Every finding on record at Careone at Somerset Valley

Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure that equipment functioned in a manner to ensure dishes and dishware were appropriately cleaned and the appropriate measuring device was utilized to ensure proper sanitizer concentrations were maintained to limit the potential from microbial contamination and potential food borne illness.This deficient practice was evidenced by the following:On 4/6/26 at 5:11 PM, two surveyors toured the kitchen with the Executive Chef (EC) and observed the following:The dish machine was in use, and one staff member was placing dirty dish racks into the dish machine which appeared to be a high temperature machine, and the wash temperature was at 158 degrees Fahrenheit (F). The EC stated there was a leak in a water line at the back of the dish machine and that it was taped. The surveyors observed a hose taped with black tape. The EC stated the Chemical Company Representative (CC) was contacted for a service call. The surveyors then observed Dietary Staff (DS) washing pans in the three-compartment sink and the surveyors observed dishware in the sanitizer sink and asked what chemical concentration should the sanitizer level be and to demonstrate the testing process. The DS used a test strip that did not match the test strip for the Multi Quat sanitizer as observed on the poster affixed to the wall above the three compartment sink. The DS used the strip to test the sanitizer for 10 seconds and told the surveyors the level was 700. When asked the EC regarding the test strip, he confirmed that was the test strip that was used.At 5:42 PM, the surveyors interviewed the CC in the kitchen and inquired as to the type of dish machine and to show the surveyors the plate affixed to the machine regarding the specifications for use. The CC stated it was a single tank machine, and the wash should be 150 F. The CC did not show the surveyors the temperature indicating metal plate affixed to the machine and the machine was functioning and showed the surveyors a metal plate that was affixed to the left side of the dish machine and said there was no other plate. The surveyors asked the CC about the test strip that was being used to test the 3-compartment sink sanitizer. The CC looked at the test strip and stated that it was the incorrect strip to test the concentration of the sanitation and stated it was used for another products. When asked how would you know if you had the proper sanitizer concentration, he stated, if you have the wrong strip, you won't be able to know. The EC stated the chemical was switched out 1.5 months ago and the facility was not provided with another strip, and there were no other test strips in the kitchen. The CC stated he had the correct strip, retrieved it and tested the sanitizer concentration and it was between 150 - 200 parts per million and matched the correct level. The CC also informed the surveyors that the machine had a hot water booster.A review of the April 2026 High temperature Dish Machine Temperature log that was affixed to the wall documented wash standard should be greater than or equal to 150 F - should this be 160 (This did not match the manufacturer specifications). The following temperatures were logged less than 160 F, Breakfast 4/2/26 -158 F and 4/6/26- 155 F; Lunch 4/2/26- 158 F and 4/6/26 158 F; Dinner 4/4/26 152 F and 4/5/26 154 F. A review of the test strip log of April 2026 3 Compartment Sink PPM Log that was affixed to the wall documented Breakfast PPM standard 150-400 all entrees from April 1st through April 7th were documented 200, Lunch PPM standard 150-400 all entrees from April 1st through April 7th were documented 200 and Dinner PPM standard 150-400 all entrees from April 1st through April 7th were documented 200. On 4/7/26 at 1:42 PM, the surveyor interviewed the Food Service Director (FSD) in the kitchen while the staff utilized the dish machine to clean dishes. The surveyor observed the metal manufacturer specification plate affixed to the dish machine, for the Chemical Sanitation Requirements (affixed to the right side of the dish machine, not to the left as indicated by the CC). The plate revealed: Hot Water Sanitizing, Wash Temp 160 F. When the surveyor showed the FSD the metal plate and asked what the wash temperature should be, The FSD stated it was always 150-160 F. The FSD stated she was unaware of the metal plate and the 160 F wash temperature requirement. A review of the provided facility policy titled, Sanitization, Edited 5/2018 included: Procedure for Oasis 146 Use in Third Compartment [NAME]. Fill Sink #3 (sanitizer sink) with water and Oasis 146 Multi-Quat Sanitizer solution (Use 200ppm-400ppm). Verify temperature in sanitizer sink is above 75F (24C). b. Use QT-40 Test Strips to ensure concentration of sanitizer in Sink 3 is within proper efficacy range. Note: Place a sample of solution from sink 3 in a small container and allow to cool to room temperature 65-75F or (18-24C). Dip test paper in container solution for 10 seconds. Remove and compare test paper color to the color chart on the test strip package. If appropriate ppm levels are not obtained or if there is an issue with the dispensing system for the Oasis 146 Multi-Quat sanitizer, notify the Food Service Director for further direction. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in a manner that maintained and promoted dignity by failing to have residents dressed in a dignified manner during the group meal time and activities. This deficient practice was identified for 2 of 2 cognitively impaired residents reviewed for dignity (Resident #11 and Resident #29) was evidenced by the following:1.On 04/06/26 at 5:55 PM, during the initial tour, the surveyor observed Resident #11 seated in a wheelchair in the main dining room wearing only their incontinent brief and hospital type gown. The Licensed Practical Nurse (LPN) who was in the hallway next to their room informed the surveyor that Resident #11 had developmental disabilities and could not communicate their needs. A strong offensive urine odor also permeated from the room. During an interview with the Certified Nurse Aide (CNA), she confirmed the observation of the urine odor. On 4/6/26 at 6:45 PM, the surveyor observed an incontinence check for the roommate of Resident #11 to determine the source of the urine odor. The roommate had a urine catheter in place and their incontinent brief was not soiled and did not have a strong urine odor. On 4/7/26 at 8:45 AM, the surveyor observed Resident #11 in the main dining room and was wearing their incontinence brief and two hospital type gowns. The surveyor entered Resident #11's room, and the same offensive urine odor permeated in the room. Resident #11's bed was already made and was covered with a clean sheet. The CNA who cared for Resident #11 was in the room, and the surveyor inquired regarding Resident #11's care. The CNA stated that Resident #11 was dependent on staff for all care and was incontinent of bowel and bladder. The CNA stated that Resident #11's bed was soaked with urine due to incontinence and she provided incontinence care to Resident #11 and then changed the bed. On 4/7/26 at 10:30 AM, the surveyor observed Resident #11 sitting in the main dining room, along with other residents, and was still wearing the hospital gowns that were observed at 8:45 AM. On 4/7/26 at 10:40 AM, the surveyor interviewed the Director of Nursing (DON) and inquired regarding Resident #11 attending activities in the main dining room while wearing a hospital type gown. The DON stated that Resident #11 was admitted from a group home and they did not have any clothing. On 04/07/26 at 10:48 AM, the surveyor interviewed the Licensed Social Worker (LSW) regarding Resident #11 sitting in the main dining room in a hospital gown and inquired if the facility had reached the group home regarding Resident #11's clothing. The LSW informed the surveyor that the group home had dropped some clothing off for Resident #11. The surveyor then asked the LSW why Resident #11 was sitting in the main dining room wearing only a hospital type gown during activities. The LSW stated that Resident #11 had clothing and should not be sitting in the dining room wearing only a hospital type gown. The surveyor then asked why any resident should not be sitting in the dining room wearing only a hospital type gown and she stated, this is a dignity issue. On 4/7/26 at 12:30 PM, the surveyor reviewed Resident #11's medical record. The admission Face Sheet, an assessment summary, reflected that Resident #11 had diagnoses which included, but were not limited to; Down's Syndrome (a genetic condition caused by an extra chromosome 21 resulting in low muscle tone, flattened affect and mild-to -moderate intellectual disability), depression and unspecified dementia with other behavior disturbances, acute respiratory failure with hypoxia. The admission Minimum Data Set (MDS), an assessment tool used by the facility that facilitates resident care, dated 03/26/26, indicated that Resident #11 scored 03 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had a severe cognitive impairment, and had impaired decision-making skills. The MDS also indicated that Resident #11 was totally dependent on staff with activities of daily living ADLs. A review of the Comprehensive Care Plan dated 3/20/26, reflected a focus for ADL self-care deficit related to physical limitations. Resident #11 also had a care plan for urinary incontinence related to impaired mobility initiated 3/20/26. The goal was to maintain existing ADL self-performance, maintain in as clean and dry a dignified state as possible. The interventions included assistance with daily hygiene, grooming, dressing, oral care and eating as needed. Initiated 3/20/26. Other interventions for incontinence were to remind and assist as needed with toileting at routine times such as upon arising in morning, after meals, activities, therapy and at bedtime. On 04/07/26 at 11:39 AM, the surveyor Interviewed the CNA who provided care to Resident #11. The CNA stated that she provided care to Resident #11, Resident #11 had their incontinence brief on, one hospital type gown to cover their back and one covering in the front. The surveyor then asked the CNA if it was appropriate for a resident to be seated in the dining room wearing a gown during meals and activities, and she stated, I did not observe any clothing in the room except for a T-shirt. The surveyor then asked if she had informed the nurse and she stated, No. The CNA stated that she was told to wash and get Resident #11 out of bed and to transfer the resident into the dining room. The CNA continued and stated, usually the residents would tell us what they wanted to wear but Resident #11, was unable to communicate. On 04/08/26 at 10:10 AM, during a second interview with the DON, the DON confirmed that residents should not have had hospital type gowns on while attending activities or eating in the main dining room. The DON added, the staff knew better, and were educated. The DON stated that it would have been more appropriate for the staff to serve the residents in their room if they do not have any clothing to wear. On 4/10/26 at 8:45 AM, the surveyor observed Resident #11 sitting in the dining room along with other residents for activities. Resident #11 was wearing regular clothing. On 4/10/26 at 10:30 AM, the surveyor again interviewed the LSW regarding Resident #11's clothing. The LSW stated that some of the clothing was in the room, and she went to retrieve some clothing in the laundry. There was no documentation on Resident #11's medical record that Resident #11's group home was contacted and refused to provide regular clothing for Resident #11, or gave authorization for Resident #11 to attend activities in the main dining room while dressed in a hospital type gown and incontinence brief. The above concerns were presented to the Director of Nursing, and the Licensed Home Administrator on 4/8/26 at 2:30 PM and the survey team asked the facility to provide any additional information for review. On 4/10/26 at 11:04 AM, the administrative team which included the DON, the [NAME] President of Clinical Operation and the Licensed Nursing Home Administrator met with the team and no additional information was provided regarding the above concerns. 2. On 4/07/26 at 8:26 AM, the surveyor observed Resident #29 sitting in a wheelchair in the main dining room. Resident #29 was wearing an incontinent brief and a sweatshirt under a hospital gown. When the surveyor interviewed Resident #29 and asked if they were comfortable, Resident #29 stated that their legs were cold. On 4/07/26 at 8:38 AM, the surveyor interviewed the CNA who was assigned to Resident #29. The CNA and the surveyor observed Resident #29 sitting in the dining room wearing an incontinent brief and a sweatshirt under a hospital gown. The CNA stated that the CNA who worked the 11:00 PM-7:00 AM shift brought them to the dining room for breakfast. When the surveyor inquired if Resident #29 should have been completely dressed before eating breakfast in a common area the CNA stated no, it was ok that they were eating breakfast in a hospital gown and incontinent brief. The CNA further stated that after they had finished eating breakfast they would have been showered and then dressed. On 4/07/26 8:50 AM the surveyor and nurse observed Resident #29 sitting in the dining room wearing an incontinent brief and a sweatshirt under a hospital gown. The Nurse stated usually they should have been dressed but depended on if they refused. The Nurse then stated that it was ok because they were comfortable that way. On 4/7/26 at 10:30 AM, the surveyor reviewed Resident #29's medical record. The admission Face Sheet, an admission summary reflected that Resident #29 had diagnoses which included but were not limited to Dementia (progressive loss of intellectual functioning), muscle weakness, cerebral ischemia (brain injury), hypertension (high blood pressure) and chronic kidney disease (kidneys are damaged for more than a few months). The admission Minimum Data Set (MDS), an assessment tool used by the facility that facilitates resident care, dated 04/06/26, indicated that Resident #29 scored 04 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was severely cognitively impaired. The MDS also indicated that Resident #29 was totally dependent on staff with activities of daily living ADLs. A review of the Comprehensive Care Plan dated 4/03/26, reflected a focus for ADL self-care deficit related to physical limitations. The goal was to be clean, dressed and well-groomed daily to promote dignity and psychosocial well-being. The interventions included assistance with daily hygiene, grooming, dressing, oral care and eating as needed. Initiated 4/02/26. The above concerns were presented to the Director of Nursing, and the Licensed Home Administrator on 4/8/26 at 2:30 PM and the survey team asked the facility to provide any additional information for review. On 4/10/26 at 11:04 AM, the administrative team which included the DON, the [NAME] President of Clinical Operation and the Licensed Nursing Home Administrator met with the team and no additional information was provided regarding the above concerns. A review of the facility's policy titled, Dignity last revised October 2025, revealed the following: Policy Statement: Residents are treated with dignity and respect at all times. Policy interpretation and implementation: Each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to: maintain personal grooming styles (e.g., hair styles, nails, etc.). Attends the activities of their choice, including religious, political, civic, recreational, or social activities. Dress in clothing they prefer, sleep, eat, and conduct activities of daily living as they choose. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: addressing the underlying motives or root causes for behavior; and not challenging or contradicting the resident's beliefs or statements. NJAC 8:39-4.1(a)(12)(14)

Based on observation, interview, and document review, it was determined that the facility failed to maintain a clean and sanitary environment for 1 of 13 resident rooms (Room # 16) observed. The deficient practice was evidenced by the followingOn 04/06/26 at 5:55 PM, the surveyor in the presence of another surveyor toured the facility, and both surveyors entered Room # 16 occupied by Resident #11 and Resident # 5 and observed the following:The curtain was visibly soiled with a large amount of yellow substance. There was an offensive and lingering odor of urine in the room. A Certified Nurse Aide (CNA) was in the room and stated that she just provided incontinence care to Resident #11 and the urine odor persisted in the room.On 4/6/25 at 6:45 PM, the surveyor returned to the room and the offensive urine odor of urine was very strong. The surveyor observed Resident #11 seated in the main dining room with a staff member. The surveyor observed a Licensed Practical Nurse (LPN) with the medication cart next to room [ROOM NUMBER]. Upon inquiry, LPN stated that Resident #11 was incontinent of both bowel and bladder and had a developmental disability. The LPN further stated that Resident #11 was fully dependent on staff for all care. The surveyor then asked the LPN if she could assist or have another staff member assist with an incontinence observation, and the LPN enlisted a CNA, and both assisted for incontinent care for Resident #5.Resident #5 had an indwelling Foley catheter (a tube into the bladder that drains the urine to a drainage bag), and their incontinence brief was not soiled. However, the offensive urine odor persisted in the room.On 4/7/26 at 8:45 AM, the surveyor entered Resident #11's room. The offensive urine odor still permeated in the room. During an interview with the CNA who cared for Resident #11, she stated that she provided incontinence care to Resident #11 and changed the bed, and confirmed that the urine odor persisted. When asked if she reported the offensive urine odor to the nurse, she stated that the facility was aware.On 4/7/26 at 8:55 AM, the surveyor asked the Director of Nursing (DON) to join the surveyor in observing Resident #11 and Resident # 5's room. The DON confirmed the offensive urine odor and stated that they could not identify why the urine odor still persisted after care. The DON stated that, prior to this morning, she was not made aware of, or identified the offensive urine odor that was in the room. She checked the bathroom and the floor and could not detect where the offensive urine odor was coming from. The surveyor then asked the DON if she had checked the mattress? The DON stated No, and confirmed that the offensive urine odor could not be from the mattress. The DON further stated that housekeeping was informed, and a deep cleaning would be performed to the room.On 04/07/26 at 11:42 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the strong urine odor in the room and inquired regarding if environmental rounds were completed. The ADON stated that she made rounds with the DON daily before the morning meeting and was not aware of the offensive urine odor. The ADON stated that she spoke with housekeeping this morning regarding the offensive urine odor and the issue will be addressed.On 04/10/26 at 8:20 AM, the surveyor interviewed the Licensed Social Worker (LSW) and inquired if she was aware of the offensive urine smell inside the room. The LSW stated, usually she did not go inside rooms, but when she entered the room after it was brought to her attention, she confirmed that she could smell the urine odor. The LSW stated that the CNAs should have informed housekeeping of the urine odor. The surveyor then asked the LSW if it was ok for any resident to live in an environment with a strong urine smell and she stated, No, it is the resident's rights to live in a clean comfortable environment.On 4/10/26 at 9:03 AM, the surveyor Interviewed the Housekeeping Director (HD) regarding Resident #11 and Resident #5's room. The surveyor then inquired regarding the process for cleaning the rooms. The HD stated that housekeeping staff were to clean the room daily. However, if a room needed some extra attention, the CNAs were to inform housekeeping staff of what needed to be done. The surveyor inquired regarding the strong urine odor in the room. The HD stated that she was not informed of the offensive urine odor prior to Tuesday 4/8/26. The HD stated once she was informed, she ordered her staff to perform a deep cleaning, but the lingering odor was still detected. The surveyor then inquired regarding the mattress. The HD the HD stated since both residents had now been transferred to another room, she completed a deep cleaning on 4/9/26. She stated that she removed and washed the mattress cover, and the mattress could not be saved, the urine was embedded into the mattress, the mattress was discarded into the trash. She stated, had she been informed, she would have taken the mattress out, cleaned it or replaced it prior to the surveyor inquiries.The surveyor then interviewed the Licensed Nursing Home Administrator (LNHA) about the process to report environmental concerns. He stated that the HD was to report to him any concerns regarding the environment. The surveyor then asked the LNHA if he was made aware of the offensive urine odor in the room. The LNHA stated that he spoke to HD regarding Resident #11 and Resident #5's room and they confirmed the offensive urine odor which persisted even after a deep cleaning. The surveyor then inquired regarding Resident #11's mattress. The LNHA stated that the HD also reported that urine was embedded into the mattress and the mattress could not be saved. The LNHA stated both residents had to be moved to another room to facilitate carbolization (high level cleaning procedure) of the room. The surveyor then asked the LNHA what was the facility's responsibility for the environment for all of the residents. The LNHA stated to provide a clean comfortable environment for all residents. The surveyor then inquired if the environment was clean and comfortable for those two residents, the LNHA confirmed the urine smell in the room and stated clearly, the residents should not have been exposed to that smell.On 4/8/26 at 2:45 PM, the above concern was presented to the administrative staff. As of exit day on 04/10/26 at 11:04 AM, the facility had no additional information to provide.A review of the facility provided, Homelike Environment dated 2001, included but was not limited to Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and ImplementationStaff provides person-centered care that emphasizes the resident's comforts, independence and personal needs and preferences.The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include:Clean sanitary and orderly environment.Clean bed and bath linens that are in good condition.Pleasant, neutral scents;The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include:Institutional odors.N.J.A.C. 8:39-31.4(a)(c)

