Every finding on record at Chatham Hills Subacute Care Center

Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration for a medication (Gabapentin) (used to treat nerve pain) to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times and was not administered 41 times from June 2025 until surveyor inquiry September 2025. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was identified for one (1) resident, (Resident #2), reviewed for dialysis services and was evidenced by the following: On 9/15/25 at 9:50 AM, the surveyor interviewed Resident #2 who was in their room sitting in a wheelchair. Resident #2 stated that they were blind and were ready to go for hemodialysis. The resident added that they were picked up around 10 AM and came back to the facility around 4 PM. The surveyor reviewed the medical record for Resident #2. A review of the admission Record revealed diagnoses that included, but not limited to, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and complete traumatic amputation at knee level, unspecified lower leg (surgical amputation of left leg below the knee). A review of a comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 6/12/2025, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's individualized interdisciplinary care plan revealed as a focus area, with an initiated date of 6/9/25, Resident #2 has an implanted left upper chest wall port-a-cath (an implantable medical device that provides long-term access to a vein) for hemodialysis. Another focus area revealed Resident #2 is on pain medication therapy r/t (related to) surgery (LBKA) (left below knee amputation) with an initiated date of 8/2/25 and an intervention/task included, but not limited to, Administer medication as ordered. A review of the resident's Medication Review Report (MRR) reflected a physician's order (PO) dated 6/9/25 for Hemodialysis M/W/F (Monday/Wednesday/Friday) chair time 10:50 AM at [name of dialysis facility and phone number redacted]. In addition, the MRR revealed a PO with a start date of 6/7/25 for Gabapentin Oral Tablet 100 MG (milligrams) (Gabapentin) Give 1 tablet by mouth three times a day for neuropathy (a condition that damages the nerves outside the brain and spinal cord). A review of the June 2025 electronic medication administration record (EMAR) indicated a medication administration time of 1300 (1:00 PM) that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed on 6/9/25, 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/23/25, 6/25/25 and 6/30/25 all the 1:00 PM administration documentation on those dates had a code number 3 entered for administration which corresponded to Out of facility. In addition, on 6/27/25 at 1 PM there was a code number 9 entered for administration documentation which corresponded to Other/See Nurses Notes. A total of 9 out of 24 doses for June 2025. A review of the July 2025 EMAR indicated a medication administration time of 1300 (1:00 PM) that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed on 7/2/25, 7/4/25, 7/7/25, 7/9/25, 7/11/25, 7/14/25, 7/16/25, 7/18/25, 7/21/25, 7/23/25, 7/25/25, 7/28/25 and 7/30/25 all the 1:00 PM administration documentation on those dates had a code number 3 entered for administration which corresponded to Out of facility. A total of 13 out of 31 doses for July 2025. A review of the August 2025 EMAR indicated a medication administration time of 1300 (1 :00 PM) that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed on 8/1/25, 8/4/25, 8/6/25, 8/8/25, 8/11/25, 8/13/25, 8/15/25, 8/18/25, 8/20/25, 8/22/25, 8/25/25, and 8/29/25 all 1:00 PM administration documentation for those dates had a code number 3 entered for administration which corresponded to Out of facility. A total of 12 out of 31 doses. A review of the September 2025 EMAR indicated a medication administration time of 1300 (1:00 PM) that occurred during the time that the resident was out of the facility at dialysis. Further review of the EMAR revealed on 9/1/25, 9/3/25, 9/5/25, 9/8/25, 9/10/25 and 9/15/25 all 1:00 PM administration documentation for those dates had a code number 3 entered for administration which corresponded to Out of facility. In addition, on 9/12/25 at 1:00 PM there was a code number 9 entered for administration documentation which corresponded to Other/See Nurses Notes. A total of 7 out of 15 doses. A review of the corresponding electronic progress notes (EPN) for the above dates listed in June, July, August and September revealed that the resident was out of the facility at dialysis and had not received the Gabapentin at 1:00 PM. On 9/16/25 at 10:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was full time on the 7 AM to 3 PM shift and administered medications to Resident #2. LPN #1 also stated that the resident was at dialysis on M/W/F and was unable to administer the 1 PM dose of Gabapentin and indicated that on the EMAR by coding the number 3 which reflected that the resident was out of facility. LPN #1 stated I am not sure what else I should have done. LPN #1 then added Maybe I could let my supervisor know. On 9/16/25 at 10:25 AM, the surveyor with the Unit Manager/Registered Nurse (UM/RN) reviewed the EMAR for Resident #2. UM/RN stated the 1 PM administration time for Gabapentin was when the resident was out to dialysis on M/W/F. UM/RN also stated that the medication nurse should be looking at the days and times the resident went to dialysis and the resident would not return for the 1 PM dose. UM/RN added that she thought that may have been the reason the physician's order was changed. UM/RN explained the nurse should call the physician every time there was a missed dose to find out if that was allowed or if the physician wanted to make a change and there would be a progress note documenting that. UM/RN acknowledged that there was no progress note entries regarding the physician was called when the resident missed their 1 PM Gabapentin on dialysis days. On 9/16/25 at 12:27 PM, the surveyor, in the presence of another surveyor, interviewed the Consultant Pharmacist (CP) via telephone. CP stated medication reviews were done monthly, and he was not the only pharmacist that has done reviews because he rotates his staff. CP also stated that a resident that was on dialysis should not have medications scheduled when they were out of the facility for dialysis. CP added that he would expect the medication nurse to follow the chain of command meaning that the nurse would go to the supervisor to make the change necessary. A review of the facility policy Dialysis dated as approved 2/3/25 provided by the Director of Nursing (DON) revealed The facility has established standards of care for the dialysis resident. A review of a facility policy Administering Medication Schedule/Policy dated as approved 12/2023 provided by the DON reflected Medications are administered in a safe and timely manner, and as prescribed. In addition, Medications are administered in accordance with prescriber orders, including any required time frame. A review of a facility policy Medication Errors dated as approved 3/3/25 provided by the DON reflected The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples included, but not limited to:. ii. Medication omission. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to maintain proper food service sanitation practices and properly store potentially hazardous foods to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 9/11/25 at 10:20 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and another surveyor and observed the following: The walk-in freezer had a solid piece of ice on the floor on the right side of a rack under the fan. The FSD stated that during the defrosting stage ice seemed to build up. An opened cardboard box labeled puff pastry was observed with ice buildup on top. The box was removed from the freezer by the FSD to further inspect. When opened, the sheets of puff pastry were observed to be half covered by clear plastic packaging and two solid pieces of ice were in direct contact with the exposed puff pastry. The FSD stated, this is not safe practice. I apologize. There was a hard plastic rack with pots and pans that were air drying. The rack had a pinkish brown dry film on the surfaces between the tines of the rack. The FSD acknowledged the discolored film on the rack. On 9/11/25 at 12:45 PM, the surveyor observed the nourishment pantry on the south nursing unit with another surveyor. A review of the temperature log for the refrigerator revealed inconsistent monitoring and documentation of temperatures. The log indicated the temperature was to be recorded in the morning and evening. There were missing entries on the mornings of 9/4, 9/5, 9/6, 9/7, and 9/11. There were missing entries on the evenings of 9/2, 9/4, 9/6 and 9/7. On 9/17/25 at 11 AM, the surveyor interviewed the FSD in the presence of another surveyor. The FSD stated, the ice building up that we saw during our tour was when the walk-in freezer automatically goes through a defrost cycle, usually about twice a day. The FSD acknowledged that when the freezer went into the automatic defrosting cycle, water dripped down and would refreeze on the items below. The FSD stated the ice buildup the surveyor observed was not from a recent defrost cycle but has been there. During this same interview, the FSD stated that he was recently made aware that it was his departments responsibility to monitor and record the temperatures of the refrigerators in the pantries. He added that it was the kitchen staff's responsibility to check the refrigerators to make sure the temperature does not go into the danger zone (temperatures between 41 degrees Fahrenheit (F) and 135 degrees F allows the rapid growth of pathogenic microorganisms that can cause foodborne illness). The FSD acknowledged that there could be potentially hazardous foods stored in the pantry refrigerators and that it was important to ensure that temperatures were in acceptable ranges for food safety. A review of facility provided policy General Sanitation of Kitchen Created 2013, reflected that The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. A review of an undated facility provided policy Cleaning Instructions: Freezers, reflected that Freezers will be defrosted as needed (when frost is greater than or equal to 1/4 inch thick, the freezer should be defrosted), or per the manufacturer's instructions. A review of facility provided policy Food Storage Created 2024, reflected that Food is stored in an area that is clean, dry, and free from contaminants. Within this policy, item number 15 Frozen Foods: contained the following: a. All freezer units are always kept clean and in good working condition. b. Freezer temperatures should be checked at least two times a day. Check for proper functioning of the unit at the same time. A review of an undated facility provided policy Freezer & Refrigerator Temperature Form, reflected Recording frequency: Check and record temperatures at least twice per day, such as at the start and end of a shift. A review of an undated facility provided policy Pantry Policy, reflected that The facility maintains infection control measures to prevent the spread of food borne illness. NJAC 8:39-17.2(g)

Based on observation, interviews, record review and review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist's (CP) failed to identify and address irregularities for a.) a medication prescribed for neuropathy (damage, disease, or dysfunction of one or more nerves that can cause burning or shooting pain, numbness, and tingling) was not administered 41 times from 6/7/25 through 9/15/25 when the resident was consistently out of the facility to attend dialysis treatments at 1 PM. This was identified for 1 of 1 residents reviewed for dialysis (Resident #2); and b.) inadequate monitoring and documentation for the reason an as needed anti-anxiety medication (Xanax) was administered. This was identified for 1 of 5 residents, (Resident #6), reviewed for unnecessary medications. The deficient practice was evidenced as follows; REFER to F698 1. On 9/15/2025 at 9:50 AM, the surveyor observed Resident #2 in their room seated in a wheelchair, dressed and groomed. The resident stated they were waiting to be transported to a dialysis treatment (treats kidney failure by filtering waste products and excess fluid from your blood). Resident #2 stated, they were scheduled for a 10 AM pick up on Monday, Wednesday and Friday and returned at approximately 4 PM. The resident stated that they were diabetic, legally blind and had a left leg amputation. A review of the residents admission Record (an admission summary) reflected diagnoses which included but were not limited to; absence of leg below the knee, type 2 Diabetes Mellitus, end stage renal (kidney) disease and dependence of renal dialysis. A review of a comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/12/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the residents cognition was intact. A review of the Medication Review Report, reflected the resident had a physician's order (PO) for Gabapentin Oral Tablet 100 mg, Give 1 tablet by mouth three times a day for neuropathy, dated 6/6/25 and to start 6/7/25. It further reflected it was discontinued and replaced with two additional PO's whereby doses were scheduled for the morning and bedtime, dated 9/15/25. A review of the electronic Medication Administration Records (eMARs) from 6/7/25 through 9/15/25, reflected the PO as noted above to be given at 9 AM, 1 PM and 5 PM, with a start date of 6/7/25 and a discontinuation date of 9/15/25. During the month of June 2025, nine out of 24 days the residents 1 PM dose was not given due to the resident being out of the facility. For the same reason the following 1 PM doses were unable to be administered: in July 2025, the resident missed 13 out of 31, in August 2025, the resident missed 12 out of 31 doses and in September 2025, the resident missed seven out of 15, 1 PM doses. This added up to a total of 41 missed doses. A review of the Drug Regimen Reviews, reflected the residents' medications were reviewed by a CP on the following dates 6/9/25, 6/12/25, 7/11/25 and 8/8/25. The surveyor reviewed the facility provided Nursing Summary Report's, which reflected the CP recommendations after their drug regimen reviews. The CP provided recommendations dated 6/9/25, 8/8/25 and 9/5/25; none of which identified or addressed the PO for gabapentin to be administered at 1 PM, when the resident was out of the facility. On 9/16/2025 at 12:27 PM, the surveyor interviewed the CP via phone in the presence of two additional surveyors. He stated that he or his staff conducted resident medication reviews on admission and monthly thereafter. The CP stated that residents that leave the facility for dialysis treatments should not have medications scheduled for administration while out of the facility. He further stated that he would expect the nurse to identify this and to follow the chain of command to address the concern. The CP stated that medication reviews were documented in the Evaluation tab in the electronic medical record (EMR). He stated they document the medication review was completed and whether or not any recommendations were made. The CP added, If recommendations were made nursing is provided a Nursing Summary Report with the findings. The surveyor informed the CP as to the resident specific concerns. He offered no further information. REFER to F605 2. On 9/12/2025 at 11:22 AM, the surveyor interviewed a resident representative (RR) in the presence of Resident #6 in their room. RR stated they had no concerns with the care the staff was providing at the facility. RR added the resident had a mind of (redacted) own and does not remember things and gets confused. The surveyor observed the resident was well groomed and drinking sips of water on their own from a cup and when finished would give the cup to the RR. The surveyor also observed the resident telling the RR approximately three (3) times during the interview, they needed to go to the bathroom and the RR explained each time to the resident they had a catheter, that it was new and probably felt funny but did not have to be taken to the bathroom. The resident responded each time okay and would continue taking sips of water. The surveyor then observed the resident repositioning themselves in the wheelchair and the RR stated that sometimes the resident tried to stand on their own but was not [NAME]. The surveyor reviewed the medical record for Resident #6. A review of the resident's admission Record revealed diagnoses which included, but not limited to, traumatic subdural hemorrhage with loss of consciousness status unknown (a brain injury from trauma), aphasia (a disorder that affects how you communicate), muscle weakness (generalized), dysarthria (weakness in the muscles used for speech) and anarthria (inability to produce speech sounds due to dysfunction of muscles controlling speech), other abnormalities of gait and mobility, unspecified psychosis not due to a substance or known physiological condition ( a mental health condition causing distorted thought and behaviors), dementia in other diseases classified elsewhere, mild, with behavioral disturbance and Alzheimer's Disease, unspecified. