Every finding on record at Cedar Grove Respiratory and Nursing Center

During rounds on 05/15/2025 at 09:39 AM survey #2 observed the wardrobe door in room [ROOM NUMBER]-unit B peeling off with sharp edges. During an interview on 05/20/2025 at 09:25 AM with surveyor #2, the Acting Maintenance Director (AMD) said they inspect random rooms weekly. The AMD said that when they see furniture in need of repair, they order replacement furniture it can sometimes take two weeks to a month to be replaced. When asked if there should be peeling furniture in residents' rooms, the AMD said no it can be a dignity and safety issue. During an interview with surveyor #2 Licensed Nursing Home Administrator (LHNA) said that there should not be any broken or peeling furniture in residents' rooms and that they are working on replacing all furniture that is not in good repair to provide a homelike environment. A review of an undated facility provided policy tilted Homelike Environment revealed, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. N.J.A.C. 8:39-31.4(a) Complaint # NJ00176427 Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 2 of 4 units (B and C units). This deficient practice was evidenced by the following: On 05/13/2025 at 10:01 AM during initial tour, Surveyor #1 observed that in bedroom [ROOM NUMBER]B, the wall mounting was broken off, with pieces of jagged wood exposed. In addition, there was brown debris on both the floor and the wall near the dresser. On 05/13/2025 at 11:05 AM during initial tour, Surveyor #1 observed that in bedroom [ROOM NUMBER]A, the wall mounting was broken off from the wall, with pieces of jagged wood exposed. On 05/14/2025 at 8:19 AM, Surveyor #1 observed that the closet in bedroom [ROOM NUMBER]B was missing a drawer front. On 05/14/2025 at 12:36 AM, Surveyor #1 observed that in bedroom [ROOM NUMBER]B, the wall mounting was broken off, with pieces of jagged wood exposed. In addition, there was brown debris on both the floor and the wall near the dresser. On 05/15/2025 at 9:36 AM, Surveyor #1 observed that in bedroom [ROOM NUMBER]B, the wall mounting was broken off, with pieces of jagged wood exposed. In addition, there was brown debris on both the floor and the wall near the dresser. During an interview with Surveyor #1 on 05/19/2025 at 12:31 PM, the Licensed Nursing Home Administrator (LNHA) said that the broken wall mountings, exposed jagged wood, brown debris on the floor and wall, and missing drawer front are not appropriate and do not reflect a home-like environment. During an interview with Surveyor #1 on 05/20/2025 at 9:25 AM, the Acting Maintenance Director (AMD) said that the broken items are documented in the facility's electronic maintenance system, and he receives alerts on his phone through the system. He conducts weekly rounds in resident rooms and responds as needed when issues arise. Facility staff notify him when something requires repair. He emphasized that the facility should not have broken furniture, it does not look appealing. A review of the undated facility policy, titled, Homelike Environment, revealed, The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Those characteristics includes a.) clean, sanitary, and orderly environment. N.J.A.C. 8:39-31.3(a)

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to administer Tube Feedings per Physician's order (PO). This deficient practice was identified for 1 of 5 residents (Resident #82) reviewed for receiving nutrition via Tube Feeding (TF) and was evidenced by the following: On 05/14/2025 09:08 AM, the surveyor entered Resident # 82's room and observed the resident in bed. The surveyor observed that the resident had a TF (nutrition received through a flexible tube surgically inserted into the stomach) formula hanging on a pole, attached to a TF pump, and infusing at a rate of 55 ml/hr (milliliters per hour). On 05/14/2025 at 1:04 PM, the surveyor observed Resident #82 in the bed. The surveyor further observed a TF connected to a TF pump and infusing at a rate of 55 ml/hr. The surveyor reviewed the medical record for Resident #82. According to the admission Record the resident was admitted to facility with diagnoses which included but were not limited to: dysphagia (a swallowing disorder) and gastrostomy status (a surgical procedure used to insert a flexible tube, often referred to as a G-tube, through the abdomen and into the stomach, in which they receive nutrition). According to the most recent Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/11/2025, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was severely cognitively impaired. A review of the 05/12/2025 nutrition note reflected a recommendation to adjust the TF related to high blood sugar. TF recommendation Glucerna 1.5 at 60ml/hr. The Order Summary Report revealed a PO dated 05/12/2025 for the following: Resident on enteral feeding of (Glucerna 1.5) via pump at the rate of (60ml/hr to start at (1800) and down at (1400) or until the completion of total volume (1200ml). The above PO for Glucerna via pump was transcribed to the May 2025 electronic Medication Administration Record (eMAR) indicated that Resident #82 had received TF at 60 ml/hr and was signed by the nurses. A review of the Care Plan a document that summarizes a person's health condition, specific care needs and health condition) included a focus for: I have a nutritional problem. Interventions included to Provide and serve diet as ordered. NPO; Glucerna 1.5 @ 60ml/hr total volume 1200ml. On 05/15/2025 at 01:44 PM, when the surveyor informed the nurse manager that Resident #82's TF was at 55ml/hr when the 5/12/25 PO was for 60ml/hr she stated that it was not acceptable and that she will investigate the discrepancy. A review of the facility provided Enteral Tube Feeding policy, with a revision dated of November 2018, reflected to check the enteral nutrition label against the order before administration. Check the following information: g. rate of administration. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 2 nurses administer medications for 6 residents with 33 opportunities for error. There were 3 errors resulting in an error rate of 9% as evidenced by the following: During the medication pass on 05/14/2025 from 8:00 AM until 8:55 AM, the surveyor observed the following: At 8:43 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer a Cholecalciferol (Vitamin D3) 1000 unit capsule to Resident #72. The LPN stated she is giving a capsule not a tablet. The Physician Order (PO) dated 08/31/2023 indicated to give a Cholecalciferol 1000 unit tablet; not a capsule. At 8:45 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer a Cholecalciferol (Vitamin D3) 25 micrograms capsule to Resident #45. The Physician Order (PO) dated 02/15/2024 indicated to give a Cholecalciferol 25 micrograms tablet; not a capsule. At 8:55 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer a Cholecalciferol (Vitamin D3) 1000 unit capsule to Resident #146. The Physician Order (PO) dated 03/26/2025 indicated to give a Cholecalciferol 1000 unit tablet; not a capsule. At that time the surveyor stated the order reflected to give a tablet. The LPN responded, Yes, I know. When interviewed on 05/14/2025 at 11:09 AM, the LPN acknowledged that she gave a Cholecalciferol capsule when the order is for a tablet to Resident #72, #45, and #146. The LPN said there were no Cholecalciferol tablets available. She furthered that she should have called the doctor and had the order changed to Cholecalciferol capsules. When interviewed on 05/14/25 at 11:09 AM, the Assistant Director of Nursing said if the order for Cholecalciferol was a tablet, then give a tablet. If not available, then call the doctor and have them change the order to what is available. A review of the facility provided policy, Administering Medications, with a revision date of April 2019 reflected 4. Medications are administered in accordance with prescriber orders, including any required time frame and 10. The individual administering medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. NJAC 8:39-29.2(d)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that a medication was secured in a locked compartment accessible only to authorized personnel with a key. This deficient practice was identified for 1 of 4 units (C unit). This deficient practice was evidenced by the following: On 05/14/2025 at 12:40 PM, the surveyor observed an opened 4% Lidocaine patch (pain-relief patch) on top of the dresser in room [ROOM NUMBER]A. During an interview with the surveyor on 05/19/2025 at 12:45 PM, the Director of Nursing said that the patch should not have been left on the resident's dresser and stored in a locked medication cart for safety reasons. A review of the facility's undated policy, titled, Medication Labeling and Storage, revealed that, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light control. Only authorized personnel have access to keys. NJAC 8:39-29.2(d)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility A.) failed to use appropriate infection control practices, specifically hand hygiene when providing wound care and B.) failed to implement infection control measures for the handling and storage of respiratory equipment. The deficient practice was identified for 1 of 3 residents (Resident # 110) reviewed for Pressure Ulcer/Injury and 1 of 3 residents (Residents #9) reviewed for respiratory care. The deficient practice was evidenced by the following: A review of Resident # 110's Minimum Data Set (an assessment tool) revealed under section M that he/she had a pressure ulcer. A review of Resident # 110's Electronic Medical Record (EMR) under Orders revealed an order that revealed, Acetic Acid Irrigation Solution 0.25 % (Acetic Acid): Use 1 application via irrigation every day shift for Wound Care Cleanse sacrum with Acetic Acid 0.25% Solution and pat dry. Pack with Acetic Acid 0.25% gauze and cover with foam dressing daily and PRN [as needed] for accidental removal/soilage. AND Use 1 application via irrigation as needed for Wound Care Cleanse sacrum with Acetic Acid 0.25% Solution and pat dry. Pack with Acetic Acid 0.25% gauze and cover with foam dressing daily and PRN for accidental removal/soilage. A review of Resident # 110's Care Plan located in the EMR revealed a focus for, I have actual skin breakdown r/t [related to] sacrum wound. The Care Plan focus was initiated on 2/26/2025. On 5/14/2025 at 10:59 AM, after obtaining permission from Resident # 110, the surveyor observed wound care being administered by Licensed Practical Nurse (LPN) # 1. Once LPN # 1 set up the area and applied non-sterile disposable gloves, she removed a used incontinence brief from the mattress area into a plastic bag for disposal. At that time, LPN # 1 removed the gloves and applied a new pair of non-sterile disposable gloves. LPN # 1 did not complete hand hygiene between changing gloves. After irrigating the wound, LPN # 1 used her finger which was covered by a non-sterile disposable glove to depress the saturated gauze into the wound. LPN # 1 then applied a clean, dry dressing over the wound area. LPN # 1 did not change gloves between applying the moistened gauze in the wound and the clean, dry dressing. At approximately 11:20 AM on the same date, LPN # 1 removed the non-sterile, disposable gloves and applied a new pair. She did not complete hand hygiene in between changing gloves. At that time, she then placed the used supplies into a plastic trash bag. On the same date at 11:28 AM during an interview with the surveyor, LPN # 1 replied, Yes when the surveyor asked when changing gloves, should hand hygiene be performed. During the same interview, LPN # 1 replied, Yes when the surveyor asked when adding the gauze to the wound, should you have used a sterile applicator instead of using your finger to depress the dressing into the wound. It should be noted, two, sterile, cotton-tipped applicators were observed on top of the treatment cart during the wound care. They were never brought into the room. On 5/14/2025 at 11:48 AM during an interview with the surveyor, the Infection Preventionist replied, Yes when asked if LPN # 1 should have performed hand hygiene in between glove changes. A review of the facility provided policy titled, Wound Care revealed a revision date of October 2010. Under the section titled, Steps in the Procedure the policy revealed, Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. A review of the facility policy titled, Handwashing/Hand hygiene with a revised date of October 2023, revealed under the section titled, Indications for Hand Hygiene that hand hygiene is indicated, g. immediately after glove removal. N.J.A.C. § 8:39-19.4 (a) B.) On 05/13/2025 at 10:26 AM during the initial tour, surveyor #2 observed Resident #9 in bed in his/her room with the nebulizer mask (a medical device that converts liquid medication into a fine mist that can be inhaled through the lungs) on the bed side table exposed to the air. Surveyor # 2 also observed Resident # 9's continuous positive airway pressure (C-PAP; a machine that uses mild air pressure to keep breathing airways open while you sleep) nose piece exposed to the air and on the floor. On 05/15/2025 at 09:09 AM during rounds surveyor #2 observed Resident # 9's C-PAP nose piece exposed to the air and on the floor. A review of Resident # 9's admissions record revealed that, Resident # 9 was admitted with but not limited to Heart Failure, Asthma (a long-term inflammatory disease in the lungs), Chronic Pulmonary Edema (a buildup of fluid in the lungs), and Obstructive Sleep Apnea (a sleep disorder that causes repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing. A review of Resident #9's admission Minimum Data Set (MDS) dated [DATE] revealed under section O that the resident uses a non-invasive mechanical ventilator. (a respiratory method that delivers positive airway pressure without an invasive artificial airway) A review of Resident #9's Electronical Medical Record revealed a physician's order with a start date of 07/10/2024 for C-PAP on for naps and bedtime, as well as a physician's order with a start of 03/06/2025 to keep respiratory tubing/Neb kit: in a bag when not in use. During an interview on 05/19/2025 at 10:00 AM with surveyor #2 the Infection Preventionist (IP), said that all respiratory equipment should be kept in a bag when not in use for cleanliness and to keep them off the floor. During an interview on 05/19/2025 at 10:33 AM with surveyor #2 the B unit, Unit Manger Register Nurse (UMRN), said that respiratory equipment should be kept in a bag at the bed side when not use to prevent contamination. During an interview on 05/19/2025 at 12:46 PM with surveyor #2, the Director of Nursing (DON) said the nebulizer masks and C-PAP mask should be kept in a plastic bag when not in use for infection control. A review of a facility provided policy titled Administering Medication Through a Small Volume Nebulizer, revealed under section, Steps in the Procedure that, 29. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. 8:39-19.4 (k)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that the resident call system was maintained in an operable condition. This deficient practice was identified on 1 of 4 units (C unit). This deficient practice was evidenced by the following: On 05/13/2025 at 10:01 AM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. On 05/14/2025 at 12:26 PM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. On 05/15/2025 at 9:36 AM, the surveyor observed that in bedroom [ROOM NUMBER]B, the call bell device cord was detached from the wall system. During an interview with the surveyor on 05/19/2025 at 12:45 PM, the Director of Nursing said that the call bell cords need to be securely attached to the wall system for safety reasons. A review of the facility's undated policy, titled, Call System, Residents, revealed that, The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. NJAC 8:39-31.8(c)9

