered should be signed off on the MAR by the nurse. The UM also stated that it is the policy that nurses should record medication administration and that if there is a blank space in the MAR, then policy was not followed. The UM also stated that resident's foley catheter care includes recording foley catheter output every shift on the TAR or MAR. An interview was conducted on 07/09/2026, at 01:50 P.M., with the Director of Nursing (DON) who was questioned about the blank on Resident #4's MAR on 06/17/2026 and stated that the nurse should have written a progress note as to why it was not received. The DON further stated that the nurses must follow the doctor's orders and that if an intervention wasn't documented, it wasn't done. DON also stated that foley catheter output should be documented every shift and the expectation is that nurses document foley catheter output on the TAR every shift. The DON further stated that if documentation of care was not done, policy was not followed.A telephone interview was attempted on 07/10/2026, at 11:11 A.M., with RN #2 to discuss the blank space on Resident #4's TAR from 06/16/2026 night shift and the blank space on Resident #4's eMAR from 06/17/2026 06: 00A.M, unable to reach RN for interview.A telephone interview was conducted on 07/10/2026, at 02:40PM, with LPN #1 who provided care to Resident #4 during the day shift on 06/13/2026, 06/18/2026, and 06/25/2026. LPN #1 reported that the resident's catheter was drained, and output was checked on 06/13/2026, 06/18/2026, and 06/25/2026 day shifts, but it was not recorded. The aide tells us what the output is. The facility policy is that catheter output is recorded at the end of every shift by the nurses. Review of the facility policy titled Documentation of Medication Administration with a revised date of November 2022. Under Policy Interpretation and Implementation reveals: 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: a. the resident's name; b. name and strength of drug; c. dosage; d. route of administration; e. date and time of administration; f. reason(s) why a medication was withheld, not administered, or refused (as applicable); g. initials, signature and title of the person administering the medication;. Review of the facility policy titled Administering Medication with a revised date of April 2019. Under Policy Interpretation and Implementation reveals: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 21. If a drug I withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. For centers using electronic documentation (e.g. eMAR), enter the appropriate documentation code. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. For centers using electronic documentation (e.g. eMAR), electronic signatures are utilized.Review of the facility policy titled Catheter Care, Urinary with a revised date of August 2022. Under Policy Interpretation and Implementation reveals: Input/Output. 2. Follow the facility procedure for measuring and documenting input and output.Review of the facility policy titled Charting and Documentation with a revised date of July 2017. Under Policy Interpretation and Implementation reveals: 4. The following information is to be documented in the resident medical record: .B. Medications administered; c. Treatments or services performed; and 9. Documentation of procedures and treatments will include are-specific details, including a. the date and time the procedure/treatment was provided. N.J.A.C. 8:39-35.2 (d) 9

Part B 2. The surveyor interviewed Resident #98 on 5/30/25 at 10:58 AM. The resident was seated in a wheelchair at the bedside. The resident stated they were currently receiving chemotherapy. The resident stated they were experiencing generalized weakness and weakness of the left leg resulting in difficulty with ambulation. The resident stated they use the call bell device to request assistance getting from the bed to the wheelchair, for toileting, and for dressing. The resident stated the call bell response can be very slow. The resident described an incident which had occurred the previous week. The resident had propelled their wheelchair into the bathroom unassisted. The resident transferred themself onto the toilet and had a bowel movement. The resident rang the call bell for assistance with cleaning themself. The resident waited for one half hour, received no response, and stood up from the toilet and used the wheelchair as a rolling walker pushing the wheelchair in front of themself and ambulated to the bedside. The resident attempted to place a pillow case on the wheelchair cushion so that they could sit down without soiling the seat. The wheelchair moved and the resident fell onto their knees. The resident rang the call bell and waited 45 minutes for the Certified Nursing Assistant (CNA) to respond. There were no injuries as a result of the incident. A review of the electronic medical record revealed the following information. The resident was admitted for short term rehabilitation with diagnosis including, but not limited to, polyneuropathy (nerve ending degeneration); diffuse large B cell lymphoma; chemotherapy induced pancytopenia (low levels of red and white blood cells); anemia; protein calorie malnutrition. The 5/2/25 admission Miniumum Data Set assessment tool (MDS) indicated the resident had no cognitive deficits; was dependent on staff for toileting hygiene, was dependent on staff for standing from a sitting position, transferring to and from a bed and wheelchair, and getting on and off the toilet. The MDS indicated the resident used an indwelling urinary catheter and was frequently incontinent of bowel. The fall care plan, initiated 4/25/25 and revised 5/29/25, indicated the resident was at risk for falls due to impaired balance and poor coordination. The resident was noted to have had a fall on 5/24/25 without injury. Fall precaution interventions included, but were not limited to, reinforce the need to call for assistance and remind the resident to lock the wheelchair prior to transfers. The electronic medical record progress notes did not contain any reference to the 5/24/25 fall incident. The surveyor interviewed the resident's CNA on 6/02/25 at 10:45 AM. She stated the resident needs stand by assistance of one person. She stated his left leg is weak and sometimes gives out without warning and you have to be there to support him if that happens. The surveyor discussed concerns of the slow call bell response and the subsequent resident's fall with the Licensed Nursing Home Administrator and the Director of Nursing on 6/2/25 at 3:00 PM. No further information was provided to the surveyor. Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to ensure a cognitively impaired resident, who had a diagnosis of Alzheimer's Disease, and dysphagia (difficulty swallowing) with a history of aspiration (when material such as food or drink enters the airway or lungs), received the appropriate physician ordered moderately thick (honey thickened; liquids thickened with an agent for a honey-like consistency) liquid consistency. This deficient practice was observed for 1 of 4 residents reviewed for accidents and accident prevention (Resident #62). During a lunch observation on 5/30/25 at 12:25 PM, Surveyor #1 and #2, observed the Activity Aide (AA) deliver a cup of liquid to Resident #62 in the North dining room. Surveyor #1 and #2 observed the AA pour a pre-thickened nectar consistency beverage into the cup of liquid. The resident immediately began drinking the liquid and started to cough. Surveyor #1 and #2 approached Resident #62 and reviewed the resident's meal ticket. At that time, Surveyor #1 called the Licensed Practical Nurse (LPN) over to check the resident's meal ticket. The LPN then verified the resident's meal ticket which indicated that the resident was on honey thickened liquids (HTL) and should have received only HTL to prevent choking. The LPN stated that the resident's green dot on the wristband indicated the resident had an order for HTL and confirmed that the liquid in Resident #62's cup had not been thickened to Honey Thick (HT) consistency. An interview on 5/30/25, with the Speech Language Pathologist (SLP) confirmed that giving Resident #62 liquids that were not HT consistency could cause aspiration pneumonia. The facility's failure to ensure cognitively impaired residents received and consumed liquids in the appropriate form as prescribed by a physician, posed the likelihood of aspiration which could result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/30/25 at 12:25 PM, when Resident #62 was observed coughing after being served the incorrect liquid consistency. The facility's administration was notified of the IJ on 5/30/25 at 3:58 PM. The facility submitted an acceptable written Removal Plan on 6/2/25 at 12:02 PM. The survey team verified the implementation of the Removal Plan through observation and interview during the continuation of the on-site survey on 6/2/25. The facility further failed to ensure staff provided adequate supervision for a resident at risk of falls resulting in a fall for Resident #98, and failed to ensure safety interventions for fall prevention were in place for a resident at risk for falls, Resident #62 for 2 of 2 residents reviewed for falls. The evidence was as follows: PART A A review of the facility's Dysphagia Management Program (Formerly Think Green/ Think Blue) policy, dated revised 1/3/25, indicated: Policy: Patients will have their diet and hydration managed safely and effectively, meeting their individual nutritional and hydration needs . Purpose: The Dysphagia Management Program (DMP) is designed to raise awareness of staff regarding patients with swallowing problems requiring alternate liquid consistencies. The DMP is a clinical system adopted by the center for the care of an individual at risk for aspiration and choking .Patients assessed by the interdisciplinary team receive therapeutic diets as ordered by a physician to assist in the management of the identified swallowing problems . Process: The Director of Nursing will complete the DMP Identifier form which will adopt a color to identify patients in the DMP. Use of a color-coded wristband and color code on the meal tray card is mandatory for this program. The Nurse receiving the physician order starts the identification system for any individual on thickened liquids (Moderately thick, mildly thick) or NPO (nothing by mouth.) Thickening Liquids: Commercially prepared thickened liquids will be purchased and used when possible. Some liquids will not be available pre-thickened by the manufacturer. A further review of the facility's DMP policy indicated: Commercially prepared thickened liquids will be purchased and used when possible. Some liquids will not be available pre-thickened by the manufacturer and will need to be thickened using bulk thickener by trained staff with demonstrated competency using the product. Diet and Liquid Consistency Orders: Diet and liquid consistencies are adopted from the International Dysphagia Diet Standardization Initiative (IDDSI) Guidelines as follows: Pureed (PU4) Moderately thick liquid (MO3) Dining with thickened liquids: Liquids will be delivered pre-thickened from the food and nutrition services department. Liquids may be thickened by the Speech Language Pathologist at bedside for a speech evaluation or for home education. Staff Education: Staff will be introduced to the dysphagia management program and International Dysphagia Diet Standardization Initiative (IDDSI) terminology during orientation and on an ongoing basis. A review of the facility's Identification System policy undated, indicated: Policy: A system has been developed to provide identification to staff of specific individualized patient/resident needs while maintaining confidentiality. Identification of specific needs will be indicated on the patient's/resident's wrist band, medical chart, room, door, or bedside with designated colored dots or specific symbolic stickers. Patients assessed by the interdisciplinary team receive therapeutic diets as ordered by a physician to assist in the management of the identified swallowing problems . Identification as follows: Red Dot=Diabetic Green Dot=Thickened Liquid (N-Nectar Thick/ H-Honey Thick) Blue Dot= Fluid Restriction Orange Dot= Nothing by Mouth (NPO) . During a lunch observation on 5/30/25 at 12:25 PM, Surveyor #1 and #2, observed the AA deliver a cup of liquid to Resident #62 in the North dining room. Surveyor #1 and #2 observed the AA pour a pre-thickened nectar consistency beverage into the cup of liquid. The resident immediately began drinking the liquid and started to cough. Surveyor #1 and #2 approached Resident #62 and reviewed the resident's meal ticket. The surveyors observed that Resident #62's meal ticket on their tray indicated moderate thick liquids and was highlighted with a green marker. At that time, Surveyor #1 called the Licensed Practical Nurse (LPN) over to check the resident's meal ticket. The LPN then verified the resident's meal ticket which indicated that the resident was on HTL and should have received only HTL to prevent choking. The LPN showed the surveyors that the resident had a green dot with an H on their wristband which indicated the resident had an order for HTL. The LPN confirmed that the liquid in Resident #62's cup had not been thickened to HT consistency. On 5/30/25 at 12:42 PM, during an interview with the surveyors, the AA stated that the resident requested an additional beverage, so the AA obtained a cup of tea from the food truck. The AA confirmed that it was a cup of tea that had not been pre-thickened from the kitchen, so she poured a small amount of nectar pre thickened liquid into the tea. The AA stated that she was not aware of what Resident #62's diet was, but that the resident's family member told her that the beverage needed to be thickened. The AA confirmed that she should have called the kitchen to send the appropriate HT beverage for the resident and that she should not have thickened it herself. The surveyor asked the AA what the green highlight on the resident's meal ticket indicated and what the green dot/H on the wristband that Resident #62 was wearing indicated. The AA did not respond. On 5/30/25 at 12:45 PM, Surveyor #2 observed the Speech Language Pathologist (SLP) evaluate the liquid Resident #62 had consumed. The SLP stirred the liquid with the straw and stated she had to get a spoon from the nurse. The SLP used a spoon to assess the liquid and stated, this is not honey thick. The SLP confirmed that moderately thick liquids were considered honey thick. On that same date, at that time, during an interview with Surveyor #1 and #2, the SLP confirmed that giving the resident liquids that were not moderate consistency could cause aspiration pneumonia. The SLP stated that the AA should not have served the incorrect liquid consistency. She further stated that the kitchen staff and nurses usually thicken the liquids and that she also did bedside pharyngeal swallow assessments where she altered the consistencies of the beverages to assess the resident's ability to swallow and tolerate foods and beverages. On 5/30/25 at 1:00 PM, during an interview with Surveyor #1, the Nurse Practitioner, who stated that she worked with the pulmonary physician, confirmed that the resident had a physician's order for moderately thick liquids and should be provided with HTL only. The NP stated that she assessed the resident who had clear lungs, no wheezing and oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) between 94-96%. The NP stated that she ordered a chest x-ray for tomorrow morning (5/31/25), to monitor the resident for possible aspiration pneumonia. On 5/30/25 at 1:42 PM, during an interview with Surveyor #1 and #2 the Director of Nursing (DON) stated that the AA should have followed the facility's policy which would be to have the kitchen staff add thickener to the beverage before serving it to the resident. On 5/30/25 at 2:26 PM, during an interview with Surveyor #1, the Food Service Director (FSD) who prepared Resident #62's lunch meal and beverages, stated that the dietary staff thickens the coffee and hot tea in the kitchen and then sends it on the food truck. The FSD further stated that milk, juices and water were pre thickened by the vendor. The FSD confirmed that extra thin liquid hot beverages were sent up in the food trucks during meal service. The FSD stated that if Resident #62 requested additional beverages, the staff should have obtained them from the kitchen. At that same time, Resident #62's family member who was seated next to the resident, stated that the resident was supposed to be on HTL and that they didn't thicken it enough. The surveyor reviewed the medical record for Resident #62. According to the admission Record, Resident #62 had diagnoses which included but were not limited to; pneumonitis due to inhalation of food and vomit (aspiration pneumonia), dysphagia, Alzheimer's Disease, and pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). A review of the admission Respiratory Care Evaluation, dated 5/24/25, reflected Resident 62's primary diagnoses included but were not limited to; pneumonitis due to inhalation of food and vomitus (aspiration pneumonia) and pleural effusion (a buildup of fluid between the tissues that line the lungs and chest.) A review of the Speech Language Pathologist (SLP) Speech Evaluation and Plan of Treatment dated 5/26/25, reflected the patient presented with oropharyngeal phase dysphagia (swallowing disorder that affects the oral and pharyngeal phases making it difficult to move food from the mouth into the throat and esophagus) characterized by prolonged bolus formation, oral transport time and post swallow residue placing patient at risk for aspiration. The patient's pharyngeal phase of swallow was positive for cough after they swallowed with thin liquids. The SLP determined that a dysphagia intervention was warranted and assessed the least restrictive diet that the patient could safely tolerate with no overt clinical signs or symptoms of aspiration. Recommendations included: moderately thickened liquids with a pureed diet. The recommendation was signed by the physician on 5/26/25. A review of the Physician's Order Summary Report, dated 5/29/25, included a diet order for, Pureed (PU4) Texture, Moderately Thick (MO3) consistency, fortified cereal. A review of the resident's individualized comprehensive care plan (ICCP) included a focus of, [Resident #62] has nutritional status as evidenced by therapeutic diet, swallowing difficulty, at risk for malnutrition initiated on 5/29/25. An intervention dated 5/29/25, included thickened liquids as ordered. A review of the Nurse Practitioner (NP) Progress Note dated 5/30/25 at 11:07 AM, reflected Resident #62 was previously admitted to the hospital due to a hypertensive emergency, with complaints of cough and difficulty of breathing. The chest x-ray was positive for pulmonary congestion and pneumonia and showed patchy air space disease on the right lower lobe lung field. Resident #62 was treated with antibiotics. A review of the of chest x-ray results dated 5/30/25 9:31 PM, reflected right lower lobe infiltrate, unchanged from prior chest x ray results. An acceptable Removal Plan was received on 6/2/25 at 12:02 PM, which indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included: NP assessed the resident, AA was removed from the facility until investigation was completed, the staff was educated on policies for dysphagia and aspiration risk, appropriate fluid consistency, following resident specific diet orders, the importance of adherence to diet orders, and to obtain from the kitchen any additional thickened beverage needed. The survey team verified the implementation on-site during the continuation of the survey on 6/2/25. NJAC 8:39-17.4(a)(1)(2); 27.1(a) 3. On 05/30/25 at 11:50 AM, the surveyor observed Resident #62 in his/her room in bed. The surveyor observed that there were no floor mats in place, and no functioning bed alarm on the bed. The surveyor observed a bed alarm on a shelf on the wall across from the foot of resident's bed. During an interview with Resident 62's family member who was seated at the resident's bedside stated that Resident 62's spouse expressed concern for the resident as he/she had a history of frequent falls. The family member stated that she had notified the social worker and admission staff of the resident's fall history and requested floor mats to be placed on each side of the bed as the resident had them in place during their last admission. A review of the admission Record reflected that Resident #62 was admitted to the facility with diagnoses that included but were not limited to; malfunctioning of the cystostomy (medical device inserted into the bladder to drain urine) pneumonitis r/t inhalation of food and vomit, and Alzheimer's disease. A review of Resident #62's Annual Minimum Data Set (MDS), an assessment tool dated 3/17/25 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. Section GG indicated Resident #62 required staff assistance for activities of daily living and transfers. MDS indicated history of 2-3 falls in previous 6 months. A review of Resident #62's Fall risk evaluation dated 5/11/25 assessed Resident #62's as high risk for falls with a history of 1-2 falls in past 3 months. A review of Resident #62's Individualized Comprehensive Care Plan (CP) initiated on 3/10/23 reflected a focus area that indicated the Resident was at risk for falls due to impaired balance/poor coordination and medication side effects. The interventions included but were not limited to; bed alarm and fall mats on both sides of the bed. On 5/30/25 at 3:33 PM, the surveyor observed Resident #62 in bed, with no observed floor mats and no bed alarm on the bed. On that same date, at 3:34 PM, the surveyor accompanied by the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) assigned to Resident #62's care, entered the resident's room. The LPN and CNA confirmed that the there were no fall mats in place and there was no bed alarm in use, and both acknowledged the mats and bed alarm should have been in place for fall prevention. The surveyor requested the fall prevention/management policy and procedure but it was not provided. On 6/3/25 at 2:18 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse and Assistant Director of Nursing. No further information was provided by the facility. NJAC 8:39-17.4(a)(1)(2); 27.1(a)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) disposition and removal of a narcotic medication for an Unsampled Resident who was discharged on 5/21/25, b.) consistent quality control testing was conducted for the blood glucose (bg) used for residents, c) supplies that required dating when opened were dated, d.) a blood pressure medication was administered for Resident #47, in accordance with the physician orders, e.) a narcotic medication was disposed in accordance with facility policy that allowed for accurate reconciliation and accountability (Resident #10). The deficient practices were identified on 2 of the 3 medication carts inspected, and two of two residents reviewed for pain regimen (Resident #10 and 47) and was evidenced by the following: 1.) On 6/3/25 at 12:47 PM, the surveyor and the Licensed Practical Nurse (LPN #1) began the began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located on the north side of the second-floor cart #4. On 6/3/25 at 12:51 PM, in the presence of LPN #1, the surveyor observed an envelope labeled for Unsampled discharged Resident's (UDR) Alprazolam 0.5 milligram (mg) contained 1 tablet and was dated 4/7/25. At that time, the surveyor and LPN #1 reviewed the electronic Medical Record (eMR) together. The eMR reflected the order for Alprazolam 0.5 mg, give 1 tablet every 24 hours as needed for anxiety, initiated on 4/4/5 was not administered on 4/7/25 and the record did not show the reason why the dispensed narcotic from the electronic back-up machine (EBM) was not administered. Further review of the eMR revealed the UDR was discharged to home on 5/21/25. At that time, the surveyor and LPN #1 reviewed the narcotic accountability log in the narcotic box which showed that two nurses checked the narcotic box for accountability on all three shifts from April 2025 to June 3, 2025. At that time, during an interview with the surveyor, LPN #1 stated that the proper way to dispose of the narcotic from the EBM was to inform her manager, document on the envelope the reason for the return, return the narcotic medication to the EBM together, document the reason for the return on the EBM and both signed the documentation of the reason and the return. LPN #1 confirmed that the UDR's Alprazolam should not have been with the active inventory on the cart. 2.) On 6/3/25 at 12:58 PM, during the medication storage inspection of cart 4 on the second floor, the surveyor and LPN #1 observed two unlabeled blood glucose (bg) machine (monitor). A review of the quality control log for cart 4 reflected only one log and did not identify which machine was tested for quality of accuracy. At that time, during an interview with the surveyor, LPN #1 stated she used both bg glucose monitors and alternated while drying from cleaning. The 11:00 PM to 7:00 AM nurse was responsible to ensure the machines were tested for quality and accuracy. At that time, the LPN/Unit Manager (LPN/UM) walked over to the medication cart and confirmed with the surveyor that she observed two unlabeled bg monitors and 1 bg log. The LPN/UM confirmed both machines should have been labeled, the log should have been labeled and there should have been a corresponding log that identified the testing of each bg monitor, 3.) On 6/3/25 at 1:30 PM, during the medication storage inspection of cart 2 on the second floor , the surveyor and LPN #2 observed two unlabeled bg monitors. A review of the quality control log for cart 2 reflected only one log and did not identify which machine was tested for quality of accuracy. At that time, the LPN stated she alternated the use of bg monitors for the residents during her shift. At that time, the Registered Nurse/ Unit Manager walked over to the cart and confirmed observation of the two bg monitor and one quality control log. The RN/UM acknowledged that the one log did not identify which monitor was tested for accuracy of bg reading. The RN/UM stated she would ensure the bg monitors were labeled, initiate another log, inform the Infection Preventionist (IP) and the Director of Nursing (DON). 4.) On 6/3/25 at 1:08 PM, during the medication storage inspection of cart 4 on the second floor, the surveyor and LPN #1 observed an opened and undated bg test strip. At that time, the surveyor and LPN #1 reviewed the manufacturer's specification of the [brand redacted] bg test strips, under storage and handling included to use within 6 months of first opening or the expiration date on the label, whichever comes first. At that time, LPN #1 acknowledged and confirmed that she should have dated the bg test strips to ensure it was not use pass the expiration date. 5.) On 6/3/25 at 12:21 PM, the surveyor observed Resident #47 in their room seated in a chair. At that time, Resident #47 stated they had returned from rehabilitation department and had no complaints of pain. The surveyor reviewed the medical record for Resident #47. A review of the eMAR included an active physician's order for 2.5 mg of Amlodipine (medication used to lower high blood pressure), give 1 tablet by mouth one time a day for hypertension. Hold is systolic blood pressure (top reading of bp) is below 90 and heart rate below 60, ordered on 5/24/25. The eMAR reflected that the Amlodipine was administered from 5/24/25 to 6/3/25 without evidence that the newly initiated bp medication was monitored as ordered by the physician. On 6/3/25 at 2:39 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), [NAME] President of Special Clinical Project (VPSCP), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the surveyor discussed the concern regarding the administration of Amlodipine without the evidence that a parameter was taken, in accordance with the physician's order. 6.) Refer to F-697 On 6/3/25 at 9:26 AM, the surveyor observed Resident #10 seated in the dining area with other residents. The surveyor overheard the resident speaking loudly from the nurse's station, I want my pain medication. The surveyor observed the nurse's medication cart that was parked next to the nurse's station. The surveyor observed LPN #3 in the dining area, standing next to Resident #10 and the rehabilitation staff. The surveyor observed LPN #3 explain to the resident and the rehabilitation staff that she had already administered the pain medication to the resident. At that time, the surveyor observed the resident becoming more aggravated and told the rehabilitation staff I'm not going with you without Tylenol (Acetaminophen, a non-narcotic pain relief medication). On 6/3/25 at 9:49 AM, in the presence of the LPN/UM, the two (2) surveyors observed LPN #3 arrived on the unit, and stated she went to get Ativan (Lorazepam; medication for anxiety) because she was informed by the therapist of being struck by the resident. LPN #3 stated she knew the resident very well and confirmed that she told the resident she had given them Tylenol. Resident #10 always asked for Tylenol and would not remember when they received it. At that time, LPN #3 confirmed that she did not assess Resident #10 for pain, was aware of the pain complaint and the request for their pain medication, Tylenol. On 6/3/25 at 10:13 AM, LPN #3 informed the surveyors that the resident was assessed by the Nurse Practitioner who was in the building. LPN #3 stated that she would not administer the Ativan at that time. On 6/3/25 at 10:34 AM, the surveyor inspected LPN #3's medication cart for the Lorazepam and found Resident #10's envelope of 0.5 mg Lorazapem (narcotic medication used for anxiety from the EBM) that was empty. LPN #3 informed the surveyor that she discarded the Lorazepam in the drug disposal solution (bottle of solution used to disintegrate pills and tablets) without another nurse/witness. LPN #3 explained the process for the disposal of narcotic medication from the EBM. LPN #3 stated that sometimes we bring it back to the EBM' On 6/3/25 at 11:01 AM, during an interview with the surveyor, the DON stated that narcotic medication dispensed for administration, when refused or not administered should be returned to the EBM and that discarding of narcotics were to be completed with another nurse. On 6/4/25 at 12:37 PM, during a meeting with the survey team, the LNHA, VPSCP, and the ADON, the DON stated that the narcotic medications dispensed from the EBM for Resident #10 and #47 should have been returned to the EBM and disposed with a witness and not left in the medication cart. At that time, the DON also stated that the LPN should have assessed the resident for pain and before the removal of the psychotropic (Lorazepam) for administration. At that time, the DON also stated that Resident #47 was assessed, and the order should have been entered with the parameters in accordance with the physician's order, the bg test strips should have been dated and the bg log should have reflected for both bg monitors that was used by the nurses on the medication cart to monitor bg levels of residents. No further information was provided. A review of the undated, facility provided policy for [name of the EBM redacted] ecosystem return guideline, under procedures included that controlled returns are kept separate from regular scheduled medication returns . A review of the provided facility policy for Medication Labeling and Storage dated/revised in February 2023 ,included that discontinued, outdated or deteriorated medications and biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . A review of the provided facility policy for Blood Glucose Monitoring dated/revised on 7/2/2012, included, under procedures to follow manufacturer's direction for operation of bg monitor including quality control testing and high low sensitivity. NJAC 27.1(a), 29.4(c)(g)(k), 29.7(c)