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 9/19/25, reflected the resident had a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition. A review of the September 2025 electronic medication administration record (EMAR) had a physician's order (PO) dated 8/28/25 for Xanax Oral Tablet 0.25 milligram (MG) (Alprazolam) Give 1 tablet by mouth every 8 hours as needed (PRN) for Anxiety for 14 days. with a start date of 8/28/25. Further review of the EMAR revealed Xanax administration four (4) times on the following dates and times: 9/3/25 at 19:30 (7:30 PM), 9/4/25 at 10:23 AM and 19:57 (7:57 PM), and 9/6/25 at 18:26 (6:26 PM). The EMAR also revealed the PO dated 8/28/25 was discontinued on 9/11/25 and another PO dated 9/11/25 indicated Xanax Oral Tablet 0.25 milligram (MG) (Alprazolam) Give 1 tablet by mouth every 6 hours PRN for Anxiety for 14 days. was administered three (3) times on the following dates and times: 9/11/25 at 18:41 (6:41 PM), 9/13/25 at 19:18 (7:18 PM) and 9/14/25 at 9:39 AM. A review of the corresponding nursing progress notes for the dates identified above for the Xanax administration revealed the following: -on 9/3/25 at 19:30 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. - on 9/3/25 at 22:10 (10:10 PM) indicated PRN administration was: Effective. -on 9/3/25 at 22:41 (10:41 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. -on 9/4/25 at 10:23 AM indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. Resident is very anxious and when redirected was unsuccessful. - on 9/4/25 at 14:38 (2:38 PM) indicated PRN administration was: Effective. -on 9/4/25 at 19:57 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. - on 9/4/25 at 21:58 (9:10 PM) indicated PRN administration was: Effective. -on 9/4/25 at 22:01 (10:01 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. -on 9/6/25 at 18:26 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. - on 9/6/25 at 19:39 (7:39 PM) indicated PRN administration was: Effective. -on 9/6/25 at 19:52 (7:52 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. -on 9/11/25 at 17:53 (5:53 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. -on 9/11/25 at 18:41 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety for 14 days. -on 9/13/25 at 19:18 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety for 14 days. Resident was restless. -on 9/13/25 at 19:47 (7:47 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. - on 9/13/25 at 22:02 (10:02 PM) indicated PRN administration was: Effective. -on 9/14/25 at 9:39 AM indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. - on 9/14/25 at 10:21 AM indicated PRN administration was: Effective. Further review of the nursing progress notes revealed an inconsistency on 9/5, 9/7, 9/8, 9/9, 9/10 and 9/12 there were skilled services nursing notes that indicated similar documentation; Resident is exhibiting signs/symptoms of delirium has inattention. and Xanax was not administered on those dates. On 9/15/2025 at 11:12 AM, the surveyor interviewed Registered Nurse (RN)/UM who stated when a PRN medication being used for anxiety was administered there would be a progress note indicating what behaviors the resident was exhibiting to indicate the need for the medication. RN/UM was aware that Resident #6 had anxiety and stated the resident could get very agitated, yells, wants to go home or wants to call a family member and frequently asked to go to the bathroom but has a catheter. RN/UM added that the resident had to be redirected but sometimes that had not worked. RN/UM also stated that the nurses document in the EBMR the targeted behaviors the resident exhibits and enter the number of episodes the behavior was exhibited and there would also be a progress note explaining what happened. At that time, the surveyor, with the RN/UM, reviewed the EMAR for Resident #6. RN/UM verified the administration of Xanax PRN on 9/3/25 and acknowledged that there was no progress note explaining why the Xanax PRN was needed. RN/UM also reviewed the EBMR for the date of 9/3 and shift that the Xanax PRN was administered and stated that there was no documentation as to the behaviors exhibited or non-drug interventions tried. RN/UM then stated that she would have to check the other dates the Xanax PRN was administered. On 9/15/2025 at 11:35 AM, RN/UM stated that she had looked through the progress notes and EBMR and could not find the documentation as to why the Xanax PRN was administered. On 9/16/2025 at 10:01 AM, the Director of Nursing (DON) explained that the nurses were able to electronically enter targeted behaviors in the EBMR which was similar to the EMAR for documentation of the number of times a behavior was exhibited. The DON further explained a nursing progress note should indicate what took place for the need for the use of a PRN medication for behaviors. The DON also stated that anxiety had to be explained as to what the behaviors were that were exhibited and that would be in the progress notes. A review of the EBMR for the corresponding dates and shift times for the administration of Xanax PRN revealed the following: For the targeted behavior of Fighting entries were as follows; -on 9/3/25 the 3 PM to 11 PM shift was blank for the number of times the behavior occurred and interventions. - on 9/4/25 the 7 AM to 3 PM shift was zero (0) for the number of times the behavior occurred and interventions. For the 3 PM to 11 PM shift had the number 2, and the intervention was redirect. -on 9/6/25 the 3 PM to 11 PM shift had the number 3, and the intervention was one on one, activity and redirect. -on 9/11/25 the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions. -on 9/13/25 the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions. -on 9/14/25 the 7 AM to 3 PM shift was blank for the number of times the behavior occurred and any interventions. For the targeted behavior of Hitting/scratching/pinching entries were as follows; -on 9/3/25 the 3 PM to 11 PM shift was blank for the number of times the behavior occurred and interventions. - on 9/4/25 the 7 AM to 3 PM was zero (0) for the number of times the behavior occurred and interventions. For the 3 PM to 11 PM shift had the number zero (0), and the intervention was redirect. -on 9/6/25 the 3 PM to 11 PM shift had an X and the intervention was redirect. -on 9/11/25 the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions. -on 9/13/25 the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions. -on 9/14/25 the 7 AM to 3 PM shift was blank for the number of times the behavior occurred and interventions. The EBMR also revealed an inconsistency that there were dates (9/5/25 and 9/12/25) with entries that there were occurrences of the identified behaviors above and the resident had not received Xanax PRN. There were no other documented entries of behaviors occurring or interventions. On 9/15/2025 at 1:32 PM, the surveyor, with the RN/UM, further reviewed Resident #6's EBMR. UM/RN explained the nurses were supposed to enter numbers and not X's to show the number of times a behavior was exhibited by the resident and there was a section to indicate what is done meaning any interventions that were tried for the identified behavior. RN/UM added that there should also be a progress note explaining what occurred and that the interventions tried had not worked so there was a need for the medication to be administered. RN/UM acknowledged that Resident #6's EBMR and progress notes had not correlated to why the Xanax PRN was administered and there was no documentation to indicate that the interventions had failed. A review of the electronic Consultant Pharmacist (CP) Drug Regimen Review dated 9/11/25 for Resident #6 revealed The medication regimen of the resident was reviewed, and a recommendation was made to the attending physician. On 9/15/25 at 2:07 PM, the surveyor was provided by the DON, two (2) forms titled Note to Attending Physician/Prescriber completed by the CP dated 9/11/26 which correlated to the electronic CP Drug Regimen Review indicating that there were recommendations made. The two (2) forms titled Note to Attending Physician/Prescriber were not regarding the documentation for the need for the use of Xanax PRN. On 9/16/2025 at 11:49 AM, the surveyor in the presence of another surveyor interviewed the Consultant Pharmacist (CP) who stated that he was the CP for the facility as well as rotating his staff so that there were always fresh eyes reviewing. CP added that he performed onsite inspections and chart auditing as well as remote electronic chart auditing. CP explained a review of behavior monitoring for a resident on a psychotropic medication involved correlating the medications with the MDS and if the resident was a candidate for a gradual dosage reduction. CP further explained he attended monthly meetings to discuss residents on psychotropic medications and made sure that the PO for a PRN psychotropic medication had stop order dates and reviewed the utilization to see if the medication could be discontinued or changed to routine use. CP stated that Xanax ordered PRN for anxiety was an appropriate indication for use and the nurses were responsible for documenting how a resident expressed anxious behaviors. CP stated that anxiety was a broad-spectrum term. CP also stated there was a verbal discussion of the residents on psychotropic medications at the meetings and does not look at behavior documentation. CP acknowledged that behavior documentation should correlate with the need for a PRN psychotropic medication. CP was informed of Resident # 6's Xanax PRN use and inadequate documentation and stated that he would review. There was no additional information provided by the CP. On 9/16/2025 at 1:22 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The above concerns regarding the documentation for the need and non-pharmacologic interventions tried for Xanax PRN use were reviewed. The DON stated there were monthly meetings to verbally discuss all residents on a psychotropic medication that she attended with the CP, nurses and psychiatric nurse practitioner. The DON added that they do not go over the EBMR. On 9/17/2025 at 10:11 AM, the survey team met with the LNHA, DON, Infection Preventionist and RN/UM. The DON stated that she talked to the nurses that had administered the Xanax PRN, and they all spoke to the resident constantly wanting to go (meaning leave the facility), screaming and getting up out of the wheelchair to walk on their own. The DON added the nurses had not documented the behaviors. The DON and RN/UM acknowledged the documentation of behaviors and failed non-pharmacologic interventions had not correlated to the need for the Xanax PRN to be administered. The DON also stated that the Psychiatric Consult indicated that the resident was having behaviors. The DON acknowledged that the CP attended the monthly meetings discussing the residents on psychotropic medications and should report any irregularities with the documentation. The DON acknowledged that the CP had not made any recommendation regarding the documentation of the need for Xanax PRN. The DON stated during the monthly meeting, they should review what behaviors are documented, how many times and what non-drug interventions were tried. A review of the facility policy Pharmacy Services dated as approved 12/20/24 provided by the DON reflected The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. In addition, The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): .c. administration of medications. A review of the facility policy Medication Regimen Review dated as approved 6/11/25 provided by the DON reflected The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. In addition, The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: c. duplicative therapies or omissions of ordered medications; NJAC 8:39-29.3(a)(1)

Based on observation, interview, and record review, and review of other facility documentation, it was determined that the facility failed to ensure that a Licensed Practical Nurse followed the PO to notify physician when blood sugar was less than 70 or above 250 for 1 of 1 resident's reviewed for medication administration, (Resident #15).This deficient practice was evidenced as follows:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 9/11/25 at 11:15 AM, the surveyor observed Resident #15 sitting up in their chair. Resident #15 was watching television (TV). On 9/12/25 at 10:11 AM, the surveyor reviewed Resident # 15's electronic medical records (EMR) that revealed the following:The admission Record (an admission summary) revealed that Resident #15 had diagnoses that included but were not limited to; Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), and hypertension (high blood pressure).A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/3/25, reflected that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was moderately impaired. A review of care plan (CP) dated 4/1/25 with a focus that reflected Resident #15 had DM. The interventions that were included but were not limited to; diabetic medications as ordered by the doctor, and to monitor and document for side effects and effectiveness. A review of the Order Summary Report (OSR) reflected that Resident #15 had active POs as followed:Finger stick (a quick and relatively painless method for measuring blood sugar levels) blood sugar, two times a day for Insulin dependent diabetes mellitus (IDDM) before breakfast and before dinner, notify physician if sugar less than (<) 70 or above (>) 250 with a start date 4/1/25. Insulin Aspart Flex Pen 100 UNIT/ML Solution pen-injector: Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units >400 blood sugar report to MD., subcutaneously before meals and at bedtime for DM1 with a start date 7/12/25. The corresponding physician order was transcribed into the August 2025 through September 2025 electronic Medication Administration Record (eMAR). Further review of the August - September 2025 eMARs for Resident #15 revealed that nurses signed and reflected a checkmark which means that the BS was checked two times a day as per physician orders. Surveyor #1 observed there were several entries where the residents blood sugar was over 250 and where the nurses should have notified physician as per PO for the following dates and times: Date Time BS8/3/25 5 PM 2998/7/25 5 PM 2608/8/25 9 AM 2588/10/25 5 PM 2778/11/25 5 PM 307 8/12/25 5 PM 2978/18/25 5 PM 3198/20/25 5 PM 3158/26/25 5 PM 3588/28/25 5 PM 284 8/29/25 5 PM 3559/1/25 5 PM 342 9/4/25 9 AM 2889/9/25 9 AM 2699/12/25 5 PM 334A Review of August - September 2025 Nursing Progress Notes (PN) did not reflect a PN where the nurses had written that the physician was notified when Resident #15's BS were above 250. During an interview with the surveyor on 9/15/25 at 10:42 AM, the Licensed Practical Nurse (LPN) stated that if there was a PO for fingerstick and to notify the physician for BS below 70 pr above 250 she would notify the physician and then document in her PN. The LPN further stated that documentation was important for continuous care and the next shift nurses would have an idea of what kind of care was provided to the resident during the previous shift. The surveyor reviewed the August eMAR with LPN #1 where she had documented BS above 250 for 8/8/25, 8/11/25, 8/18/25 and 8/29/25. LPN #1 stated, Usually the nurse practitioner is here, and we just tell her. The LPN further stated, I should have documented but I am not sure if I did. And if you did not document, you did not do it. During an interview with the surveyor on 9/15/25 at 11:03 AM, the North Unit Registered Nurse / Unit Manager (RN/UM) stated the nurses would do finger stick before administering insulin. In the presence of the surveyor, the RN/UM reviewed the PO for Resident #15. The RN/UM stated the nurses would inform the physician if the BS was below 70 or above 250 and then document in PN. The RN/UM stated she expected nurses to write a PN after they reported abnormal BS to the physician. In the presence of the surveyor, the RN/UM reviewed nursing PN's for Resident #15. The RN/UM stated that she did not see any notes when the BS was out of the parameters and that the physician was notified. During an interview with Surveyor on 9/15/25 at 12:42 PM, the Director of Nursing (DON) stated, a lot of times, we communicate with the doctors via telephone or text message. The DON further stated that the nurses should document so that everybody was on the same page and that documentation was important for other nurses and doctors to see the communication notes. The surveyor mentioned that there were two orders for blood sugar checks for Resident #15. The DON stated there should not be two orders and if the nurses observed two separate orders for BS, the nurses should call the doctor to get clarification. On 9/16/25 at 1:23 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON to present above mentioned concerns. The DON acknowledged that the nurses should have called the physician when BS were out of parameters and documented. The DON further stated the nurses should have called the physician to get clarification for the duplicate orders to check BS.A review of the facility provided policy Medication Orders revision date 11/2014, included under Supervision by a Physician: 3. Orders must be written and maintained in chronological order.A review of the facility provided policy Insulin Administration revision date 1/2025 included under Steps in the procedure: 2. Check blood glucose per physician order or facility protocol. A review of the Charge Nurse/LPN Job Responsibility included but were not limited to; Nursing Care Functions: Communicate with primary care physician and members of the comprehensive care planning team regarding the status of residents; follow up on critical labs, order requests and physician notification. The section Charting and Documentation Functions: Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. On 9/17/25 at 10:09 AM, the survey team met for an Exit Conference with the LNHA, DON, RN/UM, and Infection Preventionist/Assistant DON (IP/ADON). The DON stated, I have really nothing to say. The DON acknowledged that it should not have happened. NJAC 8:39-27.1 (a), 29.2 (d)