NJ 167523 Based on interview, record review, and policy review, the facility failed to protect the resident's right to be free from physicial abuse by another resident for one (Resident (R) 19) of nine residents reviewed for abuse. R23 approached R19, while the resident was in her bathroom and hit R19's back, neck, and shoulders. R19 sustained pain and fear during the altercation. Finding include: Review of a policy provided by the facility titled Abuse, Neglect and Exploitation, dated July 2023 indicated .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . 'Abuse' means the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . 1. Review of R19's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted initially to the facility on [DATE]. Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/23 indicated R19 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated R19 required extensive assistance of one staff member for bed mobility and for transfers. Review of R19's EMR titled SBAR [Situation, Background, Assessment, and Recommendation] Progress Notes, located under the Prog [Progress] Note tab and dated 09/17/23, indicated R19 was approached by R23 when R19 was in her wheelchair and in her bathroom and had a physical confrontation. The SBAR indicated R19 had pain after the incident. The physician and the responsible party were notified of the resident-to-resident incident. Review of R19's EMR titled Care Plan located under the Care Plan tab dated 11/29/23 indicated the resident was at risk for misappropriation, neglect, and/or abuse. The goal was not to experience any form of abuse. During an interview on 12/05/23 at 12:46 PM, R19 stated she did not remember the name of the resident she had an altercation with, but stated she was fearful, and pain was caused at the time of the incident. R19 stated she was in the bathroom and the resident came into the bathroom and began to hit her. R19 stated she yelled out and staff came in to separate the resident from her. The resident stated she was not currently afraid and had not seen the other resident again. 2. Review of R23's EMR titled admission Record located under the Profile tab indicated R23 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia with other behavioral disturbances. Review of R23's EMR titled Care Plan located under the Care Plan dated 09/01/23 indicated the resident had impaired cognitive function. Review of R23's EMR titled admission MDS with an ARD date of 09/08/23 revealed a BIMS score of five out of 15 which revealed R23 was severely cognitively impaired. The assessment indicated R23 had no behaviors which affected others. The assessment indicated R23 was ambulatory. Review of R23's EMR titled SBAR Progress Notes, located under the Prog Note tab and dated 09/17/23, indicated R23 was . physically aggressive towards another resident . Prior to this incident, R23 would wander about the facility and was easily redirectable by staff. An attempt was made to interview R23, the resident was not interviewable. Review of a document provided by the facility titled Investigational Summary, dated 09/17/23, indicated the Long-Term Care Ombudsman was notified of the resident-to-resident which involved R23 and R19. According to the report, both residents were separated and a Stop sign was posted across the doorway of R19's room to prevent R23 from entering. The investigative report indicated both residents did not sustain injury from the incident. The report revealed the physician was notified and ordered laboratory blood values and urinalysis for both residents. In addition, mental health services were ordered for each resident. The report indicated the facility could not substantiate the allegation of abuse. The investigation was completed by the Director of Nursing (DON). During an interview on 12/05/23 at 1:57 PM, the former Social Services Assistant (SSA1) stated when she worked at the facility, she would receive information on allegations of abuse from nursing so she could follow up with the resident. SSA1 stated her definition of abuse was anything that might be harmful to the resident. SSA1 was asked if R19 was abused by R23, and she stated more than likely R19 was abused by R23. SSA1 stated R23 was not in her right mind, and R19 stated she was hurt but there were no injuries. During an interview on 12/06/23 at 4:34 PM, the DON confirmed she investigated the incident between R19 and R23. NJAC 8:39-4.1 a (5)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 05/03/2023 from 08:32 to 09:04 AM, the surveyor, accompanied by the Dietary Director (DD), observed the following in the kitchen: 1. On an upper shelf under the refrigeration unit of the walk-in refrigerator, an opened box contained individual packets of [NAME] Sour Cream. The packets had a use by date of [DATE]. The DD removed the box of individual sour cream packets to the trash. 2. On a lower shelf of the walk-in refrigerator, a sheet pan contained a package of ground beef pulled from the freezer to defrost. The ground beef had a pull date of 4/27/23 and a use by date of 5/2/2023, a period of 6 days. The DD stated, Its garbage, we should only go 5 days after pull from freezer. On 5/09/2023 at 12:16 PM the surveyor observed a dietary aide (DA) exit the kitchen door pushing a food cart to be delivered for the lunch meal. The DA had her hair in lengthy braids. The DA was not wearing a hair net and her hair was exposed. On interview the DD agreed that the DA was not wearing a hair net, and her hair was exposed in the kitchen. A review of the facility policy titled Dining Services Policy and Procedure 2G: Standards for Dry Storage. The following was revealed under the heading INSTRUCTIONS: 7. Don't keep or use food beyond the expiration or use by dates. A review of the facility policy titled Dining Services Policy and Procedure 2F FIFO (First in, First out), undated, revealed the following under the heading INSTRUCTIONS: 3. Individuals receiving goods will arrange them in dry storage, coolers, and freezers with new items behind old items to ensure that older items are used first. (First In, First Out inventory rotation). 4. The individuals who remove products from storage will use the older stock first. The following was revealed under the heading MONITORING: 1. A direct supervisor will monitor that all foodservice employees are adhering to the above stated employee policy during all hours of operation. N.J.A.C. 18;39-17.2(g)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 1 of 1 resident (Resident #423) investigated under the Environment Task. On 05/03/2023 at 09:40 AM, during the initial tour of the facility, the surveyor observed Resident #423 asleep in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On 05/11/2023 at 09:56 AM, the surveyor observed Resident #423 awake in bed. At that time, the surveyor observed the handheld call system on the floor adjacent to the bed. On the same date at 10:00 AM, during an interview with the surveyor, Resident #423 said the handheld call system is on the floor sometimes and makes it difficult to get care. He/She stated that he/she leaves the door open so the staff can hear him/her. A review of Resident #423's Care Plan located in the Electronic Medical Record, revealed that he/she is at risk for falls. The Care Plan revealed an intervention to, Place call bell within reach. On 05/17/2023 at 01:01 PM, during an interview with the surveyor, the Director of Nursing (DON) replied, Within reach, on their bed if they are on their bed. when asked where should a handheld call system be placed within the resident's room. The DON confirmed that the handheld call system should not be on the floor and that staff should put it back if it is inadvertently placed on the floor. A review of the facility policy titled, Call System, Resident dated September 2022 revealed under Policy Interpretation and Implementation number 1., Each resident is provided with a means to call staff directly for assistance from his/her bed . N.J.A.C. S 8:39-31.8

Based on observation and interview it was determined that the facility failed to create a homelike environment during dining by not removing food from serving trays. The deficient practice was observed in the facility's main dining room and was evidenced by the following: 1. On 05/03/2023 at 12:06 PM, the surveyor observed the main dining room at the lunch meal. 8 residents were present at various tables. 8 of 8 residents were observed to be eating their lunch meal from a plastic tray. 2. On 05/08/2023 at 12:06 PM, the surveyor observed the main dining room at the lunch meal. 11 of 11 residents present in the dining room were observed eating their lunch meal from a plastic tray. The facility did not provide a policy or procedure for dining pertaining to not serving residents on trays in the dining room. N.J.A.C. 8:39-4.1(a)(12)

Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to contain oxygen/nebulizer delivery systems in a manner to prevent the spread of infection for 1 of 6 residents (Resident #120) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/03/2023 at 09:59 AM, during the initial tour of the facility, the surveyor observed Resident #120 lying in bed while receiving oxygen via nasal cannula. Resident #120 stated that he/she wore received oxygen continuously. On 05/09/2023 at 08:40 AM, Resident #120 was observed sitting up in bed eating breakfast. The nebulizer mask was in the top drawer of the opened bedside table. The mask was uncovered and exposed. Portable oxygen was observed to be in a back pocket of the resident's wheelchair. The oxygen tubing was hanging from the push handle and was exposed while not in use. On 05/09/2023 at 01:57 PM Resident #120 was observed seated in their wheelchair in their room. The nebulizer mask was observed in the top drawer of the bedside table with the drawer open. The mask was not in use and was uncovered and exposed. On 05/10/2023 at 09:17 AM Resident #120 was observed in bed with oxygen via nasal cannula (n/c). The nebulizer mask was hanging from the bed and suspended above the floor. The mask was uncovered and exposed. According to the Admission Record, Resident #120 was admitted to the facility with diagnoses including but not limited to: dyspnea (shortness of breath), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen, and encounter for palliative care (comfort care). A review of the quarterly Minimum Data Set Resident Assessment Instrument (MDS), an assessment tool, Resident #120 had a Brief Interview for Mental Status score of 12/15, indicating moderate cognitive impairment. According to section G of the MDS Resident #120 required extensive assistance with most activities of daily living. Section I of the MDS revealed that Resident #120 had active diagnoses of chronic obstructive pulmonary disease. Section O of the MDS revealed that Resident #120 received oxygen therapy. A review of the Order Summary Report, dated 05/17/2023, revealed the following physician orders: AHC: Oxygen Tubing Storage: keep tubing in bag when not in use for infection control, order date 05/23/2022. O2 (oxygen) 2L (liters) via nasal cannula (a device used to deliver supplemental oxygen) every day and night shift for copd, order date 01/16/2022. DuoNeb Solution 0.5-2.5 (3) MG/3ML (milligram/milliliter) 3 ml inhale every 8 hours for COPD, order date 07/20/2022. A review of Resident #120's comprehensive care plan revealed a care plan Focus of: I have alteration in respiratory status, and I am on Chronic O2 r/t (related to) COPD. Interventions include: give nebulizer treatments as ordered. According to the Medication Administration Record, dated 05/01/2023-05/31/2023, Resident #120 received Duoneb Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3cc (cubic centimeters) inhale orally every 8 hours for COPD on the following dates and times: 5/1/2023 up to 5/17/2023 at 0600, 1400, and 2200. According to the Treatment Administration Record, dated 5/1/2023-5/31/2023, Resident #120 had the following treatment completed for day and night 5/1/2023 up to 5/16/2023: Respiratory Tubing/Neb Kit: Keep in bag when not in use. Labeled with name and room #. Change as needed every shift for infection control. Start date 08/23/2022 1900. On 05/11/2023 at 09:48 AM, the surveyor observed Resident #120 lying in bed with oxygen via n/c. The nebulizer mask was observed on the floor and under the over the bed table. The mask was not covered and was exposed and in contact with the floor. The surveyor asked the resident if he/she had had a nebulizer treatment this morning. Resident #120 responded that he/she had not had a nebulizer treatment today and that they last had received a treatment yesterday. The surveyor interviewed the Licensed Practical Nurse (LPN #2) assigned to Resident #120 on this shift. LPN #2 confirmed that Resident #120 received the prescribed Duoneb solution is delivered via nebulizer mask. On 05/17/23 at 07:39 AM, the surveyor had LPN #3 come to Resident #120's room. Resident #120 was observed sleeping with oxygen via n/c. The nebulizer mask was lying on the floor next to the bed with mask face down on the floor surface. When shown to LPN #3, LPN #3 stated, That should be in a bag when it is not in use. The night shift must have forgotten to bag it. The plastic storage bag is on top of the bedside table. On 05/17/23 at 10:54 AM the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1) assigned to the B-Unit where Resident #120 resided. The surveyor asked RN/UM #1 what the facility practice for respiratory equipment was when not in use. RN/UM #1 responded, Bagged, dated. Cleaned. On 05/17/23 at 01:10 PM the surveyor asked the facility Director of Nursing (DON) what the facility practice was for nebulizer mask storage when not in use, The DON replied, Should be bagged and labeled when not in use. The surveyor reviewed the facility policy titled Oxygen Administration, undated. The following was revealed under the heading Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measure include: c. Keep delivery devices covered in plastic bag when not in use. N.J.A.C. 8:39-27.1(a)

Complaint # NJ00160866 Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide pain management that met professional standards of practice related to pain management. Specifically, by giving pain medication outside of the window of administration. This deficient practice was identified for 1 of 1 resident investigated for pain. The deficient practice was evidenced by the following: On 05/09/2023 at 12:12 PM, during an interview with the surveyor, Resident #108 said that medications are sometimes an hour or an hour and a half late. He/She has called the police about his/her medications being late. A review of Resident #108's quarterly Minimum Data Set (MDS) an assessment tool dated 02/27/2023, revealed that Resident #108 received scheduled and PRN (as needed) pain medication. It further revealed that Resident #108 experienced pain almost constantly. A review of Resident #108's electronic medical record (EMR) revealed a diagnosis of but not limited to chronic pain, low back pain, gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints), and polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident #108's physician's orders located in the EMR revealed an order for Tylenol Extra Strength tablet, 1000 mg (milligrams) to be given by mouth every 8 hours for pain. A review of Resident #108's care plan located in the EMR revealed that Resident #108 is at risk for pain related to a medical condition/diagnosis. The care plan further revealed an intervention to administer medication as ordered. A review of the Medication Administration Audit for January 2023 revealed Tylenol Extra Strength tablets were administered on the following dates and times: 01/04/2023 scheduled for 02:00 PM and given at 03:46 PM 01/06/2023 scheduled for 10:00 PM and at given 11:55 PM 01/07/2023 scheduled for 02:00 PM and given at 05:22 PM 01/07/2023 scheduled for 10:00 PM and given at 12:30 AM on 01/08/2023 01/12/2023 scheduled for 02:00 PM and given at 03:19 PM 01/14/2023 scheduled for 10:00 PM and given at 11:39 PM. 01/15/2023 scheduled for 02:00 PM and given at 04:50 PM 01/18/2023 scheduled for 10:00 PM and given at 12:02 AM on 1/19/2023 01/19/2023 scheduled for 02:00 PM and given at 03:48 PM 01/29/2023 scheduled for 02:00 PM and given at 04:12 PM 01/27/2023 scheduled for 10:00 PM and given at 05:11 AM on 01/28/2023 On 05/17/2023 at 09:30 AM, during an interview with the surveyor, Registered Nurse/Unit Manager #1 stated that the window of time for administering medications was an hour before and an hour after the scheduled time. She further confirmed that the above orders were given outside of the administration time after the surveyor showed her the administration times. On 05/17/2023 at 01:01 PM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that the window of time for administering medications was an hour before and an hour after the scheduled time. When the surveyor asked whether a Tylenol Extra Strength scheduled for 2:00 PM should be given at 5:22 PM, the DON replied, No. A review of the facility policy titled, Administering Medications with a revision date of April, 2021, states under Policy Interpretation and Implementation number 4., Medications are administered in accordance with prescriber orders, including any required time frame. The policy further revealed under number 7., Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) NJAC 8:39-27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) to maintain a detailed record of receipts and accurate reconciliation of controlled medications for 7 of 7 Drug Enforcement Administration (DEA) 222 forms (a form used for ordering controlled substances)and b.) failed to ensure that controlled drugs are reconciled in accordance with facility policy and professional nursing standards on 1 of 5 SHIFT to SHIFT CONTROLLED MEDICATION COUNT LOG (B Unit, Cart #1). This deficient practice was evidenced by the following: A.) On 05/11/2023 at 09:22 AM, Surveyor #1 requested all of the DEA 222 forms for the last six (6) months from the Assistant Director of Nursing (ADON). The ADON provided Surveyor #1 with seven (7) DEA 222 forms. Surveyor #1 reviewed the DEA 222 forms and found seven of seven forms were not completed and accurately documented as follows: 1. DEA 222 form #221418084 was written on 12/22//22 and contained an order for 1 package of 20 Oxycodone IR (Immediate release) 5 milligram (mg), 1 package of 20 Oxycodone IR 10 mg, and 1 package of 10 Morphine Sulfate 10 mg/0.5ml (milliliter). The DEA 222 form was missing the number received and date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. 2. DEA 222 form #221418085 was written on 1/17/2023 and contained an order for 1 package of 30 Oxycodone IR 10mg. The DEA 222 form was missing the number received and date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. 3. DEA 222 form #221418091 was written on 1/26/23 and contained an order for 1 package of 20 Oxycodone IR 10mg and 1 package of 30 Oxycodone IR 5mg. The DEA 222 form was missing the number received and the date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. 4. DEA 222 form #221418086 was written on 3/10/23 and contained an order for 1 package of 30 Oxycodone IR 5mg tab (tablet), 1 package of 30 Oxycodone IR 10mg tab, 1 package of 10 Morphine Sulfate 10mg/0.5ml, 1 package of 10 Fentanyl 25mcg (microgram)/hr (hour) Patch. The DEA 222 form was missing the number received and the date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. 5. DEA 222 form # 221418087 was written on 3/21/23 and contained an order for 1 package of 30 Oxycodone IR 15mg tab and 1 package of Fentanyl 25mcg/hr Patch. The DEA 222 form was missing the number received and the date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. 6. DEA 222 form #221418088 was written on 4/4/23 and contained an order for 1 package of 10 Hydrocodone/Acetaminophen 5mg/325mg and 1 package of 30 Fentanyl 25mcg/hr patch. The DEA 222 form was missing the number received and the date received. 7. DEA 222 form #230310473 was written on 5/4/22 {?23}and contained an order for 1 package of 20 Oxycodone IR 5mg tab, 1 package of 30 Oxycodone IR 10mg tab and 1 package of 30 Oxycodone IR 15mg. The DEA 222 form was missing the number received and the date received. The printed instructions on the front of the DEA 222 form indicated Part 5: To BE FILLED IN BY PURCHASER, number of packages received and date received. On 05/11/2023 at 10:47 AM, Surveyor #1 requested copy of the back of the DEA 222 form from the ADON. On 05/11/2023 at 11:00 AM, Surveyor #1 received a copy of the back of the DEA 222 form from ADON. The back of the DEA 222 form includes Instructions for the DEA 222 form under part 5 Controlled Substance Receipts, 1. purchaser fills out this section on its copy of the original order form 2. Enter the number of packages received and date received for each line item. 3. purchaser must keeps its copy of each executed order form and all copies of unaccepted or defective forms and any attached statements or other related documents available for inspection for a period of 2 years. A review of an undated facility policy titled Federal Regulations Regarding DEA Form 222, revealed under the Procedures for obtaining, executing and filing of DEA Form 222 are described described within this code. 2. Receiving C-II Controlled Substances (Part 5) A. Verify that the quantities, packaging size and items received from the pharmacy match what is on the retained copy of the original 222 form. B. Fill in the number of packages received, and the date received for each item. During an interview with Surveyor #1 on 05/17/2023 at 07:37 AM, the ADON said I was not aware there were directions for completing the DEA 222 form until you asked for a copy. I then saw what you were looking at and I will be completing part 5 as well. 40041 B.) On 05/11/2023 at 10:11 AM, the B-Wing Medication Cart #1 was inspected by Surveyor #2 in the presence of Licensed Practical Nurse (LPN #1). A review of the SHIFT to SHIFT CONTROLLED MEDICATION COUNT LOG for the month of May revealed a signature in the 7P-7A (7PM-7AM) signature box for the off-going nurse. During an interview at the time of observation, LPN #1 replied yes when asked if the incoming and outgoing signatures noted on the controlled medication count log for May 11th, 7A-7P and 7P- 7A were hers. When asked should the same incoming nurse sign both the incoming 7AM-7PM and off-going 7P-7A box at the start of the 7AM shift, LPN #1 replied, Usually I don't, but I did today, because I still have to leave at some point. On the same date at 10:53 AM, during an interview with Surveyor #2,Registered Nurse/Unit Manager (RN/UM #1) was asked to describe the process for the narcotic count. RN/UM #1 stated it should be a double count with incoming and outgoing nurse, the incoming nurse signs the incoming signature box that he or she verified the narcotic count. During an interview with the Surveyor #2 on 05/17/2023 at 09:52 AM, the ADON replied, absolutely not when asked should the incoming nurse sign both incoming and outgoing at the same time. A review of a facility policy Controlled Substances revised date of April 2019 indicates, .12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. N.J.A.C. 8:39-29.7(c)