Based on observation, interview, and record review, it was determined that the facility failed to consistently ensure a) the medication administration record was not signed prior to medication administration, b) medication was administered in accordance with manufacturer specifications and c) cautionary instructions were included for proper administration.The deficient practice was identified for 2 of 5 residents (Resident #26 and #54), who were administered medication by 2 of 4 nurses observed and was evidenced by the following:a) On 4/7/26 at 9:14 AM, the surveyor observed Registered Nurse (RN) preparing medications for Resident #26. At 9:19 AM, the surveyor observed the RN poured from a labeled envelope, (1) tablet of Sucralfate 1 gram (gm) and two (2) tablets of Oxycodone 5 mg (milligram) into a medication cup and this was not reflected on the electronic Medication Administration Record (eMAR).At that time, the surveyor questioned why the Sucralfate and Oxycodone were not reflected on the eMAR for administration. The RN stated that she had previously prepared the medications, was called away and signed the eMAR prior to administration.At that time, the surveyor and the RN reviewed the eMAR together and revealed that Resident #26 had the following orders and administration schedule:-Sucralfate 1 g, 1 tablet by mouth before meals and at bedtime for gastric ulcers. The order was initiated on 3/17/26 and scheduled for administration at 7:30 AM.-Oxycodone 5 milligrams (mg), 2 tablets by mouth every 4 hours as needed for severe pain (pain scale of 8-10). The order was initiated on 3/29/26.On 4/7/26 at 9:32 AM, during an interview with the surveyor, the RN acknowledged and confirmed that she should not have pre-signed the medications as administered. b) On 4/7/26 at 9:50 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #54 in applesauce. The medications prepared included the following:-Prednisone 10 mg, 1 tablet by mouth one time a day for inflammation for 3 days. Take with food. The order was initiated on 4/6/26 and scheduled at 9:00 AM.-Metoprolol tartrate 50 mg, 1 tablet two times a day for hypertension (high blood pressure), hold for systolic blood pressure less than 100 or heart rate less than 60. No additional instruction was reflected. On 4/7/26 at 10:00 AM, the LPN confirmed she was ready to administer the medications to Resident #54 and that the resident had breakfast between 8:00 AM and 8:30 AM, that morning. On 4/7/26 at 10:03 AM, the surveyor observed the LPN encouraged Resident #54 to drink water and administered the medications that were in applesauce.On 4/7/26 at 10:20 AM, the surveyor and the LPN reviewed the eMAR together and observed that the Prednisone instructions for administration indicated Take with Food. The LPN stated she missed the cautionary. c) At that time, the surveyor and the LPN continued to review the eMAR and observed that the Metoprolol had no cautionary. The LPN stated that she was aware that the medication should have been administered with meals but thought that since the resident already ate and that she had administered it with applesauce that it would have been sufficient. At that time, the LPN acknowledged and confirmed that she should have called the kitchen or provided a snack with the administration of Prednisone and Metoprolol.A review of the Consultant Pharmacist recommendation dated 4/7/26 indicated Metoprolol tartrate is recommended to be scheduled and given with or immediately following a meal and review 9:00 AM administration.On 04/9/26 at 12:05 PM, in the presence of a surveyor, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns that occurred during the medication pass: The RN that signed/certified that one (1) pill of Sucralfate and two (2) pills of Oxycodone were administered to Resident #26 when they were not, the administration of Prednisone against the cautionary, and the Metoprolol tartrate that did not have a cautionary to allow for proper administration.On 04/10/26 at 10:08 AM, during a meeting with the survey team, and the LNHA, the DON acknowledged and confirmed that the eMAR should not be signed prior to administration because a medication error could occur and the administration of Prednisone without food was an error. The DON also stated that the Metoprolol tartrate cautionary was deleted when the parameters were added and that this was a data entry error. The DON further stated that the nurses have been educated not to remove the medication cautionary when entering an order.A review of the provided facility policy titled, Administering Medications dated 4/2019 included the following: Medications are administered in accordance with prescriber orders, including required time frame. The individual Administering the medication initials the residents MAR [medication administration record] on the appropriate line after giving each medication and before administering the next one. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure 1 of 2 antiretroviral medications (Tivicay) used to treat Human Immunodeficiency (HIV) was available which resulted in 6 missed doses, and was administered in accordance with the physician order and professional standards of practice and the facility policy of medication administration. The deficient practice was identified for 1 of 5 residents (Resident #26), and medication administered by 1 of 4 nurses observed and was evidenced by the following:On 4/7/26 at 9:14 AM, the surveyor observed Registered Nurse (RN #1) prepare medications for Resident #26 that included Tivicay (Dolutegravir) 50 milligrams (mg), 1 tablet by mouth one time a day for HIV, initiated on 3/17/26 and was resident's own medication. At that time, the RN stated she did not have the medication in stock that day, it was also not available yesterday [4/6/26], was expected to arrive later that day and would inform the physician.The surveyor then reviewed the medical record for Resident #26 which revealed the following:According to the admission Record, (face sheet) an admission summary, Resident #26 was admitted to the facility with diagnoses which included but were not limited to; HIV, diabetes and carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (a bacteria that is resistant to many antibiotics). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/22/26, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #26 was cognitively intact. A review of the Care Plan (CP) included a focus on the Resident's immunosuppressive drug therapy to treat HIV, was at risk for adverse effects, which was initiated on 3/17/26. The interventions included, to obtain blood pressure, report significant deviation from resident's baseline and to obtain laboratory results as ordered by the Medical Doctor (MD), initiated on 3/17/26. The Goal was to have no irreversible side effects related to drug therapy. The CP did not reflect an intervention for the HIV medication brought to the facility by the resident. A review of the April 2026 electronic Medication Administration Record (eMAR) for Tivicay reflected the nurses documented a 9 from 4/1/26 to 4/7/26 which indicated refer to progress notes. A review of the Nurse's Progress Notes included the following:-On 4/7/26 at 9:12 AM, the nurse documented that Tivicay was not available, the MD was made aware, and the pharmacy was contacted to make a stat (immediate) delivery.-On 4/6/26 at 9:16 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note.-On 4/5/26 at 8:41 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note.-On 4/4/26 at 9:29 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note.-On 4/3/26 at 9:00 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note.-On 4/2/26 at 8:58 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note.-On 4/1/26 at 8:39 AM, the nurse documented the name of the medication, administration instructions, did not indicate if Tivicay was administered and did not indicate the reason for the exception note. On 4/8/26 at 7:48 AM, the surveyor reviewed the eMAR for Resident #26 which reflected a one-time order for late administration of Tivicay on 4/7/26 at 4:00 PM. Further review of the medical record reflected the MD assessed the resident. At that time, the surveyor discussed the concern with the Director of Nursing (DON) regarding Resident #26's missed doses and requested for proof of receipt when the Tivicay was received. On 4/8/26 at 9:13 AM, the surveyor and the DON reviewed the packing slip together which reflected Tivicay was received on 4/7/26. The DON stated that there were no other receipts for Tivicay and Resident #26 was admitted into the facility with their own supply of Tivicay. A review of the 4/8/26 at 11:05 AM, Progress Note signed by the Nurse Practitioner (NP) did not reflect the resident assessed for the 6 missing doses of Tivicay but included that the resident's recent CD4 count was 444 and undetectable for HIV RNA. On 4/9/26 at 8:23 AM, during a follow-up interview with the surveyor, the DON stated she was not made aware by any of the nurses of the Tivicay that was not available for administration to Resident #26, until the day of the medication pass observation on 4/7/26. On 4/9/26 at 8:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who documented 9 on the eMAR from 4/1/26 to 4/5/26.The LPN informed the surveyor that the 9 meant the Tivicay was not available for administration and that he had informed the resident that a refill was required. The LPN also stated that the resident informed him that they had nobody to obtain the refill on their behalf and could not get the medication from the pharmacy. The LPN added that he informed the nurse on the oncoming shift who was also a supervisor, he did not inform the Physician (MD), the Assistant Director of Nursing (ADON) and the DON. On 4/9/26 at 8:40 AM, during an interview with LPN #2 who was assigned to the high-side, stated that medications that were not in stock were documented with a 9 on the eMAR, the MD was informed, pharmacy would be called for immediate delivery, and the DON would also be informed. On 4/9/26 at 9:04 AM, during an interview with the surveyor, RN #2 stated she recalled the conversation with LPN #1 when she told LPN #1 to discuss options with the resident. RN #2 confirmed that she did not speak with Resident #26, call the family,or inform the ADON and the DON. At that time, RN #2 acknowledged and confirmed that she should have followed up with the resident, called the pharmacy, and informed the MD. RN #2 stated the medication was for HIV and should not be missed more than two days for optimal treatment. On 4/9/26 at 12:05 PM, in the presence of a surveyor, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the 6 missing doses that were not administered to Resident #26 in accordance with the physician orders and the miscommunication between staff when the DON and the MD were not informed until the medication pass observation that occurred on 4/7/26. On 4/10/26 at 8:11 AM, the surveyor observed Resident #26 in bed, stated that they were aware they had missed one dose of the Tivicay while in the facility and had missed two doses in the past when they were not a resident in the facility and they were not informed of any consequences of missed doses. On 4/10/26 at 10:08 AM, during an interview with the surveyor, the Social Worker stated she was not informed of any resident that required assistance with their refill when the medication was brought from home and that nursing was responsible for obtaining the resident's medications. On 4/10/26 at 10:08 AM, during a meeting with the survey team, and the LNHA, the DON stated that the nurses failed to timely report the missing medications. The DON also stated that the 6 missed Tivicay doses could cause the Resident's viral load from undetected to detected [the amount of detectable HIV in a person's blood]. The DON stated that a CD4 count lab test was pending and was assessed by the Nurse Practitioner last night for the missed doses. A review of the provided facility policy titled, Unavailable Medications, dated 2/2019 included that Medications used by residents in nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident. A review of the provided facility policy titled Administering Medications, dated and revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed. NJAC 8:39-11.2(b), 27.1 (a) 29.2(d)

Based on interview and record review, it was determined that the facility failed to fully inform in advance the resident representative of a resident who had no capacity to consent to the risk of using psychotropic medications, benefits, alternative options and of the black box warning (Deemed by the the Food and Drug Administration to possiblly cause severe harm). This deficient practice was identified for 1 of 5 residents (Resident #11) reviewed for unnecessary medications and was evidenced by the following:On 04/08/26 at 10:08 AM, the surveyor reviewed the medical records of Resident #11. According to the admission Record, (face sheet) an admission summary, Resident #11 was admitted to the facility with diagnoses which included but were not limited to; Down Syndrome (a genetic condition associated with developmental delays with mild to moderate impairment in cognitive functioning and physical features), dementia and seizures. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/26/26, reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #11 had severe cognitive impairment. Further review of the MDS reflected the resident had no symptom of psychosis and received antipsychotics, an antianxiety, and antidepressants. A review of the 04/08/26 Order Summary Report (OSR) included the following medication and psychotropics (affects the brain activities associated with mental processes and behavior):-Aricept (Donepezil) 10 milligrams (mg), 1 tablet by mouth in the evening for Alzheimer dementia, ordered on 03/19/26.-Aripiprazole (Abilify; a psychotropic) 2 mg, 1 tablet by mouth once a day for depression, ordered on 03/19/26.-Duloxetine (Cymbalta; a psychotropic) 20 mg, 1 capsule by mouth once a day for depression, ordered on 03/19/26-Lorazepam (Ativan; a psychotropic) 0.5 mg, 1 tablet by mouth two times a day for anxiety, ordered on 03/20/26.- Mirtazapine (Remeron; a psychotropic) 15 mg, 1 tablet by mouth in the evening for depression, ordered on 03/19/26.- Quetiapine (Seroquel; a psychotropic) 200 mg, 1 tablet by mouth two times a day for psychosis, ordered on 03/19/26.- Quetiapine (Seroquel; a psychotropic) 50 mg, 1 tablet by mouth one time a day for psychosis, ordered on 03/19/26. A review of the Care Plan included a focus on the resident's difficulty with understanding, and communication related to the resident's decline in cognitive status. Resident #11 was at risk for adverse effects related to use of anti-depression, anti-anxiety, anxiolytic, and antipsychotic medications, initiated on 03/20/26. The intervention did not reflect education and notification of the Resident's representative (RR). A review of the 03/20/26, Consultant Pharmacist Recommendations included the following:Aricept and Quetiapine may increase the risk of QT prolongation (an asymptomatic heart rhythm disorder and may lead to arrythmia) and arrythmias (an active, irregular heart rhythm), consider periodic electrocardiogram (ECG/EKG) monitoring.Concurrent use of Aripiprazole and Quetiapine may be considered duplicate therapy [atypical antipsychotics]; rationale for both medications was requested.The use of multiple antidepressants (Duloxetine and Mirtazapine) increases the risk of side effects; the expected benefits outweighing the risk were requested.Aripiprazole and Quetiapine together increased the risks of stroke, death in person with dementia, worsening of delirium, falls, movement disorders (extrapyramidal symptoms; EPS) and lower levels of sodium (Syndrome of Inappropriate Secretion of Antidiuretic Hormone; SIADH). A review of the 03/24/26, psychiatric evaluation signed by the Doctor of Nurse Practice (DNP) revealed that the resident was unable to follow interview questions and was monitored for 5 psychotropic medications (Aripiprazole, Duloxetine, Lorazepam, Mirtazapine and Quetiapine) and Aricept for dementia. Further review of the medical records did not reveal documented evidence that an Informed Consent for use of Psychotropic Medications (IPCP) for Duloxetine and Abilify was provided to the RR prior to administration in the facility. An IPCP dated 03/23/26, was obtained for Resident #11's Lorazepam, Mirtazapine and Quetiapine, however, did not reflect the benefit, and or risks expected from administration, and the possible side effects were discussed with the RR.On 04/08/26 at 11:00 AM, during an interview with the surveyor, the Registered Nurse/Support Nurse (RN/SN) informed the surveyor that all newly admitted residents, or residents with new or changed psychotropic medications received an IPCP. The guardian, or residents' power of attorney or RR were provided with the IPCP when the resident was cognitively impaired. On 04/08/26 at 11:27 AM, the surveyor, the RN/SN and the Director of Nursing reviewed Resident #11's medical record together. At that time the RN/SN and the DON acknowledge and confirmed that an IPCP for Abilify and Cymbalta were not in the medical record.On 04/10/26 at 10:38 AM, during a telephonic interview with the surveyor, RR stated that originally in March 2026, she was informed of one (1) to two (2) medications and 2 days ago she received a message informing her that there were 5 psychotropic medications. The RR stated she called back but was provided with the incorrect phone number on the message.On 04/9/26 at 12:05 PM, in the presence of a surveyor, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the missing IPCP for Abilify and Duloxetine and IPCP that was found for Mirtazapine, Lorazepam and Quetiapine that did not include the side effects, the expected benefit and, or risk associated with medications.On 04/10/26 at 10:08 AM, during a meeting with the survey team, and the LNHA, the DON confirmed that the IPCP for Abilify and Duloxetine was not there.No further information was provided.A review of the provided facility policy titled, Psychopharmacologic Medication, dated/revised 09/16/18 included that written informed consent shall be obtained for all classes of psychopharmacologic medication after risks and benefits of therapy have been discussed with the resident or the resident's legal representative. NJAC 8:39-4.1(a)2

