Every finding on record at Complete Care at Bey Lea, LLC

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) follow a physician's order for medications with a parameter and acceptable professional standards of practice; and b.) follow physician's order to not take blood pressure on right arm due to limb restrictions for 1 of 38 residents (Resident #36) reviewed for medication administration.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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of 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 9/22/2025 at 10:04 AM, the surveyor reviewed the electronic medical record (EMR) for Resident 26. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Parkinson's Disease (movement disorder of the nervous system that worsens over time) and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/26/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition as severely impaired. The surveyor requested Resident #36's Pharmacy Consultant Recommendations and Facility Response:7/10/2025: Please review order for right arm precautions. Documentation shows use of incorrect arm for blood pressure monitoring; Medication error(s) noted. Midodrine is not always held as required by physicians hold order. Please review.Facility provided the following response: Action taken: Staff Educated. 8/12/2025: Please review order for right arm precautions. Documentation shows use of incorrect arm for blood pressure monitoring; Medication error(s) noted. Midodrine is not always held as required by physicians hold order. Please review.Facility provided the following response: Action taken: Staff Educated. 9/10/2025: Please review order for right arm precautions. Documentation shows use of incorrect arm for blood pressure monitoring; Medication error(s) noted. Facility provided the following response: [resident discharged ]A review of Resident #36's Medication Administration Recor (MAR) included the following physician orders (PO): Vital Signs No [blood pressure] [right] arm every shift. Upon review of the EMR, vital sign entries identified that blood pressure was obtained from the resident's right arm: 9/1/2025; 9/2/2025; 9/3/2025; 9/5/2025; 9/6/2025/; 9/10/2025; 9/12/2025; 9/13/2025; 9/14/2025; 9/15/2025; 9/16/2025; 9/17/2025; 9/20/2025; 9/21/2025; 9/23/2025. A PO, with a start date of 6/24/2025, for Midodrine (medication used to treat low blood pressure) HCL Oral Tablet 5mg. Give 1 tablet orally three times a day for Hypotension (low blood pressure). Hold if SBP (top number of the blood pressure) over 130. Upon review of the August MAR, on the following dates Midodrine was administered with SBP over 130: 8/72025 MORNING; 8/12/2025 MORNING; 8/15/2025 AFTERNOON; 8/17/2025 EVENING; 8/18/2025 MORNING AFTERNOON; 8/26/2025 MORNING. Upon review of the July MAR, on the following dates Midodrine was administered with SBP over 130: 7/3/25 MORNING; 7/4/25 MORNING EVENING; 7/5/2025 MORNING; 7/6/2025 MORNING; 7/7/2025 AFTERNOON; 7/9/2025 EVENING; 7/10/2025 AFTERNOON; 7/17/2025 MORNING; 7/18/2025 MORNING AFTERNOON; 7/19/2025 MORNING; 7/20/2025 MORNING; 7/21/2025 MORNING AFTERNOON; 7/25/2025 AFTERNOON EVENING; 7/26/2025 AFTERNOON; 7/28/2025 AFTERNOON; 7/31/2025 MORNING. Upon review of the September MAR, on the following dates Midodrine was administered with SBP over 130: 9/12/2025 MORNING; 9/19/2025 MORNING; 9/22/2025 AFTERNOON.On 9/24/2025 at 10:10 AM, the surveyor interviewed Licensed Nurse Practitioner (LPN #1) who confirmed that she was aware that the medication Midodrine usually has patient specific parameters. When asked why the parameters are important with Midodrine LPN #1 responded that it was only to be given when resident's blood pressure is low to raise it higher. LPN #1 further explained that if it was given outside of the physician's order then it would be considered a medication error. LPN #1 acknowledged that there was consistent education in the facility regarding medication parameters and the administration of medications. On 9/24/2025 at 10:40 AM, the surveyor interviewed Unit Manager Licensed Practical Nurse (UM/LPN #1) who advised that physician orders are always to be followed. When inquired about the medication Midodrine, UM/LPN #1 stated that there is always ongoing education regarding physician ordered parameters. UM/LPN #1 confirmed that the medication should not be administered to residents if the blood pressure was over the specific parameters. If it was given, then it would be considered a medication error. The surveyor reviewed the EMR documentation regarding the limb restriction and parameters to which UM/LPN #1 confirmed that physician orders were not followed. UMLPN #1 further acknowledged that education was consistently provided regarding regarding medication parameters, specifically the medication Midodrine. On 9/252025 at 9:45 AM, the surveyor interviewed the Director of Nursing, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, who acknowledged that pharmacy consultant identified that Resident #36's Midodrine parameters and limb restriction and that they were not being followed for numerous months despite both staff education and facility wide education. A review of the facility's Medication Administration Policy, Implemented 9/1/24, included under the heading Policy Explanation and Compliance Guidelines: [.] 8. Obtain and Record vital sings, when applicable or per physician orders, When applicable hold medication for those vital signs outside of the physician's prescribed parameters [ .].A review of the facility's Medication Error Policy, Implemented 9/27/24, included under the heading Policy Explanation and Compliance Guidelines: 1. The facility shall ensure a medications will be administered as follows: a. According to Physician's Orders [.]; 4. 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; 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible; b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions; c. Document actions taken in the medical record; d. Once the resident is stable, the nurse report the incident to the appropriate supervisor and completes the incident or occurrence report. N.J.A.C. S 8.39-29.2 (d)

Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain proper care for a resident with a nephrostomy tube (NT) (a tube inserted through the skin into the kidney to divert urine to an external drainage bag); b.) ensure a resident's urinary collection bag remained in a privacy bag; and c.) document a resident's urinary catheter output as ordered by the physician. This deficient practice was identified for 2 of 3 residents (Resident # 25 and Resident # 115) reviewed for catheter care. This deficient practice was evidenced by the following: 1.) On 09/23/2025 at 9:00 AM, Surveyor #1 completed incontinent rounds with the Licensed Practical Nurse/Charge Nurse (LPN/CN) on the Sub-Acute Unit, Resident #115 was observed lying in bed with the head of the bed elevated approximately 45 degrees. The resident's right NT was kinked and secured with white tape that was stained with a brown substance. Clear, pale-yellow urine was visibly draining into the drainage bag positioned at the bottom of the resident's bed. A dressing was present over the NT insertion site; however, it was not labeled or dated. A review to the admission record, an admission summary, revealed the resident was admitted to the facility with diagnoses including, but not limited to, malignant neoplasm of bladder (a type of cancer that begins in the tissues of the bladder, the organ that stores urine.), and other artificial openings of urinary tract (a surgically created passage for urine to leave the body). A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 09/12/2025, included a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Further review of Section H: Bladder and Bowel revealed that the resident has a NT. A review of the resident's individual comprehensive care plan, dated 09/02/2025, identified a focus area related to the presence of a NT due to bladder cancer, along with an intervention to monitor the tube. A review of the order summary report, dated as of 09/22/2025, included the following physician orders (PO): a PO, dated 09/05/2026, for right NT, nephrostomy apply clean dry dressing daily every evening shift. During an interview with Surveyor #1 on 09/23/2025 at 9:30 AM, the LPN/CN stated that the dressing for Resident #15's right nephrostomy tube is changed daily and should always be dated, an undated dressing makes it unclear whether it has been changed. LPN/CN also noted that the drainage bag for the nephrostomy tube should not have been positioned at the bottom of the resident's bed but rather placed in a proper drainage bag holder to prevent urine backup, which can lead to infection. During an interview with Surveyor #1 on 09/24/2025 at 11:42AM, the Director of Nursing stated that nephrostomy tubing is connected to a drainage bag depending on the type of appliance the resident arrives with from the hospital. There should be no tape applied to the nephrostomy tube connected to the drainage bag, and the drainage bag should be secured to the side of the bed to allow gravity to ensure proper drainage. A review of a facility policy undated titled, Nephrostomy Tube, revealed that, Residents with nephrostomy will receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Check tube(s) frequently for kinks or obstructions. These are likely to occur if the resident lies on the insertion sites. A review of a facility policy undated titled, Clean Dressing Change, under policy explanation and compliance guidelines revealed that, Secure dressing. [NAME] with initials and date. NJAC 8:39-27.1 (f) 2.) On 9/23/2025 at 8:36 AM, Surveyor # 2 observed from the hallway Resident #25's urinary catheter drainage bag with no privacy bag. Surveyor # 2 reviewed the medical record for Resident #25. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: urinary tract infection and sepsis (a life threatening response to an infection) . A review of the resident's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/26/25, identified that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition as moderately impaired. Review of Section H of the MDS identified Resident #25 with an indwelling catheter. A review of the Treatment Administration Treatment (TAR) included the following physician orders (PO): A PO, with a start date of 8/20/2025, for [indwelling] catheter care (every) shift and was needed every shift. The following dates were blank without any nursing initials for the month of September: 9/5/25 Evening Shift; 9/11/25 Night Shift; 9/13/25 Evening Shift. A PO, with a start date of 8/20/2025, to monitor [indwelling catheter] for (signs/symptoms) of infection every shift. The following dates were blank without any nursing initials for the month of September: 9/5/25 Evening Shift; 9/11/25 Night Shift; 9/13/25 Evening Shift. A PO, with a start date of 8/20/2025, to monitor urine output & record (every) shift. The following dates were blank without any nursing initials for the month of August: 8/29/25 Day shift. 9/5/25 Evening Shift; 9/11/25 Night Shift; 9/13/25 Evening Shift. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 1/1/25, that the resident had an indwelling catheter. Interventions included: monitor and document intake and output as per facility policy; monitor/record/report to MD for (signs/symptoms) of UTI. On 9/24/2025 at 10:04 AM, Surveyor # 2 interviewed Certified Nursing Assistant (CNA #1) who confirmed that urinary drainage bags were to be placed in a privacy bag. When asked how urinary output were monitored, CNA #1 responded that they empty the bag, measure the amount, and report the output to the nurse who was responsible for documenting the amount. When asked why the documentation of the urinary output was important, CNA #1 stated that this was part of the resident's plan of care. On 9/24/2025 at 10:10 AM, Surveyor # 2 interviewed Licensed Nurse Practitioner (LPN #1) who confirmed that either the CNA or the nurse can empty the urinary drainage bag and measure the amount, but the nurse was responsible for documenting the amount in the chart. When asked how urinary drainage bags are to be maintained at bedside, UMLPN #1 reported that they were to be in a privacy bag. When asked about blanks in the MAR, UMLPN#1 stated that there should never be blanks because it could mean urinary retention. On 9/24/2025 at 10:40 AM, Surveyor # 2 interviewed Unit Manager Licensed Practical Nurse (UM/LPN #1) who described that the care of urinary catheters included monitoring for signs/symptoms of infection, urinary drainage bags maintained in a privacy bag, and that the nurses were responsible for documentation of the urinary output. The surveyor provided pictures of the urinary drainage device as observed on initial tour. UM/LPN#1 confirmed the finding. When asked if there should be blanks on the TAR, UM/LPN#1 denied. On 9/24/2025 at 11:44 AM, Surveyor # 2 interviewed the Director of Nursing, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, who acknowledged that urinary drainage bags are to be maintained in privacy bags and that physicians orders should be completed in their entirety and identify as such in the electronic medical record. A review the facility policy titled, Catheter Care, Implemented 9/27/24,, revealed under the title Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Additionally, under the title Policy Explanation: 1. Catheter Care will be performed every shift and as needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use [ .]. A review the facility policy titled, Documentation in Medical Record, Implemented 10/1/24, revealed under the title Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information not provide a picture of the resident's progress through complete, accurate, and timely documentation. N.J.A.C. 8:39-19.4 (a)

Number of residents sampled: 8Number of residents cited: 1Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate incontinence care for a resident who was dependent on staff for Activities of Daily Living. This deficient practice was identified for 1 unsampled resident (Resident #32) out of 8 residents observed during incontinence rounds on 2 of 2 nursing units and was evidenced by the following:On 9/23/2025 at 8:56 AM, the surveyor performed incontinence rounds with Licensed Practical Nurse/ Unit Manager (LPN/UM) and observed Resident #32 in bed. LPN/UM exposed the resident's green incontinence brief from the front and stated that the resident was dry. LPN/UM #1 proceeded to close the brief. The surveyor noticed that the edge of the incontinence brief appeared layered. The surveyor asked LPN/UM to expose the back of the incontinence brief. The surveyor observed another dry green incontinence brief inside the outer green incontinence brief. The surveyor asked LPN/UM if applying 2 briefs on the resident was appropriate. LPN/UM stated that it was not right and that they will educate the nursing aide from hospice care who probably did it. The surveyor reviewed the medical record of Resident #32.A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) and aphasia (a language disorder that affects a person's ability to communicate).A review of the resident's most current quarterly Minimum Data Set (MDS), an assessment tool dated 9/6/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severely impaired cognition. The MDS further assessed that the resident was dependent on staff assistance for toileting hygiene and that the resident was always incontinent of bowel and frequently incontinent of bladder.A review of the resident's Individualized Care Plan (ICP) included a problem area initiated on 8/21/2025, that the resident had incontinence of bladder and bowel and was totally dependent on staff for bathing, dressing and personal hygiene.On 9/24/2025 at 11:30 AM, during an interview with the survey team, the Director of Nursing (DON) stated that it is not appropriate for residents to wear 2 incontinence briefs because it can cause skin issues.A review of facility-provided policy titled Incontinence Care date implemented on 9/27/2024, included under Policy Explanation and Compliance Guidelines: 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. N.J.A.C. 8:39 - 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to review and revise comprehensive person-centered care plan that identified furnished services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for a resident with a right arm blood pressure restriction. This deficient practice was identified for 1 of 38 residents (Resident #36) reviewed for care planning.This deficient practice was evidenced by the following: On 9/22/2025 at 10:04 AM, the surveyor reviewed the electronic medical record (EMR) for Resident 26. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Parkinson's Disease (movement disorder of the nervous system that worsens over time) and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/26/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition as severely impaired. A review of Resident #36's Medication Administration Recor (MAR) included the following physician orders (PO): Vital Signs No [blood pressure] [right] arm every shift. Upon review of the EMR, vital sign entries identified that blood pressure was obtained from the resident's right arm:A review of the resident's individual comprehensive care plan (ICCP) did not identify Resident #36's right arm limb restriction for blood pressures.On 9/24/2025 at 10:40 AM, the surveyor interviewed Unit Manager Licensed Practical Nurse (UM/LPN #1) who advised that she was not sure if it would be added but believed it would be a good idea.On 9/252025 at 9:45 AM, the surveyor interviewed the Director of Nursing, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, who acknowledged that the limb restriction was not on the care plan.A review the facility policy titled, Comprehensive Care Plans, Implemented 9/1/24, revealed under the title Policy: to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measure objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified [.]. In addition, the following was identified under the section titled Policy Explanation and Compliance Guidelines: [.]3. The comprehensive care plan will describe at a minimum, the following: a. The services that re to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being; [.] f. Resident specific intervention that reflect the resident's needs and preferences [.]; 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment [.]. N.J.A.C. S 8:39-11.2 (e)