NJ Complaint: #NJ00160866 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow the prescriber's orders and accepted professional standards and principles by administering medications past the required time frame. The deficient practice was identified for 1 of 1 resident reviewed for being free of significant med errors. The deficient practice was evidenced by the following: A review of Resident #108's quarterly Minimum Data Set (an assessment tool) dated 02/27/2023, revealed that Resident #108 had a brief interview of mental status score of 15 which indicated he/she was cognitively intact. A review of Resident #108's physician's orders revealed the following orders but not limited to Digoxin tablet 250mcg (micrograms, medication used to manage and treat heart failure) one time a day and to hold for a heart rate greater than 60 beats per minute, lisinopril (medication used to treat high blood pressure) tablet 2.5mg (milligrams) one time a day, furosemide (medication used to manage and treat heart failure) tablet 40mg one time a day, and metoprolol tartrate (medication used to treat high blood pressure and chest pain) tablet 50mg ever 12 hours and to hold for a systolic blood pressure less than 95mmHg (millimeters of mercury) and/or a heart rate less than 60 beats per minute. On 05/10/2023 on 11:43 AM, during an interview with the surveyor, Resident #108 said that they have informed the facility about receiving late medications and the facility did nothing about it when the surveyor asked if he/she told anyone about getting medications late. A review of Resident #108's Medication Administration Audit Report for January 2023 revealed the following medications were administered past the required time frame as follows: On 01/03/2023: Lisinopril (medication used to treat high blood pressure) scheduled for 09:00 AM was given at 10:31 AM Digoxin scheduled for 09:00 AM was given at 10:29 AM Furosemide (medication used to treat and manage fluid retention) scheduled for 09:00 AM was given at 10:31 AM Metoprolol Tartrate (medication used to treat high blood pressure and chest pain) scheduled for 09:00 AM was given at 10:31 AM On 01/16/2023: Metoprolol Tartrate scheduled for 03:00 PM was given at 05:18 PM 01/18/2023 Metoprolol Tartrate scheduled for 09:00 PM was given at 12:15 AM on 01/19/2023 01/19/2023: Lisinopril scheduled for 09:00 AM was given at 10:12 AM Digoxin scheduled for 09:00 AM was given at 10:12 AM Furosemide scheduled for 09:00 AM was given at 10:12 AM Metoprolol Tartrate scheduled for 09:00 AM was given 10:12 AM 01/20/2023: Metoprolol Tartrate scheduled for 03:00 PM was given 05:57 PM 01/21/2023 Metoprolol Tartrate scheduled for 03:00 PM was given at 04:17 PM 01/22/2023: Lisinopril scheduled for 09:00 AM was given at 01:22 PM Digoxin scheduled for 09:00 AM was given at 01:22 PM Furosemide scheduled for 09:00 AM was given at 11:57 AM Metoprolol Tartrate scheduled for 09:00 AM was given at 01:21 PM 01/22/2023: Metoprolol Tartrate scheduled for 09:00 PM was given at 10:17 AM and the 03:00 PM dose was given at 4:43 PM. 01/26/2023 Metoprolol Tartrate scheduled for 03:00 PM was at given 05:41 PM. On 05/17/2023 at 01:01 PM, during an interview with the surveyor, the Director of Nursing (DON) replied, Hour before and an hour after when asked what the window of time for administering medications was. The DON further revealed that, Depending on the medication in your body, you take a medication and it builds up a level in your system and you want to maintain that level, so you are controlled. A review of the facility policy titled, Administering Medications with a revision date of April, 2021, states under Policy Interpretation and Implementation number 4., Medications are administered in accordance with prescriber orders, including any required time frame. The policy further revealed under number 7., Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.) N.J.A.C.: 8.39-29.2 (d)

Based on observation, interview, and document review, it was determined that the facility failed to store a biological (Tubersol INJ [injection], used to aid in the diagnosis of tuberculosis infection [TB]) in accordance with the manufacturer's instructions. This deficient practice was identified in 1 of 5 medication carts inspected. On 05/11/2023 at 10:11 AM, the B-Wing Medication Cart #1 was inspected, by the surveyor, in the presence of Licensed Practical Nurse (LPN #1). Upon opening the bottom right-hand drawer, the surveyor observed an unopened box of house stock Tubersol INJ (Injectable) 5/0.1 ML (Milliters) manufactured by [company name]. A label affixed to the outside of the box indicated Refrigerate, Do Not Freeze, as well as an image of a refrigerator and the word REFRIGERATE written in bold letters next to the image. At the time of the observation, LPN #1 stated that she was unsure of how long the Tubersol had been in the drawer. On the same day at 10:53 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM #1) replied, in the fridge when asked how Tubersol should be stored. In addition, RN/UM #1 replied yes when asked should the Tubersol be stored under a controlled temp that's monitored. On 05/17/2023 at 09:52 AM, during an interview with the surveyor, the Assistant Director of Nursing confirmed that Tubersol should be stored in the refrigerator. The facility was unable to provide a policy pertaining to the storage of Tubersol. A review of the Tubersol manufacturer package insert indicated, Store at 2 to 8 C (35 to 46 F). N.J.A.C. 8:39-29.4(h)

Based on observation, interview, and record review, it was determined that the facility failed to provide all the items that were on the menu. This deficient practice occurred during one lunch meal that was observed in the main dining room and was evidenced by the following: 1. On 05/09/2023 at 11:48 AM, during the lunch meal in the main dining room, the surveyor observed 12 residents were present in the dining room. According to the menu, residents were to receive a slice of apple pie at the lunch meal on 05/09/2023. The surveyor observed 12/12 residents in the main dining room receive strawberry ice cream for dessert at the lunch meal instead of apple pie. The surveyor interviewed resident #39 during the lunch meal observation. Resident #39 stated to the surveyor when he pointed out that they were provided strawberry ice cream instead of apple pie, Sometimes we get a piece of cake that is pink and sometimes we get strawberry ice cream, but we never get strawberry shortcake. The surveyor then told the resident that the dessert for the lunch meal was apple pie on 05/09/2023. Strawberry shortcake was to be served on 05/10/2023 at the lunch meal. 2. On 05/09/2023 at 12:09 PM, the surveyor interviewed the facility Dietary Director (DD). The DD stated, We don't have strawberry shortcake. I've been doing red velvet cake. I can't get strawberry filling. The surveyor asked the DD what the facility process was for menu substitutions. The DD replied, I have to get the dietitian to sign the substitution log. I didn't do it before making the substitution. The menu comes from corporate, and I've sent plenty of emails about not getting strawberry filling to make the strawberry shortcake. The DD then printed out a blank menu substitution form in the dietary office in the presence of the surveyor. The DD then filled in a lunch substitution of strawberry ice cream for apple pie and stated, All I have to do now is get the dietitian to sign it. The surveyor asked for a copy of the substitution form. The DD asked the surveyor if she should have the dietitian sign off on it first. The surveyor responded, No. (Note that surveyor and DD both were mistaken in thinking strawberry shortcake was to be served at the lunch meal on 05/09/2023. Both agreed to the mistake and agreed that apple pie was to be served at the lunch meal on 05/09/2023 and strawberry short cake was to be served at the lunch meal on 05/10/2023.) Apple pie was not available at the lunch meal, as indicated on the menu on 05/09/2023. 3. On 05/10/2023 at 01:31 PM, the surveyor conducted an interview with the facility dietitian. The dietitian told the surveyor, I signed off on the dietary director's menu substitutions today for the past couple of days. The surveyor asked if she (dietitian) approves the menu substitution prior to the DD making the change or after the substitution has already been made. The dietitian responded, No, I just sign off on them when I get to it. The facility did not provide a policy or procedure for menu substitutions. N.J.A.C. 8:39-17,2(b)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a person-centered comprehensive care plan (CP) or develop a person-centered comprehensive care plan in a timely manner a) addressing the placement and care of hand mitts on left/right hands (Resident #23), b) addressing the use, care, cleaning and storage of a nebulizer (a machine that delivers aerosol medication into the lungs) (Resident #126), and c) failure to develop a hospice care plan in a timely manner for a resident enrolled and disenrolled in hospice services (Resident #69) . This deficient practice was observed for 3 of 33 residents reviewed and was evidenced by the following: a) On 2/11/2022 at 11:14 AM, the surveyor observed Resident #23 in bed, on a ventilator with a [CONDITION(S)] in place. At that time, the surveyor noted a left-hand Posey mitt in place, (Posey Mitts are used to help protect patients who are prone to disrupting medical treatment or self-harm). According to the Admission Record, Resident #23 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS), an assessment tool, dated 10/30/2021, indicated daily use under Section P, the restraint section. A review of the February 2022 Order Summary Report for Resident #23 revealed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #23's Care Plan provided to the surveyor on 2/17/2022 at 10:10 AM did not include a care plan for restraints or Posey Mitts. During an interview with the surveyor on 2/22/2022 at 10:32 AM, the Assistant Director of Nursing (ADON) reviewed the comprehensive care plan for Resident #23. The ADON acknowledged that the care plan did not include a plan for the use of restraints/mitts for Resident #23. b) On 2/11/2022 at 11:20 AM, during the initial tour of the B Unit, the surveyor observed a nebulizer connected to tubing, a mask and medication cup resting on the resident's four drawered dresser. During an interview with the surveyor at that time, resident #126 acknowledged the nebulizer was his/hers and that he/she took it When I get winded. According to the Admission Record, Resident #126 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) A review of an Admission MDS, dated [DATE], revealed that Resident #126 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident's cognition was intact. A review of the resident's Order Summary Report revealed an order dated 1/24/2022 for [MEDICATION(S)] Nebulizing Solution (2.5 MG (milligrams)/3 ML (milliliter)) 0.083%, 3 ML inhale orally via nebulizer (a machine that delivers aerosol medication into the lungs) every 4 hours as needed for SOB (shortness of breath.) A review of Resident #126's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #126's Care Plan provided to the surveyor on 2/17/22 at 12:40 PM, did not include a Care Plan for the nebulizer use, care, cleaning, or storage. During an interview with the surveyor on 2/22/22 at 09:35 AM, the ADON reviewed Resident #126's Care Plan and acknowledged that the Care Plan did not include the nebulizer. c) During a review of the medical record (MR) on 2/14/2022 at 9:56 AM, the quarterly MDS dated [DATE], revealed that Resident #69 had a BIMS score of 5/15, indicating severe cognitive impairment. In addition, section O of the MDS revealed that resident #69 received hospice care while a resident in the facility. In addition, the Order Summary Report had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] According to the Admission Record, Resident #69 was admitted to the facility with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/15/2022 at 11:32 AM the surveyor reviewed the electronic MR. According to the hospice document titled [hospice name] Long Term Care Facility-Business Office Notification, Resident #69 was admitted to hospice services on 3/30/2021. A further review of facility documentation revealed that Resident #69 was discharged from hospice care on 1/21/2022, per the [hospice name] Long Term Care Facility-Business Office Notification sheet. On 2/15/22 at 12:02 PM the surveyor reviewed Resident #69's comprehensive care plan via the electronic MR. The surveyor observed a care plan addressing the following: Resident is on Hospice Care (hospice name) on comfort care only Severe Dementia, Date Initiated: 09/22/2021. The care plan initiation date for hospice occurred approximately 6 months from hospice enrollment for Resident #69. On 2/22/2022 at 2:06 PM the surveyor conducted an interview in the presence of the facility Director of Nursing (DON), ADON, Administrator and Regional Clinical Service Director (RCSD). The surveyor asked when the care plan should have been developed after Resident #69 was enrolled on hospice care. The DON and RCSD responded, Nursing would definitely collaborate with hospice to develop the care plan which should have occurred within 24-48 hours. The surveyor reviewed the facility policy titled Care Planning, Date Revised: April 03, 2021. The following was revealed under the heading Policy: II. The Care Plan serves as a course of action where the resident .resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed bases. (sic) The following was revealed under the heading Procedure: VIII. A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. V. (page 3) The IDT will revise the Comprehensive Care Plan as needed at the following intervals: A. Per RAI schedules. B. As dictated by changes in the resident's condition. C. In preparation for discharge. D. To address changes in behavior and care, and E. Other times as appropriate or necessary. A review of an undated facility policy titled, Restraints, revealed the following under the Care Planning section: Care plans for residents with restraints will reflect: A. The type of restraint to be used B. The medical symptoms requiring the use of restraints C. The treatment team's goals in using the restraint D. Interventions that address the immediate medical symptom(s) and the underlying problems that may be causing the symptom(s) E. Systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use F. Frequent observation and release every 2 hours for toileting and/or repositioning and checking the condition of skin and impaired circulation if indicated G. The use of postural support and the method of application will be specified in the resident's Care Plan. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to A) develop and implement a policy to track facility staff vaccination status to ensure all eligible staff were vaccinated by the required dates and B) follow their own policy for contingency plans by not ensuring unvaccinated staff wore an N 95 mask to mitigate the potential spread of COVID-19. This deficient practice was evidenced by the following: On 2/11/22 during entrance conference, the facility was asked to provide a matrix of the vaccination status of all their staff. The facility provided a sheet of paper, separated by department, and listed the number of total vaccinated and unvaccinated staff. The paper did not identify or specify which facility staff were vaccinated or unvaccinated. A.) A review of the facility provided matrix on 2/16/22, revealed 25 new hire employees from November of 2021 to February 2022. Of those 25 new hire employees, 8 are no longer on the schedule, 6 have pending exemptions, and 11 were unvaccinated. During an interview with surveyor #1 on 2/17/22 at 10:05 AM, the Director of Nursing (DON) said the Infection Prevention Nurse (IPN) and Assistant Director of Nursing (ADON) were responsible for maintaining their COVID-19 vaccine policy. The DON acknowledged staff could have received the vaccine in the community or in house at their monthly clinic. When asked how long an employee could work without being vaccinated the DON said, I will get you that answer. Surveyor #1 asked for clarification since the completed vaccination matrix revealed 3 pending exemptions and the IPN submitted employee documentation for 17 exemptions. The IPN also provided dates of hire for the 25 new employees, however, only 23 new hires were listed. The DON responded, I know. I think it was confusing how it was on that form (Matrix). During an interview with surveyor #1 on 02/17/22 at 12:30 PM, the IPN explained a new hire probationary period is 3 months. The IPN also stated, First dose of the vaccine should have been by January 27th, 2022, I believe, and the 2nd by February 27, 2022. The IPN confirmed to surveyor #1, I am responsible to track vaccinations as the IPN. During an interview with surveyor #3 on 2/17/22 at 12:40 PM, the Temporary Nursing Assistant (TNA #2), who was one of the 11 documented unvaccinated employees, said she was vaccinated at a community pharmacy with the first dose of a 2-dose vaccine in January of 2022. TNA #2 stated, Administration made me verbally aware that to continue employment that I would need to be fully vaccinated. During a follow up interview with surveyor #1 on 2/17/22 at 1:25 PM, the IPN said she was not given a deadline for vaccines or exemption completion dates. The IPN further said she was not familiar with the vaccination requirements and had not had time to read the most recent guidance. During an interview with surveyor #5 on 2/17/22 at 1:43 PM, TNA #3 said upon hire she was told by Human Resources that she had until 2/25/22 to get vaccinated or lose her job. She went on to say she scheduled her 1st vaccination on 2/22/22 to be received during the facility vaccination clinic. Surveyor #2 went to the unit to speak with TNA #4 on 2/17/22 at 1:42 PM and was told TNA #4 had been sent home because she did not have her vaccine. During an interview with surveyor #6 on 2/17/22 at 1:54 PM, TNA #1 denied being vaccinated and filled out a non-medical exemption form. She went on to say that when she was first hired, they told me I had to be vaccinated. They never really pushed for it. During an interview with surveyor #1 on 2/22/22 at 10:29 AM, the IPN said the tracking process for staff vaccines is, I have a log to track dates of vaccines, boosters, and a swabbing log. She went on to say she puts the unvaccinated in there as well and checks every time there is a clinic. The IPN continued, I send out a voice print (electronic voice mail) to staff regarding updating me on if they have received the vaccine. The IPN said she asks during orientation, who is vaccinated, and they will submit me their card [ .] If unvaccinated I will offer them a clinic and if they want to sign up, they can, or I offer them the community option for vaccines. The IPN said, If they give me a card, I will update the list [ .] I don't have a time frame for when they need to get vaccinated by. The ADON added, We don't have a way to track the unvaccinated and will need to come up with something. During an interview with the surveyor on 2/22/22 at 1:52 PM, the DON and the Regional Clinical Service Director (RCSD) said the reviews for exemptions should not take long. There was no specific timeframe provided to the surveyor. The RCSD went on to say that at this time all unvaccinated staff are unable to work until they provide proof of vaccination or file for an exemption. The RCSD further stated that moving forward staff must be fully vaccinated before they start here and/or file for an exemption. B.) On 2/17/22 at 12:40 PM, TNA # 2 was observed by surveyor #3 to be wearing a surgical mask. When asked if she had been instructed by Administration to wear an N-95 level mask while working in the facility TNA #2 said, I was not made aware that I was to wear N-95 mask due to my vaccination status. TNA #2 said she had been fit tested (specific test performed under a hood using sweet/sour smell to ensure correct fit of the mask). On 2/17/22 at 1:43 PM, TNA #3 was observed by surveyor #5 wearing a surgical mask and full-face shield. When asked about what mask she should be wearing she said she wears an N-95 in the yellow zone (area for persons under investigation/ PUI for Covid). On 2/17/22 at 1:54 PM, TNA #1 was observed to be wearing a surgical mask and eye protection. When asked by surveyor #6 about her use of an N-95 mask she said, No, not really. I did use it in the subacute covid area. I wear just a surgical mask. During an interview with surveyor #1 on 2/17/22 at 1:25 PM, when asked about mitigation, the IPN said mitigation was nasal swab twice a week, staff should wear PPE in green zone (no covid or PUI) consisting of face shield and surgical mask. The IPN went on to say, No, staff does not need to wear N-95 at all times. During an interview with surveyor #1 on 2/17/22 at 2:13 PM, the DON was asked what mitigation process was utilized for unvaccinated or partially vaccinated staff. The DON replied, It should be an N-95 mask and face shield. The DON went on to say that the ADON or IPN should have told them (unvaccinated/partially vaccinated new employees) during orientation of the requirement. The DON also said the Unit Managers or Supervisors are responsible for monitoring staff on the units to ensure they are compliant with their N-95 mask usage. A review of a facility policy titled (Company Name) Covid-19 Vaccine Policies and Procedures, updated 1/26/2022 revealed under the Staff Vaccine Requirements section All facility staff are required to have received at least one dose of an FDA authorized Covid-19 vaccine by January 27, 2022, and the second dose by February 28, 2022, and any booster shots for which they are eligible. In addition, the policy revealed the following under the Additional Precautions and Contingency Plans for Unvaccinated Staff: Require use of a NIOSH-approved N-95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct acre to or otherwise interacting with patients. NJAC 8:39-5.1(a)