Complaint # NJ403814Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 5 residents (Resident #4, 10, 43, and 64) observed for incontinence care on 1 of 2 Nursing units (South unit).This deficient practice was evidenced by the following:On 9/16/25 at 7:40 AM, the surveyor completed an incontinence tour on the South Nursing Unit and observed the following:1.) On 9/16/25 at 7:40 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #10 in bed. CNA #1 exposed Resident #10's incontinence brief, and the surveyor observed that it was saturated with urine and feces. The surveyor observed that the bladder pad that was inserted in the brief was also saturated with urine and feces. CNA #1 confirmed that the brief and bladder pad were saturated with urine and feces. Resident #10 stated that she had not been changed since the previous night at approximately 9:00 PM. The resident further stated that he/she would like to be changed more often.A review of Resident #10's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Urinary Tract Infection, chronic kidney disease, and urinary retention.A review of Resident #10's Annual Minimum Data Set (MDS), an assessment tool dated 6/202/5, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #10's cognition was intact. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was frequently incontinent of bladder and always incontinent of their bowels. Section E revealed that Resident #10 did not refuse evaluations or activities of daily living care.A review of Resident #10's Individualized Care Plan (CP) initiated on 1/23/25 had a focus area that included [Resident] requires assistance with functional mobility and ADLs, with interventions that included but were not limited to; dependent on staff for toileting hygiene and personal hygiene; [Resident] is on URGE bladder incontinence medication (medication for overactive bladder) initiated on 1/28/24 with interventions that included but were not limited to; check the resident every 2 hours and as required for incontinence. 2.) On 9/16/25 at 7:50 AM, the surveyor, accompanied by CNA #1, observed Resident #43 in bed. CNA #1 exposed Resident #43's incontinence brief, and the surveyor observed that it was saturated with urine. CNA #1 confirmed that the brief was saturated with urine.A review of Resident #43's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Multiple Sclerosis (a chronic autoimmune disease) and an overactive bladder.A review of Resident #43's MDS dated [DATE], revealed Resident #43 had a BIMS score of 6 out of 15, which indicated severely impaired cognition. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was incontinent of bowel and bladder. A review of Resident #43's CP initiated on 11/14/23 had a focus area that included [Resident] requires assistance with ADLs, with interventions that included but were not limited to; dependent on staff for personal hygiene; and a CP initiated on 9/16/22 with a focus area that indicated Resident is at risk for a urinary tract infection with interventions that included but were not limited to; check at least every 2 hours for incontinence. 3.) On 9/16/25 at 7:53 AM, the surveyor, accompanied by CNA #1, observed Resident #64 in bed. CNA #1 exposed Resident 64's incontinence brief, and the surveyor observed that it was wet with urine. CNA #1 confirmed that the brief was wet. The resident stated that they had not been changed recently and further stated that the last change may have been last night.A review of Resident #64's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; acute kidney failure and diabetes mellitus.A review of Resident #64's Quarterly MDS, dated [DATE], revealed that Resident #64 had a BIMS score of 15 out of 15, indicating that the resident's cognition was intact. The MDS further revealed that the resident was dependent on staff for toileting hygiene, and he/she was frequently incontinent of bladder and always incontinent of bowel. A review of Resident #64's CP initiated on 5/3/24 had a focus area that included [Resident] requires assistance with ADLs, with interventions that included but were not limited to; dependent on staff for toileting hygiene. 4.) On 9/16/25 at 7:57 AM, the surveyor, accompanied by CNA #1, observed Resident #4 in bed. CNA #1 exposed Resident 4's incontinence brief, and the surveyor observed that it was saturated with urine and feces. CNA #1 confirmed that the brief was saturated with urine and feces. A review of Resident #4's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: acute kidney failure with tubular necrosis (damage to the renal tubule cells which impairs the kidney's ability to filter blood) and diabetes mellitus.A review of Resident #4's most recent MDS, dated [DATE], revealed that Resident #4's cognitive skills for daily decision making were severely impaired. The MDS further revealed that the resident was dependent on staff for personal and toileting hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident #4's CP initiated on 6/12/25 had a focus area that included [Resident] requires assistance with ADLs, with interventions that included but were not limited to; dependent on staff for toileting hygiene. At that same time, during an interview with the surveyor, CNA #1 stated that incontinence care should be provided every 2 hours on all shifts and that it did not appear to have been done.On 9/16/25 at 9:30 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager stated that incontinence rounds should be conducted 3-4 times on all shifts.On 9/16/25 at 10:15 AM, during an interview with the surveyor, the staffing coordinator called the CNA (CNA #2), who was assigned to Residents #10 and #4 on the 11-7 AM shift. The CNA stated that she had 17 residents on her assignment and that she had provided incontinence care for them. On 9/16/25 at 10:20 AM, the staffing coordinator called the CNA (CNA #3) who was assigned to care for Residents #43 and #64 on the 11-7 AM shift. CNA #4, who had 17 residents assigned to their care during the 11-7 AM shift, did not return the call.On 9/16/25 at 1:22 PM, the survey team discussed the above observations and concerns with the Director of Nursing and Licensed Nursing Home Administrator.A review of the facility's Activities for Daily Living policy dated 2/3/25 reflected .the facility will provide activities of daily living for those needed for self-care: bathing, dressing, toileting . NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan (CP) that included the use of antipsychotic medication for a diagnosis of schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, changing how people think, feel and act ). The deficient practice was identified for 1 of 20 residents (Resident #3) reviewed for Care Plans.This deficient practice was evidenced by the following: On 9/12/25 at 11:57 AM, the surveyor observed Resident #3 in the common area, in a wheelchair, waiting for lunch.The surveyor reviewed the admission Record (or face sheet, an admission summary) which revealed that the resident had been admitted to the facility with diagnoses that included schizoaffective disorder.A review of the Comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ADR) of 8/23/25, revealed the resident had a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS also reflected that the resident had a diagnosis of schizophrenia (which included schizoaffective disorder) and was receiving antipsychotic medication.A review of Resident #3's physician orders (PO) revealed a PO, dated 8/19/25, olanzapine 10mg, give one tablet at bedtime for schizoaffective disorder (Olanzapine is an atypical antipsychotic medication used primarily to treat schizophrenia and bipolar disorder, balancing brain chemicals like dopamine and serotonin.).A review of Resident #3's care plan (CP) with a start date of 8/19/25, revealed that Resident #3 did not have a care plan addressing the diagnosis of schizoaffective disorder or for the use of an antipsychotic medication.On 9/15/25 at 10:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that the diagnosis of schizoaffective disorder and the use of antipsychotic medications should absolutely be addressed on the care plan. On 9/16/25 at 10:20 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Comprehensive Care Plans with an approved date of 1/13/25. The policy statement included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under the policy interpretation and implementation section of the policy it stated, 1.The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident and 2. The comprehensive, person-centered care plan is developed within seven days of the completion of the required MDS assessment (Admission, Annual or Significant change in Status), and no more than 21 days after admission.On 9/16/25 at 1:21 PM, the surveyor met with the LNHA and the Director of Nursing (DON) to review facility concerns found during the survey. The DON stated Resident #3 should have had a care plan addressing the diagnosis of schizoaffective and the use of an antipsychotic medication. NJAC 8:39-27.1(a)

Complaint #403805Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that written notice of a resident's transfer to a hospital was provided to a family member or guardian for 1 of 4 residents (Resident #102) reviewed for hospitalization.This deficient practice was evidenced by the following: A review of Resident #102's admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; post operative care of a surgical wound of the right buttock, an antibiotic-resistant infection of the surgical wound site and a history of a ruptured aneurysm (a rupture of a weakened area of a blood vessel) in the brain. The admission Record further reflected the resident's mother was listed as his/her emergency contact and court appointed guardian. A review of Resident #102's admission Minimum Data Set (MDS), an assessment tool, dated 3/14/2025 reflected the resident had a severely impaired cognition and was dependent on staff for all activities of daily living (ADLs) care. A review of Resident #102's medical record reflected the resident was transferred to the hospital on 3/18/2025 at 10:00AM, for further evaluation of low blood pressure, rapid heart rate and elevated body temperature. On 09/15/2025 at 10:10 AM, the surveyor interviewed the Unit Manager (UM), for the North Unit. The UM confirmed she did not provide written notice that Resident #102 was transferred to a hospital to the resident's guardian. On 09/15/2025 at 12:30 PM, the surveyor interviewed the facility's Licensed Social Worker (LSW). The LSW confirmed she had not provided written notice of Resident #102's was transfer to the resident's guardian. On 09/12/2025 at 10:12 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA confirmed the facility had not provided written notice that Resident #102 was transferred to a hospital to the resident's guardian. A review of the facility policy, Emergency Transfer or Discharge, dated 3/12/2025, revealed.Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures . Notify the representative (sponsor) or other family member. N.J.A.C. 8.39 27.1(a)

Refer to F756Based on observation, interview and record review, it was determined that the facility failed to ensure a resident was free from unnecessary administration of an as needed psychotropic medication, (Xanax) (an anti-anxiety medication), by adequately documenting and monitoring non-drug interventions that were attempted and failed prior to administration and exhibited targeted behaviors identified for the need for medication use. The deficient practice was identified for one (1) of five (5) residents, (Resident #6), reviewed for unnecessary medications and was evidenced by the following:On [DATE] at 11:06 AM, the surveyor interviewed the certified Nursing Aide (CNA #1) who stated that she had been working at the facility for approximately one month and was assigned to Resident #6. CNA #1 stated that the resident required total care (meaning that the resident required help with hygiene and dressing), could follow cues, require assistance when standing and pivoting but was not [NAME]. She explained the resident was pleasant and able to tell her what they wanted and could answer questions at the moment but was confused and had no safety awareness. CNA #1 was unable to speak to behaviors that the resident had and stated the resident could self-propel and sometimes would go to other rooms and would try to stand up unassisted. On [DATE] at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was the nurse administering medications to Resident #6. LPN #1 stated the resident could become combative at times when they did not want to do something, explaining the resident had no understanding that they could not walk on their own and wanted to go home. LPN #1 added the resident was confused, thinking that they were not supposed to be here and had an indwelling urinary catheter (a tube that remains inserted into the bladder to collect urine) and kept asking to go to the bathroom to urinate. LPN #1 also explained the resident had anxiety related to being unable to go home and could escalate and became combative or pushed staff. LPN #1 also stated that usually the resident was in the activity area and could tell you want they wanted and answer questions but would not remember. LPN #1 also stated that the resident was compliant with taking their medications. On [DATE] at 11:22 AM, the surveyor interviewed a resident representative (RR) in the presence of Resident #6 in their room. RR stated they had no concerns with the care the staff was providing at the facility. RR added the resident had a mind of (redacted) own and does not remember things and gets confused. The surveyor observed the resident was well groomed and drinking sips of water on their own from a cup and when finished would give the cup to the RR. The surveyor also observed the resident telling the RR approximately 3 times during the interview, they needed to go to the bathroom and the RR explained each time to the resident they had a catheter, that it was new and probably felt funny but did not have to be taken to the bathroom. The resident responded each time okay and would continue taking sips of water. The surveyor then observed the resident repositioning themselves in the wheelchair and the RR stated that sometimes the resident tried to stand on their own but was not [NAME].The surveyor reviewed the medical record for Resident #6.A review of the resident's admission Record revealed diagnoses which included, but not limited to, traumatic subdural hemorrhage with loss of consciousness status unknown (a brain injury from trauma), aphasia (a disorder that affects how you communicate), muscle weakness (generalized), dysarthria (weakness in the muscles used for speech) and anarthria (inability to produce speech sounds due to dysfunction of muscles controlling speech), other abnormalities of gait and mobility, unspecified psychosis not due to a substance or known physiological condition ( a mental health condition causing distorted thought and behaviors), dementia in other diseases classified elsewhere, mild, with behavioral disturbance and Alzheimer's Disease, unspecified.A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition.A review of the individualized care plan report (ICPR), created and revised on [DATE], revealed a focus area Resident #6 uses psychotropic medications r/t (in relation to) Behavior management with interventions to Monitor/record occurrence of for targeted behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. Another intervention was Offer nonpharmacologic interventions such as conversation, hand massage, diversional activities, music therapy, redirection, reassurance, education on deep breathing and relaxation techniques, or assist to a quieter environment.A review of the [DATE] electronic medication administration record (EMAR) had a physician's order (PO) dated [DATE] for Xanax Oral Tablet 0.25 milligram (MG) (Alprazolam) Give 1 tablet by mouth every 8 hours as needed (PRN) for Anxiety for 14 days. with a start date of [DATE]. Further review of the EMAR revealed Xanax administration four (4) times on the following dates and times: [DATE] at 19:30 (7:30 PM), [DATE] at 10:23 AM and 19:57 (7:57 PM), and [DATE] at 18:26 (6:26 PM). The EMAR also revealed the PO dated [DATE] was discontinued on [DATE] and another PO dated [DATE] indicated Xanax Oral Tablet 0.25 milligram (MG) (Alprazolam) Give 1 tablet by mouth every 6 hours PRN for Anxiety for 14 days. was administered three (3) times on the following dates and times: [DATE] at 18:41 (6:41 PM), [DATE] at 19:18 (7:18 PM) and [DATE] at 9:39 AM.A review of the corresponding nursing progress notes for the dates identified above for the Xanax administration revealed the following:-on [DATE] at 19:30 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days.- on [DATE] at 22:10 (10:10 PM) indicated PRN administration was: Effective.-on [DATE] at 22:41 (10:41 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention.-on [DATE] at 10:23 AM indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days. Resident is very anxious and when redirected was unsuccessful.- on [DATE] at 14:38 (2:38 PM) indicated PRN administration was: Effective.-on [DATE] at 19:57 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days.- on [DATE] at 21:58 (9:10 PM) indicated PRN administration was: Effective.-on [DATE] at 22:01 (10:01 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention.-on [DATE] at 18:26 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days.- on [DATE] at 19:39 (7:39 PM) indicated PRN administration was: Effective.-on [DATE] at 19:52 (7:52 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention.-on [DATE] at 17:53 (5:53 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention. -on [DATE] at 18:41 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety for 14 days.-on [DATE] at 19:18 indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety for 14 days. Resident was restless.-on [DATE] at 19:47 (7:47 PM) indicated a skilled services nursing note Resident is exhibiting signs/symptoms of delirium has inattention.- on [DATE] at 22:02 (10:02 PM) indicated PRN administration was: Effective.-on [DATE] at 9:39 AM indicated an administration note Xanax Oral Tablet 0.25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety for 14 days.- on [DATE] at 10:21 AM indicated PRN administration was: Effective.Further review of the nursing progress notes revealed an inconsistency on 9/5, 9/7, 9/8, 9/9, 9/10 and 9/12 there were skilled services nursing notes that indicated similar documented Resident is exhibiting signs/symptoms of delirium has inattention. and Xanax was not administered on those dates.On [DATE] at 11:01 AM, the surveyor interviewed LPN #2 who stated that she had worked at the facility approximately 2 years and floats between units and was the medication nurse for Resident #6. LPN #2 stated that she was aware Resident #6 had a PO for Xanax PRN but was unsure if she had ever needed to administer the medication. LPN #2 reviewed the EMAR and stated that the resident had received the Xanax PRN but that she had not administered the medication. LPN #2 added that she would indicate in the electronic behavior monitoring report (EBMR) what behaviors the resident was having to warrant the Xanax PRN administration. LPN #2 was unsure if a progress note was needed but stated the Unit Manager (UM) would know. On [DATE] at 11:12 AM, the surveyor interviewed Registered Nurse (RN)/UM who stated when a PRN medication being used for anxiety was administered there would be a progress note indicating what behaviors the resident was exhibiting to indicate the need for the medication. RN/UM was aware that Resident #6 had anxiety and stated the resident could get very agitated, yells, wants to go home or wants to call a family member and frequently asked to go to the bathroom but has a catheter. RN/UM added that the resident had to be redirected but sometimes that had not worked. RN/UM also stated that the nurses document in the EBMR the targeted behaviors the resident exhibits and enter the number of episodes the behavior was exhibited and there would also be a progress note explaining what happened. At that time, the surveyor, with the RN/UM, reviewed the EMAR for Resident #6. RN/UM verified the administration of Xanax PRN on [DATE] and acknowledged that there was no progress note explaining why the Xanax PRN was needed. RN/UM also reviewed the EBMR for the date of 9/3 and shift that the Xanax PRN was administered and stated that there was no documentation as to the behaviors exhibited or non-drug interventions tried. RN/UM then stated that she would have to check the other dates the Xanax PRN was administered. On [DATE] at 11:35 AM, RN/UM stated that she had looked through the progress notes and EBMR and could not find the documentation as to why the Xanax PRN was administered.On [DATE] at 10:01 AM, the Director of Nursing (DON) explained that the nurses were able to electronically enter targeted behaviors in the EBMR which was similar to the EMAR for documentation of the number of times a behavior was exhibited. The DON further explained a nursing progress note should indicate what took place for the need for the use of a PRN medication for behaviors. The DON also stated that anxiety had to be explained as to what the behaviors were that were exhibited and that would be in the progress notes.A review of the EBMR for the corresponding dates and shift times for the administration of Xanax PRN revealed the following:For the targeted behavior of Fighting entries were as follows;-on [DATE] the 3 PM to 11 PM shift was blank for the number of times the behavior occurred and interventions.