Based on observation, interview, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to contain respiratory equipment, specifically a nasal cannula (a medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) in protective coverings for 1 of 1 resident (Resident #65) reviewed for respiratory care. This deficient practice was evidenced by the following: Findings include: On 09/21/2025 at 11:04 AM Resident #65 was observed seated in the activity room. Staff indicated to the surveyor that Resident #65 was hard of hearing (HOH).According to the admission Record Resident #65 was admitted to the facility with the following but not limited to diagnoses: Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs), acute and chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues), dementia, and major depressive disorder. A review of the resident assessment/minimum data set (MDS), an assessment tool, dated 8/10/2025 revealed that Resident #65 had a Brief Interview for Mental Status score of 8, which indicated moderate cognitive impairment. According to Section GG Resident #65 required substantial/maximal assistance with oral hygiene, upper body dressing and personal hygiene and was dependent on staff for toileting hygiene, lower body dressing and putting on/taking off footwear. Section O revealed that Resident #65 received continuous oxygen therapy on admission to the facility and while a resident. According to the Order Summary Report with active orders as of 09/24/2025, Resident #65 had the following physician order: O2 (oxygen) via nasal cannula at 3L/min (liters/minute) PRN (as needed) for SOB (shortness of breath). Order Date: 9/23/2025. A review of the comprehensive care plan revealed that Resident #65 had the following care plan Focus: [resident name] has oxygen therapy PRN SOB Date Initiated: 08/13/2025. Interventions included Oxygen Settings: O2 via nasal cannula @ 3L PRN SOB. On 09/22/2025 at 9:21 AM Resident #65 was observed seated in a wheelchair in their room. Resident #65 was HOH and did not respond to the surveyor's voice. O2 via n/c was in place and being delivered at 3L/min. Oxygen tubing was observed to be dated 9/18/25. On 09/23/2025 at 8:54 AM Resident #65 was observed in bed with the head of bed elevated and eating his/her breakfast meal. The surveyor observed the oxygen concentrator (a machine that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for you to breathe) on the window side of the bed and not in use. The surveyor observed the oxygen tubing/nasal cannula on the floor next to the bed. The tubing and nasal cannula were in direct contact with the floor, not covered, and exposed to contamination. On 09/23/2025 at 11:13 AM the surveyor entered room of Resident #65 after knocking. Resident #65 was not present. The surveyor observed the O2 concentrator located on the window side of the bed. The concentrator was not in use. The O2 tubing and nasal cannula were observed to be on the floor in the same manner as the previous observation. The tubing and nasal cannula were exposed to contamination while in contact with the floor. The tubing was observed to be dated 9/18/2025. On 09/24/2025 at8:42 AM Resident #65 was observed lying in bed with their eyes closed. The O2 concentrator was not in use and the oxygen tubing/nasal cannula was observed to be on the floor and unprotected. The tubing and cannula were in contact with the floor and exposed to contamination. At 8:48 AM the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #65 for that shift. The LPN followed the surveyor into Resident #65's room and told the surveyor that the oxygen tubing/nasal cannula should not be on the floor and that it should be bagged when not in use because it as an infection control issue. The LPN removed the tubing from the oxygen concentrator and said she was going to replace the tubing/nasal cannula with a new set. On 09/24/2025 at 11:43 AM during a meeting with facility administration the facility Director of Nursing (DON) told the surveyor that when not in use (oxygen tubing/nasal cannula) it should be bagged at the bedside. The surveyor asked the DON why It was important to protect respiratory equipment when not in use and the DON relied, it is bagged to prevent contamination.A review of the facility provided policy titled Oxygen Administration, date implemented: 9/27/2024, revealed the following under the heading Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. In addition, the following was observed under Policy Explanation and Compliance Guidelines:4. (d.) Keep delivery devices covered in plastic bag when not in use. N.J.A.C. 8:39- 27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store medical supplies in accordance with professional standards, as evidenced by the presence of expired supplies. This deficient practice was identified in 1 of 2 medication storage rooms inspected.The deficient practice was evidenced by the following: On [DATE] at 10:25 AM, the surveyor inspected the Star Unit Medication medication storage room in the presence of Registered Nurse (RN #1) who advised that the nurses are responsible for maintaining the storage room. The surveyor observed inside the locked medication refrigerator a 2 milliliter (mL) multi-dose vial of Methotrexate (a medication used to slow the growth of certain cells) inside of a biohazard reclosable plastic bag. The medication did not have a patient's name or dosage. RN #1 confirmed that the medication should have patient's name.On [DATE] at 10:25 AM, the surveyor interviewed Unit Manager Licensed Practical Nurse (UM/LPN #2) who confirmed that the medication was brought in by a resident's family, but they were recently discharged and no longer in the building. UM/LPN #2 confirmed that the medication should be labeled with the resident's name. On [DATE] at 11:44 AM, the surveyor interviewed the Director of Nursing, in the presence of the Regional Clinical Director, Regional Director of Operations, and Clinical Operations, who acknowledged that the medication should have been identified with a resident's name and administration dosage. A review of the facility's Medications Brought to the Facility by the Resident/Family Policy, implemented [DATE], included under the heading Policy Interpretation and Implementation: 1. The facility shall ensure medications will be administered as follows: a. According to Physician's Orders [.]; N.J.A.C. S 8:39-29.4 (g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) soiled linens were appropriately handled in the nursing unit and b.) appropriate Personal Protective Equipment (PPE) was utilized during incontinence round to a resident who required Enhanced Barrier Precautions (EBP), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This deficient practice was identified for 1 unsampled resident (Resident #49) observed during incontinence tour and occurred on 1 of 2 resident units (subacute rehab unit), respectively and was evidenced by the following:Reference: Enhanced Barrier Precautions (EBP) are an infection prevention and control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes, including the routine use of gloves and gowns during all high-contact resident care. https://www.nj.gov/health/cd/documents/topics/hai/EBP_in_Nursing_Homes_Algorithm.pdf1.) On 9/23/2025 at 8:38 AM, during an incontinence tour with Certified Nursing Assistant (CNA) #1, the surveyor observed an EBP sign on an unsampled resident's door. The surveyor also observed an untied plastic bag containing linen on the floor next to the PPE bin outside the room. CNA #1 confirmed that the content of the bag was soiled laundry from the resident. CNA #1 completed hand hygiene and donned gown and gloves. CNA #1 assisted the resident in the bathroom. The surveyor observed the resident to be wearing a foley catheter connected to a right urine leg bag. CNA #1 exposed the resident's incontinence brief for the surveyor to view. The brief was not soiled. CAN #1 continued to assist the resident in the bathroom. The plastic bag containing the soiled laundry remained outside the doorway of the unsampled resident's room. On 9/23/2025 at 11:38 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that dirty laundry needs to be sealed in a plastic bag and goes straight to the dirty utility room. The IP further stated that nothing stays on the floor. On 9/24/2025 at 11:30 AM, during an interview with the survey team, the Director of Nursing (DON) stated that soiled linen should be sealed in a plastic bag and taken to the soiled utility room at once and not sit on the floor. A review of the facility-provided policy date implemented on 9/27/2024 titled Handling Soiled Linen included under Policy Explanation and Compliance Guidelines the following: 4. Used or soiled linen shall be collected at the bedside and placed in a linen bag or designated lined receptacle. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.2.) On 9/23/2025 at 9:03 AM, during an incontinence tour with Licensed Practical Nurse/ Unit Manager (LPN/ UM), the surveyor observed an EBP sign outside Resident #49's room. A PPE bin was also observed by the doorway. LPN/ UM washed their hands and donned gloves but did not put on a protective gown. LPN/ UM pulled the resident's bed linen and exposed the resident's green incontinence brief on the front side. The surveyor asked LPN/ UM to expose the back of the brief, too. LPN/ UM turned the resident to the side and unfastened the incontinence brief to expose the back of the resident. The green incontinence brief was observed to be wet at the back. LPN/ UM refastened the brief and stated to the surveyor that the resident would get changed. The surveyor asked LPN/ UM why the resident was on EBP. LPN/ UM stated that the resident had an MDRO.On 9/23/2025 at 11:38 AM, during an interview with the surveyor, the IP stated that staff needs to wear gown and gloves when doing close and prolonged high contact care activities to residents on EBP. The IP also stated that incontinence care is included in the high contact care activities. On 9/24/2025 at 11:30 AM, during an interview with the survey team, the DON stated that incontinence care is included in the high-contact activities requiring staff to wear gown and gloves for residents on EBP. A review of the facility-provided policy date implemented on 9/1/2024 titled Enhanced Barrier Precautions included under Definitions: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. N.J.A.C. 8:39 - 19.1 (a)N.J.A.C. 8:39 - 19.4 (a) (c)

Complaint #: NJ181912 (414550), 2565108,Based on interviews, record review and review of pertinent facility documentation on 8/21/25 and 8/25/25, it was determined that the facility failed to: follow Physician Orders and consistently document catheter care on residents on the Treatment Administration Records (TAR) in accordance with the professional standards of nursing practice. This deficient practice was identified for 3 of 5 residents (Resident #1, Resident #3 and Resident #4), reviewed for catheter care. This deficient practice is evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The nurse practice act for the State of New Jersey states, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical 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. According to the admission Record, Resident #1 with diagnoses that included but not limited to Chronic Kidney Disease, Stage 5 and Inflammatory Reaction due to Indwelling Urethral Catheter, and Personal History of Malignant Neoplasm of the Bladder. According to the Minimum Data Set (MDS), an assessment tool dated 05/30/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated the resident had moderate cognitive impairment. A review of the August 2025 Physicians Orders Sheet (POS) for Resident #1 revealed the following orders:Change urostomy bag and wafer weekly and as needed (PRN) every day shift every Friday for urostomy with an order date of 11/25/2024.Monitor urostomy output every shift with an order date of 11/25/2024. A review of Resident #1's Care Plan revealed that Resident #1 had a urostomy initiated on 8/22/2024. A review of Resident #1's Treatment admission Record, a form utilized for documentation of physician ordered treatments by the nurses for July 2025, showed blank spaces indicating the tasks were not completed as follows:Monitor urostomy output every shift on 7/2/2025, 7/27/2025, and 7/28/2025 on the day shift. On 7/13/2025, 7/16/2025, and 7/28/2025 on the night shift.Monitor Urostomy stoma for signs and symptoms of infection every shift for monitoring on 7/2/2025 and 7/27/2025 on the day shift. A review of Resident #1's Treatment admission Record, a form utilized for documentation of physician ordered treatments by the nurses for August 2025, showed blank spaces indicating the tasks were not completed as follows:Monitor urostomy output every shift on 8/6/2025 and 8/15/2025 on the day shift.Monitor Urostomy stoma for signs and symptoms of infection every shift for monitoring on 8/15/2025 on the day shift.Change Urostomy bag and wafer weekly and as needed (PRN) every day shift every Friday for urostomy on 8/15/2025 and 8/29/2025. A review of the July and August 2025 progress notes for Resident #1 did not include documentation for the aforementioned dates related to the urostomy. 2. According to the admission Record (AR), Resident #3 had diagnoses which included but were not limited to Obstructive and Reflux Uropathy (backward flow of urine from the bladder into the kidneys), Dementia, Dysphagia, Oropharyngeal Phase, and Type 2 Diabetes. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of Care, dated 9/16/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated the resident had moderate cognitive impairment. A review of the October 2024 Physician's Order Summary Report (OSR) for Resident #3 revealed the following orders:Document Foley drainage every shift for neurogenic bladder with an order date of 10/21/2024.Maintain Foley/Suprapubic Catheter Privacy bag at all times every shift with an order date of 10/21/2025.Monitor Foley/Suprapubic Catheter every shift for s/s of infection every shift with an order date of 10/21/2024.Render Foley/Suprapubic Care every shift and PRN as needed for care with an order date of 10/21/2024. A review of Resident #3's Care Plan revealed that Resident #3 had a suprapubic Catheter for Obstructive Uropathy initiated on 9/11/2024. Interventions included but were not limited to monitor and document intake and output. A review of Resident #3's Treatment admission Record, a form utilized for documentation of physician ordered treatments by the nurses for September and October 2025, showed blank spaces indicating the tasks were not completed as follows:Document Foley drainage on 9/13/2025 and 10/14/2025 on the day shift. On 9/19/2025 and 10/3/2025 and 10/22/2025 on the evening shift.Maintain Foley/Suprapubic Catheter Privacy bag on 9/13/2025 and 10/14/2025 on the day shift.Monitor Foley/Suprapubic Catheter on 9/13/2025 and 10/14/2025on the day shiftRender Foley/Suprapubic Care on 10/14/2025 on the day shift. A review of the September and October 2025 progress notes for Resident #3 did not include documentation for the aforementioned dates related to the urostomy. 3. According to the admission Record, Resident #4 had diagnoses that included but not limited to Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Other Mechanical Complication of Indwelling Urethral Catheter, Neuromuscular Dysfunction of Bladder, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. According to the Minimum Data Set (MDS), an assessment tool dated 07/01/25, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated the resident had moderate cognitive impairment. A review of the August 2025 Order Summary Report (OSR) for Resident #4 revealed the following orders: Change Suprapubic dressing daily, monitor for signs and symptoms of infection with order date of 1/21/2025.Flush suprapubic catheter with 10cc sterile to maintain patency with order date on 5/14/2025.Maintain suprapubic catheter Privacy Bag at all times every shift with an order date of 1/21/2025.Document Foley drainage every shift with an order date of 12/22/2024.Monitor Suprapubic Catheter every shift for s/s of infection every shift for neurogenic bladder with an order date of 1/21/2025.Render Suprapubic care every shift and PRN every shift for care with an order date of 1/21/2025. A review of Resident #4's Treatment admission Record, a form utilized for documentation of physician ordered treatments by the nurses for July showed blank spaces indicating the tasks were not completed as follows:Change Suprapubic dressing daily, monitor for signs and symptoms of infection on 7/2/2025, 7/27/2025 on the day shift.Flush suprapubic catheter with 10cc sterile, to maintain patency on 7/2/2025, 7/27/2025 on the day shift.Document Foley drainage every shift on 7/3/2025, 7/27/2025, 7/28/2025, 8/6/2025, and 8/15/2025 on the day shift. On 7/13/2025, 7/28/2025 on the night shift.Maintain suprapubic catheter Privacy Bag at all times every shift on 7/2/2025, 7/27/2025 on the day shift.Monitor Suprapubic Catheter every shift for s/s of infection every shift for neurogenic bladder on 7/2/2025, 7/27/2025 on the day shift.Render Suprapubic care every shift and PRN on 7/2/2025, 7/27/2025 on the day shift. A review of Resident #4's Treatment admission Record, a form utilized for documentation of physician ordered treatments by the nurses for August 2025 showed blank spaces indicating the tasks were not completed as follows:Change Foley Drainage Bag weekly on 11-7 shift every Thursday for Foley Care on 8/28/2025 on the night shift.Document Foley drainage every shift on 8/6/2025, 8/15/2025 on the day shift.A review of the July and August 2025 progress notes for Resident #4, did not include documentation for the aforementioned dates related to the urostomy. During an interview with the surveyor on 08/25/2025 at 12:16 PM, the Director of Nursing (DON) confirmed that there were blanks on the TARs for the aforementioned residents and stated that the nurses should have documented on the TAR for all tasks as ordered to ensure that the proper care was provided to the residents. She further stated that the expectation was for documentation to be completed at minimum, each shift. During an interview with the surveyor on 08/25/2025 at 1:23 PM, the DON stated, I do not have anything further in writing that proved the treatments were completed. During an interview with the surveyor on 08/25/2025 at 1:59 PM, the Registered Nurse (RN) confirmed the blanks on the TAR and stated, there should be no blanks because we take care of the patients and if it was not documented, it was not done. The RN further stated that the Unit Manager, Supervisor, and the DON were responsible to oversight the nurses to ensure the documentations were completed. During an interview with the surveyor on 08/25/2025 at 2:17 PM, the Unit Manager (UM) confirmed the blanks on the TAR and stated that there should be no blanks. The UM stated that staff should have documented because it is a medical record, it may have had an effect on the resident's well-being. A review of a facility policy titled, Catheter Care, received from the DON at 1:23 PM, with a date implemented on 9/1/2024, revealed under Policy, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The policy also reflected under Policy Explanation the following:1. Catheter care will be performed every shift and as needed by nursing personnel.2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.8. Empty drain bags every shift as needed. A review of a facility policy titled, Documentation in Medical Record, received from the DON at 1:23 PM, with a date implemented on 10/1/2024, revealed under Policy that, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also reflected under Policy Explanation and Compliance Guidelines the following:1. Licensed staff and interdisciplinary team members shall document all assessments, observation, and services provided in the resident's medical record in accordance with the state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. NJAC 8:39-27.1(a)