Based on interview and record review, it was determined that the facility failed to refer Resident #14 to the appropriate state-designated authority for level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This deficient practice was identified for 1 of 4 residents reviewed for Level II PASARR. On 2/11/2022 at 2:21 PM the surveyor reviewed Resident #14's electronic and paper record. According to the Admission record Resident #14 was admitted to the facility with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A further review of the medical record revealed a positive Level I screen for mental illness (MI) for the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Level I screen revealed that within the last 2 years had Resident #14 had either/both experienced one psychiatric treatment episode that was more intensive than routine follow-up care and/or due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials. On 2/15/22 at 8:54 AM the surveyor requested a copy of the Level II PASARR evaluation and determination screen for Resident #14 from the facility Assistant Director of Nursing. The facility Acting Director of Social Work (ADSW) at 10:27 AM explained to the surveyor, We do not have the Level II screen for Resident #14. It was determined that he/she did not have their level II screen on the third week of January (2022) when we audited the C unit medical records for PASARR completion. The ADSW further explained, Social services is responsible for contacting the particular agency for positive Level I screens. I'm here on contract for the facility since August. I've been in and out because they haven't been able to retain staff. The department has been bad, that is why our audits are bad. It's due to staffing. We have 1 full time person and me part time. On 2/17/2022 at 9:23 AM the facility social worker provided the surveyor with a fax transmittal of the PASARR Level II Psychiatric Evaluation, dated 2/17/2022 at 17:10 (5:10 PM) to the New Jersey Division of Mental Health and Addiction Services for Resident #14. On 2/23/2022 at 10:09 AM the surveyor conducted a follow-up interview with the facility ADSW. The ADSW explained, The State Agency has not come to the facility at this time to evaluate the resident. I made the referral prior to vacation but they haven't been here yet. The surveyor reviewed the facility provided Pre-Admission Screening Resident Review (PASARR), Policy No. -NP-123, date revised: November 01, 2021. The following was revealed: Purpose: To ensure that all Facility applicants are screened for mental illness and/or intellectual disability prior to admission and to ensure this assessment effort is coordinated with the appropriate state agencies if indicated. Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. III. Screening Results A. If the Level I screening results indicate that the applicant should receive the Level II screening, the Facility shall contact the appropriate state agency for additional screening.

Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to revise a care plan when there was a change in the medication regime for 1 of 33 sampled residents, (Resident # 58). This deficient practice was evidenced by the following: During the initial tour of the ventilatory unit on 2/11/22 at 10:40 AM, Resident #58 was observed lying in bed with their [CONDITION(S)] connected to a mechanical ventilator with their eyes closed. A review of the Admission Record revealed Resident #58 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Order Summary Report dated active orders as of 2/16/22, did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/14/22 at 1:35 PM, the surveyor reviewed Resident #58's Care Plan that revealed a focus area of I am at risk for bleeding secondary to the use of anticoagulant therapy for [CONDITION(S)] prophylaxis (blood clot prevention) with a Date Initiated of: 8/24/2021 and Revision on: 8/24/2021. During an interview with the surveyor on 2/16/22 at 10:39 AM, the Registered Nurse Unit Manager (RNUM #2), revealed when a new admission comes, a standard care plan is done and individualized with medications and treatments. RNUM #2 said we do skin risk, pain, falls, Activities of Daily Living's then based on history and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RNUM #2 went on to say the Unit Manager is responsible to do care plans and if medications are discontinued, the Unit Manager is responsible to make sure care plan is revised as needed. She went on to say that yes, it is my responsibility to resolve or revise care plan. During an interview with the surveyor on 2/16/22 at 10:54 AM, the Assistant Director of Nursing (ADON) said ultimately the Unit Manager is responsible for updating and revising the care plans. During an interview with the surveyor on 2/22/22 at 1:50 PM, the Director of Nursing (DON) said her expectations of care plan revisions is they are to be done whenever there is a resident change in condition, quarterly, upon admission and readmissions and as needed. A review of a facility policy titled Care Planning with a revised date of April 03, 2021, revealed under the IDT section V. The IDXT will revise the Comprehensive Care Plan as needed at the following intervals: D to address changes in behavior and care . NJAC 8:39-11.2(i)

Based on observation, interview and record review it was determined that the facility failed to evaluate a resident's wound pain management and/or administer pain medication prior to completing wound care. Documentation in the progress notes identified that the resident had been experiencing pain with wound care since 11/15, but did not receive pain management prior to wound care until 1/16. This was identified for Resident #9, 1 of 7 residents reviewed for pressure ulcers. In addition, the facility failed to provide 1 resident with the correct amount of fluids per the resident's fluid restriction orders. This was identified for Resident #21, 1 of 1 residents reviewed for [MEDICAL TREATMENT]/fluid restrictions. This deficient practice was evidenced by the following: 1. During an initial tour of the facility on 2/5/16 at approximately 10:30 a.m., the Unit Manager (UM) providing the surveyor with information, said Resident #9 had a sacral pressure ulcer and was seen by a wound care nurse. When the medical record was reviewed, the surveyor observed that Resident #9 had [DIAGNOSES REDACTED]. The 1/2/16 review of the Resident Assessment Instrument (an assessment tool) identified the resident as severely cognitively impaired and requiring extensive staff assist for activities of daily living. A review of the 11/2015 and 12/2015 Treatment Administration Records indicated that the resident's wound treatments were being done at 5 a.m. and 2 p.m. The Wound Healing Solutions evaluation forms for 11/2015 and 12/2015 both noted patient demonstrating evidence of discomfort when affected area palpated. When reviewed, the surveyor observed that the [MEDICATION NAME] Disposition of Remaining Doses revealed that Resident #9 did receive as-needed pain medication on 11/4/15 at 4 p.m., 11/8/15 p.m. at 1:30 p.m., 11/10/15 at 4:20 a.m., 11/14/15 at 8 a.m., 11/15/15 at 8 a.m., 11/16/15 at midnight, 1/8/16 at 7 p.m. and on 1/9/16 at 5 a.m. There was no documentation as to the exact type of pain the resident was being medicated for at those times (the resident was still receiving as-needed pain medication for the [MEDICAL CONDITION]). The times of the mediation administration did not always coincide with being administered prior to a wound treatment. The surveyor reviewed the Progress Notes written by the UM dated 11/23/15, 12/1/15, 12/6/15, 12/21/15 and 1/5/16 which stated that Resident #9 was seen by the Wound Nurse Practitioner (NP) for follow-up for wound management. The UM's Progress Notes included that Resident #9 demonstrated, evidence of discomfort when affected area palpated. No standard or routine pain medication had yet been ordered prior to wound treatment. The Nurse Practitioner's (NP) report dated 1/15/16, revealed that Resident #9 upon assessment exhibits and verbalizes pain while wound palpated/when repositioning. The NP's report dated 1/21/16, revealed that Resident #9 demonstrated evidence of pain when affected area palpated. When interviewed on 2/10/16 at 11:15 a.m., the wound NP stated that when asked the resident did not verbalize she was in pain, but when the wound was palpated (touched) the resident would exhibit signs and symptoms of pain. When the 1/2016 Physician order [REDACTED]. The 1/21/16 Progress Note written by the UM revealed pain noted and PRN (as-needed) pain med (medication) in place and effective at this time. The 1/22/16 Progress Note written by the UM revealed evidence of discomfort during care. Hospice made aware and new recommendation received for routine pain med prior to wound care. Resident #15 then received pain medication prior to treatments BID starting 1/23/16. The surveyor observed that on 1/28/16, the POS revealed an order to change the [MEDICATION NAME] order from BID to 5 a.m. and PRN (as needed). The 2/2016 POS revealed 2 treatment orders (1) for [MEDICATION NAME]/Zinc Oxide cream. Apply to sacral ulcer, periwound and bilateral gluteus twice daily at 7 to 3 and 3 to 11 and (2) to cleanse the sacral wound with normal saline solution and apply Silver Alginate to the wound covering the wound with a dry dressing once daily at 5 a.m. The [MEDICATION NAME] Disposition of Remaining Doses further revealed that starting 1/25/16, Resident #9 received one daily dose of pain medication in the early morning with no PRNs administered. When interviewed on 2/10/16 at 9 a.m., the UM stated she attended wound rounds with the NP and that Resident #9's pain should have been addressed on 1/15/16. The UM could not explain the delay in ordering pain medication prior to treatment. The UM stated that Resident #9 should receive pain medication prior to each wound treatment and was uncertain why the [MEDICATION NAME] order was changed to once daily and PRN. The surveyor reviewed the Pain Management policy which stated that the facility should Review the resident's treatment record or recent nurses' notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: (b) Treatments such as wound care or dressing changes. On 2/9/16 at 8:35 a.m., the surveyor observed the UM perform a treatment to the resident's sacral wound. Resident #9 did not exhibit any signs or symptoms of pain during the treatment and stated, it tickles when the UM cleaned the wound with normal saline. The surveyor later observed in the Medication Administration Record [REDACTED]. 2. During a tour of the facility on 2/5/16 at approximately 10 a.m., the Unit Manager providing tour information said Resident #21 received [MEDICAL TREATMENT] and went out to a [MEDICAL TREATMENT] center 3 times a week. According to the medical record, the resident had [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] at a [MEDICAL TREATMENT] center on Tuesdays, Thursdays and Saturdays and was out of the facility from approximately 1 p.m. to 6 p.m. The physician's orders [REDACTED]. The orders also included a 1500 ml per day fluid restriction. The surveyor did not see any breakdown on the POS for how much fluid the dietary department was allowed to provide and/or, how much fluid the nursing department was to provide. The surveyor reviewed the Medication Administration Record [REDACTED]. The surveyor observed a Fluid Restriction/Push Guide sheet that was kept in the front of the MAR binder which included different amounts of fluid restrictions and how much each fluid restriction would be allotted to nursing and dietary based on the individual amount of the restriction. The 1500 cc (cc is equivalent to ml) fluid restriction noted that the total given by dietary would be 840 cc and total given by nursing would be 660 cc. (The resident's careplan addressed the resident being on a fluid restriction but also did not provide a breakdown of fluids allotted to the dietary department or the nursing department.) On 2/9/16 at 2 p.m., the surveyor went to the dietary department and asked the Food Service Director (FSD) for a print-out of Resident #21's diet/fluid orders. The FSD provided the surveyor with a print-out of the meal orders for each of the 3 meals that day. The surveyor observed that the breakfast meal included 240 ml of coffee and 4 oz (120 ml) of milk. The noon meal included 180 ml of soup and 240 ml of coffee. The evening meal included 180 ml of soup, 4 oz (120 ml) of apple juice and 4 oz of coffee. This totaled 1200 ml of fluid the dietary department was providing to the resident that day. That amount was greater than the amount allotted to the dietary department based on the Fluid Restriction/Push Guide. With the dietary department providing 1200 cc and the nursing department providing 660 cc, that would total 1800 ml daily, 300 cc more than the amount the resident was ordered to receive. On 2/10/16 at 7:30 a.m., the surveyor observed the resident sitting in bed eating breakfast. The resident's breakfast tray included 240 ml of coffee and 240 ml of milk. That total of 480 ml was more than half of the dietary department's daily allotment of fluids and there was still 2 more meals to go for the day. According to the Fluid Restriction/Push Guide, the breakfast meal was to include only 360 ml of fluid. NJAC 8:39 - 27.1 (a)