- on [DATE] the 7 AM to 3 PM shift was zero (0) for the number of times the behavior occurred and interventions. For the 3 PM to 11 PM shift had the number 2 and the intervention was redirect.-on [DATE] the 3 PM to 11 PM shift had the number 3 and the intervention was one on one, activity and redirect.-on [DATE] the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions.-on [DATE] the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions.-on [DATE] the 7 AM to 3 PM shift was blank for the number of times the behavior occurred and any interventions.For the targeted behavior of Hitting/scratching/pinching entries were as follows;-on [DATE] the 3 PM to 11 PM shift was blank for the number of times the behavior occurred and interventions.- on [DATE] the 7 AM to 3 PM was zero (0) for the number of times the behavior occurred and interventions. For the 3 PM to 11 PM shift had the number zero (0) and the intervention was redirect.-on [DATE] the 3 PM to 11 PM shift had an X and the intervention was redirect.-on [DATE] the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions.-on [DATE] the 3 PM to 11 PM shift had an X for the number of times the behavior occurred and interventions.-on [DATE] the 7 AM to 3 PM shift was blank for the number of times the behavior occurred and interventions.The EBMR also revealed an inconsistency that there were dates ([DATE] and [DATE]) with entries that there were occurrences of the identified behaviors above and the resident had not received Xanax PRN.There were no other entries of behaviors occurring or interventions.On [DATE] at 1:32 PM, the surveyor, with the RN/UM, further reviewed Resident #6's EBMR. UM/RN explained the nurses were supposed to enter numbers and not X's to show the number of times a behavior was exhibited by the resident and there was a section to indicate what is done meaning any interventions that were tried for the identified behavior. RN/UM added that there should also be a progress note explaining what occurred and that the interventions tried had not worked so there was a need for the medication to be administered. RN/UM acknowledged that Resident #6's EBMR and progress notes had not correlated to why the Xanax PRN was administered and there was no documentation to indicate that the interventions had failed.On [DATE] at 11:49 AM, the surveyor in the presence of another surveyor interviewed the Consultant Pharmacist (CP) who stated that he was the CP for the facility as well as rotating his staff so that there were always fresh eyes reviewing. CP added that he performed onsite inspections and chart auditing as well as remote electronic chart auditing. CP explained a review of behavior monitoring for a resident on a psychotropic medication involved correlating the medications with the MDS and if the resident was a candidate for a gradual dosage reduction. CP further explained he attended monthly meetings to discuss residents on psychotropic medications and made sure that the PO for a PRN psychotropic medication had stop order dates and reviewed the utilization to see if the medication could be discontinued or changed to routine use. CP stated that Xanax ordered PRN for anxiety was an appropriate indication for use and the nurses were responsible for documenting how a resident expressed anxious behaviors. CP stated that anxiety was a broad-spectrum term. CP also stated there was a verbal discussion of the residents on psychotropic medications at the meetings and does not look at behavior documentation. CP acknowledged that behavior documentation should correlate with the need for a PRN psychotropic medication. CP was informed of Resident # 6's Xanax PRN use and inadequate documentation and stated that he would review.There was no additional information provided by the CP.On [DATE] at 1:22 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The above concerns regarding the documentation for the need and non-pharmacologic interventions tried for Xanax PRN use were reviewed. The DON stated there were monthly meetings to verbally discuss all residents on a psychotropic medication that she attended with the CP, nurses and psychiatric nurse practitioner. The DON added that they do not go over the EBMR. On [DATE] at 10:11 AM, the survey team met with the LNHA, DON, Infection Preventionist and RN/UM. The DON stated that she talked to the nurses that had administered the Xanax PRN and they all spoke to the resident constantly wanting to go (meaning leave the facility), screaming and getting up out of the wheelchair to walk on their own. The DON added the nurses had not documented the behaviors. The DON and RN/UM acknowledged the documentation of behaviors and failed non-pharmacologic interventions had not correlated to the need for the Xanax PRN to be administered. The DON also stated that the Psychiatric Consult indicated that the resident was having behaviors. The DON stated during the monthly meeting, they should review what behaviors are documented, how many times and what non-drug interventions were tried.A review of the electronic Psychiatric Progress Note dated [DATE] for 9:50 AM revealed cc (chief complaint): f/u (follow up): anxiety and Seen per nursing request. Per nursing having periods of anxiety, at times severe, exit seeking behaviors, poor safety awareness. No overt aggression. Will change Xanax to Q6H (every 6 hours) PRN.A review of the facility policy dated as revised [DATE] for Medication Orders provided by the DON reflected PRN Medication Orders-When recording orders for medications, specify the type, route, dosage, frequency, strength and the reason for administration.A review of the facility policy dated as revised [DATE] for Psychotropic Medication Use provided by the DON reflected Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Antipsychotics; b. Anti-depressants; c. Anti-anxiety medications; and d. Hypnotics. Non-pharmacologic approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose and allow for discontinuation, in an effort to discontinue these medications. A review of the facility policy dated as revised [DATE] for Behavioral Assessment, Intervention and Monitoring provided by the DON reflected Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. Under General Guidelines, Behavioral pr Psychological Symptoms of Dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. A. Appropriate assessment and treatment of behavioral symptoms requires differentiating between behavioral symptoms that can be managed by treating underlying factors, and those that cannot. Current guidelines recommend the use of non-pharmacologic interventions for BPSD. Under Management, When medications are prescribed for behavioral symptoms, documentation will include: a. rationale for use, b. potential underlying causes of behavior; . e. specific target behaviors and expected outcomes;. NJAC 8:39-11.2(b), 27.1(a), 29.2(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident's environment, equipment, and living area in a safe, sanitary, and homelike manner. This deficient practice was identified in 1 of 2 nursing units (South Unit room [ROOM NUMBER]) observed for environment, and was evidenced by the following:On 9/11/25 at 11:50 AM, the surveyor observed in room [ROOM NUMBER], a tube feeding pump (moves the formula through the feeding tube into the stomach at a controlled rate) soiled with a yellow and brown substance. The surveyor also observed two floor mats that were heavily soiled with black and brown substances. On 9/15/25 at 12:58 PM, the surveyor observed the tube feeding pump was no longer in room [ROOM NUMBER]. The surveyor observed that the floor mats were still heavily soiled with a brown and black substance. On 9/15/25 at 1:15 PM, the surveyor showed the Licensed Practical Nurse (LPN) the soiled mats. The LPN confirmed the mats were soiled and should have been cleaned by the housekeeping staff or the maintenance staff. The LPN confirmed that the nurses were responsible for ensuring that the tube feeding pump was cleaned properly. The LPN stated that the pump had been removed from room [ROOM NUMBER]. On September 15, 2025, at 1:30 PM, during an interview with the surveyor, the Registered Nurse Unit Manager confirmed that feeding pumps should be cleaned by nurses for infection control purposes. On 9/16/25 at 1:22 PM, the survey team discussed the above observations and concerns with the Director of Nursing and Licensed Nursing Home Administrator. The surveyor showed the DON a picture of the soiled Tube Feeding Pump. The DON confirmed that it should have been cleaned properly by the nurse who administered the feeding. NJAC 8:39-27.1 (a)

Based on record review, observation, interview, and review of facility policy, the facility failed to ensure staff followed enhanced barrier precautions (EBP) while providing Activities of Daily Living (ADLs) care for one resident out of 24 facility residents (Resident (R) 1) on EBP. This failure increased the risk of the spread of infections in the facility. Findings include: Review of the facility list of residents on EBP provided by the facility and titled, Enhanced Barrier, undated, revealed 24 residents were on EBP. The list documented R1 was on EBP. Review of R1's ''Care Plan,'' located in the electronic medical record (EMR) under the Care Plan tab, revealed an admitted [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system. Review of R1's Physicians Order, located in the EMR under the Orders tab, dated 02/13/25 revealed R1 was on EBP. Observation on 02/13/25 at 11:20 AM, revealed an EBP sign posted at the entrance of R1's room. The sign directed providers and staff to wear gloves and a gown for high contact cares which included dressing, bathing/showering, and transferring. During this observation, Certified Nurse Aide (CNA) 1 entered R1's room with a mechanical lift. CNA1 did not don PPE when she entered the room. During this same observation, CNA2 was observed finishing up Activities of Daily Living (ADL) with R1. R1 was observed in a geri-chair (a reclining wheelchair). CNA2 was holding soiled linens, clothing, and briefs in a clear bag and preparing to exit R1's room. CNA2 was not wearing PPE. During an interview on 02/13/25 at 11:31 AM, with both CNAs, CNA1 revealed she was not aware that R1 was on EBP. This surveyor pointed towards the EBP sign on the outside of R1's room. CNA1 stated that there was no PPE cart outside the door, and this is the reason why she did not don PPE (gown and gloves). CNA2 repeated, there is no cart in front of the room and stated, this resident does not have a wound. During an interview on 02/13/25 at 11:35 AM, Licensed Practical Nurse (LPN) 1 confirmed that R1 was on EBP and staff should always follow EBP precautions. During an interview on 02/13/25 at 11:52 AM, the facility Director of Nursing (DON) revealed that there were too many residents on EBP for a supply to be placed at each resident's room. The DON stated posted EBP signage was to be followed by all staff and if staff were unsure, they were to refer to the nurse. Review of the facility's policy titled, Enhanced Barrier Precautions, review date 09/29/24 revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention used to reduce transmission of multidrug-resistant organisms . EBP is an extension of standard precautions utilized for residents . all staff must wear gloves and gown during high contact activities for residents . dressing, bathing/showering . transferring . N.J.A.C. 8:39-19.4(m)(n)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illnesses. This deficient practice was evidenced by the following: On [DATE] from 10:10 AM to 10:42 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the kitchen, and observed the following: In the walk-in freezer, the surveyor observed a box of hamburger patties and a box of hot dogs with no labels or dates and both boxes with the inner plastic bags open to the air. The FSD stated that there should be a received date and opened dates. She also stated that the inner bags should be closed. The surveyor also observed the fry basket with an item that resembled a french fry. The FSD stated that nothing was fried for breakfast on this day. On [DATE] in the South unit pantry, the surveyor observed 2 boxes of cereal that were outdated as follows: A box of corn flakes with a date of May0123 and a box of rolled oat cereal with a date of Feb1423. A review of facility provided policy titled Food Receiving and Storage revised [DATE] revealed under Refrigerated/Frozen Storage: 1.All food stored in the refrigerator or freezer are covered, labeled and dated (use by date) 8. Frozen foods are maintained at a temperature to keep frozen food solid. Wrappers of frozen food must stay intact until thawing. A review of facility provided policy titled Refrigerators Freezers , undated revealed: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. N.J.A.C. 18:,d+[DATE].2(g)

NJ #167099 Based on observations, interviews, and record review it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 residents (Resident #41 and #18) reviewed for Enhanced Barrier Precautions on 2 of 2 units (North and South Unit) and was evidenced by the following: 1. On 05/24/24 at 7:45 AM, during incontinence rounds with the Infection Preventionist on the South Unit, the surveyor observed an Enhanced Barrier Precautions sign outside of unsampled Resident #41's door. There was a PPE bin located under the sign. The IP entered the room with the surveyor and asked the resident for permission to conduct an incontinence check. The resident granted permission. The IP performed hand hygiene and removed gloves from a box. She then pulled the curtain and donned (put on) the gloves. At that time, the surveyor requested to speak with the IP in hallway and pointed out the signage at the door. The Enhanced Barrier Sign read Stop: Enhanced Barrier Precautions Everyone Must: . Wear gloves and a gown for the following High-Contact Resident Care Activities .Changing briefs or assisting with toileting. The IP acknowledged the signage and stated she needed to wear a gown and gloves for incontinence check. She then donned a gown and gloves and proceeded with the incontinence check. The surveyor reviewed the electronic medical record (eMR) for Resident #41. A review of the Admission Record (AR, an admission summary) revealed the resident was admitted to the facility with diagnoses which include but not limited to: Secondary Malignant Neoplasm of Breast (breast cancer cells spread from the primary (first) cancer in the breast to other parts of the body) and Hemothorax (a collection of blood in the space between the chest wall and the lung). A review of the Order Summary Report (OSR) revealed a physician order (PO) for Enhanced Barrier Precautions dated 4/23/24. A review of the care plan (CP) revealed: Focus: [name redacted] is on Enhanced Barrier Precaution related to being at risk for MDRO (Multi-Drug Resistant Organism) dated 4/23/24 .Interventions: ENHANCED BARRIER PRECAUTIONS: wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and during therapy. 48423 2.) On 05/22/24 at 12:04 PM, during the initial tour of the facility, the surveyor observed Resident #18 in their room, sitting in wheelchair, by the window. The resident showed the surveyor their gall bladder drain tube which was placed in a privacy bag and secured to the right-side armrest of the wheelchair. The surveyor did not observe any Enhanced Barrier Precaution (EBP) signs or a PPE bin at the door. On 05/23/24 at 10:34 AM, the surveyor observed the resident #18 sitting up in their bed. No EBP sign and PPE bin noted at the door. On 05/24/24 at 07:48 AM, during incontinence rounds with the Registered Nurse/ Unit Manager (RN/UM), the surveyor did not observe an EBP sign or a PPE bin at Resident#18's door. The RN/UM and the surveyor went to the room and the RN/UM checked the resident for incontinence. The surveyor observed the RN/UM wearing only gloves, no gown. The RN/UM picked up the biliary drain tube (a thin, flexible tube that allows bile to flow out from a blocked bile duct into a collection bag outside the body) to show the surveyor that it was attached to the drainage bag. The RN/UM stated, it (the tube) was inserted about 2 months ago. The surveyor reviewed the eMR for Resident #18. A review of the Resident #18's AR revealed the resident was admitted to the facility with diagnoses which included, but were not limited to: acute cholecystitis (inflammation of the gallbladder that develops over hours), immunodeficiency (failure of the immune system to protect the body adequately from infection, due to the absence or insufficiency of some component process or substance) due to conditions classified elsewhere, obstruction of bile duct (a condition that occurs when the bile ducts, which are small tubes that carry bile from the liver to the small intestines become blocked or narrowed), and encounter for change or removal of drains. A review of the OSR revealed a PO for Enhanced Barrier Precaution r/t [related to] being at risk for MDRO (Multidrug resistant organism) dated 05/22/24. A review of the CP revealed a focus of [Name Redacted] is on Enhanced Barrier Precautions related to being at risk for MDRO dated 4/23/24 and interventions: EBP: wear gown, and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and during therapy. On 05/24/24 at 12:05 PM, during an interview with the surveyor , the RN/UM stated that EBP were used for any resident that had wounds, urinary catheters, feeding tubes and residents with IV antibiotics. The RN/UM explained the process was first to obtain the PO, enter them in the computer, then we put the EBP signs on the doors and place a PPE bin at the door and inform the resident's family. The RN/UM acknowledged that there should be a EBP sign on the door and the required PPE the staff should use when providing direct care to the resident. The RN/UM further stated, PPE is important and is required for the protection of the staff and the other residents. On 05/24/24 at 12:17 PM, the surveyor and the UM/RN walked to Resident # 18's room and checked the door, the UM/RN confirmed that there was no EBP sign on the door. She stated, Yes, there should be a sign on the door. On 05/30/24 at 12:50 PM, during a meeting with Regional Nurse #1, Regional Nurse #2, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the survey team, the above-mentioned observations for Resident #41 and #18 was presented. On 05/31/24 at 9:41 AM, during a meeting with the survey team and the LNHA, the DON acknowledged that the staff did not use the proper PPE while checking resident's for incontinence. A review of the facility's policy Enhanced Barrier Precautions Policy dated 4/18/24, revealed: Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .f. changing briefs or assisting with toileting .5. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required, 11. PPE is available outside of the resident rooms. NJAC 8:39-19.4(a)(2)(c)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following: On 05/22/2024 at 10:31 AM, during the initial kitchen tour with the Food Service Director (FSD), the surveyor observed debris and trash around the dumpster area, including cardboard and paper. The FSD stated that housekeeping was responsible for this area. On 05/29/2024 at 01:17 PM, the surveyor interviewed the Administrator, who stated the dumpster area was cleaned up immediately after the debris was identified by the surveyor. Review of facility provided policy Waste Management Policy, dated 01/03/24, included: #3. The area around the container shall be kept clean and clear at all times. N.J.A.C. 8:39-19.3(c)