Based on observation, interview, and record review, it was determined that the facility failed to provide residents with the care needed to meet the residents highest practical level for residents who were dependent on staff for bathing. This deficient practice was identified for 1 of 3 residents (Resident #5) reviewed for Activity of Daily Living (ADL) care . The deficient practice was evidenced by the following:On 4/6/26 at 5:55 PM, during the initial tour the surveyor observed Resident #5 in their room and the room had a strong odor of urine, and the curtain was visibly soiled. The resident was nonverbal and could not communicate with the surveyor.On 4/6/26 at 6:45 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) observed in the hallway next to Resident #5's room. The LPN stated that Resident #5 was dependent on staff for all care. On 04/07/26 at 8:32 AM, the surveyor entered the room and observed a Certified Nurse Aide (CNA) in the room providing care to Resident #5. The CNA showed to the surveyor Resident #5's scalp, right cervical area and the right ear. The areas were covered with white flakes. The CNA stated, I don't know what it is, I called the nurse to assess and the nurse did not come yet. On 04/07/26 at 11:00 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding Resident #5's shower schedule. The ADON could not confirm that Resident #5 had a shower on 4/6/26 as scheduled. She opened the Task (computer system where CNAs documented the care provided and could not verify when Resident #5 last received a shower). She provided the shower log which confirmed that Resident #5 was scheduled to receive a shower on 4/6/26 during the 3:00 PM-11:00 PM shift.On 4/7/26 at 1:15 PM, the Licensed Nursing Home Administrator (LNHA) provided a form titled, Documentation Survey Report v2) for the month of April 2026. When inquired why Resident #5 did not receive a shower on 4/6/26 as scheduled, the LNHA did not have any comment. The resident had been at the facility since February 2026 and had not had a shower. The care Plan did not indicate that the resident's preference was to have a bed bath instead of a shower. There was no documentation on the task nor in the Progress Notes, that Resident #5 received a bed bath instead of a shower.The surveyor reviewed Resident #5's clinical record on 04/07/26 at 12:30 PM. The admission Face Sheet (an admission summary) reflected that Resident #5 had diagnoses which included but were not limited to: cerebral infarction, acute respiratory failure and malignant neoplasm of the bone.The admission Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care dated 03/04/26, reflected that Resident #5 (was severely cognitively impaired and) received a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. (for cognitive skills for decision making skills). Section GG of the MDS, which addressed Functional Abilities, reflected that Resident #5 was dependent on staff for all activities of daily living. The resident plan of care dated 02/25/26 last revised 03/06/26, revealed a focus for ADL Self-care deficit related to physical limitations. The goal was for Resident #5 to receive assistance necessary to meet ADL needs. Initiated 02/27/26. The interventions implemented included: Assist to bathe/ shower as needed. Assist with daily hygiene, grooming and dressing.On 04/07/26 at 1:30 PM, the surveyor interviewed the CNA and inquired where the care provided would be located. The CNA informed the surveyor that all the care provided was entered and could be located under Task on the computer system. The CNA reviewed with the surveyor the Task for February and March. There was no data, and she could not locate where staff documented that Resident #5 had a shower. The page was blank and indicated no history. The CNA stated it should have shown when the resident received a shower. The CNA showed to the surveyor where she entered that she gave a bed bath to Resident #5 on 4/7/26 during the 7:00 AM-3:00 PM shift. On 4/7/26 at 1:45 PM, the LNHA provided the Documentation Survey Report for the month of April to the surveyor. When inquired why Resident #5 did not receive a shower on 4/7/26 as scheduled, the LNHA replied, I don't know. The resident had been at the facility since February 2026 and had not had a shower. The care Plan did not indicate that the resident's preference was to have a bed bath instead of a shower. There was no documentation on the task nor in the Progress Notes, that Resident #5 received a bed bath instead of a shower. The staff signed that Resident #5 received a shower 26 days out of 31 days in March although the DON stated that the facility was not equipped to provide shower. On 04/10/26 at 9:15 AM, the surveyor interviewed the Director of Nursing (DON) and inquired regarding Resident #5 shower schedule. The DON stated that the facility was a sub-acute facility and was not equipped for a Gurney (wheeled padded stretcher designed to transfer residents) who do not have any trunk control. The DON further stated that Resident #5 received a bed bath on their shower scheduled days. The surveyor asked the DON to show on the form where staff would document that residents received a bed bath instead of shower. The DON stated that the Documentation Survey Report v2 should have been modified to include bed bath instead of shower.The above concerns were presented to the administrative staff on 4/8/26 at 2:40 PM.A review of the facility's policy titled, Activities of daily living (ADL) Supporting, last revised March 2018, included the following:Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and ImplementationAppropriate care and services will be provided for residents who are unable to carry out ADLs independently. With the consent of the residents and in accordance with the care plan, including appropriate support and assistance with hygiene, bathing, dressing, grooming and oral care.On 4/10/26, at 11:20 AM, during the exit conference no additional information was provided.N.J.A.C. 8:39-27.2(d)(h)(j)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the appropriate oxygen administration for 1 of 1 resident (Resident #39) reviewed for respiratory care. This deficient practice was evidenced by the following:On 4/6/2026 at 5:27 PM, the surveyor observed Resident #39 in bed, with the head of the bed elevated, receiving oxygen (O2) via nasal cannula (NC-a tube with two prongs at the end that deliver oxygen through the nose) being delivered by an O2 concentrator set at 4.5 liters per minute (LPM). No humidification was present. On 4/7/26 at 7:50 AM, Surveyor #2 observed the Registered Nurse (RN) knock on Resident #39's door then entered the room with a blood pressure machine in preparation for medication administration. The surveyor observed Resident #39 seated on their bed receiving O2 via nasal cannula, the O2 concentrator was on and set at 4.5 liters per minute (LPM). At that time, the RN confirmed viewing the setting at 4.5 LPM.At that time, Surveyor #2 and the RN exited the room and reviewed the physician's order. The RN stated the resident had an order for oxygen concentrator to be set at 2 LPM. The RN confirmed that the O2 concentrator setting was wrong and was not set according to the physician order. The RN stated that he would contact the Respiratory Therapist and the Medical Doctor (MD) regarding the observation. The RN could not say if he assessed the resident that morning prior to the medication pass observation.On 4/7/26 at 11:59 AM, the surveyor observed the resident lying in bed, the head of bed was elevated, receiving O2 via NC with the concentrator on and set at 2 LPM. On 4/7/20 at 1:02 PM, the surveyor reviewed the electronic medical record (EMR). The admission record (an admission summary) reflected that Resident #39 had diagnoses that included but were not limited to; surgical aftercare following surgery on the respiratory system, acute respiratory failure, hypertensive heart and chronic kidney disease, and dependence on renal dialysis (a machine used to filter toxins out of the blood). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 3/5/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated fully intact cognition. The physician orders included an order dated 3/6/26 for oxygen at 2 LPM. A review of the individual comprehensive care plan (ICCP) included a focus area dated 2/27/26, that the resident was at risk for respiratory impairment related to CHF (congestive heart failure) (the heart does not pump blood effectively, leading to fluid buildup in the lungs and other body parts). Interventions included administer oxygen per physician order. On 4/9/2026 at 12:05 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). On 4/10/2026 at 10:09 AM, the LNHA stated that the facility acknowledged the oxygen setting was wrong (on entrance tour and on 4/7/26). The DON stated the nurse should be checking anytime they enter the room to ensure the oxygen setting was correct. A review of the facility provided policy Oxygen Administration, revised October 2010, included:Purpose:The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation:Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.General Guidelines:2. Humidification is recommended for oxygen flows above 4L/min to prevent dryness and irritation of the nasal passages and airways and may be added for resident comfort, upon request, for oxygen flows less than 4L/min.Steps in Procedure:8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. NJAC 8:39-27.1 (a); 29.2 (d)

Complaint #'s: NJ 169236, 173607 Based on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure all residents reached their highest practical wellbeing by failing to: a) provide timely incontinence care, b) provide consistent timely call bell response for resident assistance, c) ensure meals and water were in reach for residents who were deemed dependent with care needs , d) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey and had the potential to affect all residents who resided at the facility. The deficient practice was evidenced by the following: Refer to F558, F677, S560 and S1680 Surveyor #1: On 10/30/24 at 8:45 AM, the surveyor entered Resident #110's room and the resident stated they were soiled and staff would not answer the call light. At 9:00 AM the surveyor observed incontinence care with Certified Nurse Aide (CNA) #1. Resident #110's incontinence brief was observed saturated with urine. The surveyor exited the room and returned at 9:40 AM. Resident #110 informed the surveyor again that they had not yet been provided with incontinence care. On 10/30/24 at 9:13 AM, Surveyor #1 interviewed a Certified Nurse Aide (CNA #1) regarding the amount of staff, who stated that staffing is not great now. CNA #1 stated that on average she had 10-12 residents in her care and CNA #1 added that today was a lucky day she had 9 residents. On 10/30/24 at 9:50 AM, the surveyor interviewed CNA #1 who performed the incontinence observation with the surveyor at 8:45 AM. CNA #1 informed the surveyor that Resident #110 stated that they could wait, and CNA #1 confirmed that incontinence care was not provided when both the surveyor and CNA #1 observed the incontinence brief saturated with urine. CNA #1 informed CNA #2 who had Resident #110 on their assignment that Resident #110 needed to be changed. The surveyor then asked CNA #1 regarding the process for incontinence care in regards to dependent residents. CNA #1 stated that all staff were able to assist residents with care. On 10/30/24 at 9:53 AM, the surveyor observed Resident #112 in bed. The resident was visibly upset and informed the surveyor that they were admitted to the facility on [DATE] at 4:00 PM. Resident #112 stated they had diarrhea at that time, their lips were dry and could not get a sip of water all night. The Resident stated that they activated the call light and no one entered the room to inquire regarding their concerns. The surveyor then observed two cups of water were on the bedside table in the far right corner of the room, along with the breakfast tray and were both out of direct reach of the resident. Resident #112 stated that the tray was delivered around 8:00 AM in the morning, and they had surgery and were unable to get out of the bed to reach the meal tray and the water. The resident stated, please get someone. At 10:15 AM, the surveyor exited the room and observed the Assistant Director of Nursing (ADON ) sitting at the nurse's station. The surveyor accompanied the ADON to the room and Resident #112 expressed concerns over not being able to reach the water on the bedside table during the night, and staff not answering the call light. Resident #112 was able to inform the ADON that their mouth was dry and they could not get out of the bed and could not reach the breakfast tray left on the bedside table. The ADON apologized for the concerns, moved the bedside table next to the bed, then informed the resident that she would warm the breakfast meal in a few minutes. On 10/30/24 at 12:53 PM, the surveyor interviewed CNA #2 regarding staffing. CNA #2 stated that she could have between 10-13 residents in her care during the day and weekends are about the same. On 11/06/24 at 8:37 AM, in the presence of the Assistant Director of Nursing (ADON) Resident #112, an awake and alert resident, informed Surveyor #1 that on 11/5/24 they activated the call light. Staff entered the room and turned the light off and then left the room. Resident #112 stated that they activated the call light again after 10 minutes, and it took almost one hour for staff to provide incontinence care. On 11/7/24 at 9:15 AM, Surveyor #1 interviewed the Director of Nursing (DON) regarding the concerns with staffing. The DON informed the surveyor that the facility was aware of the staffing issues. The surveyor then inquired regarding the acuity. [level of care required by the residents to be performed by Registered Nurse (RN)]. The DON stated she was aware of the staffing ratio set forth by the regulations for the CNAs, however, she could not comment on any staffing process related to the acuity of the residents and the required RN hours that were based on the acuity. The 2 weeks of AAS-12 [acuity based staffing] staffing from 10/13/2024 to 10/26/2024, the facility was deficient in RN staffing as follows: For the week of 10/13/24 Required RN Staffing Hours: 177 -10/13/24 had 168 actual staffing hours, for a difference of -9 hours. -10/14/24 had 168 actual staffing hours, for a difference of -9 hours. -10/16/24 had 176 actual staffing hours, for a difference of -1 hours. -10/17/24 had 152 actual staffing hours, for a difference of -25 hours. -10/19/24 had 168 actual staffing hours, for a difference of -9 hours. For the week of 10/20/24 Required RN Staffing Hours: 197.25 -10/20/24 had 168 actual staffing hours, for a difference of -29.25 hours. -10/21/24 had 176 actual staffing hours, for a difference of -21/25 hours. -10/22/24 had 184 actual staffing hours, for a difference of -13.25 hours. -10/24/24 had 160 actual staffing hours, for a difference of -37.25 hours. -10/25/24 had 160 actual staffing hours, for a difference of -37.25 hours. -10/25/24 had 152 actual staffing hours, for a difference of -45.25 hours. 48781 Surveyor #2: On 10/30/24 at 9:39 AM, the surveyor #2 interviewed the Resident #15 who stated, My only concern is they're short on staffing here. I prefer to go on my diaper in bed and when I call them at night, they don't come. They tell me I don't need to be changed because I didn't move my bowels, so I lay there wet for hours this happens every night. On 10/30/24 at 10:06 AM, the surveyor #2 interviewed the Resident #60 who stated, My issue is the night shift, getting changed at night is very long. Last night I waited for half an hour, they left me in the toilet for half an hour, I can't stay too long on the toilet. They tell me they have other patients to attend to. On 10/31/24 at 2:43 PM, Surveyor #3, in the presence of the Life Safety surveyor, and the Maintenance Director (MD) and staff, interviewed the Director of Nursing (DON) regarding how the facility assesses the time from when a call bell is activated until care is rendered. The DON stated, there are no system to assess time for call bell responses, no computerized time audits. The MD confirmed there was no electronic system to monitor call bell response for time. The DON stated they would just talk to the residents to find out concerns related to call bells. On 11/6/24 at 9:51 AM, the surveyor #2, in the presence of the survey team, interviewed the Staffing Coordinator. The SC stated, I'll staff CNAs according to the census, I know the ratio of CNA to patient on day shift 1/8, evening shift 1/10, and night shift 1/14. We use agency but there's never enough, and the 7:00 AM-3:00 PM and 11:00 PM-7:00 AM shifts are the hardest to staff. A review of the 5 weeks of AAS-11 [certified nurse aide minimum staffing levels] revealed the facility was deficient as follows: 1. For the 2 weeks of complaint staffing from 10/01/2023 to 10/14/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -10/01/23 had 4 CNAs for 48 residents on the day shift, required at least 6 CNAs. -10/02/23 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -10/03/23 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -10/04/23 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -10/05/23 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -10/06/23 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/07/23 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/08/23 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/09/23 had 4 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/10/23 had 4 CNAs for 54 residents on the day shift, required at least 7 CNAs. -10/11/23 had 4 CNAs for 52 residents on the day shift, required at least 6 CNAs. -10/12/23 had 4 CNAs for 50 residents on the day shift, required at least 6 CNAs. -10/13/23 had 5 CNAs for 49 residents on the day shift, required at least 6 CNAs. -10/14/23 had 4 CNAs for 49 residents on the day shift, required at least 6 CNAs. 2. For the week of Complaint staffing from 05/05/2024 to 05/11/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -05/05/24 had 5 CNAs for 49 residents on the day shift, required at least 6 CNAs. -05/06/24 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -05/07/24 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -05/08/24 had 3 CNAs for 47 residents on the day shift, required at least 6 CNAs. -05/09/24 had 4 CNAs for 47 residents on the day shift, required at least 6 CNAs. -05/10/24 had 5 CNAs for 48 residents on the day shift, required at least 6 CNAs. -05/11/24 had 4 CNAs for 48 residents on the day shift, required at least 6 CNAs. 3. For the 2 weeks of staffing prior to survey from 10/13/2024 to 10/26/2024, the facility was deficient in CNA staffing for residents on 14 of 14-day shifts and deficient in total staff for residents on 2 of 14 overnight shifts as follows: -10/13/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/14/24 had 4 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/15/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/16/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/17/24 had 4 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/18/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/19/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/20/24 had 5 CNAs for 53 residents on the day shift, required at least 7 CNAs. -10/21/24 had 4 CNAs for 59 residents on the day shift, required at least 7 CNAs. -10/22/24 had 7 CNAs for 59 residents on the day shift, required at least 7 CNAs. -10/22/24 had 3 total staff for 59 residents on the overnight shift, required at least 4 total staff. -10/23/24 had 5 CNAs for 57 residents on the day shift, required at least 7 CNAs. -10/24/24 had 5 CNAs for 55 residents on the day shift, required at least 7 CNAs. -10/24/'24 had 3 total staff for 55 residents on the overnight shift, required at least 4 total staff. -10/25/24 had 4 CNAs for 55 residents on the day shift, required at least 7 CNAs. -10/26/24 had 4 CNAs for 53 residents on the day shift, required at least 7 CNAs. On 11/7/24 at 9:15 AM, the surveyor #1, in the presence of the survey team interviewed the DON regarding the concerns with staffing. The DON informed the surveyor that the facility was aware of the staffing issues. The DON was aware of the staffing ratio set forth by the regulations for the CNAs. A review of the facility's most current policy and procedure titled, Answering the Call Light, revised in September 2022 revealed, Answer the resident call system immediately If the resident's request is something you can fulfill, complete the task within five minutes if possible. A review of the FacilityAssessment Tool, dated 06/17/2024 revealed: Part 3: Facility resources needed to provide competent support and care for our resident population every day and during emergencies. 3.1 . a staffing plan has been developed to meet the professional, technical, and administrative needs of the center. The plan is informed by historical experience, current resident population and business plans, and projected changes. The approach takes into consideration both the type of staff (licensure or other credential) and number of staff required for each unit, including nights and weekends. The plan is customizable and updated with changes in staffing, census, occupancy, and specialty needs . NJAC 8:39-25.2(b), 27.1(a), 27.2(h)