C#'s NJ , NJ , NJ , NJ , NJ , NJ , NJ THIS IS A REPEAT DEFICIENCY Cited during the complaint survey dated 2/4/15. Based on observation, interviews, medical record review and review of other facility documentation, it was determined that the facility; A. Failed to arrange a safe transport to the hospital for 1 of 1 residents (Resident #12), who had a [DIAGNOSES REDACTED]. The facility staff allowed the resident to be transferred by his/her Responsible Party (RP) to the emergency room without the benefit of a medical transport or EMS (Emergency Medical Services). Resident #12 was admitted to the hospital with [REDACTED]. B. Failed to obtain a physician's order for the use of [REDACTED]. This resulted in the resident developing an unstageable/necrotic pressure ulcer (PU) to the left lateral foot; C. Failed to administer nectar thickened liquids (NTL) on two separate occasions in accordance with physician's orders for 1 of 20 sampled residents (Resident #14). The resident was transferred to the hospital the following day with the [DIAGNOSES REDACTED].>D. Failed to implement physician's orders for 4 of 20 sampled resident's (Resident #2, #4, #8 and #15); E. Failed to administer medications and supplements in accordance with physician's orders and scheduled medication/supplement administration times for 2 of 5 residents observed during a medication pass (Resident #6 and Resident #7). The deficient practices were evidenced by: 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 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. A-1. According to Resident #12's Admission Record, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) an assessment tool dated 12/22/2014, Resident #12 had a BIMS (Brief Interview of Mental Status) score of 4, indicating severe cognitive impairment. The resident was Care Planned for the use of [MEDICAL CONDITION] medications, Dementia, Sundowning (a symptom of [MEDICAL CONDITION] and other forms of dementia), aggressiveness with other residents and wandering. Her daughter is listed as her P.O.A. (Power of Attorney). On 8/31/14 at 16:18 (4:18 p.m.) the Interdisciplinary Notes, provided to the survey team on 9/17/15, indicate that the Resident had been out of bed, vital signs were normal and denied any pain or acute distress. The next note documented was on 9/4/14 at 15:36 (3:36 p.m.) by the Nurse Practitioner (NP). The note states: I was asked to see the Resident today because she is complaining of abdominal pain. The NP documented that an exam was performed and vital signs were taken. When asked to point to where it hurts, she points to right upper quadrant - states pain has been there all day .breathing easy and unlabored-diminished breath sounds, no crackles-No wheezes-resident flinches with pain with deep inspiration .Impression: Possible [MEDICATION NAME]. Plan US (ultrasound) of abdomen. A Progress note dated 9/4/2014 at 23:22 (11:22 p.m.) documented by the Nurse Manager, who had contacted the Resident #12's responsible party on 9/4/2014, indicated that the Resident's P.O.A. had informed them that (Resident #12's) gall bladder had been removed. A late Progress Note, dated 9/5/14 (for 9/4/14) at 7:01 a.m., written by a Licensed Practical Nurse (LPN), documented that the resident had been complaining of pain on 9/4/14 in the morning and the Nurse Practioner (NP) was called and asked to come in to examine the resident. The PN also documented that if the ultrasound was negative, and an x-ray will be ordered to rule out rib fx (fracture). A review of a PN dated 9/5/14 at 19:27 (7:27 p.m.) written by the Nurse Practitioner (NP), documented that the she saw Resident #12, the US was done and the results were pending. The NP again examined the resident and Resident #12 was still was complaining of right upper and right lower quadrant (abdomen) pain. The NP further documented that the resident's breathing is easy/unlabored. A review of Resident #12's Interdisciplinary Note dated 9/5/14 at 22:35 (11:35 p.m.) reflected that evening a nurse documented that the ultra sound was done and that the Supervisor was aware. The note also indicated that Md (sic) will review results. An Interdisciplinary Notes dated 9/6/2014 at 18:49 (6:49 p.m.) (written by a nurse), indicated: 3pm (3:00 p.m.), resident c/o (complained of) persistent pain in (his/her) chest to (his/her) (responsible party). VSS (vital signs) 122/80, 71, 20 T (temperature) 97.1. Pulseox (PO2) 95% (at) room air. Dr (doctor) .examined resident orders received to send resident to (hospital) for eval (evaluation) per POA's request. The resident was given a breathing treatment and sent to the hospital at 4:00 p.m. with POA. A review of the emergency room (ER) records dated 9/6/14 reflected that the resident was received in the ER at 16:24 (4:24 p.m.). The Triage Notes document as follows: PT (patient) c/o chest pain and abdominal pain x (times) 2 days. Pt (patient) has increased pain with inspiration. Pt's (responsible party) drove pt to the ER from (the facility). Pt had ultrasound and (responsible party) reports 'plural effusion'. After an examination by the ER physician, the physician documented the conclusion as: Findings of a small right-sided [MEDICAL CONDITIONS] involving a muscle off the right main [MEDICAL CONDITION] artery extending laterally and towards the right upper lobe. The resident was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. The surveyor was unable to read physician progress notes [REDACTED].#3 and RN #6 to read the physician progress notes [REDACTED]. A review of the policy entitled Transfer or Discharge, Emergency under the title Policy Interpretation and Implementation reflected: 1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedure: f. Assist in obtaining transportation. The policy did not specifically include a specific type of transportation, how to arrange for transportation, or which type of transportation to use in cases of emergency. During an interview on 10/9/2015 at 3:00 p.m. with RN #2, regarding what to do if a physician orders a resident to go to the hospital and is short of breath, RN #2's response was not to let the family take the resident to the hospital and the Resident would be sent by ambulance. B-1. According to the Medical Record (MR), Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], indicated that the resident's cognitive status was severely impaired and that the resident required total assistance with ADLs. There were no pressure wounds documented. The Braden Scale for Predicting Pressure Sore Risk dated 2/16/15 showed a score of 10 which indicated high risk for skin breakdown. The Care Plan to prevent skin breakdown was initiated two days after admission on 2/18/15. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. The Admission Nursing Evaluation dated 2/16/15, indicated that there was no pressure wounds. The Physician Order Sheet (POS) dated 2/16/15, showed an order for [REDACTED].>The February/March 2015 Treatment Administration Record (TAR) indicated that the weekly skin assessments were not initialed as completed on 2/23, 3/2, 3/7, or 3/16/15. The Physician's orders dated 3/9/15 and 3/17/15, showed orders to pad the CAM boot with the abdominal pad every shift. There was no Physician's order for the application or removal of the CAM boot documented. The March 2015 TAR had Physician's orders transcribed to pad the CAM boot with abdominal padding every shift. The treatment was initialed as completed from 3/9 to 3/18 except on 3/12, during the 7:00 a.m. to 3:00 p.m. and on 3/17, during the 11:00 p.m. to 7:00 a.m. shifts. There was no documentation indicating that the feet were assessed. The Care Plan further revealed that on 2/22/15, redness was noted on the resident's bilateral buttocks, on 2/27/15 Moisture Associated [MEDICAL CONDITION] (MASD) was identified, on 3/6/15 the buttocks wounds progressed to Stage 2, and on 3/9/15, left heel necrosis was identified. There was no documentation in the medical record that indicated Resident #5's feet were assessed. There was no documentation in the Progress Notes (PN) on 2/22/15 written by a Register Nurse regarding the redness located on the bilateral buttocks, on 2/27/15 regarding the MASD, and on 3/6/15, regarding the Stage 2 wounds to the buttocks. The PN dated 3/9/15, indicated a necrotic area was identified on the left lateral foot. The size of the necrotic area was not documented. The NP was notified. The POS dated 3/9/15, showed orders to apply Santyl ointment (a debridement agent) to the left lateral foot and to cover with a dry dressing daily. The Wound Consult dated 2/27/15, indicated MASD of the sacral region. Moisture erosions along the right gluteus. The NP Physical Exam included but was not limited to the following: for the extremities; no cyanosis, no orthopedic abnormalities, nonambulatory and had right [MEDICAL CONDITION]. There was no documentation that indicated the resident's feet were assessed. The Wound Consult dated 3/6/15, indicated MASD of the sacral region, Stage 2 pressure ulceration to the left and right sacral/gluteal regions. The Physical Exam by the NP included but was not limited to the following: for the extremities; no cyanosis, no orthopedic abnormalities, nonambulatory and had right [MEDICAL CONDITION]. There was no documentation that indicated the resident's feet were assessed. The Podiatry Consult dated 3/10/15, showed a [DIAGNOSES REDACTED]. The Podiatry Consult dated 3/26/15, indicated the Left Sub 5th metatarsal ulcer was still present, discontinue the Santyl order and begin [MEDICATION NAME] (a topical antibiotic) to the Left Sub 5th metatarsal ulcer daily with dressing. Further review of the medical record revealed that the [MEDICATION NAME] was never written as an order and/or transcribed onto the TAR. A review of Resident #5's March 2015 TAR reflected a physician's order for Santyl ointment to the left lateral foot daily. The TAR was initialed by the nurses on 3/26, 3/28, 3/29 and 3/30/15 that indicated the Santyl treatment was continued and not discontinued. The POS dated 2/16/15, did not specify when to weigh the resident. The weekly and monthly option was left blank. The PN's for Resident #5 were reviewed from 2/16/15 to 3/31/15. There was no documentation for weights. The Weights and Vitals Summary indicated that on 3/16/15, Resident #5 was weighed with the Hoyer lift and weighed 186 pounds (lbs). On 3/29/15, Resident #5 was weighed with the Hoyer lift and weighed 175.6 lbs. indicating that Resident #5 lost 10.4 lbs within 13 days. There was no documentation that indicated that the physician was notified of the change in weights. The surveyor conducted an interview on 9/23/15 at 11:50 a.m., with the Director of Nursing (DON). The DON stated that skin checks for any kind of pressure wounds should be on the Care Plan. The surveyor conducted an interview on 9/23/15 at 1:20 p.m., with the Physical Therapist (PT). The PT explained that a physician order was needed for boots and skin checks. The PT further explained that Resident #5 was admitted to the facility with the MAFO (Molded Ankle-Foot Orthosis) boot and that the resident wore the boot on the right leg. However, there was no documentation in the medical record that indicated that the resident wore the MAFO boot on the right leg. The PT stated that the MAFO boot was used to relieve pressure. The PT further stated that the CAM boot was a black boot used for sprains, stability, and support. C-1. According to the Admission Record, Resident #14 was admitted to the facility 12/2014, with [DIAGNOSES REDACTED]. On January 20, 2015, the facility upon request, faxed into the Department of Health (DOH) two incident reports regarding Resident #14 receiving clear liquids dated 1/4/2015 and 1/8/2015. The incident report dated 1/4/2015, with the incident time as 10:24 am, stated under Incident Description: I gave resident regular water by mistake while administering her 9 a.m. meds - she is ordered NT (Nectar Thickened) liquids. Listed on the Incident Report under the section entitled Agencies / People Notified, the Resident's son and the Physician were listed as being notified. On 1/8/2015, following the first instance, Resident #14 was provided a second time with water that was not thickened. The Incident report provided states: Resident asked non nursing staff member for water. Two sips of regular water given. Resident coughed. No choking. No s.o.b. (shortness of breath). Under the section entitled Resident Description it states: Resident currently on abt (antibiotics) for pneumonia and has had a cough present. Resident is only to have nectar thick fluids. I'm fine. Can I have some water? Under the section entitled Agencies / People Notified it lists Family Member and Physician. The facility staff failed to report the incident to the Department of Health. On 9/17/15 at 9:15 am, RN #4 was interviewed by the surveyor regarding these two instances. This RN #4 stated that she remembered the second instance. It was someone who was trying to be helpful. Someone who didn't know the difference between A and B bed. RN #4 went on to state that she was not working when the first incident occurred but said: Think that one occasion it was a nurse. A med (medication) nurse that gave water with meds. At 10:25 am the surveyor attempted to review the physician progress notes [REDACTED]. The surveyor asked RN #3 and RN #6 to read the physician progress notes [REDACTED]. Because the notes were not timed, it could not be determined if the Physician saw the resident before or after the incident. The facility staff were requested to provide documentation regarding the investigations of these two instances. RN #4 provided documentation regarding the incident of 1/8/2015 on 9/23/2015 at 10:45 a.m. When documentation regarding the 1/4/2015 investigation was requested on 9/23/2015 at 10:45 a.m., the RN #4 stated: There was only one instance of the Resident (#14) getting clear liquids. I couldn't find any other documentation of any other incident regarding (Resident # 14). I must have been mistaken. The surveyor attempted to interview RN #3 and two CNA's regarding Resident #14 on 9/23/2015 at 9:30 a.m. None of those staff members were working in the facility at that time of the incidents. CNA #3 stated that she had taken care of Resident #14 but was not working 1/4/2015 or 1/8/2015. None of the nurses who took care of him are here any more. All staff interviewed on 9/16/2015 and 9/23/2015 did, however, know that when a resident is receiving thickened liquids, a pink dot is displayed next to their name and posted outside the residents door. The Administrator and Director of Nursing were asked to provide documentation of investigations to the surveyors on the days of the survey (9/16, 9/17 and 9/23/2015). The staff members failed to provide any investigation for the 1/4/2015 incident. Three interviews, an incident report and a form entitled Incident Report Check Off List were provided on 9/23/2015 at 10:45 am regarding the incident of 1/8/2015. D-1. According to the Admission Record, the Resident #2 was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had a moderate cognitive deficit, was non-ambulatory and required supervision with ADLs. Resident #2's Care Plan initiated on 4/19/15 reflected the resident had an actual fall with serious injury. Interventions included but were not limited to; monitor/document/report PRN (as necessary) for 72 hours pain, bruises and/or change in mental status to the resident's physician. A review of PNs dated 4/19/15 at 12:50 p.m. written by a RN indicated Resident #2 had sustained a fall outside, when a visitor was pushing the resident in a rolling walker backwards. The resident tipped over and hit his/her head on (the) road. The resident was alert and was bleeding profusely from the occipital part (the back) of the head. Emergency services (911) were called and transported the resident to the hospital for evaluation. A review of Resident #2's emergency room record dated 4/19/15 reflected the resident received 2 staples for a laceration to the scalp that measured 1.0 cm (centimeter). Discharge instructions reflected the resident was to have the staples removed in 10 days. A review of a physician order sheet (POS) dated 4/19/15 reflected a telephone order was obtained to remove staples in 10 days. A review of Resident #2's TAR for April 2015 did not reflect the physician's order to remove staples in 10 days. A review of Resident #2's physician progress notes [REDACTED]. A review of Resident #2's PN's from 4/26-5/4/15 did not document the condition, assessment and/or presence of the staples to the back of Resident #2's head. A review of a PN dated 5/5/15 at 22:26 (10:26 p.m.) written by a LPN, documented Staples intact on back of (Resident #2) head. There was no documentation that reflected the physician was notified that the staples were not removed on 4/29/15. A review of PN's dated 5/6/15 at 17:53 (5:53 p.m.) written by RN #2 reflected Resident #2 was seen by the Nurse Practitioner (NP) Who stated the staples to the back of the resident's head will be ready to be removed in the morning. The scab surrounding staples reduced with warm water soaks. The responsible party was made aware of the resident's status and treatment plan. A review of Resident #2's Care Plan reflected a revision was made on 5/7/15 by RN #2, that indicated Remove staples on 5/7/15 by NP date initiated 5/7/15. A subsequent PN dated 5/7/15 at 16:22 (4:22 p.m.) written by RN #2 indicated the 2 staples were removed by the NP and a scant amount of blood was noted after the procedure. A review of Resident #2's physician progress notes [REDACTED]. There were no prior physician progress notes [REDACTED]. During an interview on 9/16/15 at 1:10 p.m. with RN #2 (Unit Manager), she stated that Resident #2 was transferred to her unit on 5/4/15. RN #2 confirmed that Resident #2 still had the 2 staples in place when the resident was transferred to the unit. In addition, she revealed that she doesn't know why the staples were not removed until 5/7/15. RN #2 stated Isn't there a MD (medical doctor) note? As I recall there was no treatment to the area. In addition, she revealed that the 2 staples were scabbed over and the nursing staff had to soak the area to remove the scab in order to remove the staples. During an interview with the Director of Nursing (DON) on 9/17/15 at 9:15 a.m., she stated that the reason the staples were not removed was because no one notified the physician. The DON revealed that she disciplined the nurse (RN #5) because she didn't notify the physician. A review of RN #5's employee file did not show a disciplinary action for the aforementioned incident. The DON provided the surveyor with a statement from RN #5 dated 5/20/15 that indicated that the nurse saw the physician's order to remove the staples in 10 days and indicated that she notified the NP that the resident had returned from the ER and needed the staples removed in 10 days. RN #5 documented that she transcribed the physician's order to remove the staples on the April 2015 TAR for I believe 4/29/15 and boxed it in. A review of two statements both dated 5/20/15 and obtained during the course of the facility's investigation, indicated that both nurses had transcribed the order to the remove the staples onto the April TAR. However, a review of Resident #2's April 2015 TAR did not reflect that the physician's orders were transcribed onto the April TAR. A review of an entry on a facility calendar dated 4/29/15 obtained as part of the facility's investigation documented (Resident #2)-staples out by MD indicating the staples were to be removed on that date (4/29/15). This calendar was not part of the resident's medical record. A review of the facility's Wound Care policy revised 10/2010, reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1.) Verify that there is a physician's order for the procedure. D-2. According to the Admission Record Resident #4 was admitted to the facility in 1/2015, with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], indicated the resident required extensive assistance and was totally dependent on staff with ADLs. There was no pressure wounds documented. The Braden Scale for Predicting Pressure Sore Risk dated 1/30/15, showed a score of 16 which indicated the resident was a high risk for skin breakdown. The Care Plan initiated on 1/30/15, identified the potential skin impairment related to fragile skin. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. In addition, a pressure relieving mattress was implemented. The Admission Nursing Evaluation dated 1/30/15, indicated that there was no pressure wounds. The POS dated 1/30/15, showed an order for [REDACTED]. The PN dated 2/3/15 and 2/4/15, indicated the nurse administered a treatment to the sacral wound. However, there was no orders written for the treatment until 2/8/15, and no description of the wound. The PN dated 2/8/15, indicated that an open area on the sacrum/coccyx area was identified. There was no assessment of the wound. The NP was made aware and ordered a wound consult and treatment. Barrier cream was applied and the wound was covered with a dry dressing until the treatment ointment was available. The Nursing Supervisor was made aware and a low air loss mattress was requested. The POS dated 2/8/15, showed the following order: cleanse sacral wound with NSS (Normal Saline Solution) Apply [MEDICATION NAME] to sacral decub (decubitus ulcer) cover with border dsg (dressing) daily. The February 2015 TAR indicated that the aforementioned treatment was not administered until 2/10/15; two days after the order was written. The Wound Consult dated 2/11/15, described the sacral wound as Unstageable. An interview was conducted by the surveyor on 9/16/15, with the DON. The DON explained that she was uncertain of the frequency the skin assessments were conducted for the residents. An interview was conducted by the surveyor on 9/16/15 with Assistant Director of Nursing (ADON). The ADON stated weekly skin assessments were done on all of the residents. A post-survey telephone interview was conducted by the surveyor on 10/8/15 at 2:19 p.m. with the Administrator. The Administrator explained that when the medication or ointment was not available at the facility; the emergency back-up pharmacy delivered ordered items to the facility. The Administrator further stated that there should not be a delay in treatment administration. The facility policy titled, Pressure Ulcer Risk Assessment included but was not limited to: .Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Monitoring .Nurses will conduct skin assessments at least weekly to identify changes .Documentation The following information should be recorded in the resident's medical record: 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas). There was no evidence that the policy was consistently followed. D-3. According to the Admission Record, Resident #8 was admitted to the facility in 8/2013, with [DIAGNOSES REDACTED]. An MDS dated [DATE], revealed Resident #8 scored a 3 for cognition which indicated severe cognitive impairment and was totally dependent on staff for all ADLs and needed assistance of two (2) staff for bed mobility, defined as how the resident moves to and from lying position, turning side to side and positions body while in bed . A CP initiated 9/2013 and reviewed 7/29/2015, included a focus on the potential for pressure ulcer development related to (r/t) immobility. Interventions included but were not limited to; (Resident #8) needs total dependence assistance to turn/reposition . An MDS Kardex Report/Certified Nurses Aide (CNA) CP, with a print date of 5/18/2015, included that Resident #8 needed total dependence of two person physical assistance for bed mobility and transfers and on 7/6/2015 the CP was updated to include not to turn on the left side r/t the fracture. A review of NN dated 7/7/2015, included that an x-ray of the left arm was ordered on [DATE] due to persistent swelling which revealed a moderately displaced fracture in the distal shaft of the left humerus. A Physician Order Sheet (POS) dated 8/10/2015, included an order to follow-up with an orthopedic appointment on 8/31/2015, for a [DIAGNOSES REDACTED]. A POS dated 8/11/2015, included; only restart getting OOB (out of bed) with Hoyer when ok (okay) with orthopedic. An orthopedic consult recommendation dated 8/31/2015, included but was not limited to; may resume full activity, please manipulate LUE (left upper extremity) with care. A POS dated 9/1/2015, included but was not limited to; discontinue left arm soft cast, resume full weight bearing to LUE (left upper extremity), do not manipulate arm, follow up (F/U) in 4 wks. with an Orthopedic appointment on 9/28/2015, follow-up with PT/OT (physical and occupational therapy.) During a tour of the unit with the Registered Nurse Unit Manager (RN #4) on 9/16/2015 at 10:10 a.m., the surveyor observed Resident #8 in bed. The surveyor asked RN #4 if Resident #8 gets out of bed (OOB) daily and the Unit Manager (UM) stated that Resident #8 had sustained a fractured humerus which had healed and they were awaiting the results from a PT referral. The UM confirmed that Resident #8 needed assistance of 2 staff members for mobility in bed. During an interview with the surveyor on 9/17/2015 at 2:20 p.m., RN #4 stated that Resident #8 had not yet been OOB since the 9/1/2015 Physician Order (PO) to resume full weight bearing to LUE because RN #4 thought PT should be involved. RN #4 stated he had sent a referral to the PT Department but was unable to provide a PT referral form to the surveyor. RN #4 thought the PT Department was waiting for the next F/U appointment with the orthopedic physician before evaluating the resident. During an interview with the surveyor, accompanied by RN #4, on 9/17/2015 at 2:45 p.m., the PT Director stated that she did not have and was not aware of a PT referral for Resident #8. The PT Director stated that Resident #8 was evaluated and seen after being diagnosed with [REDACTED]. The PT Director explained that a POS to resume full activity meant that a resident can do what they did before and Resident #8 had been able to get OOB via a Hoyer lift. D-4. Resident # 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the medical record on 9/17/2015, admission orders [REDACTED]. The Resident's clinical care plan initiated 1/12/2015 documents under Focus: (Resident # 15) has nutritional problems r/t (related to) use of mechanically altered and therapeutic diet and [DIAGNOSES REDACTED]. [MEDICATION NAME] include: provide and serve diet as ordered, honor food preferences, weights as ordered. On 9/17/2015 documentation of weights for Resident # 15 were requested. The MDS Coordinator provided a sheet of paper that contained two weights recorded on the same day 1/12/2015 and timed 20:29 and 19:54 with the same weight of 210. No further weights for this resident were provided. The Resident was transferred from the facility on 1/28/2015 due to a change in mental status. The surveyor asked the MDS Coordinator if there were any further weights for this resident and the MDS Coordinator responded that was all. E-1. Resident # 6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] indicated that the resident had moderate cognitive impairment and received assistance with ADLs. The September 2015 POS showed an order for [REDACTED]. The September 2015 Medication Administration Record [REDACTED]. On 9/16/15 at 9:05 a.m., the surveyor conducted a medication pass observation with Licensed Practical Nurse (LPN) #4. The surveyor observed LPN #4 administer [MEDICATION NAME] 50 mg to Resident #6. LPN #4 did not offer food to the resident. During an interview on 9/16/15 at 9:28 a.m., LPN #4 stated that breakfast was served at 8:00 a.m. The surveyor received a typed memo on 10/9/15 from the Dining