Based on observation, interview, and record review it was determined that the facility failed to provide pain management that is consistent with professional standards of practice, the resident's goal and preference, and ensure a.) an assessment of a resident's pain was conducted after verbalized pain, and an as needed pain medication was administered when requested (Resident #10) c.) administer the correct narcotic pain medication based on the resident's reported pain intensity and in accordance with the physician's order (Resident #47). This deficient practice was identified for 2 of 2 residents investigated for pain management and was evidenced by the following: 1.) On 6/3/25 at 9:26 AM, the surveyor observed Resident #10 seated in the dining area with other residents. The surveyor overheard the resident speaking loudly from the nurse's station, I want my pain medication. The surveyor observed the nurse's medication cart that was parked next to the nurse's station. The surveyor observed the Licensed Practical Nurse (LPN #1) in the dining area, standing next to Resident #10 and the rehabilitation staff. The surveyor observed LPN #1 explain to the resident and the rehabilitation staff that she had already administered the pain medication to the resident. At that time, the surveyor observed the resident becoming more aggravated and told the rehabilitation staff I'm not going with you without Tylenol (Acetaminophen, a non-narcotic pain relief medication). On 6/3/25 at 9:32 AM, the surveyor observed Resident #10 speak loudly again asking for their two (2) Tylenol. At that time, another rehabilitation staff and the LPN/ Unit Manager (UM) entered the dining room in tandem. The other rehabilitation staff attempted to redirect the aggravated resident by explaining that she was informed that the resident received their Tylenol and that they would wait for the medication to take effect before bringing them to the rehabilitation treatment area, then left the dining area. On 6/3/25 at 9:33 AM, the surveyor reviewed the medical record for Resident #10. According to the admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included: multiple fractures of the right side, ribs, compression fracture of the thoracic vertebra (twelve bones of the backbone to which the ribs are attached) and vascular dementia (damage to blood vessels in the brain leading to reduced blood flow and oxygen supply causing decline in thinking skills). A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, dated 5/12/25, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It showed that the resident received scheduled pain medication, experienced pain occasionally, and rarely or not at all affected their sleep or activities that involved rehabilitation therapy, in the last 5 days. A review of the individualized comprehensive care plan (ICCP) included a focus that Resident #10 had pain, related to their disease process; the associated intervention included, administer pain medication per physician orders, and both were initiated on 5/8/25. Further review of the ICCP reflected another focus related to Resident #10's verbal/physical agitation/aggression related to cognitive impairment; the associated intervention included to evaluate pain and administer analgesia (pain relief medication) as ordered, and both were initiated on 5/12/25. On 6/3/25 at 9:33 AM, the surveyor reviewed Resident #10's electronic Medication Administration Record (eMAR) for June 2025. The eMAR included a physician order for Acetaminophen Extra Strength 500 milligram (mg), give one (1) tablet by mouth every 6 hours as needed for pain. Not to exceed three (3) grams per 24 hours, ordered on 5/8/25. The eMAR did not reflect another active order for pain medication and did not reflect administration of Tylenol on 6/1/25 and 6/2/25. On 6/3/25 at 9:40 AM, the surveyor walked into the dining area where Resident #10 was seated. The surveyor observed a Certified Nursing Assistant (CNA) seated next to Resident #10 and the Unit Manager was seated in the corner of the dining area. At that time, Resident #10 informed the surveyor that they had back pain and asked for Tylenol. On 6/3/25 at 9:41 AM, the CNA stated that she saw LPN #1 in the dining room speak with Resident #10 and was aware of the resident's reported experience of pain and request of pain medication. On 6/3/25 at 9:43 AM, the LPN/UM stated that he did not hear the resident verbalize request for pain medication. On 6/3/25 at 9:48 AM, in the presence of two surveyors, the CNA and the LPN/UM, the resident emphatically stated, I want my Tylenol. At that time, the LPN/UM proceeded to telephonically call LPN #1 who was assigned to Resident #10 from his cellular phone. At that time, a surveyor asked the LPN/UM if he had access to the eMAR and why could he not administer the Tylenol to Resident #10 who had verbalized pain. The LPN/UM stated that he wanted to be certain that the Tylenol was not administered before he gave a dose. The LPN/UM did not review the eMAR at that time. On 6/3/25 at 9:49 AM, in the presence of the LPN/UM, the two (2) surveyors observed LPN #1 arrived on the unit, and stated she went to get Ativan (Lorazepam; medication for anxiety) because she was informed by the therapist of being struck by the resident. LPN #1 stated she knew the resident very well and confirmed that she told the resident she had given them Tylenol. Resident #10 always asked for Tylenol and would not remember when they received it. At that time, LPN #1 confirmed that she did not assess Resident #10 for pain, was aware of the pain complaint and the request for their pain medication, Tylenol. On 6/3/25 at 9:57 AM, LPN #1 informed the surveyors and the LPN/UM that Resident #10 was forgetful, struck people and always asked for their pain medication. The LPN #1 admitted that she had told the resident that she administered the Tylenol, when she did not. The LPN #1 acknowledged and confirmed that while knowing of the resident's complaint of pain experience, knowing the resident had an active order of pain medication that may be administered on an as needed basis, she chose not to administer the Tylenol. On 6/3/25 at 10:13 AM, LPN #1 informed the surveyors that the resident was assessed by the Nurse Practitioner who was in the building. LPN #1 stated that she would not administer the Ativan at that time. On 6/3/25 at 10:16 AM, the surveyors entered Resident #10's room and observed Resident #10 in bed, the head of the bed was elevated, both knees were propped up by a pillow underneath. Resident #10 stated that while seated in the wheelchair, they experienced a pain level of more than 10 out of 10 being the most severe. The resident also stated they also had a 10 out of 10 abdominal pains. At that time, the surveyors observed Resident #10 moaning, had facial grimacing, appeared very drowsy, almost unable to open their mouth. The resident stated why didn't anyone give some pain medication before. On 6/3/25 at 10:21 AM, the surveyors, observed LPN #1 requested for assistance from the CNA who was caring for Resident #10's roommate. At that time, LPN #1 and the CNA re-positioned the resident for medication administration. While the resident was repositioned, the resident moaned, grimaced, and continued to verbalize their experienced pain. On 6/3/25 at 10:24 AM, the surveyors observed LPN #1 administer Tylenol to Resident #10's . On 6/3/25 at 12:02 PM, during a meeting with the survey team, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the two (2) surveyors discussed the concern regarding LPN #1 who did not assess Resident #10's pain after verbalized complaint, visual and auditory evidence of pain and the concern that an as needed pain medication, ordered by the physician, care planned by the interdisciplinary team was not administered to relieve Resident #10's experience of pain. At that time, the DON stated that the resident was assessed and was administered the Tylenol after surveyor inquiry. The DON also stated that Resident #10 should have been assessed for pain, LPN #1 should not have assumed that the verbalized pain and the request for Tylenol was part of their usual behavior, against the resident's care plan; the assumption of their behavior was the reason why the LPN did not administer the Tylenol. The DON stated that the LPN was re-educated by the [NAME] President of Special Project (VPSP). 2. On 6/2/25 at 11:09 AM, during a meeting with two (2) surveyors, Resident #47 discussed their concern regarding the long delays in receiving their pain medication for a pain level of 8 out of 10 on the worst days. On 6/3/25 at 12:21 PM, the surveyor observed Resident #47 in their room seated in a chair. At that time, Resident #47 stated they had returned from rehabilitation department and had no complaints of pain. Resident #47 stated that the nurse had informed her that her pain regimen was recently changed from Oxycodone 10 mg or Oxycodone 5 mg depending on their pain level to just 5mg. On 6/3/25 at 12:29 PM, during an interview with the surveyor, LPN #2 stated she knew of Resident #47. The rehabilitation staff picked up the residents who were awake, dressed and who already had their meal. LPN #2 stated she conducted pain assessments before and after rehabilitation treatment. The pain medication administered to the resident's were based on their reported pain level. At that time, LPN #2 stated that when she went to the electronic Back-Up machine to obtain the Oxycodone 10 mg, did not pop-up on the screen as an option. The surveyor reviewed the medical record for Resident #47 According to the AR the resident was admitted to the facility with diagnoses that included: aftercare following joint replacement therapy and osteoarthritis (degenerative joint disease). A review of the CMDS, dated [DATE], reflected a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It showed that the resident received scheduled pain medication, and an as needed pain medication, experienced pain frequently, occasionally affected their sleep and frequently affected activities that involved rehabilitation therapy, in the last 5 days of the assessment. A review of the ICCP reflected a focus that Resident #47 was at risk for generalized pain related to their disease process, started on 5/2/25. The associated intervention included to administer pain medication per physician orders, started on 5/1/25. A review of the electronic Medication Administration Record for May 2025 revealed the following physician's orders and administration. -Oxycodone 10 mg, give 1 tablet every 6 hours as need for severe pain, pain scale of 8-10. The order was started on 4/30/25. on 5/7/25 at 7:19 PM, was administered for pain level 7 on 5/8/25 at 4:15 PM, was administered for pain level 7 on 5/9/25 at 5:20 PM, was administered for pain level 0 on 5/11/25 at 7:00 PM, was administered for pain level 0 on 5/12/25 at 4:42 PM, was administered for pain level 5 on 5/23/25 at 5:16 PM, was administered for pain level 5 on 5/26/25 at 11:08 AM, was administered for pain level of 7 -Oxycodone 5 mg, give 1 tablet every 4 hours as needed for moderate pain scale of 5-7. The order was started on 4/30/25 and stopped on 5/28/25. on 5/21/25 at 8:15 AM, was administered for pain scale of 8 on 5/23/25 at 8:00 AM, was administered for pain scale of 8 on 5/24/25 at 8:15 AM, was administered for pain scale of 8 on 5/27/25 at 10:51 AM, was administered for pain scale of 8 -Oxycodone 5 mg, give 1 tablet every 6 hours as needed for pain [level of] 7-10 that was initiated on 5/28/25. The new order was not properly sequenced against the Oxycodone 10 mg, for the nurse to know which dose to administer. On 6/3/25 at 2:39 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), [NAME] President of Special Clinical Project (VPSCP), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the surveyor discussed the concern regarding the administration of the Oxycodone that was not in accordance with the resident's pain scale, and the physician's order. The surveyor also discussed the concern regarding the Oxycodone 5 mg that was ordered on 5/28/25, and not properly sequenced against the Oxycodone 10mg, and the Oxycodone 10 mg that was not available in the electronic back-up machine for administration. On 6/4/25 at 12:37 PM, during a meeting with the survey team, the LNHA, VPSCP, and the ADON, the DON stated that the nurses have been re-educated regarding pain scale. The DON also stated that the nurse should have called the doctor, obtained an order to double the Oxycodone 5 mg, informed leadership of the unavailable medication. A review of the provided facility policy, Pain Assessment and Management dated/revised 10/2022 included that the pain management program was based on the facility's commitment to appropriate assessment and treatment of pain based on professional standards of practice, comprehensive care plan and the resident's choice related to pain management. A review of the provided facility policy, Administering Pain Medications dated/revised 10/2022, included that the purpose of the procedure was to provide guideline for assessing the resident's level of pain prior to administering analgesic pain medication. Preparation included, to review the resident's care plan to assess for any special needs of the resident. NJAC-8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 21 residents reviewed for accommodation of needs (Resident #62), and was evidenced by the following: On 05/30/25 at 11:50 AM, the surveyor observed Resident #62 in his room in bed. The call bell device was located on the floor between the resident's bed and roommates' bed not within Resident #62's reach. The surveyor reviewed the medical record for Resident #62. A review of the admission Record reflected that Resident #62 was admitted to the facility with diagnoses that included but were not limited to; malfunctioning of the cystostomy (medical device inserted into the bladder to drain urine) pneumonitis r/t inhalation of food and vomit, and Alzheimer's disease. A review of Resident #62's Annual Minimum Data Set (MDS), an assessment tool dated 3/17/25 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. Section GG indicated Resident #62 required staff assistance for activities of daily living and transfers. A review of Resident #62's Individualized Comprehensive Care Plan (CP) initiated on 3/10/23 reflected a focus area: Resident is at Risk for falls due to impaired balance/poor coordination, medication side effects, with interventions that included but were not limited to; Have commonly used articles within easy reach, and reinforce the need to call for assistance. On 5/30/25 at 3:33 PM, the surveyor observed Resident #62 in bed with their call bell on the floor, not within the resident's reach. On that same date, at 3:34 PM, the surveyor accompanied by the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) assigned to Resident #62's care, entered the resident's room. The LPN and CNA confirmed that the call bell should have been placed within the resident's reach. A review of the facility's Answering the Call Light policy, undated reflected .The purpose of this policy is to assure the call light is plugged in and functioning at all times, and to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower of bathing facility and from the floor. On 6/3/25 at 2:18 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse and Assistant Director of Nursing. NJAC 8:39- 27.1(a)