C#: NJ181912 (414550), 2573201 Based on interviews, a review of the medical record, and other pertinent facility documents on 8/21/202 and 8/25/25, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). The facility also failed to follow the Certified Nursing Assistant's job description, and its policy titled, Documentation in Medical Record for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows:1. According to the admission Record, Resident #1 with diagnoses that included but not limited to Chronic Kidney Disease, Stage 5 and Inflammatory Reaction due to Indwelling Urethral Catheter, and Personal History of Malignant Neoplasm of the Bladder. According to the Minimum Data Set (MDS), an assessment tool dated 05/30/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated the resident had moderate cognitive impairment. The MDS also showed Resident #1 needed total assistance with Activities of Daily Living (ADLs). Review of Resident #1's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for July 2025, showed blank spaces indicating the tasks were not completed as follows:Bladder documentation on 7/7/2025, 7/12/2025, 7/13/2025, 7/17/2025, 7/21/2025, and 7/26/2025 on the day shift. On 7/4/2025, 7/7/2025, 7/25/2025, and 7/27/2025 on the evening shift. On 7/1/2025, 7/4/2025, 7/6/2025, 7/7/2025, 7/8/2025, 7/10/2025, 7/11/2025, 7/15/2025, 7/20/2025, 7/21/2025, 7/27/2025, and 7/31/2025 on the night shift. Review of Resident #1's Documentation Survey Report Version (v2) for August 2025 showed blank spaces indicating the tasks were not completed as follows:Bladder documentation on 8/17/2025 on the day shift. On 8/3/2025, 8/4/2025, 8/9/2025, and 8/23/2025 on the evening shift. On 8/1/2025, 8/6/2025, 8/7/2025, 8/17/2025, 8/18/2025, 8/19/2025, and 8/22/25 on the night shift. 2. According to the admission Record (AR), Resident #2 had diagnoses which included but were not limited Dementia and Essential Hypertension. A review of the MDS dated [DATE], Resident #2 had a BIMS score of 3/15, which indicated the resident had severe cognitive impairment. The MDS also showed Resident #2 needed total assistance with most ADLs. Review of Resident #2's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for July 2025, showed blank spaces indicating the tasks were not completed as follows:Eating-Assist or feed resident at all meals on 7/1/2025, 7/7/2025, and 7/21/25 on the evening shift. On 7/2/2025, 7/12/2025, and 7/31/2025 on the night shift.Nutrition: Meal Intake on 7/1/20257/7/2025 and 7/21/2025 on the evening shift.Nutrition: HS (Night) Snack on 7/1/2025, 7/7/2025, and 7/21/2025 on the evening shift. Review of Resident #2's Documentation Survey Report Version (v2) for August 2025 showed blank spaces indicating the tasks were not completed as follows:Eating-Assist or feed resident at all meals on 8/4/2025, 8/20/2025, and 8/22/25 on the evening shift. On 8/4/2025, 8/9/2025, and 8/16/2025 on the night shift.Nutrition: Meal Intake on 8/4/2025, 8/20/2025, and 8/22/2025 on the evening shift.Nutrition: HS (Night) Snack on 8/4/2025, 8/20/2025, and 8/22/2025 on the evening shift 3. According to the admission Record (AR), Resident #3 had diagnoses which included but were not limited to Obstructive and Reflux Uropathy (backward flow of urine from the bladder into the kidneys), Dementia, Dysphagia, Oropharyngeal Phase, and Type 2 Diabetes. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of Care, dated 9/16/2025, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated the resident had moderate cognitive impairment. The MDS also showed Resident #3 needed assistance with Activities of Daily Living (ADLs). Review of Resident #3's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for September 2025, showed blank spaces indicating the tasks were not completed as follows:Bladder Documentation on 9/17/2025, and 9/28/2025 on the day shift. On 9/28/2025 on the evening shift. On 9/12/2025, 9/16/2025, 9/17/2025, 9/22/2025, 9/27/2025, 9/28/2025, and 9/30/2025 on the night shift.Eating on 7/17/2025 and 9/28/2025 on the day shift. On 9/28/2025 on the evening shift. On 9/12/2025, 9/16/2025, 9/17/2025, 9/22/2025, 9/27/2025, 9/28/2025, 9/30/2025 on the night shift.Nutrition: Meal Intake on 9/17/2025, 9/28/2025 on the day shift. On 9/17/2025 and 9/28/2025 on the evening shift. Review of Resident #3's Documentation Survey Report Version (v2) for October 2025 showed blank spaces indicating the tasks were not completed as follows:Bladder Documentation on 10/11/2025 on the day shift. On 10/11/2025 and 10/20/2025 on the evening shift. On 10/10/2025, 10/16/2025, 1017/2025, and 10/18/2025 on the night shift.Eating on 10/11/2025 on the day shift. On 10/11/2025, 10/20/2025, and 10/22/2025 on the evening shift. On 10/10/2025, 10/16/2025, 10/17/2025, and 10/17/2025 on the night shift.Nutrition: Meal Intake on 10/11/2025 on the day shift. On 10/20/2025 on the evening shift. 4. According to the admission Record, Resident #4 had diagnoses that included but not limited to Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Other Mechanical Complication of Indwelling Urethral Catheter, Neuromuscular Dysfunction of Bladder, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. According to the Minimum Data Set (MDS), an assessment tool dated 07/01/25, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated the resident had moderate cognitive impairment. The MDS also showed Resident #4 needed assistance with Activities of Daily Living (ADLs). Review of Resident #4's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for July 2025, showed blank spaces indicating the tasks were not completed as follows:Bladder Documentation on 7/7/2025, 7/12/2025, 7/13/2025, 7/17/2025, 7/21/2025, and 7/26/2025 on the day shift. On 7/4/2025, 7/7/2025, 7/25/2025, and 7/27/2025 on the evening shift. On 7/1/2025, 7/4/2025, 7/6/2025, 7/8/2025, 7/10/2025, 7/11/2025, 7/15/2025, 7/20/2025, 7/21/2025, 7/27/2025, and 7/31/2025 on the night shift. Review of Resident #5's Documentation Survey Report Version (v2) for August 2025 showed blank spaces indicating the tasks were not completed as follows:Bladder Documentation on 8/17/2025 on the day shift. On 8/3/2025, 8/4/2025, 8/9/2025, and 8/23/2025 on the evening shift. On 8/1/2025, 8/6/2025, 8/7/2025, 8/17/2025, 8/18/2025, 8/19/2025, and 8/22/2025 on the day shift. 5. According to the admission Record (AR), Resident #5 had diagnoses which included but were not limited to Alzheimer's Disease with Early Onset, and Dysphagia following Unspecified Cerebrovascular Disease. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of Care, dated 7/3/2025, Resident #5 had a Brief Interview for Mental Status (BIMS) score of 0/15, which indicated the resident had severe cognitive impairment. The MDS also showed Resident #5 needed total assistance with Activities of Daily Living (ADLs). Review of Resident #5's Documentation Survey Report Version (v2), a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for July 2025, showed blank spaces indicating the tasks were not completed as follows:Nutrition: Meal Intake on 7/1/20257/3/2025, 7/5/2025, 7/10/2025, 7/11/2025, 7/12/2025, 7/14/2025, 7/28/2025, and 7/31/2025 on the day shift at 0800. On 7/1/2025, 7/3/2025, 7/5/2025, 7/10/2025, 7/11/2025, 7/12/2025, 7/14/2025, 7/28/2025, and 7/31/2025 on the day shift at 1200. On 7/3/2025, 7/7/2025, 7/20/2025, 7/22/2025, 7/28/2025, and 7/30/2025 on the evening shift at 1700.Nutrition: HS snack on 7/3/2025, 7/7/2025, 7/20/2025, 7/22/2025, 7/28/2025, and 7/30/2025 on the evening shift at 2000. Review of Resident #5's Documentation Survey Report Version (v2) for August 2025 showed blank spaces indicating the tasks were not completed as follows:Nutrition: Meal Intake on 8/7/2025, 8/9/2025, 8/12/2025, 8/13/2025, 8/16/2025, 8/17/2025, and 8/19/2025 on the day shift at 0800. On 8/1/2025, 8/7/2025, 8/9/2025, 8/12/2025, 8/13/2025, 8/16/2025, 8/17/2025, and 8/19/2025 on the day shift at 1200. On 8/3/2025, 8/16/2025, 8/17/2025, 8/20/2025, and 8/2025 on the evening shift at 1700. Nutrition: HS snack on 8/3/2025, 8/16/2025, 8/17/2025, 8/20/2025, and 8/22/2025 on the evening shift at 2000. During an interview with the surveyor on 08/25/2025 at 12:16 PM, the Director of Nursing (DON) confirmed that there were blanks on the ADL sheets for the aforementioned residents and stated, we need to be able to show the care was provided to our residents. She further stated that the CNAs should have ensured that the documentation was completed for the shift. During an interview with the surveyor on 08/25/2025 at 1:23 PM, the DON stated, I do not have anything further in writing that proved the ADLs were completed. During an interview with the surveyor on 08/25/2025 at 1:59 PM, the Registered Nurse (RN) confirmed the blanks on the TAR and stated, there should be no blanks because we take care of the patients and if it was not documented, it was not done. The CNAs should have documented. The RN further stated that the nurses were responsible to oversight the CNAs and to ensure tasks were completed. During an interview with the surveyor on 08/25/2025 at 2:08 PM, the CNA confirmed blanks on residents' ADL Sheets. She stated that there should be no blanks on the ADL sheets because it is important to show documentation of the care that was provided to the residents throughout the shift. She further stated that the CNAs should have documented the care provided by the end of the shift. During an interview with the surveyor on 08/25/2025 at 2:17 PM, the Unit Manager (UM) confirmed the blanks on the TAR and stated that there should be no blanks. The UM stated that staff should have documented because it is a medical record, it may have had an effect on the resident's well-being. A review of the residents' medical records showed no further evidence that the tasks mentioned above were completed. At the time of the survey, the facility could not provide evidence that the aforementioned tasks were completed. A review of a facility policy titled, Documentation in Medical Record, received on 8/25/2025 from the DON at 1:23 PM, with a date implemented on 10/1/2024, revealed under Policy that, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy also reflected under Policy Explanation and Compliance Guidelines the following:1. Licensed staff and interdisciplinary team members shall document all assessments, observation, and services provided in the resident's medical record in accordance with the state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. A review of the Certified Nurse Assistant under Major Duties and Responsibilities included but were not limited to:Assist residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures.Coordinates dining room services at assigned meal times, including set-up and clean up, meal tray delivery, feeding assistance, and documentation of meal intake.Delivers nutritional supplements to residents at assigned times and provides assistance as necessary to ensure intake.Completes flow sheets daily to indicate that the specified task was done. N.J.A.C.: 8:39-27.1(a)

C/O # NJ 175730 Based on observation, interview and review of other facility documentation, it was determined that the facility failed to provide resident Health Shakes (a nutritional supplement) for 9 of 9 Health Shakes observed for delivery. This deficient practice was evidenced by the following: On 10/16/2024 at 11:55 AM, on Pleasant Plains Unit, the surveyor observed nine (9) four (4) ounce Health Shakes with the individual resident names sitting on a tray on top of the nurses station. Each container was labeled with the resident name along with AM 10/16. During an interview with the surveyor on 10/16/2024 at 12:06 PM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM #1) why are the Health Shakes still sitting on the counter. She replied Thats a good question. When asked should these have been provided to resident's, the LPN/UM replied Sure, they should have been passed out already. During an interview with the surveyor on 10/18/2024 at 01:48 PM, the Director of Nursing (DON) was asked what is the expectation for passing of AM snacks/Health Shakes. The DON replied, The Health Shakes should be administered around 10 am, that is when they are scheduled. On 10/21/2024 at 8:52 AM, the DON provided a facility policy titled Medication Orders last updated 6/28/24, the following was revealed under Recording Orders section 7. Commercial Dietary Supplements-When recording orders for commercial dietary supplements, specify the type, amount and frequency. NJAC 8:39-27.1(a)