C# NJ , NJ , NJ & NJ Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to update and/or the resident's Care Plans (CP) for 3 of 20 sampled residents (Resident #14, #5 and #2). Resident #14's care plan was not updated after the first incident of being administered thin liquids. A subsequent incident occurred 4 days later, when Resident #14 was administered thin liquids a second time and on 1/9/15 was hospitalized with a [DIAGNOSES REDACTED].#5), who developed an unstageable necrotic area to the left heel. The deficient practices were evidenced by: The surveyors reviewed the medical records on 9/15/15, 9/16/15, and 9/23/15. 1. According to the Admission Record, Resident #14 was admitted to the facility in 12/2014 with [DIAGNOSES REDACTED]. On 12/29/2014 the Physician documented in the Physician order [REDACTED]. On 1/20/2015, the facility, upon request, faxed into the Department of Health (DOH) two incident reports regarding Resident #14 receiving clear (thin) liquids. On that date, the facility provided Incident Reports dated 1/4/2015 and 1/8/2015. The incident report dated 1/4/2015, with the incident time 10:24 a.m., reflected under Incident Description: I gave resident regular water by mistake while administering (his/her) 9 a.m. meds - (he/she) is ordered NT (Nectar Thickened) liquids. The second Incident Report dated 1/8/2015 with the time of the incident 2:30 p.m., documented Resident #14 was provided with water. This Incident Report reflected under Incident Description: Resident asked non nursing staff member for water. Two sips of regular water given. Resident coughed. No choking. No s.o.b. (shortness of breath). Under the section entitled Resident Description the report stated: Resident currently on abt (antibiotics) for pneumonia and has had a cough present. Resident is only to have nectar thick fluids. According to a Universal Transfer Form dated 1/9/2015 and timed 10:00 a.m., the resident was transported to the hospital with the reason for transfer (handwritten was an upward arrow) that indicated the resident had an increased temp (temperature). Listed as the [DIAGNOSES REDACTED]. The Care Plan (CP) provided to the surveyor on the day of the survey showed an updated focus, goals and interventions added on 1/8/2015, after the second instance of the Resident receiving clear liquids. It reflected (Resident #14) has pneumonia. 1-8-15 (Resident #14) received two sips of water. There were no indication that the Care Plan was updated after the 1/4/2015 incident when the Resident received water from a nurse. On 9/17/15 at 9:15 a.m., Registered Nurse (RN) #2 was interviewed regarding these two instances. RN #2 stated that she remembered the second instance. It was someone who was trying to be helpful. Someone who didn't know the difference between A and B bed. RN #4 went on to say that she was not working when the first incident occurred but said: Think that one occasion it was a nurse. A med (medication) nurse that gave water with meds. On 9/17/15 at 10:25 a.m. the surveyor attempted to review the physician progress notes [REDACTED]. The notes were also given to RN #3 and RN #6 to interpret. Neither of these nurses were able to interpret the physician progress notes [REDACTED]. In addition, the notes were not timed, it could not be determined if the Physician observed the Resident before or after the incident. Facility staff were requested to provide documentation regarding the investigations of these two incidents. RN #4 provided documentation regarding the incident of 1/8/2015 on 9/23/2015 at 10:45 a.m. When documentation regarding the 1/4/2015 investigation was requested a second time RN #4 stated: There was only one instance of the resident getting clear liquids. I couldn't find any other documentation of any other incident regarding (Resident #14). I must have been mistaken about the other one. The Surveyor attempted to interview RN #3 and two Certified Nursing Assistants (CNA) regarding Resident # 14. None of those staff members were working in the facility at that time of the occurrences of Resident #14 receiving unthickened water. CNA #3 stated that she had taken care of this resident but was not working that day. She went on to say: None of the nurses who took care of her are here any more. 2. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool dated 2/28/15, indicated that the resident's cognitive status was severely impaired and that the resident required total assistance with Activities of Daily Living (ADLs). There were no pressure wounds documented. The Braden Scale for Predicting Pressure Sore Risk dated 2/16/15, showed a score of 10 which indicated high risk for skin breakdown. The Care Plan (CP) to prevent skin breakdown was implemented two days after admission on 2/18/15. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. The Admission Nursing Evaluation dated 2/16/15, indicated that there were no pressure wounds. The Physician order [REDACTED].>The February/March 2015 Treatment Administration Record (TAR) indicated that the weekly skin assessments were not initialed/documented as having been completed on 2/23, 3/2, 3/7, or 3/16/15. The POS dated 3/9/15 and 3/17/15, showed orders to pad the CAM boot with the abdominal pad every shift. There were no specific physician's orders [REDACTED]. The March 2015 TAR showed to pad the CAM boot with abdominal padding every shift. The treatment was initialed as completed from 3/9 to 3/18 except on 3/12, during the 7:00 a.m. to 3:00 p.m. shift, and on 3/17, during the 11:00 p.m. to 7:00 a.m. shift. There was no documentation indicating that the feet were assessed. The CP further revealed that on 2/22/15, redness was noted on the resident's bilateral buttocks, on 2/27/15 Moisture Associated [MEDICAL CONDITION] (MASD) was identified. On 3/6/15 the documentation indicated that the buttocks wounds progressed to Stage 2, and on 3/9/15, left heel necrosis was identified. There was no documentation in the Medical Record (MR) that indicated Resident #5's feet were ever assessed. There was no documentation in Resident #5's Progress Notes (PN) on 2/22/15 about the redness located on the bilateral buttocks, on 2/27/15 about the MASD, and on 3/6/15 about the Stage 2 wounds. The PN dated 3/9/15 at 19:40 (7:40 p.m.) written by an LPN, indicated a necrotic area was identified on the left lateral foot. The size of the necrotic area was not documented. The PN indicated that the Nurse Practitioner (NP) was notified, and the POS dated 3/9/15, showed orders to apply Santyl ointment to the left lateral foot and to cover with a dry dressing daily. The Wound Consult dated 2/27/15, indicated MASD of the sacral region. Moisture erosions along the right gluteus. The Physical Exam listed on the Wound Consult included but was not limited to the following: for the extremities the NP documented that there was no cyanosis, no orthopedic abnormalities, was nonambulatory and had right [MEDICAL CONDITION]. There was no documentation that indicated the resident's feet were assessed at that time. The Wound Consult dated 3/6/15, indicated MASD of the sacral region, Stage 2 pressure ulceration to the left and right sacral/gluteal regions. The Physical Exam listed on the wound consult included but was not limited to the following: for the extremities the NP documented; that there was no cyanosis, no orthopedic abnormalities, was nonambulatory and had right [MEDICAL CONDITION]. There was no documentation that indicated the resident's feet were assessed at that time. The Podiatry Consult dated 3/10/15, showed a [DIAGNOSES REDACTED]. The Podiatry Consult dated 3/26/15, indicated the Left Sub 5th Metatarsal Ulcer was still present and to discontinue the Santyl order and to begin [MEDICATION NAME] (a topical antibiotic) to the Left Sub 5th Metatarsal Ulcer daily with a dressing. Further review of the MR revealed that the [MEDICATION NAME] was not written as an order and/or transcribed onto the TAR. The CP initiated on 3/9/15, identified left heel necrotic area. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. However, the Care Plan was not updated/revised for use of the CAM boot. The surveyor conducted an interview on 9/23/15 at 11:50 a.m., with the Director of Nursing (DON). The DON stated that skin checks for any kind of pressure wounds should be documented on the Care Plan. The surveyor conducted an interview on 9/23/15 at 1:20 p.m., with the Physical Therapist (PT). The PT explained that a physician's orders [REDACTED]. The PT further explained that Resident #5 was admitted to the facility with a MAFO (Molded Ankle-Foot Orthosis) boot and wore it on the right leg. The PT also stated that the MAFO boot was used to relieve pressure. However, there was no documentation in the MR that indicated that Resident #5 wore the MAFO boot on either leg. The PT further stated that a CAM boot was a black boot used for sprains, stability and support. 3. The surveyor reviewed Resident #2's medical record on 9/15/15 and 9/16/15. According to the Admission Record, the resident was admitted to the facility with medical [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had a moderate cognitive deficit, was non-ambulatory in the corridor, and required supervision with ADLs. Resident #2's CP initiated on 3/6/15 indicated the resident was at risk for falls. Interventions included but were not limited to; the use of a bed and chair alarm, a safe environment, make sure call bell is within reach. A review of an electronic Incident Report (IR) dated 4/12/15 at 10:35 a.m. completed by RN #2, indicated that Resident #2 pushed open the front (lobby) internal door and fell backwards onto his/her bottom. The resident's description of the incident was I was hurrying and fell back when I pushed the door. I did not hurt anything. I'm o.k. (okay). The IR reflected there was one staff person who witnessed the incident. The Progress Note (PN) dated 4/12/15 at 11:44 a.m., reflected the resident was educated to wait for assistance to open the door. There was no documentation that indicated Resident #2's CP was updated to reflect the new intervention. A review of an IR dated 4/19/15 at 12:40 p.m. reflected that personnel saw patient lying on the ground with (a visitor). The visitor informed the staff person that she was pushing Resident #2 backwards on walker down sidewalk to parking lot and the resident went over backwards hitting (his/her) head on the road. The resident was awake and alert and bleeding profusely from the back of the head. The resident informed the staff person that he/she was going out to church when the visitor was pushing him/her and I went over backwards. The IR reflected the predisposing factor was the resident was walking without proper assistive device. The PN's dated 4/19/15 at 12:50 p.m., confirmed the aforementioned incident. Resident #2's CP was updated on 4/19/15, that reflected the resident had an actual fall with serious injury. Interventions included but not limited to; monitor/document/report PRN (as necessary) for 72 hours pain, bruises and/or change in mental status to the resident's physician. However, there was no documentation that reflected Resident #2's CP was updated with new interventions to address reoccurrence. During an interview on 9/16/15 at 1:05 p.m., Resident #2 stated that he/she had a fall outside about 3 weeks ago. The surveyor asked the resident if he/she could recall any other fall incidents and the resident stated No. During an interview on 9/17/15 at 9:15 a.m., the DON stated that after a fall occurs they will do an incident report, get statements from staff, do a conclusion, then update the care plan after the conclusion of the investigation. During an interview on 9/17/15 at 11:15 a.m., RN #2 stated that the facility's policy when an accident or incident occurs is; the witnessing person or nurse will collect the statements and/or interview the resident. In addition, she stated that the resident's CP should be updated as soon as possible, we immediately implement interventions if it's something we can do. During an interview on 9/17/15 at 9:15 a.m., the DON stated that after a fall occurs, they will do an incident report, get statements from staff, do a conclusion, then update the care plan after the conclusion of the investigation. On 9/23/15 at 8:50 am, the Administrator stated that CPs are updated immediately by the Unit Managers after incidents. NJAC 8:39-27.1 (a)