Based on observation, interview, and record review, it was determined that the facility failed to maintain an environment and resident care to limit the spread of potential infection by failing to: a) adhere to acceptable standards of infection control practices for the cleaning and storage of shared glucometer after each resident use. This deficient practice was observed during medication administration and for 1 of 3 medication carts (Cart #2), b) ensure that respiratory masks and tubing were properly stored to prevent the spread of potential infection. This deficient practice was identified for 2 of 2 residents reviewed for respiratory care, Resident #22 and #61, c) mitigate the spread of infection by using a contaminated disinfectant wipe to wipe a clean surface and perform adequate hand hygiene per facility policy. This deficient practice was identified for 1 of 3 nurses observed during the medication administration pass, d) ensure a process was in place to identify residents who were on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of resistant organism for all residents, staff and visitors in accordance with the Centers for Disease Control and Prevention), by failing to post clear signage outside of resident rooms indicating the type of Protective Personal Equipment (PPE) required and defining high risk resident care activities, and to have the PPE and alcohol-based hand sanitizer (ABHS) available outside or within each resident's room who required EBP. This deficient practice was identified for 18 of 19 residents reviewed for EPB and was evidenced by the following: a) On 10/30/24 at 12:15 PM, the surveyor observed a Licensed Practical Nurse (LPN) checking Resident #210's blood sugar. The LPN retrieved the uncovered glucometer (a machine that tests blood glucose level) from the medication cart, along with other supplies, and without first cleaning the glucometer, then entered Resident #210's room, then used the lancet to obtain the blood sample, and placed the blood sample on the test strip. The LPN then removed the used test strip from the glucometer, exited the resident's room and placed the glucometer directly into the medication cart without first cleaning the glucometer. On 10/30/24 at 1:30 PM, the surveyor interviewed the LPN regarding the facility process for the cleaning of shared medical equipment. The LPN stated that all medical equipment was to be disinfected after each resident use. The surveyor then inquired regarding the observed practice of the glucometer machine not being cleaned before or after being used and then stored in the medication cart. The LPN confirmed that she did not disinfect the glucometer. Upon further inquiry, the LPN stated that she had received education on infection control during her orientation. A review of the manufactures's specifications for the glucometer indicated the following: The Evencare G3 Meter should be cleaned and disinfected between each patient. To clean the meter, clean the meter surface with one of the approved disinfectant. Allow the surface of the meter to remain wet at room temperature for the contact time. on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. On 11/6/24 at 1:00 PM, the facility was made aware of the above concerns. On 11/7/24 at 11:20 AM, the facility provided copies of education for all the staff involved. No further information was provided. b) On 10/30/24 at 10:04 a.m., the surveyor observed Resident #22 in the bed with their eyes closed, and observed a nebulizer (used for providing aerosol breathing treatments) machine on the bedside table with the nebulizer mask placed directly on the night stand surface along with other resident and belongings. The surveyor returned to the room on 10/30/24 at 12:35 PM, and the nebulizer mask remained on the night stand. The medical record reflected Resident #22 was admitted to the facility with medical diagnoses which included, but were not limited to, acute pulmonary edema, muscle weakness, other viral pneumonia and End Stage Renal disease. The medical record also revealed that Resident #22 had an order for Ipratropium-Albuterol 0.5 -2.5 (3) milligrams /3 milliliter 1 vial inhale every 6 hours for wheezing, shortness of breath. On 11/06/24 at 10:30 AM, the surveyor observed a Bipap machine and mask (device that helps breathing) on the bedside table in Resident #61's room. The Bipap mask was placed directly on the bedside table along with other items. The surveyor exited the room and accompanied the Registered Nurse ( RN) back into the room to observe the Bipap mask. The RN informed the surveyor that all respiratory equipment was to be disinfected and placed in a plastic bag after each use to prevent the spread of infection. A review of Resident #61's electronic medical record reflected an order for Bipap at bedtime with oxygen at 2 liters, and off in the morning. Resident #61 medical record revealed that Resident #61 had diagnoses of hypertension and chronic obstructive pulmonary disease. A review of the facility policy titled, Departmental (Respiratory Therapy ) Prevention of infection edited 3/18/24 indicated the following: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The following was noted under Infection control Considerations related to medication Nebulizers/ Continuous Aerosol: After completion of therapy, remove the nebulizer container. Rinse the container with fresh tap water; and dry on a clean paper towel or gauze sponge. Store the circuit in plastic bag, marked with date and resident's name, between uses. 38079 c) On 10/31/2024 at 7:30 AM, the surveyor conducted a medication pass observation with the Licensed Practical Nurse (LPN) was observed in the room of an unsampled resident room [ROOM NUMBER]. The LPN applied the blood pressure cuff to the resident's bare arm, a pulse oximeter to the resident's bare finger, and obtained the temperature with a no touch thermometer. Next the LPN obtained a disinfectant wipe and wiped down the blood pressure cuff, pulse oximeter, and thermometer all with the same wipe. On 10/31/2024 at 7:59 AM, the LPN was observed in an unsampled resident's room, room [ROOM NUMBER], to administer medications. The LPN had donned (put on) gloves to apply the blood pressure cuff to the resident's bare arm, applied the pulse oximeter to the resident's bare finger, and used a no touch thermometer to obtain the resident's temperature. The LPN then used a disinfectant wipe to disinfect the blood pressure cuff, pulse oximeter, and thermometer all with the same wipe. The LPN removed her gloves and entered the resident's bathroom. The LPN turned on the water, wet her hands, applied soap, applied friction for 14 seconds, rinsed her hands, dried her hands, and used a new paper towel to turn off the faucet. Next the LPN donned gloves to use a glucometer to check the resident's fasting blood sugar. After doffing (removing) her gloves, the LPN entered the resident's bathroom. The LPN turned on the water, wet her hands, applied soap, applied friction for 16 seconds, rinsed her hands, dried her hands, and used a new paper towel to turn off the faucet. On 10/31/2024 at 8:09 AM, the LPN used a disinfectant wipe to clean the dirty glucometer and next used the same contaminated disinfectant wipe to wipe down the top of the medication cart. On 10/31/2024 at 8:37 AM, the LPN stated that when performing hand washing, she should apply friction for 20 seconds. She stated that the purpose of hand washing was to prevent the spread of infection. On 10/31/2024 at 12:57 PM, during an interview with a surveyor, the Infection Preventionist Registered Nurse stated, We use the purple and the blue wipes. We are not supposed to use the same wipes for multiple items, each item has to be cleaned separately with a different wipe, not the same wipe. A review of the facility provided, Hand Washing skill dated 08/14/2024, included but was not limited to; 4. [NAME] all surfaces of hands, wrist, and fingers producing friction, for at least 20 seconds. The skill competency was signed by the LPN and the evaluated as having been performed correctly. A review of the facility provided policy, Administering Medications revised April 2019, included but was not limited to; 25. Staff follows established facility infection control procedures . A review of the facility provided policy, Handwashing/Hand Hygiene edited 03/18/2024, included but was not limited to; Washing Hands 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. A review of the facility provided policy, Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022, included but was not limited to; Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. 48781 d) On 10/30/24 at 9:00 AM, during the initial tour of the sub-acute unit, the surveyor observed that their was no EBP signage on doorways for any resident rooms. There were no PPE or ABHS at the entrance to the rooms. PPE was observed at the end of the hallways. On 10/30/24 at 12:40 PM, the surveyor observed some residents rooms had an orange dot next to their name on the front of their door. room [ROOM NUMBER]-D, Resident #18 had no orange dot. The door had green dot with FR written on it. The room [ROOM NUMBER]-W, contained Resident #259, who had an orange dot by their name. On 10/31/24 at 7:47 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), working at the facility per-diem, less than a year. The surveyor asked the LPN about the green and orange dots on the door to room [ROOM NUMBER]. The LPN stated she was Not sure what the orange dot on door means. The green dot might be for EBP because 2-D is on dialysis. I've been away for three months, things might be different here. On 10/31/24 at 12:39 PM, the surveyor reviewed the Electronic Medical Record (EMR) revealed Resident #18 received dialysis treatments and Resident # 258 had an indwelling urinary catheter. On 10/31/24 at 9:01 AM, the surveyor observed two family members (FM #1 and FM #2) of Resident #259, enter the room without using ABHS. The surveyor asked the family and both residents in if they knew what the orange and green dots next to the name on the door meant, the FM #1 stated, We don't know what that means, they don't explain anything here, I didn't notice that at all. It is not brought to our attention. FM #2 stated, I've seen it but don't know what that is and no one told us. Resident #18 in the other bed stated, I didn't know what that is. On 10/31/24 at 11:00 AM, the surveyor interviewed a housekeeping staff in the hallway, the stated they been working almost two years in the facility, regarding what the green and orange dots indicated on in Resident #259's and 18's Room. She stated, I have no idea what the dots mean, orange dot has to have precautions, but I don't know what. I had in-service last month on PPE and EBP. On 10/31/24 at 12:57 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON)/ Infection Preventionist (IP), Registered Nurse (RN), who has been working in the facility for over two years, regarding the facility's process for EBP. She stated, If a patient comes in with tube feeding [food via tube into stomach], Foley [type of urinary catheter], dialysis, catheter, wounds, we must use precautions. Before going into the resident's room, wash hands or use Alcohol base hand sanitizer (ABHS) until it dries. PPE must be put on before entering the room if direct contact is provided. She then stated they give report every day and we also have the orange dot next to the patient's name for those who are on EBP. The ADON/IP stated we were told not to put signage on the door, but only in the inside of the patient's room., and the Social Worker (SW) then notified families via e-mail that resident is on EBP. On 10/31/24 at 1:23 PM, the Director of Nursing (DON) provided the surveyor with in-services for EBP that were conducted on 6/3/24, which revealed the per-diem LPN was not in attendance. The surveyor asked the DON if all staff should be in-serviced on EBP and the DON acknowledged, We expect that all staff including per-diems to be in-serviced on EBP as well. On 10/31/24 at 2:00 PM, the surveyor and the ADON/IP nurse went into Resident #259 and 18's room to check the EBP signage. The signage was noted inside the room against the wall next to the door. FM #1 of the Resident #259 was in the room at the time and the surveyor asked if they observed the sign and knew what it meant. FM #1 stated, I didn't really see the sign and I don't know what that is and no one ever told us. The surveyor asked the ADON/IP if the EBP signage should be visible to all staff and visitors and residents, and how would staff know what PPE to use before entering the room. The ADON/IP responded, I was told that the State rule said you cannot have it in front of the door. The sign also does not stick on the door good, so I put it inside the room. The ADON/IP was asked if the sign should be visible for everyone to see. The ADON/IP acknowledged that the EBP signage should be visible for everyone to see to know what type of precautions and what PPE to put on. The surveyor observed room [ROOM NUMBER]-D still had no orange dot next to the resident's name by the door. On 11/01/24 at 1:00 PM, a review of the EHR order summary for the Resident #18 and the Resident #259 had no orders for EBP. The Resident #18 order summary revealed: hemodialysis diagnosis of end stage renal dialysis; Dialysis Days M, W, F and time: 3PM chair pick up time: 2:15-2:25PM Dialysis Center. Check right upper chest site for bleeding post dialysis. The Resident #259 order summary revealed: urinary catheter: indwelling size:16 French balloon size:10cc change PRN for obstruction. as needed for Neurogenic Bladder Change. On 11/4/24 at 8:30 AM, the surveyor interviewed the ADON/IP nurse regarding who is responsible for tracking residents on EBP. She stated, I don't do the tracking for those who are on EBP. I have the tracking for those who have active infection only. On 11/4/24 at 8:32 AM, another surveyor (#2) observed dots on doors in the hallway and one PPE cart in the hallway. The surveyor observed that there was no signage on the doors. When questioned, the ADON/IP nurse stated that there were no signs to indicate what precautions the residents are on and the cart is for the whole hallway, and there is signage in the room and the dots are the process. Another surveyor asked the ADON/IP nurse what the protocol for the dots was, and how would visitors know what they represented. The ADON/IP nurse stated, the staff would look for someone who never visited here before, and educate them, it is enhanced barrier. On 11/4/24 at 10:48 AM, the ADON/IP was not able to provide information that the previous SW notified the families of 2-D and 2-W of EBP information, she stated, I asked the SW and she does not have it. On 11/4/24 at 12:10 PM, the surveyor interviewed the ADON/IP nurse, in the presence of the survey team. The ADON/IP nurse stated, When we have admissions, if they don't have IV, Catheter, we don't initiate EBP. If they have dialysis, catheter, IVs, PICC lines, tube feedings, wounds, the nurses do it right away, they put the bins in the hallway, orange sticker on the door, the signage is put in the room. The doctors stop by the nurse's station, any of the nurses will tell them, the patient is on EBP, we see families right away, we tell them the EBP. I must ask the administrator about putting the signage on the doorway. The corporation reviews the guidance and I'm told what to do. On 11/6/24 at 8:53 AM, the surveyor interviewed the ADON/IP nurse regarding missing PPEs from EBP rooms the previous week, including orange dots and ABHS. The ADON/IP nurse stated, I don't know how many residents are on EBP right now. room [ROOM NUMBER]-D should have had an orange sticker on her door last week and should have PPEs by their door. On 11/6/24 at 9:11 AM, the surveyor observed in the presence of the ADON/IP nurse, resident rooms 20, 26 and 28 with orange dots by their names, no PPE or ABHS by the doorways. She then stated, It should be by the doorway so that it's accessible to everyone. On 11/6/24 at 9:15 AM, the surveyor was in room [ROOM NUMBER]-W in the presence of the DON. The surveyor asked the Resident #15 if he/she knew what the EBP sign on the wall near the bathroom meant, the resident stated, I don't know what that is, no one ever explained it to me. The resident was moved from 5-D to 10-W on 10/31/24 with orange dot on doorway for dialysis-EBP. The surveyor observed no PPEs or ABHS by the resident's doorway. The surveyor asked the DON why that was. The DON stated, The PPE is not by the doorway because it takes up too much room and it's further down on the hallway. On 11/6/24 at 12:37 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON regarding concerns with the facility's EBP process. The surveyor requested for the list of residents on EBP name, room numbers and what type of EBP and the facility's evidenced based guidance of their EBP policy. On 11/7/24 at 8:19 AM, the surveyor interviewed the IP nurse and she stated, The LNHA, the DON and me reviewed the CDC guidance for EBP yesterday and that is why we moved the signage of the EBP on the front of the residents' doors, including placing the PPEs and ABHS on front of doorways. The surveyor asked the ADON/IP nurse if the CDC guidance was ever reviewed prior to admitting residents on EBP in the past and the IP nurse stated, I saw a webinar before on guidelines that corporate tells us and we follow what corporate tells us to do. The ADON/IP acknowledged, we were doing it wrong as per CDC guidance. On 11/7/24 at 11:30 AM, the survey team met with LNHA and DON regarding concerns with EBP residents. A review of the most current facility policy Enhanced Barrier Precautions dated 4/10/24 revealed, Staff are trained in EBP'S and alerted to the signage to look for, prior to caring for residents on EBPs. Signage is posted indicating the type of precautions and PPE required. Discreet signage may be implemented, to maintain a homelike environment. A review of the CDC guidelines on HTTPS://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, dated July 12, 2022, stated, Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gowns and gloves); For EBP, signage should also clearly indicate the high-contact resident activities that require the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room; Ensure access to ABH rub in every resident room (ideally both inside and outside of the room); Provide education to residents and visitors. NJAC 8:39-19.4(a)(c)(k)

Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to follow professional standards of practice by administering Midodrine (medication to increase blood pressure) outside of the physician parameters. This deficient practice was identified for 1 of 15 residents (Resident #40) reviewed for medications and 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 11/01/2024 at 9:42 AM, the surveyor observed the resident sitting in a wheelchair in the unit common area. On 11/01/2024 at 9:45 AM, the surveyor reviewed the medical records for Resident #40. The Admission Record revealed diagnoses which included but were not limited to; transient ischemic attack, and [NAME] encephalopathy. A review of the Order Summary Report included a physician order dated 09/16/2024, for Midodrine 5 mg (milligrams) give 1 tablet every 8 hours for orthostatic hypotension and hold if the SBP (systolic blood pressure) is greater than 130. A review of the resident-centered care plan included a focus area cardiac disease related to . hypotension initiated 09/08/2024 with interventions that included administer medications according to physician's orders. A review of the Medication Administration Record (MAR) for September 2024, revealed 36 opportunities to administer Midodrine. Three doses of Midodrine were administered outside of the parameter: 9/18/24, SBP 138; 9/20/24, 135; and 9/28/24, 146. A review of the October 2024 MAR revealed 87 opportunities to administer Midodrine. Ten doses of Midodrine were administered outside of the parameter: 10/4/24, 135; 10/13/24, 139; 10/14/24, 135; 10/17/24, 135; 10/18/24, 152 and 139; 10/23/24, 150 and 135, 10/26/24, 138; 10/31/24, 139. On 11/01/24 at 9:46 AM, the Registered Nurse stated that if Midodrine was administered outside the physician's ordered parameter, it could cause the resident's blood pressure, to go very high and that was why, we must hold it. On 11/01/24 at 10:02 AM, the surveyor interviewed the Director of Nursing (DON) about Midodrine and the DON stated that if Midodrine was administered outside the parameters, the resident might have an adverse reaction. She further stated that, there is a reason to hold medication. A review of the facility provided policy, Administering Medications revised April 2019, included but was not limited to; 4. Medications are administered in accordance with prescriber orders . NJAC 8:39-27.1(a)

Complaint # NJ 169236, 173607 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care for 2 of 13 residents reviewed for Activities of Daily Living (ADL), Resident # 110 and #112. The deficient practice was evidenced by the following: a. On 10/30/24 at 8:45 AM, the surveyor entered Resident #110's room and the resident stated they were soiled and staff would not answer the call light. At 9:00 AM, the surveyor observed incontinence care with Certified Nurse Aide (CNA) #1. Resident #110's incontinence brief was observed saturated with urine. The surveyor exited the room and returned at 9:40 AM. Resident #110 informed the surveyor again that they had not yet been provided with incontinence care. On 10/30/24 at 9:50 AM, the surveyor interviewed CNA #1 who performed the incontinence observation with the surveyor at 8:45 AM. CNA #1 informed the surveyor that Resident #110 stated that they could wait, and CNA #1 confirmed that incontinence care was not provided when both the surveyor and CNA #1 observed the incontinence brief saturated with urine. CNA #1 informed CNA #2 who had Resident #110 on their assignment that Resident #110 needed to be changed. The surveyor then asked CNA #1 regarding the process for incontinence care in regards to dependent residents. CNA #1 stated that all staff were able to assist residents with care. On 10/30/24 at 10:45 AM, the surveyor interviewed CNA #2 who had Resident #110 on her assignment. CNA #2 revealed that she had been informed by CNA #1 that Resident #110 needed to be changed. On 10/31/24 at 11:30 AM, the surveyor reviewed Resident #110's Electronic Medical Record (EMR) which revealed the following: The admission face sheet (an admission summary) reflected that Resident #110 had diagnoses which included but were not limited to; wedge compression fracture of T11-T12, [Thoracic vertebrae 11-12] and unspecified severe protein caloric malnutrition. Resident #110 had a care plan in place for ADL Self Care Deficit related to physical limitations. The Goal, initiated 10/22/24, indicated Resident #110 was to receive assistance necessary to meet ADL needs. Interventions included: Assist with hygiene and grooming and oral hygiene. b. On 11/04/24 at 8:30 AM, the surveyor observed Resident #112 in bed. Resident #112 stated that they were last changed last night at 10:00 PM. The surveyor alerted the CNA assigned to the resident of the resident's concerns. The surveyor observed the CNA perform incontinence care. Resident#112's incontinence brief was satureated with urine and and covered with feces. In the presence of the CNA, the resident stated that they were not provided with incontinence care on the 11:00-7:00 AM shift. On 11/06/24 at 8:26 AM, the surveyor observed Resident #112 in bed. Resident #112 expressed concerns over the delay in answering the call light specifically on the 11-7 shift. Then at 8:37 AM, in the presence of the Assistant Director of Nursing (ADON), Resident #112 stated that last night they were soiled and needed to be changed. They activated the call light, then someone came in and turned the light off, but did not provide care. Resident #112 stated that they activated the call light again after 10 minutes and it took almost one hour to receive incontinence care, the wait was too long, and with a bedsore, it hurts. The surveyor asked the resident, how do you know it was over an hour to wait for staff to provide care. The resident stated, I looked at the clock. I was up and watching the election. On 11/06/24 at 10:30 AM, the surveyor reviewed the EMR which revealed: Resident #112 was admitted to the facility with diagnoses which included but were not limited to; Dilated cardiomyopathy, Paroxysmal Atrial Fibrillation and unspecified Falls. On 11/06/24 at 12:20 PM, the facility was made aware of the above concerns with incontinence care. On 11/07/24 at 8:48 AM, during a telephone interview with the CNA #3 who cared for the resident on the 11:00 PM-7:00 AM shift, the CNA revealed that she had 22 residents, she try to manage. On 11/07/24 at 11:30 AM, the facility stated staff was educated regarding incontinence care, and no further information was provided. A review of the facility's policy for ADLs, last revised 2018, revealed under policy interpretation and implementation the following: Appropriate care and services will be provided for residents who are unable to carry out ADLs. independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, toileting, mobility and dining. The Facility Assessment Tool, dated 06-17-24 revealed Part 2: Services and care we offer based on our residents' needs; General Care: Activities of Daily Living; Specific Care of Services Provided: Bathing, showers, oral/[NAME] care,dressing, eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence in doing as much of these activities independently; General Care: Bowel and Bladder; Specific Care of Sercies Provided: Bowel/bladder toileting programs, incontinence prevention and care, intermmittent or indwelling or other urinarycatheter, ostomy, responding to requests for assistance to the bathroom promptly. NJAC 8:39- 27.2(h)