Based on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following: On 6/2/25 at 10:10 AM, the surveyor looked for the most recent State inspection results on the north and south Nursing Units and was unable to locate them. On 6/2/25 at 10:15 AM, during an interview with the surveyor, the receptionist stated that the prior year's survey results were in a binder in the lobby but was not sure where they were located. After a search, the surveyor located the binder on the back wall of the lobby lying flat on the top shelf of a cabinet behind a decorative container not easily accessible to residents. On 6/2/25 at 10:30 AM, the surveyor conducted a group meeting with 6 alert and oriented residents chosen by the facility. Six of 6 residents stated they did not know where to find the State inspection results. On 6/3/25 at 12:16 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the prior year's state inspection results were in a binder on the shelf by the receptionist. The surveyor told the DON that the binder was observed on the shelf lying flat behind a decorative container, not at wheelchair level and not easily accessible to residents. The DON acknowledged that the binder should be easily accessible to the residents. On 6/3/25 at 2:18 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA), DON, Assistant DON and Regional Registered Nurse. The LNHA acknowledged that the binder should be kept in an area that is accessible to residents and that residents should be able to access the book without asking for it. NJAC 8:39-9.4(b)(c)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a nebulizer mask was stored in accordance with infection control measures for 1 of 4 residents reviewed for Respiratory therapy, Resident #41. 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 5/29/25 at 11:10 AM, the surveyor observed Resident #41 in bed on a specialty mattress with Oxygen (O2) delivered via a nasal cannula (NC) tubing attached to the O2 Concentrator at 2 liters per minute (LPM). The surveyor observed a Nebulizer machine (small machine that turns liquid medication into a fine mist, making it easy to inhale directly into the lungs) on the Resident's nightstand (not in use) and the mask was attached to the tubing. The surveyor observed the mask had been placed on the machine which was soiled with a brown substance. The mask was not stored appropriately in a plastic bag for infection prevention. The surveyor reviewed the medical record for Resident #41. A review of the admission Record reflected Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to; Chronic Obstructive Pulmonary Disease (a lung disease that causes breathing difficulties by damaging the airways in the lungs). A review of the current Order Summary Report (OSR) reflected Resident #41 had an active Physician's orders (PO) with a start date 6/2/25 for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally via nebulizer every 8 hours for COPD: document abnormal lung sounds, separate 15mins from other treatments. A review of the admission Minimum Data Set (MDS), an assessment tool revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating severe cognitive impairment. A review of Resident #41's Care Plan (CP) included a Focus which indicated the Resident was at risk for respiratory impairment r/t bronchitis and COPD initiated 3/18/25 with interventions that included but were not limited to; administer medications/treatments per physician's orders (PO); administer oxygen per PO. On 6/3/25 at 8:00 AM, the surveyor observed Resident #41 in bed on a specialty mattress with O2 delivered via a NC tubing attached to the O2 Concentrator at 2 LPM. The surveyor observed the Nebulizer machine on the Resident's nightstand with the mask on the nebulizer, not stored in a plastic bag for infection control prevention. On 6/3/25 at 8:03 AM, during an interview with the surveyor, the Licensed Practical Nurse confirmed that the Nebulizer Mask should have been stored in a plastic bag for infection control prevention. A review of the facility's undated Administering Medications Through a Small Volume (handheld) Nebulizer policy included .When equipment is completely dry, store in a plastic bag with the resident's name and date on it. On 6/3/25 at 2:18 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing and Regional Nurse. NJAC 8:39-19.4(a); 27.1(a)

NJ00173564 Based on observation, interview, and record review it was determined that the facility failed to maintain an accurately documented and complete record for 2 of 21 records reviewed (Resident #98, 363). The deficient practice was evidenced by the following: 1. The surveyor interviewed Resident #98 on 5/30/25 at 10:58 AM. The resident was seated in a wheelchair at the bedside. The resident stated they use the call bell device to request assistance getting from the bed to the wheelchair, for toileting, and for dressing. The resident stated the call bell response can be very slow. The resident described a fall incident which had occurred the previous week on 5/24/25. A review of the electronic medical record revealed the following information. The 5/2/25 admission Miniumum Data Set assessment tool (MDS) indicated the resident had no cognitive deficits as evidenced by a Brief Interview for Mental Status score of 15 out of a possible 15. The fall care plan, initiated 4/25/25 and revised 5/29/25, indicated the resident was at risk for falls due to impaired balance and poor coordination. The resident was noted to have had a fall on 5/24/25. The electronic medical record (EMR) progress notes did not contain any reference to the 5/24/25 fall incident. On 5/30/25 at 1:30 PM, the surveyor requested from the Director of Nursing the 5/24/25 fall investigation. On 5/30/25 at 2:30 PM, the surveyor observed a late entry in the EMR progress notes written by the Licensed Practical Nurse (LPN) on 5/30/25 at 2:09 PM describing the resident's 5/24/25 fall incident. On 6/2/25 at 11:26 AM, the surveyor interviewed the LPN who was assigned to the resident on the day of the fall. She stated she wrote a fall progress note, however, she did not attach it correctly to the electronic record. The surveyor discussed the charting omission with the Licensed Nursing Home Administrator and the Director of Nursing on 6/2/25 at 3:00 PM. No further information was provided to the surveyor. A review of the facility policy titled Charting and Documentation specified incidents and accidents involving residents are to be documented in the medical record. 2. On 5/30/25 at 9:41 AM, the surveyor reviewed the closed medical record for Resident #363. According to the admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included: high blood pressure, heart failure and acute respiratory failure with hypoxia (low level of oxygen to the body's tissues). A review of the most recent comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care dated 5/30/24, reflected a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. Additionally, the CMDS revealed the resident required substantial/maximal assistance (helper does more than half the effort) for toileting, showering and lower body dressing. Further review of the CMDS reflected that the resident was occasionally incontinent of bowel and bladder. A review of the individualized comprehensive care plan (ICCP) included a focus on Resident #363's self-care deficit, initiated on 5/3/24. The interventions included assistance of one (1) nursing staff with activities of daily living (ADL, eating, bathing, dressing, toileting, and bowel and bladder care). A review of the Point of Care/Task list (POC; a documentation form of the care rendered by the assigned Certified Nursing Assistant (CNA) to their assigned resident) on 5/4/25 for the 11:00 PM to 7:00 AM shift did not reflect documentation on the POC. On 6/4/25 at 10:45 AM, the surveyor left a message for the CNA who was assigned to Resident #363. On 6/3/25 at 2:39 AM, On 6/3/25 at 2:39 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), [NAME] President of Special Clinical Project (VPSCP), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the surveyor discussed the concern regarding the missing documentation to show that care was rendered for Resident #363 on 5/6/24 during the 11:00 PM to 7:00 AM shift. On 6/4/25 at 12:37 PM, during a meeting with the survey team, the VPSCP, the DON and the ADON, the LNHA stated that during the morning clinical meetings the staff reviewed the POC completion rate which was at 90% for that day. The expectation was that the POC was signed to indicate the care was rendered. At 12:54 PM, during a meeting with the survey team, the VPSCP, the DON and the LNHA, the ADON stated he had spoken with the CNA who was on duty on 5/6/24 for the 11 PM to 7 AM shift. The ADON provided a statement signed/dated 6/4/25 from the CNA, co-signed/ witnessed 6/4/25 by the ADON. The document reflected that the nurse recalled the resident and provided care however did not know why the POC for Resident #363 was not signed. A review of the facility provided policy, Charting and Documentation dated/revised July 2017, under the policy statement reflected that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record . CNAs are permitted to document ADL care . No additional information was provided. NJAC 8:39-35.2 (d)(6)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure the consistent coordination/communication was provided between facility staff and hospice staff to meet the resident's needs (Resident #4). This deficient practice was identified for one (1) of one (1) resident reviewed for hospice and end of life care. This deficient practice was evidenced by the following: On 5/29/25 at 10:12 AM, during the initial tour, a surveyor observed Resident #4 seated in a geriatric chair (Geri chair; large, padded chair designed to assist individuals with limited mobility). At 11:30 AM, during an interview with a surveyor the Licensed Practical Nurse (LPN) on the unit stated Resident #4 was on hospice care. The surveyor reviewed the medical record for Resident #4. According to the admission Record (AR; or face sheet, an admission summary), the resident was admitted to the facility with diagnoses that included: Parkinson's Disease (progressive neurological disorder), seizures and dysphagia (difficulty swallowing). A review of the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 4/21/25, reflected a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. Additionally, the qMDS revealed the resident was dependent for toileting hygiene, shower/bathing, and lower body dressing. Further review of the qMDS reflected the resident was always incontinent of bladder and bowel functions. A review of the active Order Summary Report (OSR) that were active as of 5/1/25, revealed a physician order (PO) for Hospice Evaluation and Treatment with [name redacted] hospice, ordered by the physician on 4/29/25. A review of the individualized comprehensive care plan (ICCP) included a focus that the resident was under Hospice/Palliative Care need due to terminal/end stage disease, initiated on 5/5/25. The interventions included for hospice staff to visit, provide care, assistance and/or evaluation and administer, initiated on 5/12/25. A review of the medical record for the resident revealed a hospice new admission comfort kit recommendations by the admitting Hospice Registered Nurse (RN) signed/dated on 5/1/25. The recommendations included a medication, Bisacodyl 10 milligram (mg) rectal suppository to be inserted every 6 hours daily as needed if no bowel movement in three (3) days for constipation. A review of the active OSR that were active as of 6/3/23 did not include the order for Bisacodyl 10 mg and did not reflect an order for a bowel regimen to prevent constipation/impaction. A review of the Nurse's Progress Notes did not show the physician was informed, nor a documented rationale that explained why the hospice recommendation for the Bisacodyl 10 mg was not followed. A review of the 30-day, look back of the Point of Care/Task list (POC; a documentation form of the care rendered by the assigned Certified Nursing Assistant (CNA) to their assigned resident) dated 5/5/25 to 6/3/25, included a monitoring of the resident's bowel movement (BM). The POC reflected that on occasion (5/10/25 and 5/23/25) the resident did not have BM. On 6/3/25 at 2:39 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), [NAME] President of Special Clinical Project (VPSCP), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the surveyor discussed the concern regarding the inconsistent coordination/communication between facility staff and hospice for Resident #4 wherein the hospice nurse recommended Bisacodyl and a response was not reflected. On 6/4/25 at 12:37 PM, during a meeting with the survey team, the LNHA, VPSCP, and the ADON, the DON acknowledged that the order should have been carried out and the communication should have been documented. A review of the facility provided policy, Hospice Program, dated/revised July 2017, included that a member of the interdisciplinary team was responsible for communicating with hospice representatives, and other health care providers participating in the provision of care for the terminal illness, related conditions, and other conditions , to ensure quality of care for the resident and family, NJAC 8:39-27.1(a)