C#NJ , NJ & NJ Based on interviews and review of the medical record (MR) and other facility documentation, it was determined that the facility failed to assess for pain management and/or administer pain medication during a surgical procedure for 1 of 20 sampled residents (Resident #10). The resident during the procedure exhibited signs and symptoms of non-verbal pain including but was not limited to; kicking. This deficient practice was evidenced by; 1. According to the facility Admission Record, Resident #10 was admitted in 7/2014, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 3/25/2015, revealed Resident #10 had severe cognitive impairment and was totally dependent on staff for all activities of daily living (ADLs). Review of Resident #10's Care Plan (CP), initiated 1/2015, included but was not limited to; a focus on the potential for pain related to (r/t) Chronic Physical Disability and indicated that Resident #10 prefers to have pain controlled by : medication. Interventions included but were not limited to; anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/record/report any signs of non-verbal pain such as; mood/behavior changes: aggressive, squirmy, restless, constant motion; body: tense rigid, thrashing. Observe and report changes in usual routine; withdrawal or resistance to care. The CP also included that Resident #10 was Ventilator Dependent with Percutaneous Endoscopic Gastrostomy (PEG) for full nutritional support. A Physician order [REDACTED]. A Medication Administration Record [REDACTED]. A Skilled Nursing Note (NN), dated 3/12/2015 at 4:33 p.m. by Licensed Practical Nurse (LPN #2), included that LPN #2 provided 1:1 monitoring (one staff member to one resident) of Resident #10 on 3/12/2015. At 7:30 a.m. Resident #10's blood pressure was taken by a nurse on the team and (Resident #10) started getting angry and pulling at (his/her) tubing and swatting at this (LPN #2) nurse . LPN #2 also documented in the NN dated 3/12/2015 at 4:33 p.m., that a PRN (as needed) [MEDICATION NAME], an anti-anxiety medication was administered, however; (Resident #10) didn't calm down. The podo (Podiatrist #2) doctor came in to cut (Resident #10's) toe nails and (Resident #10) had just fallen asleep and as soon as (the Podiatrist #2) started, (Resident #10) started kicking. So this nurse (LPN #2) had to assist the doctor by holding (Resident #10's) legs down so the doctor could cut (Resident # 10's) nails. (Resident #10) then proceeded to hit the nurse multiple times. This nurse (LPN #2) tried to explain to (Resident #10) that the doctor was trying to cut (his/her) nails to make (his/her) toes feel better. This nurse (LPN #2) tried to explain to (Resident #10) that (his/her) toe would feel better in a minute because (he/she) had an ingrown nail with bleeding on .right great toe. Additionally, the aforementioned NN included; (Resident #10) doesn't seem like (he/she) understands. So this nurse (LPN #2) just sat by (Resident #10) and continued to place (Resident #10) back on vent, place (his/her) mittens back on (his/her) hands, cover .with a sheet because (Resident #10) continued to pull .gown and sheets off .Then the (staff) nurse came into the room to check (Resident #10's) blood sugar and (Resident #10) reached over and started hitting this nurse (LPN #2) again. Finally around 1 p.m. (Resident #10) fell asleep . During an interview with the surveyor on 9/23/2015 at 12:00 p.m., the Director of Nursing (DON) stated she began working at the facility in 4/2015, and reviewed the MR and the NN of 3/12/2015, for Resident #10 sometime in 5/2015. The DON stated she spoke with LPN #2 r/t the aforementioned NN about holding the resident's legs down, asked for clarification and obtained a statement dated 5/20/2015. Additionally, the DON added that she updated the CP after review of the NN. Further review of Resident #10's CP reflected it was updated on 5/20/2015 and included a focus on resistance to care related to (r/t) Anxiety and Dementia and potential to demonstrate physical behaviors (self-inflicted injury) r/t Dementia. Interventions included but not limited to; provide opportunities for choice during care provision, if resident resists with ADLs then reassure resident, leave and return 5-10 minutes later and try again; when agitated, intervene before escalation; assess and address for contributing sensory deficits and give as many choices as possible about care and activities. A review of the written statement, dated 5/20/2015, and signed by LPN #2, included that the podiatrist asked LPN #2 to assist in holding Resident #10's foot steady while the ingrown toenail was cut out on 3/12/2015. The podiatrist had completed the left and right foot without an issue but needed my (LPN #2's) assistance, when (Podiatrist #2) cut out the ingrown toenail, on the right foot. (Resident #10) was kicking the podiatrist with (his/her) feet. That is why (Podiatrist #2) asked me (LPN #2) to assist. I (LPN #2) did not apply any pressure; I (LPN #2) only gently held the foot steady so the podiatrist could cut (Resident #10's) toenails. (Resident #10) went to sleep immediately following the event. During a telephone interview with the surveyor on 9/23/2015 at 11:30 a.m., LPN #2 confirmed that she wrote an explanation statement for the NN dated 3/12/2015 after the DON asked her for clarification r/t holding the resident down during the podiatry procedure on 3/12/2015. LPN #2 explained that she was on light duty and did not and could not have held the resident down and stated she just held the foot steady. The surveyor asked for clarification r/t the statement dated 5/20/2015 about the resident kicking the podiatrist and LPN #2 stated that when the podiatrist started to cut the nail, the resident started to move his/her feet. Resident #10 was not kicking, just moving because it hurt. Review of a Podiatry Consult Report dated 3/12/2015 at 11:33 a.m., and Progress Note (PN) dated 3/12/2105, by Podiatrist #2 included that an ingrown toenail on the Right (R) hallux (great toe) bilateral (B/L) borders was removed and nails trimmed for Resident #10. Recommendations included that [MEDICATION NAME] (a topical antibiotic) and band-aid be applied for 7 days with an antibiotic for 10 days and follow-up in 1 week. The PN included that on vascular and dermatological exam; nail borders were ingrown with [DIAGNOSES REDACTED], [MEDICAL CONDITION], purulence and pain on palpation. The PN included that the offending nail borders removed. Abscess drained. [MEDICATION NAME] and gauze applied. Trimmed remaining nail . There was no documentation in the PN that any medication was offered and/or administered for pain. During a telephone interview with the surveyor on 9/23/2015 at 1:45 p.m., Podiatrist #2 confirmed that she treated Resident #10 on 3/12/2015 for the ingrown toenail and was assisted by a nurse to hold the resident's foot steady because Resident #10 was kicking. (Resident #10) was not understanding, (Resident #10) was kicking. I try to continue with care and the nurse applied minimal pressure on the knee so the leg could not be flexed. I don't believe in sedation. (The toe) was infected, yes, it is painful, tender, (Resident #10) did not understand due to dementia, (Resident #10) had no idea it was infected. (Resident #10) needed to have it done. We all have to do things we don't want to. During an interview with the surveyor on 9/23/2015 at 9 a.m., the Registered Nurse Unit Manager (RN #4) stated that if a cognitively impaired resident becomes combative during care, the care giver should; discontinue care, assess for pain, administer pain medication if needed and come back at a later time. During an interview with the surveyor on 9/23/2015 at 9:30 a.m., a 7-3 shift Registered Nurse (RN #7) who had worked at the facility for over [AGE] years, stated that a resident's foot can be lifted for care from the podiatrist but not held down and care should be stopped if a resident exhibits a behavior of kicking and the staff should come back later. RN #7 confirmed that an assessment for pain should be done and documented. During an interview with the surveyor on 9/23/2015 at 12:00 p.m., the Director of Nursing (DON) confirmed that she did not initiate an Incident Report (IR), inservices, and/or follow-up the investigation after obtaining the statement from LPN #2 on 5/20/2015. The DON also confirmed that she did not speak with the Podiatrist about the incident or any other residents about podiatry care. At that time, the DON confirmed that if a resident exhibits combative behavior during care it is a refusal and the care should be stopped, the resident approached at a later time, and additional interventions tried such as; assessing pain, administering pain medications, use another care giver, and/or notify the responsible party. Review of a facility policy titled Pain Assessment and Management, revised 10/2010, included but was not limited to the following; The purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs .Pain management .includes .effectively recognizing the presence of pain .Recognizing Pain: Observe the resident for .behavioral (non-verbal) signs of pain. Behavior such as resisting care, irritability, depression .verbal and/or facial expressions .Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. NJAC 8:39- 27.1 (a) & NJAC 8:39-4.1 (a) 4