Based on observations, interviews, and review of other pertinent facility documents, it was determined that the facility failed to obtain a physician's order for supplemental oxygen and develop a care plan for 1 of 1 resident (Resident #53) reviewed for respiratory care. This deficient practice was evidenced by the following: On 10/15/2024 at 10:39 AM during the initial tour of the facility the surveyor observed Resident #53 lying in bed and receiving oxygen via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). The oxygen concentrator was observed to be set at 2 liters per minute (L/min) and the oxygen tubing appeared to be dated 10/4/24. According to the Admission Record, Resident #53 was admitted to the facility with the following but not limited to diagnoses: Dementia, anxiety disorder, diabetes mellitus, and chronic obstructive pulmonary disease. A review of the comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 09/16/2024, revealed Resident #53 had a Brief Interview for Mental Status score of 9/15, which indicated moderate cognitive impairment. Section O of the MDS indicated that Resident #53 received intermittent oxygen therapy on admission and while a resident in the facility. Section O also revealed that Resident #53 received respiratory therapy for a total of 4 days. A review of Resident #53's Order Summary Report, with active orders as of 10/18/2024, did not reveal a physician's order for supplemental oxygen use. In addition, the surveyor reviewed the 09/01/2024-09/30/2024 Medication Administration Record (MAR) and the Treatment Administration Record (TAR), as well as the 10/01/2024-10/31/2024 MAR and TAR for Resident #53. The MAR's and TARs did not reveal that Resident #53 received supplemental oxygen. A review of the comprehensive care plan for Resident #53 did not reveal that Resident #53 had a care plan developed for supplemental oxygen. On 10/16/2024 at 08:10 AM the surveyor observed Resident #53 with oxygen via nasal cannula while lying in bed. The oxygen concentrator was on and set at 2L/min. The oxygen concentrator had surgical tape dated 10/9/2024. on the front of the concentrator. On 10/16/2024 at 10:52 AM Resident #53 was observed to be out of the room. The surveyor observed that the oxygen tubing was currently disconnected from the oxygen concentrator and the concentrator was turned off at the time of observation. On 10/18/2024 at 09:10 AM the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #53's unit. The surveyor asked LPN #1 if residents who are receiving supplemental oxygen require a physician order? LPN #1 told the surveyor, Yes, we need an order for oxygen if it is standing or PRN (as necessary). LPN #1 further explained that if you came in from the hospital with it (supplemental oxygen), it should be on the admission orders. If it happens after admission, then we would contact the physician for the order. On 10/18/2024 at 09:39 AM Resident #53 was observed lying in bed with the head of the bed elevated. Resident #53 was observed to receive oxygen at 1L/min by nasal cannula. On 10/18/2024 at 10:07 AM the surveyor reviewed the Orders section of the electronic medical record (EMR). Review of Resident #53's orders revealed that there was no current order for Resident #53 to receive supplemental oxygen. The surveyor also reviewed Resident #53's 09/01/2024-09/30/2024 and 10/1/2024-10/31/2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) in the EMR. No orders for supplemental oxygen treatment were observed. On 10/18/2024 at 12:47 PM the surveyor interviewed the Licensed Practical Nurse/unit manager (LPN/UM #2) assigned to Resident #53's unit. The surveyor asked LPN/UM #2 if a resident receiving supplemental oxygen required a physician order. LPN/UM #2vtold the surveyor, Yes, a resident requires a physician's order for oxygen. LPN/UM #2 further stated to the surveyor that you need an order for everything. On 10/18/2024 at 01:37 PM during a meeting with facility administrative staff which included the Regional Licensed Nursing Home Administrator (RLNHA), the facility Director of Nursing (DON), and the Regional Nurse Manager (RNM), the surveyor told the staff that Resident #53 was observed to receive supplemental oxygen via nasal cannula on the following dates: 10/15/2024, 10/16/2024, and 10/18/2024. When asked if a resident who receives supplemental oxygen requires a physician order the staff all agreed that a resident receiving oxygen should have a physician order and a care plan. The surveyor reviewed the facility policy titled Oxygen Administration; date implemented: 9/1/2024. The following was revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. In addition, the following was revealed under the heading Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs. e. Monitoring for complications associated with the use of oxygen. The surveyor reviewed the facility policy titled Comprehensive Care Plans; date implemented: 9/1/2024. The following was revealed under the heading Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. In addition, the following was revealed under the heading Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications by failing to ensure and that the required Federal narcotic acquisition forms (DEA 222 form) were dated and signed as of the day it was submitted for filling for 1of 9 forms provided, and was evidenced by the following: On 10/16/24 at 10:03 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed one of the nine provided forms had been pre-signed by the facility's Medical Director (MD) prior to submission to the provider pharmacy for filling. The forms were as follows: Order form number: 240371632 240371633 240371634 240371640 240371639 240371638 240371637- pre-signed by Medical Director 240371636 240371635 On 10/16/24 at 12:07 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed there were nine DEA 222 forms in the facility provided binder and one form had been pre-signed by the MD. The DON stated she was unaware there were any pre-signed forms. The process was she would complete the form then have the MD review and sign it before it was sent to the pharmacy to be filled, so there should be no pre-signed forms. On 10/18/24 at 11:55 AM, the surveyor attempted to interview the MD via telephone, but the MD was unavailable. On 10/18/24 at 1:40 PM, the survey team met with the facility DON, Licensed Nursing Home Administrator (LNHA) and Regional Nurse Manager to discuss concerns found on survey. All three acknowledged there should be no pre-signed DEA 222 forms. On 10/21/24 at 9:24 AM, the surveyor in the presence of the survey team, interviewed via telephone the facility MD, who stated the facility used his DEA number to order narcotics. When narcotic medication needed to be ordered the DON filled out the DEA 222 forms then he would sign the form to be sent to the provider pharmacy for filling. The surveyor then asked the MD why there was a pre-signed form found in the facility binder? He stated he was informed of the finding and thought he remembered when it happened, that in his haste he had signed the wrong form, and his expectation was that the form would be destroyed. The MD acknowledged there should be no pre-signed forms because the forms could be misdirected or misused for drug diversion. A review of the Instructions for DEA Form 222, under Part 1. Purchaser Information, 6. The order form must be signed and dated by the purchaser on the day it is submitted for filling. A review of the facility provided, undated 6.0 Controlled Dangerous Substance Inventory for Back Up Box and Emergency Kits policy . A DEA Form 222 must be completed to obtain the par level of Schedule II CDS in the emergency box supply. Upon signature of the Medical Director or his/her designee, the two copies are sent to the pharmacist in charge . NJAC 8:39-29.7(c)

Based on observation, interview, review of the Electronic Medical Record (EMR), and review of other facility documentation, it was determined that the facility failed to initiate a person-centered care plan for Hospice services. This deficient practice was identified for 1 of 2 residents reviewed for Hospice services (Resident #26) and was evidenced by the following: During the initial tour on 10/15/2024 at 10:59 AM, Resident #26 was observed lying in bed with their eyes closed. A review of the EMR on 10/15/2024 at 03:49 PM, revealed the following: According to the Admission Record Resident #26 was admitted with diagnoses including but not limited to: Alzheimer's disease. A review of the most recent comprehensive Minimum Data Set, an assessment tool used to facilitate care, dated 01/31/2024 revealed Resident #26 had a Brief Interview for Mental Status score of 1 of 15 indicating severe cognitive impairment. Under section O resident received hospice while a resident. A review of the Order Summary Report with Active Orders as of 10/18/2024, showed a physician order dated 01/17/2024 for hospice Eval (evaluation) & Treat w (with)/ [company name] Hospice. A review of the care plan for Resident #26 did not include a Hospice Care plan. During an interview with the surveyor on 10/18/2024 at 10:05 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #1) was asked what the process is when a resident or family requests hospice services. LPN/UM #1 replied the Social Worker would be notified and he would put out a referral to the hospice company of choice. We get the order from the physician and then hospice comes and does the evaluations. We give them options and they can choose a company. When questioned as to who provides the care, LPN/UM #1 replied Hospice aides do resident care if they can but if not, our staff are responsible to make sure resident care is performed and they assist with meals. The Hospice nurses come at least weekly, and we can reach them by phone. The surveyor asked who is responsible for completing the care plan. LPN/UM #1 replied The hospice is responsible for completing the care plan. LPN/UM #1 confirmed that yes, we have a care plan on all hospice patients in the EMR. On 10/18/2024 at 10:13 AM, the surveyor requested LPN/UM #1 to pull Resident #26's care plan up in the EMR. LPN/UM #1 pulled up a hospice care plan with date initiated of 10/17/24 and said he/she has been on hospice awhile and this done by the corporate nurse. During an interview with the surveyor on 10/18/2024 at 10:25 AM, the Regional Nurse Manager (RNM) was asked if she initiated the Hospice care plan for Resident #26. The RNM replied I did an audit yesterday (10/17/2024) and updated his/her care plan to include hospice. The surveyor asked if this resident had a care plan for hospice prior to yesterday and she replied, I don't remember that there was a care plan prior to that. During an interview with the surveyor on 10/18/2024 at 01:50 PM, the Director of Nursing was asked if the expectation was that a resident on hospice would have a care plan in the EMR. The DON said Yes, if there had been one (care plan) it would be in the medical record. During a follow-up interview on 10/21/2024 08:53 AM, the DON said no there was no hospice care plan for Resident #26. Unfortunately, that was an oversight, and it has been updated and corrected. The DON confirmed Resident #26 should have had a care plan when he/she first started hospice. A review of a facility policy on 10/16/2024 at 10:15 AM, titled Hospice Program with reviewed date of March 2024, revealed under the Policy Interpretation and Implementation section 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the residents highest practicable physical, mental and psychosocial well-being. 14. The coordinated care plan will reflect the resident's goals and wishes, as stated in his or her advanced directives and during on going communication with the resident or representative, including: a. palliative goals and objectives; b. palliative interventions and c. Medical treatment and diagnostic tests. 15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including but not limited to; a. diagnosis; b. problem list; c. symptom management (pain, nausea vomiting etc.) d. bowel and bladder care; e. nutrition and hydration needs; f. oral health; g. skin integrity; h. spiritual, activity and psychosocial needs; and mobility i and positioning. NJAC 8:39-(27.1)(a)

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure medication and treatment carts were secured while unattended for 1 of 5 medications carts and 1 of 2 treatment carts. Findings included: Review of a facility policy titled, Storage of Medications, reviewed January 2023, revealed, 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The policy continued, 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. During an observation on 05/17/2023 at 5:17 AM, there was an unlocked and unattended medication cart on Pleasant Plains hallway. During an interview on 05/17/2023 at 5:20 AM, Licensed Practical Nurse (LPN) #16 indicated the unlocked medication cart should not have been left unattended. LPN #16 indicated she was not the last one to use the cart, then walked away and left the medication cart unlocked. The surveyor opened the top drawer to the medication cart and asked LPN #16 if it was safe. LPN #16 then returned to the medication cart and locked it. During an observation on 05/17/2023 at 5:24 AM, a treatment cart that contained prescription creams was observed unlocked and unattended on the low end of Pleasant Plains hallway. During an interview on 05/17/2023 at 5:25 AM, LPN #16 indicated all the carts needed to be locked. LPN #16 indicated she had not accessed the treatment cart, and it had probably been unlocked since she came in at 12:00 AM. During an interview on 05/17/2023 at 5:50 AM, LPN #17 indicated medication and treatment carts should not be left unlocked. During an interview on 05/18/2023 at 10:50 AM, the Director of Nursing (DON) indicated unattended medication and treatment carts should be locked when not in use so no one could access them. During an interview on 05/19/2023 at 11:35 AM, the Administrator indicated he expected the medication and treatment carts to be locked if not being watched. New Jersey Administrative Code S 8:39-29.4(h)

Based on record reviews, interviews, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was accurately completed prior to admission for 2 (Resident #43 and Resident #91) of 3 residents reviewed for PASARRs. Findings included: A review of the facility policy, titled, Coordination-Pre-Admission Screening and Resident Review program, updated January 2023, indicated, It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. The policy further indicated The facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. 1. A review of an Admission record revealed the facility admitted Resident #91 on 03/30/2023 with diagnoses to include major depressive disorder and chronic post-traumatic stress disorder. A review of Resident #91's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/31/2023, revealed the resident had an active diagnosis to include depression. A review of Resident #91's Preadmission Screening and Resident Review Level I Screen, dated 03/27/2023, indicated the resident did not have a known or suspected diagnosis of a major mental illness. An interview on 05/18/2023 at 2:31 PM with the Social Worker (SW) revealed the PASARR level I came from the hospital, but he was responsible for reviewing it for accuracy. The SW stated if there were any discrepancies, he would complete a new one that reflected the correct resident information. The SW reviewed Resident #91's PASARR level I dated 03/27/2023 that was completed on admission and verified that section two did not indicate the resident's diagnosis for major depressive disorder or post-traumatic stress disorder or any mental illness diagnosis. The SW stated it was completed incorrectly, and he should have caught that and corrected that section and submitted the correct PASARR level I for a level II determination. The SW stated it was important to ensure the PASARR level I was completed accurately to ensure residents were in the appropriate level of care and received any additional services they were potentially eligible to receive. An interview on 05/19/2023 at 8:34 AM with the Director of Nursing (DON) revealed that upon admission a resident's PASARR level I was completed by the hospital. However, the facility was responsible for reviewing the level I to ensure it was accurate and reflected the resident's correct diagnoses. The DON stated if the PASARR level I was inaccurate and completed prior to admission, the facility would send the level I back to the hospital to redo. The DON stated the facility would still have been responsible for reviewing it for accuracy, and it would be sent to the social work department if there were any inaccuracies. The DON stated she would have expected the Social Worker (SW) to review Resident #91's PASARR level I and correct any inaccuracies before submitting it for level II determination. An interview on 05/19/2023 at 11:19 AM with the Administrator revealed their admissions department requested the PASARR level I from the discharging hospital. Per the Administrator, if the hospital did not send one then the Social Worker would be responsible for completing the form. The Administrator stated he thought the one sent from the hospital was reviewed, but he was not sure if the SW corrected the PASARR level I if there were discrepancies. The Administrator stated he would expect that all PASARR level I screens were completed and submitted accurately. 47914 2. A review of Resident #43's Admission Record indicated the facility admitted Resident #43 on 01/09/2018 with diagnoses that included unspecified dementia, major depressive disorder, anxiety disorder, and mixed obsessional thoughts and acts. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #43 had active diagnoses that included anxiety disorder, depression, post-traumatic stress disorder, and mixed obsessional thoughts and acts. A review of Resident #43's care plan initiated 01/28/2022, revealed Resident #43 used antidepressant medication due to depression. Interventions directed staff to administer antidepressant medications as ordered by the physician, monitor adverse reactions, and provide non-pharmacological interventions. A review of Resident #43's Pre-Admission Screening and Resident Review Level I Screen, dated 01/08/2018, revealed the screening form indicated Resident #43 did not have a diagnosis or evidence of a major mental illness. An interview on 05/18/2023 at 2:31 PM with the Social Worker (SW) revealed the PASARR level I came from the hospital, but he was responsible for reviewing it for accuracy. The SW stated if there were any discrepancies, he would complete a new one that reflected the correct resident information. The SW reviewed the Level I PASARR completed on 01/08/2018 for Resident #43 and confirmed the diagnoses should have been included in section two of the PASARR level I screen. The SW stated it was completed incorrectly, and he should have caught that and corrected that section and submitted the correct PASARR level I for a level II determination. The SW stated it was important to ensure the PASARR level I was completed accurately to ensure residents were in the appropriate level of care and received any additional services they were potentially eligible to receive. An interview on 05/19/2023 at 8:34 AM with the Director of Nursing (DON) revealed that upon admission a resident's PASARR level I was completed by the hospital. However, the facility was responsible for reviewing the level I to ensure it was accurate and reflected the resident's correct diagnoses. The DON stated if the PASARR level I was inaccurate and completed prior to admission, the facility would send the level I back to the hospital to redo. The DON stated the facility would still have been responsible for reviewing it for accuracy, and it would be sent to the social work department if there were any inaccuracies. The DON stated she would have expected the Social Worker (SW) to review Resident #43's PASARR level I and correct any inaccuracies before submitting it for level II determination. An interview on 05/19/2023 at 11:19 AM with the Administrator revealed their admissions department requested the PASARR level I from the discharging hospital. Per the Administrator, if the hospital did not send one then the Social Worker would be responsible for completing the form. The Administrator stated he thought the one sent from the hospital was reviewed, but he was not sure if the SW corrected the PASARR level I if there were discrepancies. The Administrator stated he would expect that all PASARR level I screens were completed and submitted accurately. New Jersey Administrative Code S 8:39-5.1(a)