Based on observation, record review, and staff interview the facility failed to ensure food stored in the unit refrigerators on one of four units was stored in a sanitary manner. This failure had the potential to affect the 15 residents on the 1south unit with a census of 82. Findings include: Observation on 09/25/23 at 9:03 AM revealed the first floor south resident refrigerator located by the nursing station contained a container of caramel dip that was not labeled with the date it was opened and was not labeled with a resident name; a container of what appeared to be partially eaten pasta dish with Resident (R) 49's name written on it, the container was not dated to indicate when it was placed in the refrigerator. There was one four-ounce container of Ready Care mighty shake on the shelf in the door. The container was not dated to indicate when it was thawed out. The manufacturer's instructions on the container stated to be used within 14 days of thawing. Interview with the Dietary Manager on 09/25/23 at 9:30 AM at the time of the observation revealed the food should have been dated and labeled with the date it was placed in the refrigerator and the shake should have been dated with the date it was thawed out. Review of the Foods Brought by Family/Visitors policy with a revised date of October 2017 stated containers of food will be labeled with the resident's name, the item name, and the date. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on observations, interview, record review and policy review, the facility failed to clean the filter of the Oxygen concentrator for the use of delivering supplemental oxygen for one of four residents (Resident (R) 9) reviewed for Oxygen of the twenty-six sampled residents Findings include: Review of R9's Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R9 was admitted to the facility on [DATE] with the following diagnosis of Parkinson's Disease and hypertension. Review of the annual Minimum Data Set (MDS) in the EMR, with an Assessment Reference Date (ARD) of 07/27/23 coded the resident as having a Brief Interview Mental Status (BIMS) score of 13 out of 15. This represented R9 was cognitively intact. On 09/25/23 at 9:49 AM an observation was made at which time the resident was wearing the oxygen at 2liters/minute by nasal cannula. The filter had a white lint like substance on it. On 09/27/23 at 11:20 AM R9's oxygen concentrator had a white lint like substance on it. Review of R9's Orders under the Orders tab in the EMR revealed there was a physician's order for R9 to receive Oxygen (O2) at 2 liters/min by nasal cannula as needed to keep the resident's oxygen saturation above 90 percent. Interview with the Director of Nursing (DON) on 09/27/23 at 11:35 AM revealed, Maintenance is supposed to clean those. I don't know how often. Follow up interview on 09/27/23 at 2:06 PM, DON stated, I talked to our respiratory therapist, and he showed me the cleaning list that he had done. He admitted that he missed R9 when he cleaned them. Review of the facility's policy titled, Departmental Respiratory Therapy- Prevention of Infection, with a revision date of 08/28/18, stated, Check filters once weekly while they are in continuous use . NJAC 8:39-19.4(k)

Based on observation, staff interview, record review, and policy review, the facility failed to store medication in a locked compartment when left unattended (first floor medication cart #1), failed to have a medication label that could be read (second floor medication cart #2) as well as fail to ensure the medication cart was secure when out of the site of the nursing staff. Findings include: 1. Review of the facility's policy titled, Medication Labeling and Storage with a revision date of February 2023, stated . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . During the Medication Pass Observation on 09/27/23 at 9:28 AM. Registered Nurse (RN)8 was preparing the pills to administer to R63. RN8 stated, There is no Tylenol in my cart, so I have to go and get it. RN8 left pills on top of the med cart to go into nurses' station. While looking for the Tylenol, RN8 turned her back to the cart. This medication cart was on the first floor, cart #1. On 09/27/23 at 9:55 AM, RN8 stated, I should have placed them in the top drawer and locked the cart and no I could not see the cart when I turned my back. Review of the cup revealed the following medication was in the cup: Memantine, Zoloft, Metformin, Cilostazol, Ativan. Review of Resident (R)63's Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R64 was admitted to the facility on [DATE] with the following diagnosis of Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) in the EMR, with an Assessment Reference Date (ARD) of 08/18/23 coded the resident as having a Brief Interview Mental Status (BIMS) score of two out of 15. which indicated the resident was severely cognitively impaired. Review of R63's EMR, the physician had ordered Acetaminophen Tablet 325 mg Give 2 [sic] tablets by mouth two times a day for pain Two tablets = 650 mg[milligram]. This order was written on 11/08/22. Interview with the Director of Nursing (DON) was interviewed on 09/29/23 at 11:30 AM. DON stated, We have been reviewing the med (medication) pass with all of our nurses for some time now. We were hoping this would help when the state came to do the med (medication) pass with them. 2. Review of the facility's policy titled, Medication Labeling and Storage with a revision date of February 2023, stated . Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at a minimum: a. medication name (generic and /or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions. Review of R82's Face Sheet in the EMR) under the Profile tab revealed R82 was readmitted to the facility on [DATE] with the following diagnoses of diabetes mellitus and paraplegia. Review of the admission MDS) in the EMR, with an ARD of 09/01/23 coded the R82 as having a BIMS score of 00 out of 15 indicating severe cognitive impairment. Observation on 09/28/23 at 9:07 AM, of Medication Cart 2 located on the second floor, had R82's Ipratropium Bromide and Albuterol Sulfate Inhalation solution 0.5 mg & 3 mg/3 ml. The label on the medication zip lock bag for R82's, the label for this medication could not be read. The only information on this label that could be read was R82's name. Interview with Unit Manager (UM) 4 at time of observation stated, You can't read that label. Looks like it got wet or something. The nurses should have called the pharmacy to see if this could be refilled. 3. Review of the facility's policy titled, Security of Medication Cart with revision date of April 2007 indicated, Medication carts must be securely locked at all times when out of the nurse's view. Observation on 09/25/23 at 9:30 AM revealed an unlocked medication cart next to room [ROOM NUMBER] North nursing station was unlocked and out the sight of the nurse. The med cart. No medications were on top the cart however, the drawers to the cart were easily accessible to anyone walking down the hall. RN8 came from a resident's room to the unlocked medication cart at 9:33 AM. Interview on 09/25/23 at 9:33 AM with RN8 revealed someone had called them to a resident's room to see something and they walked away from the cart without locking the medication cart. RN8 stated they had been trained to lock the medication cart when away, but they forgot. 4. Observation on 09/25/23 at 4:28 PM revealed an unlocked medication cart next to 1 South nursing station. The cart was out the sight of the nurse. No medications were on the cart however, the drawers to the cart were easily accessible to anyone walking down the hall. Interview on 09/25/2023 at 4:38 PM with Licensed Practical Nurse (LPN) 3 revealed they were the nurse on the unit and acknowledged they forgot to lock the medication cart. LPN3 stated they were working with two different medications carts and forgot to lock one prior to walking away. LPN3 stated it was a mistake and they had been trained to lock the cart when away from it. 5. Observation on 09/27/23 at 8:57 AM revealed an unlocked medication cart next to room [ROOM NUMBER] South Hall. The cart was out the sight of the nurse. No medications were on the cart however, the drawers to the cart were easily accessible to anyone walking down the hall. RN7 came of a resident's room to the unlocked medication cart at 9:02 AM. Interview on 09/27/2023 at 9:02 AM with RN7, revealed they went into a room to wash their hands and was away from the cart for a couple of minutes. RN7 stated they normally lock the medication cart and leaving them open was not the normal practice. Interview on 09/27/23 at 2:44 PM with the DON stated they have educated staff multiple times on locking the computer screen they are away from them. DON stated they have a pharmacy consultant who does medication pass with the staff monthly and they go over serval things such as ensuring the electronic health record and medication cart is locked. DON stated they anticipate that staff should keep resident information confidential at all times. NJAC 8:39-29.4(a)(f)(h)

Based on observation, interview, record review, and facility policy review, the facility failed to protect the private health information for eleven of eleven (R49, R312, R65, R41, R311, R28, R309, R310, R35, R68 and R308) residents reviewed for resident rights out of 22 sampled residents by leaving the resident's personal and medical information exposed on an open and unattended computer screen in an area accessible to the public. Findings included: Review of a facility's policy titled, Computer Terminals/Workstations, revision date April 2014, revealed, .3. A user may not leave his/her workstation or terminal unattended unless the terminal screen is cleared and the user is logged off. Each user must log off at the end of his/her work shift . Observation of the medication cart on the 1 North Hall on 09/25/23 at 9:30 AM revealed the medication cart was observed unattended. The computer screen on the cart was open and showed R49's face, name, room number, and medications the resident received. The cart was unattended with the c until 9:33 AM when Registered Nurse (RN) 8 returned. Interview on 09/25/2023 at 9:33 AM with RN8, revealed someone had called them to a resident's room to see something and they walked away from the cart without locking the screen. RN8 stated they had been trained to lock the computer screen when away, but they forgot. Observation of a medication cart on the 1 South Hall on 09/27/2023 from 8:57 AM to 9:02 AM revealed medication cart on the 1 South Hall was observed unattended. The computer screen on the cart was open and showed R312, R65, R41, R311, R28, R309, R310, R35, R68 and R308 face, name, room number listed under the medication administration record (MAR) tab. The cart was unattended with the computer screen open to resident's confidential information until 9:02 AM when RN7 returned. Interview on 09/27/2023 at 9:02 AM, RN7 stated they went into a room to wash their hands and was away from the cart for a couple of minutes. RN7 stated they normally lock the computer screen leaving them open was not the normal practice. RN7 stated they understood they should keep the computer screen locked forHealth Insurance Portability and Accountability Act (HIPAA) reasons. Interview on 09/27/2023 at 2:44 PM with the Director of Nursing (DON) revealed they have educated staff multiple times on locking the computer screen they are away from them. The DON stated they have a pharmacy consultant who does medication pass with the staff monthly and they go over several things such as ensuring the electronic health record and medication cart is locked. DON stated they anticipate that staff should keep resident information confidential at all times. NJAC 8:39-4.1(a)18 NJAC 8:39-35.2(i)(k)

Based on record review, staff interview, and policy review, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a notice including the reason the services were ending or what the options were prior to the discontinuation of therapy services. This had the potential to affect one of three residents (Resident (R)259) who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review. Findings include: Review of the electronic medical record (EMR) for R259 revealed she was admitted to the facility on [DATE]. R259 had Medicare benefits and when she was discharged from skilled therapy services on 07/13/23, she had not exhausted her Medicare benefit days. However, the facility failed to notify her representative regarding the expiration of benefits prior to the expiration date. Further review of the EMR failed to reveal any documentation of R259 and/or R259's representative being given written notification of the discontinuation of covered services. Review of the Nursing Facility Beneficiary Protection Notification Review, provided on paper, revealed she was discharged from Medicare part A services on 07/13/23 and remained in the facility with benefit days remaining. During an interview on 09/26/23 at 9:45 AM with the Director of Nursing (DON), the DON stated R259 was not issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN). We didn't think she needed it since she stayed in the facility. Review of the facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 09/2022, documented, Policy: Residents are informed in advance when changes will occur to their bills. Skilled Nursing Facility Advance Beneficiary Notice .1. If the director of admissions or benefits coordinator believe (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the services(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice .for the following triggering events: .c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. NJAC 8:39-5.1(a)

C #: NJ 560 Based on interviews, review of the medical records, and pertinent facility documents on 7/14/21, it was determined that the facility's staff failed to accurately document and reconcile the administration of controlled medication for 1 of 3 residents (Res #2) reviewed for medication administration. This deficient practice is evidence by the following: 1. According to the ADMISSON RECORD (AR) form, Res #2 was admitted to the facility on [DATE], with diagnosis that included but was not limited to: Anxiety Disorder. The Order Review Report (ORR) form dated 7/1/21 to 7/31/21 showed the following orders: On 7/2/21 and 7/3/21 showed an order for [MEDICATION(S)] tablet 0.5 mg (milligram)/ml (milliliter) give 1 tablet by mouth every 12 hours for Anxiety. The MEDICATION ADMINISTRATION RECORD (MAR) for the month of 7/2020 showed the aforementioned order. The Omnicell (facility's back up medication) form for Res #2 dated 7/1/21 to 7/10/21 showed that on 7/3/21 at 12:00 am signed by the Registered Nurse (RN #1), the [MEDICATION(S)] 0.5 mg was taken from the Omnicell for Res #2. However, it was not documented on the MAR that the aforementioned medication was administered to the Resident on 7/3/21 at 12:00 am. Furthermore, the MAR showed that the aforementioned medication was administered to Res #2 on 7/3/21 at 9:00 pm. However, the Omnicell form did not indicate that the [MEDICATION(S)] was taken from the Omnicell for Res #2. The Controlled Drug Administration Record showed the aforementioned medication order for Res #2. However, there was no documentation to support that the [MEDICATION(S)] medication was administered on the aforementioned dates/time. The surveyor conducted an interview with the Director of Nursing (DON) on 7/14/21 at 4:37 pm. The DON stated controlled medications taken out of the Omnicell must be documented on the resident's MAR and declining sheet. The facility's policy titled MEDICATION DISPENSING CONTROLLED SUBSTANCES, revised on 1/2015 showed that .POLICY: I. Controlled dangerous substances are handed by the facility in a manner that promotes propre storage, security and compliance with applicable state and federal regulations .3. DISPENSING OF CONTROLLED DANGEROUS SUBSTANCES .c) A declining inventory sheet will be provided with each dispensed prescription for controlled dangerous substances c. When a CDS [control drug substance] medication is administered, in addition to following proper procedure for the charting of medication, the nurse must document on the declining inventory sheet the date of administration, the quantity administered .the amount of medication remaining and his/her initials . NJAC 8:39-29.2 (d)