Complaint # NJ 169236, 173607 Based on observation, interview, and record review it was determined that the facility failed to ensure the resident's bedside table and the call light was accessible. The deficient practice was identified for 1 of 15 residents reviewed (#112) for accommodation of need and was evidenced by the following: On 10/30/24 at 9:53 AM, the surveyor observed Resident #112 in bed. The resident appeared upset and informed the surveyor that they were admitted to the facility on [DATE] at 4:00 PM. Resident #112 stated they had diarrhea at that time, their lips were dry and could not get a sip of water all night. The Resident stated that they activated the call light and no one entered the room to inquire regarding their concerns. The surveyor then observed two cups of water were on the bedside table in the far right corner of the room, along with the breakfast tray and were both out of direct reach of the resident. Resident #112 stated that the tray was delivered around 8:00 AM in the morning, and they had surgery and were unable to get out of the bed to reach the meal tray and the water. The resident stated, please get someone. At 10:15 AM, the surveyor exited the room and observed the Assistant Director of Nursing (ADON ) sitting at the nurse's station. The surveyor accompanied the ADON to the room and Resident #112 expressed concerns over not being able to reach the water on the bedside table during the night, and staff not answering the call light. Resident #112 was able to inform the ADON that their mouth was dry and they could not get out of the bed and could not reach the breakfast tray left on the bedside table. The ADON apologized for the concerns, moved the bedside table next to the bed, then informed the resident that she would warm the breakfast meal in a few minutes. On 10/30/24 at 10:38 AM, the surveyor interviewed Certified Nurse Aide (CNA #1) who confirmed the breakfast tray was delivered around 8:00 AM this morning, and stated that she did not deliver the breakfast tray to the resident's room. On 10/30/24 at 11:39 AM, the surveyor interviewed CNA #2 who was the regular assigned CNA for Resident #112. The CNA informed the surveyor that she was not familiar with the resident's routine. On 10/31/24 at 10:40 AM, the surveyor reviewed the medical record for Resident #112 which revealed the following: The Admission Record indicated the resident had diagnoses which included, but were not limited to: Dilated cardiomyopathy, Paroxysmal Atrial Fibrillation and unspecified Falls. Resident #112 was awake, alert, oriented, and able to make their needs known. On 11/06/24 at 8:37 AM, the surveyor interviewed Resident #112 with the ADON present. Resident #112 stated that staff failed to answer the call light in a timely manner. Resident #112 stated they watched the clock, they activated the call light, someone came turned off the light and left the room. They activated the call light 10 minutes later, and staff took almost one hour to answer the call light. The Resident stated in the presence of the ADON, I watched the clock, I was up watching the election. On 11/06/24 at 12:20 PM, the surveyor discussed the inaccessibility of the bedside table, with the water and the breakfast tray for Resident #112 with the Director of Nursing (DON) and the Liscensed Nursing Home Administrator (LNHA). On 11/07/24 at 9:45 AM, the surveyor inquired to the DON regarding residents concerns with the delay in answering the call bell during the 11:00 PM -7:00 AM shift. The DON stated the call bell concerns were addressed under grievance and she will provide the grievance forms for review. A review of the grievance forms revealed that the concerns with the call bell dated back from July. The DON informed the surveyor that she met with the residents and addressed their concerns. The DON stated that the call bell issue was related to staffing and the facility was aware and working on it. On 11/7/24 at 10:30 AM, during a telephone interview with CNA #3, who was assigned to the 11:00 PM-7:00 AM shift, regarding the delay in answering the call bell, the CNA stated, I had 22 residents during the night, I tried to manage but it is difficult. NJAC 8:39-27.1(a); 4.1

Based on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyors observed three nurse administer 30 doses of medication to four residents and there were 3 errors which resulted in a medication error rate of 7.6%. On 10/31/2024 at 7:24 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to a resident on her assignment. The unsampled resident was administered Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour 100 MG (milligram) Give 1 tablet by mouth one time a day for HTN (hypertension) Take with or immediately following meals. At the time of the medication administration, the facility breakfast trays were not delivered, and the LPN had not provided, offered, or instructed the resident to take the medication with food. On 10/31/2024 at 7:59 AM, the surveyor observed the LPN administer medication to another resident on her assignment. The unsampled resident was administered Metformin Tablet 1000 MG Give 1 tablet by mouth two times a day for DM (diabetes mellitus) Give with meals. The unsampled resident was also administered Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for HTN Take with or immediately following meals. At the time of the medication administration, the facility breakfast trays were not delivered, and the LPN had not provided, offered, or instructed the resident to take the medications with food. On 10/31/2024 at 8:37 AM, the LPN acknowledged she gave the medication too early and without food. She stated it should have been given with food per the physician's orders. A review of the facility provided, Medication Pass Observation dated 05/15/2024, conducted by the facility pharmacy representative, included but was not limited to; 9. Medication Administration . C. Aware of and follows cautionary messages e.g. give with food . The competency was signed by the LPN and the pharmacy representative as having been performed correctly. A review of the facility provided policy, Administering Medication revised April 2019, included but was not limited to; 4. Medications are administered in accordance with prescriber orders . NJAC 8:39-29.2(d)

Based on observation, interview and review of facility documents, it was determined that the facility failed to ensure that medications were labeled and dated upon opening, expired medications were removed from active inventory upon expiration: This deficient practice was identified on 1 of 3 medications carts inspected and was evidenced by the following: On 10/30/24 at 12:15 PM, in the presence of the Licensed Practical Nurse (LPN) the surveyor inspected the low hall medication cart on the sub-acute unit. The surveyor observed a Humalog insulin pen (a medication used to treat high blood sugar) with an expiration date of 10/27/24. An other insulin pen which was delivered on 10/22/24. The Insulin pen was opened and not dated. On 10/30/24 at 12:45 PM, the surveyor interviewed the LPN responsible for the medication cart. The LPN stated that the Humalog insulin should have been dated upon opening. The LPN did not provide any rationale for the expired Insulin dated 10/27/24 still in the medication cart. On 11/06/24 at 11:35 AM, the surveyor interviewed again the LPN regarding the expired Insulin observed in the medication cart on 10/30/24. The LPN stated that the insulin was discontinued and should have been removed from the medication cart. According to the manufacturer recommendations, Humalog insulin needs to be discarded 28 days after opening. NJAC-8:39-29.4

Complaint #NJ 160833 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to communicate the unavailability of medications from the pharmacy to the physician in accordance with professional standards of practice. This deficient practice was identified for 2 of 18 residents (Resident #16 and #217) reviewed for standards of practice and 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 casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 9/8/23 at 10:12 AM, the surveyor observed Resident #16 sitting up in bed watching television. The resident stated to the surveyor he/she had recently missed a few doses of Lantus, insulin glargine, (a long-acting injectable insulin used to treat high blood sugar). The resident further stated they received the Lantus, which was a long-acting medication as well as a short acting insulin, and if needed additional doses of the short acting insulin for exceptionally high blood sugar levels. The surveyor reviewed the medical record for Resident #16. A review of the Admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included acquired absence of right leg below the knee (amputation), end stage renal (kidney) disease, and diabetes. A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/27/23, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review reflected the resident received insulin injections. A review of the Order Summary Report (OSR) included a Physician's Order (PO) dated 7/20/23, for Lantus Solostar subcutaneous solution pen-injector 100 units/ milliliter (ml) (insulin glargine); inject 10 units subcutaneously (below the skin) two times a day for diabetes. A review of the corresponding August 2023 Medication Administration Record (MAR) revealed the 9:00 AM Lantus dose was not administered on 8/5/23 and 8/6/23. The nurse had recorded a 9 which indicated other/See nurse notes. A review of the resident's August 2023 Nursing Progress Notes revealed on 8/5/23 at 8:39 AM, and 8/6/23 at 12:38 AM, an administration note for Lantus indicated the medication was awaiting pharmacy delivery. There was no documentation that the physician had been notified the resident did not receive their Lantus medication because they were awaiting pharmacy delivery. A review of the corresponding September 2023 Medication Administration Record (MAR) revealed the 9:00 AM Lantus dose was not administered on 9/1/23 and 9/2/23. The nurse had recorded a 9 which indicated other/See nurse notes. A review of the resident's September 2023 Nursing Progress Notes revealed on 9/1/23 at 9:46 AM, and 9/2/23 at 8:37 AM, an administration note for Lantus indicated the medication was awaiting pharmacy delivery. There was no documentation that the physician had been notified the resident did not receive their Lantus medication because they were awaiting pharmacy delivery. On 9/15/23 at 12:50 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated the resident had diabetes and received both short acting and long-acting insulin for elevated blood sugar levels. The LPN stated if a resident did not have medication available, the first thing to do was to call the pharmacy and find out why the medication had not been delivered. Once she knew the reason she would call the physician, make them aware of the delay and ask how to proceed. She further stated the nurse was required to document if they called the pharmacy or the physician if there was a missing medication. The nurse should also let a supervisor know. At that time, the LPN and the surveyor reviewed the August and September 2023 MAR. The LPN stated a 9 indicated a nursing note had been triggered and a progress note must be made. The LPN stated she had entered the note awaiting pharmacy delivery but should have also documented the physician had been notified and included their instructions on how to proceed. On 9/18/23 at 12:32 PM the surveyor interviewed the Director of Nursing (DON) who stated she had reviewed the August and September MAR for the resident and acknowledged there were dates the resident had not received their morning Lantus injection because the nurse indicated the mediation was unavailable from the pharmacy. The DON stated it was the responsibility of the nurse to know how many doses were left in the insulin pen and reorder the medication as needed from the pharmacy. If the resident had not received their medication, the nurse should have documented that they made the physician aware and recorded their response in the nursing progress notes. On 9/20/23 at 11:20 AM, the surveyor attempted to interview the consultant pharmacist via telephone, left a message, but the consultant pharmacist did not return the call. On 9/20/23 at 11:33 AM, the surveyor interviewed the resident's physician who stated if a resident was going to miss a dose of medication the nurse was supposed to let them know. The physician further stated they did not remember if he had been notified that the resident had missed any Lantus doses. On 9/21/23 at 10:11 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and survey team acknowledged that the facility obviously had a documentation problem, that they were unable to find any documentation the physician had been made aware of the missing medication and subsequent missed doses of Lantus. A review of the facility's Miscellaneous Special Medications policy dated effective February 2019, included . Unavailable Medications .Nursing staff shall: notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available . If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction. 2. On 9/15/23 at 1:50 PM, the surveyor reviewed the closed medical record for Resident #217 who was discharged from the facility. The surveyor reviewed the medical record for Resident #217. A review of the Admission Record face sheet reflected the resident was admitted to the facility in January of 2023 with diagnoses which included hepatic encephalopathy (altered mental status because of liver failure), diabetes, and end stage renal (kidney) disease. A review of the Admission Evaluation dated 1/14/23 at 9:21 PM, reflected the resident was alert and oriented to person, place, and time with clear speech. A review of the OSR included a PO dated 1/15/23, for rifaximin oral tablet 550 milligram (mg); give 1 tablet by mouth two times a day every Tuesday, Thursday, Saturday and Sunday for hepatic encephalopathy, 9:00 AM and 5:00 PM. A review of the corresponding January 2023 MAR revealed the first scheduled dose for rifaximin was 5:00 PM on 1/15/23. There was no dose scheduled for 9:00 AM on 1/15/23. As a result, the resident did not receive their morning dose. On 9/20/23 at 10:50 AM, the surveyor interviewed the DON who stated the resident was admitted to the facility after 9:00 PM on 1/14/23. The resident's rifaximin was started on 1/15/23 at 5:00 PM. The DON stated the resident should have received a dose of rifaximin at 9:00 AM on 1/15/23 but did not because it was not available from the pharmacy. The DON stated there was no documentation that the physician was made aware the resident did not receive a dose of rifaximin on 1/15/23 at 9AM. On 9/20/23 at 11:20 AM, the surveyor attempted to interview the consultant pharmacist via telephone, left a message, but the consultant pharmacist did not return the call. On 09/20/23 at 11:20 AM, the surveyor interviewed the Licensed Practical Nurse weekend supervisor (LPN/WS) who admitted the resident to the facility who stated the process was to verify the medication with the physician, enter the orders and if something was unavailable notify the physician and document that in the medical record. The LPN/WS could not recall the resident and was unsure if she had documented the physician was notified. On 9/20/23 at 11:33 AM, the surveyor interviewed the resident's physician who stated the nurse was supposed to notify him if there was a medication that was unavailable from the pharmacy. The physician could not recall the resident and was unsure if he had been notified of the resident missing their first dose of rifaximin. A review of the facility's Miscellaneous Special Medications policy dated effective February 2019, included . Unavailable Medications .Nursing staff shall: notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available . If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store, label, and date potentially hazardous foods to prevent food-borne illnesses. This deficient practice was evidenced by the following: On 09/08/2023 at 9:30 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following: 1. In the dry storage room, there was a 2-pound bag of dry roasted sea salt peanuts that was wrapped in clear plastic with a label with an opened date of 07/12/23 and used by 07/25/23. The FSD discarded them. 2. In the reach-in freezer, there was a 5 lb. bag of cheese medium-squared ravioli that was opened and wrapped in clear plastic not labelled or dated. The FSD discarded them. 3. In the reach-in refrigerator, there was a 1/4 metal pan size pan of potato salad dated 09/04/23 with a used by date of 09/06/23. The FSD discarded it. On 09/08/23 at 11:30 AM, the surveyor met with the FSD who stated food that were opened, repacked, should be labeled and dated with an opened and used by date. The FSD stated that food that were opened and repacked in refrigerator/ freezer should be labeled and dated with an opened date and a used by date. The FSD stated food should be labeled and dated and used before the used by date so that the residents would not get sick. On 09/20/23 12:27 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and were informed of the findings. A review of the facility's policy Food Receiving and Storage Policy with a revised date of November 2022, indicated dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date) and all foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded. NJAC 8:39-17.2(g) 48617