Based on interviews, record review, and facility policy review, it was determined that the facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) level I for 1 (Resident #11) of 3 residents reviewed for PASARRs. Specifically, the facility failed to submit an updated PASARR level I when Resident #11 was diagnosed with bipolar disorder and unspecified psychosis after admission. Findings included: Review of the facility's policy, titled, Coordination - Pre-Admission Screening and Resident Review Program, updated in January 2023, indicated, It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal regulations. The policy indicated, Coordination includes: a. Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. b. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Further review of the policy revealed, A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. A review of Resident #11's Admission Record revealed the facility admitted the resident on 02/18/2021. Per the record, on 12/30/2021, the resident received a diagnosis of bipolar disorder and on 02/08/2023 a diagnosis of unspecified psychosis not due to a substance or known physiological condition. Review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2023, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed Resident #11 had active diagnoses that included bipolar disorder and psychotic disorder (other than schizophrenia). A review of Resident #11's care plan, with an initiation date of 06/17/2021, revealed the resident displayed signs and symptoms of a mood disorder. Interventions directed staff to administer medications as ordered, monitor the side effects and effectiveness of the medications, and obtain a psychiatric consult as needed. A review of Resident #11's PASARR level I dated 06/17/2021 revealed Resident #11 did not have a diagnosis of bipolar disorder or psychosis disorder and had a negative screening for mental illness. Review of the resident's medical record revealed, Resident #11 had not had another PASARR level I screen completed since 06/17/2021. During an interview on 05/18/2023 at 2:31 PM, the Social Worker (SW) stated he relied on the nursing staff to notify him if a resident had a new mental health diagnosis that required another PASARR level I be completed. The SW stated that with Resident #11's new diagnoses of bipolar disorder and unspecified psychosis, the resident should have had another PASARR level I completed. The SW stated PASARRs should be completed accurately and timely to ensure residents received the proper level of care. During an interview on 05/19/2023 at 8:42 AM, the Director of Nursing (DON) stated she would have to check the facility's policy on whether another PASARR level I screen needed to be completed when a resident had a new mental health diagnosis. The DON later stated it was important to ensure it was completed because the level I screen evaluated a resident's need for further treatment or intervention. During an interview on 05/19/2023 at 11:10 AM, the Administrator stated he was not familiar with the PASARR process and was not sure if another screen needed be conducted when a resident had a new mental health diagnosis after admission. New Jersey Administrative Code S 8:39-5.1(a)

Based on observations, interviews, record reviews, and facility policy review, it was determined that the facility failed to ensure that hand hygiene, including glove change, was performed during incontinence care for 2 (Resident #7 and Resident #75) of 2 residents observed for incontinence care. Findings included: Review of a facility policy titled, Handwashing/Hand Hygiene, dated January 2023, specified, 7. Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: j. after contact with blood or bodily fluids; k. after handling used dressings, contaminated equipment, etc. The policy further indicated, 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1. A review of an Admission Record indicated the facility admitted Resident #75 on 12/13/2021 with diagnoses that included urinary tract infection, acute pyelonephritis, and acute kidney failure. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/21/2023, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance with toilet use and personal hygiene. Per the MDS, the resident was occasionally incontinent of bladder and bowel. A review of Resident #75's plan of care, initiated 12/27/2021, revealed the resident was at risk for skin impairment related to episodes of incontinence. This care plan directed staff to provide perineal care as needed to prevent breakdown. During an observation of incontinence care for Resident #75 on 05/17/2023 at 5:25 AM, Certified Nursing Assistant (CNA) #18 washed her hands and applied gloves. Resident #75's brief was minimally soiled. CNA #18 provided incontinence care, removed the soiled brief, and then obtained and applied a clean brief without changing gloves or performing any type of hand hygiene. CNA #18 indicated gloves should be changed after the soiled brief was removed. CNA #18 indicated she did not change her gloves. 2. A review of an Admission Record indicated the facility admitted Resident #7 on 09/12/2022 with diagnoses that included stage 3 chronic kidney disease and overactive bladder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2023, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance with toilet use and personal hygiene. Per the MDS, the resident was always incontinent of bladder and bowel. A review of Resident #7's plan of care, initiated 09/21/2022, revealed the resident was at risk for skin impairment related to the need for assistance with activities of daily living and incontinence. This care plan directed staff to provide perineal care as needed to prevent breakdown. During an observation of incontinence care for Resident #7 on 05/17/2023 at 5:33 AM, CNA #13 washed his hands and applied gloves. Resident #7's brief was soiled with urine and a small amount of bowel. CNA #13 provided incontinence care, removed the soiled brief, and then obtained and applied the clean brief without changing his gloves or performing any type of hand hygiene. During an interview on 05/17/2023 at 1:22 PM, the Infection Control Preventionist (ICP) indicated it was the facility's policy to wash hands prior to putting gloves on and to change gloves if they became soiled. The ICP indicated if gloves became soiled, hand hygiene should be performed. The ICP indicated gloves should be changed between dirty and clean tasks for infection control. When informed that staff did not change gloves during incontinence care through applying the clean brief, the ICP stated that was an infection control issue. During an interview on 05/18/2023 at 10:53 AM, the Director of Nursing (DON) indicated gloves should be changed when they became soiled and in between residents for infection control purposes. The DON indicated if gloves had been in contact with bodily fluid, then she would change the gloves. The DON indicated she expected that if gloves became soiled during incontinence care, they should be changed before touching unsoiled items. During an interview on 05/19/2023 at 11:35 AM, the Administrator indicated his expectation according to the facility's policy was that if gloves were soiled, they should be changed. New Jersey Administrative Code S 8:39-19.4(a)