COMPLAINT # 157599 Based on observations, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) was consistently provided meal assistance as needed. This deficient practice was identified for 2 of 5 residents (Resident #10 and #32) reviewed for ADLs and was evidence by the following: 1. On 05/22/24 at 12:03 PM, during the initial tour of the South Unit, the surveyor observed Resident #32 lying in bed. The resident's eyes were closed. On 05/23/24 at 11:07 AM, the surveyor observed the resident dressed, lying in bed. There was staff in the room assisting the resident's roommate. The surveyor reviewed the electronic medical record (EMR) for Resident #32. A review of the Resident's Admission Record (AR) (an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: Cerebral Infarction due to Embolism of Right Middle Cerebral Artery (occurs when blood flow to the brain is blocked or reduced), Hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and Hemiparesis (a mild or partial weakness on one side of the body) following Cerebral Infarction affecting Left non-dominant side, and Dysphagia (difficulty swallowing food or liquid) following unspecified Cerebrovascular Disease. A review of the resident's Annual Minimum Data Set, (MDS), an assessment tool used to facilitate the management of care, dated 3/22/24, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident was severely cognitively impaired. A further review of the resident's MDS, Section GG for Functional Abilities and Goals, revealed that the resident was Dependent (Helper does ALL of the effort) on assistance for eating. A review of the Order Summary Report (OSR) revealed a physician order (PO) for Pleasure Feeds diet, Puree Solids texture, Honey Thickened Liquids consistency, Lunch tray only dated 3/6/23. A review of the resident's care plan (CP) revealed a Focus: [name redacted] is at increased dehydration risk r/t (related to) nutrition support via tube feeding, Dysphagia on honey Thickened Liquids and diuretic use, revised on 7/31/23, .Interventions: Monitor oral intake of food and fluid if applicable, Diet order: Pleasure Feeds diet, Puree Solids texture, Honey Thickened Liquids consistency, lunch tray only, created 10/4/22. On 05/23/24 at 12:40 pm, the surveyor observed Resident #32 in a reclining chair watching television. There was a lunch tray on the bed side table, which was located near the resident. There was no staff member in the room. The surveyor observed the tray with utensils in a clear plastic wrap, that did not appear to be opened, the meal cover was intact, and the containers on the tray were not opened. On 05/23/24 at 1:22 PM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the surveyor observed Resident #32's lunch tray. The surveyor asked if the utensils looked as if it was opened, the DON stated, no. The DON removed the plate cover and both the DON and ADON confirmed that the food had not been touched. The DON asked Certified Nursing Assistant (CNA) #1, who was Resident #32's assigned CNA, in the presence of the surveyor, if she had asked the resident if they wanted to eat, the CNA was unable to answer the DON. 2. On 05/23/24 at 12:40 pm, the surveyor observed Resident #10's bedside table without a lunch tray. The surveyor asked the resident if they had eaten, the resident stated, no. The surveyor asked Resident #10 if they were hungry, the resident stated, yes. At 1:04 PM, the surveyor made CNA #1 aware that Resident #10 stated that they did not get a lunch tray. The CNA entered the room and went into the resident's bathroom to wash her hands. The CNA exited the room and walked down the hallway. At 1:22 PM, Resident #10's assigned Licensed Practical Nurse (LPN) and CNA #1 returned to the room with a tray for the resident. The DON and the ADON came to the room at that time. The LPN began feeding Resident #10. At 1:24 PM, the surveyor interviewed the DON, who stated if they (the residents) need assistance they should be fed. She further stated, this (resident not being fed) should not occur. She stated the process was that the nurses and the aides should check to make sure the residents get their trays and that the assigned aides should make sure they assist residents that need to be assisted. The surveyor reviewed the EMR for Resident #10. A review of the Resident's AR revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: Dysphagia, Oropharyngeal Phase, and Unspecified Protein-Calorie Malnutrition (happens when you are not consuming enough protein and calories). A review of the resident's most recent quarterly MDS, dated [DATE], revealed that the resident had a BIMS score of 3 out of 15, which indicated the resident was severely cognitively impaired. A further review of the resident's MDS, Section GG for Functional Abilities and Goals, revealed that the resident required Supervision or touching assistance for eating. A review of the OSR revealed a PO for Regular diet Puree Solids texture, Nectar Thickened Liquids consistency dated 3/23/23. A review of the CP revealed a Focus: [name redacted] is at risk for alteration in nutritional status r/t dx (diagnosis) of dementia, dysphagia, unspecified protein calorie malnutrition, htn (hypertension, high blood pressure) , Revision on 5/9/24 .Goal: [name redacted] Intake of >75% at all meals, .Interventions: Feeding ability: supervision and set-up help needed, Date Initiated: 05/16/2023. A review of the facility's undated policy Resident Dining Policy revealed: Our facility audits the food and nutrition services department regularly to ensure that resident's needs are met, and that dining is a safe and pleasant experience for residents. On 05/30/24 at 12:50 PM, during a meeting with Regional Nurse #1, Regional Nurse #2, the Licensed Nursing Home Administrator (LNHA), the DON and the survey team, the above observations for Resident's #10 and #32 were presented. At that time, the audits for the above-mentioned Resident Dining Policy were requested. On 05/31/24 at 9:41 AM, during a meeting with the survey team and the LNHA, the DON acknowledged that no patient should be missed for meal pass. No additional information was presented for the audits as per the above mentioned Resident Dining Policy. NJAC 8:39-27.2(e)

Complaint #: NJ00167644 Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) clarify duplicate physician's orders for an over-the-counter medication, Ferrous Sulfate and b). failed to obtain a medication for pain. This deficient practice occurred for 2 of 7 residents, (Resident #63 and #133) reviewed for medication review. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1). The surveyor reviewed the medical record for Resident #63. On 5/22/24 at 10:33 AM, the surveyor observed the resident who was seated in the Long-Term Care unit dining/recreational room. The resident was seated in their wheelchair and was participating in activities. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to: hypertension (elevated blood pressure), iron deficiency anemia secondary to blood loss (a condition in which blood lacks adequate healthy red blood cells), acute posthemorrhagic anemia (acute blood loss anemia, is a condition that occurs when a person quickly loses a large amount of blood) and anxiety disorder (a mental health disorder characterized by feeling worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of the Admission Minimum Data Set (MDS), an assessment tool, used to facilitate the management of care, dated 04/23/24, reflected that the resident had a brief interview for mental status (BIMS) score of 99, which indicated that the resident was unable to complete an interview. Further review of the MDS section C1000, reflected the resident's cognitive skills for decision making were a 3 (three) which indicated that the resident's cognition is severely impaired. A review of the May 2024 Order Listing Report (OLR) revealed a physician order (PO): 1. A PO dated 05/25/24 for Ferrous Sulfate oral solution 220 (44 Fe [Iron]) mg (milligrams)/5 ml (milliliters) give 5 ml by mouth one time a day for supplement. 2. A PO dated 05/28/24 for Ferrous Sulfate 325 (65 Fe) mg give 1 tablet by mouth one time a day for supplement. A review of the May 2024, electronic medication administration record (eMAR) revealed an order for Ferrous Sulfate oral solution 220 mg/5ml, give 5 ml by mouth one time a day for supplement which was signed as being administered in the eMAR on 05/28/24 at 9:00 AM. Further review, revealed an order for Ferrous Sulfate 325 mg, give 1 tablet by mouth one time a day for supplement which was signed as being administered in the eMAR on 5/28/24 at 9:00 AM. On 5/28/24 at 1:10 PM, the surveyor interviewed the Long-Term care unit Licensed Practical Nurse (LPN) who acknowledged that she should have discontinued the Ferrous Sulfate 325 mg tablets. The LPN did not respond to the surveyor inquiry about both Ferrous sulfate tablets and liquid being signed as being administered at 9:00 AM on 05/28/24. 2). The surveyor reviewed the closed medical record for Resident #133. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to: hypertension, chronic kidney disease (long standing disease of the kidneys leading to renal disease), spinal stenosis (happens when space in the spinal cord is to small and could put pressure on the spinal cord and the nerves) and anxiety disorder (a mental health disorder characterized by feeling worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of the Admission MDS, dated [DATE], reflected that the resident had a BIMS of 6 out of 15, indicating that the resident was severely cognitively impaired. A review of the September 2023 OLR revealed the following PO dated 06/13/23: 1. Pregabalin oral capsule 100 mg, give 1 capsule by mouth one time a day for pain take with 25 mg capsule= 125 mg. 2. Pregabalin oral capsule 25 mg, give 1 capsule by mouth one time a day for pain take with 100 mg capsule=125 mg A review of the September 2023 eMAR revealed an order for Pregabalin oral capsule 100 mg, give 1 capsule by mouth one time a day for pain take with 25 mg capsule = 125 mg with an order date of 6/13/23 and an administration time of 9:00AM. A further review of the eMAR, revealed that the resident's medication was not signed as being administered on 9/6/23, 9/7/23, 9/8/23, 9/9/23, 9/10/23, 9/12/23, and 9/13/23. A review of the September 2023 eMAR revealed an order for Pregabalin oral capsule 25mg, give 1 capsule by mouth one time a day for pain take with 100mg capsule= 125 mg with an order date of 6/13/23 and an administration time of 9:00AM. A further review of the eMAR revealed that the resident's medication was not signed as being administered on 9/6/23, 9/7/23, 9/8/23, 9/9/23, 9/10/23, 9/12/23 and 9/13/23. A review of the facility Progress Notes (PN) revealed that the facility was documenting that the resident's Pregabalin capsules were unavailable from the pharmacy in either a medication administration notes or a nurses note from 9/6/23 until 9/13/23. The notes revealed that the medications were unavailable and were awaiting a delivery from the pharmacy. On 5/30/24 at 1:30 PM, the surveyor discussed the above concerns with the administration team which included the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and a Regional Nurse. On 05/31/24 at 10:40 AM, the DON acknowledge that the resident did not receive their Pregabalin 100 mg and Pregabalin 25 mg capsules from 9/6/23 and 9/13/23. She stated that the pharmacy needed a prescription to send out the medication and that the facility notified the physician and was awaiting a prescription from the physician. There was no additional information provided. A review of the facility's policy for Medication Administration schedule/policy that was dated 12/31/23 and was provided by the DON that revealed the following: 7. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for a resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or facility's medical director to discuss concerns. A review of the facility's policy for Physician orders that was dated 10/31/23 and was provided by the DON that revealed the following: The nurses will clarify with the physician any orders needing clarifications. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observations, interview and record review, it was determined that the facility failed to ensure that residents were served their meals in a dignified manner during meal service. This deficient practice was observed for 3 of 3 meals in 1 of 2 dining rooms. The deficient practice was evidenced by the following: On 05/22/2024 at 12:24 PM, the surveyor observed in the South unit dining area during mealtime that at one table, a staff member sat and fed a resident while the other resident at the same table was not eating or being fed. A second table was observed with three residents that were served their trays and eating, while one resident at the same table did not have their meal. A third table was observed with two residents that were served their trays and eating while two other residents at the same table did not have their meals. A fourth table was observed with one resident who was served their tray and was eating while two other residents at the same table were not served their trays. It was observed by the surveyor that the trays of residents eating at the same table did not arrive to the dining area on the same cart. The first cart with lunch trays arrived to the unit at 11:57 AM and the fourth cart arrived at 12:25 PM. On 05/23/2024 at 12:28 PM, the surveyor observed in the South unit dining area during mealtime that at one table three residents were served their meals and eating at approximately three minutes before another resident seated at the same table had been served. On 05/24/2024 at 08:05 AM, the surveyor observed in the South unit dining area during mealtime that at one table a resident was served their meal and eating approximately seven minutes before the tablemate was served their meal. Another table was observed with a resident who was being fed by a staff member for approximately five minutes before a family member arrived and began feeding the tablemate. On 05/24/2024 at 11:40 AM, the surveyor interviewed the licensed practical nurse (LPN), who stated that all residents sitting at one table should be eating at the same time. On 05/29/2024 at 01:18 PM, the surveyor interviewed the Administrator and Regional nurse who stated that residents at the same table should be served together for dignity issues. The Administrator stated that the new Food Service Director was sending the trays to the units by room number, not according to table seating. Review of facility provided policy Resident Dining Policy dated 04/14/24 indicated that rounds and audits will be conducted to assess: d. Whether residents at each table are served together. N.J.A.C. 8:39-4.1(a)12