Complaint Intake NJ 6 Based on the facility policy, record review, and interviews, it was determined that the facility failed to ensure a resident received care according to professional standards of practice by failing to promptly notify the physician of abnormal x-ray results for a resident with a femoral fracture, potentially delaying treatment and surgical interventions. A nurse reported to the physician and family that the x-ray results were negative, however, the x-ray results showed that the resident had a fracture. This affected 1 (Resident #3) of 3 residents reviewed for falls. Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assistance with activities of daily living (ADLs). A review of the care plan dated 01/20/2021, and revised on 02/04/2021 due to a fall, revealed the resident was at risk for falls due to impaired mobility and forgetfulness. An intervention noted on 02/05/2021 indicated that a bed and chair alarm were initiated. A review of the progress notes dated 02/04/2021 revealed Resident #3 was found lying on the floor on the right side near the wall next to the bathroom. The physician was notified and assessed the resident. A review of the physician's notes dated 02/04/2021 revealed the resident had a fall and complained of right hip and knee pain. The resident was assessed for injuries and was able to move extremities, with no shortening observed and no acute fracture seen. A stat x-ray was ordered to rule out a fracture and Tylenol 360 was given for mild pain. A review of the treatment administration record (TAR) for 02/04/2021 - 02/08/2021 revealed the resident did not complain of pain. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the occupational therapy treatment note dated 02/05/2021 revealed the resident completed bilateral upper strength therapeutic exercises. Dynamic sitting balance was completed. The resident was deferred from standing balance until x-ray results were completed. A review of the x-ray results of the right hip dated 02/05/2021 revealed a right intertrochanteric femoral fracture with mild superior apex angulation with the rami intact. The right knee had no fracture. A review of the progress notes dated 02/05/2021 revealed the unit nurse reported to the physician and the responsible party that the x-ray results were negative. A review of the progress notes dated 02/06/2021 revealed the resident had 0 pain with no impairment, with range of motion on both the upper and lower extremities. A review of the progress notes dated 02/07/2021 revealed the resident's pain level was zero, and range of motion performed indicated the resident was able to move all extremities. A review of the physician's progress notes dated 02/08/2021 revealed the physician indicated the resident's x-ray of the right hip and knee indicated right acute intertrochanteric femoral fracture. The family was notified, and the resident was sent out to the ER for an evaluation and admitted to the hospital with a right hip fracture. During an interview on 07/28/2021 at 3:30 PM, Registered Nurse (RN) #1 revealed he found Resident #3 on the floor and assessed the resident after the fall. RN #1 revealed Resident #3 moved all extremities without any pain and had no facial grimacing or grunting. RN #1 further revealed the physician was at the facility and immediately assessed the resident with full range of motion of all extremities, with no shortening observed and no acute fracture seen. RN #1 revealed the resident did complain of mild pain and was given Tylenol, and a stat x-ray was ordered on 02/04/2021. RN #1 revealed he was assigned on second shift to care for Resident #3 throughout the weekend. The resident was assessed and moved all extremities, and nothing was displaced. RN #1 further revealed the resident was assisted up in the wheelchair to go to the bathroom and did not complain of any pain. During an interview on 07/28/2021 at 12:41 PM, Licensed Practical Nurse (LPN) #1 revealed she cared for the resident on first shift during the weekend. LPN #1 further revealed she assessed the resident first thing in the morning, and there was no bruising or displacement of the hip or leg. The resident had no facial grimacing or yelling out and no indicator of pain. LPN #1 revealed after the resident finished occupational therapy, the therapist let her know the resident was having mild discomfort and was given Tylenol. During an interview on 07/28/2021 at 1:15 PM, the Occupational Therapist (OT) revealed she worked with the resident after the fall. The OT further revealed Resident #3 had gotten up on the side of the bed and seemed to be in mild pain on 02/05/2021. The OT revealed the resident was observed without any displacement and was able to sit on the side of the bed without facial grimacing and only complained of mild pain. The OT further revealed the resident's nurse was notified, and the resident received Tylenol. During an interview on 07/28/2021 at 3:24 PM, the Medical Director revealed the charge nurse should have looked at the entire x-ray results and reported it to the physician. The Medical Director was aware of the situation and the delay did not cause the resident harm. The resident's pain was managed, and the resident had range of motion. When the physician saw the resident after the fall there was no displacement. After the physician was aware Resident #3 had a fracture, the resident was sent to the hospital and was admitted to the hospital with a fractured hip. During an interview on 07/28/2021 at 4:00 PM, the Director of Nursing (DON) revealed the charge nurse no longer worked at the facility, and the physician was unavailable for interview. The DON revealed the procedure for reporting x-ray results was to notify the physician of the complete results. The DON further revealed the results of the x-ray were received at the facility on 02/05/2021, and the unit manager reported to the physician and the RP the results of the right knee with no fracture but failed to report the fractured intertrochanteric right femoral fracture. A review of the facility policy, dated April 2007, titled, Test Results, read in part: 1. Results of laboratory, radiological, and diagnostic tests shall be reported to the resident's Attending Physician or to the facility. 2. Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results. New Jersey Administrative Code § 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure appropriate infection control practices and monitoring of a visitor to an end of life resident were followed to prevent the spread of infection. This deficient practice was identified on 1 of 1 units and was evidenced by the following: On 11/20/2020 at 9:12 AM, the Director of Nursing (DON) stated that the facility had one unit that consisted of two zones of cohort (grouping of residents). The Yellow Zone consisted of residents that were identified as persons under investigation/observation (PUI) and were under quarantine for 14 days for monitoring for possible exposure to Covid-19. The Green Zone consisted of residents that completed the 14 days quarantine process, were negative for COVID-19 and did not display signs and symptoms of infection. The DON added that the Yellow Zone consisted of Rooms 5 to 33 and the Green Zone consisted of Rooms 1 to 4. The DON also confirmed that the facility had a current outbreak of COVID-19 and there were zero COVID-19 residents in the building. She stated that those that had been confirmed with COVID-19 had been transferred to a COVID dedicated sister facility once the positive test result was reported. At 11:00 AM, the surveyor reviewed the facility form titled, Daily Assignments which revealed a CNA had Rooms 1 to 7 and the LPN had rooms 1 to 9. The rooms consisted of residents that were in the Green Zone, as well as residents in the Yellow Zone (PUI). On the same day at 11:35 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who also confirmed that there was a current outbreak in the facility of short-term residents. The LNHA added that they had to recently extend the Yellow Zone to incorporate residents exposed to a staff member that was confirmed to be COVID-19 positive and that the Green Zone was at the end of the hallway after the Yellow Zone. She added that the floor plan had been finalized on 11/17/2020. At 12:45 PM, the surveyor interviewed the Unit Manager (UM) who confirmed the rooms that residents housed in the Yellow Zone, as well as the rooms that housed residents in the Green Zone. The rooms were as previously mentioned during the interview above with the DON. The UM confirmed that there was no other way to get to the Green Zone without walking down the hallway of the Yellow Zone. She added that the hallway of the units were considered clean areas. Beginning at 12:55 PM, the surveyor toured the resident unit. Upon entry to the unit, the hallway split into a V shape. The hallway to the left was identified as the Yellow Zone (PUI) and the right side of the hallway the Yellow Zone began at room [ROOM NUMBER] and went down to room [ROOM NUMBER]. These rooms were also identified as housing residents that were PUI. There were yellow signs on each door that revealed the type of precautions staff were to take upon entry and required Personal Protective Equipment (PPE). The surveyor observed a Certified Nursing Assistant (CNA #1) wearing scrubs, hair cover and an N95 mask covered by a surgical mask, push the closed metal meal cart from the hallway by room [ROOM NUMBER] and left it in the hallway by room [ROOM NUMBER]. CNA #1 then walked down the hallway, donned a yellow gown in the hallway and entered room [ROOM NUMBER]. He was then observed exiting room [ROOM NUMBER] with a completed food tray. In the doorway of room [ROOM NUMBER], he removed the gown, folded it and placed it in an unmarked foot pedal operated metal bin located in the hallway outside of room [ROOM NUMBER]. The metal bin was located directly next to a plastic three drawer bin that contained clean PPE. CNA #1 then placed the meal tray on the tray cart and preformed hand hygiene with Alcohol Based Hand Rub (ABHR). At 1:00 PM, the surveyor observed a Licensed Practical Nurse (LPN) exit room [ROOM NUMBER] holding a folded yellow gown in her hands and placed it in the bin labeled Gowns Only that was in the hallway outside room [ROOM NUMBER]. This bin was also immediately next to a bin that contained clean PPE. The LPN then used ABHR that was on the top of the clean PPE bin. At 1:03 PM, the surveyor observed a staff member exit a room in the middle of the hallway holding a gown folded in her hands, she walked down the hallway and discarded the gown in the bin by room [ROOM NUMBER]. She then used ABHR that was on the clean PPE bin. During this time period, the surveyor observed that the doors to the Rooms 5 to 19 were closed. The doors to Rooms 1 to 4 were opened to the hallway. There was a sign and yellow square for the rooms identified in the Yellow Zone and there was a green square near the rooms in the Green Zone. The surveyor also observed a portable, flexible, retractable screen that was in the hallway between room [ROOM NUMBER] (Yellow Zone) and room [ROOM NUMBER] (Green Zone). There was space below and above the screen and it did not extend the entire width of the hallway which allowed for an unobstructed access from the Yellow Zone to the Green Zone and back again. At 1:05 PM the surveyor observed CNA #1 enter and exit room [ROOM NUMBER], then room [ROOM NUMBER], then room [ROOM NUMBER] and back to room [ROOM NUMBER] of the Green Zone. At that same time, the surveyor observed a Regional Staff Member wearing an N95 covered by a surgical mask, goggles and street clothes walk down the hallway of the Yellow Zone and into the Green Zone hallway without having to move any barrier that separated the two zones. She then turned around and went back down the hallway into the Yellow Zone. She did not enter any resident rooms. At 1:10 PM, the surveyor observed a staff member who identified themselves as an Occupational Therapist (OT) exit room [ROOM NUMBER], with a yellow gown folded in her hands and discarded the gown in the bin outside room [ROOM NUMBER]. At this time, the surveyor interviewed the OT who stated that the gloves were discarded in the garbage can in the resident room prior to exit and that the gown used in the resident room was removed and folded in on itself and placed in the bin in the hallway. She added that the hallway was considered a clean area. At 1:25 PM, the surveyor observed on the Yellow Zone hallway that led to the Green Zone. The surveyor observed five bins spread throughout the hallway that contained clean PPE, and there were two bins on the hallway, one by room [ROOM NUMBER] and one by room [ROOM NUMBER], that were labeled Gowns Only. There was a sixth bin of clean PPE and a third Gown Only bin outside of room [ROOM NUMBER]. There were no bins of PPE observed in the Green Zone. At 1:35 PM, the surveyor observed a staff member exit room [ROOM NUMBER] with a yellow gown in one hand and a face shield in the other hand. After walking in the hallway, she placed the gown in the bin by room [ROOM NUMBER] and placed the face shield down on the top of the clean PPE bin while she removed a bleach wipe from the container. The staff member identified themselves as a Physical Therapy Assistant (PTA) to the surveyor. The surveyor observed the PTA while she cleaned the face shield with a bleach wipe, discarded the wipe, and then conducted hand hygiene with ABHR. The PTA stated that PPE was removed prior to leaving the residents room and that the gown was placed in a bin in the hallway. At 1:42 PM, the surveyor knocked and entered room [ROOM NUMBER] in the Green Zone after someone stated, Come in. The door to the room was open to the hallway. Resident #1 was in the bed with their eyes closed and there was a person sitting in a motorized wheelchair next to the right side of the bed wearing a surgical mask that was folded under their chin thus exposing their nose and mouth. Resident #1 was not wearing a facial covering. The person in the motorized wheelchair identified themselves as the spouse of Resident #1 and that they resided in the Assisted Living Residence (ALR) on the other side of the building. The spouse stated that they come, Two to three times a day to sit with their spouse and confirmed that they entered the unit from the hallway that separated the ALR and Rehabilitation Unit and that they traveled down the hallway through the Yellow Zone to Resident #1's room in the Green Zone. They added that they were not told that they were not allowed to visit their spouse. They added that the staff would remind them to conduct hand hygiene and to cover their mouth and nose with the mask when in the hallway. This resident then stated that they had not been informed of the current outbreak of COVID-19 in the facility. At 1:50 PM, the surveyor observed the same CNA don a yellow gown prior to entry into room [ROOM NUMBER] and then observed that same staff member exit room [ROOM NUMBER] and while in the door frame, removed his gown and folded it up and placed it in the bin outside the room and conducted hand hygiene with ABHR. At that time, the surveyor interviewed the CNA who stated that his assignment consisted of Rooms 1 to room [ROOM NUMBER] and added that rooms 1 - 4 were in the Green Zone and Rooms 5 - 7 were in the Yellow Zone. The CNA confirmed that PPE was removed prior to leaving the resident room and that the spouse of the resident in room [ROOM NUMBER] visits regularly and that they resided in the ALR. He added that the spouse traveled down to the Green Zone through the Yellow Zone in their motorized wheelchair (WC). At 2:18 PM, the surveyor interviewed the Local Health Department point of contact (LHD), who confirmed that the facility had reported the current outbreak and that there was also a current outbreak at the attached ALR. She added that there was a potential for cross contamination when staff were shared between the Yellow and Green Zone's and potential of cross contamination when a visitor from the ALR traveled to the Green Zone through the Yellow Zone. At 2:53 PM, the surveyor reviewed the Admission Record of Resident #1 which revealed their most current admission to the Rehabilitation Unit was in September of 2020 and their most recent COVID-19 test result received on 11/17/2020 was negative. There was also a Physician order [REDACTED]. At 2:58 PM, the surveyor interviewed the Executive Director (ED) of the ALR, who confirmed that they had a current outbreak of CVOID-19 in their building. He added that he was not aware that an ALR resident was traveling to the Rehabilitation Unit on the other side of the building. He added that the residents in the ALR were screened every shift for signs and symptoms related to COVID-19 and were also tested weekly because of the current outbreak. At 3:18 PM, the ED of the ALR provided a lab result of Resident #1's spouse received on 11/17/2020 which revealed that the COVID-19 virus was not detected and that the spouse did not exhibit signs and symptoms of illness on the screen that was last completed on 11/20/2020. At 3:30 PM, the surveyor interviewed the DON who confirmed that the facility started using re-usable gowns in August of 2020. She added that there were bins with clean PPE and bins for soiled gowns throughout the hallway of the Yellow Zone. Also, that full PPE (N95, face shield or goggles, gloves and re-usable gowns) were required to care for residents in the Yellow Zone and that the gloves were discarded in the resident room, while the re-usable gown was removed in the resident room, folded and carried out of the resident room to the Gown Only bins in the clean hallway. She added that the gloves were discarded in the resident room because they were dirty and that she was not sure that anyone would walk down the hallway carrying a gown once they exited a resident room. The DON added that the re-usable gowns would be picked up by the laundry service to be washed and sanitized for re-use. She added that the projector screen was placed between room [ROOM NUMBER] & room [ROOM NUMBER] to differentiate the Green Zone from the Yellow Zone. The DON confirmed that the hallway separating the two zones was not completely sealed off because you needed to get to the rooms in the Green Zone from the Yellow Zone and to prevent cross contamination. The DON confirmed that she was made aware that the spouse of Resident #1 had visited him/her when the facility was in Phase 1 and Phase 2 because Resident #1 was on end of life [MEDICATION NAME] care. The DON stated that she had spoken to Resident #1's spouse on 11/17/2020 and made them aware that there was a current outbreak and that they would have to hold off on visiting. She added that there was not an outbreak at the ALR and that she had not documented the conversation with Resident #1's spouse. The DON also stated that she was not aware that Resident #1's spouse continued to visit and that she had not informed her staff that she had spoken to them about not visiting during an active outbreak. The DON also confirmed that the facility does not have a Red Zone (COVID Positive Zone) at this time and that there were no COVID Positive residents in the building. The DON added that all staff and residents in the building were tested weekly because, Anyone could become positive. The surveyor then reviewed the facility cohort plan that read under General Cohorting Guidelines: *Separate COVID + from all other cohort groups; COVID + may room with COVD +. *Staff work with single cohort - consider all depts, all shifts and establish plan. The Yellow Zone identified the Patient Type as potentially incubating (the period of time between infection with germs and the appearance of symptoms of illness) which consisted of Admits & readmits without history of COVID-19, or recovered greater than 6 months, asymptomatic (without symptoms) with known or potential facility exposure and symptomatic PUI not yet confirmed. Under activity and movement, it read: Use face mask if transport thru green zone medically necessary. The Green Zone identified patient type as naive or recovered, no known exposure, Admits or readmits greater than 14 days up to 6 months and COVID recovered greater that 14 days since symptoms onset. Under activity and transport it read: Do not travel thru yellow or red zone. The surveyor then reviewed the sign that had been placed on each resident room in the Yellow Zone which read: Stop: Quarantine; Droplet/Contact Precautions; In addition to standard precautions Only essential personnel should enter this room. If you have questions, ask nursing staff. Everyone Must: including visitors, doctors, and staff. The surveyor then reviewed Centers for Disease Control (CDC) guidance provided by the facility on; How to safely remove PPE example 1 read: There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucus membranes with potentially infectious materials. Remove all PPE before exiting the patient room except a respirator, if worn. Under number 3: Gown read: *Gown front and sleeves as contaminated! *If your hands get contaminated during gown removal, immediately wash your hands or use an alcohol-based hand sanitizer. *Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. *Pull gown away from neck and shoulders, touching inside of gown only. *Turn gown inside out. *Fold or roll into a bundle and discard in waste container. How to safely remove PPE example 2 read under number 1: Gown and Gloves: *Gown front and sleeves and the outside of the gloves are considered contaminated! *If your hands get contaminated during gown or gloves removal, immediately wash your hands or use an alcohol-based hand sanitizer. *Grasp the gown in the front and pull away from your body so that the ties break, touching outside of gown only with gloves hands. *While removing the gown, fold or roll the gown inside-out into a bundle. *As you are removing the gown, peel off your gloves at the same time, only touching the inside of the gloves and gown with your bare hands. Place the gown and gloves into a waste container. On 11/23/2020 at 12:39 PM, the surveyor reviewed the facility form titled: Visitation Informed Consent that had been signed by the spouse of Resident #1 on 11/17/2020 and read: To reduce the risk of transmitting the infection we require that all visitors: *Complete the screening questionnaire and have your temperature taken. *Wash your hands often or use an alcohol-based hand sanitizer, and avoid touching your eyes, nose, and mouth with unwashed hands. *Avoid close contact with others by staying 6 feet apart from other people - especially other residents and caregivers. *Cover your mouth and nose with a mask or face cover at all times. *Cover your coughs and sneezes and wash your hands immediately after handling tissues. *Report any symptoms, including fever, cough, shortness of breath or taste/smell. At 2:39 PM, the surveyor reviewed the facility Policy and Procedure titled, Personal Protective Equipment - Contingency and Crisis Use of Isolation Gowns (COVID-19 Outbreak), dated April 2020 it read: General Procedure for Donning and Doffing Gowns 1. To put on gown: a. Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. b. Fasten in back of neck and waist. 2. To remove gown: a. Gown front and sleeves are contaminated. If your hands get contaminated during gown removal, immediately wash your hands or use an alcohol-based hand sanitizer. b. Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. c. Pull gown away from neck and shoulders, touching inside of gown only. d. Turn gown inside out. e. Fold or roll into a bundle and discard in a waste container. f. Perform hand hygiene immediately. The surveyor then reviewed the facility Policy and Procedure titled, Coronavirus Disease (COVID-19 - Visitors, revised July 2020 read: Policy Statement For the safety of residents and staff, visitation policies are in compliance with current recommendations from the Centers for Disease Control and Preventions and The Centers for Medicare and Medicaid Services. Under policy Interpretation and Implementation: 1. During a coronavirus outbreak, visitors are limited to certain [MEDICATION NAME] care situations, such as end of life. These situations are determined at the discretion of the facility and on a case-by-case basis. 2. The Infection Preventionist maintains a list of individuals who have permission to enter the facility as a visitor. This list is updated and made accessible on a daily basis. 3. Notices of visitation restrictions are posted outside the facility entrance. 4. Visitor entrances are staffed by personnel who have been trained on the current visitation policies and are qualified to conduct visitor screening. 5. Health screens are conducted on any potential visitor prior to being allowed in the building. Anyone showing signs or symptoms of respiratory infection or other signs/symptoms of possible COVID-19 infection or exposure are not allowed to enter the facility, regardless of the [MEDICATION NAME] care situation. 6. If visitation is permitted, strict adherence to infection precautions are required. Any visitors permitted in the facility are required to: a. Wear a facemask; b. Adhere to all infection precautions; c. Restrict their visit to a designated area of the facility; and d. Inform the facility if they develop a fever or symptoms consistent with COVID-19 within 14 days of visiting the facility. The facility did not provide evidence that they had screened Resident #1's spouse upon arrival to the Rehabilitation Unit, nor did the facility provide documentation that they reviewed the ALR screen completed on Resident #1's spouse on the day of the observation on11/20/2020. N.J.A.C. 8:39 19.4