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 consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 9:42 AM to 10:47 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the Dry Storage room a on top of a wheeled cart, a cleaned and sanitized stand up mixer was uncovered and exposed. On interview the FSD stated, On our previous survey the surveyor told us to not cover the equipment when not in use. The surveyor referred the FSD to the Sanitation Code. 2. On a middle shelf in the dry storage room, a stack of 10 cleaned and sanitized china plates were stored in a plastic tub uncovered, not in the inverted position and were exposed. On interview the FSD stated, They should be wrapped. In addition, on an upper shelf of the same storage rack, 2 separate stacks of cleaned and sanitized hotel pans were uncovered and not in the inverted position. On interview the FSD stated, They should be covered or inverted. I am going to wash them again and wrap them before use. 3. On a lower shelf of a multi-tiered rack in the dry storage room, a clear plastic container contained plastic forks that residents use to eat food. The forks were exposed as the container was only half covered and the plastic bag was ripped exposing the plastic forks. On interview the FSD stated, I'm gonna throw them away they are exposed. In addition, on the same shelf, a sleeve of plastic lids had been opened. The lids were not sealed and were exposed. The FSD stated, I'm gonna throw them away, their exposed. 4. On the multi-level can storage rack, a can of Golden Sweet Corn had a significant dent on the upper side seam. On interview the FSD stated, That should have been put in the dented can area. The FSD removed the can and placed it in the designated dented can area. 5. On a middle rack of a multi-tiered storage rack in the walk-in refrigerator, a half-pan contained (2) cooked pork loins. The pan was labeled open date/prep/pulled [DATE] and had a use by date [DATE]. On interview the FSD stated, I think it's good for 6 days. They cooked it, froze it, and then pulled for defrost. I can't figure it out, I'm gonna throw it away. The pork loins were thrown in the trash. On further interview the FSD stated, I am responsible and the cook for monitoring expiration dates. 6. On a counter in the cook's prep area, a cleaned and sanitized meat slicer was uncovered and exposed. When interviewed the FSD stated, On our last state survey, the surveyor said that they don't want the equipment bagged so we stopped bagging it. Surveyor referred FSD to the Sanitation Code. On [DATE] from 11:22 AM to 11:52 AM the surveyor, accompanied by the FSD, observed the following in the kitchen: 1. A dietary aide (DA) was observed to scoop ice from the ice machine and place the ice on the cold beverages to be served with the lunch meal. The DA was observed to wear disposable gloves and upon completion of scooping ice removed and threw the disposable gloves in the trash. The surveyor then observed the DA perform hand hygiene at the designated hand washing sink. The DA proceeded to turn on the faucets, wet their hands under running water, applied soap, performed vigorous hand washing for 5 seconds then proceeded to put hands under the running water and continue to perform vigorous hand washing for 10 seconds under the running water, which effectively removed the soap from his hands. The DA then proceeded to grab a hand towel, dry hands and then threw hand towel in the designated waste receptacle. The DA then grabbed an additional hand towel, turned off faucets and threw hand towel in the waste receptacle. On interview the DA stated, I turned on the faucet and wet my hands. I then put on soap and washed my hands. The surveyor questioned how long hand washing should be performed and the DA stated, twenty seconds. The surveyor stated to the DA that he was observed to perform handwashing for 5 seconds before placing his hands under running water. The DA stated, Oh. On interview the FSD stated, Yes, we do hand washing in-services and the DA has been in-serviced on proper handwashing. The FSD provided the surveyor with a copy of the Hand washing/Proper wearing of Personal Protective Equipment in-service, dated [DATE]. The DA's name was observed on the roster and had completed the handwashing in-service. The surveyor reviewed an undated facility policy titled Receivable and Storage Policy. The following was observed at Procedure 1. Upon delivery, all foods items will be checked to ensure packaging is intact and marked off against the packaging slip. Check for signs of thawing and refreezing on perishable (large ice crystals on the product) food items. Check for signs of torn, damaged and dents on all food items. Ensure that there are no broken case(s). Check for missing labels, shortage, or overages upon order delivery. All food and nonfood items that are unacceptable at time of delivery will be returned to the vendor. All dented cans will be place (sic) only on designated area and must be marked as dented cans. The following was also revealed at 7: All open items such as disposable plates, lids, cups, spoons, forks, knives and others must be sealed and (sic) from dust. The surveyor reviewed an undated facility policy titled Dating and Labeling Policy. The following was revealed under the Procedure section: 4. Ready to eat foods must be dated with a 72-hour use by date and discarded when expired. 10. Discard all foods that expire immediately. The surveyor reviewed an undated facility provided policy titled Hand Washing Policy/Competency Form. The policy revealed the following at 2. How to Wash Hands: Turn on the faucet using a paper towel to avoid contaminating the faucet, Wet hands and forearms with warm water (minimum 110 F) and apply an antibacterial soap, Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Scrub for a minimum of 20 seconds within the 30-second hand washing procedure. Apply vigorous friction between fingers and fingertips. Rinse with clean running warm water. Rinse thoroughly Dry hands with paper towel. Turn the faucet off with a new paper towel or use a hand blow drier. Use the towel to open the door if needed, then discard the towel. NJAC 8:,d+[DATE].2 (g) NJAC 8:24 4.11(1 and 2)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE) when entering and exiting rooms of residents who were on Transmission Based Precautions (TBP). This deficient practice was identified for 4 of 11 resident's reviewed, (Resident #8, #9, #10, and #11) on 1 of 3 nursing units during a COVID-19 Focused Infection Control Survey. This deficient practice was evidenced by the following: On 2/16/21 at 9:33 AM, the surveyors reviewed the map of the facility with the facility's Administrator. The facility map indicated that rooms 9 through 25 were considered People Under Investigation (PUI) because that was where the new and re-admissions to the facility resided. At 11:22 AM, the surveyor observed double doors that were shut. Signs posted on the doors indicated that the unit was considered PUI. The surveyor entered the PUI unit by rooms [ROOM NUMBERS] and observed plastic bins containing PPE outside of the entranceways to every resident's room on the unit. At 11:31 AM, the surveyor observed the Certified Nursing Aide (CNA #1) on the PUI unit standing inside of Resident #11's room pouring the resident a drink. The surveyor observed that the CNA's gown was not securely tied around her back and neck, leaving the back of the CNA's clothing exposed. The surveyor observed the CNA remove her gown and hang it on a hook by the entrance to the resident's room. At 11:33 AM, the surveyor interviewed CNA #1 upon exiting Resident #11's room. CNA #1 stated that each staff member was given a gown at the start of their shift that they use individually to provide care for the resident's on TBP and that the gown should be tied in the back. At 11:54 AM, the surveyor observed CNA #1 enter Resident #8's room on the PUI unit holding a lunch tray. CNA #1 was observed wearing a KN95 mask covered with a surgical mask, face shield, gown, but no gloves inside of the resident's room. The surveyor observed CNA #1 place the lunch tray on the resident's over bed table, remove her gown inside of the resident's room, apply Alcohol Based Hand Rub (ABHR), exit the resident's room and clean off her face shield with an alcohol wipe. The surveyor did not observe the CNA change out her surgical mask upon exiting the resident's room. At 11:57 AM, the surveyor observed CNA #1 enter Resident #9's room on the PUI unit holding a lunch tray. CNA #1 was observed wearing a KN95 mask covered with a surgical mask, face shield, gown, and no gloves inside of the resident's room. The surveyor observed the CNA place the lunch tray on the resident's over bed table and then touch the resident's over bed table with her bare hands. The surveyor observed the CNA remove her gown inside of the resident's room, apply ABHR, exit the resident's room and clean off her face shield with an alcohol wipe. The surveyor did not observe the CNA change out her surgical mask upon exiting the resident's room. At 12:00 PM, the surveyor observed CNA #1 enter Resident #10's room on the PUI unit holding a lunch tray. The CNA was observed wearing a KN95 mask covered with a surgical mask, face shield, gown, and no gloves inside the resident's room. The surveyor observed the CNA place the lunch tray on the resident's over bed table and then touch the resident's over bed table with her bare hands. The surveyor observed the CNA remove her gown inside of the resident's room, apply ABHR, exit the room and clean off her face shield with an alcohol wipe. The surveyor did not observe the CNA change out her surgical mask upon exiting the resident's room. At 12:02 PM, the surveyor interviewed CNA #1 who stated that prior to entering a resident's room she had to don full PPE which included a KN95 mask, a surgical mask over, a face shield, and gown. The CNA stated that she had to clean her face shield after exiting a resident's room. The CNA stated that she didn't change out her surgical mask because she was wearing a face shield. The CNA further stated that if the resident asked for something and she was providing care to the resident, she would wear gloves. The CNA stated that she didn't have to wear gloves when touching items in the resident's rooms, only when providing care. At 12:34 PM, the surveyor interviewed the Director of Nursing/Infection Preventionist (DON/IP) who stated that before staff entered a resident's room on the PUI new and re-admission unit, the PPE that was required to be donned included a N95 or KN95 mask, surgical mask over, face shield, gown, and gloves. The DON/IP further stated that when staff exited the resident's room, they were required to disinfect their eye wear and don a new surgical mask. The DON/IP stated that the staff was required to do this because the PUI rooms were considered contaminated. Review of the facility's Policy for Emergent Infectious Diseases (COVID-19) (Outbreak Plan) updated 01/28/2021 indicated that Cohort 4 were considered New or Re-Admissions to the facility. The facility's Outbreak Plan further indicated, This cohort consists of all persons from the community or other healthcare facilities whose COVID-19 status is unknown. This cohort serves as an observation area where persons remain for 14 days to monitor for symptoms that may be compatible with COVID-19. Review of New Jersey Department of Health Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated 10/22/2020 indicated, Full Transmission-Based Precautions and all recommended COVID-19 PPE should be used for all patients/residents who are New and re-admissions. Review of NJDOH/CDS Recommendations for Long-Term Care Facilities during COVID-19 Pandemic dated 11/10/2020 indicated, For suspect or confirmed COVID-19 case(s), Standard and Transmission-based Precautions including use of N95 respirator or higher (or facemask, if unavailable), gown, gloves, and eye protection is recommended. NJAC 8:39-19.4(a)(1-2); 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate infection control practices, kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: During a tour of the kitchen, with two surveyors and the Food Service Director (FSD) on 8/1/19 at 9:31 AM, the surveyors observed the following: 1. The ice scoop and holder (exposed at the bottom to prevent wet nesting) was mounted directly over the handwashing sink. The FSD stated that it should not have been mounted there because it had the potential to be splashed during handwashing processes. 2. There was a suspended heater observed directly above the ice machine bin. The heater had a large buildup of a black and brownish substance on the fan blades and along the exterior of the unit. 3. There was a white cutting board observed on a clean dry rack that had grooves and a black substance on both sides. The FSD stated that it was stained and should not be in use and she removed it from the rack. 4. Two fan covers in the walk-in refrigerator were observed to have a buildup of a black and brownish substance. In addition, two refrigerator racks had a buildup of a white grease like substance. The substance was easily wiped off with a paper towel in the presence of the FSD. The FSD stated that the racks should not be that way and further stated the racks would be removed and power washed. 5. The walk-in freezer had a large buildup of ice. The FSD stated that she had to scrape ice from the floor at times and that the maintenance department was aware of the ice buildup. 6. The pot washing and dish machine room ceiling had multiple areas of peeling/hanging paint over areas that clean cooking equipment and small wares were transported. There was also a ceiling grate that had debris suspended over this same area. In addition, there was an exhaust duct directly over the clean exit of the dish machine that had a large buildup of a black and brownish substance. 7. The three-compartment pot washing sinks were observed with debris. The wash sink had an excessive amount of a dark substance and discolored water. The rinse sink was filled with water and had a large amount of floating particles. The stainless-steel table extension to the sanitizer sink had a buildup of particles. The FSD stated that the sink water should not have been that way and that the water should be changed every two hours or as needed (as a posted sign indicated). The FSD proceeded to drain the sinks. In addition, there were three square dish machine racks on the floor under each pot washing sink propped under the drain release levers. The FSD stated that the racks were placed to keep water from draining from the sinks and that maintenance was aware. 8. A dietary aide was observed removing a stack (approximately 20) of wet plate liners from the dish machine exit and stacking them on a rack in an inverted position. The FSD stated that was how they air dry small ware and that it dried by dripping. She was unable to explain how the plate liners would completely dry if stacked wet. During an interview with the surveyor on 8/7/19 at 10:46 AM, the Regional FSD stated that he reorganized the dish room so the staff could properly air dry the plate liners. Two surveyors returned to the kitchen on 8/1/19 at 11:35 AM, and observed the following: 1. There were 90 domed plate covers on a drying rack on the lunch tray line. Forty-one of those covers were observed to have a plastic hanging peeling substance on the underside of the cover which would have been placed directly over the plated lunch meal. At 11:42 AM, the Regional FSD approached the surveyors. He stated that the hanging, peeling plastic on the plate covers was probably due to heat from the dish machine and wear and tear. He further stated the plate covers should not be used as plastic could fall into the food. The Regional FSD proceeded to remove the domed plate covers prior to lunch service. 2. There was a stack of beige meal trays on the tray line. Multiple trays were observed to be cracked and in disrepair. The Regional FSD stated he would inspect the trays and remove the cracked trays from use. During an interview with the surveyor on 8/1/19 at 1:43 PM, the Regional FSD reported that he had removed 15 cracked trays. 3. At 11:56 AM, in the presence of the Food Service Director (FSD), Dietary Aide (DA) #1 washed his hands with a friction time of nine seconds. He turned off the hot and cold-water faucets and then proceeded to take towels to dry his hands. At 11:57 AM, the FSD described the proper handwashing process in front of DA #1 as follows: ensure paper towels were available, turn on the water, apply soap, apply friction for 20 seconds (as indicated on a sign posted above the sink), rinse hands, dry hands with paper towels, discard the paper towels and take another clean paper towel to turn off faucets. At 11:59 AM, DA #1 repeated the handwashing process. DA #1 had a friction time of 10 seconds. He then turned off the hot and cold-water faucets and proceeded to take paper towels to dry his hands. At 12:01 PM, DA #1 repeated the handwashing process again in the presence of the FSD and the Regional FSD. DA #1 had a friction time of 10 seconds. The FSD stated that the friction time was 20 to 21 seconds, but further stated that she did not count. The Regional FSD stated that the friction time should have been longer. At 12:07 PM, in the presence of the FSD, the Regional FSD verbally guided DA #1 through the correct handwashing process. 4. On 8/1/19 at 12:07 PM, the surveyors observed a dietary aide with facial hair, exceeding 1/4 inch, in the kitchen without a beard restraint. In the presence of two surveyors, the Regional FSD (who was wearing a beard restraint) stated the dietary aide should be wearing a beard restraint. During an interview with two surveyors at that time, the dietary aide stated that he did not usually wear a beard restraint. 5. At 12:09 PM, in the presence of the FSD, DA #2 washed his hands with a friction time of eight seconds. At 12:11 PM, DA #2 repeated the handwashing process for 20 seconds. After performing hand hygiene, DA #2 discarded the paper towels he used to dry his hands by opening the garbage cover with his hand. 6. At 12:14 PM, two surveyors observed DA #3 leave the tray to line to answer the phone while wearing gloves. DA #3 also used a pen to write on a clipboard. After hanging up the phone, DA #3 removed and discarded his gloves and then reapplied a pair of new gloves prior to returning to the tray line without handwashing. At that time, the surveyor interviewed DA #3 who stated that he should have washed his hands between glove changes but had not. During an interview with the surveyor on 8/7/19 at 10:46 AM, the FSD (in the presence of the Regional FSD) stated that the purpose of proper hand hygiene in a kitchen environment was to prevent food borne illness. The Regional FSD added that it would also help prevent cross contamination. During an interview with the surveyor on 8/7/19 at 11:48 AM, the Registered Dietitian (RD) stated the importance of proper hand hygiene in a kitchen environment was related to food sanitation, infection control, and to protect the residents. During an interview with the surveyor on 8/7/19 at 12:10 PM, the Nurse Practice Educator (NPE) stated that handwashing competencies were conducted upon staff hire and periodically. She further stated that the staff were required to do a return demonstration. She also stated that staff are required to wash their hands when they are visibly dirty, before and after glove use and as needed. The NPE described the handwashing process as follows: open faucets, wet hands, retrieve soap and apply friction and under nails for 20 seconds, rinse, take paper towels to dry hands and then another clean towel to turn off faucets. She further stated that if any part of the sink was touched during this process, the staff member needed to start over and repeat the process. She also stated that during the in-service process, if the staff member was struggling she would physically demonstrate the process herself. The NPE further stated the importance of proper hand hygiene in a kitchen environment was related to food handling and food safety and that if proper hand hygiene was not followed, it could affect the residents and the whole facility. During an interview with the surveyor on 8/7/19 at 12:38 PM, the FSD and the Regional FSD stated that staff should wash their hands upon entry and reentry to the kitchen, in between tasks, after glove changing and when gloves become worn or soiled. During an interview with the surveyor on 8/7/19 at 11:10 AM, the Maintenance Director stated that he received emails from the FSD regarding maintenance concerns. He also stated that he entered the kitchen most mornings and received verbal communication as well for immediate concerns. He further stated that he would be involved with cleaning ducts and hanging heaters and that the heater was recently cleaned. The Maintenance Director stated that he would be notified if the fan blades in the walk-in refrigerator needed to be cleaned, whereby the fan covers would need to be removed. He and the surveyor observed the grate with hanging substances in the dish machine room. The Maintenance Director stated that the grate provided a fresh air source to the room from outside and the hanging matter were leaves. He further stated he shut it off for cleaning. In addition, the Maintenance Director acknowledged the peeling hanging paint in the dish machine room and stated that it was on the list to get repaired. During a meeting with the survey team on 8/8/19 at 9:51 AM, the Administrator stated it was the responsibility of the food service department to clean elevated areas in the kitchen and had access to ladders. He further stated that in-services were completed for all the kitchen concerns identified by the surveyors. Review of the email correspondences, dated 5/9/19, 6/10/19, 6/17/19, 7/29/19, and 7/31/19, between the FSD and Maintenance Director that were provided to the surveyor by the FSD, did not reflect the maintenance concerns identified by the surveyors during the kitchen tours. Review of the kitchen's Master Cleaning Schedule did not reflect scheduled cleaning and accountability for refrigerator racks, fan covers or high dusting/cleaning. Review of an undated facility policy titled, Cross Contamination, reflected that plastic ware or dishware that were chipped or cracked should have been disposed of. Review the facility policy titled, Safety and Maintenance of Dining Services Equipment and Small Wares, updated 7/19, reflected that food service staff should identify and report any broken small wares, and the FSD or designee would be held accountable for the maintenance of all equipment. Review of the facility policy titled, Pot Washing, dated 12/1/17, reflected that all pots and wares should be air dried. Review of the facility policy titled, Cleaning Instructions: Cutting Boards, updated 1/19, reflected that if cutting boards were damaged/chipped/cracked or stained they should be immediately discarded. Review of an undated facility policy titled, Uniform Policy, reflected that facial hair coverings should be worn to cover facial hair over ¼ inch in length. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 11/18, reflected that the facility considered hand hygiene the primary means to prevent the spread of infection. The policy further reflected that the hand washing process included that the friction component with soap lathered hands should be 20 seconds, to dry hands and then turn off faucets with a clean, dry paper towel. Review of the facility's Food Service policy titled, Handwashing Policy and Procedure, revised 2/25/19, indicated a list of occasions in which employees should wash their hands. Some of which included the following: before each shift, before putting on gloves, after removing gloves, after taking a break, after handling the garbage, and before handling food or clean equipment. It further reflected that the hand washing process included that the friction component with soap lathered hands should be 20 seconds, to dry hands and then turn off faucets with a clean, dry paper towel. NJAC 8:39-17.2(g); 19.4(a)(1); 19.4(n)