C #: NJ 560 Based on interviews and record review, as well as review of pertinent facility documents on 7/14/21, it was determined that the facility failed to report an allegation of elder abuse to the New Jersey Department of Health (NJDOH) and to follow the facility policy on Abuse Investigation and Reporting for 1 of 3 residents (Res #2). This deficient practice is evidenced by the following: 1. According to the ADMISSION RECORD (AR) form, Res #2 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 7/5/21, showed that Res #2's cognition was intact and required limited assistance from staff in Activities of Daily Living (ADL). The INVESTIGATION REPORT (IR), showed that on 7/2/21, the facility investigated an incident involving Res #2. The IR showed Res # 2 verbalized to the Social Worker (SW) that the Resident requesting transfer to another facility because he/she did not understand why the facility had to do a body assessment and felt the Resident should have been able to say no to the body assessment. The IR showed that the Licence Practical Nurse (LPN #1) who performed the body assessment responded to the Resident by saying doesn't your husband look at your ass? I need to as well. Attached with the IR, the statement from the SW dated 7/5/21 at 3:09 pm. The SW stated what was written on the IR. The SW wrote They [LPN #1 and Certified Nursing Aide (CNA #1)] told the Resident it was procedure and they would have to do it. Patient was then transferred to bed and reports both staff members then proceeded to check his/her entire body, including his/her private parts, which the Resident expressed feeling violated by. Attached with the IR, the statement from the Nursing Supervisor (NS) dated 7/5/21. The NS stated that LPN #1 and CNA #1 did a body assessment and looked at his/her private parts. Resident #2 did not like CNA #1's attitude. Telephone interview with Resident #2 on 7/14/21 from 11:00 am to 1:00 pm, the Resident stated what was on the IR. The Resident stated that he/she felt violated during the body assessment on 7/2/21 which he/she mentioned to the SW. The Resident stated that he/she mentioned allegation of elder abuse to the SW and administration. Interviewed with the SW and NS on 7/14/21 and 7/15/21 from 12:00 pm to 2:00 pm. The SW confirmed what she wrote on her aforementioned statement. She remembered the Resident was very angry and stated felt violated. The NS stated that the Resident complained about CNA #1's attitude. However, she did not investigate further why the Resident felt that way and she should have. During the interview with the Administrator on 7/14/21 at 12:32 pm, she stated that the aforementioned incident was investigated. However, the facility did not report it to the NJDOH. The facility's policy titled Abuse Investigation and Reporting, dated 2001 and revised on 7/2017 showed .All reports of resident abuse, neglect, exploitation .(abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) .Reporting .2. All alleged violation of abuse, neglect, exploitation or mistreatment .will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse .b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone . NJAC 8:39-9.4(e)(3)(i)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) practice appropriate hand hygiene for 2 of 6 staff; b) ensure proper use of personal protective equipment (PPE) for 2 of 4 staff; and, c) sanitize the table used for staff testing in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene, which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. According to the U.S. CDC's Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20 included guidelines to Collection of Diagnostic Respiratory Specimens It specified that, Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. 1. On 11/17/20 at 9:15 AM, surveyors met with the Licensed Nursing Home Administrator (LNHA), who informed the surveyors that there were no positive COVID-19 residents or staff in the facility. The LNHA stated that the positive resident on 11/15/20 was transferred to another facility. She further noted that four units in the facility were a Yellow Zone, which meant that all residents were treated as persons under investigation (PUI). At that same time, the LNHA stated that all staff was mandated to wear an N95 mask and a face shield or goggles when on the units and must wear full PPE, which includes an N95 mask, gown, gloves, and eye protector or a face shield when inside resident rooms. At 9:36 AM, the surveyor observed the Housekeeper (HK) on the 1st floor North unit perform hand hygiene. The HK applied soap without wetting her hands with water and dried her hands with the same paper towel that she first used to turn off the faucet. On that same date and time, the HK, in the presence of the Licensed Practical Nurse (LPN), stated, I should have wet my hands before applying soap. She further said that she should not have used the same paper towel that she used to turn off the faucet because I contaminated my hands again. On that same day at 11:35 AM, the surveyor observed the Medical Doctor exit the 1st floor South yellow unit and washed her hands using the sink in the front reception area. The surveyor observed the MD turn on the faucet and she rinsed her hands under running water for 5 seconds without applying soap or lathering her hands outside of running water. The surveyor asked the MD why she washed her hands for only 5 seconds without using soap. The MD replied, that she should have washed her hands properly using soap and friction. 2. On 11/17/20 at 9:55 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that the 1st floor South unit staff must wear an N95 mask and a face shield or an eye protector while on the unit and must wear full PPE when inside the resident ' s room. The LPN/UM stated that the gown and gloves must be removed before leaving the resident's room. She further noted that a gown should not be worn in the hallway. At 10:07 AM, the surveyor observed the Occupational Therapist (OT) came out of the resident room with an N95 mask, an eye protector, and a gown and approached the 1st floor South nursing unit and talked to the LPN/UM. The OT did not remove her gown when she was in the hallway. On that same date at 10:13 AM, the surveyor asked the LPN/UM why the OT was wearing a gown in the hallway. The LPN/UM stated, that's why I spoke to her because she should not be going out of the resident's room with a gown. She should have removed her gown before leaving the resident's room. She further stated that the OT should not be wearing a gown in the hallway. At 10:43 AM, the OT informed the surveyors that the 1st floor South unit was a Yellow Zone, which means that the residents were PUI and staff must wear a complete PPE when inside the resident's room and should remove gown and gloves before leaving the resident's room for infection control. On that same date and time, the OT stated to the surveyors that, It was something new to us, the changing of a gown in each resident and I should not have gone outside the resident's room with a gown. She further stated, It was an honest mistake. On 11/17/20 at 11:20 AM, the surveyor observed the MD wearing an N95 mask, entered the 1 South yellow PUI unit, donned a gown, and proceed to the nurse's station. The MD spoke with the LPN and then entered room [ROOM NUMBER]W. The surveyor observed the unit's signage, which instructed that no gowns were to be worn in the hallway. On 11/17/20 at 11:28 AM, the surveyor observed the MD exit room [ROOM NUMBER]W still wearing the same gown. The MD went to the nurse's station and talked with the LPN. The surveyor asked the LPN what the facility policy was for donning and doffing gowns. The LPN replied that all staff don gowns before entering the rooms and remove the gowns and place them in the bins located in each bathroom. On that same day, at that same time, the surveyor interviewed the MD, who acknowledged that she should have removed her gown inside the resident's room but that she was not aware that was the protocol. The surveyor and MD observed the unit's signage that clearly instructed that no gowns were to be worn in the hallway. 3. On 11/17/20 at 10:03 AM, the surveyor observed the Registered Nurse (RN) perform Covid -19 nasal swab testing for the Assistant Director Of Nursing (ADON). The RN donned his gown, washed his hands, gathered his supplies atop the table without first cleansing/disinfecting it, performed the nasal swab, and placed the container which contained the specimen on the table. The RN removed his gloves and gown and washed his hands. The next staff member (CNA) came into the room and sat down at the table. The RN donned his gown and gloves and again placed the supplies on the table without disinfecting it. The surveyor stopped the RN and asked him to step out of the room. The surveyor asked the RN if and when he disinfected the work table. The RN replied that he had not disinfected it but further stated that he, should have been doing it after every test. He left the room and obtained the Microkill disinfectant bleach wipes, and disinfected the table. At that time, the ADON stated that the RN, should be disinfecting the table before each test. The surveyor asked the ADON for the facility P&P for testing. At 11:40 AM, the surveyors met with the LNHA, Director of Nursing (DON), and Assistant Director of Nursing (ADON) and were made aware of the concerns. At 12:08 PM, the LNHA, in the OT's presence, acknowledged to the surveyors that the staff should not be wearing a gown in the hallway according to the Yellow Zone PPE use Single use of Gowns Protocol that was provided by the DON and the Regional Nurse. At 1:34 PM, the survey team met with the LNHA, ADON, and Regional Nurse. The ADON again stated that the RN should have disinfected the table between staff testing. The surveyor asked the Administrator who trained the staff on the proper procedure for Covid-19 testing. The Administrator stated that she was unsure as the educator was out with Covid. The Administrator further stated the facility did not have a policy for the step by step testing of staff or residents. The facility provided no further information. A review of the facility's Handwashing/Hand Hygiene Procedure with a reviewed date of 2/28/2020 that was provided by the DON included, Wet hands first with water, apply soap and vigorously rub hands together creating friction to all surfaces for a minimum of 20 seconds. Dry hands thoroughly with paper towels, and then turn off faucets with a clean, dry paper towel. Discard towels into trash. A review of the facility's Yellow Zone PPE Use guidelines dated 10/26/20 that was provided by the DON indicated, No gowns are to be worn in the hallway. NJAC 8:39-19.4 (a) NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) failed to maintain adequate hand washing practices during meal services. This deficient practice was evidenced by the following: On 08/31/19 at 8:53 AM, in the presence of the Food Service Director (FSD) and the Regional FSD, the surveyor observed the following: 1. Inside the Milk refrigerator, the surveyor observed an opened and undated one gallon of regular milk with an expiration date of 9/6/19. The FSD stated, I opened the milk this morning for the eggs. I should have dated the milk. Inside the reach-in freezer, the surveyor observed the following: 2. Two frozen hamburger patties wrapped in aluminum foil with a use by date of 8/29/19. The Regional FSD discarded the hamburger patties in the presence of the surveyor. 3. One package of Asian style frozen vegetables stored in a plastic bag inside a cardboard box which was opened and undated. The box did not have a receive date. The FSD discarded the frozen vegetables in the presence of the surveyor. The FSD could not speak to why the box of frozen vegetables did not have a receive date and said it should have. 4. There was one package of frozen cookie dough in a plastic bag inside a cardboard box which was opened and undated. There was no receive date on the box. The FSD discarded the cookie dough in the presence of the surveyor and said the box should have been dated when the plastic bag containing the cookie dough was opened and there should have been a receive date on the box. 5. There was a box of fully cooked sausage opened and undated. The FSD discarded the sausage in the presence of the surveyor. 6. There was a three-gallon container of chocolate ice cream opened and undated. There was no receive date on the ice cream container. The FSD discarded the chocolate ice cream in the presence of the surveyor and said he did not know why there was no receive date on the container. The surveyor reviewed the facility's undated policy titled, Food Labeling Guidelines. The policy indicated that All items are dated with the delivery date including month/day/year on the case or container stored in to ensure FIFO (first in first out). Items are labeled and sealed when opened with the opening date and the name of the item if it is not clearly identifiable. Items are checked routinely for 'use by' dates and used or discarded. The manufactures expiration date, when available, is the 'use by' for unopened items. On 8/30/19 at 12:15 PM, during the lunch observation in the dining room on the second floor, the surveyor observed the Activity Assistant #1 turned on the faucet, applied soap to her hands and immediately rinsed her hands under running water. On 9/3/19 at 11:57 AM, during the lunch observation in the second floor dining room, the surveyor observed the Dietary Aide turned on the faucet, applied soap to her hands and immediately rinsed her hands under running water. The Dietary Aide (DA #1) dried her hands and used the same paper towel to turn off the faucet. On that same day at 12:00 PM, the surveyor observed Activity Assistant #2 applied soap to her hands and washed them under running water. On that same day at 12:13 PM, the surveyor observed DA #1 turned on the faucet, applied soap to her hands and immediately rinsed her hands under the running water. DA #1 applied soap to her hands 3 times and immediately rinsed her hands under running water each time. On that same day at 12:18 PM, the surveyor observed the Dietary Chef remove his gloves and don a new pair gloves without first washing his hands. He then left the steam table area to discard a plate of cold food. When he reentered the steam table area he removed his gloves, turned on the faucet, applied soap to his hands and immediately rinsed his hands under running water. On 9/5/19 at 12 PM, during the lunch meal observation, the surveyor observed DA #1 washed her hands. DA #1 used the same paper towel to dry her hands and turn off the faucet. The surveyor reviewed the facility's Handwashing/Hand Hygiene Policy dated 2001 and revised (MONTH) (YEAR) which reflected: 1. Wet hands first with water, apply soap and vigorously rub hands together creating friction to all surfaces for a minimum of 20 seconds (or longer.) 2. Rinse hands thoroughly under running water. 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Use an alcohol- based hand rub containing at least 62% alcohol; or alternatively soap and water after removing gloves. On 9/3/19 at 12:32 PM, the survey team brought the above observation and concern to the attention of the Director of Nursing (DON) and the Administrator. The DON stated that the Dietary staff and the Activity staff were not following the facility's policy on Hand Hygiene and would be inserviced immediately. No further information was provided. NJAC 8:39-17.2(g) NJAC 8:39-19.4 (n)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set - Discharge Assessment in accordance with federal guidelines. This deficient practice was identified for 3 of 3 residents reviewed for resident assessment, Residents #1, #2, and #70. This deficient practice was evidenced by: 1.) On 9/4/19 at 10:00 AM, the surveyor reviewed Resident #1's electronic medical record. The record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was discharged to the community on 5/16/19. The surveyor reviewed the Minimum Data Set (MDS) 3.0 Assessment History assessment tool, including all the completed MDS's for the resident. The MDS assessment history revealed that there was no Discharge Assessment MDS completed for the resident's discharge date of [DATE]. 2.) On 9/4/19 at 10:20 AM, the surveyor reviewed Resident #2's electronic medical record. The record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was discharged to the hospital on [DATE]. The surveyor reviewed the MDS 3.0 Assessment History assessment tool, including all the completed MDS's for the resident. The MDS assessment history revealed that there was no Discharge Assessment MDS completed for the resident's discharge date of [DATE]. 3.) On 9/4/19 at 10:50 AM, the surveyor reviewed Resident #70's electronic medical record. The record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was discharged to the community on 8/12/19. The surveyor reviewed the MDS 3.0 Assessment History assessment tool, including all the completed MDS's for the resident. The MDS assessment history revealed that there was no Discharge Assessment MDS completed for the resident's discharge date of [DATE]. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated (MONTH) (YEAR)) page 2-11 Discharge refers to the date a resident leaves the facility. There are two types of OBRA required discharges: return anticipated and return not anticipated. A Discharge assessment is required with all types of discharges. The manual revealed on Page 2-17 A Discharge Assessment - return not anticipated MDS must be completed not later than discharge date + 14 days. The assessment must also be transmitted to the QIES ASAP system not later than the MDS completion + 14 days. On 9/4/19 at 11:47 AM, the surveyor spoke with the MDS Coordinator who confirmed that there were no discharge assessment MDS's completed for Resident #1, #2 and #70. On 9/4/19 at 1:00 PM, the surveyor informed the Administrator and the Director of Nursing regarding the above concern. They did not provide any further information. NJAC 8:39-11.2

Based on observation, interview and record review it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 20 residents reviewed, Resident #70 as evidenced by the following: On 9/4/19 at 10:50 AM, the surveyor reviewed the records of Resident #70. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted under hospice care services on 6/25/19. The surveyor reviewed the MDS assessments for Resident #70. SCSA MDS was not noted that it was completed. SCSA MDS is a federally mandated process comprehensive assessment that is required when a resident enrolls in a hospice program and must be completed within 14 days after the determination date to ensure that the residents will be assessed including a care plan meeting with the Interdisciplinary Team to provide the resident the best quality of care. On 9/4/19 at 11:47 AM, the surveyor spoke with the MDS Coordinator who stated that the SCSA MDS was not completed. The surveyor informed the Administrator and the Director of Nursing who did not provide any further information. NJAC 8:39-11.7