Based on observation, interview and record review, it was determined that the facility failed to follow physician orders [REDACTED].#150); b.) during the wound care observation for 1 of 1 nurse observed; and c.) for applying positioning/pressure relieving boots for 1 of 1 resident reviewed for devices (Resident #49). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse (LPN) is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. During the initial tour on 08/13/19 at 8:00 PM, the surveyor observed Resident #150 sitting in a wheelchair wearing eyeglasses with eyes closed. Review of the Admission Record revealed Resident #150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ongoing care plan, initiated 05/02/19 and revised on 07/15/19, revealed a focus for [MEDICAL CONDITION] related [MEDICAL CONDITION](hypertension) with the intervention to Administer medication per physician orders. Review of the physician orders [REDACTED]. (The blood pressure is recorded as two numbers. The first number represents the systolic blood pressure (SBP) which indicates how much pressure your blood is exerting against your artery walls when the heart beats. The second number represents the diastolic blood pressure (DBP)which indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats.) Review of the Medication Administration Records (MAR) for the months of May, June, (MONTH) and (MONTH) of 2019 revealed the following: The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. On 08/15/19 at 1:13 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #150. LPN #1 stated that she would give the medication when the systolic blood pressure (the first number) was greater than 160. At that time, the Director of Nursing (DON) reviewed the order and stated that it is not how the doctor wants it, I don't believe. The DON further stated that usually the order is written for the systolic blood pressure. LPN #1 stated that usually it is for one or the other, systolic or diastolic. At that time, the DON called the physician. The DON placed the physician on speaker phone and he stated that the order should have been based on the systolic number. The DON stated that the order should be clarified. At that time, the surveyor interviewed the DON who stated that the pharmacy is the first to review a new order and the pharmacist will contact the facility with any questions or concerns to clarify the order with the physician. Then, monthly, the pharmacist consultant reviews the resident's medications and will recommend anything for the facility to follow up on and correct. Review of the monthly Consultant Pharmacist Review for Resident #150, dated 06/27/19 and 07/29/19, did not reveal any comments for the as needed [MEDICATION NAME]. On 8/16/19 at 9:31 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON confirmed that she wrote the [MEDICATION NAME] order with the blood pressure order parameters of 160/100. The ADON stated the physician wrote the order that way as he was monitoring the blood pressure and [MEDICAL CONDITION] of Resident #150. The ADON confirmed that she did not question the parameters because I see cardiologists write that way. The ADON stated that if she was the nurse administering the medication, she would only give the medication if the pressure was greater than the parameters of 160/100. Review of the the Physician/Practitioner Progress Note, dated 5/22/19, revealed Nurse reports continuous high BP readings sbp 170's-190's. The progress note further revealed the physician added [MEDICATION NAME] 10 mg every 12 hours prn (as needed) for blood pressure greater than 160/100. On 8/16/19 at 10:06 AM, the surveyor interviewed LPN #2 who administered the [MEDICATION NAME] on 05/25/19 to Resident #150 for a BP of 174/96. LPN #2 stated that the resident's blood pressure varies from time to time and the reason she gave the medication was because both numbers (the SBP and DBP) were over the normal range (normal blood pressure means systolic pressure is less than 120 and diastolic pressure is less than 80). LPN #2 stated, she wanted to prevent a stroke, [MEDICAL CONDITION] or something. 2. On 08/15/19 at 10:48 AM, the surveyor observed LPN #1 and LPN #2 at the treatment cart outside of Resident #2's room as they prepared to administer wound care to the resident. LPN #1 reviewed the treatment orders. She then asked LPN #2 to write the treatment orders on a sheet of paper for reference. On 08/15/19 at 11:26 AM, LPN #1 removed the dressing from Resident #2's sacral area (located at the base of the spine above the tail bone). At 11:29 AM, she removed a second dressing from a wound located above the sacrum in the area of the left buttock. On 08/15/19 at 11:37 AM, LPN #1 cleansed the wound located in the region of the left buttock with normal saline solution (NSS). At 11:41 AM, she cleansed the sacral wound with NSS. On 08/15/19 at 11:44 AM, LPN #1 used a cotton-tipped swab to pack silver alginate into the wound bed located at the left buttock, applied a 4 x 4 gauze dressing over the wound and covered the area with a foam dressing. On 08/15/19 at 11:49 AM, LPN #1 applied TheraHoney (promotes natural removal of damaged tissue) to the sacral wound. She used a cotton-tipped swab to pack silver alginate into the wound bed. LPN #1 placed a 4 x 4 gauze on top of the wound before she covered the area with a foam dressing. On 08/15/19 at 12:35 PM, the surveyor observed LPN #1 document in the Treatment Administration Record (TAR) that she provided wound care to Resident #2. LPN #1 first signed out the following order: TheraHoney Gel (Wound Dressings) Apply to Mid lower back topically every day shift for Excoriation. She then signed out the second treatment: Cleanse sacrum with NSS pat dry pack loosely with silver alginate, cover with comfort foam dressing prn (as needed) may substitute foam drsg (dressing) for super absorbent BID (twice daily) every day and evening shift for wound care. On 08/15/19 at 1:35 PM, the surveyor interviewed LPN #1, who stated that both orders that she charted as administered pertained to the sacral wound, as it was considered one wound. She further stated that she applied TheraHoney to the sacral (lower) portion of the wound and not to the wound bed located above the sacral wound at the left buttock. On 08/16/19 at 9:45 AM, the surveyor interviewed LPN #2 who stated that she did wound rounds and was responsible to communicate with the physician for wound treatment orders. LPN #2 indicated that she was familiar with Resident #2's wound care orders and treatments. The surveyor asked LPN #2 if TheraHoney was supposed to be applied to Resident #2's sacral wound? She stated, Not to my knowledge. No, it's supposed to be in the lower back. On 08/16/19 at 8:51 AM, the Clinical Resource Coordinator (CRC) stated that the Director of Nursing (DON) interviewed LPN #1 and provided a written summary of the wound care that was provided to Resident #2. The written summary documented that LPN #1 stated that she did two separate treatments to the same wound. According to the summary, LPN #1 further stated that she reviewed the treatment orders prior to wound care but confused the application. On 08/16/19 at 12:07 PM, the surveyor interviewed the CRC who stated that LPN #1 administered TheraHoney into Resident #2's sacral wound rather than to the mid low back as ordered. The CRC confirmed the sacral wound presents as two wounds but is considered one wound. The bridge between both wounds is a tunnel/flap. Review of the Visit Report for Resident #2, dated 08/13/19, revealed Multi Wound Chart Details and Assessment by the Advanced Nurse Practitioner (ANP). The document revealed that Resident #2 had a Stage 4 (full thickness with bone exposed) Pressure Injury at the sacral area that measured 12.4 x 4.2 x 0.8 (no unit of measurement provided). The treatment recommendations were: Sacral, Pack loosely with silver alginate and cover with bordered gauze BID (twice a day). The ANP documented a second wound located at the Inferior Back mid and the wound type was described as an abrasion (rubbing or scraping surface by friction) that measured 1.2 x 0.8 x 0.1 (no unit of measurement provided). The treatment recommendations were Inferior mid lower back: Apply [MEDICATION NAME] and cover with border gauze QD (daily). 3. On 08/13/19 at 7:30 PM, during the initial tour of the facility, the surveyor observed Resident #49 in bed. The resident was awake and alert, but non-verbal. At that time, the surveyor observed that the resident's feet were bare and resting directly on the sheets covering the mattress. On 08/13/19 at 7:52 PM, the surveyor reviewed the resident's medical record which revealed that the physician's August, 2019 Order Summary Report included an order, dated 7/24/19, for Prafo boots (positioning/pressure relieving boots) on both feet at all times, may remove for hygiene. The start date for this order was 07/25/19. On 08/13/19 at 8:17 PM, the surveyor observed Resident #49 in bed. The resident's feet were bare and exposed. There were no boots on his/her feet. On 08/14/19 at 9:19 AM, the surveyor observed Resident #49 sleeping in bed. The resident's feet were exposed and uncovered. There were no boots on the resident's feet. On 08/14/19 at 9:38 AM, the Certified Nursing Assistant (CNA) entered the room and began to provide morning care to Resident #49. On 08/14/19 at 10:30 AM, the surveyor observed Resident #49 out of bed to a chair next to the bed. The resident was wearing the positioning/pressure relieving boots at that time. On 08/14/19 at 1:23 PM, the surveyor initiated a telephone call to the resident's Guardian/Emergency Contact #1. The Guardian stated that she visited Resident #49 two to three times a week. She stated that when Resident #49 was in the hospital he/she wore booties on both feet while in bed. The Guardian described the devices as inflatable boots to release pressure on the legs. She said that the hospital removed the boots at the end of his/her stay. At this facility, she had seen Resident #49 in and out of bed. The Guardian stated that she did not notice that Resident #49 had worn any type of boots when she had visited. She stated that when she visited, the resident was wearing only socks. On 08/14/19 at 1:35 PM, the surveyor interviewed the CNA, who stated that Resident #49 wore the boots on a daily basis. The CNA stated that he did not know what the evening shift did about the boots. The CNA stated that he was going to put the resident to bed now and that Resident #49 wore pressure relieving boots in bed. On 08/16/19 at 8:46 AM, the CRC stated that the Director of Nursing will initiate in-services to ensure that staff apply boots according to the physician's orders [REDACTED]. NJAC 8:39- 27.1 (a)

Complaint #:NJ , NJ Based on interviews and review of the medical record and other facility documentation, it was determined that the facility failed to consistently assess, implement timely interventions, follow and/or obtain physician orders [REDACTED].#1, #2 and 4). Resident #1 was found to have a 0.5 x 0.5 broken skin area on the sacrum on 8/5/2013 and there was no indication that a physician was notified until 8/8/2013 when Resident #1 had developed 2 PUs; Right (R) buttock measuring 1.0 x 1.5 x 0.0 and Left (L) buttock measuring 0.5 x 1.0 x 0 and a treatment was ordered. Resident #2 was admitted with 3 PUs (2 vascular) and treatments were not implemented according to the physician orders. In addition, the sacral PU had no measurement on admission, but was assessed by nursing as Stage 2 PU. The Sacral PU was not assessed by the physician until 34 days later and was assessed as unstagable. This deficient practice is evidenced by the following; 1. According to the facility Face Sheet, Resident #1 was admitted to the facility in 7/2013 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 7/29/2013, indicated resident was alert, oriented and totally dependent on staff for activities of daily living (ADL). The "Interdisciplinary Plan of Care" (CP) for Actual Impaired Skin Integrity dated 7/29/2013, showed an alteration in skin integrity. Interventions included but was not limited to; treatment per doctor, reposition every two hours and as needed, observe wound for clinical signs of infection or wound deterioration, monitor and document wound condition every week and as needed, keep doctor and family updated, heel wedges bilaterally and off load heels. On 8/9/2013, a Stage 2 sacral PU was added to the CP. A Braden Scale, used for predicting PU risk, dated 7/19/2013 showed a score of "15" which indicated "low risk". On 8/3/2013 a Braden Scale noted a score of "14" which indicated "moderate risk". A "Resident Evaluation Form", an initial nursing assessment, dated 7/19/2013 indicated Resident #1 had vascular ulcers. A Skilled Daily Nurses Note (NN), dated 7/19/2013 at 11:00 PM confirmed the initial nursing assessment. A review of the admission physician orders [REDACTED]. A review of the 8/2013 PO showed; "Braden Scale on admission and weekly x 2" and a "weekly skin observation". A review of the 7/2013 and 8/2013 Treatment Administration Record (TAR) showed the "Braden Scale" was completed only twice (7/19/2013 and 8/3/2013) out of 4 opportunities and the weekly skin assessment was completed and signed for once (7/19/2013) out of 4 opportunities. A review of the 7/2013 and 8/2013 Treatment Administration Record (TAR) showed a PO initiated 7/20/2013 to "Reposition Q (every) 2 hours" and was scheduled to be signed/initialed by the licensed nurse for every shift. The 7/2013 TAR was not signed/initialed for 16 out of 36 opportunities. "Reposition Q 2 hrs" was not carried over to the 8/2013 TAR. During interviews with the surveyor on 8/16/2013 at 2 PM and 8/19/2013 at 11 AM 2 staff Registered Nurses (RN) confirmed that staff repositioned Resident #1 Q 2 hours. Review of an untimed NN, dated 8/5/2013 showed "complained of pain in sacrum 5/10 (pain rating) noticed #2 small skin breakdown, [MEDICATION NAME] applied, placed pillow under sacrum (with positive) results". There was no indication in the NN that a physician was notified. Faxed to the NJ Department of Health on 8/22/2013 was a Skin and Body Alert form dated 8/5/2013 at 2 AM for Resident #1 and an Incident Report (IR). The form noted a statement from the 11 PM-7 AM shift RN who documented she assessed the sacral area and found a 0.5 x 0.5 broken skin area. She noted that she called the physician and left a message and endorsed it to the next shift staff which the IR also confirmed. Review of the 8/2013 TAR and POS showed no reference to a sacrum treatment until 8/8/2013. Review of the NN showed no documentation that the physician was contacted from 8/5 until 8/8/2013 when a NN dated 8/8/2013 at 1:00 PM, showed, "Wound to sacral area dressing done, 2 wounds. Right buttock 1.0 x 1.5 x 0.0, L buttock (actually at base of coccyx) 0.5 x 1.0 x 0 [MEDICATION NAME] dressing applied. A POS, dated 8/8/2013 showed a physician's telephone order; "Santyl to sacral/buttock wounds and [MEDICATION NAME] dressing every 72 hours ". It was transcribed incorrectly to the 8/2013 TAR as "[MEDICATION NAME] dressing every 72 hours to the sacral/ buttock wounds" and did not include to use "Santyl". The TAR was signed/initialed as completed on 8/8/2013. Resident #1 was sent to the hospital on [DATE] with a change in mental status. Review of a hospital Emergency Admission assessment dated [DATE] showed Resident #1 was admitted with a Stage I sacrum PU and an unstagable sacrum PU. The surveyor requested "PU and Non PU Skin Condition Records" from the Director of Nursing (DON) and wound nurse. During an interview with the surveyor on 8/19/2013 at 11:00 AM and 11:55 AM, both the DON and wound nurse stated the records were completed but they were unable to locate a "PU and Non PU Skin Condition Record" for Resident #1's sacral ulcer. The Wound Nurse and DON confirmed that the "PU and Non PU Skin Condition Records" are initiated on admission or discovery of a new wound and completed weekly with measurements, location and description until healed. In a post survey telephone interview with the surveyor on 8/23/2013 at approximately at 12:30 PM, the primary RN for Resident #1 stated she was notified of the sacral wound on 8/5/2013 but forgot to follow up. She stated " I should have done it." In a post survey telephone interview with the surveyor on 8/23/2013 at approximately 12:15 PM and in an interview on 8/19/2013 at 11:55 AM, the DON stated that a physician should be notified of a new wound and treatments should be ordered and initiated. She confirmed that all treatments need a PO and all treatments should be signed/initialed as completed. 2. According to the facility face sheet, Resident #2 was admitted to the facility in January, 2013 with [DIAGNOSES REDACTED]. A MDS, dated [DATE] showed Resident #2 needed assistance with ADLs, was at risk for PU and had 3 "unstageable" PU. A "Resident Evaluation Form", an initial nursing assessment upon admitted d 1/2/2013, showed Resident #2 was admitted with; Bilateral (B/L) Sacral PU and Right(R) ankle and Left (L) Heel wounds. A Braden Scale, used to predict PU risk, dated 1/2/2013 showed Resident #2's score was "15"; a score of 15-18 represented "Low Risk". An admission "Skilled Daily Nurses Note" (NN) dated 1/2/2013 at 11:05 PM showed "pt. (patient) has Stage II to B/L sacral areas, allevyn dsg. (dressing) applied. Pt. has Stage III to R ankle, yellow slough present-santyl and dsg. applied. Stage II to L heel- [MEDICATION NAME] and dsg applied". A facility CP dated 1/2/2013 showed a problem related to (r/t) potential alteration in, skin integrity r/t hospital acquired unstageable PU due to presence of slough on wound bed (R lateral foot/ankle, R heel and L heel). Remains at risk to develop further skin breakdown due to (d/t) poor mobility status and incontinence of bowel and bladder. Goals included; having no new open areas of skin breakdown and no signs/symptoms of infection to existing PU. Interventions included but were not limited to; assess for risk factors that may lead to skin breakdown, encourage good nutrition/hydration, assess skin with care and let nurse or MD (physician) know of any concerns, treatments as ordered and assess everything that comes in contact with residents skin as a potential risk for pressure. There was no mention of the sacral PU in the CP.A physician "Admitting Evaluation/History" dated 1/3/2013 showed L heel, Stage II and Sacral Decubitius (PU). Resident #2 was followed by an Infectious Disease (ID) physician for weekly measurements and assessments for wound. "Doctors Progress Notes" (DPN) dated 1/8/2013, 1/22/2013 and 1/29/2013 from the ID physician showed measurements of the lower extremity vascular ulcers. There was no documentation r/t the sacral ulcer until the next ID physician consult on 2/5/2013. Measurements included Sacral Ulcer; 11 cm by 10.5 cm by 0.1 cm with 50% necrosis, unstageable with 50% necrosis and the plan noted Allevyn to sacrum BID (twice daily).Review of POS dated 1/2/2013, showed "Sacral area, clean with NSS (Normal Saline Solution) apply [MEDICATION NAME] dsg. Q (every) every 3 days until healed (to) B/L areas and Zinc Oxide to buttocks Q shift".Review of the 1/2013 TAR confirmed the 1/2/2013 orders to the sacral PU and the [MEDICATION NAME] dsg. was signed as completed on 1/2/2013 and blocked out to be completed on 1/5, 8, 11, 14, 17, 20, 23, 26 and 29/2013 but it was not initialed/signed as completed; but written through the areas to be initialed/signed was "see new order". Review of the POS [REDACTED]. treatment.On 1/8/2013, the POS showed an order for [REDACTED]. On 1/27/2013 the POS showed an order for [REDACTED]. The TAR confirmed the POS for Dermalevin but was not signed/initialed as completed for 1 of 2 opportunities from 1/27/2013 through 1/30/2013 and there was no indication on the back of the TAR as to why the treatment was not done on 1/30/2013.The 2/2013 POS did not carry over the 1/27/2013 PO for Dermalevin but the 2/2013 TAR showed "apply [MEDICATION NAME] to sacral area after cleansing with NSS and change every 3 days" order from the 1/2/2013 PO along with the [MEDICATION NAME] order. The [MEDICATION NAME] dsg was signed as administered on 2/2/2013. Review of the POS [REDACTED]. On 2/5/2013, the POS showed an order for [REDACTED]. The POS also noted "Turn and Reposition Q 2 hrs. nurse must document, make sure the CNA (certified nurses aide) is aware to turn and reposition the patient".The 2/2013 TAR confirmed the order for the Allevyn dressing and was signed/initialed as completed from 2/5 through 2/8/2013. The TAR confirmed the order for repositioning and was signed as completed every 2 hrs. from 2/5 through 2/8/2013. During an interview by the surveyor on 8/19/2013, at approximately 3:45 PM, the Administrator stated the Q 2 hr. documentation started because of a family concern. During interviews with the surveyor on 8/19/2013, at 3:10 PM and 3:20 PM, 2 staff CNAs confirmed residents are repositioned Q 2 hours. Review of the medical record from 1/2/2013 through 2/5/2013 showed no weekly assessment of the sacral PU. Review of a NN dated 1/31/2013 at 7:30 AM showed; "Uncooperative, Attempted to slide fr. (from) bed 2x (times) and developed Stage II (2) sacral ulcer- OOB (out of bed) to chair to dining hall". At 2 PM the NN showed; "sacral dressing done". No wound assessment was documented r/t the sacral ulcer. On 2/1/2013 the NN at 4:30 PM showed "wound care provided to sacrum...".The surveyor requested an Incident Report (IR) on 8/16 and 8/19/2013 from the DON and Administrator for the 1/31/2013 newly developed sacral PU documented in the NN on 1/31/2013 and both confirmed that they were unable to locate one. The DON stated that for any new PU, an IR is filled out and the physician and family are notified.Review of the medical record for Resident #2 showed no facility "PU Record" for the sacral ulcer which was noted upon admission and the additional sacral ulcer noted on 1/31/2013. The "PU Record" would include but not limited to; the wound location, weekly measurements and assessments. During an interview with the surveyor on 8/16 at 11:00 AM and 8/19/2013 at 11:55 AM, the DON stated she was unable to locate any PU Record r/t the sacral PU for Resident #2. The DON stated that the facility protocol is to assess a wound and document the findings including measurements in the NN and fill out the PU Record when the initial wound is noted or upon admission and continue assessments weekly until healed. She added that all treatments when stopped need a d/c (discontinue) order from the physician and all treatments completed were to be signed/initialed in the TAR. Review of a hospital Emergency Admission Record dated 2/9/2013 at 12 AM showed Resident #2 was admitted with a Stage 3 PU of the Sacrum.A faxed summary to the NJ Department of Health from the facility Administrator received on 8/22/2013 showed that an IR for the PU noted on 1/31/2013 was not indicated as the resident had the sacral PU upon admission and it was not developed in house. 3. According to the facility face sheet, Resident #4 was admitted to the facility in 2/2013 with [DIAGNOSES REDACTED]. An MDS dated [DATE] showed Resident #4 had moderate cognitive impairment and needed assistance with all ADLs and had one Stage 3 PU which was present on admission. A CP, dated 2/11/2013 showed Resident #4 had a PU located on the sacrum and interventions included but were not limited to; weekly PU healing assessment by wound team and wound care per facility protocol and/or specified by the physician. Review of NNs showed Resident #4 had been admitted to the hospital on [DATE] for debridement of the Sacral wound and returned on 5/21/2013 with a Stage 4 Sacral wound measuring 13 cm by 17 cm by 3 cm. A POS dated 5/21/2013 showed an order for [REDACTED]. Wound vac tu, Thurs. and Sat. (Tuesday Thursday, Saturday)" and to reposition every 2 hours. Review of the 5/2013 TAR confirmed the POS of 5/21/2013 and the sacral wound treatment was blocked out to be completed on 5/23, 5/25, 5/28 and 5/30/2013. The TAR was not signed as completed 2 times out of 4 opportunities (5/28 and 5/30/2013) and there was no indication on the back of the TAR as to why the treatment was not signed/initialed as completed. In addition the TAR showed the POS for repositioning and was to be initialed/signed as completed every shift for a total of 3 times daily. The TAR was not signed as completed for 11 out of 33 opportunities. Review of NN dated 5/30/2013 at 1 PM showed the sacral wound dressing was complete according to the POS however review of the NN for 5/28/2013 showed no documentation that the dressing was applied/changed. During a post survey telephone interview with the surveyor on 8/23/2013 at approximately 12:15 PM and on 8/29/2013 at 1:30 PM, the DON was unable to confirm if the dressing had been completed on 5/28/2013. She confirmed that physician orders [REDACTED]. The DON did confirm that she spoke with staff and confirmed that Resident #4 had been turned every 2 hours, but staff had forgotten to sign/initial the TAR.A facility policy titled "Skin Integrity Program: Evaluation and Documentation of Wounds", dated effective 4/1/2010 showed; Regular observations of PU and other wounds will be made by the licensed nurse and documented. Purpose: to accurately report observations to the primary care provider, guide treatments and track wound healing through the accurate observation and documentation of the size, type, location, appearance, characteristics and progress of wounds.Upon admission of a resident with a wound, or upon discovery of a new wound the following observations should be made and documented: Type and cause, location, measurements, stage, general appearance and signs of infection. The initial observation and ongoing progress of pressure related areas will be documented on the designated form for PU. Upon discovery of a new wound on an existing resident, and Incident and Accident report will be initiated.Weekly wound observations are conducted to track the progress (or lack of progress) with a comprehensive evaluation. When possible the weekly observation should be conducted by a consistent individual as wound measurements can vary based on individual techniques. Only one area may be evaluated and documented per form. Weekly documentation will include the date observed and location, measurements, appearance, evidence of healing or lack of progress. Lack of progress within 2-4 weeks deterioration of the wound at any time together with consideration of the overall clinical condition should prompt notification of the primary care provider for modification of current treatments, dressings or other interventions. NJAC: 8:39-27.1 (e)