Based on interview and record review, it was determined that the facility failed to consistently implement care plan interventions for a resident who was assessed to be at high risk for accidents and injury. The facility failed to provide adequate supervision for a cognitively impaired resident who exhibited behaviors of wandering and inappropriate urination in common areas. The lack of specific, measurable interventions, as well as failure to consistently implement interventions in place resulted in Resident #10 experiencing 24 falls with injury in a 9 month time span. The faciliy also failed to consistently update and/or implement fall interventions for a resident with a fall history, Resident # 20, who sustained a fall requiring emergency room evaluation and treatment for [REDACTED]. This deficient practice was identified for 2 of 12 residents reviewed for fall care plan interventions, Resident #10 and #20, and was evidenced by the following: 1. During the initial tour of the facility on 7/9/15 at 11 a.m., the nurse identified Resident #10 as being at risk for falls. The resident was observed in the hallway with a Velcro seatbelt in place. Review of a timeline provided by the facility revealed the resident sustained [REDACTED]. The resident fell at the facility on 9/10/14 and sustained a pelvic fracture. On 9/19/14, the resident fell and fractured the right pelvis. On 11/13/14, the resident fractured the right wrist. On 6/3/15, the resident fell and sustained a [MEDICAL CONDITION] rib. On 7/14/15 at 1:30 p.m., the surveyor reviewed the medical record of Resident #10 which revealed that the resident had a care plan to address falls initiated 9/3/14. The careplan was last revised on 5/29/15. The care plan included the following interventions: Chair alarm and bed alarm. Bed in the lowest position. Keep the resident in supervised areas. Dycem to the wheelchair. Floor mat when the resident was in bed. Therapy screen. Toileting program. On 7/14/15 at 9:15 a.m., the surveyor observed seven residents at the Nurse's station and five residents in the dayroom; there were no staff in attendance. On 7/15/15 from 9 a.m. to 10:20 a.m., Resident #10 was observed in the hallway self propelling, removing his/her shoes. There was no attempt made by staff to redirect him/her to the day room, or engage him/her in any activity. On 7/15/15, Resident #10 wheeled out of the dayroom and went to the room to use the bathroom. The surveyor followed the resident to the room where he/she attempted to remove the seatbelt. The surveyor alerted the staff of the resident's whereabouts. On 7/16/15 at 9:15 a.m.,the surveyor observed eight residents at the Nursing Station, seven residents were in the dayroom; there were no staff in attendance. A review of the Fall Investigative Reports revealed that Resident #10 was found on the floor in most instances. For example, on 8/30/14 the resident was left unattended in the bathroom. On 9/10/14, the resident reported to the staff that he sustained a fall. The resident was transferred to the Emergency Department and diagnosed with [REDACTED]. A review of the Fall Investigative Report revealed the facility was not consistently following the interventions addressed on the care plan. Resident #10 was referred to Physical Therapy after most of the falls. The Physical Therapy recommendations were to increase supervision as Resident #10 was cognitively impaired. Resident #10 sustained four falls with injury. The resident care plan for falls failed to address the line of supervision to keep the resident safe and lacked specific and measurable interventions to keep the resident safe. Resident #10 had a care plan for behavior which addressed the following concerns, wandering and inappropriate urination. According to the progress notes the resident had multiple instances of maladaptive behavior from 9/14/14 to 7/2/15. Although the care plan addressed the behavior of wandering and inappropriate urination, the behavior was not being monitored by staff. The care plan was not revised to provide directions to the care staff on how to manage the resident's behavior at night. There was no documented evidence that the Interdisciplinary team convened and re-addressed the maladaptive behavior. During a pre-exit conference on 7/16/15 at 1:30 p.m., with the administrative staff, both the ADON and the Administrator revealed that they were not aware of the extent of the behaviors exhibited by Resident #10. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for rehab after he/she suatained a fall from home with intracranial bleeding. During the initial tour of the facility on 7/9/15 at 10:45 a.m., the nurse identified the resident as being at risk for falls. On 7/14/15 at 9:15 a.m., the surveyor observed the resident in bed. The resident was able to answer all questions appropriately. The surveyor reviewed the medical record of Resident #20 on 7/14/15 at 11:30 a.m., which revealed that the resident sustained [REDACTED]. On admission the resident was provided with a bed and chair alarm to alert the staff of the resident's whereabouts. Further review of the clinical record revealed the following: 4/22/15 (1910) 7:10 p.m., Roommate shouting out the resident was on the floor. The alarm did not sound. After this fall, the tab alarm was changed to a sensory pad. 5/4/15 (2024) 8:24 p.m., observed laying on the floor in front of the wheelchair. The alarm did not sound. According to the investigative report provided by the facility, the CNA who cared for the resident was not informed that the resident was to have a sensory pad instead of a tab alarm. An interview with the ADON on 7/15/15 at 1:30 p.m. confirmed the same. Further review of the clinical record revealed that on 5/11/15 at 7:15 p.m., the resident was found lying on the floor with a small amount of blood on the floor, and a laceration to the forehead. The resident was transferred to the Emergency Department (ED) for evaluation. The resident required 3 staples to close the laceration. The surveyor reviewed the form titled, Resident status/ Resident Care Card that revealed the Care Card was not revised in a timely manner on 4/23/15, after the fall of 4/22/15, in order to provide directives that directed care staff of the type of devices required based on the resident's status and needs. NJAC=8:39-11.2 (2), 27.1(a) Refer to F 323.

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision to promote a safe environment, and failed to monitor and supervise a cognitively impaired resident who was identified with unpredictable behavior of wandering into other resident's room and being disruptive. Resident #10 also exhibited multiple instances of urinating in public areas and in other resident rooms which caused the potential for falls for Resident #10, and posed an environmental hazard for other residents. Resident #10 sustained four falls with fractures from 9/10/2014 to 6/2015 resulting in emergency room visits and hospitalization for pain management and treatment. In addition, the facility failed to consistently update and/or implement fall interventions for a resident with a fall history. Resident #20 sustained a fall on 5/11/15, which required an emergency room visit and 3 staples to close the laceration on the scalp. This deficient practice was identified for 2 of 12 residents reviewed for falls, Resident #10 and #20, as evidenced by the following: 1. During the initial tour of the facility on 7/9/15 at 10:30 a.m., the nurse told the surveyor that Resident #10 was alert but forgetful, had a behavior of yelling and was a high fall risk. The surveyor observed the resident seated in the hallway in a wheelchair with a self-releasing Velcro seatbelt attached. On 7/9/15 at 12:50 p.m., the surveyor observed the resident in the dining room eating lunch. The resident was wearing a right wrist brace. On 7/10/15 at 9:30 a.m., the surveyor observed the resident in their room. The resident indicated that he/she wanted to use the bathroom. The surveyor went to the hallway and informed one of the Certified Nursing Assistant (CNA) that the resident was in the room and wanted to use the bathroom. On 7/10/15 at 10:20 a.m., the surveyor reviewed the medical record of Resident #10 who was admitted [DATE], with [DIAGNOSES REDACTED]. The resident had behavior problems which included combativeness, yelling, and a history of wandering aimlessly throughout the halls and in and out of other residents' rooms. Further review of the clinical record revealed that the resident had 24 falls from 8/30/14 to 6/5/15 as follows: 8/30/14 at 1344 (1:44) p.m., the resident was left unattended in the bathroom, the resident was found in the bathroom on the floor. 9/10/14 at 0400 (4 ) a.m., the resident reported to the staff that he/she fell . The resident sustained [REDACTED]. The resident was transferred to the emergency room (ER) and diagnosed with [REDACTED]. The resident was transferred to a room closer to the nurse's station. 9/16/14 at 2110 (9:10) p.m., the resident climbed out of bed and was noted seated on the floor by the door. Interventions at that time included having a urinal within reach and a low bed with floor mat. 9/19/14 at 2125 (9:25) p.m., the resident was found on the floor outside of the dayroom. Resident #10 was transferred to the ER and admitted with right superior pelvic fracture. Two hour toileting was added to the care plan (CP). 9/23/14 at (0845) 8:45 a.m., the resident was found sitting upright against the wall in another resident's bathroom. No visible injury at this time. Dysem and and anti-tipper was added to the wheelchair. 9/30/14 22:45 (10:45) p.m., the resident was found seating on the floor by the foot of the bed, and sustained a skin tear to left elbow which measured 2 x 1 cm with bleeding. A scoop mattress was added as intervention. 10/3/14 (1245) 12:45 p.m., the resident was found on the floor in another resident's room. 10/3/14 (19:46) 7:46 p.m., the same day, the resident was found on the floor in the hallway. A therapy screen for wheelchair positioning was done and a self-releasing seat belt was added to CP. 10/10/14 (0330) 3:30 a.m., Resident #10 fell in his/her room. 30 minute checks were done x 9 hours. 10/22/14 (18:37) 6:37 p.m., the resident was observed seated on the floor in the room. No apparent injury was identified. Self-releasing seatbelt re-ordered. Place resident near nurse's station when climbing out of bed was added to CP. 11/7/14, the resident was identified with right wrist discomfort and later diagnosed on [DATE], with a right wrist fracture. 12/8/14 (1000) 10 a.m., the resident was found lying on floor by the CNA and sustained a skin tear to upper left arm. 12/26/14 (23:10) 11:10 p.m., the resident was found crawling on floor mat. The resident indicated that he/she was trying to go to the bathroom. A Therapy screen was initiated. 1/3/15 (0011) 12:11 a.m., the resident was found in the bathroom of another resident's room. 1/16/15 (1000) 10:00 a.m., the resident was observed sitting on the floor ma. No injury noted. 3/23/15 (0335) 3:35 a.m., the resident was found sitting on the floor mat with his/her back against the bed. No injury noted. 3/23/15 (0823) 8:23 a.m., the same day, the resident was found on the floor mat. No injury noted. 3/28/15 (0830) 8:30 a.m., the resident was found sitting on the floor mat. 4/1/15 0430 (4:30) a.m., the resident was found on floor next to the bed. The resident reported back pain, no bruise on assessment. After toileting, the resident was to be taken near nurse's station. 4/6/15 1745 (5:45) p.m., the resident reported he/she slipped, fell on the floor and hit his/her head and sustained a skin tear. The resident wheeled self from the Dayroom to the Activity room and the fall was not witnessed by staff. 4/17/15 2250 (10:50) p.m., the resident was found sitting on his/her buttocks in the room. 5/29/15 2325 (11:25) p.m., the resident was found sitting on the floor in the dayroom. The resident indicated he/she was on his way to use the bathroom. No injuries noted. 6/2/15 1830 (6:30) p.m., the resident fell in the bathroom. No injuries noted. Non skid socks were added to CP. 6/3/15 1105 a.m., toppled over in wheelchair with seatbelt attached. Front antitippers attached to wheelchair. 6/5/15 0330 (3:30) a.m., the resident was found on floor along roommates side of the room, holding his/her head and crying in pain. The resident sustained [REDACTED]. Resident #10 was sent to the ER for an evaluation. The resident complained of rib pain during transfer, as a result, a Bilateral X- Ray of the rib was done. Resident #10 sustained a fracture of the left 10th rib. The surveyor reviewed Resident #10's care plan for falls, initiated on 9/3/2014. The care plan failed to address the line of supervision required to keep the resident safe. Resident #10 fell at the facility 24 times. Most of the falls were not witnessed and had occurred on the 3 p.m.-11 a.m. and 11 p.m.-7 a.m. shift and were unwitnessed. The facility did not have specific interventions in place to prevent further falls. During the group interview on 7/10/14 at 10:30 a.m., 5 of 5 residents in attendance expressed concerns over residents who wandered unsupervised throughout the facility and into other resident's rooms during the night. The surveyor reviewed Resident #10's Progress notes from 9/10/2014 to the time of the survey which revealed multiple incidents of behaviors such as wandering; urinating in the hallway and in other resident's rooms; and removing items from other residents rooms and on the medication cart. Many times it was documented that the resident was aggressive with staff and not easily redirected. Examples of the uncontrollable behavior as found in the progress notes, included the following: On 9/17/14 at (22:54) 10:54 p.m., Wanders in wheelchair unclipping alarm, unzipped pants pulling them down trying to urinate in hallway. Gave urine bottle, still noncompliant. 9/29/14 (untimed) Resident is awake a lot during the night. Not easily redirected. Resident incontinent of urine, and urinating in the garbage can. 10/01/14 (0820) 8:20a.m., Climbing out of bed, attempting to urinate in the garbage can. 10/12/14 (1448) 2:48 p.m., Resident very agitated continue to attempt to enter other resident room and ambulate without assistance. 10/27/14 (0708) 7:08 a.m., Resident in and out of other resident rooms. 11/17/14 (0628) 6:28 a.m., .urinated all over in and out of other residents rooms. 11/18/14 (Late entry-untimed) Resident was pacing the unit in wheelchair, in and out of resident's room. Cannot redirect. 11/23/14 (untimed) Received resident in wheelchair, going in and out of other residents rooms. 11/28/14 (0310) 3:10 a.m., In wheelchair with seatbelt on and propelling self in and out of residents rooms. Resident is not easily redirected. 11/29/14 (0700) 7:00 a.m., .awake all shift, slept for one hour. Propelling self around unit, in and out of other residents's rooms, dumped full pitcher of orange juice on floor. Attempted to take other stuff off med carts and from desk. Very difficult to redirect. 11/29/14 (1247) 12:47 p.m., Propelled self in wheelchair and down the hallway. Was in and out of other residents room. Attempted to eat other resident lunch from their trays, not easily redirected. 11/30/14 (0638) 6:38 a.m., Roaming around unit in and out of other residents rooms. Waking them up and taking their belongings . 12/1/14 (0727) 7:27 a.m., Propels self around in and out of other residents rooms waking them up. 12/7/14 (15:35) 3:35 p.m., Resident confused pacing around, going to other residents rooms. 12/8/14 (0419) 4:19 a.m., Resident wandering in the wheelchair and going into other residents rooms, touching anything in site, not easily redirected. 12/10/14 (0636) 6:36 a.m., Resident in and out of residents rooms, not easily redirected. 12/14/14 (0701) 7:01a.m., Up all shift, difficult to redirect, urinating on floor, in and out of other residents rooms, attempted to urinate on other residents. 12/15/14 (0726) 7:26 a.m., Up in wheelchair, wandering around unit, urinating where ever he wants. 12/18/14 (0457) 4:57 a.m., Resident awake all shift, wandering into other residents rooms. Touching everything, not easily redirected. 3:30 a.m., still awake and wandering into rooms, also urinating in hallway. 12/19/14 (untimed) Punching wall during care this am. unable to redirect. 12/21/15 (0334) 3:34 a.m., Resident in and out of other residents rooms., pulling stuff off the counters and of the medication cart. Resident urinated on the floor in the hallway twice even though he was toileted prior to this behavior. Not easily redirected. 12/22/14 (0552) 5:52a.m., Awake all night, very resistive with redirection. In and out of other residents rooms. 12/28/14 (2251) 10:51p.m., Resident aggressive, yelling at other residents and staff, pacing hallways all shift, going to other residents rooms, difficult to redirect. 1/3/15 (0018) 12:18 a.m., Was propelling himself in wheelchair into multiple residents rooms, being very loud, yelling at other residents. Continued to remove his pants several times and urinating on the floor. Became combative while attempting to redirect. 1/28/15 (0105) 1:05 a.m., Resident was verbally and at times physically attempting to bother other residents, using foul language and attempting to grab unto other residents, using an angry tone upsetting other residents throughout the shift. Multiple attempts made at redirection, unsuccessful. Continually wanders into many residents rooms throughout the shift. Attempted to urinate on floor in hallway.Behavior continued entire shift. 1/31/15 (2149) 9:49 p.m., Resident exhibiting aggressive behavior. Punching the walls, entering other residents rooms, talking over other residents and staff. 2/01/15 (untimed) Wandering, yelling whistling. 2/12/15 (2300) 11:00 p.m., Agitation, aggressive behavior. 2/17/15 (0703) 7:03 a.m., increased anxiety, yelling, whistling loudly. Resident was unable to redirect. 2/28/15 (2206) 10:06 p.m., Xanax given related to being aggressive while being escorted out of other residents rooms. 3/14/15 (0733) 7:33 a.m., Awake most of the shift, urinating on the floor in hallway. 3/30/15 (0415) 4:15 a.m., Wandering on unit and in other residents rooms. 5/03/15 (untimed) Yelling out loud, shouting out loud, trying to grab staff clothing, resident is difficult to redirect. 5/06/15 (2223) 10:23 p.m., Became restless and agitated, going into other residents rooms and yelling out. 5/18/15 (0030) 12:30 a.m., Propelling self around unit, banging on walls, tables other chairs windows,, scratched arms and legs, pulling clothing. 5/30/15 (untimed) Resident confused, whistling, roaming through other residents rooms. difficult to redirect. 6/24/15 (2343) 11:43 p.m., Resident very agitated, try to punch the wall. 6/25/15 (0656) 6:56 a.m., Resident wandering in and out of other residents rooms. Becoming agitated when staff trying to redirect. Resident continued to be agitated and go into other residents rooms. 6/27/15 (2337) 11:37 p.m., Resident confused, difficult to redirect. getting agitated toward staff, very agitated, hitting wheelchair with his own hand. The surveyor reviewed of the care plan for behavior, initiated 12/03/14 (last revised 1/8/15), that revealed the Interdisciplinary team (IDC) team identified behaviors such as, yelling at other residents, wanders unit, in and out of rooms, urinates in inappropriate places, combativeness with care, aggressiveness with staff and others. The interventions included the following: 1. Monitor for specific behavior. 2. Notify nurse of any episode. 3, Notify MD of any change in behavior. 4. Medication as ordered. 5. Monthly psychotropic summary. 6. Monitor Lab. 7. Provide non pharmacological interventions. 8. Redirect away from other residents if aggression or combativeness occurs. The care plan did not identify how the resident's behavior would be managed during the day to promote sleep at night. The resident was awake most of the night, and drowsy during the day. The behavior monitoring sheet provided by the facility indicated that the resident's behavior such as wandering and inappropriate urination was not being monitored. The behavior identified was, Anxiety. The behavior of wandering and inappropriate urination was not being monitored. On 7/15/14, the resident's roommate told the surveyor that the resident was up most of the night and going through his/her belongings. A nursing progress notes dated 5/23/15, confirmed that Resident #10's roommate could not sleep because of the disturbances. On 7/14/15 at 10:30 a.m., the Unit Manager stated that Resident #10 wandered in the hallway and in other resident's rooms mostly at night, was combative with care and verbally abusive to staff and other residents. An interview with the CNA who cared for the resident revealed the resident was mostly compliant during the day and was more of a problem at night. He was aware that the resident wandered in other resident's rooms at night. On 7/15/15 the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON stated that she was not aware of the inappropriate urination and the wandering behavior. She stated she was aware that the resident was awake to use the bathroom frequently. On 7/16/15 at 2:15 p.m., the Administrator stated that he was not aware of the extent of the behavior. Review of the physician progress notes [REDACTED]. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted for rehab after he/she sustained a fall at home with intracranial bleeding. During the initial tour of the facility on 7/9/15 at 10:45 a.m., the nurse identified the resident as being at risk for falls. On 7/14/15 at 9:15 a.m., the surveyor observed the resident in bed. The resident was able to answer all questions appropriately. The surveyor reviewed the medical record of Resident #20 on 7/14/15 at 11:30 a.m., which revealed that the resident sustained [REDACTED]. On admission the resident was provided with a bed and chair alarm to alert the staff of the resident's whereabouts. Further review of the clinical record revealed the following: 4/22/15 (1910) 7:10 p.m., Roommate shouting out the resident was on the floor. The alarm did not sound. After this fall, the tab alarm was changed to a sensory pad. 5/4/15 (2024) 8:24 p.m., observed laying on the floor in front of the wheelchair. The alarm did not sound. According to the investigative report provided by the facility, the CNA who cared for the resident was not informed that the resident was to have a sensory pad instead of a tab alarm. An interview with the ADON on 7/15/15 at 1:30 p.m., confirmed the same. Further review of the clinical record revealed that on 5/11/15 at 7:15 p.m., the resident was found lying on the floor with a small amount of blood on the floor, and a laceration to the forehead. The resident was transferred to the Emergency Department (ED) for evaluation. The resident required 3 staples to close the laceration. A review of a form titled, Resident status/ Resident Care Card revealed that the Care Card was not revised in a timely manner on 4/23/15, after the fall, in order to provide directives that directed care staff of the type of devices required based on the resident's status and needs. NJAC 8:39-27.1 (a) (Refer to F282)