C# NJ & NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to provide necessary care and services, and/or failed to appropriately and/or adequately assess, monitor, intervene, and/or care plan when 2 of 4 sampled residents (Resident #1 and Resident #3) manifested a change in their medical condition/status. Resident #1 had episodes of loose bowel movements/ diarrhea (LBM) between [DATE] to [DATE], and multiple episodes of vomiting on [DATE] with no documentation of proper monitoring and/or assessment either in the skilled daily nurse's notes (SDNN) and/or the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 8:00 AM to 2:35 PM, Resident #1 complained of being weak, complained of nausea vomiting and diarrhea, became lethargic and unresponsive, required a 911 call, cardiopulmonary resuscitation (CPR), and expired in the facility on the same day. Resident #3, who was identified by the facility with Aspiration risk from [DATE] by the speech therapist (SLP), and was confirmed with silent aspiration after a cookie swallow test from [DATE], had no interdisciplinary care plan (IDCP) in place for aspiration risk to ensure that all staff knew how he should be fed or given his fluids. On [DATE], Resident #3 began choking while being fed by a Certified Nursing Assistant (CNA), required [MEDICATION NAME] maneuver, a call to 911, and a hospital transfer. Resident #3 arrived in the hospital on [DATE] at 10:03 AM, unresponsive with pupils fixed and dilated, and found "...to have choked on some fruit salad" prior to transfer. Resident #3 expired on the same day [DATE] in the hospital at 3:15 PM with a [DIAGNOSES REDACTED]. This deficient practice is evidenced by the following: A review of Resident #1 and Resident #3's medical records by the surveyor on [DATE] and [DATE] revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated [DATE], reflected Resident #1 with intact cognitive abilities, required extensive assistance with most of her activities of daily living (ADL's) except for eating (independent). A resident evaluation form dated [DATE], documented Resident #1 as continent of both bowel and bladder with a mini mental score of "29" out of 30. A review of the physician's orders [REDACTED]. > [DATE]: [MEDICATION NAME] 4 mg 1 tab po (by mouth) every 6 hours as necessary (PRN). >[DATE] at 7:00 PM: [MEDICATION NAME] 17 gm po daily, and Senna 8.6 mg 2 tabs po daily. > [DATE] (no time indicated): [MEDICATION NAME] 1 tab po every 6 hours, and vitals every 6 hours. A review of the ,[DATE] Personal Care Record for Resident #1, used by the CNA's to indicate care provided as well as track bowel movements, had no documentation of LBM for Resident #1 from ,[DATE] to [DATE] except on [DATE] during ,[DATE] shift . A review of Resident #1's medication administration records (MARS) from [DATE] to [DATE], reflected the following: > physician's orders [REDACTED]. > [MEDICATION NAME] 1 tab ordered on [DATE] for every 6 hours, was transcribed as a PRN every 6 hours, and was not transcribed or administered in accordance with the physician's orders [REDACTED]. In addition, there was no indication on the back of the MAR indicated [REDACTED]. The [MEDICATION NAME] was not administered every 6 hours in accordance with the physician's orders [REDACTED]. > [MEDICATION NAME] PRN ordered on [DATE], was signed as administered on [DATE] (8:00 PM), [DATE] (9:00 PM), [DATE] (6:30), and [DATE] (6:20). There was no documentation on the back of the MAR indicated [REDACTED]. >[MEDICATION NAME] ordered on [DATE] was being signed daily from [DATE] until [DATE] at 9:00 AM. The medication had circled initials from ,[DATE] to [DATE]. The Back of the ,[DATE] MAR indicated [REDACTED]. There was no documentation for why [MEDICATION NAME] was circled on [DATE]. > Senna, ordered on [DATE] was signed daily at 9:00 AM until the medication had circled initials from ,[DATE] to [DATE]. The back of the ,[DATE] MAR indicated [REDACTED]. There was no documentation about the Senna circled on [DATE]. A review of the IDCP dated [DATE] and interim careplan from [DATE] for Resident #1, reflected no revisions and/or updates to address Resident #1's problems with diarrhea, nausea, and vomiting in order to set up specific goals and interventions for an evaluation. Further review of the IDCP dated [DATE] on alteration on nutrition, reflected Resident #1 with [MEDICAL CONDITION], and inadequate oral intake with decreased meal consumption. Interventions included to monitor weights as ordered, and updated food and fluid preferences PRN. Goals included for her skin to remain intact, and to tolerate diet as ordered. A review of the skilled daily nurse's notes (SDNN) revealed the following: -[DATE] at 6:00 PM, admitted as alert and oriented x 3 with bilateral lungs clear. Last bowel movement was noted at 7:00 PM on [DATE]. - [DATE], had no indication the Resident #1 had any problems. (The [MEDICATION NAME] order PRN was obtained on this day with no documentation on the SDNN about why the order was obtained, and why it was administered to the resident as indicated on the ,[DATE] MAR. There was no indication on the SDNN of nausea and/or vomiting.) - [DATE] on ,[DATE] shift, Resident #1 complained of constipation. The physician was made aware, and ordered [MEDICATION NAME] daily, and Senna daily. - [DATE], 7:40 AM was out for [MEDICAL CONDITION] appointment, and returned at at 12:00 PM with complaint of diarrhea x 1 at her appointment. (There was no further documentation of LBM until [DATE]) -[DATE] (no time indicated), documented Resident #1 with "LBM x 3", physician was made aware with orders carried out. (There was no indication at what times the Resident had her LBM, how much LBM per episode, and how the LBM looked like. There was no indication on the SDNN check off boxes that the resident had diarrhea. The [MEDICATION NAME] was administered once on [DATE] according to the MAR indicated [REDACTED] -[DATE], had no documentation on all shifts that Resident #1 had nausea, vomiting or diarrhea. ( This was contrary to the Physical Therapy progress notes (PTN) dated [DATE] that Resident #1 "...was very naseous throughout treatment session today. Pt was able to complete the session despite vomiting multiple times..."). There was no indication that Resident #1 was administered [MEDICATION NAME] PRN on [DATE] for nausea and/or vomiting. The SDNN boxed check off's, had no indication on all shifts that Resident #1 had nausea and/or vomiting. - [DATE] (no time indicated), documented Resident #1 with poor appetite and LBM x 1. It was further documented that Resident #1 had "... diarrhea x 2 [MEDICATION NAME] given..." There was no further assessment of the diarrhea on the SDNN, and the boxes for diarrhea on all shifts for [DATE] were left blank. - [DATE], 8:00 AM, Resident son phoned unit manager stated "mom reported to him she is not feeling well." The nurse went to see Resident #1 who remained alert and oriented x 3 and verified she "feels weak". The physician was notified with laboratory work ordered. The resident requested to remain in bed and was refusing her medications and physical therapy. The son came to assist the resident with her lunch at 12:00 PM, consumed 25 % of her meal. At 1:40 PM, complained of nausea/vomiting/diarrhea x 1, a call was placed to the physician for a change with Resident #1's status, and an order was received to send the resident to the hospital for evaluation. At 1:50 PM, the son told the nurse that ..."mom looks worse", was noted to be lethargic upon assessment, and 911 was called at 1:55 PM. At 2:00 PM, "pulse noted to be diminished", and at 2:10 PM, CPR was initiated by Emergency Medical Services (EMS) upon arrival. Resident #1 was pronounced dead at 2:35 PM. ( There was no indication of a follow up with Resident #1's LBM after she was administered [MEDICATION NAME] at 6:30 AM on [DATE], and no indication that she was administered and/or offered any medications when the resident complained of diarrhea/nausea and vomiting at 1:40 PM on [DATE].) During an interview by the surveyor on [DATE] with the LPN/unit manager at 10:20 AM about how they monitor their resident's bowel movements in the facility, revealed that they have a personal care record book for CNA's to fill out every shift which include a section for bowel movements. When asked by the surveyor about what their practice with LBM documentation, the LPN/unit manager stated that it should be documented on the nurse's notes. She could not remember Resident #1. An interview by the surveyor on [DATE] at 12:20 PM with the LPN who took care of Resident #1 on [DATE] when she expired, revealed that she floats on the units, and could not recall if she cared for Resident #1 prior to [DATE]. She further stated that whatever she wrote on the SDNN was what took place. According to the LPN, she remembers updating the Assistant Director of Nursing (ADON) at that time about the resident's condition, but the ADON no longer works at the facility. The LPN could not recall from [DATE] how much diarrhea Resident #1 had on her shift, and could not recall if Resident #1 had any diarrhea prior to her shift on that day. Further interview with the LPN about their practice with monitoring/documenting about LBM/diarrhea, revealed that they are suppose to monitor by documenting an assessment of the LBM on the nurse's notes, and a follow up on the next shift. If any medications were administered, there should be documentation on the back of the MAR indicated [REDACTED] During an interview by the surveyor on [DATE] at 1:00 PM with the Director of Nursing (DON), corroborated the LPN's statement about their practice when someone was administered a PRN medication. The DON further stated that it is "standards of practice" to document the effectiveness of a PRN medication when administered, and if a medication had circled nurse's initials, there should be documentation about why the nurse's initials were circled. An interview by the surveyor on [DATE] at 2:05PM with the facility's RN/MDS Coordinator about their practice with care planning, revealed that Resident #1's care plan should have been updated by nurse on the floor when she began to have a change in her status like diarrhea/LBM. She further stated that there should be documentation on the nurse's notes about the resident's LBM's including an assessment. 2. According to his readmission POS, Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His diet order was Regular (level 4), NAS (no added salt), low cholesterol/fat diet. An MDS dated [DATE], reflected Resident #3 with severely impaired cognitive ability, and required extensive assistance with his ADL's except for eating (supervision). A review of his undated care card, used by the CNA's as their guide on how to take care of their assigned residents, reflected Resident #3 on a regular diet, and independent requiring "set-up" for eating. An IDCP dated [DATE] on alteration in nutrition status, CAA #12, documented Resident #3 with unintended weight loss, and decreased meal consumption. Interventions included but were not limited to; provide diet as ordered, NAS, low fat, regular; provide assistance as necessary with meals; [MEDICATION NAME] as appetite stimulant, and invite resident to food related activities. A nutritional services progress (NPN) notes dated [DATE], documented Resident #3 with some coughing while eating, and the speech therapist was notified. Care plan to continue under "RAP #12". Further review of the NPN dated [DATE], documented Resident #3 on Regular with nectar thick liquid "by tsp ,[DATE] @ a time", and care plan to continue under "RAP #12". The new recommended interventions were not added on the IDCP. A clinical dysphagia evaluation dated [DATE] by the SLP, documented that Resident #3 was referred for swallow competency and safety of current diet following "...nsg report of choking..." Summary of findings included; mild oropharyngeal dysphagia negatively compounded by poor cognitive abilities, and silent aspiration cannot be ruled out (R/O). Modified [MEDICATION NAME] Swallow recommended in order to R/O silent aspiration. Immediate recommendations included 1:1 feeding to ensure small single bites and sips, alternate solids, and liquids, and to check for pocketing. All the recommendations were written by the SLP on a therapy communication to nursing sheet dated [DATE] for approval from the physician. A cookie swallow test (MBS/VFSS) summary dated [DATE], had recommendations of regular diet, NTL feed by ,[DATE] teaspoon. The recommendations also included; "straight forward head posture ,[DATE] tsp nectar liquids. The MBS had impressions that Resident #3 had mild oral phase and moderate pharyngeal phase dysphagia. Further Review of the POS Dysphagia Eval" on [DATE]. On [DATE] at 11:30 AM, and order for diet change to "...soft NDD3 with nectar thick liquids" was obtained. The order also included; 1:1 feeding assistance, no straws, small bites and sips, alternating solids and liquids, aspiration precautions, maintain therapeutic restrictions, and Modified [MEDICATION NAME] Swallow study to R/O silent aspiration. On [DATE], an order was obtained for Regular diet with nectar thick liquids (NTL), ,[DATE] teaspoon at a time. There was no revisions and/or updates on Resident #3's IDCP about the [DATE] and [DATE] orders and recommendations about the resident's dietary needs. The care card for the CNA's had no updates as well. A review of the SDNN for Resident #3 revealed the following: - [DATE] at 9:30 AM- Resident #3 was in activities, was given a cookie and he started to .."spit up and vomit. Speech therapist notified." -[DATE] at 11:30 AM- The primary physician was notified of the SLP recommendations, new orders obtained, and Dietary was notified. -[DATE] at 1:00 PM, noted blood in Resident #3's urine. Fluids offered and encouraged, call placed to the physician with orders obtained. - [DATE] at 11:00 PM, primary physician was notified of MBS evaluation and recommendations with new orders received. -[DATE] at 1:00 PM, the "aid advised of 1:1 feeding to be done". -[DATE] at 11:00 PM, "ate with assist in dining room, aspiration prec...." -[DATE], Resident #3 was coded a s a "1" (supervision) for eating. At 11:00 PM, was noted that snack was offered, and provided NTL juice ,[DATE] tsp at a time. -[DATE], the functional status for eating was coded as a "2", meaning limited assistance. It was further documented at 9:00 AM, the Resident #3 was being fed by a CNA when he appeared to be choking. [MEDICATION NAME] maneuver was initiated with success "Mouth sweep done to remove excess food from mouth". The resident was alert and responsive at this time. The primary physician was called in the room to assess the resident who denied any pain. At 9:15 AM, Resident #3 started to seize and became unresponsive in the presence of his physician. CPR was initiated and 911 was called. The paramedics arrived at 9:20 AM, and was transferred to the hospital at 10:30 AM. A physician's progress note dated [DATE], corroborated what happened with Resident #3 as documented on his [DATE] SDNN that he was called in the room. A review of the hospital record where the resident was transferred on [DATE], reflected that Resident #3 was received in the ED (emergency department) with choking episode during breakfast, was on respiratory and [MEDICAL CONDITION], and was orally intubated by "ALS". Upon arrival to the ED, Resident #3 was unresponsive, pupils fixed and dilated, and ventilated by "Ambu". It was further documented that the medics who intubated the resident while at the facility obtained a copious amount of food from his pharynx. Further review of the hospital record, reflected that his chest x-ray shows right sided infiltrates c/w aspiration pneumonia. Resident #3's disposition [DIAGNOSES REDACTED]. During an interview by the surveyor on [DATE] at 12:10 PM and 1:35 PM with the SLP who evaluated Resident #3, verified that the resident was at risk for aspiration, and did not think that regular diet was appropriate. She further stated that she downgraded the diet until the MBS was obtained due to Resident #3 being very impulsive and shovels large volume of food in his mouth. The ST also stated that Resident #3 liked cookies, and he had pharyngeal weakness. When questioned about the surveyor about Resident #3's lack of care plan on how he should be fed by staff when she made her recommendation from [DATE] and when he came back from his MBS with recommendations. The ST revealed that she only writes on the recommendation sheets for nursing, and does not update the care plans as instructed by her therapy director. Further interview with the SLP, revealed that the care cards used by the CNA's should have been updated when her recommendations were sent to nursing and approved by the physician, and she would only update the care plans if there is a need for adaptive devices. The SLP denied having any documented inservices for nursing staff on how to feed the resident or how to give him his fluids from the time her recommendations from [DATE] was ordered and when resident #3 came back from his MBS, and thinks that she "maybe spoke with staff". The SLP further revealed that the biggest threat was liquid aspiration for Resident #3, and that she discussed the MBS result with the family, and told them they would follow what was recommended. An SLP note dated [DATE], corroborated the SLP's statement that she spoke with the family of Resident #3 about following the MBS results with recommendations for soft to regular diet with NTL by ,[DATE] tsp sips. It was further documented that the family did not want to resume speech therapy since they did not think it will change the resident's difficulty regulating volume and rate of intake independently. During an interview by the surveyor on [DATE] at 11:20 AM with the CNA who was with Resident #3 during breakfast on [DATE], revealed that she was the regular CNA on ,[DATE] shift. She further stated that she was feeding the resident his breakfast which included cinnamon roll and fresh fruit (cantaloupe and pineapple) in his room and thickened liquids, when his cup of juice fell and she picked it up. When she looked up, the resident was gasping for air and she called for a nurse. The ,[DATE] CNA, revealed that she fed him bite sized at a time, and sips of juice at a time. When asked how she gave him his juice, she responded that she provided him one teaspoon at a time. When asked by the surveyor if she was given any inservices on how to feed or let the resident drink by anyone, she responded that "not to my knowledge". The CNA also stated that they had a care card on how to take care of their residents, and if someone required NTL or 1:1 feeding it should be documented on the care card. The CNA could recall that there was a time when their speech therapist told her Resident #3 was a feeder and needed aq teaspoon for fluids. According to the CNA, resident #3 eats fast and allows the staff to feed him with no difficulty. Further interview with the CNA, revealed that a nurse responded to her call and performed [MEDICATION NAME] on Resident #3, who brought up a small amount of food that" flew out" from his mouth, and the resident was alert, and continued to gasp for air. The CNA remembered that the primary physician was called, they put the resident in the bed and she left the resident with the physician and nurses. When she came back, 911 was called and Resident #3 was no longer alert and responsive. During an interview by the surveyor on [DATE] with an LPN who performed the [MEDICATION NAME] maneuver on Resident #3, revealed that she was passing by the resident's room when she heard the CNA's call for help. Resident #3 was in his wheelchair, had his hands around his neck, and could not say anything or talk. The LPN proceeded to perform the [MEDICATION NAME], food came out from the resident's mouth, and had more food in his cheeks during the mouth sweep. The resident later said he was "okay", and the LPN corroborated the CNA's statement about the primary physician being in the room afterwards. Interview by the surveyor on [DATE] at 3:00 PM with the Registered Nurse (RN) who has worked in the facility for 2 years, and was the nurse who obtained the MBS result and relayed it to the primary physician of Resident #3 on [DATE], verified that she was the nurse who obtained the diet for Resident #3 om [DATE]. The RN could not recall if she updated the IDCP or the CNA care card, but stated that she relayed to staff about the resident's diet and recommendations before dinner came. The RN also revealed Resident #3 being a high risk for aspiration from the MBS result, and it should have been documented on the IDCP. During an interview by the surveyor on [DATE] with the Director of Therapy/PT, revealed that nurses documents on the IDCP during their weekly meetings. He further stated that he thought Resident #3 remained on soft diet (NDD3) instead of Regular Diet. The VFSS/ Cookie Swallow Test result conducted from [DATE], and was addressed to the resident's primary physician dated [DATE], reflected that Resident #3 was sent for evaluation to rule out aspiration, and currently was on soft level 3 diet with NTL. The recommendation reflected that "...A diet upgrade is not recommended at this time. It is recommended that the Patient continue consuming soft-regular solids and nectar liquids." In addition, it is recommended that the patient receive one on one supervision for feeding with NTL by teaspoons to ,[DATE] teaspoon amounts. The patient is a self feeder, but is unable to control sip size despite maximum cues provided by therapist". Pharyngeal [MEDICATION NAME] exercises to improve lingual control, training on double swallow to clear pharyngeal residues, and forward head posture is recommended. A letter that was faxed by the facility to the Department of Health and Senior Services dated [DATE] signed by both the SLP and Director of Therapy/PT included a copy of the cookie swallow test form [DATE] (Exhibit A) that was signed by an the RN as relayed to the physician on [DATE], and the full report of the cookie swallow test addressed to Resident #3's primary physician dated "[DATE]" (Exhibit B). According to the letter signed by both the SLP and PT, nursing was not made aware of the recommendations on Exhibit B, and the report was only obtained by the SLP for her copy. It was further documented that Resident #3 was no longer under the care of the SLP on [DATE], and therefore could no longer make recommendations about the diet without an order from the doctor or family consent. The SLP was the one who recommended the MBS studies from [DATE] to rule out aspiration, and met with the family of Resident #3 on [DATE] when according to the letter signed by both the SLP and PT, Resident #3 was no longer on SLP services. It was the same SLP who conveyed to the surveyor that she did not think regular diet was appropriate for Resident #3, and wrote in her [DATE] note that the MBS recommendation was soft to regular diet with NTL by ,[DATE] tsp sips, and the primary physician and nursing will carry out recommendations from MBS. A review of diet levels provided by the PT to the surveyor on [DATE], reflected that there is no soft-regular diet. Diet levels only included; puree, mechanical altered, soft diet, and regular. A review of the facility's policy and procedure on MDS/Care Plans for rehabilitation dated [DATE], reflected that therapists should work collaboratively with the other disciplines to update the comprehensive resident care plans. Care plans are updated as the resident's status changes. It was further documented that typically the interim care plans updated by the therapists address issues such as alteration in nutritional status. The policy on communication-resident specific information: Care Card dated [DATE], documented that pertinent information to assist the nursing assistant in providing care to a resident will be documented on a care card. Charge nurse/ Unit manager is responsible to assure care card is initiated and kept updated. the purpose of the care card is for resident specific information is communicated to nursing assistant to maintain continuity of care. A review of the policy on Notification of Status Changes, included to ensure a timely and complete notification to physicians on a resident's change in condition and pertinent related information. The process included; - nurse will obtain any new orders as warranted from the physician. The orders are to be documented on the POS. Document reason for physician notification and any new orders on the interdisciplinary notes. - updated resident care plan with any new problem or any change in approaches related to existing care plan problem. Examples of indication for physician notification included but were not limited to; diarrhea and emesis. Documentation guidelines include; -to chart change in condition- be sure to document new resident problems, resolution of old problems, or deterioration in the resident's condition - record observations- document your observations of the resident's response to the plan of care. - Be specific. There was no evidence that these facility policies were consistently followed by staff to ensure that any resident including Resident #1 and Resident #3, who experienced any change in their status/condition, or were consistently, adequately and/or appropriately provided necessary care and services by staff. NJAC 8:,[DATE].1 (a) 8:,[DATE].1 (b)