Complaint #: NJ Based on observation, interviews and review of medical records and other facility documentation it was determined that the facility failed to provide a therapeutic diet according to physician's orders [REDACTED].#2 and #3) at risk for weight (wt.) loss. Resident #2 was assessed as at risk for wt. loss and had no history of wt. loss/gain, however in a 5 week period he gained and lost significant amounts every week. He was admitted on [DATE] with a weight of 171.6 pounds (lbs.) and on 2/8/2013 weighed 147 lbs. Resident #2 was discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. These deficient practices are evidenced by the following; 1. According to the facility Face Sheet, Resident #2 was admitted to the facility in 1/2/2013 with [DIAGNOSES REDACTED].A Minimum Data Set (MDS), dated [DATE] showed Resident #2 needed assistance with all activities of daily living (ADLs), including eating, was on a mechanically altered diet, had no history of weight loss or gain, weighed 172 lbs and height of 68 inches and was admitted with a Pressure Ulcer (PU).A "Resident Evaluation Form", an initial nursing assessment, dated 1/2/2013 showed Resident #2 weighed 171.6 lbs., was alert and confused and needed assistance with eating.A Care Plan (CP) for "Alteration in Nutrition Status", dated 1/6/2013 showed Resident #2 had the potential for wt. loss related to (r/t) "anabolic need and potential weight loss" evidenced by "meal rounds and PU (on the) heel/sacrum". Goals included but were not limited to; maintaining weight at 172 lbs. plus/minus 3%, PO intake greater or equal to 75% at meals and for the skin to heal. Interventions included but were not limited to; provide diet as ordered: regular soft diet and provide supplements as ordered: Hi-Cal with medication pass, 8 ounces (oz) NTL offered between meals, monitor weights as ordered and coordination of care/referral. A Nutritional Assessment, dated 1/6/2013, by the Registered Dietitian (RD) showed Resident #2 weighed 171.6 lbs. with a usual body weight of 172 plus/minus 2 lbs. and noted a weight in July/2012 of 180 lbs. during the previous admission. The "current weight status" was checked as "normal". The "Assessed Risk Level" was noted as "Moderate" and showed the resident needed 1:1 assistance with meals at times. The assessment confirmed goals and interventions noted in the CP for "Alteration in Nutrition Status". A Physician order [REDACTED]. A POS dated 1/8/2013 showed; Assist with meals, Hi-cal with medication pass, 120 milliliters (ml) TID (three times daily), 8 oz. NTL at 2 PM and 8 PM, and Health Shake with meals TID. A 1/2013 Treatment Administration Record (TAR) showed an order date of 1/2/2013 for "Weekly Weights" to be completed on the 7 AM-3 PM shift. The TAR showed the following weights;Admission Wt. 1/2/2013 171.6 lbTAR 1/7/2013 - 176.6 (5.6 lb increase or 3% wt. gain)TAR 1/14/2013 - 164.2 (12.4 lb decrease or 7% wt. loss)TAR 1/21/2013 - 168 (93.8 lb increase or 2% wt. gain) TAR 1/28/2013 - no weight documented RD notes 2/1/2013 - 154.8 (17 lb decrease or 11% wt. loss since 1/2/2013)RD notes 2/8/2012 - 147.6 (7.4 lb decrease or 5% wt. loss) The January and February/2013 TAR and the RD notes showed no re-weights. Review of "Nutritional Services Progress Notes" (NPN) by the RD and the CP showed no reassessment r/t wt. loss/gain after 1/7/2013 when a 3% wt. gain was noted or after 1/14/2013 when a 7% wt. loss was noted. On 2/1/2013, a NPN by the RD showed Resident #2 weighed 154.8 lbs., a 17 lb. wt. loss (11% wt. loss) in 30 days (since 1/2/2013). Review of the February TAR and Medication Administration Record (MAR) showed no documentation of Resident #2's wts. Review of the "Skilled Daily Nurses Notes" (NN) from 1/2/2013 through 2/11/2013 showed no reference to Resident #2's wt. loss. The NN on 1/7/2013 at 2:15 PM, 1/15 at 4:50 PM, 1/19 at 5 PM, 1/21 11 PM, 1/22 at 3:05 PM, 1/26 at 4:30 PM,1/27 at 1:30 PM and 2/3 (untimed) showed Resident #2's appetite was fair. On 1/20 at 1:30 PM, appetite was noted as good and on 2/5 appetite fair and consumed 50% of breakfast and lunch and supplemental drinks, 2/6 at 3 PM and 8 PM, poor appetite was documented. Review of the January and February, 2013 TAR from 1/2 through 2/8/2013, confirmed the following POs from 1/8/2013; - "Hi-Cal with medication pass 120 ML TID" (three times daily). Hi-Cal was not signed as administered on 7 out of 92 opportunities and was initialed/signed and circled which indicated refused for 5 of 92 opportunities; -"8 ounces of NTL to be given at 2 PM and 8 PM". The NTL was not signed as administered 9 out of 61 opportunities from 1/8 through 2/8/2013. -"Health Shake with meals TID", Health Shake was not signed as administered 8 out of 91 opportunities. In addition, there was no documentation on the TARs as to the amount of supplements, Health Shakes, Hi-Cal and NTL, consumed and no documentation on the back of the TARs as to why the supplement was not administered. The 2/1/2013 NPN by the RD showed that the "Magic cup (ice cream)" at lunch and dinner was 50% consumed, Hi-Cal with medication pass 120 cc was consumed 100%, Health Shake with meals TID was 50% consumed and noted a decrease in PO breakfast with lunch and dinner at 50% consumption. Recommendations included; a 3 day Calorie Count (CC), change diet to regular mechanical altered and the addition of a 2 PM Ensure pudding.A "Dietitian's Note to Physician" Sheet by the RD, dated 2/1/2013 for Resident #2 showed "Significant weight loss" and noted the following recommendations; a 3 day Calorie Count (CC), change diet to regular mechanical altered, 1:1 supervision at all meals and the addition of 2 PM Ensure pudding and a CMP (complete metabolic profile/blood test). The note was initialed by the physician. During an interview with the surveyor on 8/19/2013 at approximately 3:45 PM, the DON stated that the "Dietitian's Note to Physician" Sheet is usually put in the POS section of the medical record for the physician to review and when signed, the orders are to be initiated by the nursing staff. The "Dietitian's Note to Physician" Sheet was found in the "Dietitian's" section of the medical record and not in the POS section of the medical record. Review of the 2/2013 POS showed no orders for the above recommendations. During an interview with the surveyor on 8/16 at 2:20 PM and on 8/19/2013 at 3:30 PM, the RD stated that she was unaware of Resident #2's fluctuating wt. loss/gain prior to 2/1/2013. She stated that the staff at that time were not consistently writing down the weekly wts. on the MAR and the usual practice is to write the wts. on the MAR, however the staff mistakenly documented Resident #2's wts. on the TAR and she did not check the TAR. She added that she keeps track of all the weekly weights in her own notes and if a wt. is not listed she leaves a note for the staff to follow up; but she could not remember what happened during Resident #2's first month in the facility. She stated that she would have informed the physician and/or completed a "Dietitian's Note to Physician" r/t the wt. loss/gain prior to 2/1/2013 had she been aware. In addition, the RD stated that on 2/1/2013 when Resident #2's wt. was noted at 154 lb., a 17 lb. loss in 1 month, she wrote a "Dietitian's Note to Physician" Sheet with her recommendations. She stated that the usual procedure is for the nurse to notify the physician of the dietitian's recommendations and document it in the POS and/or the NN. The surveyor asked if the RD had noted the following week (2/7/2013) that her recommendations to change in diet to mechanically altered, add Ensure supplement and CMP had not been ordered by the physician. The RD stated she figured the physician had just not ordered them. The RD did state that the 3 day Calorie Count (CC) was done. Review of the 3 day CC sheet, dated 2/2/2013 through 2/4/2013 listed spaces for each meal to be documented which included; breakfast, snack, lunch, snack, dinner and snack. The CC on 2/2/2013 for breakfast showed that Resident #2 consumed 75% of juice, 50% of milk, 50% of cereal and 25% of eggs. Lunch and dinner was left blank. On 2/3/2013, breakfast showed "0%" consumed, lunch showed "15%" and dinner showed "15%". On 2/4/2013, breakfast showed "15%" consumed, lunch "20%" and dinner "20%". There was no documented breakdown of specific food items consumed on 2/3 and 2/4/2013. There was no indication that snacks were offered or consumed. Review of the January/2013 CNA "Resident Performance" Sheet showed "Monitor Meal Consumption Inform Nurse if Less than 25%" consumed. The sheet was not specific for each meal but was specific to a shift. It noted for the 7 AM-3 PM shift (which would include breakfast and lunch) and the 3 PM-11 PM shift (dinner),that out of 58 opportunities to document the percentage of food consumed at each meal, (from 1/2 through 1/31/2013) there was no percentage of food consumption documented 32 times. The "Resident Performance" Sheet showed Resident #1's food consumption ranged from 25% to 75% (25 times) and 100% (1 time) when documented. The February/2013 CNA "Resident Performance" Sheet showed out of 14 opportunities, meal consumption was not documented 7 times and Resident #2's food consumption ranged from 25% to 50%. From 2/2 through 2/4/2013 during the time the 3 day CC was being conducted, the "Resident Performance" Sheet showed on 2/2/2013 for the 7 AM-3 PM shift (breakfast and lunch) that there was no documentation of food consumed, the 3 PM-11 PM shift (dinner) showed 25% consumed, however the 2/2/2013 CC was blank for dinner. On 2/3/2013 the 7 AM-3 PM shift showed 25% which was different from the CC which showed 0% for breakfast and 15% for lunch. The 3 PM-11 PM shift showed 0% and the CC showed 15%. On 2/4/2013, the 7 AM-3 PM shift did not document a percentage consumed and the 3 PM-11 PM showed 50%, however the CC showed only 15% for breakfast, 20% for lunch and dinner. Review of the CNA "Resident Performance" Sheet from 1/2/2013 through 2/8/2013 showed Resident #2's meal consumption was documented at 25%-8 times, 50%-9 times, 75%-14 times and 100%-1 time.During an interview with the surveyor on 8/19/2013 at 3:30 PM, the surveyor asked the RD how the food intake percentages were calculated for the 3 day CC, why wasn't the food consumed itemized and why did the CC and the CNA documentation of food intake percentage differ. The RD stated that Resident #2 "was just not eating much and it would be hard to determine any percentage". She stated she did not know why the CNA "Resident Performance" sheet and CC differed for percentage of food consumed. Review of the RD's NPN dated 2/7/2013 showed the CC was less than 25% PO intake, current PO intake not meeting energy, protein or fluid needs. Recommendations included appetite stimulant,[MEDICATION NAME] (protein supplement) and [MEDICATION NAME] (medication used to improve wakefulness). Review of the "Dietitian's Note to Physician" dated 2/7/2013 showed the above recommendations and included; "(decreased) PO intake (less than) 20% meals, refusing supplements-HiCal ...wt loss. Review of the POS dated 2/7/2013 showed a telephone physician order [REDACTED]. A NPN dated 2/8/2013 showed Resident #2's wt. at 147.6 lbs., a 7.4 lb. wt. loss in 1 week, and noted the [MEDICATION NAME] were initiated, however review of the 2/2013 MAR showed the [MEDICATION NAME] were not signed/initialed as given on 2/7/2013. During interviews with the surveyor on 8/16/2013 at 11:55 AM and 8/19/2013 at 3:30 PM, the Director of Nursing (DON) stated that she was not the DON at the facility in January and February/2013, but the policy for notifying the physician of a 3 lb. or more wt. loss/gain was the same then as now. She further stated that she was unsure of why the CNA "Resident Performance" Sheet did not break down percentage consumption specific to each meal item, and confirmed that all medications/supplements should be signed/initialed after they are given and if they are not given/refused, a note is written by the nurse on the back of the MAR/TAR describing the reason. During an interview with the surveyor on 8/19/2013 at 1:30 PM, a unit day shift staff Registered Nurse (RN #1) stated that the usual procedure for weighing residents is that a CNA will obtain the wts., the nurse then documents the wt. in the MAR. If there is a significant change of more than 2 lbs., "we would talk to the Doctor, then document it in the notes". She added that the RN or the Charge RN would follow up with the RD recommendations and call the physician to communicate the recommendations and write the orders on the POS. She stated that if the "Dietitian's Note to Physician" was signed/initialed by the physician then that would be considered an order. During an interview with the surveyor on 8/16/2013 at approximately 3:30 PM, the Assistant Director of Nursing (ADON) who was the acting DON during the time period of January and February/2013, stated that the weekly weights were to be documented on the MAR, not the TAR, checked by the nurse or RD weekly and any wt. change of 3 lb or more was to be communicated to the physician and documented in the medical record. She stated that if a weight was not on the MAR, it was the responsibility of the staff nurse to find out why. She added that the nurse is responsible for calling/notifying the physician of the RD's recommendations and documenting it in the medical record. During an interview with the surveyor on 8/16/2013 at 4:45 PM, the Administrator stated that she had reviewed Resident 2's medical record a few months ago and "We identified the problem of no documentation of weekly weights on the MAR ...Now we check every week, the CNAs were inserviced..." 2. According to the facility Face Sheet, Resident #3 was admitted to the facility in 8/2013 with [DIAGNOSES REDACTED].An MDS, dated [DATE] showed Resident #3 was cognitively impaired and needed total assistance with ADLs, including eating. The MDS showed Resident #3 was admitted with a Stage 4 PU and was on a Mechanically Altered Diet. An Interdisciplinary Care Plan (CP) for "Alteration in Nutrition Status" started 8/5/2013, showed Resident #3 had the potential for wt. loss related to (r/t) "anabolic and difficulty chewing" and evidenced by "meal rounds and a Stage 4 PU". Goals included but were not limited to; maintaining wt. at/or equal to 111 lbs plus/minus, no less than 5%, PO (by mouth) intake greater/equal to 65% at meals and supplement intake greater/equal to 75-100%. Interventions included but were not limited to; provide diet as ordered: regular soft diet and provide supplements as ordered: fortified food, house supplement with meal and monitor PO intake at meal rounds.An undated Certified Nurses Aide (CNA) CP showed Resident #1 was on a "LF/LC" (low fat/low cholesterol) diet and was totally dependent on staff to be fed.A Physician order [REDACTED].During a meal observation by the surveyor on 8/16/2013 at 12:15 PM, Resident #3 was observed seated in the the Dining Room being assisted with eating by a Certified Nurses Aide (CNA #1). Her lunch meal consisted of rice, mixed vegetables, fish and a 4 ounce house supplement. On the table was her meal ticket which noted the diet as "Soft, No Restriction" with a "Special Request - Supermashed". During an interview with the surveyor on 8/16/2013 at 12:30 PM, the facility Dietary Manager stated that "Supermashed" meant fortified mashed potatoes. The Dietary Manager stated that Resident #3 should have had "fortified mashed potatoes" on the meal plate instead of the rice. He stated that it is the responsibility of the CNA to make sure that the resident gets the meal the physician ordered. During an interview with the surveyor at approximately 12:20 PM, CNA #1 stated that he did not place the meal in front of the resident as it was served by the dietary staff and he did not review the meal ticket.Review of Resident #3's weights showed no weight loss since admission 8/2/2013. A "Resident Performance" Sheet is completed by CNAs and included documentation of the percentage of meals consumed. The 8/2013 "Resident Performance" sheet showed "Monitor Meal Consumption Inform Nurse if Less than 25%". The Sheet was not specific for each meal but was specific to a shift. It noted, for the 7 AM-3 PM shift (which would include breakfast and lunch) and the 3 PM-11 PM shift (dinner), that out of 27 opportunities, there was no percentage of food consumption documented 4 times. The "Resident Performance" Sheet showed Resident #1's food consumption ranged from 25% to 100%. Review of the CNA "Resident Performance" Sheet from 8/2/2013 and 8/15/2013 showed Resident #3's meal consumption was documented at 25%-9 times, 50%-9 times, 75%-2 times and 100%-1 time. A facility policy titled "Meal Service" showed "Basic Responsibility: Licensed Nurse and Nursing Assistant". It included but was not limited to; to assure that each resident receives the correct diet in conformance with physician's orders [REDACTED]. Nursing Services will distribute food trays to residents in resident room, dining rooms and ancillary dining rooms in a timely manner. "Procedure": Assure accuracy of diet served to each resident. Take note of the percentage of food consumed.A facility policy titled " Nursing Assistant(CNA) Duties, general Guidelines ... " ; Make sure the food percentage ...records are completed before going off duty. A facility policy titled "Job Description-Dietitian" showed The dietitian is responsible for the nutritional oversight of all residents within the facility in accordance with federal, state and local standards. Responsibilities included but were not limited to; Review of weekly weights of all residents as applicable; must complete reassessment and CP revision on all residents that display a significant weight change of greater than or equal to 3% in one week.A facility policy titled "Weight Monitoring" and dated 1/2009 showed; "Purpose: to ensure that each resident receives appropriate nutrition to maintain a healthy body weight...Process: Residents are weighed upon admission and weekly for four weeks and then monthly...Nursing should communicate any discrepancies in weekly weights of 3 pounds or more once verified by reweigh. It is the responsibility of the RD to review the monthly weights.NJAC 8:39-27.1 (d)