NJ Based on interview and review of medical records and facility documents it was determined that the facility failed to assure that identified safety devices were in place to prevent falls for 1 of 3 sampled residents (Resident #1.) Resident #1 had a 5/25/11 physician's order for a sensory wheelchair alarm to be checked for placement and function each shift. On 1/17/12 the alarm was not in place when the resident fell from the wheelchair, sustaining a left hip fracture which required hospitalization , surgery, pain management, orthopedic follow-up, and physical/occupational therapies. This deficient practice is evidenced by the following: 1. Resident #1 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the 10/7/11 Minimum Data Set (MDS,) an assessment tool, the resident was alert and oriented, non-ambulatory, totally dependent upon staff for transfers, and required extensive two person assist for locomotion. The resident had a prior fall in the facility on 3/22/11 when she was found on the floor after having fallen out of bed. A Reportable Event Record/Report and associated facility investigation faxed by the facility to the Department of Health and Senior Services on 1/19/12 indicates that on 1/17/12 at 2:55 P.M. the resident was found on the floor of her room by a therapy aide. At 3:08 P.M. nursing staff responded to the resident's room and an assessment was conducted. The resident complained of left hip pain, and limitation of movement of the left hip was noted. The resident stated she had fallen to the floor while leaning forward in her wheelchair to button her roommate's sweater. The resident's family and physician were notified of the incident by staff and the resident was transported to the emergency room for evaluation. The resident was admitted to the hospital on [DATE] at 5:38 P.M. with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the Admission Nursing Evaluation of the same date reflects a left hip surgical wound with 6 staples. At time of assessment, the resident described her pain level as a "10" on the Wong-Baker pain rating scale of 1-10, with 10 being the worst pain. Review of the facility investigation including staff statements indicates no chair alarm was present at the time of the incident. Upon review of Physician Order Sheets, the following orders regarding safety/fall risk were noted: 5/25/11- sensory alarm to bed, check placement and function each shift; 6/15/11- low bed against the wall with floor mat on exposed side nightly; 7/1/11- sensory wheelchair alarm, check placement and function each shift. Upon review of the resident's Plan of Care, the surveyor noted that on 5/25/11 interventions were specified for a chair alarm and a bed alarm, both of which had been crossed off with a yellow marker prior to the surveyor's review of this document on 1/31/12. No associated date was found for the highlighting/discontinuance of the interventions. During an interview on 1/31/12 at 10:45 A.M. the Unit Manager (UM) reviewed the Plan of Care with the surveyor and stated that the facility had implemented both chair and bed alarms on 5/25/11, and the yellow marker reflected that they were discontinued. The UM was unable to provide an explanation or documentation as to when or why the chair alarm had been discontinued. On 7/1/11 a new physician's order was generated for a wheelchair alarm, check for placement and function each shift. Review of the Treatment Administration Record (TAR) revealed documentation of wheelchair alarm checks for placement and function during July 2011. However, the monthly TAR's from August 2011 through the incident of 1/17/12 revealed no documentation of a wheelchair alarm being present. In addition, no documentation was found in the Interdisciplinary (IDT) Progress Notes regarding the presence of any chair alarm during that same time period. In an interview with the surveyor on 1/13/12 at 11:15 A.M. the certified nurse's aide (CNA) who was the resident's primary day shift caregiver since the resident's initial admission stated that the resident had a wheelchair alarm "in the beginning." However, since she had not seen the alarm on the wheelchair in a long time, she had assumed it had been discontinued, and had not questioned its absence. At the request of the surveyor, the Unit Manager and the Director of Nursing (DON) reviewed the resident's medical record and confirmed that no physician order was found to discontinue the chair alarm. In an interview with the surveyor on 1/31/12 at 1:30 P.M. the DON stated that staff failed to carry the chair alarm order over from the July 2011 TAR to the August 2011 and subsequent TAR's through January 2012. The DON confirmed that no documentation could be found for presence of the chair alarm after July 2011 until the post-fall readmission on 1/21/12. Neither the DON or the Unit Manager were able to provide an explanation why the chair alarm order was not carried over onto the August 2011 TAR or why the chair alarm was yellowed out as discontinued on the Plan of Care. 8:36-27.1(a)

A. Based on surveyor observations, interview, and review of documents provided by the facility, it was determined that the facility failed to protect residents, staff and visitors from a fire hazard by permitting the use of an unattended, non-compliant electrical space heater in a room containing combustible material. This resulted in an immediate jeopardy situation for residents, staff and visitors. The immediate jeopardy was identified on 5/22/11 and corrected on 5/22/11 at 3:38 p.m. based on the immediate removal of the space heater and submission of an acceptable plan of correction which was implemented by the facility. This deficiency continues at a scope and severity of D based on evidence in Part B. The deficient practice was evidenced by the following: On Sunday, 05/22/11, at 2:30 p.m., the surveyor observed a portable electric space heater in the Central Supply storage room. The heater was in the on position displaying a temperature of 67 degrees Fahrenheit (F). The heater was on the floor and was placed 2-inches from binders of paper on a low shelf. There were no staff present in the locked room and the key to enter was provided by the Director of Nursing (DON). The heater was immediately removed. On 5/23/11 at 11:30 a.m., the surveyor accompanied by the Director of Environmental Services observed that the door to the Central Supply storage room was not provided with a self-closing device. Once opened, the door remained open. The room measured 18-feet by 20-feet with 10-foot a ceiling. The room contained shelving units with storage of flammable paper and plastic supplies. The facility was of ordinary wood construction Type V(111) requiring an automatic fire sprinkler system. However, there was no heat detection or smoke detectors provided in the Central Supply room. In an interview at that time, the facility's Director of Environmental Services (DES) stated that the electric heater did not belong to the facility and said the facility allowed these electric heaters when there was a heating failure. (Refer to K70.) At 2:45 p.m., in the presence of the surveyor, the facility's Director of Maintenance (DM) tested the electric heater and measured the temperature of the heating element to be 221 degrees F. and rising when set on "High" and 158 degrees F. on "Low" which did not comply with the requirements of the Life Safety Code. (Refer to K70.) The surveyor interviewed the DON at 3:10 p.m. The DON stated that the Central Supply staff person worked Monday to Friday from 8 a.m. to 4:30 p.m. and that the Central Supply was not staffed on the weekends. In a second interview, at 3:38 p.m., the DON stated that the facility's policy was to not permit the use of electric heaters. On 5/23/11, at 9:30 a.m., the staff member assigned to Central Supply confirmed that she worked until 5:30 on Friday, 5/20/11, and stated that the heater was not on and she doesn't use it. The surveyor interviewed the DM at 11:30 a.m. The DM stated that there was a key to the Central Supply room in the emergency key box in the Maintenance Dept. and that the Central Supply employee and Nursing Supervisor were the only staff with a key. A review of the facility's Safety Manual, Policy Number HSE 017, "Use of Portable Comfort Heaters" noted that portable comfort heaters are permitted in business occupancies but shall not be placed in close proximity to combustible materials. There was no evidence that this policy was followed. The facility was notified of the immediate jeopardy on 5/22/11 at 3:38 p.m. The heater was removed at the time of discovery on the initial tour. The facility provided an acceptable plan of correction (POC) on 5/23/11 at 10:30 a.m. which included the following: A. Rounds were conducted in all resident and non-resident areas of the facility to remove any and all portable heaters in Bey Lea Village. B. The policy for the use of portable heaters was reviewed and updated. C. All staff was to be in-serviced in compliance information and receive an updated policy by 5/23/11. D. Monthly audits will be conducted by the Maintenance Director/Designee to ensure strict compliance of the policy. E. Result of the monthly audits will be reported at monthly QI meetings. B. Based on observation, interview and record review it was determined that the facility failed to provide planned interventions intended to prevent falls. This deficient practice was identified for 1 of 5 residents, Resident #6, reviewed for falls and was evidenced by the following. During the initial tour on 5/22/11 at 11:15 a.m., the unit nurse told the surveyor that Resident #6 had a [DIAGNOSES REDACTED]. The nurse further stated that the resident had a history of [REDACTED]. Later at 2 p.m., the surveyor observed the resident seated in a wheelchair in the doorway of her room. The resident was confused, mumbling and had a lap buddy and sensor alarm in place. On 5/24, the surveyor reviewed Resident #6's medical record. The resident had a fall from the wheelchair on 4/13/11 which resulted in a hematoma to the scalp. The resident was evaluated at the hospital and returned to the facility. On 4/15/11, the resident was transferred to the hospital related to Behavioral Disturbances and was admitted . The resident returned to the facility on [DATE] with an adjustment to her psychoactive medications. According to a 4/29/11 nurses note, the resident was seated in a wheelchair at the nurses station, stood up and "sat self " on the floor. On 4/30/11 a physician order [REDACTED]. On 4/30/11 the resident attempted to go to the bathroom unattended. Staff were alerted by the sound of a sensor alarm on the resident's bed. On 5/1/11 the resident was found on the floor in her room. According to the fall investigation the staff were alerted to the resident's room by the bed sensor alarm sounding. The resident was sent to the hospital for evaluation and returned with a contusion to the forehead. On 5/2/11 a physician order [REDACTED]. On 5/24/11 at 1:15 p.m., the surveyor observed Resident #6 lying on top of the bed fully dressed. The bed was in a normal height position; the side rail was down, and there was no floor mat in place. The resident's wheelchair was next to the bed. The lap buddy was not in the resident's room. At 1:45 p.m. the resident remained in the bed without fall interventions in place. The surveyor interviewed the resident's primary Certified Nurse Aide (CNA) at 1:45 p.m. The CNA stated that she did not put the resident into the bed and in fact was unaware that the resident was in bed. The Unit Nurse Manager (UNM) was also unaware that the resident was in bed. The UNM stated that she would investigate how the resident got into the bed. On 5/25 at 8:30 a.m., the UNM told the surveyor that after the investigation it was determined that the resident's lap buddy was not re-applied after lunch and that the resident propelled herself back to the room and transferred herself to bed. The UNM further stated that the sensor alarm on the wheelchair had not sounded. She stated that a "light was flashing" indicating that it was on but it did not sound. The UNM told the surveyor that a CNA was interviewed who stated that he had been in the resident's room to tend to the roommate and noted that the resident was in bed. The CNA stated that he did not transfer the resident. The CNA did not intervene to put the physician-ordered fall interventions in place. The CNA left the resident unsupervised in the room without lowering the bed and putting the floor mat in place. NJAC 8:39-27.1(a) NJAC 8:39 -31.2(e), 31.7(f)