C# NJ & NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to consistently transcribe and/or implement medications in accordance with physician's orders [REDACTED]. This deficient practice is evidenced by the following: A review of Resident #1 and Resident #2's medical records by the surveyor on 6/14/12 revealed the following: Cross Reference to F-309/G 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. > 10/28/11: [MEDICATION NAME] 4 mg 1 tab po (by mouth) every 6 hours as necessary (PRN). >11/4/11 at 7:00 PM: [MEDICATION NAME] 17 gm po daily, and Senna 8.6 mg 2 tabs po daily. > 11/11/11 (no time indicated): [MEDICATION NAME] 1 tab po every 6 hours, and vitals every 6 hours. A review of Resident #1's medication administration records (MARS) from 10/26/11 to 11/27/11, reflected the following: > physician's orders [REDACTED]. > [MEDICATION NAME] 1 tab ordered on [DATE] for every 6 hours, was transcribed as a PRN every 6 hours, and was not transcribed or administered in accordance with the physician's orders [REDACTED]. There was no indication on the back of the MAR indicated [REDACTED]. The [MEDICATION NAME] was not administered every 6 hours in accordance with the physician's orders [REDACTED]. > [MEDICATION NAME] PRN ordered on [DATE], was signed as administered on 10/28/11 (8:00 PM), 11/8/11 (9:00 PM), 11/10/11 (6:30), and 11/11/11 (6:20). There was no documentation on the back of the MAR indicated [REDACTED]. >[MEDICATION NAME] ordered on [DATE] was being signed daily from 11/5/11 until 11/12/11 at 9:00 AM. The medication had circled initials from 11/12 to 11/14/11. The Back of the 11/11 MAR indicated [REDACTED]. There was no documentation for why [MEDICATION NAME] was circled on 11/12/11. > Senna, ordered on [DATE] was signed daily at 9:00 AM until the medication had circled initials from 11/12 to 11/14/11. The back of the 11/11 MAR indicated [REDACTED]. There was no documentation about the Senna circled on 11/12/11. During an interview by the surveyor on 6/14/12 at 12:20 PM with the Licensed Practical Nurse (LPN), who took care of Resident #1 on 11/14/11 about their practice with monitoring/documenting about LBM/diarrhea, revealed that they are suppose to monitor by documenting an assessment of the LBM on the nurse's notes, and a follow up on the next shift. If any medications were administered, there should be documentation on the back of the MAR indicated [REDACTED]. During an interview by the surveyor on 6/14/12 at 1:00 PM with the Director of Nursing (DON), corroborated the LPN's statement about their practice when a resident was administered a PRN medication. The DON further stated that it is "standards of practice" to document the effectiveness of a PRN medication when administered, and if a medication had circled nurse's initials, there should be documentation about why the nurse's initials were circled on the back of the MAR. 2. According to his face sheet, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A POS from 6/1/12, documented orders which included [MEDICATION NAME] 2mg, 1 tablet every 6 hours as needed (PRN) for diarrhea. A review of the 6/12 MAR, reflected that the Imodiun PRN was administered to Resident #2 on 6/2/12 two times at 9:00 AM and 9:00 PM. There was no indication on the back of the MAR indicated [REDACTED]. A review of the skilled daily nurses note (SDNN), had no indication that Resident #2 had any episodes of diarrhea. A review of the facility's policy on Medication Charting dated 10/98, reflected that the policy was enforced to ensure proper documentation of medication administration. Procedures included; - If a medication is not administered, the corresponding date/time space on the MAR indicated [REDACTED]. - Medications given on PRN basis shall be recorded in the appropriate section of the MAR. In addition to the routine information required required in normal charting; the following should also be noted either in the nurse's notes or the appropriate section of the MAR. -The resident's subjective complaint. -the results of the administration of the medication. There was no evidence that this facility policy was consistently followed by staff. NJAC 8:39-27.1 (a) 8:39-27.1 (b)