C#'s NJ , NJ , & NJ Based on interviews, review of the medical record, and pertinent facility documentation, it was determined that the facility failed to consistently complete weekly skin assessments that included foot assessments, document wound size and appearance once skin breakdown was identified, and obtain specific physician orders for the indication of use for the Controlled Ankle Movement (CAM) boot for 1 of 20 sampled residents (Resident #5). Resident #5 was admitted to the facility with no skin breakdown and developed Stage 2 pressure ulcers on the right and left sacral/gluteal regions. In addition, left heel necrosis was identified 20 days after admission to the facility. Furthermore, the facility failed to complete weekly skin assessments, document the wound assessment when the wound was identified, document accurate information in the progress notes, and administer treatment as ordered by the physician for 1 of 20 sampled residents (Resident #4). An unstageable sacral wound was identified on Resident #4, nine days after admission to the facility. This deficient practice was evidenced by the following: The surveyor reviewed the medical records on 9/16, 9/17, and 9/23/15. 1. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool dated 2/28/15, indicated that the resident's cognitive status was severely impaired and that the resident required total assistance with Activities of Daily Living (ADLs). There were no pressure wounds documented. The Braden Scale for Predicting Pressure Sore Risk dated 2/16/15, showed a score of 10 which indicated high risk for skin breakdown. The Care Plan (CP) to prevent skin breakdown was implemented two days after admission on 2/18/15. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. The Admission Nursing Evaluation dated 2/16/15, indicated that there were no pressure wounds. The Physician Order Sheet (POS) dated 2/16/15, showed an order for [REDACTED].>The February/March 2015 Treatment Administration Record (TAR) indicated that the weekly skin assessments were not initialed/documented as having been completed on 2/23, 3/2, 3/7, or 3/16/15. The POS dated 3/9/15 and 3/17/15, showed orders to pad the CAM boot with the abdominal pad every shift. There were no specific Physician's Orders for the application or removal of the CAM boot documented. The March 2015 TAR showed to pad the CAM boot with abdominal padding every shift. The treatment was initialed as completed from 3/9 to 3/18 except on 3/12, during the 7:00 a.m. to 3:00 p.m. shift, and on 3/17, during the 11:00 p.m. to 7:00 a.m. shift. There was no documentation indicating that the feet were assessed. The Care Plan further revealed that on 2/22/15, redness was noted on the resident's bilateral buttocks, on 2/27/15 Moisture Associated [MEDICAL CONDITION] (MASD) was identified. On 3/6/15 the documentation indicated that the buttocks wounds progressed to Stage 2, and on 3/9/15, left heel necrosis was identified. There was no documentation in the Medical Record (MR) that indicated Resident #5's feet were ever assessed. There was no documentation in the Progress Notes (PN) on 2/22/15 written by a Register Nurse regarding the redness located on the bilateral buttocks, on 2/27/15 regarding the MASD, and on 3/6/15, regarding the Stage 2 wounds to the buttocks. The PN dated 3/9/15, indicated a necrotic area was identified on the left lateral foot. The size of the necrotic area was not documented. The NP was notified and and the POS dated 3/9/15, showed orders to apply Santyl ointment to the left lateral foot and to cover with a dry dressing daily. The Wound Consult dated 2/27/15, indicated MASD of the sacral region. Moisture erosions along the right gluteus. The Physical Exam listed on the Wound Consult included but was not limited to the following: for the extremities the NP documented; No cyanosis, no orthopedic abnormalities. + nonambulatory. R(right) [MEDICAL CONDITION]. There was no documentation that indicated the feet were assessed at that time. The Wound Consult dated 3/6/15, indicated MASD of the sacral region, Stage 2 pressure ulceration to the left and right sacral/gluteal regions. The Physical Exam listed on the wound consult included but was not limited to the following: for the extremities the NP documented; No cyanosis, no orthopedic abnormalities. + nonambulatory. R(right) [MEDICAL CONDITION]. There was no documentation that indicated the feet were assessed at that time. The Podiatry Consult dated 3/10/15, showed a [DIAGNOSES REDACTED]. The Podiatry Consult dated 3/26/15, indicated the Left Sub 5th Metatarsal Ulcer was still present and to discontinue the Santyl order and to begin [MEDICATION NAME] to the Left Sub 5th Metatarsal Ulcer daily with a dressing. Further review of the MR revealed that the [MEDICATION NAME] was not written as an order and/or transcribed onto the TAR. A review of Resident #5's March 2015 TAR reflected a physician's order for Santyl ointment to the left lateral foot daily. The TAR was initialed by the nurses on 3/26, 3/28, 3/29 and 3/30/15 that indicated the Santyl treatment was continued and not discontinued. The surveyor conducted an interview on 9/23/15 at 11:50 a.m., with the Director of Nursing (DON). The DON stated that skin checks for any kind of pressure wounds should be documented on the Care Plan. The surveyor conducted an interview on 9/23/15 at 1:20 p.m., with the Physical Therapist (PT). The PT explained that a Physician's Order was required for boots and skin checks. The PT further explained that Resident #5 was admitted to the facility with a MAFO (Molded Ankle-Foot Orthosis) boot and wore it on the right leg. The PT also stated that the MAFO boot was used to relieve pressure. However, there was no documentation in the MR that indicated that Resident #5 wore the MAFO boot on either leg. The PT further stated that a CAM boot was a black boot used for sprains, stability, and support. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS dated [DATE], indicated the resident required extensive assistance and was totally dependent on staff with ADLs. There were no pressure wounds documented. The Braden Scale for Predicting Pressure Sore Risk dated 1/30/15, showed a score of 16 which indicated the resident was a high risk for skin breakdown. The Care Plan initiated on 1/30/15, identified a potential skin impairment related to fragile skin. Interventions included but were not limited to: Identify/document potential causative factors and eliminate/resolve where possible. In addition, a pressure relieving mattress was implemented. The Admission Nursing Evaluation dated 1/30/15, indicated that there were no pressure wounds. The POS dated 1/30/15, showed an order for [REDACTED]. A review of Resident #4's PNs dated 2/3/15 and 2/4/15, written by two LPNs indicated the nurses administered a treatment to the sacral wound. However, there were no Physician's orders written for the treatment until 2/8/15, and no description of the wound was documented. A review of Resident #4's PN dated 2/8/15 written by a RN, indicated that an open area on the sacrum/coccyx area was identified. There was no documented assessment of the wound. The NP was made aware and ordered a Wound Consult and treatment. Barrier cream was applied and the wound was covered with a dry dressing until the treatment ointment was available. The Nursing Supervisor was made aware and a low air loss mattress was requested. The POS dated 2/8/15, showed the following order: cleanse sacral wound with NSS (Normal Saline Solution), Apply [MEDICATION NAME] to sacral decub (decubitus ulcer) cover with border dsg (dressing) daily. The February 2015 TAR indicated the aforementioned treatment was not administered until 2/10/15; two days after the order was written. The Wound Consult dated 2/11/15, described the sacral wound as unstageable. An interview was conducted by the surveyor on 9/16/15 at 9:17 a.m., with Assistant Director of Nursing (ADON). The ADON stated weekly skin assessments were done on all of the residents. An interview was conducted by the surveyor on 9/16/15 at 2:50 p.m., with the DON. The DON explained that she was uncertain of the frequency the skin assessments were to be conducted for the residents. A post-survey telephone interview was conducted by the surveyor on 10/8/15 at 2:19 p.m., with the Administrator. The Administrator explained that when the medication or ointment was not available at the facility; the emergency back-up pharmacy delivered ordered items to the facility. The Administrator further stated that there should not be a delay in treatment administration. The facility policy titled, Pressure Ulcer Risk Assessment included but was not limited to: .Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Monitoring: .Nurses will conduct skin assessments at least weekly to identify changes .Documentation: The following information should be recorded in the resident's medical record: 6. The condition of the resident's skin (i.e., the size and location of any red or tender areas). There was no evidence that the policy was consistently followed. NJAC 8:39-27.1(a)(e)

Based on observation, staff interview, review of the medical record and the facility's documentation, it was determined that the facility failed to consistently provide proper pain management for a resident who was admitted to the facility with a Stage 3 sacral pressure ulcer and shin wound and identified to have moderate pain. The resident verbalized his pain on two occasions during the survey and had no medication intervention. The resident was also observed to call out in pain during a pressure sore treatment with no intervention. In addition, the facility failed to monitor and observe fluid restrictions for a resident who received [MEDICAL TREATMENT]. This deficient practice was identified for 2 of 4 residents, Resident #11 and #12, as evidenced by the following: 1. On 1/19/12 at 10:00 a.m. the surveyor reviewed the medical record for Resident #11. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record revealed an initial nursing assessment sheet dated 12/23/11 which indicated that the sacral wound was assessed as a Stage 2 and measured 4x4 cm. Review of a wound consultation sheet which was completed on 12/30/11, revealed that the left shin wound measured 7x10 cm. The sacral ulcer was described as "full thickness ulceration with multiple scattered open areas, with the center region of the wound measuring 3x2 cm", the right buttock section of the wound measured 5x3 cm while the left area of the wound measured 3x2 cm. The wound was described as "possible deep tissue injury." The 1/6/12 wound sheet described the sacral wound as a "Stage 3 pressure ulcer." The surveyor reviewed the initial Minimum Data Set (MDS), an assessment tool, dated 1/10 12. Under the area marked "pain assessment," the surveyor observed the following: when the facility asked the resident if he had experienced pain in the past five days, the resident replied "yes." When the facility asked the resident if pain had limited his activity in the past 5 days, the resident replied "yes." When asked how often he experienced pain, the resident replied "occasionally." When asked about the severity of the pain experienced, the resident replied that he had "moderate pain." There was no documented evidence that the plan of care reflected the triggered care areas as indicated on the MDS. On 1/23/12 at 9:45 a.m., the surveyor went to the resident's room and observed the resident lying in bed. The surveyor asked the resident how he was and the resident replied "my rear end hurts." The surveyor reviewed the resident's medical record and the medication orders revealed no order for pain medication. At 10 a.m. that same day, the surveyor interviewed the medication nurse and asked how they managed the resident's pain. She told the surveyor that she would go and ask the resident about his pain and call the physician to obtain an order for [REDACTED]. The nurse went to the resident's room and after she left the room, she called the physician. The nurse told the surveyor at that time that the resident said he was experiencing pain. The surveyor reviewed the physician's orders [REDACTED]. At 10:10 a.m., the surveyor interviewed the unit manager (UM) and inquired about the facility's pain management protocol, specifically for resident's who were admitted with multiple wounds. She told the surveyor that they usually don't order pain medication as needed for residents, unless the resident complained of pain. The unit manager could not provide the surveyor with information regarding why pain medication was not ordered for the resident upon admission, when he was assessed to have moderate pain. On 1/24/12 at 10:40 a.m. to 10:55 a.m., the surveyor observed the resident in bed as the treatment nurse provided wound care for the sacral ulcer. The surveyor observed that when the nurse started to remove the old dressing from the wound, the resident moaned and said "that hurts." The nurse told the surveyor that she had medicated the resident prior to the treatment. The surveyor observed the wound to have an open area on the right buttock, and 2 open areas on the sacrum. As the resident continued to verbalize discomfort, the nurse continued to remove the old dressing and proceeded to cleanse the wound. During cleansing, the resident moaned in pain. The nurse tried to comfort the resident by telling him that she was almost finished with the dressing change, however still continued with the treatment. When the surveyor asked if the resident usually complained of pain during treatment, the nurse told the surveyor that this was her first time doing the treatment because it was usually done at 5 a.m. by the 11-7 shift. When the nurse applied cream to the wound, the resident yelled out again and stated "how many sores are there?" The resident's certified nursing assistant (CNA) who was helping the nurse with repositioning the resident for the treatment, told the surveyor that the resident would complain of pain if the wound was touched. He also stated he usually avoided touching the area when he provided care for the resident, and so long as he didn't touch the area, the resident didn't complain. According to wound consult team notes dated 12/30/11, 1/6/12 and 1/19/12, the resident did not complain of pain when they measured the wound. The nurse completed the treatment and then told the surveyor that the physician was in the building and that she would ask him to evaluate the resident's pain for more medication. The surveyor observed that the physician wrote another order for Tylenol 650 mg every 4 hours as needed for pain. The surveyor reviewed the facility's pain control policy. The policy stated that upon admission or as needed, they would monitor residents for symptoms of pain, provide detailed pain assessment and develop a care plan to alleviate the pain. On 1/25/12 at 11:00 a.m., during an interview with the DON and Administrator, the Administrator told the survey team that it was the policy of the facility to stop a procedure or treatment if the resident showed signs of pain or discomfort. The surveyor informed the Administrator that the nurse continued the Resident's pressure sore treatment, even though he complained of pain. On 1/25/12 at 9:45 a.m., after the resident had received his morning pain medication, the surveyor observed the resident in bed and asked how he felt. The resident stated "very good, no pain." The surveyor also observed a nurses' note dated 1/23/12 at 12:50 p.m., which stated that Tylenol "worked" and that the resident felt "good." 2. During the initial tour on 1/18/11 at 9:30 a.m., the unit manager told the surveyor that Resident #12 was admitted with [DIAGNOSES REDACTED]. The nurse also told the surveyor that Resident #12 was on 1200 ml fluid restriction per day. The surveyor then went into the resident's room and observed on the resident's bedside table, a pitcher of water filled to the top with water which measured approximately 720 ml. The surveyor also observed an 8 oz cup of liquid supplement, about 240 ml, for a total of approximately 960 ml, provided to the resident. At 12:30 p.m. that same day, the surveyor observed the resident seated on his bed eating lunch. There was a 4oz (120 ml) container of milk on the resident's tray and the water pitcher was still on the table within the resident's reach. The resident started to complain about the food and called for an alternate. A CNA responded, took the tray and brought another tray for the resident. The CNA did not remove the water pitcher from the resident's table. The surveyor reviewed the dietary slip on the resident's tray and it stated that dietary was to provide 400 ml of fluid per day. An interview with the unit manager that same day at 12:45 p.m., revealed that there was no system in place to communicate to the CNA's that the resident was on fluid restrictions. On 1/19/12 at 9:05 a.m., the surveyor observed the resident in bed with his breakfast tray on the table. There was a full water pitcher on the resident's table and 120 ml of milk on the tray. Further review of the medical record that same day revealed a physician's orders [REDACTED]. There was also an order [REDACTED]. Review of the Interdisciplinary Resident Care Plan revealed that the total daily fluid was divided between nursing and dietary, and that nursing provided a total of 840 ml/day including supplements, while dietary provided 360 ml/day. The dietary amount on the diet slip was more than what was written on the physician order. At 11:30 a.m. that same day, the surveyor accompanied the medication nurse to the resident's room and showed her the water pitcher. The nurse told the surveyor that it must have been provided by the previous shift and that Resident #11 was not supposed to have a water pitcher. She then removed the water pitcher from the room. The surveyor reviewed the resident's weight records on that same day. The medical record revealed that the resident weighed 126 lbs in 10/2011, 135 lbs in 12/2011 and 132 lbs in 1/2012, indicating a 6 lbs weight gain in 3 months. There were no other documented weights noted in the record. The surveyor reviewed the resident's care plan which indicated a goal weight of 116-120 lbs, for the resident. The surveyor reviewed the [MEDICAL TREATMENT] communication book from 5/11 to the present and noted there were no post [MEDICAL TREATMENT] weights recorded. The surveyor observed two notations in the book dated 8/2011 and 12/2011, which indicated that the dietitian requested the post weights from the [MEDICAL TREATMENT] center, however, the weights were never obtained until 1/2012 during the survey. The surveyor interviewed the UM at 12:35 p.m., and asked the UM where the weights that were recorded in the record were obtained. The UM told the surveyor that they weighed the resident at the facility monthly. She also stated that she would call the [MEDICAL TREATMENT] center to obtain the weights. The surveyor asked how they monitored the resident's fluid intake and the nurse responded that there was no system in place to record the resident's fluid intake. NJAC 8:39-27.1 (a)