Based on interviews it was determined that the facility failed to provide daily delivery of mail, to include Saturdays. This deficient practice was identified for 1 of 5 residents interviewed during the resident council group meeting (Resident #61), and was evidenced by the following: On 05/24/24 at 10:03 AM, the surveyor attended a resident council group meeting with Residents #38, #45, #48, #61 and #64. The surveyor interviewed the residents regarding mail delivery and Resident #61 stated that they did not received mail from November 2023 until mid-March of 2024. The resident stated that he/she was expecting a letter from Social Security and when they brought the concern to the social worker, she returned with a pile of mail including a letter that informed the resident was disqualified because the date had passed. The resident stated that the facility had to write a letter in order to get their (the resident) services. On 5/30/24 at 10:11 AM, the surveyor interviewed the Director of Social Services (DSS) regarding the process of delivering mail at the facility. The DSS stated that when mail was delivered to the facility, mail was dropped off with the receptionist. The business department would sort the mail and that mail would be placed in the social services mailbox and that the social worker would deliver the mail to the resident and contact family from Monday through Friday. The DSS stated that she was on maternity leave from November 2023 through April 2024 and that she was aware that the covering Social Worker (SW) was unaware about the mail delivery process and that this SW was no longer working at the facility. When a new SW started in Mid-March, she found the mail and immediately delivered the mail to the residents. She further stated that she was aware of the situation regarding Resident #61's letter from Social Security. She stated that the facility was able to get the resident Social Security services approved. On 5/30/24 at 10:40 AM, the surveyor interviewed the Business Office Manager, who stated that when she received mail from the receptionist, that she would sort out the mail. She further stated mail such as cards or magazines would be placed in the recreational department mailbox while important mail such as mail from insurance companies, bills, and checks, she would place it in the social services mailbox. She showed the surveyor the social services mailbox and stated that the mailbox had limited space, if it filled up she will bring it to the individual department. She further stated that it was the departments responsibility to deliver the mail to the residents. On 5/30/24 at 10:50 AM, the surveyor interviewed the assistant SW who told the surveyor that she was hired to replace the covering SW who was let go by the facility. She stated that when she started on 3/15/24, she found a bunch of mail that was left throughout the office and in the mailbox in the business office. She further stated that she gathered the mail and distributed the mail to all the residents. She was aware of Resident #61 and acknowledge that the resident had issues with their social security. She stated that the facility worked with the resident and social security to resolve all issues and the resident received his services. On 5/30/24 at 1:30 PM, the surveyor presented the above concerns to the administration team which included the License Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Regional Nurse. There was no additional information provided. A review of the facility's policy for Mail Delivery for residents that was undated and was provided by the DON that revealed the following: Policy statement: It is the policy of {the facility} for residents to receive and send mail in unopened envelopes in a timely manner. Protocol: 1. Mail is delivered to the reception desk daily. 2. The business office manager will separate from departmental mail and sort for each resident. 3. Once mail is sorted if any bills, notices for residents will be placed in social services mailbox. 4. If any cards, newsletters, magazines, letters they will be given to activity aid to distribute to resident. NJAC 8:39-4.1 (a)(19)

Complaint #NJ 00163449 Based on interviews and review of the medical records (MRs) and other facility documentation on [DATE] and [DATE], it was determined the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) and activate their emergency response system (ERS) which includes calling 911, notify other staff by announcing the emergency code, and retrieving the crash cart and the automatic external defibrillator (AED) when Resident #1 who was a full code (all resuscitative measures should be taken if the heartbeat or breathing stops) and did not have a physician order (PO) for Do Not Resuscitate (DNR) was found unresponsive and without a pulse or respirations in bed. This was not in accordance with their policy for Emergency Procedure-CPR and the American Heart Association (AHA) and the Basic Life Support (BLS) guidelines for Healthcare Providers. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Hypertension, Congestive Heart Failure, and Right Thalamic Intracerebral Hemorrhage with left hemiparesis (stroke with left-sided weakness). According to documentation and interviews, the facility did not immediately perform CPR or activate their ERS due to not having an order for a full code or DNR in the MR when Resident #1, who was a full code and without a PO for DNR, was found unresponsive without a pulse and respirations on [DATE] at 11:00 PM. Resident #1 was last seen responsive, trying to get out of bed an hour ago by Certified Nursing Assistant (CNA) #1. At that time, CNA #1 repositioned the resident in bed. At 11:00 PM, CNA #1 notified the Licensed Practical Nurse (LPN) #1, the resident was not looking good. LPN #1, a newly assigned agency nurse, went in the room, checked for pulse and vital signs, and found out the resident expired. LPN #1 confirmed during a telephone interview on [DATE] at 1:44 PM he was certified in CPR and did not provide CPR to Resident #1 because he was trying to figure out the resident's code status. He stated that he did not convey or explain to the Physician that he was unsure of the resident's code status. He called the Physician only to inform that Resident #1 had expired so the resident could be pronounced. He confirmed that instead of initiating CPR, he called the Director of Nursing (DON) and Assistant DON (ADON) on the telephone for instructions. However, the DON and ADON were unavailable. Although there was no PO for DNR, LPN #1 strongly insisted that because the POLST form was blank and there was no full code written anywhere in the MR, he would not start CPR at all. The nursing progress notes (PN) indicated that at 11:55 PM, the Registered Nurse/Nursing Supervisor (RN/NS) arrived on the unit for the night shift (11PM-7AM) and was notified by LPN #1 that Resident #1 expired at 11PM. The RN/NS documented that Resident #1 was a full code, CPR was initiated at 12:20 AM, LPN #2 called 911 at 12:50 AM, and the paramedics and team pronounced Resident #1 expired at 01:43 AM. During a telephone interview on [DATE] at 4:07 PM, the RN/NS stated he called the facility prior to his shift because he was going to be late; and at that time ,d+[DATE] shift LPN #2 informed him on the phone the resident had expired, and he assumed Resident #1 was not a full code or resuscitation effort was unsuccessful. The RN/NS explained that when he arrived on the unit, he received reports and asked LPN #1 what Resident #1's code status was. LPN #1 responded, I think it's not DNR. He was also informed that the Physician had already been notified the resident had expired. At that time, the RN/NS checked the chart to verify Resident #1's code status and confirmed there was no PO for DNR. He then called the DON, who instructed him to initiate CPR and call 911 An Immediate Jeopardy (IJ) past noncompliance (PNC) began on [DATE] when the facility's failed to initiate CPR and activate their ERS immediately when Resident #1, who was a full code, did not have a PO for DNR, and was found unresponsive, and without a pulse or respirations. This practice placed all residents who are a full code or had no accurate code status in the MR at risk for imminent death if found to be unresponsive without a pulse and respirations. The IJ PNC was determined to have existed on [DATE] and there was sufficient evidence that on [DATE] that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the specific regulatory requirement. The Administrator and Assistant Director of Nursing (ADON) were informed of the of the past IJ situation on [DATE]. The deficient practice is evidenced by the following: Reference: https://www.ahajournals.org/toc/circ/,d+[DATE]_suppl_3 The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations. In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. A cardiac arrest victim is not responsive. Breathing is absent or is not normal. Consequently, rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally. Reference: https://www.nj.gov/health/advancedirective/polst/ The Practitioner Orders for Life Sustaining Treatment (POLST) form enables patients to indicate their preferences regarding life-sustaining treatment. This form, signed by a patient's attending physician, advanced practice nurse or physician's assistant, provides instructions for health care personnel to follow for a range of life-prolonging interventions. This form becomes part of a patient's medical records, following the patient from one healthcare setting to another, including hospital, nursing home or hospice. 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE]. A Physician's progress notes (PN) dated [DATE] indicated diagnoses which included but were not limited to Hypertension, Congestive Heart Failure, and Right Thalamic Intracerebral Hemorrhage with left hemiparesis (stroke with left-sided weakness) A Minimum Data Set (MDS), an assessment tool, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition and the resident required extensive assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) did not include a physician order (PO) for DNR. A review of the care plan (CP) did not include a CP for the resident's code status, DNR or full code. Review of a document titled Social Service Evaluation (SSE) dated [DATE] indicated that the Social Worker documented Full Code under Advance Directive (AD). A review of Resident #1's closed chart/MR on [DATE] did not include a Physicians Orders for Life- Sustaining Treatment (POLST) form in the chart. A review of the nursing PN dated [DATE] at 12:20 AM, signed by LPN #1, indicated that Resident #1 was last seen on [DATE] at 7 PM complaining of cough and was given cough medication. Resident #1 was found unresponsive at 11 PM by CNA #1. LPN #1 went into the room, checked for pulse and vital signs, and found out the resident expired. A review of nursing PN dated [DATE] at 01:52 AM, signed by LPN #2, indicated at 11:23 PM received report that Resident #1 had expired. The outgoing nurse (LPN #1) called the Physician to notify the resident expired. Called placed to DON message left for a return call. At 11:40 PM, the supervisor was notified (over the phone) of the resident's status. At 12:50 AM, CPR was initiated, and family and 911 were called. At 1:00 AM, the police arrived, and CPR continued. Further review of nursing PN dated [DATE] at 3:37 AM signed by the RN/NS indicated at 11:55 PM, he arrived on the floor and was notified by ,d+[DATE] shift nurse (LPN#1) that Resident #1 expired at 11 PM and Physician on-call had been notified. The RN/NS documented that Resident #1 was a full code. At that time, the RN/NS noted the resident was unresponsive and had no heart sounds on auscultation. The DON was notified, and CPR was initiated at 12:20 AM. The charge nurse (LPN #2) called 911 at 12:50 AM. The paramedics pronounced Resident #1 expired at 1:43 AM on [DATE]. A review of a written employee statement signed by CNA #1 and dated [DATE] revealed on [DATE] at 10 PM, CNA #1 indicated Resident #1 was trying to get out of bed, and she went to reposition the resident's legs. At 11 PM, CNA #1 was notified by Temporary Nursing Assistant (TNA) #1 that Resident #1 was unresponsive, CNA #1 checked and confirmed the resident was unresponsive, then immediately informed the nurse (LPN #1). During a telephone interview with the surveyor on [DATE] at 10:50 AM, CNA #1 confirmed that when she checked, Resident #1 was unresponsive, not stiff and skin was warm. During a telephone interview with the surveyor on [DATE] at 1:44 PM, LPN #1 confirmed he did not initiate CPR when he found Resident #1 to be unresponsive and not breathing on [DATE] at 11 PM because he was trying to figure out the resident's code status. LPN #1 confirmed the resident had no palpable pulse and was not cold or stiff at that time. He explained that the POLST form in the resident's chart was blank, and there was no PO for a full code. He continued to explain that he notified the Physician on call only to inform Resident #1 had expired so the resident could be pronounced expired. LPN #1 confirmed he did not convey or explain to the Physician he was unsure of the resident's code status, and CPR was not initiated despite not having a PO for DNR. He continued to state he called the DON and ADON but could not be reached. Although the OSR did not indicate a PO for DNR, LPN #1 strongly insisted that because the POLST form was blank, there was no clear instructions, so the code status was not clear. He added, if a resident code status cannot be found despite not having a PO for DNR, he would not start CPR at all. During a telephone interview with the surveyor on [DATE] at 4:07 PM, the RN/NS confirmed he was the night shift (11PM-7AM) nursing supervisor on [DATE]. He stated on [DATE] after 11 PM, he called the facility to inform the nurses he was going to be late, and at that time, the nurse informed him a resident had expired. The RN/NS explained he did not ask questions because he assumed the resident was not a full code or the resuscitation effort was unsuccessful. When he arrived, he received report and asked LPN #1 what Resident #1's code status was. LPN #1 responded, I think it's not DNR and informed him the Physician had already been notified the resident had expired so that the resident could be pronounced. At that time, he found out there was no PO for DNR. The RN/NS called the DON for instructions. The RN/NS assessed Resident #1 and was noted to be unresponsive, warm to the touch, had no pulse or VS, and pupils were non-reactive. He called the DON and started CPR and call 911 after the call. During a telephone interview with the surveyor on [DATE] at 5:34 PM, LPN #2 confirmed that she was the night shift nurse on [DATE]. She stated, at around 11:20 PM, LPN #1 reported to her that Resident #1 had expired at 11 PM and the Physician had already been notified that the resident expired. She remembered LPN #1 stating, Right now, I have a situation; I have a patient that expired, LPN #1 told her to call the RP and the funeral home. At that time, there was no funeral home listed on the resident's chart, so she called the DON and left a message. LPN #2 agreed that the RN/NS aforementioned interview statement was correct. During an interview with the surveyor on [DATE] at 2:14 PM, the Social Service Director (SSD) stated Resident #1 was unable to complete the POLST form due to cognitive status. The POLST form was discussed and mailed to the family member/Responsible Party (RP), but the form was never completed. The SS was unable to explain why there was not follow discussion about the POLST form with the RP. She confirmed that Resident #1's code status was a full code since the POLST form was never completed, and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:20 AM, the Social Worker (SW) confirmed she completed the SSE on [DATE], which indicated full code under AD. She stated that a POLST form is not mandatory, but the resident or RP is encouraged to complete the form. She continued to state that Resident #1 was a full code since the POLST form was blank and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:33 AM, Resident #1's Physician stated that on [DATE], unknown time, the on-call Physician emailed him that Resident #1 had expired. He explained he was not informed that CPR was not provided, or CPR was delayed. The Physician explained that he expects the nurses to call him or the clinician on call for changes in the resident's condition so they can make clinical decisions based on the nurse's assessment. He stated the nurse should have informed the Physician on a call about the unclear code status of the resident. However, if there was no PO for DNR, the resident was full code. Additionally, the physician confirmed that signs of rigor mortis can occur a couple of hours after death, including stiffness, coldness, and cyanosis (bluish skin discoloration), which were not conveyed to the Physician on-call on [DATE]. Review of a witness statement dated [DATE] signed by the DON, indicated that she received a call from at 12:42 AM LPN #2 who reported that Resident #1 expired during 3PM-11PM shift. LPN #2 went on to say that no there was no funeral home listed on the resident's chart and the RP could not be reached. The RN/NS took the phone and explained that Resident #1 expired at 11PM and explained that the resident was identified as a full code and no code was initiated. The RN/NS went on to ask if he should pronounce Resident #1 or move forward doing the code because the on-call Physician had already been notified of the time the resident expired. The DON instructed that a code be initiated and 911 be called. During a telephone interview with the surveyor on [DATE] at 11:22 AM, The DON explained LPN #2 called and informed her at around 12:20 that Resident #1 had expired and did not have a funeral home listed on the chart. The RN/NS who was also on the phone explain what had transpired and informed her that Resident #1 was full code. She instructed the RN/NS to initiate CPR and call 911 immediately. The DON continued to state that LPN #1 should have conveyed the resident's findings when he notified the Physician because LPNs are not permitted to pronounce the resident's death. The DON acknowledged that LPN #1 should have initiated CPR immediately and activated the ERS upon confirming there was no PO for DNR. During an interview with the Assistant Director of Nursing (ADON) and Administrator on [DATE] at 6:19 PM, they both stated that nurses and CNAs who are CPR certified are expected to immediately start CPR and activate 911 if a resident is a full code and found unresponsive, not breathing and without a pulse. They both confirmed that if there was no PO for DNR or a POLST form indicating DNR, the resident is a full code. The ADON confirmed LPN #1 did not follow the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation and should have initiated CPR and activate 911 immediately. A review of the facility's undated policy titled Emergency Procedure- Cardiopulmonary Resuscitation included but was not limited to the following: Under Guidelines it was indicated that 4. The chances of surviving SCA (sudden cardiac arrest) may be increased if CPR is initiated immediately .5. Early delivery of a shock with a defibrillator plus CPR .can further increase chances of survival. 6. If an individual (resident, visitor .) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a DNR order .there are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is DNR . It was indicted under Emergency Procedure- Cardiopulmonary Resuscitation, 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. a. Instruct staff member to activate the emergency response system (code) and call 911. b. Instruct staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status .d. Initiate BLS . A review of the facility's undated policy titled Advance Directives included but was not limited to the following: Under Policy Statement it was indicated that Advance directive are honored in accordance with the state law and facility policy. Under Refusing or Requesting Treatment it was indicated that 1. The resident had the right to refuse medical or surgical treatment whether he or she has and advance directive. a. A resident will not be treated against his or her own wishes. On [DATE] at 9:44 PM, the facility provided a copy of the corrective action that was implemented which began on [DATE]. Review of the plan revealed the following: The facility reported the incident to the Ombudsman office and concluded their investigation on [DATE]. The Investigation Report included the timeline of the incident and witness statements obtained from the staff. Review of the statements from TNA #1, CNA #1, LPN #2, RN/NS, and the DON revealed that each staff member provided a signed and dated witness statements. On [DATE], the facility reported LPN #1 to the licensing board and was removed from working at the facility. On [DATE], the SW audited the medical records for all residents to ensure code status was documented using POLST form, matched the PO in the Electronic MR, and will continue this practice with future residents. On [DATE], the DON and ADON educated staff which included nursing, social service, dietary, rehabilitation, housekeeping and maintenance on rapid response (Emergency Procedue-CPR), code status (DNR, POLST), and following physician's orders and would be ongoing. On [DATE], the ADON educated the RN/NS and LPN #2 via telephone on code initiation and CPR policy and procedurea and would be ongoing. On [DATE], the facility audited and validated the facility staff CPR cards and would be ongoing. On [DATE], agency nurse education packets were updated to include facility CPR policy and procedure. All agency nurses were provided the new educations packets. All incoming agency nurses would be povided new education packets. On [DATE], all department heads which included Social Service, Admisssion, Rehabilitation, Housekeeping and Dietary were re-educated on code status and CPR policy and procedure. On [DATE], CPR protocols and mock code drill performed at the facility and would be ongoing. The surveyor reviewed and conducted onsite verification on [DATE] and [DATE] to confirm the facility had implemented all components of the corrective plan of action. After conducting records review and interviews, it was determined the facility implemented their corrective plan and the deficient practice was corrected on [DATE] prior to the survey. Review of the employee education attendance record (EEAR) dated [DATE] revealed that the RN/NS and LPN #2 received education by telephone on facility's policy and procedure for emergency procedure and CPR. Review of the EEAR dated [DATE], [DATE], and [DATE] revealed that nursing staff received education on facility's policy and procedure for emergency procedure and CPR and [DATE] on who can pronounce when a resident expired. Review of the EEAR dated [DATE] revealed that department heads received education on facility's policy and procedure for emergency procedure and CPR. Review of the EEAR dated [DATE] revealed that a mock drill in-service for all facility staff was performed at 2:20 PM and 6:30 PM and an in-service on [DATE] on CPR and code blue drill. Review of the agency nursing staff education packet included CPR certification requirements, information on facility sponsored CPR classes, and emergency response procedures. During the survey, the surveyor verified the validity of nursing staff CPR certifications. During the survey, the surveyor verified that the resident charts were audited and POLST forms (green form) were placed in front of the charts with the resident's code status. The surveyor verified that the RN/NS, LPN #2, CNA #1, and TNA #1 received education on code status and CPR protocols. During a telephone interview with the surveyor on [DATE] at 5:34 PM, LPN #2 confirmed she received education on code status and CPR protocols. During an interview with the surveyor on [DATE] at 3:10 PM, the RN/UM stated that after the incident she was educated on resident code status, emergency procedures, and CPR protocols. During an interview with the surveyor on [DATE] at 3:41 PM, RN #1 explained that she received education and attended a code drill. She explained the process for identifying code status, CPR, and emergency procedures. During an interview with the surveyor on [DATE] at 8:55 PM, LPN #3 and CNA #2 stated they both received in-service on code status, CPR, and emergency procedures. NJAC 8:,d+[DATE].1(a) NJAC 8:,d+[DATE].1(31) iii NJAC 8:,d+[DATE].6 (g)

Complaint #NJ 00163449 Based on interviews and review of the medical records (MRs) and other facility documentation on [DATE] and [DATE], it was determined the facility failed to provide services to prevent neglect of a resident (Resident #1). Resident #1 who was a full code (all resuscitative measures should be taken if the heartbeat or breathing stops) and had no advance directive or a physician order (PO) for Do Not Resuscitate (DNR) was found unresponsive and without a pulse or respirations in bed on [DATE]. The Licensed Practical Nurse (LPN) #1, failed to immediately initiate Cardiopulmonary Resuscitation (CPR) (an emergency lifesaving procedure performed when the heart stops beating) and activate their emergency response system (ERS) which includes calling 911, alarm other staff by announcing the emergency code, and retrieving the crash cart and the automatic external defibrillator (AED). Additionally, the facility failed to provide documented evidence LPN #1 who was an agency nurse and new to the facility was provided education on policies for emergency procedure which covers unclear DNR status and advance directives prior to the event. The deficient practice is evidenced by the following: Reference: https://www.ahajournals.org/toc/circ/,d+[DATE]_suppl_3 The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations. In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. A cardiac arrest victim is not responsive. Breathing is absent or is not normal. Consequently, rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally. Reference: https://www.nj.gov/health/advancedirective/polst/ The Practitioner Orders for Life Sustaining Treatment (POLST) form enables patients to indicate their preferences regarding life-sustaining treatment. This form, signed by a patient's attending physician, advanced practice nurse or physician's assistant, provides instructions for health care personnel to follow for a range of life-prolonging interventions. This form becomes part of a patient's medical records, following the patient from one healthcare setting to another, including hospital, nursing home or hospice. 1. According to the Admission Record, Resident #1 was admitted to the facility on [DATE]. A Physician's progress notes (PN) dated [DATE] indicated diagnoses which included but were not limited to Hypertension, Congestive Heart Failure, and Right Thalamic Intracerebral Hemorrhage with left hemiparesis (stroke with left-sided weakness) A Minimum Data Set (MDS), an assessment tool, dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition and the resident required extensive assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) did not reveal a physician order (PO) for DNR. A review of the care plan (CP) did not reveal a CP for the resident's code status, DNR or full code. Review of a document titled Social Service Evaluation (SSE) dated [DATE] indicated that the Social Worker documented Full Code under Advance Directive (AD). A review of Resident #1's closed chart/MR on [DATE] did not include a Physicians Orders for Life- Sustaining Treatment (POLST) form in the chart. A review of a nursing PN dated [DATE] at 12:20 AM, signed by LPN #1, indicated that Resident #1 was last seen on [DATE] at 7 PM complaining of cough and was given cough medication. Resident #1 was found unresponsive at 11 PM by CNA #1. LPN #1 went into the room, checked for pulse and vital signs, and found out the resident expired. A review of a nursing PN dated [DATE] at 01:52 AM, signed by LPN #2, indicated at 11:23 PM received report that Resident #1 had expired. The outgoing nurse (LPN #1) called the Physician to notify the resident expired. Called placed to DON message left for a return call. At 11:40 PM, the supervisor was notified (over the phone) of the resident's status. At 12:50 AM, CPR was initiated, and family and 911 were called. At 1:00 AM, the police arrived, and CPR continued. Further review of a nursing PN dated [DATE] at 3:37 AM signed by the RN/NS indicated at 11:55 PM, he arrived on the unit and was notified the by ,d+[DATE] shift nurse (LPN#1) that Resident #1 expired at 11 PM and the Physician on-call had been notified. The RN/NS documented that Resident #1 was a full code. At that time, the RN/NS noted the resident was unresponsive and had no heart sounds on auscultation. The DON was notified, and CPR was initiated at 12:20 AM. The charge nurse (LPN #2) called 911 at 12:50 AM. The paramedics pronounced Resident #1 expired at 1:43 AM on [DATE]. A review of a written employee statement signed by CNA #1 and dated [DATE] revealed on [DATE] at 10 PM, CNA #1 indicated Resident #1 was trying to get out of bed, and she went to reposition the resident's legs. At 11 PM, CNA #1 was notified by Temporary Nursing Assistant (TNA) #1 that Resident #1 was unresponsive, CNA #1 checked and confirmed the resident was unresponsive, then immediately informed the nurse (LPN #1). During a telephone interview with the surveyor on [DATE] at 10:50 AM, CNA #1 confirmed that when she checked, Resident # 1 was unresponsive, not stiff and skin was warm. During a telephone interview with the surveyor on [DATE] at 1:44 PM, LPN #1 confirmed that he did not initiate CPR when he found Resident #1 to be unresponsive and not breathing on [DATE] at 11 PM because he was trying to figure out the resident's code status. LPN #1 confirmed the resident had no palpable pulse and was not cold or stiff at that time. He explained that the POLST form in the resident's chart was blank, and there was no PO for a full code. He continued to explain that he notified the Physician on call only to inform the Physician that Resident #1 had expired so the resident could be pronounced. LPN #1 confirmed he did not convey or explain to the Physician that he was unsure of the resident's code status, and CPR was not initiated despite not having a PO for DNR. He continued to state he called the DON and ADON on the telephone but could not be reached. Although there was no PO for DNR, LPN #1 strongly insisted that because the POLST form was blank and there was no full code written anywhere in the MR, he would not start CPR at all. A document signed by LPN #1 dated [DATE] inluded a list of education materials covered in the orientation packet provided to LPN #1 on [DATE]. The document did not include an orientation/education on policy and procedures for emergency procedure- cardiopulmonary resuscitation. During a telephone interview with the surveyor on [DATE] at 4:07 PM, the RN/NS confirmed he was the night shift (11PM-7AM) nursing supervisor on [DATE]. He stated on [DATE] after 11 PM, he called the facility to inform the nurses he was going to be late, and at that time, the nurse informed him a resident had expired. The RN/NS explained he did not ask questions because he assumed the resident was not a full code or the resuscitation effort was unsuccessful. When he arrived on the unit, he received reports and asked LPN #1 what Resident #1's code status was. LPN #1 responded, I think it's not DNR and informed him the Physician had already been notified the resident had expired so that the resident could be pronounced. At that time, he found out there was no PO for DNR. The RN/NS stated he called the DON on the telephone and was instructed to immediately start CPR and call 911. Afterwards, he assessed Resident #1 who was noted to be unresponsive, warm to the touch, had no pulse, and pupils were non-reactive. He began CPR and instructed the nurse to call 911. The RN/NS was unable to confirm the accuracy of the time CPR was initiated in his documentation but stated that it was immediately before 911 was called. During a telephone interview with the surveyor on [DATE] at 5:34 PM, LPN #2 confirmed that she was the night shift nurse on [DATE]. She stated, at around 11:20 PM, LPN #1 reported to her that Resident #1 had expired at 11 PM and the Physician had already been notified that the resident expired. She remembered LPN #1 stating, Right now, I have a situation; I have a patient that expired, LPN #1 told her to call the RP and the funeral home. At that time, there was no funeral home listed on the resident's chart, so she called the DON on the telephone and left a message. LPN #2 was unable to recall if CPR was started at 12:20 AM but confirmed that the RN/NS initiated CPR and instructed her to call 911 after they spoke with the DON which was immediately before 12:50 AM. During an interview with the surveyor on [DATE] at 2:14 PM, the Social Service Director (SSD) stated Resident #1 was unable to complete the POLST form due to the resident's impaired cognitive status. The POLST form was discussed and mailed to the family member/Responsible Party (RP), but the form was never completed. The SS was unable to explain why a follow discussion about the POLST with the RP did not occur. She confirmed that Resident #1's code status was a full code since the POLST form was never completed, and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:20 AM, the Social Worker (SW) confirmed she completed the SSE on [DATE], which indicated full code under AD. She stated that a POLST form is not mandatory, but the resident or the RP is encouraged to complete the form. She continued to state that Resident #1 was a full code since the POLST form was blank and there was no PO for DNR. During a telephone interview with the surveyor on [DATE] at 11:33 AM, Resident #1's Physician stated that on [DATE], unknown time, the on-call Physician emailed him that Resident #1 had expired. The Physician explained that he expected the nurses to call him or the clinician on-call for changes in the resident's condition so they can make clinical decisions based on the nurse's assessment. He stated the nurse should have informed the Physician on-call about the unclear code status of the resident. However, the Physician agreed that if there was no PO for DNR, the resident was a full code. Review of a witness statement document dated [DATE] signed by the DON, revealed that she received a telephone call at 12:42 AM from LPN #2 and RN/NS about Resident #1. It was indicated that she was notified the resident had expired during 3PM-11PM shift and there was no funeral home listed on the chart. The DON indicated the RN/NS explained that Resident #1 was identified as a full code and no code was initiated. The RN/NS asked if he should pronounce Resident #1 or move forward doing the code because the on-call Physician had already been notified of the time the resident expired. The document further revealed that the DON instructed the RN/NS to initiate a code and call 911. During a telephone interview with the surveyor on [DATE] at 11:22 AM, The DON explained that she received a voicemail telephone message from LPN #2 at approximately 12:20 AM that Resident #1 had expired and did not have a funeral home listed on the chart. She later spoke with LPN #2 and RN/NS on the telephone at approximately 12:42 AM. The DON stated that the RN/NS explained what had transpired and informed her that Resident #1 was full code. She then instructed the RN/NS to initiate CPR and call 911 immediately. The DON continued to state that LPN #1 should have conveyed to the physician he was unsure of Resident #1's code status. She acknowledged that Resident #1 should have been resuscitated immediately and emergency protocol should have been followed since there was no PO for DNR. During an interview with the surveyor on [DATE] at 10:54 AM, the staffing coordinator (SC) stated that she would approve agency nurses to work for the facility if they meet the facility's credentialing and CPR certification requirements. Afterwards, the newly assigned agency nurses are provided orientation which included education materials either through an online link or a packet that is handed to them on their first day. The agency nurses are required to submit the signed acknowledgement for the receipt and understanding of the orientation/education packet to the ADON or the shift supervisor prior to start. During a follow up interview with the surveyor on [DATE] at 1:11 PM, the ADON confirmed that the process for hiring agency nurses explained by the SC was accurate. The ADON explained that she verbally educates newly assigned agency nurses on emergency procedures, CPR, POLST, and code status before they start. However, she was unable to provide documentation that the education was provided to LPN #1. A review of the facility's undated policy titled Emergency Procedure- Cardiopulmonary Resuscitation included but was not limited to the following: Under Guidelines it was indicated that 4. The chances of surviving SCA (sudden cardiac arrest) may be increased if CPR is initiated immediately .5. Early delivery of a shock with a defibrillator plus CPR .can further increase chances of survival. 6. If an individual (resident, visitor .) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. it is known that a DNR order .there are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is DNR .Under Emergency Procedure - Cardiopulmonary Resuscitation it was indicated that. 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. a. Instruct staff member to activate the emergency response system (code) and call 911. b. Instruct staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status .d. Initiate BLS . A review of the facility's undated policy titled Advance Directives included but was not limited to the following: Under Policy Statement it was indicated that Advance directive are honored in accordance with the state law and facility policy. Under Refusing or Requesting Treatment it was indicated that 1. The resident had the right to refuse medical or surgical treatment whether he or she has and advance directive. a. A resident will not be treated against his or her own wishes. NJAC 8:,d+[DATE].1(a) NJAC 8:,d+[DATE].1(31)iii NJAC 8:,d+[DATE].6(g)