C# NJ & NJ Based on interviews, review of medical records, and other facility documentation, it was determined that the facility failed to ensure that a nursing care plan (IDCP) was consistently in place, initiated and/or revised to address a change in condition for 2 of 4 sampled residents (Resident #1 and Resident #3). Resident #1 had episodes of loose bowel movements/diarrhea (LBM) between [DATE] to [DATE], and multiple episodes of vomiting on [DATE] with no IDCP in place to address these problems. On [DATE] at 8:00 AM to 2:35 PM, Resident #1 complained of being weak, complained of nausea vomiting and diarrhea, became lethargic and unresponsive, required a 911 call, cardiopulmonary resuscitation (CPR), and expired in the facility on the same day. Resident #3, who was identified by the facility with Aspiration Precautions from [DATE] by the speech therapist (SLP), and was confirmed with silent aspiration after a cookie swallow test from [DATE], had no interdisciplinary care plan (IDCP) in place to address his risk for aspiration to ensure that all staff knew how he should be fed or given his fluids. On [DATE], Resident #3 began choking while being fed his breakfast by a Certified Nursing Assistant (CNA), required [MEDICATION NAME] maneuver, a call to 911, and a hospital transfer. Resident #3 arrived in the hospital on [DATE] at 10:03 AM, unresponsive with pupils fixed and dilated, and was noted "...to have choked on some fruit salad" while in the facility. Resident #3 expired on the same day, [DATE] in the hospital at 3:15 PM with a [DIAGNOSES REDACTED]. This deficient practice is evidenced by the following: Cross Reference to F-309/G A review of Resident #1 and Resident #3's medical records by the surveyor on [DATE] and [DATE] revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool dated [DATE], reflected Resident #1 with intact cognitive abilities, required extensive assistance with most of her activities of daily living (ADL's) except for eating (independent). A resident evaluation form dated [DATE], documented Resident #1 as continent of both bowel and bladder with a mini mental score of "29" out of 30. A review of the physician's orders [REDACTED]. > [DATE]: [MEDICATION NAME] 4 mg 1 tab po (by mouth) every 6 hours as necessary (PRN). >[DATE] at 7:00 PM: [MEDICATION NAME] 17 gm po daily, and Senna 8.6 mg 2 tabs po daily. > [DATE] (no time indicated): [MEDICATION NAME] 1 tab po every 6 hours, and vitals every 6 hours. A review of the [DATE] (,[DATE]) Personal Care Record for Resident #1 from ,[DATE] to [DATE], used by the CNA's to indicate care provided as well as track bowel movements, had no documentation of LBM for Resident #1 except on [DATE] during the ,[DATE] shift A review of Resident #1's medication administration records (MARS) from ,[DATE] to ,[DATE] ([DATE] to [DATE]), reflected the following: > Vitals signs dated as ordered on [DATE] for every 6 hours, was not initiated until [DATE]. > [MEDICATION NAME] 1 tab ordered on [DATE], was transcribed as a PRN every 6 hours, and not every 6 hours as it was documented on the ,[DATE] POS. The [MEDICATION NAME] was documented as administered 1 x on [DATE] ("6:30"), 1 x on [DATE] (6:00 PM), and 1 x on [DATE] (6:30 AM). There was no indication on the back of the MAR indicated [REDACTED]. The [MEDICATION NAME] was not administered every 6 hours in accordance with the physician's orders [REDACTED]. > [MEDICATION NAME] PRN ordered on [DATE], was signed as administered on [DATE] (8:00 PM), [DATE] (9:00 PM), [DATE] (6:30), and [DATE] (6:20). There was no documentation on the back of the MAR indicated [REDACTED]. >[MEDICATION NAME] ordered on [DATE] was being signed daily from [DATE] until [DATE] at 9:00 AM. The medication had circled initials from ,[DATE] to [DATE]. There was no documentation for why [MEDICATION NAME] was circled on [DATE]. > Senna, ordered on [DATE] was signed daily at 9:00 AM until the medication had circled initials from ,[DATE] to [DATE]. The back of the ,[DATE] MAR indicated [REDACTED]. There was no documentation about the Senna circled on [DATE]. A review of the IDCP dated [DATE] and interim careplan dated [DATE] for Resident #1, reflected no revisions and/or updates to address Resident #1's problems with diarrhea, nausea, and vomiting in order to set up specific goals and interventions for an evaluation. Further review of the IDCP dated [DATE] on alteration on nutrition, reflected Resident #1 with [MEDICAL CONDITION], and inadequate oral intake with decreased meal consumption. Interventions included to monitor weights as ordered, and updated food and fluid preferences PRN. Goals included for her skin to remain intact, and to tolerate diet as ordered. A review of the skilled daily nurse's notes (SDNN) revealed the following: -[DATE] at 6:00 PM, admitted as alert and oriented x 3 with bilateral lungs clear. Last bowel movement was noted at 7:00 PM on [DATE]. - [DATE], had no indication that Resident #1 had any problems. (The [MEDICATION NAME] order PRN was obtained on this day with no documentation on the SDNN about why the order was obtained, and why it was administered to the resident as indicated on [DATE] MAR. There was no indication on the SDNN of nausea and/or vomiting.) - [DATE] on ,[DATE] shift, Resident #1 complained of constipation. The physician was made aware, and ordered [MEDICATION NAME] daily, and Senna daily. - [DATE], 7:40 AM was out for [MEDICAL CONDITION] appointment, and returned at 12:00 PM with complaint of diarrhea x 1 at her appointment. (There was no further documentation of LBM until [DATE]) -[DATE] (no time indicated), documented Resident #1 with "LBM x 3", physician was made aware with orders carried out. (There was no indication at what times the Resident had her LBM, how much LBM per episode, and how the LBM looked like. There was no indication on the SDNN check off boxes that the resident had diarrhea. The [MEDICATION NAME] was administered once on [DATE] according to the MAR indicated [REDACTED] -[DATE], had no documentation on all shifts that Resident #1 had nausea, vomiting or diarrhea. (This was contrary to the Physical Therapy progress notes (PTN) dated [DATE] that Resident #1 "...was very naseous throughout treatment session today. Pt was able to complete the session despite vomiting multiple times..."). There was no indication that Resident #1 was medicated PRN on [DATE] for her nausea and/or vomiting. The SDNN boxed check off's, had no indication on all shifts that Resident #1 had nausea and/or vomiting. - [DATE] (no time indicated), documented Resident #1 with poor appetite and LBM x 1. It was further documented that Resident #1 had ...."diarrhea x 2 [MEDICATION NAME] given...." (There was no further assessment of the diarrhea on the SDNN, and the boxes for diarrhea on all shifts for [DATE] were blank). - [DATE], 8:00 AM, Resident son phoned unit manager stated "mom reported to him she is not feeling well." The nurse went to see Resident #1 who remained alert and oriented x 3 and verified she "feels weak". The physician was notified with laboratory work ordered. The resident requested to remain in bed and was refusing her medications and physical therapy. The son came to assist the resident with her lunch at 12:00 PM, consumed 25 % of her meal. At 1:40 PM, complained of nausea/vomiting/diarrhea x 1, and a call was placed to the physician for a change with Resident #1's status. An order was received to send the resident to the hospital for evaluation. At 1:50 PM, the son told the nurse that "...mom looks worse", was noted to be lethargic upon assessment, and 911 was called at 1:55 PM. At 2:00 PM, "pulse noted to be diminished", and at 2:10 PM, CPR was initiated by Emergency Medical Services (EMS) upon arrival. Resident #1 was pronounced dead at 2:35 PM. (There was no indication of a follow up with Resident #1's LBM after she was administered [MEDICATION NAME] at 6:30 AM on [DATE], and no indication that she was administered and/or offered any medications when the resident complained of diarrhea/nausea and vomiting at 1:40 PM on [DATE]). An interview by the surveyor on [DATE] at 2:05 PM with the facility's RN/MDS Coordinator about their practice with care planning, revealed that Resident #1's care plan should have been updated by the nurse on the floor when she began to have a change in her status like diarrhea/LBM. She further stated that there should be documentation on the nurse's notes about the resident's LBM's including an assessment. 2. According to his readmission POS, Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His diet order was Regular (level 4), NAS (no added salt), low cholesterol/fat diet. An MDS dated [DATE], reflected Resident #3 with severely impaired cognitive ability, and required extensive assistance with his ADL's except for eating (supervision). A review of his undated care card, used by the CNA's as their guide on how to take care of their assigned residents, reflected Resident #3 on a regular diet, and independent requiring "set-up" for eating. An IDCP dated [DATE] on alteration in nutrition status, CAA #12, documented Resident #3 with unintended weight loss, and decreased meal consumption. Interventions included but were not limited to; provide diet as ordered, NAS, low fat, regular; provide assistance as necessary with meals; [MEDICATION NAME] as appetite stimulant, and invite resident to food related activities. A nutritional services progress (NPN) notes dated [DATE], documented Resident #3 with some coughing while eating, and the speech therapist was notified. Care plan to continue under "RAP #12". Further review of the NPN dated [DATE], documented Resident #3 on Regular with nectar thick liquid "by tsp ,[DATE] @ a time", and care plan to continue under "RAP #12". A clinical dysphagia evaluation dated [DATE] by the speech therapist (SLP), documented that Resident #3 was referred for swallow competency and safety of current diet following "...nsg report of choking..." Summary of findings included; mild oropharyngeal dysphagia negatively compounded by poor cognitive abilities, and silent aspiration cannot be ruled out (R/O). Modified [MEDICATION NAME] Swallow recommended in order to R/O silent aspiration. Immediate recommendations included 1:1 feeding to ensure small single bites and sips, alternate solids, and liquids, and to check for pocketing. All the recommendations were written by the SLP on a therapy communication to nursing sheet dated [DATE] for approval from the physician. A cookie swallow test (MBS/VFSS) summary dated [DATE], had recommendations of regular diet, nectar thick liquids (NTL) feed by ,[DATE] teaspoon. The recommendations also included; "straight forward head posture ,[DATE] tsp nectar liquids. The MBS had impressions that Resident #3 had mild oral phase and moderate pharyngeal phase dysphagia. Further Review of the POS [REDACTED]. On [DATE] at 11:30 AM, an order for [REDACTED]. The order also included; 1:1 feeding assistance, no straws, small bites and sips, alternating solids and liquids, aspiration precautions, maintain therapeutic restrictions, and Modified [MEDICATION NAME] Swallow study to R/O silent aspiration. On [DATE], an order was obtained for Regular diet with nectar thick liquids (NTL), ,[DATE] teaspoon at a time. There was no revisions and/or updates on Resident #3's IDCP about the [DATE] and [DATE] orders and new recommendations about the resident's dietary needs. The care card for the CNA's had no updates. A review of the SDNN for Resident #3 revealed the following: - [DATE] at 9:30 AM- Resident #3 was in activities, was given a cookie and he started to .."spit up and vomit. Speech therapist notified." -[DATE] at 11:30 AM- The primary physician was notified of the SLP recommendations, new orders obtained, and Dietary was notified. -[DATE] at 1:00 PM, noted blood in Resident #3's urine. Fluids offered and encouraged, call placed to the physician with orders obtained. - [DATE] at 11:00 PM, primary physician was notified of MBS evaluation and recommendations with new orders received. -[DATE] at 1:00 PM, the "aid advised of 1:1 feeding to be done". -[DATE] at 11:00 PM, ...."ate with assist in dining room, aspiration prec...." -[DATE], Resident #3 was coded as a "1" (supervision) for eating. At 11:00 PM, was noted that snack was offered, and provided NTL juice ,[DATE] tsp at a time. -[DATE], the functional status for eating was coded as a "2", meaning limited assistance. It was further documented at 9:00 AM, that Resident #3 was being fed by a CNA when he appeared to be choking. [MEDICATION NAME] maneuver was initiated with success...."Mouth sweep done to remove excess food from mouth". The resident was alert and responsive at this time. The primary physician was called in the room to assess the resident who denied any pain. At 9:15 AM, Resident #3 started to seize and became unresponsive in the presence of his physician. CPR was initiated and 911 was called. The paramedics arrived at 9:20 AM, and was transferred to the hospital at 10:30 AM. A physician's progress note dated [DATE], corroborated what happened with Resident #3 as documented on his [DATE] SDNN that he was called in the room. A review of the hospital record where the resident was transferred on [DATE], reflected that Resident #3 was received in the ED (emergency department) with choking episode during breakfast, was on respiratory and [MEDICAL CONDITION], and was orally intubated by "ALS". Upon arrival to the ED, Resident #3 was unresponsive, pupils fixed and dilated, and ventilated by "Ambu". It was further documented that the medics who intubated the resident while at the facility obtained a copious amount of food from his pharynx. Further review of the hospital record, reflected that his chest x-ray shows right sided infiltrates c/w aspiration pneumonia. Resident #3's disposition [DIAGNOSES REDACTED]. During an interview by the surveyor on [DATE] at 12:10 PM and 1:35 PM with the SLP who evaluated Resident #3, verified that the resident was at risk for aspiration, and did not think that regular diet was appropriate. She further stated that she downgraded the diet until the MBS was obtained due to Resident #3 being very impulsive and shovels large volume of food in his mouth. The SLP also stated that Resident #3 liked cookies, and he had pharyngeal weakness. When interviewed by the surveyor about Resident #3's lack of care plan on how he should be fed by staff when she made her recommendation from [DATE] and when he came back from his MBS with recommendations. The SLP revealed that she only writes on the recommendation sheets for nursing, and does not update the care plans as instructed by her therapy director. Further interview with the SLP, reveals that the care cards used by the CNA's should have been updated when her recommendations from [DATE] were sent to nursing and approved by the physician. The SLP denied having any documented inservices for nursing staff on how to feed the resident or how to give him his fluids from the time her recommendations from [DATE] were ordered and when Resident #3 came back from his MBS, and said that she thinks she "maybe spoke with staff". The SLP further revealed that the biggest threat was liquid aspiration for Resident #3, and that she discussed the MBS result with the family, and told them they would follow what was recommended from the MBS result. A SLP note dated [DATE], corroborated the SLP's statement that she spoke with the family of Resident #3 about following the MBS results with recommendations for soft to regular diet with NTL by ,[DATE] tsp sips. It was further documented that the family did not want to resume speech therapy since they did not think it will change the resident's difficulty regulating volume and rate of intake independently. During an interview by the surveyor on [DATE] at 11:20 AM with the CNA who was with Resident #3 during breakfast on [DATE], revealed that she was the regular CNA on ,[DATE] shift. She further stated that she was feeding the resident his breakfast which included cinnamon roll and fresh fruit (cantaloupe and pineapple) in his room and thickened liquids, when his cup of juice fell and she picked it up. When she looked up, the resident was gasping for air and she called for a nurse. The ,[DATE] CNA, revealed that she fed him bite sized at a time, and sips of juice at a time. When asked how she gave him his juice, she responded that she provided him one teaspoon at a time. When asked by the surveyor if she was given any inservices on how to feed or let the resident drink by anyone, she responded that "not to my knowledge". The CNA also stated that they had a care card on how to take care of their residents, and if someone required NTL or 1:1 feeding it should be documented on the care card. The CNA could recall that there was a time when their speech therapist told her Resident #3 was a feeder and needed a teaspoon for fluids. According to the CNA, Resident #3 eats fast and allows the staff to feed him with no difficulty. Interview by the surveyor on [DATE] at 3:00 PM with the Registered Nurse (RN) who has worked in the facility for 2 years, and was the nurse who obtained the MBS result and relayed it to the primary physician of Resident #3 on [DATE], verified that she was the nurse who obtained the diet for Resident #3 on [DATE]. The RN could not recall if she updated the IDCP or the CNA care card on [DATE], but stated that she relayed to staff about the resident's diet and recommendations before dinner came. The RN also revealed Resident #3 being a high risk for aspiration from the MBS result, and it should have been documented on the IDCP. The RN stated to the surveyor that she should have updated the care card for the CNA's on [DATE], but was unsure with who should have updated the IDCP. During an interview by the surveyor on [DATE] with the Director of Therapy/PT, revealed that nurses document on the IDCP during their weekly meetings. He further stated that he thought Resident #3 remained on soft diet (NDD3) instead of regular diet before he was discharged . The VFSS/ Cookie Swallow Test result conducted from [DATE], and was addressed to the resident's primary physician dated [DATE], reflected that Resident #3 was sent for evaluation to rule out aspiration, and currently was on soft level 3 diet with NTL. The recommendation reflected that "...A diet upgrade is not recommended at this time. It is recommended that the Patient continue consuming soft-regular solids and nectar liquids. In addition, it is recommended that the patient receive one on one supervision for feeding with NTL by teaspoons to ,[DATE] teaspoon amounts. The patient is a self feeder, but is unable to control sip size despite maximum cues provided by therapist". Pharyngeal [MEDICATION NAME] exercises to improve lingual control, training on double swallow to clear pharyngeal residues, and forward head posture is recommended. A letter that was faxed by the facility to the Department of Health and Senior Services dated [DATE] signed by both the SLP and Director of Therapy/PT included a copy of the cookie swallow test form [DATE] (Exhibit A) that was signed by the RN as relayed to the physician on [DATE], and the full report of the cookie swallow test addressed to Resident #3's primary physician dated "[DATE]" (Exhibit B). According to the letter signed by both the SLP and PT, nursing was not made aware of the recommendations on Exhibit B, and the report was only obtained by the SLP for her copy. It was further documented that Resident #3 was no longer under the care of the SLP on [DATE], and therefore could no longer make recommendations about the diet without an order from the doctor or family consent. The SLP was the one who recommended the MBS studies from [DATE] to rule out aspiration, and met with the family of Resident #3 on [DATE] when according to the letter signed by both the SLP and PT, Resident #3 was no longer on SLP services. It was the same SLP who conveyed to the surveyor that she did not think regular diet was appropriate for Resident #3, and wrote in her [DATE] note that the MBS recommendation was soft to regular diet with NTL by ,[DATE] tsp sips, and the primary physician and nursing will carry out recommendations from MBS. A review of diet levels provided by the PT to the surveyor on [DATE], reflected that there is no soft-regular diet. Diet levels only included; puree, mechanical altered, soft diet, and regular. A review of the facility's policy and procedure on MDS/Care Plans for rehabilitation dated [DATE], reflected that therapists should work collaboratively with the other disciplines to update the comprehensive resident care plans. Care plans are updated as the resident's status changes. It was further documented that typically the interim care plans updated by the therapists address issues such as alteration in nutritional status. The policy on communication-resident specific information: Care Card dated [DATE], documented that pertinent information to assist the nursing assistant in providing care to a resident will be documented on a care card. Charge nurse/ Unit manager is responsible to assure care card is initiated and kept updated. The purpose of the care card is for resident specific information is communicated to nursing assistant to maintain continuity of care. NJAC 8:,[DATE].1 (a) 8:,[DATE].1 (b) 8:,[DATE].1 8:,[DATE].2 (2)

Based on interview and record review, it was determined that the facility failed to reevaluate the continued use of an excessive dosage of a Potassium supplement (KCL) in the presence of adverse consequences for a resident (#18) whose [DIAGNOSES REDACTED]. This deficient practice resulted in a critically high Potassium level for Resident #18, necessitating an emergency room (ER) evaluation and subsequent admission to the hospital. In addition, the facility failed to administer Potassium supplements according to the manufacturer's specifications for maximum single dose. This was identified in 3 residents, Residents #18, #19 and #2, of the 5 residents sampled who received Potassium supplements. The deficient practice was evidenced by the following: 1. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. had diminished ability to remove excess potassium from the body. On [DATE] at 11:30 a.m., the surveyor reviewed the closed medical record for Resident #18. This resident was admitted to the facility's sub acute unit on [DATE], hospitalized from ,[DATE]-[DATE] and discharged home on [DATE]. Review of the physician's orders [REDACTED]. Review of the lab report dated [DATE], indicated a Potassium (k) level of "3.4" with a normal range identified from (3.3 - 5.1). A handwritten notation at the bottom of the report indicated that this result was faxed to the physician. The resident, however, was ordered and received an additional 20 meq dosage of Potassium Chloride (KCL) that day; the lab work was to be repeated in 5 days. Review of the lab report dated [DATE], indicated a( k) level of 5.8 and was identified as "#H" (High). A Physicians Order dated [DATE] at 1:00 p.m., indicated to administer "[MEDICATION NAME] 30 gm (Gram) PO x 1 dose now." [MEDICATION NAME] is a Potassium removing resin that is administered for [MEDICAL CONDITION] (high levels of Potassium) in the blood). In addition, a lab test was ordered to be done in 2 days; there was no order to discontinue the Potassium Supplement at that time. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician's orders [REDACTED]." There was no documented evidence that the Potassium supplement was held or discontinued while lab monitoring was being done until the physician's orders [REDACTED]. The lab result dated [DATE] and faxed at 10:30 a.m., (one day after the KCL was discontinued) indicated a (k) level of 6.4 and was identified as "Critical Results." A physician's orders [REDACTED].#18 to the H hospital emergency room "for [MEDICAL CONDITION]" of 6.4. Review of the hospital "Consult Notes" (CN) dated [DATE], indicated that Resident #18 was admitted to the hospital due to "[MEDICAL CONDITION] secondary to potassium supplementation in the setting of chronic [MEDICAL CONDITION]." In addition, the CN's indicated, "Obviously, potassium supplementation needs to be discontinued." During an interview on [DATE], at approximately 10:20 a.m., the facility Medical Director stated that the Potassium supplement "should have been stopped or held." 2. The review of Resident # 19's closed medical record on [DATE] at 11:50 a.m., indicated that this [AGE] year old resident had [DIAGNOSES REDACTED]. The record revealed that the resident was admitted to the facility on [DATE] and expired on [DATE]. The review of the record noted that on [DATE] laboratory test results indicated a Low Potassium, (k) level of 2.7 with a normal range between 3.3 - 5.1 MMOL/L. The result was noted as being faxed to the Physician on that date. The physician's orders [REDACTED]. The Physicians Order further indicated that KCL was to be administered 20 meq daily starting on [DATE]. On [DATE] the (k) level was reported at "3.0" and the POS noted that the dose of the KCl was increased from 20 meq daily at 9 a.m. to 40 meq daily at 9 a.m. The review of the MAR indicated [REDACTED]'s specifications are to administer this medication in single doses of 20 meq. The medical record failed to provide any documented evidence from the physician the reason why the medication had to be administered in a dose that exceeded the manufacturer's specifications. 3. Resident #2 was admitted on [DATE]. On [DATE] at 10:40 a.m., the surveyor reviewed the Physician order [REDACTED]." Manufacturer's specifications indicate that the maximum single dose for Potassium supplements is 20 mEq. Review of the MAR indicated [REDACTED]. NJAC 8:,[DATE].1(a)