Based on observation, interview and record review, it was determined that the facility failed to: a. ensure the infection control practices for residents on transmission-based precautions were implemented in accordance with accepted national standards, and b. perform hand hygiene while caring for facility residents and c. disinfect equipment prior to and after use, d.) follow appropriate infection control procedure during wound treatment. These deficient practices were observed on 11 of 20 residents reviewed for infection control practices, Resident #252, #253, #19, #97, #11, #6, #69, #35, #57, #35, #100. The deficiency is evidenced by the following: 1. On 3/14/21 at 11:04 AM, during the initial tour, the surveyor observed the Certified Nursing Assistant (CNA) #1 wearing a disposable gown, gloves and N-95 mask, enter Resident #252's room. The surveyor observed a sign posted on Resident #252's door indicating that Resident #252 was on contact and droplet precautions. An additional sign posted on the resident's door indicated that the proper Personal Protective Equipment (PPE) that staff must wear prior to entering the resident's room included, gown, N-95 mask, goggles or face shield and gloves. On 3/14/21 at 11:19 AM, the surveyor observed CNA #1 exit the resident's room, remove her gown and gloves outside of the room and did not perform handwashing or sanitize her hands using an alcohol-based hand rub (ABHR) gel. On 3/14/21 at 11:20 AM, the surveyor was interviewing CNA #1 when the facility's fire alarm sounded. CNA #1 proceeded to respond to the alarm. The surveyor observed CNA #1 handling the doorknobs of 5 resident's rooms, while closing them. On 3/14/22 at 11:22 AM, CNA #1 was informed that the fire alarm was a drill. The surveyor resumed the interview with CNA #1. CNA #1 acknowledged that she did not wash her hands or sanitize using ABHR gel after exiting Resident #252's room. CNA #1 informed the surveyor that Resident #252 was placed on contact and droplet isolation because the resident was a new admission to the facility. The surveyor questioned CNA #1 as to why she was not wearing any goggles or faceshield prior to entering the resident's room as there was a sign posted on Resident #252's door. CNA #1 stated that she did not wear any goggles or face shield since she has her personal prescription eyeglasses. A review of Resident #252's Admission Record (AR) revealed that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record indicated that the resident was not COVID vaccinated due to refusal. On 3/17/21 at 1:05 PM, the surveyor informed the facility's Administrator, Director of Nursing (DON) and the Regional Administrator regarding the above concern. The surveyor reviewed a facility's form titled, Action Plan Updated Zones that was provided by the Administrator which revealed, New Admission Zone - Contact and Droplet Precautions Patient Status: 10-day quarantine for unvaccinated. PPE for Staff: N-95 mask, eye protection/face shield, gown, and gloves. On 3/23/22 at 11:45 AM, the surveyor interviewed the Director of Nursing who stated that personal prescription eye glasses were not acceptable to be used for protection when entering a residents room who was newly or readmitted to the facility. There was no other information provided. 2. On 3/17/22 at 10:47 AM, the surveyor observed Resident #253 in bed, alert and awake. The surveyor observed Licensed Practical Nursing (LPN) #1 assisted by CNA #1 in the room preparing for Resident #253's wound care. The surveyor observed LPN #1 place the wound treatment equipment and supplies on the resident's daily used overbed table without disinfecting or placing any barrier under the equipment. The surveyor observed LPN #1 put on gloves without performing handwashing. After putting on gloves, LPN #1 was observed touching surfaces in the room, the wheelchair, doorknob and the resident's overbed table. The surveyor observed CNA #1 perform handwashing and was scrubbing both her hands with soap under the running water. After cleansing the wound, LPN #1 removed her soiled gloves, put on a clean glove to her right hand only without performing handwashing or sanitizing with ABHR gel. The surveyor observed LPN #1, using her gloved right hand, remove all the dirty equipment on the resident's overbed table and discarded them in the garbage bin. LPN #1 proceeded to remove the glove from her right hand then touched the resident to help CNA #1 reposition Resident #253 without performing handwashing or sanitizing using ABHR gel. The surveyor observed LPN #1 perform handwashing for 10 seconds while scrubbing both hands with soap under the running water. LPN #1 did not sanitize the resident's overbed table after rendering the wound treatment. The surveyor discussed the above concern with LPN #1, who acknowledged that she did not perform handwashing and did not sanitize the resident's overbed table before and after the wound treatment administration. The surveyor reviewed the facility's policy and procedure titled, Wound Care under procedure, #1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. #5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. #19 Use clean field saturated with alcohol to wipe overbed table. On 3/17/22 at 1:05 PM, the surveyor informed the facility's Administrator and DON regarding the above concern. The facility did not provide any further information. 3. On 3/14/21 at 11:35 AM, during the initial tour, the surveyor observed a yellow STOP sign posted in Resident #19's door prior to entering. Further observation revealed that the resident's door had another sign posted indicating that Resident #19 was on contact precautions. There was also a sign indicating the proper PPE that staff must wear prior to entering the resident's door which included, gown, N-95 mask, goggles or face shield and gloves. The surveyor interviewed CNA #1 who stated that when she enters the resident's room, she does not have to wear any PPE except for the N-95 mask. CNA #1 further stated that she does not follow what was posted on the resident's door. The surveyor interviewed LPN #2 who stated that he does not wear any other PPE except for an N-95 mask when entering Resident #19's room. LPN #2 also stated that he does not follow the signage posted on Resident #19's door. LPN #2 informed the surveyor that Resident #19 goes to Hemodialysis outside of the facility. A review of Resident #19's AR revealed that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record indicated that Resident #19 was fully vaccinated with a booster dose from COVID 19. On 3/17/22 at 1:05 PM, the surveyor discussed the above concerns with the facility's Administrator and DON. A review of the facility's policy titled, Outbreak Communicable Diseases documented, #12. (a) Ordering Isolation precautions, as needed or as per state regulations; A review of the CDC guidelines updated 2/2/22 stated that In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours (e.g., for medical appointments, community outings with family or friends) and do not have close contact with someone with [CONDITION(S)]-CoV-2 infection. Quarantining residents who regularly leave the facility for medical appointments (e.g., [CONDITION(S)], [CONDITION(S)]) would result in indefinite isolation of the resident that likely outweighs any potential benefits of quarantine. On 3/23/22 at 11:45 AM, the surveyor interviewed the DON who stated that the Infection Preventionist (IP) was responsible to make rounds and ensure which resident must be placed on Transmission Based Precautions (TBP) and which resident does not require any TBP. On 3/23/22 at 12:27 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that she started the role of being an IP beginning January 2022. The IP could not explain why Resident #19 was placed on contact precautions. There was no further information provided. 4. On 3/14/22 at 10:17 AM, the surveyor observed a yellow STOP sign, a sign indicating contact precautions, and instructions on how to put on and take off PPE, posted on Resident #97's door. The surveyor interviewed LPN #3 regarding what sort of PPE needs to be worn in Resident #97's room. LPN #3 stated that the only PPE that she wears is an N-95 mask. On 3/16/2021 at 1:28 PM, two surveyors observed CNA #2 in Resident #97's room wearing a N-95 mask and no other PPE. The surveyor interviewed CNA #2 regarding her use of PPE. CNA #2 stated that while in Resident # 97's room a gown, goggles, and gloves should be worn. The surveyors observed that the two straps of CNA #2's N-95 mask were both around her neck. The surveyor asked CNA #2 how her N-95 mask should be worn. CNA #2 stated that the top strap of her N-95 mask should be worn higher on her head. A review of the electronic medical record (EMR) for Resident #97 revealed the following: The Order Summary Report indicated that Resident #97 had a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. On 3/14/22 at 10:18 AM, the surveyor observed a yellow STOP sign, a sign indicating droplet precautions, and instructions about how to put on and remove PPE on the outside of Resident #11's door. The surveyor observed the Housekeeper cleaning inside of Resident #11's room wearing a N-95 respirator mask, a hairnet, and gloves. On 3/14/22 at 10:20 AM, the surveyor interviewed the Housekeeper regarding the type of PPE that she was observed wearing in the room. The Housekeeper stated that the room is, green (known COVID-19 negative) and that the PPE that she was wearing was appropriate for the room. The surveyor asked about the order in which the Housekeeper cleaned the resident rooms on the unit. The Housekeeper stated that the entire unit is, green and that she goes from room to room and does not have to clean particular rooms first or last. A review of the EMR for Resident #11 revealed the following: The Admission Record indicated that Resident #11 was admitted to the facility with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. On 3/14/22 at 11:02 AM, the surveyor observed a yellow STOP sign, a sign indicating droplet precautions, and instructions about how to put on and remove PPE on the outside of Resident #6's door. The surveyor observed the Associate Fire Alarm Technician enter Resident #6's room wearing a surgical mask and no other PPE. The surveyor interviewed the Associate Fire Alarm Technician about the signs on Resident #6's door. The Associate Fire Alarm Technician stated that the signs meant that nurses needed to wear a gown and gloves and stuff while in the resident's room. The Associate Fire Alarm Technician indicated that the signs did not apply to him as he was just in the room briefly. The surveyor asked if he was ever educated about wearing PPE in certain rooms while at the facility. The Associate Fire Alarm Technician stated that he was not. A review of the EMR for Resident #6 revealed the following: The Admission Record indicated that Resident #6 was admitted to the facility with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 Order Recap Report indicated a PO for transmission based/ droplet precautions active as of 10/10/2021. 7. On 3/16/22 at 10:21 AM, the surveyor observed a green STOP sign on the outside of Resident #69's door indicating that Resident #69 was not on transmission-based precautions (TBP). The surveyor reviewed the Order Summary Report for Resident #69 which revealed that Resident #69 had a PO for transmission based/ droplet precautions active as of 1/13/22. On 3/16/22 at 10:24 AM, the surveyor interviewed CNA #3 and asked if Resident #69 was on TBP. CNA #3 was asked if PPE needed to be worn in the resident's room. CNA #3 stated that the resident is in the green zone and that no PPE aside from a N-95 mask needed to be worn in the resident's room. On 3/16/22 at 10:28 AM, the surveyor interviewed LPN #3 and asked if Resident #69 was on TBP. LPN #3 was asked what PPE was worn in the resident's room. LPN #3 stated that Resident #69 was not on TBP and stated that only a N-95 mask was needed to be worn in the Resident #69's room. On 3/16/22 at 10:38 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that Resident #69 was not on TBP and that the PO needed to be discontinued. 8. On 3/16/22 at 1:47 PM, the surveyor observed a green STOP sign on the outside of Resident #35's door which indicated that Resident #35 was not on TBP. A review of the Order Summary Report indicated that Resident #35 had a PO for transmission based/ droplet precautions active as of 1/7/22. On 3/16/22 at 1:48 PM, the surveyor interviewed LPN #3 and asked if Resident #35 was on TBP. LPN #3 stated that Resident #35 was not on TBP and that no additional PPE needed to be worn in that room. On 3/17/22 at 1:05 PM, the surveyor presented these concerns to the DON and Licensed Nursing Home Administrator (LNHA). On 3/22/22 at 10:42 AM, the surveyor interviewed the LNHA regarding the TBP policies of the facility. The LNHA stated that during the COVID-19 pandemic residents who were leaving the facility for renal [CONDITION(S)] were on TBP. This requirement has changed and residents receiving renal [CONDITION(S)] no longer need to be on TBP. The LNHA stated that she is not exactly sure when this change took effect. The LNHA stated that the change in TBP status was not communicated to staff and was not implemented properly. 9. On 3/23/22 at 10:27 AM, the surveyor observed a blue STOP sign on a resident's room indicating that the resident was a new admission. The resident's room had a sign indicating that the resident was on droplet precautions, and instructions on how to put on and remove PPE. On 3/23/22 at 10:28 AM, the surveyor observed the Medical Director, and a Medical Doctor enter the resident's room with the blue stop sign wearing surgical face masks and no other PPE. The surveyor observed CNA #4 inform the Medical Director and the Medical Doctor that they were in an isolation room and needed to wear PPE. The Medical Director responded to the CNA #4 explaining that he did not see the blue sign. The Medical Director indicated that he should have worn appropriate PPE, gown, gloves and a face shield. On 3/23/22 at 11:45 AM, the survey team interviewed the DON, LNHA, and Regional LNHA. The surveyor asked who was responsible for creating and carrying out the TBP policy for the facility. The DON stated that the Infection IP was responsible. The surveyor asked what the expectation was for what PPE would be worn in isolation rooms. The DON stated that she would expect to see full PPE worn in isolation rooms including gloves, gowns, goggles or face shield, and a N-95 mask. On 3/23/22 at 12:27 PM, the survey team interviewed the IP. The surveyor asked whose responsibility it was to make sure the correct residents were on isolation precautions. The IP stated that it was her responsibility and stated that her process was to review the residents on TBP daily. The surveyor asked why some residents had orders for TBP when they no longer needed to be on TBP. The IP could not give any further information. The surveyor asked about the facility's policy for residents who leave the facility for renal [CONDITION(S)]. The IP stated that the facility's policy recently changed and that residents who left the facility for renal [CONDITION(S)] no longer had to be on TBP. The IP provide any further information to when the policy change took effect. 10. On 3/17/22 at 9:21, the surveyor observed LPN #2 monitor the blood pressure (BP) via a cuff and Oxygen level using a device, a pulse oximiter for Resident #57. The surveyor observed LPN #2 utilize the two devices and store them in a stand without sanitizing, cleaning the instruments or washing their hands. The surveyor then observed LPN #2 administer the scheduled medication to Resident #57 and wash his hands for 5 seconds under running water. Review of the Admission Record for Resident #57 documents that the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. On 3/17/22 at 9:31 AM, the surveyor observed LPN #2 monitor the blood pressure (BP) via a cuff and Oxygen level using a device, a pulse oximiter for Resident #35. The surveyor observed LPN #2 utilize the two devices, sanitize the devices and store them in a stand. The surveyor observed LPN #2 wash his hands for 5 seconds under running water. On 3/17/22 at 9:50 AM, the surveyor interviewed LPN #2 who stated that he should have sanitized/cleaned the reusable equipment before and after every resident use. LPN #2 did not offer any further information for handwashing. Review of the Admission Record for Resident #35 documents that the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 12. On 3/17/22 at 9:59 AM, the surveyor observed LPN #1 administer the scheduled medication to Resident #100 and wash her hands for 5 seconds under running water. On 3/17/22 at 10:20 AM, the surveyor asked LPN #1 to wash her hands, while being observed. LPN #1 washed her hands for 10 seconds under running water. On 3/17/22 at 10:22 AM, the surveyor interviewed LPN #1, she did not offer any further information regarding handwashing. Review of the Admission Record for Resident #100 documents that the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/22 at 1:02 PM, the surveyor reviewed the Cleaning and Disinfection of Resident-Care Items and Equipment and Handwashing / Hand Hygiene Policies. Review of the Cleaning and Disinfection of Resident-Care Items and Equipment policy documents, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1. The following categories are used to distinguish the levels of sterilization / disinfection necessary for items used in resident care: d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Review of the facility Handwashing/Hand Hygiene policy that documents, This facility considers hand hygiene the primary means to prevent the spread of infections. Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. On 3/17/22 at 1:07 PM, the surveyor discussed the device sanitizing/cleaning and hand washing issues with the DON and the Administrator. There was no further information that was supplied at the time. NJAC 8:39 - 19.4, 27.1 (a),